Every finding on record at Stonegate Health Campus

Based on observation, interview, and record review, the facility failed to maintain best practices in the food service area, resulting in the potential to spread food borne illness to all residents who consume food from the kitchen.Findings include:On 02/09/2026 at 9:45am-10:33am during the initial kitchen tour with Director of Food Services A, observed the meat slicer visibly soiled with crumbs accumulating on surface, stored in the dry storage room in the kitchen. During this observation, Director of Food Services A was interviewed on how often the meat slicer is used and answered it's used about twice a year and it's cleaned before use. On 02/09/2026 at 9:45am-10:33am observed dust accumulation on metal lids stored on a rack near the handwashing sink, located in the kitchen. On 02/09/2026 at 9:45am-10:33am observed the can opener visibly soiled. During this observation, [NAME] B was interviewed on how often the can opener is cleaned and stated it's cleaned every night. On 02/09/2026 at 9:45am-10:33am observed the mixer visibly soiled with black and yellow residue. During this observation, Director of Food Services A was interviewed on how often the mixer is cleaned and she stated it's cleaned every time it's used. On 02/09/2026 at 10:33am observed built up residue on the surface near the nozzles of the juice machine in the dining area near the kitchen. During this observation, Director of Food Services A was asked how often the juice machine surfaces are cleaned and she stated the nozzles are cleaned on a rotation and the backsplash surface is wiped down daily. On 02/09/2026 at 10:35am observed accumulated residue on the nozzles of the Folgers coffee machine in the cafe kitchenette. During this observation, Director of Food Services A was asked how often the nozzles are cleaned and she stated it's cleaned on a rotation. According to the 2022 Food Code, 4-601.11 Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils, Equipment food-contact surfaces and utensils shall be clean to sight and touch, the food-contact surfaces of cooking equipment and pans shall be kept free of encrusted grease deposits and other soil accumulations, nonfood-contact surfaces of equipment shall be kept free of an accumulation of dust, dirt, food residue, and other debris.On 02/09/2026 at 11:05am-11:55am during lunch observation, observed macaroni pasta salad was sitting on ice at the food prep line and was temped at 49 F using Thermapen. During this observation, Director of Food Services A was asked what temperature the pasta salad should be cold holding, and stated she wasn't sure. On 02/09/2026 at 11:05am-11:55am observed mechanical pasta salad in a tub without ice on the food prep line and it was temped at 52 F using Thermapen. According to the 2022 Food Code, 3-501.16 Time/Temperature Control for Safety Food, Hot and Cold Holding, Except during preparation, cooking, or cooling, or when time is used as the public health control, time/temperature control for safety food shall be maintained: .at 5 C (41 F) or less. According to the facility's policy on hot and cold holding, Cold foods should be 40 degrees or less when the temperature is taken in the kitchen at the time of service. On 02/09/2026 at 11:49am observed [NAME] D battering raw fish with one gloved hand, then removed the soiled glove with their other gloved hand and then proceeded to put fries onto a plate with the same gloved hand. According to the 2022 FDA Food Code, 3-304.15 Gloves, Use Limitation .If used, single-use gloves shall be used for only one task such as working with ready-to-eat food or with raw animal food, used for no other purpose, and discarded when damaged or soiled, or when interruptions occur in the operation. On 02/10/2026 at 11:20am fried shrimp on the steam table was temped at 127 F and 124 F using Thermapen. During this observation, Director of Food Services A was asked what the hot holding temperature is for the fried shrimp, and she stated it's usually around 160 F. The fried shrimp was temped again by Director of Food Services A and it was 114 F. According to the 2022 FDA Food Code, 3-501.16 Time/Temperature Control for Safety Food, Hot and Cold Holding, Except during preparation, cooking, or cooling, or when time is used as the public health control . time/temperature control for safety food shall be maintained .at 57 C (135 F) or above. According to the facility's hot and cold holding policy, Hot food in the steam table should be at least 135 or higher degrees Fahrenheit and arrive approximately at greater than or equal to 120 degrees Fahrenheit when the resident is served.

Based on interview and record review, the facility failed to ensure Minimum Data Set (MDS) assessments were completed timely for six residents (R5, R6, R8, R17, R64, R84) of seven residents reviewed for MDS assessments. Findings include:Resident #5: R5 is [AGE] years old and most recently admitted to the facility on [DATE] with diagnoses that include chronic kidney disease, chronic respiratory failure, dependence on renal dialysis and diabetes mellitus. On 02/10/2026, record review of the Minimum Data Set (MDS) assessments in the electronic medical record (EMR) revealed an MDS Quarterly assessment that was opened on 01/06/26 and closed on 01/26/26. Resident #6: R6 admitted to the facility on [DATE] with diagnoses that include coronary artery disease, hypertension and traumatic brain dysfunction. R6 has a brief interview for mental status (BIMS) score of 14, indicating they are cognitively intact. On 02/10/2026, record review of the Minimum Data Set (MDS) assessments in the electronic medical record (EMR) revealed an MDS Quarterly assessment that was opened on 01/05/26 and closed on 01/26/26. The assessment was completed seven days late. Resident #8: R8 admitted to the facility on [DATE] with diagnoses that include stroke, hemiplegia, anxiety and depression. R8 has a BIMS score of 15, indicating they are cognitively intact. On 02/10/2026, record review of the Minimum Data Set (MDS) assessments in the electronic medical record (EMR) revealed an MDS Quarterly assessment that was opened on 01/02/26 and closed on 01/26/26. The assessment was completed 10 days late. Resident #17: R17 admitted to the facility on [DATE] with diagnoses that include chronic kidney disease, anemia, stroke and epilepsy. On 02/10/2026, record review of the Minimum Data Set (MDS) assessments in the electronic medical record (EMR) revealed an MDS Quarterly assessment that was opened on 01/06/26 and closed on 01/26/26. The assessment was completed six days late. Resident #64: R64 is [AGE] years old and admitted to the facility on [DATE] with diagnoses that include atrial fibrillation, hypothyroidism, anemia and acute kidney failure. On 02/10/2026, record review of the Minimum Data Set (MDS) assessments in the electronic medical record (EMR) revealed an MDS Quarterly assessment that was opened on 12/22/25 and closed on 01/26/26. The assessment was completed 21 days late. Resident #84: R84 is [AGE] years old and admitted to the facility on [DATE] with diagnoses that include diabetes mellitus, repeated falls, cognitive communication deficit and hyperlipidemia. On 02/10/2026, record review of the Minimum Data Set (MDS) assessments in the electronic medical record (EMR) revealed an MDS Quarterly assessment that was opened on 01/02/26 and closed on 01/26/26. The assessment was completed 10 days late. On 02/10/2026 at 12:46PM, an interview was conducted with Minimum Data Set (MDS) Coordinator F, MDS F was asked how many days you get to complete a quarterly assessment. MDS F stated, we get 14 days from the assessment reference date (ARD) to complete the assessment. MDS F was asked to review a quarterly MDS assessment for R17. MDS F was asked if the quarterly assessment is considered late since it was completed on 01/26/26. MDS F stated, yes, it is late. MDS F was provided a list of seven residents who had late assessment and asked to provide the information on when the assessment was started and when it was completed. MDS F provided the requested information, six of the seven residents had late MDS quarterly assessments. On 2/10/26 at12:56PM an interview was conducted with Corporate MDS Support G: Corporate G was asked why these assessments were completed late. Corporate G stated the unfinished areas of the quarterly assessments are the social services section. We have been down to one social worker since December, and we were down to one prior to our newest Social Worker coming on. The social worker who recently left us most recently left on 01/16/26. Corporate G' was asked if they were aware there was a problem with MDS assessments being completed on time. Corporate G stated, yes, we were aware that we were late completing the social services sections of the MDS assessments. Corporate G was asked if this information was being taken to Quality Assurance (QA) to put a plan in place to correct it. Corporate G stated, no, but we probably should of. On 02/10/2026 at 1:13PM, an interview was conducted with the Nursing Home Administrator (NHA). The NHA was asked about the late MDS assessments and why they were late. The NHA stated we have had 1.5 MDS nurses in the facility recently and we have been approved for another full time MDS nurse. However, we have had trouble hiring a second person as of now. The NHA was asked if they were aware that these assessments were late. The NHA stated, yes, the corporate nurse and I identified this, and we have been looking into MDS completion. I gave the MDS Coordinator a discipline for not completing the MDS timely. So, yes, I was aware that this was an issue. Review of the Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, revealed that Quarterly MDS Assessments are to be completed 14 days from the ARD.

Based on observation, interview, and record review, the facility failed to ensure safe and sanitary practices were followed for respiratory equipment including changing/dating oxygen tubing and humidification canisters for four residents (R5, R7, R19 and R81) and the storage of a nebulizer treatment chamber and mouthpiece for one resident (R5) of five residents reviewed for respiratory care. Findings include:R19:According to a review of R19's medical record, the resident was admitted to the facility on [DATE] for skilled nursing care related to medical diagnoses of chronic kidney disease (CKD), chronic obstructive pulmonary disease (COPD), permanent atrial fibulation (AFIB/ irregular heart rhythm), diabetes mellitis type II (DM), and congestive heart failure (CHF). R19's Minimum Data Set (MDS) record revealed a Brief Interview of Mental Status (BIMS) assessment score of 12/15 that indicated moderate cognitive impairment.On 02/09/2026 at 10:20AM, During an observation of R19 she was resting in bed, wearing oxygen (O2) via nasal cannula (NC) on 3 liters (L), the O2 tubing and humidification canister had no date of initiation identified.On 02/11/2026 at 8:20AM, During an interview with ICP nurse H she was asked about respiratory equipment use and storage. When she was asked about the procedure for changing of O2 tubing and humidification canisters the ICP nurse H said that the O2 tubing is changed two times a month and is done on night shift, she further said that the humidification chamber is changed at the same time. ICP nurse H said they are dated and initialed each time they are changed. ICP nurse H indicated she did monthly rounds in which this was an included item on the check off list and provided logs from November, December and January and said she had not completed rounds for February, so it had not been completed. ICP nurse H indicated that the nurses that worked on the floor changed the tubing and canisters and that she monitored it monthly.On 02/11/2026 at 10:00AM, An observation of R19 was made, she was resting in her bed watching television, wearing oxygen (O2) via nasal cannula (NC) on 3 liters (L), the O2 tubing and humidification canister had no date of initiation identified.On 02/11/2026 at 11:00AM, During a follow up interview with ICP nurse H she clarified that the respiratory equipment policy said O2 tubing was changed monthly. When ICP nurse H was queried about the humidification canisters, she replied they were to be changed when the O2 tubing was changed. ICP nurse H confirmed that they both were to be dated and initialed when changed.A record review of R19's care plan revealed: Problem: Resident has potential for complications; functional and cognitive status decline related to respiratory disease R/T: COPD. Approach: Administer oxygen per MD order and as needed.R5:According to a review of R5's medical record, the resident was admitted to the facility on [DATE] for skilled nursing care related to diagnoses of hypertensive CKD stage 5 (end stage kidney failure requiring dialysis), chronic obstructive pulmonary disease (COPD), atrial fibulation (AFIB/ irregular heart rhythm), diabetes mellitis type II (DM), Anemia (low blood count). R5's Minimum Data Set (MDS) record revealed a Brief Interview of Mental Status (BIMS) assessment score of 11/15 indicated moderate cognitive impairment.On 02/09/2026 at 1:30 PM, During an observation of R5, he was sitting up in his wheelchair in his room. R5 was wearing O2 via NC set at 2.5L, the O2 tubing had no date of initiation identified. The humidification canister was dated 01/09.On 02/10/2026 at 8:40 AM, During an observation of R5, he was resting in bed, in his room watching tv. R5 was wearing O2 via NC set at 6L, the O2 tubing had no date of initiation identified. The humidification canister was dated 01/09. R5's nebulizer medication chamber was observed on the bed side chair with the mouthpiece rested on a pair of black shoes (that were also on the chair), next to a red stuffed 'hermit crab' that R5 said his grandson had brought him when he visited, there was a hand grabber tool laid on top of all of that a crossed the seat of the chair. On 02/11/2026 at ~(approximately)10:00 AM, R5 was not present in his room and observation of R5's room revealed O2 tubing that had no date of initiation identified. The humidification canister was dated 01/09.A record review of R5's orders revealed:Dated 08/04/2025: Order Set O2- Change oxygen tubing monthly. Once A Day on the 1st of the MonthDated 02/06/2026: ipratropium-albuterol solution for nebulization; 0.5 mg-3 mg (2.5 mg base)/3 mL; amt: 1 treatment; inhalation Special Instructions: for SOB Three Times A Day 06:00 AM - 10:00 AM, 11:00 AM - 01:00 PM,06:00 PM - 10:00 PM.Dated 08/04/2025: Mask and tubing should be cleaned weekly with soapy water and rinsed. Air dry and place mask in clean setup bag. Once A Day on Mon 06:00 AM - 02:00 PM.R7:According to a review of R7's medical record, the resident was admitted to the facility on [DATE] for skilled nursing care related to diagnoses of Acute post hemorrhagic anemia (blood loss and low blood count), chronic obstructive pulmonary disease (COPD), chronic respiratory failure, atrial fibulation (AFIB/ irregular heart rhythm), and diabetes mellitis type II (DM). R7's Minimum Data Set (MDS) record revealed a Brief Interview of Mental Status (BIMS) assessment score of 10/15 indicated resident had moderate cognitive impairment.On 02/09/2026 at 10:47 AM, During an observation of R7, she was resting in bed and had on O2 via NC set at 2L, the O2 tubing had a label that said 121 and the humidification canister had no date of initiation identified.On 02/10/2026 at 08:22 AM, During an observation of R7, she was resting in bed and had on O2 via NC set at 2L, the O2 tubing was dated 2/10 at 2 PM and humidification canister had no date.On 02/11/2026 at 09:32 AM, During an observation walk through of R7's room with ICP nurse H R7's humidification canister had no date.A record review of R5's orders revealed: Dated 02/04/2026: Order Set O2- Change oxygen tubing monthly. Once A Day on the 1st of the Month 10:00 PM - 06:00 AMR81:According to a review of 81's medical record, the resident was admitted to the facility on [DATE] for skilled nursing care related to diagnoses of fracture of right acetabulum (hip) with replacement, chronic obstructive pulmonary disease (COPD), chronic obstructive pulmonary disease (COPD), permanent atrial fibulation (AFIB/ irregular heart rhythm), diabetes mellitis type II (DM), congestive heart failure (CHF).diabetes mellitis type II (DM), congestive heart failure (CHF). R81's Minimum Data Set (MDS) record revealed a Brief Interview of Mental Status (BIMS) assessment score of 12/15 indicated moderate cognitive impairment.On 02/09/2026 at ~3:30 PM, During an observation of R81, she was sitting up in her wheelchair in her room visiting with her daughter. R81 was wearing O2 via NC set on 2L, the O2 tubing and humidification canister had no date of initiation identified. R81 said she wore her O2 all the time, she had breathing issues especially when lying down.On 02/11/2026 at 8:15AM, During an observation of R81, she was resting in bed she was wearing O2 via NC set on 3L, the O2 tubing and humidification canister had no date of initiation identified.A record review of R81's orders revealed: Dated 01/06/2026: Order Set O2- Change oxygen tubing monthly. Once A Day on the 1st of the Month 10:00 PM - 06:00 AM According to a record review of the facilities standard operating procedure (SOP) titled 'Administration of Oxygen' revealed in 'details: 14. Date the tubing for the date it was initiated. a) Tubing should be changed monthly and PRN (as needed)'.According to a record review of the facilities standard operating procedure (SOP) titled 'Respiratory equipment' revealed in 'details: 2. Oxygen administration. i)Change oxygen cannula and tubing monthly and as necessary. 3. Medication nebulizers/continuous Aerosol. c)After completion of therapy: i) remove nebulizer container. ii) rinse container with fresh tap water. iii) allow to dry on plain paper towel or gauze. iv) reconnect to administration setup. f) store circuit in plastic bag marked with date and residence name in between uses.'According to a record review of the facilities policy titled 'infection prevention and control program' the purpose statement revealed, The purpose of this policy is to: To establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. Procedure: 2. The campus shall designate a member of the clinical team to monitor the campus IPCP program to perform surveillance to identify, investigate, control, and prevent the spread of infection and reporting for the IPCP. e. Monitors compliance with infection control practices and procedures.

Based on observation, interview and record review, the facility failed to provide timely vision services for one resident (Resident #17) of two residents reviewed for vision services. Findings include: Resident #17 (R17): R17 is [AGE] years old and admitted to the facility on [DATE] with diagnoses that include cataracts, diabetes mellitus and hemiplegia and hemiparesis following cerebral infarction affecting the left side. On [DATE] at 1:07PM, during an interview with R17, observation revealed that R17 was wearing glasses. R17 was asked if her glasses were working properly. R17 stated that these glassed belong to her deceased husband, but she needed to wear something. R17 stated the glasses hurt her eyes and are not comfortable. R17 was asked if she receives vision services at the facility. R17 stated she has asked the facility about seeing vision services and they have not seen her yet. R17 stated she would like to see vision services in the facility to get new glasses. On [DATE] at 8:47AM, an interview with admissions E. Admissions E was asked if residents consent to receiving ancillary services on admission. Admissions 'E stated, yes, they consent to wanting to receive ancillary services on admission. Admissions E was asked if they were responsible for filling out the form for ancillary services or just responsible for seeing if residents want to receive ancillary services. Admissions E stated, no, we don't do that in admissions, we just ask the residents admitting if they want to receive ancillary services, the social work department is responsible for getting the form filled out for Health Drive (Ancillary service provider to the facility). On [DATE] at 8:58AM, record review of the electronic medical record (EMR) revealed a Health Drive consent form for ancillary services is signed and dated [DATE]. On [DATE] at 9:44AM, an interview was conducted with Social Worker (SW) C. SW C was asked what the process is for signing residents on to ancillary services. SW C stated, we (social work) get out and get the consents, we do the resident first meeting and that gives us the information we need to know if the resident needs ancillary services. Then we get the consent signed and get them started. During the quarterly meeting on [DATE], R17 stated she wanted to see vision services and consented to all of the ancillary services. SW C was asked when vision services were last in the facility. SW C stated they were here on [DATE]rd, 2025, they were scheduled for February 3rd, 2026, but had to cancel and they will be back out on February 17th, 2026. R17 will be on the list. SW C stated, that during the initial first meeting, if the residents don't indicate any need for services, then they don't sign up. A lot of residents are here short term, so they don't sign up at all. If the family, resident or physician indicate a need, then we can sign them up and they can start services. We don't have to wait until the quarterly meeting to get them started on services, but that is a good time to follow up. On [DATE] at 9:55AM, record review of the EMR revealed an observation form titled, Trilogy Resident First Meeting Minutes, 3.7.25 dated [DATE], that indicates that R17 consented to being signed on with health drive for ancillary services. On [DATE] at 10:00AM, record review of the EMR revealed a care plan in place that R17 has potential for impaired vision related to cataracts and presence of intraocular lens. Dated [DATE]. On [DATE] at 10:08AM, an interview was conducted with the Nursing Home Administrator (NHA). The NHA was asked if R17 should have been signed up for ancillary services at the time of that meeting on [DATE]. The NHA stated, that would be our normal process, if the resident indicated they wanted services we would sign them up at that time. Review of the policy titled, Resident's First Meeting Guidelines, revealed, 10. Questions should be answered to the best of the team members' ability. The Resident First Meeting is a time to communicate information related to care needs and medical condition and seek input from the resident or representative. If there are specific concerns or complaints that may be too lengthy to properly address, the resident or representative should be directed to the appropriate department head or the Executive Director for resolution to these issues.

Based on observation, interview and record review the facility failed to ensure Infection Prevention and Control standards of practice were followed for 1.) Personal Protection Equipment/PPE use and hand hygiene during wound care for one resident (Resident #7) in Enhanced Barrier Precautions, and 2.) the 300 Hall Medication room had a lack of access to the sink to perform hand washing, including IV supplies for one resident (Resident #14) stored under the soap dispenser. Findings Include: Medication room [ROOM NUMBER] Hall: On 2/10/2026 4:29 PM, during a tour of the 300-hall medication room with Nurse N, 2 large carboard boxes of apple sauce were observed stacked on the counter next to the sink. Both were underneath the soap dispenser. In addition, bags of IV antibiotic supplies for a resident were stacked on top of the applesauce boxes. There was also a large empty medication return bag on the counter. There was no counter space for medication preparation or for the nurses to wash their hands. On 2/10/2026 at 4:45 PM, the 300-hall medication room was reviewed with Unit Manager O. The boxes of applesauce and IV supplies were next to the sink and under the hand soap dispenser. It was observed there was no open counter space or way for a nurse to wash their hands without contaminating the IV supplies, apple sauce boxes or other items in the area. Nurse O stated, It should not be like that; I will take care of it. On 02/09/2026 at 10:04AM, During a walk-through observation of assigned residents' unit, 7 resident doors had enhanced barrier precaution (EBP) signs posted outside and 5 of the 7 rooms that were identified had a shared occupancy. There was no indication as to which resident in the shared rooms had been identified for the enhance barrier precautions. On 02/09/2026 at 10:10AM, During an interview with medication tech M she was asked how staff identified which resident in a shared room was in EBP's, she said it was indicated on the EBP sign. Medication tech M was asked to identify where on the signs the information was located. Medication tech M walked to a room with an EBP sign posted outside and confirmed it was not marked with bed A or bed B. Medication tech M said all the EBP signs were 'supposed to indicated bed A or bed B' to identify the resident confidentially. On 02/09/2026 at 10:42AM, During an interview with medication tech L she was queried on how to identify which resident required EBP's in a shared room and she pointed to an EBP sign on a resident's door, the sign had bed B written in purple marker on it. When she was asked when the signs were marked for identification and she indicated 'this morning' and further said that all the rooms with EBP signs down that hall now had bed A or bed B identified on them. R7: According to a review of R7's medical record, the resident was admitted to the facility on [DATE] for skilled nursing care related to diagnoses of Acute post hemorrhagic anemia (blood loss and low blood count), chronic obstructive pulmonary disease (COPD), chronic respiratory failure, atrial fabulation (AFIB/ irregular heart rhythm), and diabetes mellitis type II (DM). R7's Minimum Data Set (MDS) record revealed a Brief Interview of Mental Status (BIMS) assessment score of 10/15 indicated resident had moderate cognitive impairment. On 02/09/2026 at 10:47 AM, An Observation of R7's door indicated that EBP was in place for bed B, R7 was the resident in bed B. During an interview with R7 she said she had a wound on her leg that was healing well, and she was not worried about that anymore and said that she had a wound on her bottom that was 'new'. When R7 was asked to define how new it was, she confirmed that it was within the past couple of weeks. R7 said it was very sore, and she was concerned since she had an infection in her leg already. R7 said that they change her dressing on her bottom about every 3 days. R7 was agreeable to an observation of the area when her wound care was to be done. On 02/10/2026 at 08:22 AM, Nurse J was queried about R7's sore bottom and the wound care schedule, Nurse J said wound care was done on nights and was scheduled every other day. Record review of R7's orders revealed: Date: 02/04/2026: preventative- apply foam dressing to Coccyx, change every five days. Special instructions change PRN with (when) soiled. Once a day every five days 6:30 PM to 11:00 PM Date: 02/09/2026: Staff to use enhanced barrier precautions, wearing a gown and gloves at minimum during high-contact care activities. On 02/10/2026 at 02:24 PM, Nurse J was asked to check when the last treatment was done for R7's Coccyx dressing, Nurse J said she was not sure she looked at R7's record and said it was due that evening. Nurse J was asked for an observation of R7's wound care on Coccyx since R7 had complained about the area as 'being sore' and R7's order was scheduled and PRN (as needed). Nurse J agreed and gathered the wound care supplies. R7 agreed to the observation and wound care. Nurse J entered R7's room for wound care (no PPE worn), placed the supplies (gauze pads, sterile water bottle, marker and new dressing) on R7's bed tray (R7's water, books and other food items were present on the bed tray) Nurse J did not clean the bed tray nor put a barrier down before placing supplies on it. Nurse J washed her hands and put on gloves. Nurse J opened the foam dressing, placed the foam dressing on top of the opened wrapper then used the marker to date and initial the back of the dressing. Nurse J removed R7's dressing (observation of the old dressing revealed the date 2/8 BK) Nurse J laid the soiled dressing on R7's bed by her legs and continued with wound care. Nurse J wearing the same gloves then grabbed the sterile water bottle opened it then opened and moistened the gauze pads. Nurse J was wiped up and down, side to side (she did not change the gauze or follow a clean to dirty method). R7 indicated the area that was sore and Nurse J continued to use the same gauze and wiped the area again as she visualized the spot R7 referenced as 'sore'. Nurse J threw the piece of gauze away; the soiled dressing remained on the bed. Nurse J wearing her original gloves then grabbed the clean foam wound covering from the bed tray and placed it on R7's Coccyx. Nurse J then grabbed the old dressing off R7's bed and threw it in the trash. Nurse J wearing her original gloves reached over R7 and pulled her blankets up and straightened them. It was observed that Nurse J wore the same gloves throughout wound care with no hand hygiene, she recapped the sterile water, handled the call light, blankets and the bed remote after wound care with soiled gloves. After readjusting R7, Nurse J threw away the rest of the supply wrappers then removed and discarded her gloves. Nurse J said she was going to let the provider know that the area was sore and had some breakdown. During the wound care observation of R7 it was revealed she had a red area of moisture associated skin damage (MASD) about the size of a dime noted on the right coccyx, that matched the area R7 indicated was 'sore'. Nurse J took the sterile water bottle off the bed tray and walked into the hall. When asked what she was going to do with the sterile water she stated, date it and indicated it was good for 'a while after being opened' and walked away. When Nurse J returned she was queried about which resident in R7's room was on EBP, she stated (R7), is for her wounds. Throughout the observation of Nurse J's wound care for R7 there was a lack of barriers used, disposal of soiled supplies, wound hygiene, hand hygiene, and proper PPE for EBP identified resident. On 2/11/2026 ICP meeting at 8:20 AM During an interview, ICP Nurse H was asked how staff and visitors identified which resident in a shared room has EBP and need for additional PPE. ICP Nurse H said the staff looked it up in the residents' chart and said they noted bed A or bed B on the signage, so it was readily identifiable. ICP Nurse H said that was a newer practice for them. ICP Nurse H was queried about wound care for residents in EBP. ICP Nurse H explained that wound care was considered a high contact activity and required PPE for residents in EBP. Areas of concern from the observed wound care was reviewed with ICP Nurse H and she agreed that infection control standards were not followed. On 2/11/2026 at 3:35PM, During an interview wound care Nurse I was asked about wound care, EBP and PPE. Wound care Nurse I said that residents in EBP would require PPE of gown, gloves and potentially a mask for high contact activities. Wound care Nurse I was asked and agreed that a dressing change on the coccyx was a high contact activity. Wound care Nurse I explained that Nurse J came from the hospital setting and was not used to EBP because it was not widely used in the hospital setting. Wound care Nurse I was asked if Nurse J had been educated on EBP and she replied yes, all care staff are given competency on EBP. Wound care Nurse I was asked about the reason for R7's EBP and she said R7 had Methicillin resistant Staphylococcus Aureus (MRSA) in her left lower leg wound. Areas of concern from the observed wound care were reviewed with wound care Nurse I and she agreed that basic standards of wound care were not followed for R7 by Nurse J. Wound care Nurse I said she had verbally re-educated the staff on duty about EBP and presented a list dated 02/11/2026 with ~10 staff names. Wound care Nurse I further explained that she was going to clean the treatment cart and remove the contaminated bottle of sterile water that was used by Nurse J during wound care for R7. A record review of the facilities policy on hand hygiene revealed: Purpose Statement: The purpose of this policy is to: Handwashing is the single most important factor in preventing transmission of infections. Hand hygiene is a general term that applies to either handwashing or the use of an antiseptic hand rub, also known as alcohol based hand rub (ABHR). 1. All health care workers shall utilize hand hygiene frequently and appropriately. 3. Health Care Workers (HCW) shall use hand hygiene at times such as. c. Before/after having direct physical contact with residents. d. After removing gloves, worn per Standard Precautions for direct contact with excretions or secretions, mucous membranes, specimens, resident equipment, grossly soiled linen, etc. A record review of the facilities standard operating procedure on enhanced barrier precautions revealed: Guidance for enhanced barrier precautions (EBP) to decrease risk of becoming colonized and developing infections with multidrug-resistant organism (MDRO) status. EBP does not replace existing guidance regarding the use of Contact precautions for other pathogens . 1. Enhanced Barrier Precautions (EBP) will be in place during high-contact care activities for residents with the following conditions: a. Residents at an increased risk of MDRO acquisition which include i. All Residents with chronic wounds, including but not limited to, pressure ulcers, diabetic foot ulcers, unhealed surgical wounds, and venous stasis ulcers. ii. All Residents with indwelling medical devices 1. Includes but not limited to catheters, central lines, feeding tubes, tracheostomy tubes. A peripheral intravenous line is not considered an indwelling medical device for the purpose of EBP. b. Residents known to be infected or colonized with an MDRO. 2. Personal Protective Equipment (PPE) should be used even if blood and body fluid exposure is not anticipated. a. At minimum, staff shall wear gloves and gowns during high-contact care activities. May include face protection if splashes or sprays are anticipated during care.

Based on interview and record review, the facility failed to ensure comprehensive code status information for one resident (Resident #76,) of four residents reviewed for code status, resulting in a lack of a physician's order for code status for (R76). Findings include: Resident #76 (R76): R76 is [AGE] years old and admitted most recently to the facility on [DATE] with diagnoses that include chronic kidney disease, congestive heart failure, heart disease and dependence on renal dialysis. On 02/10/2026 at 9:11AM, record review of the electronic medical record (EMR) revealed there was no physician order present for code status in the order set. On 02/10/2026 at 3:17PM, an interview was conducted with Social Worker (SW) C. SW C was asked if they are responsible for entering in the orders for code status. SW C stated that the nurses do that and I am responsible for the care plans for code status. On 02/10/2026 at 3:20PM, an interview was conducted with the Director of Nursing (DON). The DON was asked who was responsible for entering the code status orders for residents. The DON stated that the admission nurse does that. They get the signed do not resuscitate (DNR) or full code and enter it in the order set. The DON stated If a resident is a DNR they have to wait for the physician's signature, while waiting for signature the resident would be a full code by default until it is signed. The DON was asked why the code status order was missed for R76. The DON stated, R76 just went to the hospital recently and we had to discontinue all of the orders. But it should have been caught upon admission during the chart review. Review of the policy titled, Guidelines for Advanced Directives, revealed, Procedure: 6. The nursing staff will confirm the desired code status and obtain an order from the physician. Verbal Wishes if witnessed by 2 people will be honored until an order is officially obtained. The DNR form will be completed documenting these desires and scanned into the medical record.

Based on observation, interview and record review the facility failed to develop and implement comprehensive care plans for 1 resident (Resident #107) of 22 residents reviewed, resulting in Resident #107 lacking Care Plans for an indwelling urinary catheter and bowel and bladder incontinence related to diarrhea and constipation, which could lead to the resident lacking necessary care and services. Findings Include: Resident #107: A record review of the Face sheet and Minimum Data Set/MDS assessment indicated Resident #107 was admitted to the facility on [DATE] with diagnoses: Diabetes, history of a stroke, urinary tract infection, bronchitis, sinusitis, GERD, obstructive and reflex uropathy (bladder dysfunction), hydronephrosis (kidney disease), urinary retention, hypertension and hypothyroidism. The MDS assessment dated [DATE] indicated the resident had full cognitive abilities with a Brief Interview for Mental Status/BIMS score of 15/15 and the resident needed some assistance with care. In addition, Section H of the MDS assessment Bladder and Bowel indicated the resident had an indwelling catheter and was frequently incontinent of bowel. On 2/09/2026 at 1:32 PM, Resident #107 was observed sitting in her bed. She said she had been having frequent diarrhea and did not know why. She said she had a history of IBS (irritable bowel syndrome) and she used Imodium (anti-diarrheal medication) at home. She said she was not sure what they give her at the facility. Resident #107 said the diarrhea was irritating a wound on her buttocks and she was uncomfortable. The resident was also observed to have an indwelling catheter. The resident said she had a foley catheter since hospitalization, and stated, I don't know why I have it. They said I had a UTI in the hospital and needed it. During a record review of the progress notes the following was identified: 2/10/2026 at 2:01 PM, a progress note from Nurse Practitioner P, . Chief Complaint: Foley catheter malfunction, stat labs, exchange of foley catheter, assessment of sacral wound. last night nursing was having difficulty with resident's catheter, it was exchanged. 2/10/2026 at 3:49 AM, a nursing progress note, Replaced resident foley cath, resident had no output in foley bag since at least 6 pm. Attempted to flush foley, was unable to flush. 2/3/2026 at 5:53 AM, a nursing progress note, Resident is (complaining of) constipation. A review of the Medication Administration Record/MAR and Treatment Administration Record/TAR for February 2026 identified the following: Staff to use enhance barrier precautions, wearing a gown and gloves at minimum during high-contact care activities, Twice a day, Foley (indwelling catheter), start dated 1/30/2026. Verify last BM (Bowel movement) and initiate BM protocol if no BM in last 72 hours, Twice a day, enter size and date of last BM, start date 1/30/2026. A review of the charting for bowel movements on 6:00 AM- 6:00 PM and 6:00 PM - 6:00 AM indicated the resident had days with no BM and some days with several BMs. A record review of the Care Plans for Resident #107 identified the following: Resident experiences episodes of incontinence r/t (related to) decreased mobility--- start date 1/26/2026. There was no mention of bowel or bladder incontinence and there was no mention the resident had episodes of diarrhea and constipation or an indwelling urinary catheter. There were no additional care plans mentioning bowel or bladder for Resident #107. Nurse Practitioner P was interviewed on 2/11/2026 at 12:41 PM, she said she saw Resident #107 on this day. She said the resident told her she had diarrhea and now her bowel medications were on hold. She received MiraLAX as needed, Maalox as needed and Senna twice a day. She said the Resident #107 had just had a dose of Imodium for diarrhea. During the interview with Nurse Practitioner P on 2/11/2026 at 12:45 PM, she said Resident #107 had a history of urinary retention, which was the reason for the urinary catheter. She said the catheter was replaced because no urine was draining. She said a bladder scan showed 500-600 ml urine in bladder and after the catheter was changed, urine flowed. She said the resident had a history of UTI's and hydronephrosis (when the kidneys swell from incomplete bladder emptying). On 2/11/2025 at 3:30 PM, during an interview with the Director of Nursing/DON related to Resident #107 lacking a Care Plan for Bowel and Bladder Continence/Incontinence, diarrhea, constipation and an indwelling urinary catheter. She said she would look into it. A review of the facility policy titled, Comprehensive Care Plan Guideline, dated revised and effective 5/22/2018 provided, Purpose Statement: To ensure appropriateness of services and communication that will meet the resident's needs, severity/stability of conditions, impairment, disability, or disease.

Based on observation, interview and record review the facility failed to ensure expired supplies were discarded and ensure that medications to be discarded were stored properly, resulting in expired supplies and medications to be discarded being available for use and consumption. Findings include: FACILITY On 01/15/25 at 08:29AM, a review of the 200 Hall medication storage room was conducted and revealed the following expired items: -Four boxes of sterile gloves were observed with expiration dates of 09/27/23 and 12/10/23. One box of sterile gloves was unopened and contained fifty pairs, the remaining three boxes were opened and missing pairs of gloves. -One opsite wound dressing was expired as of 4-2024. -Findings were confirmed with the Director of Nursing (DON). On 01/15/25 at 10:27 AM, a review of the 100 Hall medication storage room was conducted and revealed the following expired items: -Two push button blood collection sets were observed to be expired as of 02/29/2024. -One winged blood collection kit, expired 01-31-2024. -One culture and sensitivity transfer straw kit, expired 12-2023. -One 22g intravenous catheter, expired 12-01-2024. -These findings were verified with Director of Sales A and Registered Nurse (RN) C. On 01/15/25 at 01:00 PM, a review of the 300 Hall medication storage room was conducted and revealed the following expired items.: -12 expired vacutainers for blood draws, expired 12/31/22. -Five normal saline syringes, 10ml, expired 12/08/24 and 12/20/24. -Two non coring needles, expired 9/11/24. -These findings were verified with Licensed Practical Nurse (LPN) B. Review of the policy titled, Medication Storage in the Facility, revised 11/18, revealed: Expiration Dating (Beyond-use dating): F. No expired medications will be administered to a resident. G. All expired medications will be removed from the active supply and destroyed in the facility, regardless of amount remaining. The medication will be destroyed in the usual manner. The policy provided by the facility does not reference the facility procedure for expired supplies. 37666 FACILITY Medication Administration During a medication administration observation with Nurse H on 1/16/2025 at 8:15 AM, she was observed placing medications for Resident #42 in a medication cup and putting the cup in the top drawer of her medication cart. She said the medications were being held because the resident's vital signs were abnormal and were outside the parameters to give the medications. The nurse was asked what she was going to do with the medications being held and she said that if she had other residents' medications to hold, she would also put them in the cup until she was done passing medications and then she would dispose of them. She said if she had a narcotic to hold, she would also place it in the cup and then find another nurse to witness its disposal after she was finished passing medications. The top drawer of the medication cart was not able to be double locked to store narcotics. Nurse H was asked if this process was approved by the facility and she said, Doesn't it make sense?. Nurse H was asked if the process was documented in the facilities policies, and she said she didn't know but was told this was how it was supposed to be done. On 1/16/2025 at 8:50 AM, Nurse H took the medication cup with the held medications out of the top drawer and said she needed to hold some of Resident #40's medications also. The nurse began adding medications for Resident #40 to the cup and then began removing medications from the cup with her bare hands. She said she wasn't sure if she had the right medications, and she placed several on the top of the medication cart as she tried to identify them with her phone. She then picked up the medications and placed some in the cup to be discarded and some in the cup to give to Resident #40. picking them up with bare hands and placing them into the cup to give to the resident. On 1/16/2025 at 10:00 AM, during an interview with Corporate Nurse K, the medication administration observation with Nurse H was reviewed. She said she would speak to the Director of Nursing/DON immediately and re-education on the appropriate process for medication administration and storage/disposal of held medications would be provided to Nurse H. On 1/16/2025 at 3:00 PM, during an interview with the DON, the medication administration observation with Nurse H was reviewed. She said re-education had been provided to the nurse. A review of the facility policy titled, Medication Storage in the Facility, dated revised 11/18 provided, Medications and biological's are stored safely, securely, and properly . The provider pharmacy dispenses medications in containers that meet regulatory requirements .Medications are kept in these containers .

Based on observation, interview and record review, the facility failed to ensure that food preferences were followed for one resident (Resident #271) of three residents reviewed for food preferences, resulting in unhappiness and decreased breakfast consumption. Findings include: Resident #271: On 1/15/25, at 9:06 AM, Resident #271 was sitting in their bed with their breakfast tray on their overbed table. There was a sausage patty on their plate. Resident #271 had consumed everything but the sausage. Resident #271 complained they don't like pork and had told them every day. Resident #271 was asked on a scale of 1 to 10 how upset they were regarding the pork on their plate and Resident #271 stated, 5, I don't like it all. On 1/15/25, at 9:10 AM, a record review of Resident #271's meal ticket on their tray revealed . 1/15/2025 Wednesday Breakfast . Dislikes Pork . On 1/15/25, at 12:30 PM, an observation of meal service in the main corridor was conducted. Kitchen staff R was reading the meal tickets and handing the trays out for delivery. Kitchen staff E was asked if they are ensuring dislikes and preferences are followed and Kitchen Staff E offered, yes, the tickets get triple checked. A record review of the facility provided Resident Dining and Food Preferences Effective Date: 11.29.2016 revealed OVERVIEW The Dining services and Clinical Nutrition Support teams have a continued commitment to ensure our residents have the best dining experience possible. One key way to achieve this is through the gathering of resident preferences and the completion of the Resident Dining and Nutrition Preference (DNP) form . Preferences will be obtained on all resident regardless of level of care .

Based on observation, interview and record review, the facility failed to ensure Infection Prevention and Control standards of practice were followed for 1). Hand Hygiene during medication administration for 2 residents (#'s 40, #42); 2.) Personal Protective Equipment/PPE use for 1 resident (#38) in Transmission Based Precautions; and 3.) storage of resident care items to prevent water splash and contamination from the resident room sink for Resident #22, resulting in the potential for spread of infection, which could cause serious illness. Findings Include: FACILITY Infection Control Resident #22 A record review of the Face sheet and Minimum Data Set/MDS assessment indicated Resident #22 was admitted to the facility on [DATE] with diagnoses: history of a stroke, left sided weakness, difficulty swallowing, feeding tube, history of respiratory failure, anxiety, depression, and neuropathy. The MDS assessment dated [DATE] revealed the resident had full cognitive abilities with a Brief Interview for Mental Status score of 15/15 and she needed assistance with all care. On 1/14/2025 at 9:45 AM, Resident #22 was observed sleeping in bed. She shared a room with another resident and the sink was on her side of the room. The sink countertop was cluttered with open items including a toothbrush (unsure which resident's), an open package with a feeding tube declogger hanging out of the package, many personal items (unsure which resident) and medical supplies for the feeding tube in packages hanging over the sink. There was a graduated cylinder with a small connecting tube with a liquid yellow substance inside it. It was the only sink in the room and there was no way to use the sink to perform hand hygiene without dripping water or encountering a water splash onto the items around the sink. Resident #38 A record review of the Face sheet and MDS assessment indicated Resident #38 was admitted to the facility on [DATE] with diagnoses: Diabetes and heart disease. The MDS assessment dated [DATE] revealed the resident had moderate cognitive loss with a BIMS score of 8/15 and needed assistance with care. On 1/16/2025 at 8:00 AM, Resident #38 was observed to have Droplet Precaution and Contact Precaution signs posted outside her room door. A cart with Personal Protective Equipment/PPE was next to the door. The signs instructed anyone who entered the room to wear a mask and isolation gown with gloves prior to entry. Nurse Aide G was observed in Resident #38's room with a surgical mask worn incorrectly under her chin; it was not covering her nose or mouth. She was not wearing an isolation gown or gloves and was taking the resident's vital signs. When Nurse Aide G exited Resident #38's room, on 1/16/2025 at 8:05 AM, she was asked if Resident #38 was in Transmission-Based Precautions, based on the posted signs and PPE at the door. Nurse Aide G said the resident was not in precautions, that her roommate had been diagnosed with Covid-19 and moved out of the room and the roommate was in precautions. The Nurse Aide was asked about the mask under her chin and she said she wore it just in case she needed it. At 8:06 AM on 1/16/2025, Nurse H was asked if Resident #38 was in Transmission-Based Precautions and she stated, Yes, she is. I have to Covid test her again today. We are ruling out Covid. The Nurse was asked if PPE was required in Resident #38's room and she said it was. Medication Administration Resident #42 A record review of the Face sheet and MDS assessment indicated Resident #42 was admitted to the facility on [DATE] with diagnoses: Dementia, diabetes, heart disease, asthma, anxiety and depression. The MDS assessment dated [DATE] revealed the resident had full cognitive abilities with a BIMS score of 14/15 and needed some assistance with care. On 1/16/2025 at 8:10 AM, during an observation of medication administration with Nurse H, she was observed donning (putting on) gloves to test Resident #42's blood sugar level and removing the gloves and discarding them when she was finished. She did not perform hand hygiene before donning or removing the gloves. During a medication administration observation with Nurse H on 1/16/2025 at 8:15 AM, she was observed placing medications for Resident #42 in a medication cup and putting the cup in the top drawer of her medication cart. She said the medications were being held because the resident's vital signs were abnormal and were outside the parameters to give the medications. The nurse was asked what she was going to do with the medications being held and she said that if she had other residents' medications to hold, she would also put them in the cup until she was done passing medications and then she would dispose of them. She said if she had a narcotic to hold, she would also place it in the cup and then find another nurse to witness its disposal after she was finished passing medications. The top drawer of the medication cart was not able to be double locked to store narcotics. Nurse H was asked if this process was approved by the facility and she said, Doesn't it make sense?. Nurse H was asked if the process was documented in the facilities policies, and she said she didn't know but was told this was how it was supposed to be done. Resident #40 During a record review of the Face sheet and MDS assessment for Resident #40, it indicated he was admitted to the facility on [DATE] with diagnoses: End stage kidney disease, diabetes, dialysis, obesity, Crohn's disease, COPD, history of respiratory failure, and anemia. The MDS assessment dated [DATE] the resident had full cognitive abilities with a BIMS score of 14/15 and needed some assistance with care. On 1/16/2025 at 8:50 AM, Nurse H took the medication cup with the held medications out of the top drawer and said she needed to hold some of Resident #40's medications also. The nurse began adding medications for Resident #40 to the cup and then began removing medications from the cup with her bare hands. She said she wasn't sure if she had the right medications, and she placed several on the top of the medication cart as she tried to identify them with her phone. She then picked up the medications and placed some in the cup to be discarded and some in the cup to give to Resident #40. picking them up with bare hands and placing them into the cup to give to the resident. On 1/16/25 at 11:14 AM, during an interview with the Infection Prevention and Control/IPC Nurse F, she said Resident #38 was in Transmission-Based Precautions and PPE was to be worn in her room. The cluttered sink in Resident #22's room was also reviewed with the IPC and she said she would check on it. On 1/16/2025 at 3:00 PM, during an interview with the DON, the medication administration observation with Nurse H was reviewed, including Nurse H not performing hand hygiene as required and touching the residents' medications with her bare hands. She said re-education had been provided to the nurse. A review of the facility policies identified the following: Infection Prevention and Control Program, dated reviewed 12/17/24 provided, . Purpose: To establish and maintain and infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases . Guideline for Handwashing/Hand Hygiene, review date 12/17/24 provided, . Handwashing is the single most important factor in preventing transmission of infections. Hand hygiene is a general term that applies to either handwashing or the use of an antiseptic hand rub . All health care workers shall utilize hand hygiene frequently and appropriately . Health Care Workers (HCW) shall use hand hygiene at times such as: .Before/after having direct physical contact with residents . after removing gloves . Medication Administration-General Guidelines, revised 11/18 provided, Policy: Medications are administered as prescribed in accordance with good nursing principles and practices . Handwashing and Hand Sanitization: The person administering medications adheres to good hand hygiene- before beginning a medication pass, prior to handling any medication, after coming into direct contact with a resident . Guidelines for Droplet Precautions, review date 12/17/24 provided, . To provide precautions when indicated for resident infected with diseases . Examples of infections requiring Droplet Precautions include but are not limited to: . Confirmed/suspected Covid-19 . Guidelines for Contact Precaution, review date 12/17/24 provided, . To provide guidelines to prevent the spread of infectious disease organisms . Contact Precautions is a method designed to reduce the risk of transmission of microorganisms by direct or indirect methods .

This Citation Pertains to Intake # MI00148568 Based on interview and record review the facility failed to prevent misappropriation of resident property for one resident (#218) of one reviewed for abuse, resulting in Resident #218 missing $448.00 while at the facility. Findings Include: Resident #218 Personal Property A record review of the Face sheet and Minimum Data Set/MDS assessment indicated Resident #218 was admitted to the facility on [DATE] with diagnoses: Crohn's disease, colitis, acute kidney failure, chronic kidney disease, atrial fibrillation, arthritis, neuropathy, hearing loss, history of a mini stroke. The MDS assessment dated [DATE] revealed the resident had full cognitive abilities with a Brief Interview for Mental Status score of 15/15 and the resident needed some assistance with care. On 1/15/2025 at 11:44 AM, a Facility Reported Incident/FRI was reviewed for Resident #218 identifying the following: On 11/18/2024 Resident #218 reported she had $548.00 missing from her purse that was in a locked bedside drawer. The Administrator was notified, and the facility began an investigation. Including calling the local police and interviewing the resident, staff and family. An Admission inventory list titled, Inventory of Personal Items, dated recorded on 10/28/2024 was included in the investigation file and indicated the resident had $440 in $20 bills, 1 $5 bill, 3 $1 bills=$448 dollars, in a wallet in her purse. Nurse Aide L documented on the form On admission reviewed guideline that the Facility cannot assume responsibility for valuables left in my possession (Nurse Aide L). This document was not signed by the resident. On 1/15/2025 at 4:35 PM, the Administrator was interviewed. She reviewed the FRI investigation for Resident #218's missing money. She said the resident was provided a key on a stretchy bracelet for a locked drawer in her bedside dresser. She said the resident said she placed her purse into the locked drawer and did not look into her purse again until 10/18/2025 when she identified the money was missing. The Administrator reviewed there were staff interviews documented in the FRI investigation folder and some of the staff had identified the resident did not always wear the bracelet and it had been seen on the bedside dresser. The resident had also confirmed that the key was on the bedside dresser at times. During the interview with the Administrator on 1/15/2025 at 4:35 PM, the Administrator was asked about the report from the local police as it was not included in the Investigation folder. The Administrator said a female police officer had arrived on 11/19/2025 to investigate. The Administrator said the officer interviewed the resident and did not pursue it further. The Administrator was asked to review the police report and she said there wasn't one because they weren't going to pursue it. Reviewed with the Administrator there would still be a police report identifying the complaint and results of the interview. On 1/15/2025 at 4:35 PM, during the interview with the Administrator she was asked what was done to ensure a similar incident didn't occur again and she said education had been provided to the staff after the incident. Reviewed it was not located in the FRI investigation. The Administrator was asked which staff were educated and what were they educated about related to the missing money. She said she would have to get a copy of the education. The Administrator was asked if she was notified on admission that Resident #218 admitted with a large amount of money. She said she had not been notified. She said the facility had a Trust fund that residents could place their money in and the resident chose not to do that. The Administrator was asked who provided this information to the resident, she said it was in the Admission Packet. On 1/15/2025 at 4:58 PM, the Administrator obtained a police report for the interview with Resident #218. The report was written on 11/19/2024 after Officer M investigated the incident. The facility did not obtain a copy of the police report until asked about it during the survey on 1/15/2025, it had been 2 months since the incident. The investigation report titled Case Report indicated Officer M interviewed Resident #218 at the facility on 11/19/2024 at approximately 3:00 PM. Officer M indicated she spoke with the manager because a patient had reported a theft. The Officer said the manager said it was unclear when the money went missing or how much was missing. The manager told the Officer that the patient's/resident's family had been contacted and reported the resident had not given the money to them. The Officer indicated she was told the resident did not have memory issues. The Officer interviewed Resident #218 who told her she looked in her purse/wallet on 11/18/2024 and her money was missing. She said the purse was in a locked drawer, but there were times it may have been unlocked. The resident said she did not have need for money in the facility and was going to send some home with her son, but when she looked it was gone. The Officer said it was unclear how much money the resident had or when it went missing sometime between 10/28/2024-11/18/2024. On 1/16/2025 at 1:30 PM, the Administrator was asked to see the education provided to the staff related to Resident #218's missing money, she said she forgot, education was not provided to all of the staff but was reviewed with the Interdisciplinary Team/IDT during a Quality/QAPI meeting; no further information was provided related to the facility's plan to prevent other residents from missing money. On 1/16/25 at 2:56 PM, Confidential Person J was interviewed via telephone. The Confidential Person said Resident #218 had taken money to the facility and the resident said they counted it, and the resident said she kept it in a locked drawer, but when she looked on 11/18/2024 it was missing. The Confidential Person J said the resident did not have memory issues and she handled her own money that she kept with her. On 1/16/25 at 4:14 PM, the Director of Nursing/ DON was interviewed about Resident #218's missing money. The DON was asked who completed the Inventory of Personal Items when a resident was admitted to the facility. She said the Nurse Aides completed the inventory list on paper and then they handed it to the nurse who typed it into the electronic medical record. The DON was asked if the Nurse Aides received training related to the Resident's Trust Fund, so they would know the residents didn't have to keep their money in their room. The DON said the Nurse Aides did not have training on this. The DON was asked if she was made aware that Resident #218 had brought a large amount of money into the facility, and it was in her room. She said she was not aware of the money until it was reported missing. The DON was asked if any additional training for staff was provided or measures were enacted to ensure resident belongings including money were kept safe after Resident #218's money disappeared. She said she wasn't sure if anything else had been done. A record review of the facility Admission Packet revealed it was a 38-page document provided to the residents or their representative on admission. The document included information about a Resident Trust Fund on page 14 which provided You may elect to open a resident trust fund with the business office. Please complete an authorization to open a trust with the Business Office manager if you are interested in this option . There was no mention of alternatives for safe storage of valuables, including money. A review of the facility policy titled, Abuse and Neglect Procedural Guidelines, dated updated 12/16/2024 provided, . Misappropriation of Property means the deliberate misplacement, exploitation, or wrongful, temporary, or permanent use of a resident's belongings or money without the resident's consent . Reporting/Response . A written report of the investigation outcome, including resident response and/or condition, final conclusion and actions taken to prevent reoccurrence, will be submitted to the applicable State Agencies .

Based on observation, interview and record review the facility failed to ensure safe and sanitary storage of respiratory equipment for 3 residents (#3, #272, and #273)) and ensure oxygen was provided as ordered for 1 resident (#3) of 3 residents reviewed for respiratory care, resulting in the potential for exposure to infectious organisms for Residents #3, #272 and #273 and inappropriate treatment with potential for adverse reactions for Resident #3. Findings Include: Resident #3 Respiratory Care A record review of the Face sheet and Minimum Data Set/MDS assessment indicated Resident #3 was admitted to the facility on [DATE] with diagnoses: Heart failure, chronic respiratory failure, COPD, diabetes, morbid obesity, and obstructive sleep apnea. The resident had a Brief Interview for Mental status/BIMS score of 15/15, indicating full cognitive abilities. On 1/14/2025 at 10:06 AM, Resident #3 was observed lying in bed awake and talkative. He was wearing a nasal cannula with oxygen delivered from an oxygen concentrator. The oxygen was set at 5 liters a minute. When asked what it was normally set at the resident said it should be set at 5. Resident #3 said he had received oxygen for a while and was also receiving Hospice services. A one-gallon bottle of distilled water was approximately 30% empty and sitting on the floor by the bed. It was not dated when opened. A record review of the physician orders identified an order for oxygen at 4 liters via nasal cannula continuously. On 1/16/2025 at 2:30 PM, Resident #3 was observed in his room with his oxygen set at 5 liters a minutes. The resident said that is what he wanted it at. On 1/16/2025 at 4:15 PM, the Director of Nursing/DON was interviewed about Resident #3's oxygen setting of 5 liters/minute, but the physician order said the resident was to receive oxygen at 4 liters/minute. She said she would check into it. On 1/16/2025 at 4:45 PM, the DON provided a copy of a physician order for oxygen for Resident #3. The oxygen order was changed on 1/16/2025 at 4:41 PM per the following: Order set O2- Oxygen @ 2-6 L (liters) for comfort per nasal cannula continuous. A review of the facility policy titled, Administration of Oxygen, dated reviewed 12/13/24 provided, Guidelines to properly Administering Oxygen and any Respiratory procedure . 1. Verify physician's order for the procedure . Oxygen setting must be set and adjusted by a licensed nurse . 39059 Resident #272 On 1/14/25, at 2:20 PM, Resident #272 was lying in their bed. Their oxygen concentrator was dialed to 2 liters. Their nasal cannula was lying on the bed covers near the foot of the bed. Resident #272 was asked if they take their oxygen on and off and Resident #272, offered, I don't know. On 1/15/25, at 2:30 PM, a record review of Resident #272's electronic medical record revealed an admission on 01/08/2025 with diagnoses that included Influenza, Acute respiratory failure and Hypertension. Resident #272 required assistance with all Activities of Daily Living. A review of the Physician orders revealed Order Set O2-Oxygen @ 2L (liters) per nasal cannula prn saturation under 93% . A review of the care plan revealed no interventions related to the Oxygen/nasal cannula. Resident #273 On 1/14/25, at 11:15 AM, Resident #273 was not in their room. The oxygen concentrator was on and running at 3 liters. The nasal cannula was resting on top of the covers on the bed. On 1/14/25, at 11:30 AM, CNA D entered Resident #273's room and was asked how Resident #273 gets out of bed. CNA D offered, the resident is a Hoyer lift with two staff and is unable to transfer themselves. On 1/15/25, at 2:00 PM, a record review of Resident #273's electronic medical record revealed an admission on 01/06/2025 with diagnoses that included Dementia, Iron deficiency anemia and right leg fracture. Resident #273 required assistance with Activities of Daily Living. A review of the care plan revealed no intervention related to Oxygen/nasal cannula. On 1/16/25, at 8:43 AM, Resident #273 was resting in their wheelchair in their room. Their oxygen was on 3 liters via a nasal cannula. Resident #273 was asked if their oxygen bothers them or if they ever take it off and Resident #273 offered, no, I do not and explained, they might take it down towards their mouth but never takes it off. Resident #273 further explained, the staff always does it when they're helping me in and out of bed. A review of the facility provided Administration of Oxygen Approval Date: 5/2018 revealed . a nursing assistant may place the nasal cannula around the resident's ears and in the nose but should not adjust the setting on the concentrator or other administration device . Remove potentially flammable items, wool or nylon materials or other items that may potentiate static from immediate area where the oxygen is to be administered or stored . The facility failed to ensure oxygen supplies were stored in a safe and sanitary manner for R3, R272 and R273.

This Citation pertains to Intake Numbers MI00142107 and MI00144987. Based on observation, interview, and record review, the facility failed to ensure that residents were treated in a respectful and dignified manner for two residents (Confidential Resident #1 and Confidential Resident #2), who wished to remain as a confidential group of residents, from a facility census of 71 residents, resulting in a fear of accidents occurring due to call lights not being answered timely or call lights being turned off without completing the nursing task required, and residents' verbalizations of feelings of a lack of dignity, belittlement and discontentment. Findings include: CR1 and CR2 wished to remain confidential residents. Confidential Resident #1 (CR1): On 9/19/24 at 9:45 AM, CR1 was interviewed. CR1 revealed that she heard a nurse aide tell a resident: I'm busy, and you have a brief on, then just go and I'll be back. When CR1 was asked what the aide meant, CR1 further explained that since she has a diaper, she can just go. CR1 further stated, It is not verbal abuse but can be a dignity issue. CR1 indicated that the resident's daughter was present when this happened and heard this. They are both here today. Other issues brought up by CR1 were: 1. Lack of basic supplies:- Kleenex, Styrofoam cups, pull-ups One lady four days without her size- had to use a bigger 2. Not enough CNA- for example, during shower day They only have one CNA to do their residents care and all the showers scheduled for the day. Sometimes done late in the day or skipped. 3. The food is terrible. The food is not done, including Brussels sprouts and potatoes. No condiments were available. 4. Trays are passed at about 6:20 PM. Last night, CR1 claimed she ate dinner late at 7 PM because her potato was not ready. She was told to wait until all trays are passed before they can resolve her food issues. 5. During shift change- the outgoing staff would sometimes say, I'm not doing that, I'm not doing this. Passing on the job to the next shift. Confidential Resident #2 (CR2): CR2, on 9/19/24 at noon, was with her daughter in the visiting area and was observed with oxygen per nasal cannula. She was comfortable and was found not in any form of cardio-respiratory distress. CR2 said she pulled up instead of using a diaper preference, but they used the pads at the facility because they don't absorb much. She stated, I always feel bad because I pee a lot, and it gets all the sheets wet, and I did not want to have them change the entire bed sheet. I feel embarrassed. CR2 denied recalling the aide's name, who told her to Go ahead and go there. They come in, turn the call light off, and then say they will get somebody to help them. Then they forget to come back. If the aides don't turn the call light off, sometimes they may not return. Another incident, according to CR2, was just recently. CR2 described that an aide had set her up on the sink and left. CR2 realized she didn't have her oxygen on her. It is always on her, and she felt she should have it at that moment. CR2 decided to get someone and peeked out of the hall. When the staff asked what she needed, she felt dismissed when she was told by staff, It's over there. CR2 stated that she could see the nasal cannula, but she could not get through it because of obstacles while she was in her wheelchair. She could not reach for the O2 tubing and put it on her nose. She felt she was treated without dignity and was disrespected. CR2 said she felt angry and degraded. During an interview with CR2's daughter, on 10/19/24 at 12:20 PM, the daughter described that she was in her mother's room one day when her mother was in bed, and had the call light on to go to the bathroom. When the aide came, the aide told CR2 that she can just go if she had a brief on. The aide further explained that she was busy, and she will be back. CR2's daughter was even more concerned about other aides shutting off the call light and sometimes don't come back. They would just say, I forgot. On 9/19/24 at 1:30 PM, the facility's Call Light Policy and Dignity and Respect Policy was reviewed. The Guidelines for Answering Call Lights specified: . 5. Answer the resident's call light as quickly as possible. 6. Be courteous when answering the resident's call. 7. Ask permission to enter the room. 8. Call the resident by name: Mr. [NAME], how may I help you? 9. Provide privacy as needed by pulling the blinds, privacy curtains. 10. Provide the service the resident requested and turn off the call light. 11. If the service is unable to be provided do not turn off the call light until the appropriate staff is available to assist. 12. After the requested service has been provided ask Is there anything else I may do for you? 13. If nothing else is needed, return the call light to within reach of the resident. This policy was reviewed by the facility date: 12/31/23. The Resident Rights Guidelines specified: PURPOSE To ensure resident rights are respected and protected and provide an environment in which they can be exercised. PROCEDURES Procedure: 1. Residents shall not leave their individual personalities or basic human rights behind when they move to a health campus. The following is a list of rights recognized by staff at Trilogy Health Services: 2. Our residents have a right to . a. Be treated with dignity and respect b. Be given the information necessary to participate in decisions which affect them both individually and corporately. c. Have their records containing personal and financial information kept confidential. d. Privacy e. Freedom to talk with staff and express concerns/grievances without fear of reprisal f. Be treated fairly, courteously and with respect by all staff . This policy was reviewed by the facility on 12/31/23.

Based on observation, interview and record review, the facility failed to implement and operationalize procedures for pressure ulcer (wounds caused by pressure) assessment, documentation, and management for one resident (Resident #272) of one resident reviewed, resulting in a lack of accurate and timely assessments, lack of implementation of meaningful interventions, and Resident #272 developing two unstageable (full thickness tissue loss with unknown depth) pressure ulcers and a Stage two (partial thickness loss of tissue presenting as a shallow open ulcer with a red pink wound bed, without slough) pressure ulcer, unnecessary pain, the likelihood for additional wound development/progression, and decline in overall health status. Findings include: Resident #272: An observation of Resident #272 was completed on 1/8/24 at 11:59 AM. Resident #272 was sitting in a wheelchair in their room with Family Members Witness A and Witness B. An interview was completed at this time. Resident #272 was noted to be pleasant, hard of hearing, and did not consistently respond to questions when asked. When queried regarding the reason they were admitted to the facility, Witness A revealed the Resident fell at home and went to the hospital where they were diagnosed with a small stroke which affected their left side, a UTI (Urinary Tract Infection), and problems with their coumadin (blood thinner medication). When queried how long they had been sitting up in the wheelchair, Resident #272 revealed staff got them up at 7:00 (AM). Resident #272 stated they ate in the dining room and had been up since. Family Member Witness A and Witness B both disclosed Resident #272 was sitting in their wheelchair when they arrived at the facility at 9:30 AM. The Resident's Left Upper Extremity (LUE) including their arm and hand were visibly edematous and a Hoyer (mechanical lift) sling was in place under them in the wheelchair. When queried, Resident #272 and Family Witness A and B revealed the Resident was unable to move themselves without assistance and had to be transferred using a mechanical lift. When asked if they had any pressure ulcers and/or wounds on their skin, Family Witness A stated, (Resident #272) does have something on their butt. It hurts them a lot. When asked if they had a wound or sore on their bottom, Resident #272 confirmed they did. Resident #272 was then asked if the sore hurt and replied, Yes. Resident #272 also verbalized complaints of discomfort in their legs and Witness B proceeded to complete assisted passive Range of Motion (ROM) to the Resident's lower legs. When queried if facility staff had assisted them to reposition in their wheelchair since they have been sitting up, Resident #272 disclosed they had not. Witness A and Witness B added that Resident #272 had not been repositioned since they had been at the facility. Record review revealed Resident #272 was admitted to the facility on [DATE]. Review of the Electronic Medical Record revealed no documentation of medical diagnoses. Review of Resident #272's Admission Observation and Data Collection Assessment documentation, dated 1/5/24 at 4:42 PM, revealed the Resident was orientated to person and place only, required assistance to complete Activities of Daily Living (ADL), was incontinent of bowel, had an indwelling urinary catheter, and required a mechanical lift for transferring. Further review of Resident #272's Admission Observation and Data Collection Assessment detailed the following, Skin Color: Normal . Temperature: Warm . Turgor: Normal . Skin Impairment: Skin events available; Bruise, Burn, Incision, Pressure-Stasis Diabetic, wound, Rash/Lesion, Skin Tear/Laceration: Yes, complete appropriate Wound Event for further assessment . Braden Scale for pressure ulcer predictability . Sensory Perception: 4. No Impairment . Moisture: 4. Rarely Moist . Activity: 1. Bedfast . Mobility: Completely Immobile . Nutrition: 2. Probably Inadequate . Friction and Shear: 2. Potential Problem . Score: 14 . low to moderate (pressure ulcer) risk . A Baseline Care Plan Goal- Resident will have intact skin or improving skin integrity was included in the Admission Assessment. The baseline care plan included the interventions, Turn and reposition for comfort with care and Monitor fluid and nutrition intake. Resident #272 did not have a comprehensive care plan in place related to pressure ulcers and/or skin integrity. Further review of Resident #272's Electronic Medical Record (EMR) revealed no Wound Event documentation related to a pressure ulcer as indicated in the Admission Observation and Data Collection. Review of progress note documentation in Resident #272's EMR revealed one note related to skin. The note, dated 1/5/24 at 7:10 PM, detailed, Skin Assessment: Resident has several bruising to bilateral upper extremities, chest, back of both hands, left shoulder, right shoulder, both antecubital area, left side of head, left side chin/neck, abrasion below left eye, bruise to right upper thigh and right knee, back of left knee, lateral right calf bruise and large bruise to buttock/coccyx and right hip. Both forearms are edematous and back of both hands have swelling . At 8:00 AM on 1/9/24, Resident #272 was observed in the restorative area in the main dining room of the facility. The Resident was sitting in their wheelchair with a Hoyer sling in place under them. Certified Nursing Assistant (CNA) G was assisting the Resident to eat. When queried how long they had been sitting up in their chair, Resident #272 revealed staff got them up around 7:00 AM for breakfast. A review of Resident #272's Health Care Provider orders, Medication Administration Record (MAR), and Treatment Administration Record (TAR) revealed no wound care orders and/or treatments. On 1/9/24 at 9:10 AM, Resident #272 was heard yelling out for help from the hallway. From the doorway of the room, Resident #272 was observed sitting in a stationary chair in their room. The Resident was fidgeting in the chair while yelling, Help, Help and Hello, Hello repeatedly and appeared uncomfortable. There were no staff were observed in the hallway. At 9:22 AM, Visitor Witness K arrived at the facility and entered Resident #272's room. This Surveyor entered the room at this time. A pressure reduction cushion was not observed in the stationary chair where Resident #272 was sitting. At 9:38 AM on 1/9/24, Certified Nursing Assistant (CNA) G entered Resident #272's room. An interview was completed at this time. CNA G was asked about Resident #272's skin integrity and revealed they did not know as they had not gotten the Resident out of bed. When asked about Resident #272's ADL care, CNA G revealed the Resident was dependent upon staff for all care, were unable to reposition themselves, and required a Hoyer lift for transferring. When queried if Resident #272 had a pressure reduction cushion in place on the stationary chair, CNA G replied, No. When asked if Resident #272 was at risk for pressure ulcer development, CNA G indicated they were. CNA G was then queried why the Resident did not have a pressure reduction cushion in place and was unable to provide an explanation. When asked, CNA G revealed the facility does have pressure reduction cushions for use on stationary chairs. When queried regarding the last time Resident #272 had been repositioned, CNA G indicated they the Resident was repositioned when they were transferred to the stationary chair from their wheelchair following breakfast. On 1/9/24 at 10:38 AM, an interview was conducted with CNA G. CNA G revealed they had observed Resident #272's skin and stated, Their coccyx area is opened up. It's still red and bruised. On 1/9/24 at 10:56 AM, Resident #272's call light was noted to be on, and the Resident could be heard from the hallway of the facility yelling out, Help, Help and Hello, Hello repeatedly. Multiple facility staff were observed walking past Resident #272's room without addressing and/or assisting the Resident. At 11:03 AM, a staff member was observed entering Resident #272's room and the Resident was heard saying they had a bowel movement from the hallway. The staff member proceeded to exit the room. A skin and peri-care observation for Resident #272 was completed on 11:16 AM on 1/9/24 with CNA G, Physical Therapist I, and Occupational Therapist J. Resident #272 was in bed, positioned on their back. Scattered bruises in various stages of healing were noted on their neck, chest, arms, legs, hips. Resident #272 had been incontinent of stool and CNA G CNA G prepared supplies to provide care. The Resident was turned on their side by the three staff present and incontinence care was provided. A white colored cream was present on the Resident's buttocks and coccyx area which was removed with incontinence care. A dark, deep purple colored and irregularly shaped area Deep Tissue Injury (DTI) unstageable pressure ulcer was observed on the Resident's right buttock/coccyx. The skin surrounding the wound bed was observed to be reddened. A separate dark purple/red unstageable pressure ulcer with a circular shape was present on the Resident's coccyx. This area extended towards the left buttocks where an open pressure ulcer/wound was present with exposed tissue and a scant amount of visible drainage. The open area was irregularly shaped and slightly larger than a quarter. CNA G was queried regarding the white colored cream and revealed Wound Care Registered Nurse (RN) D had assessed the Resident earlier in the day and applied the cream. When queried, Resident #272 revealed their bottom was painful. A clean brief was placed on the Resident, but a treatment was not applied. Review of Resident #272's EMR revealed the following assessment documentation dated 1/9/24: - Wound Management Detail Report . Pressure Ulcer . Right Buttocks . Date/Time Identified: 1/9/24 10:24 AM . Length: 3.5 (centimeters [cm]) . Width: 2 (cm) . Stage: Unstageable - Deep Tissue . Comments: Area noted upon admission and displays as intact purple discoloration, resident educated on the importance of repositioning, and floating heels to offload pressure . - Wound Management Detail Report . Unspecified Ulcer . Coccyx . Date/Time Identified: 1/9/24 10:39 AM . Length: 6 (cm) . Width: 5.5 (cm) . Tissue Type: Epithelial Tissue . Percent of wound covered by epithelialization tissue: 10 . Area noted upon admission, displays as 90% intact purple discoloration and 10% epithelial tissue noted near coccyx area extending into L buttock . An interview was conducted MDS RN C on 1/10/24 at 9:04 AM. When queried regarding Resident #272, MDS RN C revealed they had not started the Resident's electronic MDS. Resident #272's Admission Assessment documentation was reviewed with RN C at this time. RN C was asked where Wound Event follow up documentation for skin impairment was located as indicated in Resident #272's Admission Assessment documentation. After reviewing Resident #272's EMR, RN C stated there was No wound event documentation completed. When asked why wound event documentation was not completed, RN C was unable to provide an explanation. When queried if Resident #272 had a pressure ulcer when they were admitted to the facility, RN C revealed there was no documentation of indicating the Resident had a pressure ulcer when they were admitted . An interview was conducted with Wound Care RN D on 1/10/24 at 9:14 AM. When queried if Resident #272 had pressure ulcers, RN D confirmed they did. When asked if the pressure ulcers were facility acquired, RN D indicated the wounds were present when the Resident was admitted . RN D was then asked where documentation of a pressure ulcer upon admission was located and replied, They (nursing staff) documented as bruising with no open area. RN D was asked where documentation of bruising was completed and replied that the event documentation for bruising was deleted. RN D then stated the admission nurses skin note indicated the Resident had bruising. When queried if bruising was the same thing as an unstageable DTI pressure ulcer and/or an open wound, RN D replied they were not. When asked how they were able to discern the bruising documented in the note on 1/5/24 was the same area as the DTI pressure ulcers, RN D revealed they could not confirm it was the same. When queried regarding facility policy/procedure for Residents admitted with a pressure ulcer and/or wound, RN D revealed facility nursing staff open a Wound Event for a pressure ulcer but do not stage and/or measure pressure ulcers. When asked, RN D elaborated that staff identify pressure ulcers, initiate treatments/interventions, and notify them (wound care nurse) for evaluation and staging. RN D was asked about wound measurements and revealed they measure wounds weekly. When queried if the facility takes pictures of Resident wounds/bruising, RN D stated, No. RN D was then asked how they knew Resident #272's DTI pressure ulcers were not facility acquired when there was no detailed wound assessment documentation upon admission and no wound images, RN D verbalized understanding. When queried regarding one wound type not being identified in the wound assessment evaluation completed on 1/9/24, RN D revealed both wounds were pressure ulcers. When queried if the open pressure ulcer was a stage two, RN D revealed they did not specify the wound stage in the assessment because the area may be one large DTI pressure ulcer. When asked if the pressure ulcer opened while at the facility, RN D replied, Yes. When queried if Resident #272 was at a high risk for pressure ulcer development, RN D indicated they were. A review of the Braden Score assessment for pressure ulcer risk completed as part of Resident #272's admission assessment was conducted with RN D at this time. When queried if Resident #272's sensory perception being documented as No Impairment when the Resident was unable to turn and reposition themselves was accurate, RN D revealed they would have assessed the Resident as Slightly Limited. RN D was then asked if Rarely Moist was accurate, considering Resident #272's mobility and incontinence, and indicated Occasionally Moist would be more accurate. When queried regarding Friction and Shear, RN D relayed they would have selected Problem due to the Resident requiring a Hoyer lift for transfers. A calculation of the Braden Score with RN D's responses revealed a score of 11 which categorized the Resident as High to Very High-Pressure Ulcer Risk and directed staff to implement specific interventions as part of the baseline care plan. When queried regarding the discrepancies and accuracy of the Resident's pressure ulcer risk, RN D confirmed the discrepancies and revealed staff would be educated regarding Braden scale completion. When queried what interventions were implemented when Resident #272 was admitted for pressure prevention, RN D replied, All mattresses are pressure reduction and preventative ointment following incontinence was in place. RN D was asked about the preventive ointment and revealed it is a standard protective ointment applied by CNA staff for any resident who is incontinent. When queried why the ointment was not applied during observation of incontinence care, RN D did not provide an explanation. With further inquiry, RN D revealed no specific pressure reduction interventions were in implemented at the time of admission. When asked if the first time they assessed the Resident's pressure ulcers was four days after they were admitted on [DATE], RN D confirmed it was. RN D was queried why they did not assess Resident #272's skin/wounds sooner, RN D revealed they identified documentation of bruising during record review of Resident #272's admission and assessed the Resident's skin due to the location of the bruising. When queried regarding the frequency in which Resident #272 should be turned and repositioned, RN D revealed they should be repositioned every two hours. RN D was informed of observations and interviews of the Resident not being turned and repositioned. When queried why Resident #272 was not turned and repositioned every two hours, RN D did not provide an explanation. When asked if a pressure ulcer can develop in four days, RN D confirmed they can. RN D was then asked to provide documentation demonstrating Resident #272's pressure ulcers were present upon admission to the facility and revealed they were unable to provide documentation. When queried if the pressure ulcers would be considered facility acquired, RN D did not provide a response. Review of Resident #272's hospital Integumentary Assessment documentation dated 1/4/24 revealed the Resident was at high risk for pressure ulcer development (Braden Score 15), had pressure prevention interventions in place, and did not have a pressure ulcer. Review of hospital discharge medications and treatments, dated 1/5/24, revealed no pressure ulcer wound care orders/treatments. An interview was completed with the Director of Nursing (DON) on 1/10/24 at 2:38 PM. When queried regarding Resident #272's pressure ulcers and lack of detailed documentation of the Resident's skin upon admission to the facility, the DON stated, Could have been a bad choice of words or could have been a bruise. When queried regarding lack of implementation of meaningful interventions based upon the Resident's risk and accuracy of Braden scale assessment completion, the DON indicated they had been informed of the concern and would work to educate staff. When queried regarding lack of turning and repositioning and pressure reduction devices, the DON verbalized understanding but did not provide further explanation. A facility policy/procedure related to Pressure Ulcer Prevention and Care was requested on 1/8/24 at 3:56 PM but not received by the conclusion of the survey.

This Citation pertains to Intake Numbers MI00138100 and MI00137191. Based on observation, interview and record review, the facility failed to 1.) Prevent an unauthorized exit for Resident #222, 2.) Follow a care-planned transfer status for Resident #1, and 3.) Follow standards of practice with a removal of a sling underneath Resident #5 for three residents (Resident #1, Resident #5 and Resident #222) of six residents reviewed for accidents, supervision and falls, resulting in Resident #222 exiting the building without supervision with the potential for injury and bodily harm; Resident #1 sustaining a fracture, surgery and pain to the left lower leg, and decreased mobility; and Resident #5 with a fracture to the left thigh, pain and decreased mobility. Findings include: Resident #1: A review of Resident #1's medical record revealed an admission into the facility on [DATE] and readmission on 11/21/23 with diagnoses that included chronic obstructive pulmonary disease, kidney disease, heart failure, diabetes, obstructive sleep apnea, anxiety disorder, difficulty in walking, lateral subluxation of left patella, fracture of lower end of left femur, and periprosthetic fracture around internal prosthetic left knee joint. A review of the Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview of Mental Status (BIMS) score of 11/15 that indicated moderately impaired cognition and the Resident was dependent on staff for mobility and lower body dressing. On 1/8/24 at 11:31 AM, an observation was made of Resident #1 in her room sitting in their wheelchair. The Resident was observed to have a leg brace on her left leg. The Resident was interviewed, answered questions and engaged in conversation. The Resident was queried regarding having any falls at the facility. The Resident indicated she had a fall a couple months ago and stated, I broke the femur bone, had to redo the knee. I told them I felt I was going to fall, she (Certified Resident Care Associate) said no, you are not going to fall. I went down and my knee popped. When asked if the staff were using a gait belt, the Resident indicated they were not using a gait belt and stated, She was not holding onto me. The Resident indicated that before the fall, she was going anywhere, reported going out for outings and things, and voiced frustration of decreased mobility and stated, now I am stuck right here all the time. A review of Resident #1's progress notes revealed the Resident had a fall on 11/8/23 and on 11/13/23 with the following progress notes that revealed: -11/8/23 at 11:03 PM, Resident was toileting with CRCA (Certified Resident Care Associate aka (also known as) Certified Nursing Assistant (CNA)) at her side. Writer heard resident cry out, writer entered bathroom and observed resident sitting on the bathroom floor in front of the toilet bowl, holding on to the toilet roll dispenser. Writer laid resident head down on a pillow for comfort until other staff arrived to assist in getting resident off the floor. CRCA stated the resident was standing and beginning to pivot to sit on toilet, suddenly her legs must have buckled and she was assisted to a sitting position on the floor. Writer noted a bruised bump on right knee, possibly from bumping her knee on the toilet roll dispenser as she was falling to a sitting position. Monitor bump QS (every shift) x (times) 3 days for any changes. Writer noted w/c (wheelchair) was in locked position right behind resident, resident was wearing non skid footwear. Resident is upset but easily calmed, stating, It scared me I don't know why it happened . -11/10/23 at 10:06 AM, IDT (interdisciplinary team) fall review: Resident is being reviewed for fall event on 11/8. Resident was transferring from w/c to the toilet, knees buckled and resident was lowered to the floor with assistance. Small abrasion to right knee noted which is now resolved. No further injury noted. Resident denies pain and continues to move around in w/c with no issues. The goal is to prevent injury. New intervention implemented is to increase assistance with transfers from a 1 PA (physical assist) to 2PA (two-person physical assist) and refer resident to therapy for further evaluation. Increase assistance noted during transfer and ambulation. New referral in place. PD and plan of care updated. Will continue with current interventions in place . -11/13/23 at 10:43 PM, 10 pm resident was being transferred from w/c to bed by CRCA. Resident stood up and began to pivot, legs buckled, resident was lowered to floor with assistance. Left foot was observed against the bedside furniture. Resident c/o (complains of) pain to left ankle. (On call provider group) was notified, writer spoke with (Name) NP (nurse practitioner), N.O. (new orders) X-ray to left ankle 2 view; keep resident in bed until results and further orders . -11/14/23 at 12:49 PM, Resident x ray results . Left knee 1/2 views: Acute periprosthetic fracture of the distal femur . Resident notified of x-ray result. ACE wrap and ice applied to left knee. Tramadol and Tylenol given for pain . sending resident to ER (emergency room ) . -11/21/23 at 10:21 PM, Resident returned from hospital following left femur fracture and left knee replacement surgery with brace to left leg . On 1/9/24 at 11:45 AM, an interview was conducted with the Director of Nursing (DON) and Clinical Support (CS) F regarding Resident #1's fall on 11/8 and 11/13. The DON indicated the fall on 11/8 was in the bathroom when the Residents knees buckled and the Resident was lowered to the floor. When asked about the Resident's transfer assistance at that time the DON indicated the Resident was a one person assist and after the fall on 11/8, the transfer intervention was changed to two-person assist. When asked about gait belt use the DON indicated the staff had the gait belt on the resident. When asked about hands on when using the gait belt, the DON and CS indicated that with a two person assist, both staff were to have hands on the Resident when transferring when the Resident was a 2 person assist with transfers. The CS indicated that when the fall occurred on 11/13, there was only one staff with hands on during the transfer and indicated that was the opportunity that we identified for doing education with the staff and audits of Residents' transfer status'. The CS reported the staff actually transferring the Resident was not aware that the Resident's transfer status changed after the previous fall on 11/8. The CS reported that it had been changed on the care plan, but the staff had not looked at it. On 1/9/24 at 6:05 PM, an interview was conducted with CRCA L regarding Resident #1's fall on 11/13/23. The CRCA indicated she was assigned care of the Resident that day and had been assigned the hall before. The CRCA indicated she was not made aware of a change in Resident transfer status at shift report and had not had time to review care plans for changes. The CRCA reported not being aware that the Resident had been made a two-person assist. The CRCA indicated that another CRCA was outside the room nearby but was not in the room to assist with the transfer of Resident #1 when she had fallen. The CRCA indicated she had a hold of the gait belt and lowered the Resident to the floor after the Resident's knees buckled. When queried regarding communication of changes with Resident status, the CRCA reported that care plans were to be checked but indicated that when they come in on the nightshift, they have dinner trays to pass and the time needed to review care plans was not available at the beginning of the shift. The CRCA indicated that she did not remember getting an update on transfer status for Resident #1 with report from the exiting shift CRCA. On 1/10/24 at 8:52 AM, an interview was conducted with CRCA O regarding Resident #1's fall on 11/13/23. The CRCA indicated she was not in the room when the fall occurred but was nearby the room. The CRCA indicated they were not aware that the transfer status for Resident #1 had changed to a two-person assist. The CRCA was asked about care plan review and reported we don't get time to look at the care plan upon start of the night shift, by the time we have time, it is time to chart and there was no time for charting until 10:00 PM. An interview was conducted with Confidential Staff Q when queried regarding CRCA allocated time to review care plan updates or changes, the Confidential Staff indicated that CRCA's, when coming onto shift at 6 PM, there was not time to review care plans and CRCA's don't always get updates on changes in report. The Confidential Staff indicated that upon coming into shift the CRCA's pass dinner trays immediately with no time to get to read the care plan and that care plans were not always updated with changes at the time the changes are made. Resident #5: A review of Resident #5's medical record revealed an admission into the facility on [DATE] with re-admission on 7/2/23 with diagnoses that included muscular dystrophy, depression, paraplegia, falls, contractures of bilateral knees, muscle wasting and atrophy, muscle weakness and fracture of lower end of left femur. A review of the MDS revealed a BIMS score of 15/15 that indicated intact cognition and the Resident dependent on staff for mobility such as roll left to right, sit to lying, lying to sitting, for transfers, bathing and dressing activities. On 1/7/24 at 11:03 AM, an observation was made of Resident #5 sitting up in his electric wheelchair. The Resident was dressed and well groomed. The Resident was interviewed, answered questions and engaged in conversation. The Resident was asked about any accidents that occurred in the last year. The Resident reported that he sustained a fracture in his left lower thigh area when staff were repositioning him in the bed and stated, They were trying to position me in bed, raised the head of the bed and two or three heave-ho, on one heave-ho, my leg felt like it snapped in two, my one heel dug into the mattress, they didn't do it in sequence, my leg popped loud. The Resident indicated he had x-rays done but did not get further testing done, had gone to the hospital, was in a lot of pain, and had to wear a black and blue Velcro cast on his leg. A review of Resident #5's progress notes in the electronic medical record revealed the following: -7/1/23 at 5:46 PM, CRCA's transferred resident into bed with mechanical lift. Per CRCA, resident asked them to lean him forward to get sling out from under him. Resident states he felt his knee pop and now it is painful. No redness or edema noted, no dislocation noted. Resident received PRN (as needed) Norco at 1707 (5:07 PM). (Provider service) notified and received order for left knee X-ray. -7/1/23 at 6:01 PM, Writer into see resident d/t (due to) increased pain to left knee. Resident does have Muscular Dystrophy and contractures to his bilateral knees. When asked what happened, he said after he was assisted to bed with x 2 assist CAN he was assisted to sit up to remove sling for positioning, he said he felt a pop in his left knee, and it was sore after. He rated pain 5/10 and his floor nurse in room for this conversation and obtained x-ray orders from Theoria. -7/2/23 at 9:15 AM, X-ray results: Cannot definitively exclude fracture of the distal femur. CT (computerized tomography) recommended. (On call provider service) notified and received orders to keep on bed rest until rounding provider can assess tomorrow. Resident notified and resident requesting to be transferred to ER . Resident c/o pain 8/10 to left knee, no redness or edema noted, PRN Norco administered at 0800 (8:00 AM). -7/2/23 at 3:07 PM, Resident returned from (Hospital) ED (emergency department). X-ray results: Examination is limited due to patient's body hiatus. Fracture of the distal left femur involving proximal aspect of the medial condyle, recommend further assessment with CT exam. Small to moderate suprapatellar joint effusion. Orders for follow up with ortho. Resident returned to facility with soft immobilizer to LLE (Left lower extremity), states pain is 7/10 at this time. (On call provider) notified. Received orders to leave resident on bed rest with immobilizer in place until rounding and therapy can assess tomorrow, increase Norco to 7.5/325 mg q(every) 4 h (hours) PRN. On 1/9/24 at 11:11 AM, an interview was conducted with the DON regarding Resident #5's fracture to the left femur that occurred when care provided during transferring Resident #5 on 7/1/23. The DON indicated that during a transfer with the mechanical lift to bed, the CRCA's had removed the sling from the Resident. The Resident requested to lean forward and take it out in the back of him and heard a pop to the left knee when leaning forward. The DON reported that the CRCA's were trying to make the Resident happy and followed his request on getting the sling out, but that they normally turn a Resident from side to side to remove the sling. The DON indicated the proper way was to remove the sling when turning the resident side to side and stated, despite Resident request always follow procedures. A review of the care plan did not reveal interventions or changes after the incident on 7/1/23. The DON indicated there was no update to the care plan at that time but reported the staff were educated and return demonstrations with mechanical lift transfers were done and the Resident was educated. 37668 Resident #222: Review of intake documentation dated as received on 5/9/23 revealed, On Sunday May 7th while visiting (different Resident) I overheard the staff bringing in a resident that had gotten into the parking lot. They discussed they won't report this, they cover up everything here. I don't know who they are. The patient seemed confused and ill . I just felt someone should know . another family member told me these things happen all the time . Please make sure (Resident #222) is ok. The intake further revealed a second complaint was received on 5/10/23 and attached to the original intake which detailed, We don't have adequate staff, so a resident got out of the building. Record review revealed Resident #222 was admitted to the facility on [DATE] with diagnoses which included atrial fibrillation (irregular heart rhythm), tobacco use, alcohol abuse, alcoholic fatty liver, altered mental status, and weakness. Review of the MDS assessment dated [DATE] revealed the Resident was moderately cognitively impaired and required supervision/touching to partial/moderate assistance with mobility. Resident #222 was discharged home with home health care on 5/12/23 and passed away on 12/12/23. Review of progress note documentation in Resident #222's Electronic Medical Record (EMR) revealed the following: - 5/7/23 at 3:38 PM Health Care Provider Note: Exit Seeking Event . Nurse advised (Resident #222) was observed outside the facility sitting on the curb this afternoon. The resident was escorted back to room. No reported injury. Staff will continue to monitor . Care team notified. - 5/7/23 at 4:18 PM Nurses' Note: IDT: Approx 3:05 PM informed by (Assisted Living Facility) RCA (Resident Care Aide) of this resident returned to room after being witnessed and assisted indoors from grassy area in center median of AL (Assisted Living) parking lot. Physical examination determines no apparent injury, resident denies discomfort, no skin impairments noted. Gait strong and even, ROM x 4. Resident observed ambulating within room and unit without assistive device. Resident states they 'decided to go for a walk because it was such a nice day' and that they intended to 'sit on a bench' but instead 'sat onto curb' and was 'looking for 4 leaf clovers.' Resident with BIMS (Brief Interview Mental Status Score) 9 (moderately cognitively impaired). Resident denies falling while outside, RCA reporting observing resident laying on ground then sitting up on curb. Neuro checks initiated and WNL, vital signs WNL and on-going. Safety discussed with resident and invited to explore facility courtyard areas, locations explained. Wander guard use explained and resident/son agreeable to placement . 15 min visual checks initiated x 24 hrs. ED (Executive Director) informed. - 5/7/23 at 4:45 PM Nurses' Note: Resident observed ambulating in 100-hallway with 2 CNA's (Certified Nursing Assistants) toward room at 3 PM. CNA's reported they were told resident was outside of building in the north parking lot. They went outside and observed resident sitting on the curb next to sidewalk. Aides assisted resident to standing and brought inside. Resident was observed at 2 PM by 100 hall aide. 100 hall nurse and aide were assisting other residents at the time. Resident was assessed by nurse. Resident had no skin issues or c/o (complain of) pain. Resident calm and cooperative. Stated went outside to see how nice it was and decided to sit down on the curb then was unable to stand . Wander guard placed on left ankle. Resident was agreeable to wander guard and was educated about letting staff know when would like to go outside. Son informed and agreed to wander guard. (Provider) notified as well as weekend supervisor. Resident has been calm and cooperative since event, ate snack and talked to (family) on phone in room. Resting quietly in bed at this time. 15-minute checks continue. - 5/8/23 at 1:17 PM and Edited 5/9/23 at 12:25 PM: The resident did not exit seek . planned to go outside for a walk and enjoy the sunshine. (Resident) stated lives alone at home and goes out when likes. She has had no actions noted or spoken word that wants to exit and leave the facility. (Resident) had agreed to have a bracelet (wander guard) applied that would alarm upon going for a walk as a reminder to sign self out . agreed. (Resident) is deciding if would like to keep this reminder . had reeducation provided by ED this date about letting us know when going out . agreed. Review of Assessment/Evaluation documentation in Resident #222's EMR revealed no documentation of wander/elopement assessment completion prior to or following the unauthorized facility exit on 5/7/23. Review of Resident #222's Admission Observation and Data Collection assessment dated [DATE] at 4:03 PM detailed the Resident was at moderate risk for falls, used a wheelchair for mobility, and required assistance for transfers and ADL care completion. The assessment further included a section titled, Exit/Elopement Review which indicated the Resident was not a risk for exit/elopement. Review of Resident #222's care plans revealed a care entitled, Profile Care Guide (Start: 4/26/23; Revised: 5/10/23). The care plan included the interventions: - Safety: Encourage and assist (Resident #222) with transfers. Offer to take resident outside when it's nice. - Transfers and ambulation: Independent with 2ww (wheeled walker). Remind resident to use walker if does not have it . Another care plan entitled, Falls: Resident is a risk for falling R/T (related to): decreased mobility weakness, malnutrition, non-compliant with transfer status i.e. does not use walker at times was initiated on 5/3/23 and revised: 5/10/23 in Resident #222's EMR. The care plan included the interventions: - Staff to assist resident with transfers as needed (Start Date: 5/3/23) - Encouraged/remind resident to ask for assistance when wanting to go outside (Start Date: 5/8/23) Resident #222 did not have a care plan related to exit seeking/wandering and/or elopement. Review of Resident #222's Health care provider orders revealed the order, Transfer Status: 1PA (Person Assist) with gait belt and 2ww. Ambulation Status: to restroom with staff with gait belt and 2ww (Ordered: 4/26/23; Discontinued: 5/9/23). All Resident #222's Incident and Accident (I and A) forms and any applicable investigation documentation during their stay at facility were requested. Review of provided documentation revealed the following: - Safety Events . Exit Seeking Event . Event Date: 5/7/23 3:00 PM .Date Recorded: 5/7/23 3:29 PM . Closed Date: 5/8/23 . Description: Resident observed in AL parking lot . Was the Resident seen exiting the building? No . Where was the resident found? On property . When was the Resident found .? 5/7/23 3:00 PM . behaviors prior to exit seeking . ambulates hallways independently within (sic) assistive device . Mental Status . Confusion . Exit Seeking Risk Factors . alcohol abuse, tobacco abuse . Interventions . Wandering alert device applied . Evaluate medications . 15 min visual checks X 24 hours . Evaluation Notes: No exit seeking occurred . see note . Reported to State: No. - Safety Events . Fall Event . Event Date: 5/7/23 3:00 PM .Date Recorded: 5/12/23 7:41 PM . Description: Fall .Location .Outside on Facility Grounds . What was Resident doing just prior to fall? Ambulation . observed sitting on curb outside . Was fall witnessed? No- Initiate 'Neuro check' order set . Did Resident hit head? Unknown- Initiate neuro checks . Safety equipment in place and functioning at time of incident? Other . res did not use walker . No injury noted . Mental Status . No Changes . New Interventions . Wander guard applied . Physician Notified . 6/19/23 5:56 AM . No documentation of neuro checks following the incident on 5/7/23 were present in the EMR. No documentation of interviews and/or additional investigation documentation was provided. An interview was conducted with the Director of Nursing (DON) and Clinical Support Registered Nurse (RN) F on 1/9/24 at 3:15 PM. When queried regarding Resident #222's exit from the building on 5/7/23, RN F stated they believed it had occurred on Sunday, Mother's Day. The DON specified they were not employed at the facility when the incident occurred. When asked if the facility completed an investigation, as no investigation documentation had been included with the provided I and A forms, RN F indicated an investigation had been completed, they were trying to locate it, and would provide a copy. When asked if Resident #222 had an elopement/exit risk assessment completed following admission, RN F replied, No, the first admit assessment only unless there are behaviors displayed. When queried why the I and A report for the fall was completed on 5/12/23 and indicated the fall occurred on 5/7/23, RN F replied, They (nursing staff) weren't sure if (Resident #222) fell so I told them to do the fall (I and A). When queried if they told staff to complete the I and A on 5/12/23, after the I and A for the exit I and A had been closed, RN F was unable to recall the date submitted. RN F was asked where Resident #222 was found and replied, Out in the front parking lot. RN F was then asked to show this Surveyor where Resident #222 was outside, and a tour was completed. Resident #222 exited through the front/main facility door of the Assisted Living of the facility which faced [NAME] Road (heavily traveled and busy road). A desk with a staff member was present at the front/main entrance door. When if there was a staff member working at the entrance on 5/7/23 when Resident #23 exited the building, RN F stated, I am not sure. After exiting the building, RN F specified Resident #222 was seen sitting in the grassy area of the parking lot which separates the perpendicular parking spots by someone in the Assisted Living of the facility. RN F was asked where Resident #222 was sitting and pointed to the fifth or sixth parking spot (approximately 45 feet north and fifty feet west of the building entrance). Review of facility provided investigation documentation included the following: - Undated Summary Document: May 7, 2023, Event . Short Term . Any attempts to leave prior or request for early discharge? No. fell in parking or did they sit down in parking lot? If unwitnessed complete the I&A. No injury, resident on (Assisted Living) saw (Resident) from the parking lot. 2:00 PM in room . 3:00 PM someone states (Resident #222) is in the parking lot . Sitting on curb walked back in . Smoker . Said they were going out for a walk. Explained process with requests to go outside. (Spouse) was a resident previously. Was (Resident #222) attempting to smoke due to smoking history? Ambulatory at baseline. Recommendations: Offer patch for smoking . Remove bracelet . is able to leave if chooses . Review the LOA (Leave of Absence) process . when would like to go outside . (Resident #222) does not want to feel like they are a prisoner here so let's ensure we make it clear they are not a prisoner, and we just want them to be safe. No history of elopement for hospital records . No risk factors noted here . - Individual 15 Minute Monitoring Log - Statement of Witness Form . RN EE . 5/7/23 . Resident observed ambulating in 100-hallway with two CNA's toward their room at 3:00 PM. CNA's reported they were told resident was outside of building in the north parking lot. They went outside and observed resident sitting on the curb next to sidewalk. Aides assisted resident to standing and brought inside. Resident was observed at 2:00 PM by the 100-hall aide. 100 hall aide RN and aide were assisting other residents at the time. Resident was assessed by RN . Stated went outside to see how nice it was and decide to sit down on the curb then was unable to stand . wander guard placed on left ankle. Resident was agreeable to wander guard and educated about letting staff know when they would like to go out. - Statement of Witness Form . Licensed Practical Nurse (LPN) EE . Weekend Supervisor . 5/7/23 . ADHS (Assistant Director of Health Services) notified at 3:08 PM of resident observed in grassy center median of AL parking lot; reported to writer at 3:05 PM. ADHS contacted (Administrator). Administrator spoke with writer at 3:24 PM details . Resident without apparent injury . wander guard left ankle with resident and son consent. - Completed Elopement Drill Records for March, April, May, and June 2023. On 1/9/24 at 4:17 PM, an interview was completed with the facility Administrator. When queried what occurred when Resident #222 exited the facility, the Administrator stated, I was notified that (Resident #222) was found outside. The Administrator was asked who notified them and replied, It was our weekend supervisor who is a PRN (casual status staff) now and a DON who is no longer here. When queried who had found the Resident, the Administrator revealed an individual residing on the AL side of the facility had seen the outside from their window. When asked if any facility staff were aware Resident #222 was outside of the building in the parking lot, the Administrator replied that staff were unaware Resident #222 had exited the building. The Administrator then stated, I know that (Resident #222) was out on an LOA (Leave of Absence) the day before with their family. When asked if Resident #222 exited from the same door on 5/7/23 as they did when they left to go on an LOA with their family, the Administrator verified it was the same door. When queried regarding Resident #222's ambulation status when they exited the facility, the Administrator specified the Resident was modified independent (independent with an assistive device) with a two wheeled walker and stated, (Resident #222) didn't always use their walker. When queried regarding the discrepancies identified in the Resident's Health Care Provider orders and care plan interventions related to ambulation and transferring, the Administrator stated, I would feel more comfortable asking MDS (staff). The Administrator was asked why Resident #222's fall care plan was not initiated until 5/3/23 when the Resident was admitted on [DATE] and replied, If we observed (Resident #222) without a walker or something but did provide further explanation. When queried if that was the reason the fall care plan was initiated for Resident #222, the Administrator validated it was. When queried how long Resident #222 had been outside prior to being seen by someone from the AL side of the facility, the Administrator revealed they did not know. The Administrator was then asked if the facility utilized video camera monitoring and revealed the facility does not have recording video camera surveillance at the exit doors. When queried regarding the Resident's risk factors for exit seeking/elopement including but not limited to BIMS indicating moderately impaired cognition, fall risk, history of alcohol abuse, tobacco use, ambulation status, and recent LOA, in addition to staff not knowing the Resident had exited the building, the Administrator replied, I understand what you're saying and verbalized confirmation of safety concerns. Review of facility provided investigation documentation included the following: - Undated Summary Document: May 7, 2023, Event . Short Term . Any attempts to leave prior or request for early discharge? No. fell in parking or did they sit down in parking lot? If unwitnessed complete the I&A. No injury, resident on (Assisted Living) saw (Resident) from the parking lot. 2:00 PM in room . 3:00 PM someone states (Resident #222) is in the parking lot . Sitting on curb walked back in . Smoker . Said they were going out for a walk. Explained process with requests to go outside. (Spouse) was a resident previously. Was (Resident #222) attempting to smoke due to smoking history? Ambulatory at baseline. Recommendations: Offer patch for smoking . Remove bracelet . is able to leave if chooses . Review the LOA (Leave of Absence) process . when would like to go outside . (Resident #222) does not want to feel like they are a prisoner here so let's ensure we make it clear they are not a prisoner, and we just want them to be safe. No history of elopement for hospital records . No risk factors noted here . - Individual 15 Minute Monitoring Log - Statement of Witness Form . RN EE . 5/7/23 . Resident observed ambulating in 100-hallway with two CNA's toward their room at 3:00 PM. CNA's reported they were told resident was outside of building in the north parking lot. They went outside and observed resident sitting on the curb next to sidewalk. Aides assisted resident to standing and brought inside. Resident was observed at 2:00 PM by the 100-hall aide. 100 hall aide RN and aide were assisting other residents at the time. Resident was assessed by RN . Stated went outside to see how nice it was and decide to sit down on the curb then was unable to stand . wander guard placed on left ankle. Resident was agreeable to wander guard and educated about letting staff know when they would like to go out. - Statement of Witness Form . Licensed Practical Nurse (LPN) EE . Weekend Supervisor . 5/7/23 . ADHS (Assistant Director of Health Services) notified at 3:08 PM of resident observed in grassy center median of AL parking lot; reported to writer at 3:05 PM. ADHS contacted (Administrator). Administrator spoke with writer at 3:24 PM details . Resident without apparent injury . wander guard left ankle with resident and son consent. - Completed Elopement Drill Records for March, April, May, and June 2023. An interview was conducted with RN F following review of the provided investigation documentation. When queried how long Resident #222 had been outside of the facility without staff knowledge, RN F indicated the provided summary included a timeline of the event. RN F was then asked about the lack of times on the provided summary/timeline but was unable to provide further explanation. When queried if a Missing Resident/Elopement Alarm had been paged/completed, RN F revealed it had not. RN F was then queried if the AL Resident who first saw Resident #222 outside as well as other staff, Residents, and visitors were interviewed as part of the investigation and revealed facility staff were unable to locate any other additional investigation documentation. When

Based on observation, interview and record review, the facility failed to implement and operationalize a comprehensive infection control program, encompassing outcome and process surveillance, accurate data collection/documentation/analysis and failed to ensure Personal Protective Equipment (PPE) use for transmission-based isolation precautions resulting in a lack of accurate and comprehensive infection control tracking, surveillance and data monitoring/analysis and the likelihood for spread of microorganisms and illness to all 64 facility residents. Findings include: During an interview with Resident #57 on 1/08/24 at 11:01 AM, the Resident disclosed they were recently diagnosed and treated for Influenza in December 2023. Review of the Resident's Electronic Medical Record (EMR) revealed the Resident was diagnosed with Influenza A in December 2023 at the facility. A copy of the prior six months of facility infection control data was requested from the facility Infection Control Registered Nurse (RN) M on 1/8/24 at 4:34 PM. Review of requested facility infection control data for December 2023 included a typed summary of the infection data, a written form titled, Line Listing of Resident Infections and a printed list titled, Antimicrobial Stewardship Transactions signed by the facility physician. Review of the provided information revealed the following: The summary detailed, For the month of December 2023 There were 22 total infections. 8 of those were nosocomial (facility acquired) and 14 were community acquired . Among our Nosocomial infections, 1 was respiratory, 1 was skin, and 6 were UTI (Urinary Tract Infection). The respiratory infection rate was 1.5%. Skin infection rate was 1.5%. UTI (Urinary Tract Infection) rate was 8.8%. December's Nosocomial infection rate (3.78%) increased from Novembers (2.48%). The UTI (Urinary Tract Infection) rate in Nov (sic) (8.8%) increased from November's (1.5%) . December's respiratory infection rate was 1.5% and was a decrease from Decembers (sic) 3%. There were no in-house GI, or system infections for November (sic). The summary indicated Covid-19 infections were not included. The summary did not identify infection trends, employee illnesses, influenza, possible infections not treated with antimicrobial medications, and/or actions taken to mitigate infection. There was no data related to Influenza infections included in the summary. The Antimicrobial Stewardship Transactions list contained names of four individuals with room numbers not which were not part of the Long-Term Care area of the facility. A comparison of the residents listed on the Line Listing of Resident Infections and the printed Antimicrobial Stewardship Transactions, with the four individuals whose listed room numbers where not part of the facility excluded, was completed. The following discrepancies were identified: - Two unsampled residents were included on the Line Listing of Resident Infections and listed as receiving antibiotics but were not listed on the Antimicrobial Stewardship Transactions list - Resident #57, Resident #59, Resident #68, and four unsampled Residents were listed on the Antimicrobial Stewardship Transactions list but not included on the Line Listing of Resident Infections. - Three Unsampled Residents, listed on the Line Listing of Resident Infections with specific antimicrobial medications listed had additional antimicrobial medications listed, with different dates, on the Antimicrobial Stewardship Transactions list. The Line Listing of Resident Infections for December 2023 did not include any resident infections who had not received antibiotic treatment, any influenza positive residents, and/or any carry over infections from the previous months. The listing further indicated all infections met McGeer Criteria including those receiving prophylactic antibiotics. The line listing details for individual residents listed did not identify the date infection symptoms began, diagnostic testing dates (as appropriate), the date of treatment initiation/discontinuation, and/or implementation of transmission-based precautions (as appropriate). An interview was completed with Infection Control Registered Nurse (RN) M at 1/10/24 at 9:50 AM. The facility provided Infection Control data for December 2023 was reviewed with RN M at this time. When queried regarding surveillance and tracking of Covid-19, RN M stated, Covid (tracking) is separate because they are not getting an antibiotic. RN M was asked about Covid-19 infections in the facility and revealed the facility had an outbreak during December 2023 which was reported to the health department. The facility Covid-19 surveillance data was requested at this time. When queried regarding the printed Antimicrobial Stewardship Transactions list, RN M specified the list was provided to the facility from the pharmacy and included all the antimicrobial medications ordered during a month. When queried regarding the four individuals included on the transaction list whose listed room numbers were not facility room numbers, RN M revealed the identified individuals resided in the Assisted Living and not in the long-term care area of the facility. With further inquiry regarding the above-mentioned discrepancies, RN M revealed they do not actually utilize the information on the list but had included it as it is maintained with their infection control data. When queried regarding the inconsistencies in the antibiotics ordered for the identified three Unsampled residents, RN M conveyed they did not have the answer and would need to review each individual resident's medical record. RN M was asked if Resident #57 had influenza during December 2023 and confirmed the Resident had tested positive for influenza at the facility. When queried if any other residents tested positive, RN M indicated there was one other positive flu. When queried why the residents were not included on the infection line listing, RN M stated they track flu on a separate line listing. The line listing with flu positive residents was requested for review. RN M revealed they would need to return to their office to get the list. After waiting approximately 20 minutes, RN M was located in their office. When queried regarding the list, RN M revealed they were unable to find the line listing. RN M stated, I sent it to the health department via fax and indicated they had contacted the health department to request a copy. Resident #62 was selected from the December 2023 Line Listing of Resident Infections to review with RN M. The line list data for the Resident included the following information: - Room number, Unit: 100, admitted : 10/16/23, Type of Infection: UTI (Urinary Tract Infection). If UTI was cath present? Y/N: N/A . Symptoms/Date: Blank . Cultures: Date/Site/Results: Proteus Vulgaris (gram negative bacterium found in soil, water, and fecal matter) 11/28 . Treatment: Cipro (antibiotic) 500 mg (milligrams) BID (twice a day) X 1w (week) . Other Actions: Increase Fluids . Pericare, F/U (follow-up) UA (urinalysis) . HAI (Healthcare Acquired Infection) . The form indicated the infection met McGeer Criteria. RN M was asked if Resident #62's UA was obtained on 11/28/23. After reviewing the Resident's medical record documentation, RN M stated, Culture return on 11/28. When asked when the antibiotic treatment was started, RN M reviewed the Resident's Electronic Medical Record (EMR) and stated, 12/4. RN M was asked why the antibiotic was not started until 12/4/23 when the culture was received on 11/28/23, RN M replied, The NP (Nurse Practitioner) reviewed on 12/4 and indicated treatment was started then. When queried if the Healthcare Provider was aware of the culture results prior to 12/4/23, RN M replied they did not know the reason for the delay in initiation of treatment. When asked if they reviewed and analyzed appropriate and timely treatment and interventions as part of their infection control program, RN M replied each resident's healthcare provider makes treatment determinations. When asked if they tracked/reported surveillance and tracking documentation in the infection control committee, RN M revealed they report the infection data related to percentages. When queried regarding Resident #62's signs/symptoms and when the symptoms began, RN M began reviewing the Resident's EMR. After several minutes, RN M had not provided a response and was asked if they maintain documentation of signs and symptoms of infection as part of their surveillance. RN M replied that they can always look in the EMR. When queried how they were able to identify potential spread, and trends timely, if they did not document and track signs and symptoms of infection in a manner that is easily accessible, RN M replied they understood the concern. An Unsampled Resident included on the December 2023 Line Listing of Resident Infections list was reviewed with RN M. The line listing detailed the following: - Room number, Unit: 100, admitted : 12/22/23, Type of Infection: Skin Prophy . Symptoms/Date: Prophylaxis . Cultures: Date/Site/Results: N/A . Treatment: Sulfasalazine (anti-inflammatory drug frequently used to treat ulcerative colitis and rheumatoid arthritis) 1000 mg (milligrams) BID . Other Actions: Monitor . Give meds as ordered . CAI (Community Acquired Infection) . The form indicated the infection met McGeer Criteria. When queried why the Resident was receiving the medication, RN M indicated the medication for being taking for skin prophylaxis. When queried the reason the medication was being taking prophylactically, RN M was unable to provide an explanation. RN M was then asked how the medication met McGeer criteria. After reviewing the documentation, RN M replied, It doesn't and indicated they made an error on the line list. Review of another Unsampled Resident on the Line Listing of Resident Infections for December 2023 revealed the following: - Room number, Unit: 200, admitted : 12/23/23, Type of Infection: UTI. If UTI was cath present? Y/N: N . Symptoms/Date: Re-admit on abx (antibiotics) . Cultures: Date/Site/Results: UTO (Unable to Obtain) X 3 . Treatment: Cefuroxime Axetil (antibiotic) 500 mg (milligrams) qd (every day) x 5 d (days) . Other Actions: Increase Fluids, monitor s/s (signs/symptoms . HAI (Healthcare Acquired Infection) . The form indicated the infection met McGeer Criteria. When queried if the Resident was readmitted on [DATE] on Cefuroxime, RN M reviewed the Resident's EMR and replied they were. RN M was queried regarding the Resident's readmission and indicated the Resident had been sent to the hospital and returned. When asked the date that the Resident was transferred to the hospital, RN M reviewed the EMR and stated, 12/20. RN M was asked if the Resident was sent to the hospital due to a UTI, RN M indicated they would need to review the Resident's EMR. After review, RN M disclosed the Resident was diagnoses with UTI and sepsis in the ER, admitted to the hospital, and returned to the facility on oral antibiotics. When asked why the infection was classified as CAI when it began in the facility, RN M indicated the infection was not diagnoses in the facility. RN M was asked if the infection began when the Resident was in the facility and the reason they were transferred to the hospital. RN M confirmed and revealed they did not realize the infection would be considered HAI if it was not diagnosed at the facility. When queried when the Resident began to display signs and symptoms of infection, RN M was unable to provide a timely response without completing a review of the Resident's EMR. When asked what UTO X 3 for the culture meant, RN M revealed they did not know the organism as the culture had been obtained in the hospital. When asked if the Culture and Sensitivity report was not obtained as part of the hospital medical record information received from the hospital, RN M replied they were unable to locate it. When asked, RN M revealed they frequently did not receive that information for residents admitted from the hospital. When queried how they were able to accurately track infections without the results, RN M did not provide a response. Another Unsampled Resident on the Line Listing of Resident Infections for December 2023. The line list indicated the resident was admitted on Cefuroxime Axetil (antibiotic) 250 mg BID for a UTI but did not include the Resident's room number, unit, admitted , antibiotic start date, signs/symptoms of infection, and/or any cultures. The form indicated the infection met McGeer Criteria. When queried regarding the lack of infection data of the line list, an explanation was not provided. When asked if they identified any infection trends during December 2023, RN M indicated there was an increase in UTI but that the infections were spread throughout the facility. When queried what they did in response to the increase in UTI, RN M indicated staff education would be completed. Review of the line list revealed two residents on the list in the 300 unit of the facility were identified as having UTI due to the microorganism Proteus mirabilis (gram negative bacteria). Another Resident was listed as having a UTI but the Culture results for the microorganism was listed as UTO X 3. Further review of the Line Listing of Resident Infections for December 2023 with RN M revealed other Residents who were transferred to the ER/hospital, diagnosed with an infection, and returned on antibiotics who were documented as CAI when the infection was HAI. When asked if any of the residents included on the list moved rooms or had transmission-based isolation precautions implemented, RN M was unable to provide a response without reviewing each Residents chart. When asked how they determined if there were trends and/or spread without knowing if there was movement of residents and/or appropriate precautions, RN M verbalized understanding. When queried if misidentification of HAI and CAI infections changed the infection control data reported, RN M confirmed it did. RN M was asked how they track potential infections and infections not treated with antimicrobial therapy and replied, I don't actually tract that. When queried regarding how the facility ensures comprehensive surveillance to identify, stop, and prevent the spread of possible infections when they do not track and have comprehensive system in place for surveillance, RN M verbalized understanding but was unable to provide an explanation. When queried regarding system for monitoring and tracking employee illness, RN M relayed they do not track employee call ins/illness. When asked how they identify potential transmission and/or trends of infection if they are not maintaining documentation of employee illness, RN M replied, Well, I track Covid for employees. When asked if there are infectious microorganisms, other than Covid-19, which can be transmitted from employees to Residents and vice versa, RN M replied there are. RN M verbalized they were not aware that they needed to track employee illness are part of the facility infection control program. RN M was then queried regarding process surveillance and if they complete audits and/or rounding to monitor staff and ensure compliance with infection control procedures, RN M revealed each department leader completes a check sheet monthly and gives it to them. When asked, RN M revealed they observe staff on the units as well. When queried regarding their involvement with environmental services to ensure appropriate cleaning/disinfectant products and procedures are utilized, RN M revealed they will need to be more actively involved in rounding and audits. When queried regarding the lack of comprehensive surveillance and accurate analysis of infections in the facility, RN M verbalized understanding of concerns and revealed they are new to the position. Review of facility provided policy/procedure entitled, Infection Prevention and Control Program (IPCP) (Reviewed 12/31/22) detailed, Purpose . establish and maintain an infection prevention and control program . to help prevent the development and transmission of communicable diseases and infections . Procedures: 1. The campus has a system for preventing, identifying, reporting, investigating, and controlling infections and communicable diseases that: a. Covers all residents, staff . 2. The campus shall designate a member of the clinical team to . perform surveillance to identify, investigate, control, and prevent the spread of infection . b. Surveillance activities to identify, investigate, control , and prevent the spread of infections shall be tracked per hall/unit, type of infection, and monitor lab reports to identify organism (s) . c. Reviews and critiques infection surveillance reports and statistics, recommending appropriate action for HAI and CAI. Not limited to documentation in resident's Electronic Health record, reports from lab . d. Monitors compliance with infection control practices and procedures. f. Ensures timely infection control education and training . g. Monitors health status of residents 6. Report and track staff illnesses and restrictions . 7. Outcome surveillance should be reviewed by the IPCP designee. Documentation shall be reviewed . to assist in identifying if the infection meets the McGeer Criteria . 37771 On 1/7/24 at 9:10 AM, an observation was made upon initial tour of the facility in the 300 hall. An observation of Nurse U leaving her medication cart and entering room [ROOM NUMBER]. The room had PPE (personal protection equipment) in a cart outside the door to the room. Signs on the door to room [ROOM NUMBER] indicated contact and droplet precautions and gave instruction on the use of PPE upon entering the room. The Nurse came out of the room and was asked about the isolation precautions on the door. The Nurse reported she should have had PPE on and stated, I know I'm a bad girl, I should have had it on. The Nurse indicated that the Resident was in isolation precautions for symptoms of Covid-19/Flu and indicated she had tested the Resident this morning for Covid-19 and had tested negative. On 1/7/24 at 10:50 AM, an observation was made of Resident #23, who resided in room [ROOM NUMBER], with the door closed, PPE cart outside the Resident's door and isolation signs on the door with instruction for contact and droplet isolation precautions. Staff was observed to donning PPE prior to going into the room. On 1/10/24 at 10:25 AM, an interview was conducted with the Infection Control (IC) Nurse M regarding orders to discontinue isolation precautions on Resident #23. When queried regarding facility policy on discontinuation of isolation precautions, the Nurse indicated they need to communicate with the practitioner to review the negative results and the signs and symptoms then discontinue the precautions. The IC Nurse indicated that the Resident was tested but she was unsure if the Nurse had communicated with the NP (Nurse Practitioner) at the time of the observations made on 1/7/24 and stated, If she told you she was supposed to wear the isolation then she probable should have. The IC Nurse indicated that the Resident was discontinued from isolation precautions that morning after they had gotten here. The IC Nurse reiterated they need that communication with the provider to have the precautions discontinued. A review of Resident #23's medical record revealed the following progress notes: -Dated 1/5/24 at 11:09, RN notified (Name) NP of congestion, groggy feeling resident reports this AM. Voice hoarse, occasional forced cough, no other symptoms reported at this time to writer. Resident placed in TPB precautions per (Name) NP. Influenza A&B negative and Covid rapid negative . Resident remains in isolation at this time. -Dated 1/5/24 at 7:04 PM, Progress Note by NP, .Resident being seen for congestion and fatigue. Discussion with nurse fatigue and super congested. Resident also endorses not feeling well. Denies cp (chest pain) sob (shortness of breath) n/v/d (nausea/vomiting/diarrhea). Endorses fatigue and congestion . -Dated 1/7/24 at 11:50 AM, Progress Note by IC Nurse M, Resident Covid and Flu tests resulted negative. Resident's doses state her symptoms have improved since they began on 1/5. Order received from NP to discontinue ISO (isolation).

This Citation pertains to Intake Number MI00137963. Based on observation, interview and record review, the facility failed to ensure the provision of Activities of Daily Living (ADL) care per residents' care needs and care plans for five residents (Resident #4, Resident #6, Resident #35, Resident #56, and Resident #272 ) of five residents reviewed, resulting in a lack of communication and knowledge of resident ADL care assistants' needs, lack of timely and appropriate ADL care per residents' needs and care plans, and the likelihood for the provision of an inappropriate level of assistance, unmet care needs, injury, and feelings of confusion and frustration. Findings include: Resident #272: On 1/9/24 at 8:04 AM, Resident #272 was observed in a separate, small dining room off the main dining room of the facility. The Resident was sitting in their wheelchair at a table. Certified Nursing Assistant (CNA) G was present in the small dining room. When queried regarding the small dining room area, CNA G stated it was Restorative dining for people who need assist with eating. After receiving a breakfast tray, CNA G cut Resident #272's food into small, bit sized pieces, opened their beverages, and assisted them to begin eating. After taking two bites, Resident #272 began asking for their spouse and said they were done eating. CNA G called another staff member to assist the Resident back to their room and ordered a breakfast tray to be taken to their room as the Resident had not eaten in the dining room. On 1/9/24 at 9:10 AM, Resident #272 was heard yelling out for help from the hallway. From the doorway of the room, Resident #272 was observed sitting in a stationary chair in their room. The Resident was fidgeting in the chair while yelling, Help, Help and Hello, Hello repeatedly. There were no staff were observed in the hallway. At 9:19 AM, a dietary staff member entered Resident #272's room with a breakfast tray. The staff member sat the tray on the over bed table in front of the Resident and walked out of the room. The staff member did not ask the Resident if they needed anything and did not cut/prepare the food, and/or open the beverages/packets. At 9:22 AM, Visitor Witness K arrived at the facility and entered Resident #272's room. This Surveyor entered the room at this time. Upon entering the room, Resident #272 had not ate any of the food on table in front of them. Witness K went to Resident and revealed there was no silverware on the tray. Witness K asked this Surveyor to verify, and inspection of the tray confirmed there was no silverware present. Witness K exited the room to get silverware and returned. Resident #272's call light was not observed near the Resident. When queried where their call light was, Resident #272 indicated they did not know. Witness K proceeded to look and located Resident #272's call light positioned behind them, out of sight, and not within their reach. The call light was activated when it was located by Witness K. At 9:38 AM on 1/9/24, CNA G entered Resident #272's room. An interview was completed at this time. When queried if Resident #272 needed their food cut up, CNA G stated, It's not on their (dining) ticket but it's common sense. Record review revealed Resident #272 was admitted to the facility on [DATE]. Review of the Electronic Medical Record revealed no documentation of medical diagnoses. Review of Resident #272's Admission Assessment documentation revealed the Resident was orientated to person and place only, required assistance to complete Activities of Daily Living (ADL) and required a mechanical lift for transferring, and had an indwelling urinary catheter. An interview was completed with the Director of Nursing (DON) and Clinical Registered Nurse (RN) F on 1/9/24 at 6:00 PM. The DON and RN F were informed of observations of Resident #272 including the lack of silverware and the staff member simply placing the tray in front of them and not speaking to the Resident. When asked if that was acceptable, both the DON and RN F indicated it was not. When queried regarding the Resident yelling out and their call light not being in reach, RN F stated they would address all concerns. 37771 Resident #6: A review of Resident #6's medical record revealed an admission into the facility on [DATE] and re-admission on 6/5/23 with diagnoses that included, heart failure, urinary tract infection, stroke, reduced mobility, muscle weakness, and need for assistance with personal care. A review of the Minimum Data Set (MDS) assessment revealed a Brief interview of Mental Status (BIMS) score of 10/15 which indicated moderately impaired cognition and needed substantial/maximal assistance with shower/bathe self, lower body dressing and partial/moderate assistance with personal hygiene. On 1/8/24 at 11:23 AM, an observation was made of Resident #6 in his room sitting in a wheelchair. The Resident was dressed. The Resident was interviewed, answered simple questions, engaged in conversation, though sometimes difficult to hear or understand when engaging in conversation, and sometimes responded with head shakes for 'no' and nods for 'yes'. The Resident was observed to have facial hair over his checks, neck, chin and upper lip area. The facial hair was longer than stubble and had some debris in the mustache area and in the beard on his chin. The Resident was queried if he liked to be close shaven and the Resident indicated he did while observed to be rubbing his beard and his chin. The Resident showed an electric razor among his belongings and reported that staff help him with it. When asked if staff offered shaving activity during his last shower, the Resident shook his head no. When asked if he refused to be shaven, the Resident indicated 'no' and shook his head 'yes' when asked if he liked to shave regularly. When asked if staff have not helped him with shaving for the last 3 or 4 days, the Resident indicated he had not gotten to shave. A review of Resident #6's care plan revealed a category: ADL's Resident requires staff assistance to complete ADL tasks completely and safely. Goal revealed, Resident will ADL needs met safely by staff assistance, with an approach Offer facial shaving on shower days, prn, or as requested. Document refusals. Resident #56: A review of Resident #56's medical record revealed an admission into the facility on [DATE] with diagnoses that included gastrostomy status, stroke, diabetes, heart disease, and muscle weakness. A review of the MDS revealed the Resident was cognitively intact and the Care Plan revealed a category for ADL's (activities of daily living) Resident requires staff assistance to complete self-care and mobility functional tasks completely and safely. The approaches included Offer facial shaving on shower days, prn (as needed) or as requested. Notify nursing of refusals. On 1/7/24 at 10:34 AM, an observation was made of Resident #56 lying in bed with the head of the bed elevated. The Resident had a Visitor R sitting in a chair at the Resident's foot of the bed. The Resident was observed to have long unshaven facial hair on cheeks, chin, upper lip and neck and the Resident's hair looked greasy and not combed. When asked about the Resident's preference the Resident indicated he liked to be clean shaven. The Visitor reported that the Resident was usually clean shaven and requested that the Resident get shaved. The Visitor indicated that family was going to come to shave him but would like for staff to shave the Resident if able. The Resident indicated he did not want to get up to the shower due to being so weak and no energy. When verbalized that staff can shave the Resident while he was in bed, the Resident was surprised they would do that. When asked if he has declined for staff to shave him, the Resident indicated that had they offered to shave while in bed that he would not refuse and stated, I would not decline if they would offer to give me a shave. When asked when they last washed his hair, the Resident reported he had not been up to shower. When asked when staff last washed his hair in bed, the Resident indicated they had done that before but was unsure when the last time was. On 1/8/24 at 10:51 AM, an observation was made of Resident #56 in a wheelchair in the hall, propelled by staff. The Resident was dressed, and an observation was made of the Resident unshaven with long facial hair. On 1/9/24 at 9:28 AM, an observation was made of Resident #56 lying in bed and was clean shaven. When queried, the Resident smiles, rubs his cheeks and said, Finally. The Resident indicated his daughter came in and gave him a shave. On 1/9/24 at 9:31 AM, an interview was conducted with Nurse S regarding Resident shaving facility policy. The Nurse reported that the Residents should be asked daily to shave or when needed. On 1/9/24 at 12:32 PM, an interview was conducted with CNA T regarding Resident #56 lack of shaving. The CNA indicated that the daughter came in to shave him. When asked why staff don't shave the Resident, the CNA stated, We do. When asked to see the shower sheets where the CNA indicated they would be documented, the binder at the nurses' station did not have any shower sheets in the binder for Resident #56. The CNA indicated that the staff should offer shaving with showers and that the Resident was to get bathing on Tuesday and Friday nights. On 1/9/24 at 4:24 PM, an interview was conducted with Regional Support F regarding Resident #56's lack of shaving. It was reviewed with the Regional Support that the daughter had shaven the Resident, there was no documentation of refusals, no shower sheets in the binder at the nurses' station and a request of shower sheets were asked for at this time. On 1/9/24 at 6:16 PM, CNA L was interviewed regarding Resident #56's shower and shaving activities. The CNA indicated that shaving was to be completed with showers and stated, If I shower them, I try my best to do that. When queried about Resident #56, the CNA indicated that his daughter would shave him, when asked if that was what the Resident said, the CNA indicated that information was passed on from another CNA. The CNA indicated that the Resident was very weak and did not like to sit. When asked if shaving can be completed while in bed, the CNA indicated that they could shave while the Resident was in bed. The CNA was asked about Resident #6's shaving. The CNA indicated that the Resident had an electric shaver and indicated that she plugs it in for him and he can shave himself after setting up to do so. When asked if the Resident had ever refused to shave, the CNA stated, He has not refused when I offered. On 1/10/24 at 10:52 AM, an interview was conducted with MDS Nurse C regarding Resident #56's ADL care plan. The MDS Nurse was asked about Resident #56's shaving and the daughter coming to shave the Resident. The MDS Nurse stated, If we knew the family were to shave, yes we would put that in there (ADL care plan). When asked about facility policy on refusals, the MDS Nurse indicated she was unsure, and the Refusal policy was requested. The MDS Nurse indicated that during CCM (clinical care meetings) if refusals that would come up, we would put a care plan about the refusal and intervention to identify what he (Resident #56) wants. A review of the care plan revealed no interventions or care plan for refusals or the family providing the shaving for Resident #56. On 1/10/24 at 12:51 PM, the lack of shaving and bathing activities was reviewed with the Director of Nursing (DON). The shower sheets for Residents #6 and #56 had not been received. The DON indicated they were not able to locate the shower sheets. The DON indicated she was not aware of Resident refusals and that if the Residents had refused, it should be documented and we would set up a care plan for it. The shower, shaving and ADL policy was requested. A review of the facility policies titled, Nursing ADL Documentation Guidelines, and Guidelines for Bathing Preference, was reviewed but did not give directives for the care of facial hair. 39059 Resident #4: On 1/07/24, at 9:54 AM, Resident #4 was in bed. There was fall mats to each side of the bed. Their wheelchair and walker were in the corner of the room at the end of the bed. On 1/07/24, at 12:24 PM, a record review of Resident #4's electronic medical record revealed an admission on 12/05/2019 with diagnoses that included Stroke, right sided Hemiplegia and Diabetes. Resident had severely impaired cognition and required extensive assistance with Activities of Daily Living (ADL.) A review Category: ADL's Profile Care Guide revealed . Safety . assist resident with toileting after meals . Place w/c near resident's bed with wheels locked for use in the event resident attempts to self-transfer . Approach Start Date: 07/22/2021 Transfer and Gait Status: 1 PA (person assist) with gait belt and 2 ww. Ambulation: therapy only . On 1/08/24, at 8:26 AM, Resident #4 was in their bathroom alone. The breakfast tray was on the bedside table. CNA X offered that they assisted the resident to the bathroom. On 1/08/24, at 2:27 PM, Resident #4 was in bed. The wheelchair was not near the bed and in the corner of the room. On 1/09/24, at 9:35 AM, Resident #4 was in bed. The wheelchair was not near the bed. On 1/09/24, at 2:39 PM, an observation of Resident #4's skin along with CNA Y was conducted. Resident #4 rolled to the right side of the bed put their feet on the floor and stood up while CNA Y was on the opposite side of the bed. CNA Y walked to the resident offered their 4 wheeled walker. CNA Y assisted the resident to the toilet after Resident #4 stopped to their dresser looking for undergarments. Once the resident was sitting on the toilet, CNA Y applied the gait belt to their waist. CNA Y assisted the resident back to their bed with use of the walker and gait belt. The wheelchair was in the corner of the room. Resident #6: On 1/10/24, at 9:04 AM, Resident #6 was sitting alone at a table in the main dining room. Their plate had breakfast scramble that appeared to be whole and untouched. Their water glass was tipped upside down. Their juice was in a glass goblet. Their coffee was in a coffee cup. They had a yogurt that was unopened. Their silverware was to the left of the plate on top of a napkin and appeared untouched. There was no staff in the dining room. The resident smiled when asked if she needed help. A review of Resident #6's meal ticket next to their plate revealed . Cut up all food BITE SIZED . Preferences 1/2 Cranberry 1/2 Orange juice Banana, Danish Coffee, 2 haz, 1 C mix for resident Scrambled eggs w/cut up sausage Yogurt + Beverages in Styrofoam Cup w/lid On 1/10/2024, at 9:15 AM, CNA entered the dining room and asked Resident #6 if they were done eating. The resident did not answer. CNA was asked who assisted Resident #6 in the dining room for breakfast and CNA the clinical staff should be getting their drinks. CNA was asked why her food was not cut up in BITE SIZED pieces and CNA food is supposed to be bite sized and no, that is not. Resident #6 attempted to pick up the goblet of juice and was unable to pick up the glass and pulled their arm back. CNA planned to get a new breakfast tray with the drinks in Styrofoam cups with lids and assist the resident in their room. Resident #35: On 1/07/24, at 10:13 AM, Resident #35 was standing alone in their room at bedside. Resident #35 offered that they make it to the bathroom on their own. There was no walker in the room. On 1/07/24, at 10:20 AM, Nurse E was asked if Resident #35 was safe standing on their own and Nurse E offered that the resident walks on their own. On 1/07/24, at 11:45 AM, observed Resident #35 ambulating into the dining room with CNA DD without a walker. On 1/08/24, at 9:27 AM, Resident #35 was standing up drinking coffee in their room. On 1/09/24, at 9:10 AM, Resident #35 was standing in their room pouring syrup onto their waffles. Resident had on orange pants and an orange sweater on. The resident was barefoot. Nurse W was at the end of the hall and was asked if Resident #35 normally stood up to eat their breakfast and Nurse W stated, yeah, that's her usual. On 1/09/24, at 10:57 AM, a review of Resident #35's electronic medical record revealed an admission on 05/01/2023 with diagnoses that included chronic respiratory failure, Dementia and Anxiety disorder. Resident #35 had impaired cognition and required assistance with ADL's. A review of the Category: ADL's Resident requires staff assistance to complete ADL tasks completely and safely. Resident will have ADL needs met safely by staff. Resident requires limited assistance for bed mobility, toileting, set up/supervision for transfers, personal hygiene and extensive for bathing, (fluctuations in ADL may occur) Approach Start Date: 06/28/2023 1 person assist with gait belt and 2 ww (wheeled walker) Ambulation Status: with staff to restroom with gait belt and 2 ww . On 1/09/24, at 2:21 PM, CNA Z was asked how they assist Resident #35 to and from the bathroom and CNA Z stated, they don't usually assist her and that she's independent. On 1/09/24, at 2:25 PM, CNA Y was asked if Resident #35 required assistance and CNA Y stated, she's independent. On 1/09/24, at 3:37 PM, a record review along with Nurse D was conducted. Nurse D was asked what Resident #35's transfer status was and Nurse D stated, 1 person assist with gait belt and 2 wheeled walker. Nurse D was alerted that there wasn't a walker in Resident #35's room and that the staff were offering that Resident #35 was independent. On 1/10/24, at 9:43 AM, Resident #35 was standing at their bedside table that was pushed against the wall adjacent to their bed. Resident #35 had the same orange sweater on, no pants, barefoot and was stirring their coffee with a fork. Resident #35 backed up and sat on their bed without placing their hands back onto the bed. On 1/10/24, at 9:45 AM, CNA AA entered the residents room and assisted with socks and pants. CNA AA put the same orange pants on that the resident had on the day before. CNA AA was asked how do they know what the resident needs for assistance and CNA AA stated that they get report and stated no to having a report sheet. CNA AA was asked how they would ensure the resident was getting their needs per their care plan and CNA AA stated, we can look in the computer. There was no walker noted in the room again this day.

Based on interview and record review, the facility failed to ensure that the provision of residents' rights were provided prior to or upon admission for one resident (Resident #272) of one resident reviewed, resulting in a delay of communication and receipt of residents' rights verbally or in writing, lack of Resident and/or Representative knowledge of rights, responsibilities, and a plan of care, verbalization of lack of knowledge, and the potential for misinterpretation and violation of residents' rights. Findings include: Resident #272: On [DATE] at 11:59 AM, Resident #272 was observed sitting in a wheelchair in their room with Family Members Witness A and Witness B. An interview was completed at this time. Resident #272 was noted to be hard of hearing and pleasantly confused. Resident #272 did not consistently respond when asked questions. Resident #272 was asked when they were admitted to the facility and looked at Witness A to answer. Witness A stated, We came in Friday ([DATE]) around 4:30 PM. When queried regarding the admission process including responsibilities, what to expect, and resident rights, Witness A stated, No. All they did was have (Resident #272) sign the CPR (code status) thing. Resident #272 shook their head in agreement. When asked if they received an admission packet with information about the facility in it, Witness A stated, No. When queried if they received any documentation when they were admitted , Witness A replied, No. They didn't give us any papers. Just had him sign that (CPR) one. Witness B then stated, We do not know what is going on and/or what the plan or schedule is. Witness B verbalized they were unsure what the Resident's financial obligation would be for their stay at the facility and had not been informed by facility staff. When asked, both Witnesses A and B revealed they visited Resident #272 over the weekend and had not received any additional information. Witness A stated, They (facility staff) told us they would do that (provide admission information) on Monday (today- [DATE]). When asked if they knew when staff were planning to review the admission information with them, Witnesses A and B revealed they had not heard anything and had been at the facility since 9:30 AM. On [DATE] at 3:50 PM, an interview was completed with Resident #272, Witness A, and Witness B in the Resident's room. When queried if staff reviewed resident rights and admission information with them yesterday (Monday [DATE]), Witness A revealed they did not receive any information and the resident rights were not received/reviewed until today ([DATE]). An interview was conducted with the facility Administrator on [DATE] at 6:18 PM. When queried regarding the facility admission process including the time frame in which residents' rights should be reviewed with and provided to newly admitted residents, the Administrator replied, Ideally within 24 hours. The Administrator continued, There are a couple things that the nurses do immediately like obtain a consent to treat and the code status. The Administrator was then informed that Resident #272 had not received their resident rights and/or admission information. When queried why, the Administrator revealed they would need to look into it and review the policy/procedure. A copy of the facility policy/procedure was requested at this time. A follow-up interview was completed with the Administrator on [DATE] at 8:28 AM. The Administrator was asked if they had an opportunity to follow-up regarding Resident #272's admission and provision of resident rights and replied, Our policy is vague and just says upon admission. The Administrator continued, We are looking into it to see if there is a more specific timeline somewhere. The requested policy/procedure had not been received and was requested again. The Administrator then stated, I think the resident rights are located in the welcome book in the room. The Administrator was informed that the welcome book had been reviewed and contained general contact numbers for facility staff and a map but not resident rights. The Administrator replied, May that would be a solution to add them there then. When queried, the Administrator verbalized understanding of the importance of receipt of resident rights and admission information. Review of facility provided policy/procedure entitled, Resident Rights Guidelines (Reviewed [DATE]) did not include information pertaining to informing resident of their rights verbally and in writing in a language they can understand. The policy also did not include timeframes in which the resident's would be informed/provided their resident rights. Review of Trilogy-Michigan HC Admission Packet 6.22.23_Combined revealed, You have a right to be informed, orally and in writing . about your rights and responsibilities. This right applies when you are admitted and when you request information during your stay . You will receive a copy of your nursing home's rules and regulations and this summary of your rights when you are admitted .

Based on observation, interview and record review the facility failed to ensure that a baseline care plan for edema was created upon admission for one resident (Resident #272) of one resident reviewed resulting in a lack of monitoring, interventions, and the potential for unmet care needs. Findings include: Resident #272: An observation of Resident #272 was completed on 1/8/24 at 11:59 AM. Resident #272 was sitting in a wheelchair in their room with a Hoyer (mechanical lift) sling in place under them. The Resident's Left hand was positioned in their lap and their Upper Extremity (LUE- arm and hand) was extremely edematous. Family Members Witness A and Witness B were in the room and an interview was completed at this time. Resident #272 was noted to be pleasant, hard of hearing, and did not consistently respond to all questions when asked. When queried regarding the edema in their LUE and hand, Resident #272 revealed they were having difficulty moving their fingers because their hand was so swollen. Resident #272 proceeded to demonstrate moving their fingers but was unable to make a fist. When queried how long the edema had been present, Resident #272 looked at Witness A to respond. Witness A revealed the edema started when the Resident was in the hospital. Record review revealed Resident #272 was admitted to the facility on [DATE]. Review of the Electronic Medical Record revealed no documentation of medical diagnoses. Review of Resident #272's Admission Observation and Data Collection Assessment documentation, dated 1/5/24 at 4:42 PM, revealed the Resident was orientated to person and place only, required assistance to complete Activities of Daily Living (ADL), was incontinent of bowel, and required a mechanical lift for transferring. Further review of Resident #272's Admission Observation and Data Collection Assessment, dated 1/5/24, detailed the following, Left Lower Leg Edema: Pitting +1 . Right Lower Leg Edema: Pitting +1 . Left Upper Extremity Edema: Pitting +2 . Right Upper Extremity Edema: Pitting +1 . Skin Color: Normal . Temperature: Warm . Turgor: Normal . Skin Impairment: Skin events available; Bruise, Burn, Incision, Pressure-Stasis Diabetic, wound, Rash/Lesion, Skin Tear/Laceration: Yes, complete appropriate Wound Event for further assessment . Review of Resident #272's baseline and comprehensive care plans revealed no care plans were implemented related to edema. Review of progress note documentation in Resident #272's Electronic Medical Record (EMR) revealed the following: - 1/5/24 at 7:10 PM: Skin Assessment . Both forearms are edematous and back of both hands have swelling . There was not additional documentation related to Resident #272's Upper Extremity (UE) edema. An interview was completed with MDS Registered Nurse (RN) C on 1/10/24 at 8:57 AM. When queried why there were no diagnoses listed in Resident #272's EMR, RN C stated, There is an offsite coder who enters diagnoses. RN C was asked to clarify if they were saying facility staff do not enter Resident diagnoses in the EMR and replied that was correct. When queried how long it can take for diagnoses to be entered in the EMR, RN C replied, It can take a while. RN C did not provide a specific time frame. A review of Resident #272's EMR at this time revealed diagnoses had not been entered in the EMR. When asked if diagnoses not being in the EMR five days following admission was abnormal, RN C indicated it was not. When queried regarding care plans, RN C revealed facility MDS nursing staff complete and update Resident care plans. RN C was asked about baseline care plans and revealed baseline care plans are initiated by nursing staff. When queried if Resident #272 had a care plan and interventions in place related to edema and their upper extremity edema, RN C reviewed the Resident's EMR and confirmed they did not. When asked a care plan should be implemented for an abnormal assessment finding, RN C revealed a care plan should have been implemented for Resident #272's edema. No further explanation was provided. An interview was completed with the Director of Nursing (DON) on 1/10/24 at 2:38 PM. When queried regarding Resident #272's edema and lack of baseline care plan and ongoing assessment, the DON confirmed a care plan should have been implemented. No further explanation was provided. Review of facility provided policy/procedure entitled, Comprehensive Care Plan Guideline (Reviewed 12/31/22) revealed, 1. The 48-hour baseline care plan will be completed within 48 hours of admission and will be the temporary working care plan until the comprehensive care plan is completed . b. Care plan interventions should be reflective of risk area (s) or disease processes that impact the individual resident. C. Should new identified areas of concern arise during the resident's stay, they should be addressed on the care plan .

Based on observation, interview and record review, the facility failed to provide timely assistance and accessible call lights for two residents (Resident #20 and Resident #30) of three residents reviewed, resulting in a lack of timely care, residents yelling out for assistance, call lights not being in reach, and verbalization of feelings of humiliation and frustration. Findings include: Resident #30: On 1/8/24 at 10:47 AM, Resident #30 was heard from the hallway yelling out for help repeatedly from their room. Upon knocking and entering their room, Resident #30 was observed sitting in their wheelchair on the left side of their bed. Resident #30 was fidgeting and moving in their chair with a distressed appearance. When asked if they were okay, Resident #222 stated, I'm making a potty. I'm scared to go potty. When queried if they had turned on their call light to let staff know, Resident #30 indicated they did not know where it was, and the call light was observed on the floor. Resident #30 then stated, I don't want to have to beg. Resident #30 was queried how that made them feel and indicated it made them feel horrible. A Hoyer (mechanical lift) sling was observed under the Resident in the wheelchair. A staff member was observed in the hallway of the facility at 10:51 AM and entered the Resident's room. When queried regarding the call light on the floor, the staff member did not provide an explanation but quickly picked up the call light and began assisting the Resident. Record review revealed Resident #30 was admitted to the facility on [DATE] with diagnoses which included hemiplegia and hemiparesis (one sided paralysis) following cerebral infarction (stroke), dementia, depression, weakness, psychotic disorder, anxiety, and Urinary Tract Infections (UTI). Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the Resident was severely cognitively impaired and required partial/moderate to total assistance to complete Activities of Daily Living (ADL) with the exception of set-up assistance with eating. Review of Resident #30's Electronic Medical Record (EMR) revealed a care plan entitled, (Resident #30) has frequent episodes of incontinence R/T (related to): decreased mobility . (Start Date: 7/6/22; Revised: 12/22/23). The care plan included the interventions: - Offer and assist with toileting as needed and/or per request (Start Date: 7/6/22) - Provide incontinence care as needed (Start Date: 7/6/22) A second care plan entitled, Profile Care Guide (Start Date: 6/30/22; Revised: 12/29/23) was noted in Resident #30's EMR. This care plan included the intervention, Transfers: Transfer status: Hoyer 2 pa (person assist). Ambulation: therapy only. An interview was conducted with the Director of Nursing and Clinical Registered Nurse (RN) F on 1/10/24 at 1:01 PM. When queried if Resident call lights should be in reach, both the DON and RN F confirmed call lights should be within Residents reach. The DON and RN F were then told about observation of Resident #30 on 1/8/24. When queried regarding the Resident's statements including them saying they do not want to have to beg to use the restroom, the DON and RN F did not provide an explanation but verbalized understanding of the concern. Review of facility provided policy/procedure entitled, Resident Rights Guidelines (Review Date: 12/31/22) revealed, To ensure resident rights are respected and protected and provide an environment in which they can be exercised . Procedure . 2. Our residents have a right to . a. Be treated with dignity and respect . 39059 Resident #20: On 1/09/24, at 9:01 AM, Resident #20 was in bed eating their breakfast with the assistance with set up by Nurse W. Resident #20 was alert and stated breakfast was good. On 1/09/24, at 11:30 AM, a record review of Resident #20's electronic medical record revealed an admission on 6/03/2021 with diagnoses that included Dementia, Anxiety Disorder and Heart Failure. Resident #20 had severely impaired cognition and required assistance with all Activities of Daily Living. On 1/10/24, at 9:25 AM, Resident #20 was overheard yelling, Help me. Help me while in their room. Upon entering Resident #20's room, the resident was lying flat with their covered breakfast tray on the over bed table in front of them. Resident #20 asked for help sitting up and complained they were hungry. Resident #20's call light was coiled up directly under the bed out of reach. Resident #20 offered that they couldn't reach their call light. On 1/10/24, at 9:28 AM, Nurse E entered Resident #20's room and was asked where the call light was and Nurse E stated, it's under the bed oh, I see the problem. Nurse E was asked if Resident #20 was able to reach her call light and Nurse E stated, no. Nurse E pulled the call light out from under the bed and offered it to the resident. Resident #20 was asked if they knew how to get help and Resident #20 stated, yes and pushed the red button on the call light.

Based on observation, interview and record review, the facility 1) Failed to ensure that safe practices were in place to prevent a burn from hot coffee for one resident (Resident #14) and 2.) Failed to ensure fall that prevention measures were developed and implemented to prevent a fall for one resident (Resident #218), resulting in Resident #14 sustaining a burn injury on his right thigh without additional measures to ensure all residents were protected from similar burn injuries and Resident #218 falling without preventive measures identified and implemented to aid in preventing additional falls and a fracture to the hand. Findings Include: Resident #14: A record review of the Face sheet and Minimum Data Set (MDS) assessment indicated Resident #14 was admitted to the facility on [DATE] with diagnoses: history of a stroke, arthritis, neuralgia (nerve pain), left upper limb carpal tunnel syndrome, right shoulder pain, right hand stiffness, [CONDITION(S)], weakness, hypertension. The MDS assessment dated [DATE] revealed Resident #14 had full cognitive abilities and needed 1-person extensive assistance with dressing and hygiene and 1-person limited assistance with bathing. On [DATE] at 9:59 AM, during a tour of the facility, Resident #14 was observed sitting in a wheelchair in his room watching TV. He was alert and sociable and readily engaged in conversation. A review of an Event Report dated [DATE] and Event Date: [DATE], by Nurse GG revealed, Skin Integrity Events: Burn Event: . Location of Burn #: right thigh . Degree of Burn #1: Second Degree/Superficial Partial Thickness- Extends through the epidermis downward into the superficial into the dermal layer, dermal structures are intact. Characterized by large blisters, [CONDITION(S)], pain shiny surface . Additional comments for Burn #1: Length 2 cm, width 4.5 cm, blister ruptured . Pain of burn . (nothing was recorded) . Activity during when burn occurred: (options were: drinking hot liquid; from appliance, describe; while eating; other, describe) nothing was checked; Skin risk re-assessment: (it was blank, no options were checked); New Interventions- Immediate Actions taken: (it was blank, no options were checked); Burn Re-assessment: Follow-up- Week 1 , Week 2 and Week 3 were blank. There was no documented Follow-up. On the Event Report dated [DATE] for Resident #14, Treatments was documented Apply Xeroform to left outer thigh open area (burn) after NS (normal saline) cleanse. Cover with ABD (dressing) and secure with paper tape QD (daily), [DATE]-[DATE]. A review of the progress notes for Resident #14 provided the following: [DATE] at 2:55 PM, Pt (patient) reports to writer that on ,d+[DATE] in the evening approx. 930pm Pt had been carrying hot coffee on right side of chair and had tipped over causing burn to right thigh. Pt states he didn't tell anyone because It was late and there was nothing anyone could do about it. States, it was too late to call my son and have him go to the pharmacy. Writer educated res on notifying nursing staff so appropriate measures could be taken to assure no infection would take place. Informed res we order meds through our pharmacy. Area was assessed and noted with blistered area ruptured. Xeroform dressing applied after NS cleanse. Area covered and orders placed for treatments. NP (Nurse Practitioner) notified and will assess on ,d+[DATE]. A provider note by NP, Sep 6, 2022, General: Patient is an [AGE] year old male with past medical history . [CONDITION(S)] (stroke) who is a long term resident of the facility .Patient is being seen this morning for a burn to his right thigh. Patient states he accidentally dumped coffee on himself that resulted in a burn. Patient states this happened this morning. Patient states pain with palpation, mild in nature. Noted to have a second degree/partial thickness burn to outer right thigh. First presentation of burn possibly could be a deroofed blister from burn. Noncircumferential, less then 1 palm size of a burn. Reddened/[CONDITION(S)] skin noted to base of wound. No drainage noted. Peeled skin is noted to outer layer of burn. Patient was noted to have a dressing on wound with antibiotic ointment. Will order [MEDICATION(S)] cream at this time, cleanse area with NS and apply [MEDICATION(S)] cream with abd and tape down. Wound to be monitored and dressing changed 1 time daily or as soiled . [DATE], a progress note, CNA (nurse aide) assisted res with shower this am; hair washed. Nails cleaned. No trim. Right thigh with area of burn; skin appears open . [DATE], a progress note by NP Q, .F/u (follow-up) on burn to right thigh . Patient is being seen this morning for follow up on burn to right thigh. It was noted from patient that he split hot coffee on his leg a few days ago. Patient was evaluated then with [MEDICATION(S)] (burn treatment) cream Ordered. On assessment patient is sitting in wheelchair getting cleaned up for the day. On assessment patient is denying any chest pain shortness of breath fever chills or cough. Patient states that he feels that his burn is trending towards improvement. Site is measured where it is 4cm x 4cm with surrounding [CONDITION(S)] (redness), continues to be reddened at the base, with slight continuation of appearance of deroofed blister. Site is free from signs or symptoms of infection. Will continue with [MEDICATION(S)] BID (twice a day) and continue to monitor site . On [DATE] at 10:15 AM, a Healthcare surveyor obtained the temperature of the coffee at the coffee and juice bar in the Town Square dayroom. The coffee temperature was 166.1 degrees Fahrenheit. O [DATE] at 4:15 PM, the Food Service Director E and Corporate Food Service Director F were interviewed about the coffee temperatures at the coffee and juice bar, where residents were able to obtain their own coffee and they said they had temped the coffee and it was fine. Reviewed with them it had caused a 2nd degree burn on Resident #14's leg. They were asked if any additional measures were in place to prevent this from happening again and said the coffee was fine. An interview with the Director of Nursing/DON on [DATE] at 10:45 PM, about Resident #14 developing a burn on his right thigh from a hot coffee spill, she said the resident had not notified anyone of the spill until the next day. She said he had a blister on his leg from the hot coffee and after a few days did not want a dressing on it any longer. The DON said the facility had provided the resident with a cup holder for his wheelchair and he tried it and said he didn't like it. The DON was asked if the facility had tried a different cup holder or any other measures to aid in preventing future hot coffee spills and she said she would have to check on it. During an interview with Nurse V on [DATE] at 3:12 PM, about Resident #14's hot coffee spill and burn to his right thigh, the nurse stated All I know is when I came in the next day, they said he had spilled some coffee on his leg and there was a blister. He is usually eating his dinner about 6:30 PM; then later he propels in his wheelchair to Times Square where there is a coffee and juice bar. He usually goes there in the evening and gets a cup of coffee and propels himself back with the coffee. I believe they put a cup holder on the wheelchair. I asked him about it and he said, 'I don't like it.' I said it was for safety.' The Nurse was asked if any resident could go to the coffee and juice bar and get their own coffee and she said if they were able to, they could. On [DATE] at 9:15 AM, the DON and Clinical Support Nurse W were interviewed about the hot coffee burn that Resident #14 received. They were asked what interventions were put in place to ensure that it would not happen again. Both nurses talked about Resident #14 not liking the cup holder on his wheelchair. When asked if anything else had been tried, they said it hadn't. The nurses were asked if anything had been put in place so that other residents didn't receive a burn and there was no response. A review of the physician orders for Resident #14 did not identify any orders for prevention of [CONDITION(S)] from hot coffee. A review of the Care Plans for Resident #14 dated [DATE] provided, Resident demonstrates non-compliance with physician orders and/or plan of care as evidenced by: [NAME] did not inform staff that he spilled hot coffee on his leg until the following day, dated [DATE] with Interventions: [DATE]: Burn Intervention: intervention for burn includes adding a cup holder to chair; . (Resident #14) finally allowed cup holder to be attached to his wheelchair. Cup holder in place; [DATE]- per (Resident #14's) preference he states he does not need the cup holder on his wheelchair. [DATE]: Educate resident regarding physician orders and risk and benefits of compliance. [DATE]: Encourage resident to actively participate in care plan and decision making. [DATE]: Encourage resident to participate in decision making by offering choices . [DATE]: Staff educated (resident) to notify nursing staff immediately if he spills coffee on his self so appropriate measures can be taken to assure no infection will take place. The Care Plan did not offer any additional interventions to prevent Resident #14 from receiving another burn from hot coffee or other hot liquids. A policy for accidents was requested on [DATE] at 1:30 PM and not received prior to exit on [DATE] at 4:30 PM. Resident #218: A review of Resident #218's medical record revealed an admission into the facility on [DATE] and died at the facility on [DATE]. The Resident had diagnoses that included Covid-19 acute respiratory disease, Alzheimer's disease, dementia, cerebral ischemia, heart disease, [CONDITION(S)], kidney disease, diabetes, stroke, anxiety disorder, retention of urine, and pain. The Resident had been under Hospice services. A review of Resident #218's Minimum Data Set assessments (MDS) for Resident #218 revealed the following: -Dated [DATE], OBRA Admission assessment, Section C revealed the Brief Interview for Mental Status score of ,d+[DATE] that indicated severe cognitive impairment. Section G Functional Status for Activities of Daily Living (ADL) Assistance indicated the Resident needed extensive assistance with two-person physical assist with bed mobility and transfers. -Dated [DATE], OBRA Quarterly review, Section C revealed the Brief Interview for Mental Status score of ,d+[DATE] that indicated moderate cognitive impairment. Section G Functional Status for Activities of Daily Living (ADL) Assistance indicated the Resident needed extensive assistance with one-person physical assist with bed mobility and transfers. -Dated [DATE], OBRA Significant change in status assessment, Section C revealed the Resident had moderately impaired cognitive skills for daily decision making. Section G Functional Status for Activities of Daily Living (ADL) Assistance indicated the Resident needed extensive assistance with two-person physical assist with bed mobility and transfers. A review of Resident #218's progress notes revealed the following: -[DATE] at 5:36 AM, .Writer assisted CRCA (Certified Resident Care Associate (CNA)) with patient care this shift; writer calmly and patiently approached resident with permission to care for him, res showed some resistance, but was easily convinced we would be quick and efficient . -[DATE] at 4:59 AM, .Resident became agitated with HS (nighttime) cares but was easily redirected . -[DATE] at 5:15 AM, .Resident became agitated with HS cares but was easily redirected . -[DATE] at 3:49 AM, . early last shift res (resident) experienced some agitation, was easily redirected and allowed writer to collect bold pressure and check blood sugar . -[DATE] at 5:05 AM, Resident continues on hospice care, Resident became combative with incontinence care in the night. Resident also became agitated this morning when writer woke resident up to check BP but was easily redirected. -[DATE] at 10:30 AM, Writer called to resident's room in response to CNA calling out for her help. Upon entering room writer noted resident on floor on his stomach. ROM (range of motion) performed to all 4 extremities with no c/o (complaints of) pain resident assisted to his back and 3 abrasions to his forehead, 1 abrasion to the bridge of his nose, along with a bruise beginning to form to his right upper forehead. Resident c/o mild pain to his forehead but to no other areas of his body. Resident assisted x 3 to his w/c (wheelchair) and nurse performed neuro checks which were normal. (Physician) and hospice notified . -[DATE] at 2:16 PM, IDT (interdisciplinary team) fall review: . Fall was witnessed by CRCA (Certified Resident Care Associate, (CNA)) who states during transfer from bed to w/c resident lost balance when attempting to turn and fell forward. Current transfer status 1 PA (physical assist) with gait belt, transfer status updated to 2 PA with gait belt due to staff reporting increase assistance needed with transfers . -[DATE] at 9:39 AM, Resident observed with bruise around right thumb and wrist, unable to move thumb or wrist at this time. Nurse practitioner ordering x-ray . -[DATE] at 3:39 PM, Resident x-ray shows mildly displaced intra-articular fx (fracture) at medial base of the first metacarpal right hand, (Physician group) informed and hospice informed. Wife informed. -[DATE] at 10:57 AM, IDT met to discuss resident's fall on ,d+[DATE]. Resident was being assisted with care. He was transferring into his wheelchair when he lost his balance. CRCA did attempt to stop resident from falling but was unable to. Resident's POC (plan of care) show he was a standby assist with transfers at the time of fall. The next day resident complained of pain to hand. X-ray showed fracture. Resident sent to hospital for treatment where he was casted and returned to facility. Facility contacted hospice and got order for PT (physical therapy) to evaluate for transfer status. At the time of the fall staff downgraded residents transfer status. This will remain in place until PT evaluation. At the time of the fall the POC was being followed. Reviewed by IDT . On [DATE] at 2:15 PM, an interview was conducted with the Director of Nursing (DON) and the Clinical Support Nurse (CSN) W regarding Resident #218's fall on [DATE] while the CNA was transferring the resident that resulted in facial abrasions and a fracture to the hand. The CSN indicated that the physician order was for one person assist with gait belt, but the CNA was following the care profile that indicated the Resident was a standby assist. The CSN indicated they had identified that there was a mismatch in the transfer orders between hospice and the care guide. The DON indicated that the care guide is what the CNAs use when caring for a resident and was what the care plan was. The CSN reported that they had educated the staff to ensure all care plans and orders matched and were up to date. Documentation of aggressive behavior from Resident #218 with care was reviewed. The DON was asked about assessment and re-evaluation from therapy for safe transfers with the change in the Resident and showing aggressive behaviors. The DON indicated that the aggressive behavior was with care and not during transfers and stated, I don't believe that would be a criteria to downgrade transfer status to 2 person assist. The DON was asked when did decline start occurring with Resident #218. The DON reviewed the medical record and stated, On ,d+[DATE] ([DATE]) that was my first note on his decline. When asked what kind of decline the Resident was experiencing, the DON reported stroke like symptoms, elevated blood pressures, drooping of the left side, not able to lift his arms, and explained that he would have episodes and that when he came back around, he would be slow to respond. The DON was asked if the Resident was showing these signs and symptoms during the transfer when the fall occurred. The DON indicated she did not know and reported that the episodes were isolated and stated, As his diagnoses progressed, they got more frequent. The CSN and DON were asked if a gait belt was in use during the time of the transfer and fall. The DON indicated she was unsure. The CSN reviewed documentation and indicated that a gait belt was not in use and reported that the matrix (MDS) was one person assist and the care plan/care profile was standby assist with the physician order that was a one person assist with gait belt. The CSN reported that the CRCA (CNA) can't see the orders, so they were following the care profile. On [DATE] at 10:01 AM, an interview was conducted with CNA G who had transferred Resident #218 when the fall occurred. The CNA indicated she had got him out of bed and reported the care guide had the Resident as a standby assistance. The CNA reported that when he transferred, he was confused with what he wanted to do, and stated, He was confused when he stood up and was confused on how to turn to get into the wheelchair. When asked about the Resident's history of confusion, the CNA reported the Resident was always confused with transferring, and needed cuing with directions. The CNA stated, He was so timid with how to do it. Usually, I grab his pants and guide him to where he is supposed to transfer to. The CNA indicated she had been cuing the Resident and when he went to sit down had missed the seat of the wheelchair. When asked about gait belt use, the CNA stated, Use of a gait belt is usually done with transfers. Usually, I use a gait belt on everyone. The care plan (for Resident #218) did not have it on there. On [DATE] at 10:40 AM, an interview was conducted with Therapy Director, QQ. The Therapy Director was asked about gait belt use and indicated that a gait belt was used for all transfers unless the Resident was independent or modified independent. The Therapy Director indicated that gait belts were available in the Resident rooms and that staff were to use them with transfers. The Therapy Director was asked if a gait belt were to be used with a standby assist for transfers and he had reported that a gait belt should be used for standby assistance.

Based on interview and record review, the facility failed to ensure pressure ulcer interventions were provided per professional standards to prevent the worsening of a wound for one resident (Resident #169) of 3 residents reviewed for pressure ulcers, resulting in Resident #169 developing an Unstageable pressure ulcer with 80% of the wound covered in slough (dead, stringy tissue), with irregular, macerated (the softening and breaking down of skin as a result of prolonged exposure to moisture) wound edges, resulting in discomfort, frustration and potential infection. Findings Include: The National Pressure Injury Advisory Panel (NPIAP) Pressure Injury 2019 Guidelines for Pressure Injuries identified the following: A pressure injury is localized damage to the skin and underlying soft tissue usually over a bony prominence or related to a medical or other device. The injury can present as intact skin or an open ulcer and may be painful. The injury occurs as a result of intense and/or prolonged pressure or pressure in combination with shear Stage 1 Pressure Injury: Non-blanchable [CONDITION(S)] (redness) of intact skin Intact skin with a localized area of non-blanchable [CONDITION(S)], which may appear differently in darkly pigmented skin. Presence of blanchable [CONDITION(S)] or changes in sensation, temperature, or firmness may precede visual changes. Color changes do not include purple or maroon discoloration; these may indicate deep tissue pressure injury Stage 3 Pressure Injury: Full-thickness skin loss Full-thickness loss of skin, in which adipose (fat) is visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. Slough and/or eschar may be visible. The depth of tissue damage varies by anatomical location; areas of significant adiposity can develop deep wounds. Undermining and tunneling may occur. Fascia, muscle, tendon, ligament, cartilage and/or bone are not exposed. If slough or eschar obscures the extent of tissue loss this is an Unstageable Pressure Injury. Deep Tissue Pressure Injury: Persistent non-blanchable deep red, maroon or purple discoloration Intact or non-intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration or [MEDICATION(S)] separation revealing a dark wound bed or blood filled blister. Pain and temperature change often precede skin color changes. Discoloration may appear differently in darkly pigmented skin. This injury results from intense and/or prolonged pressure and shear forces at the bone-muscle interface. The wound may evolve rapidly to reveal the actual extent of tissue injury, or may resolve without tissue loss. If necrotic tissue, subcutaneous tissue, granulation tissue, fascia, muscle or other underlying structures are visible, this indicates a full thickness pressure injury (Unstageable, Stage 3 or Stage 4) . Unstageable Pressure Injury: Obscured full-thickness skin and tissue loss Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar. If slough or eschar is removed, a Stage 3 or Stage 4 pressure injury will be revealed. Stable eschar (i.e. dry, adherent, intact without [CONDITION(S)] or fluctuance) on the heel or ischemic limb should not be softened or removed. Resident #169: A record review of the Face sheet and Minimum Data Set (MDS) indicated Resident #169 was admitted to the facility on [DATE] with Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS assessment dated [DATE] revealed full cognitive abilities with a Brief Interview for Mental Status (BIMS) score of ,d+[DATE] and the resident needed extensive 2-person assistance with bed mobility, transfers and dressing and extensive 1-person assistance with hygiene and bathing. A review of the Admission Observation and Data Collection, nursing admission assessment dated [DATE] by Nurse GG revealed, Skin: . Skin Impairment: Skin events available; Bruise, Incision Pressure-Stasis Diabetic wound, Rash/Lesion, Skin Tear/Laceration: Yes, complete appropriate Wound Event for further assessment . A Braden Scale that identifies risk for skin breakdown was completed with a score of 12.0, High Risk- Initial Skin Plan of Care= Braden Score 12 or less- High to Very High Pressure Ulcer Risk- Resident will not develop a pressure ulcer, or if a pressure ulcer present it will not worsen: Turn and reposition for comfort with care . Use lift sheet to reposition in bed; Provide pressure relieving device chair; Explain consequences of refusal of treatments and/or prevention interventions; Ensure resident is clean and dry; Ensure adequate hydration; Observe labs; Observe nutritional intake; Provide vitamins and supplements per physician order; Check [CONDITION(S)] . For bedfast resident elevate HOB (head of bed) 30 degrees or less for short periods . In further review of the Admission Observation and Data Collection, admission assessment dated [DATE] identified Activities of Daily Living : Bed Mobility- Extensive Assistance; Transfers- Extensive Assistance; Toilet use- Extensive Assistance . A review of the progress notes identified the following: [DATE] at 5:40 PM by Nurse GG, Pt (patient) arrived at facility via stretcher; transferred via 2PA (2-person assist) to slide from gurney to bed . Alert and orient x 3; Skin assessed and slight redness/ fungal to bil (bilateral) groin; Apron. Bil (bilateral) buttocks with Areas of Ecchymosis (a bruise like injury) and denuded (a top layer of skin missing) tissue to center of areas, surrounding by redness slow to blanch . Pt reports history of pain to joints; hands, knees feet. Pt requires [NAME] (moderate) assist with positioning, fear of falling compromises mobility. Incont (incontinent) of bowel and bladder. [DATE] at 3:01 PM, by Nurse LL, Writer to room to assess skin, required max X2PA 2-person assist) with bed mobility, res (resident) fearful . able to visualize dark purple areas to sacrum that appeared non blanching, noted areas of denuded skin to sacrum and buttocks. Res aware of areas to buttocks . [MEDICATION(S)] Cream Ordered to Sacrum and Buttocks . [DATE] at 3:42 PM, a Nurse Practitioner/NP note by NP HH did not mention any skin problems. In the Skin section was documented no itching or burning. There was no mention of a dark purple non-blanching area to the resident's sacrum as identified on admission and [DATE] at 3:01 PM. On [DATE] at 5:40 PM, a note by Physician II, did not mention Resident #169's skin or dark purple area on the sacrum. The [DATE] MDS section M: Skin Conditions, revealed the following: Determination of Pressure Ulcer Risk: A. Resident has a stage 1 or greater, a scar over bony prominence, or a non-removable dressing/device. The answer was blank; Risk of Pressure Ulcers: 1. Yes, was checked; Unhealed Pressure Ulcer(s): 1. Yes, was checked; Unhealed Pressure Ulcer(s): 0. No, was checked; Number of Venous and Arterial Ulcers: Enter the total number of venous and arterial ulcers present. '0', was documented; Other Ulcers, Wounds and Skin Problems: None of the above were present, was checked; Skin and Ulcer Treatments: A. Pressure reducing device for chair, B. Pressure reducing device for bed, and I. Applications of ointments/medications other than to feet, were also checked. [DATE] at 2:31 PM, a note written by Nurse Practitioner HH did not mention the resident had a dark purple wound on his sacrum; in the Skin section of the note it provided No itching or burning. There was no additional mention of Resident #169's skin. The next note to mention the resident's skin was on [DATE] at 3:30 AM, by Nurse JJ Denuded skin on buttocks and sacral area has become red, excoriated and open in some spots. Extra protective cream applied. From [DATE] to [DATE] there was no mention of the dark sacral ulcer on the resident's sacrum, size, improvement or worsening in response to the cream treatment. A provider note dated [DATE] at 8:11 PM, revealed, Skin: no itching or burning. A progress note by Nurse LL[DATE] at 2:26 PM, Writer to room with NP and CRCA (nurse aide) to assess skin, . writer provide res with education on turning and repositioning to avoid further skin breakdown . Staff assisted res x 2 max assist with turning to assess buttocks wound. Res with slight resistance but with reassurance and encouragement res turned onto (left) side . Sacrum/Gluteal Fold: 10 cm (length) x 6.5 cm (width) area of purple non blanching skin, with 90% thin slough and 10% granulation within purple area, edges irregular in shape, moderate (serosanguinous drainage), peri-wound red blanching with denuded skin .Triad (cream) ordered . weekly wound rounds continue. [DATE] at 10:08 PM a note by NP HH revealed, Wound rounds: . Patient is being seen this morning for wound care rounds . he is being followed for a deep tissue injury that was present to his bilateral buttock and sacrum area upon admission to facility . DTI (Deep Tissue Injury) to bilateral buttocks has opened. Measures 10 cm x 6.5 cm. 90% slough and 10% granulation tissue . Pressure ulcer of sacral region, unstageable . small areas opening with slough present to majority of wound bed. We will have Triad cream applied daily . [DATE] at 4:12 PM, a provider note by NP HH mentions Skin: no itching or burning . Skin: No acute changes . There was no mention of the sacral/buttock wound. The next note mentioning Resident #169's skin was on [DATE] at 4:23 PM, Writer to room with NP and CRCA to assess skin . Staff assisted res x 2 mas assist with turning to assess buttocks wound . Sacrum/Gluteal Fold: Healing 8 cm x 6.5 cm base with 90% slough and 10% granulation, small area of eschar (dead, black tissue) to right side of wound . periwound red blanching with denuded skin. Triad (cream)continue as ordered, RD (Registered Dietitian) consulted, no recommendations at this time. Weekly wound rounds to continue. [DATE] at 11:13 PM, a provider note by NP HH, Wound Rounds: Skin- DTI: Measures 8 cm x 6.5 cm 90% slough, 10% granulation tissue. Small area of eschar to right side of wound . Continue Triad cream applied daily and (with) each episode of incontinence . The next mention of the resident's sacral/buttocks wound was on [DATE] by Nurse MM, Tx (treatment) applied as ordered . There was no further description of the wound. [DATE] at 11: 54 AM, a provider note by NP HH, Wound Round: . Skin: Stage U (unstageable): Measures 7 cm x 5.5 cm. 90% slough, 10% granulation tissue. Small area of eschar (black, dead tissue) to right side of wound . Continue Triad cream applied daily . Using Triad for skin protection from incontinence. Yes, topical dressing would become saturated . There was no mention of trying alternative treatments or dressings since the resident was admitted on [DATE]. There are dressings designed for residents with incontinence. The facility does not mention attempting any other wound treatment that may have aided in preventing the wound from becoming so large with open and necrotic tissue. A note dated [DATE] at 2:22 PM by Nurse MM provided, Resident encouraged to turn and reposition off buttocks while in bed, resident refuses to let staff assist him with turning on side. Educated resident and continues to refuse to turn on side. There was no mention if the resident was assessed for pain or if he received pain medication prior to the assistance with mobility. Initially the facility documented the resident was fearful with repositioning. There was no mention if the reason for this was identified and if so what interventions were attempted. [DATE] at 1:21 PM, a note by Nurse MM Treatment applied to buttocks as ordered, resident continues to be noncompliant with turning and repositioning . The note does not mention the resident's sacrum and there is no mention of pain assessment or additional interventions. A provider progress note dated [DATE] at 11:15 PM, written after the resident discharged home on [DATE] at 3:18 PM, . Skin: Stage U (unstageable): Measures 4 cm x 3.5 cm. 80% slough, 20% granulation tissue. Small area of eschar to right side of wound. Edges thick and irregular. Moderate serosanguinous drainage. Peri-wound is red and blanching with macerated skin . Resident #169 was admitted to the facility with a discolored wound on his sacrum. There were no measurements or description of the wound per Standards of practice until 7 days after admission. The facility did not mention attempting any treatment but cream. The wound opened to a large size of 10 cm x 6.5 cm with 90% slough on [DATE] and while small on discharge at 4 cm x 3.5 cm with 80% slough, there was also eschar (black dead tissue) all of which was not present on admission. The MDS assessment dated [DATE], 2 days after admission said there were no wounds, but the sacral wound was identified on admission and on [DATE] the Nurse Practitioner said the wound was present on admission. During the Admission Assessment, it required a Wound Event; this was not completed. A review of the care plans for Resident #169 provided the following: Resident has a DTI (deep tissue injury) pressure ulcer to Sacrum, any further breakdown unavoidable r/t (related to) res noncompliance, dated [DATE] with interventions: Administer analgesics (pain medication) per MD order; Observe and report signs of infection (e.g. localized pain, redness, swelling, tenderness, drainage, odor and fever); Observe for and report signs of pain r/t pressure ulcer; Treatment per MD order. Notify MD if treatment is not effective; Weekly skin assessment, measurement, and observation of the pressure ulcer and record. All interventions were dated [DATE]. There was no indication additional interventions had been attempted. The wound drainage was documented as serosanguinous, but odor was not assessed. There was no documented assessment of the depth of the open areas. A care plan titled, Skin Integrity: At risk for further skin breakdown r/t: decreased mobility, existing DTI, weakness, medication, (diabetes), [CONDITION(S)], non-compliance with repositioning . dated [DATE] with all interventions dated [DATE]. There was no mention of reevaluation of the interventions as noncompliance was identified with repositioning. What further interventions were attempted? On [DATE] at 11:30 AM, during an interview with the Director of Nursing and Clinical Support Nurse W, reviewed Resident #169's stay at the facility and the development of the sacral wound. Discussed that the resident did not have an open wound on admission; there was a discolored area on his sacrum and then the wound opened and became large at the facility. Requested copies of the ordered treatments. On [DATE] at 1:30 PM, an interview with Confidential Person J provided, He went to the hospital after he was at the facility. At the hospital, (after he left the facility) they said he had a Stage 3 wound on his tailbone. He didn't have that when he was admitted there (at the facility). I told the head nurse. He didn't have this when I sent him there. They were giving him extra strength Tylenol every 6 hours. That was not strong enough. Would you want that? He was a diabetic. He complained about it. He would say I want something for pain. For that kind of wound you would think they would give him something more. I am so upset. It became infected and he went to the hospital. At the hospital they debrided (removed the dead black tissue) it. He became septic (an infection throughout the body) and he died . A review of the physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] Acetaminophen (Tylenol) tablet; 325 mg; Amount to administer: 650 mg; oral; Every 6 hours- prn (as needed) for pain, [DATE]-[DATE]. The medication was documented as given on [DATE], [DATE], [DATE], [DATE] and [DATE]. There were no additional pain medications. Cleanse b/l (bilateral) buttocks with warm soapy water (Do not scrub) Pat area dry, apply Triad Paste to Buttocks prn (as needed), [DATE] to [DATE]. The treatment was documented as provided one time on [DATE] at 11:11 AM. Cleanse b/l buttocks with warm soapy water, pat dry, apply [MEDICATION(S)] Protective Cream bid (twice a day) to buttocks and Sacrum [DATE]-[DATE]. Triad wound paste, (OTC- over the counter), twice a day- [DATE]-[DATE]. Weekly skin assessment, [DATE]-[DATE] The skin assessment was completed on [DATE] and revealed No new skin issues. The skin assessment was not completed again until [DATE] when it was reordered on [DATE]-[DATE]. During an interview with the Clinical Support Nurse W on [DATE] at 2:00 PM, she provided documents that identified 5 interventions: 3 dated [DATE]- Encourage to turn and reposition while in bed; pressure reducing cushion to w/c (wheelchair); APM (alternating pressure Mattress) pressure reducing mattress; [DATE]- Cleanse b/l (bilateral) buttocks with warm soapy water, pat dry, Apply Secure Protective Cream BID (twice a day) to Buttocks and Sacrum; [DATE]-Cleanse b/l buttocks with warm soapy water (Do not scrub) Pat area dry, apply Triad Paste to buttocks prn (as needed). There were no additional treatment orders for the Sacrum. A review of the facility policies revealed the following: Guidelines for Pressure Prevention, effective date [DATE] and revised [DATE], Purpose: To maintain good skin integrity and avoid development of pressure ulcers. Procedures: Care plan interventions shall be implemented based on risk factors identified in the nursing assessment . Pressure/Stasis/Arterial/Diabetic Wound Guidelines, dated revised [DATE], To provide weekly documentation of wound measurements and condition. Procedures: 1. Appropriate wound event is completed by a RN/LPN in (electronic health record). a. Complete event for each impaired area . 2. Document description of wound using: Length . Width . Depth . exudates (drainage, Color, Odor, wound margins, surrounding tissue, tunneling and/or undermining .

This Citation Pertains to Intake MI 840. Based on interview and record review, the facility failed to implement and operationalize policies and procedures to ensure care coordination and timely response to a change in condition for one resident (Resident #701) of three residents reviewed, resulting in a lack of care coordination for scheduled blood transfusion, a delay in transfer to the hospital for emergency treatment with subsequent necessary surgical interventions due to a bowel obstruction (potential life threatenng condition where digested material is unable to move through the intestines), [CONDITION(S)] (surgically created opening in the abdomen to allow for the passage of stool), and the likelihood for infection and decline in overall health status. Findings include: Review of intake documentation revealed Resident #701 had gone to the facility for therapy. The intake revealed Resident #701 was at the facility for therapy and was walking with a cane at the end of February. The intake detailed Resident had been complaining for 2 weeks they couldn't have a bowel movement. On [DATE]th, (Resident #701) begged to go to the hospital. The nurse said a (sic) aide wrote mom had a medium poop two days before. (Resident #701) got very upset and insisted they didn't (have a bowel movement) and the aide was lying. The intake further revealed Resident #701 wasn't sent to the hospital until 9:30 PM that night. The intake also revealed the facility cut (Resident #701's) wrist band off from the day before when they got her pre- blood work done for the transfusion the next day. Since they did that, (Resident #701) had to repeat the process over again (type and crossmatch for blood transfusion). Record review revealed Resident #701 was most recently admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #701 was cognitively intact and required supervision to limited assistance to complete all Activities of Daily Living (ADLs). The MDS further revealed Resident #701 was always continent of bowel/bladder, was not on a toileting program, and did not have any constipation. Resident #701's medical record revealed the Resident passed away in the facility on [DATE]. An interview was completed with Resident #701's family member Witness A on [DATE] at 8:20 AM. When queried regarding Resident #701's stay in the facility, Witness A stated, I heard (Resident #701) tell them (facility staff) every day that they couldn't go to the bathroom and (Resident #701) was trying to dig it out (manually de-impact themselves) prior to being transferred to the hospital. When asked how long Resident #701 had been unable to go to the bathroom, Witness A indicated it had been every day for a couple of weeks. Witness A revealed they were going to see Resident #701 on the Sunday ([DATE]) as they did when Resident #701 called them and said please come early because they wanted to go to the hospital. When asked how often they visited Resident #701 at the facility, Witness A revealed they visited as often as possible and always on Sundays. Witness A was asked why Resident #701 wanted to go to the hospital, Witness A revealed the Resident told them they were not able to have a bowel movement, was having stomach pain, and just did not feel well. Witness A then stated, (Resident #701's) stomach had bloated out and (the staff) teased them and asked (Resident #701) if they were pregnant. It really upset me. When asked which staff members had said that to the Resident, Witness A was unable to recall specific staff names. Witness A was then queried what occurred when they went to the facility on Sunday, Witness A stated, The nurse came in (Resident #701's) room and asked when their last Bowel Movement (BM) was. Witness A revealed Resident #701 told the nurse they couldn't remember, and the nurse said, there was one documented on Thursday. Resident #701 said it was just [MEDICATION(S)] and indicated it was not really a bowel movement. When queried happened, Witness A stated, At 10:00 AM, the nurse said they could not just send (Resident #701) to the hospital, and they had to get an X-Ray (at the facility). Witness A was asked if the Resident got an X-Ray and revealed they did but didn't end up getting sent to the hospital to after 9:00 PM. When queried regarding Witness A's hospitalization , Witness A revealed the Resident had surgery on Monday and stated, The surgeon called me and said they had never seen anyone compacted that bad. They had to leave (Resident #701's) open after the surgery. Witness A revealed the Resident had to have another surgery and ended up with a [CONDITION(S)] because so much of their intestine had to be removed. With further inquiry regarding Resident #701's stay at the facility, Witness A revealed the Resident experienced a delay in their scheduled outpatient blood transfusion. Witness A stated, They (facility) cut (Resident #701's) blood band off and then had to go through it all again. When asked what they meant, Witness A revealed the Resident had to have another type and crossmatch (laboratory blood test to ensure blood compatibility) completed which delayed the transfusion. Witness A revealed the Resident returned to the facility and got [CONDITION(S)] (infection throughout the body) before eventually passing away on Mother's Day ([DATE]) in the facility. Witness A stated, (Resident #701_ did nothing but suffer before they died . They (facility) neglected (the Resident). They didn't listen to them. Review of Resident #701's Electronic Medical Record (EMR) revealed the following progress note documentation: - [DATE] at 9:15 PM: Nursing Note: Resident requested Tums for indigestion . order for Tums 2 tabs po (oral) Q (every) 6 hours PRN (as needed) - [DATE] at 4:39 PM: Provider Note: Patient is being seen this morning to follow-up on a concern regarding medication regimen as patient states multiple home medications are not currently on regimen . denies . abdominal discomfort Patient reports appetite has remained adequate and denies any recent changes to her bowel or bladder habits . states she has had any loose stools for several days and states . bowel pattern has returned to baseline . reporting increased frequency of reflux symptoms such as indigestion . review of patient's home medications with patient's family it is noted that patient [MEDICATION(S)] was listed on hospital discharge for patient to continue. Patient has been requiring Tums for symptom management over the weekend. Will resume patient's [MEDICATION(S)] (medication used to decrease the amount of acid in the stomach) 40 mg (milligrams) twice daily and will follow patient symptoms . - [DATE] at 5:19 PM: Physician Note: Chief Complaint . Admission to facility . recently hospitalized for abdominal pain and diarrhea. CT (Cat Scan) abd (abdomen)/pelvis showed findings consistent with chronic [CONDITION(S)]. GI (Gastrointestinal Medicine) was consulted, no recommendations . Abd pain resolved. Monitor bowel habits. Routine follow up with GI . - [DATE] at 10:19 PM: Provider Note: Chief Complaint . Change in bowel habits . Patient is being seen this morning to follow-up on a change in bowel habits . states appetite has remained at baseline . Patient does report significant decline in frequency of bowel movements as well as increased difficulty with passing stool. Patient reports that her baseline status at home is to have infrequent and difficult to pass bowel movements for which she frequently requires stool softeners. Patient has not been receiving stool softeners since admission to facility . will order [MEDICATION(S)] (stool softener) nightly for patient for bowel regimen to enhance patient comfort and ease of passing stool . - [DATE] at 2:00 PM: Nursing Note: Resident c/o (complain of) not being able to have BM consistently. Requesting [MEDICATION(S)] . NP (Nurse Practitioner) notified. [MEDICATION(S)] given and ordered daily . - [DATE] at 3:35 PM: Nursing Note: Resident c/o bloating and constipation before lunch and unable to eat. Drank a few sips of ensure. Abdomen very distended, firm and tender to touch. Bowel sounds in RUQ (Right Upper Quadrant - abdomen) hyperactive (active sounds are normal), otherwise bowel sounds hypoactive. Resident stated has not been having good BM's for a long time and . usually has to 'dig them out'. Daughter here and confirmed. Resident has had documented BM's in (EMR). Stated had an enema 2 days ago with no results. Documented medium BM on [DATE]. (Health Care Provider) called and order received for Abdominal X-ray stat. X-ray ordered and completed this afternoon. Results pending . - [DATE] at 8:52 PM: Provider Note: Notified of abd XR results, done as stat on previous shift d/t (due to) constipation and largely distended abdomen in the setting of hx (history) of ischemic [CONDITION(S)]. Pt has had emesis x 1, XR (X-Ray) reveals 'Massively dilated large bowel loops, 11.8 cm (centimeters), in the central abdomen with paucity of air within the distal large bowel loops and rectum. Order given for transfer to ER. - [DATE] at 9:47 PM: Nursing Note: Writer advised by CNA (Certified Nursing Assistant) that resident had a small emesis. Small amount of brown emesis observed in basin. Abdomen is distended and absent of bowel sounds in all 4 quadrants. Previous shift progress note states that resident abdomen is distended and imaging was ordered. Writer called (mobile) X-ray to get results of imaging that shows a high-grade large bowel obstruction. VS (Vital Signs) BP (Blood Pressure),d+[DATE], P (Pulse) 91, RR (Respiratory Rate) 18, Temp 98.6, SPO2 (oxygen saturation) 95% on 2L (Liters) O2 (oxygen) via N/C (nasal canula). Called (Health Care Provider) and reported the condition . ordered resident sent emergency dept . - [DATE] at 8:22 PM: Nursing Note: Resident arrived by ambulance via stretcher . r/t (related to) bowel obstruction . - [DATE] at 2:18 AM: Nursing Note: Skin assessment complete. Resident had surgery on the bowel, incision to the left side 11.5 cm in length and has 17 staples. New stoma to the right side 4 cm x 5 cm . Some excoriation around the stoma, with 7 sutures . - [DATE] at 3:51 PM: Provider Note: Discussed with patient need for blood transfusion and possibility scheduling outpatient. - [DATE] at 8:33 AM: Nursing Note: Resident loa (leave of absence) to (outpatient transfusion center) for blood transfusion . - [DATE] at 4:13 PM: Nursing Note: Resident returned from infusion . Record review revealed the following bowel movement documentation in Resident #701's EMR: - [DATE] - Small - [DATE] - Small - [DATE] - Medium - [DATE] - Medium - [DATE] - Medium/Large - [DATE]- Medium - [DATE] - Small/Medium - [DATE]- Small (Documented by Certified Nursing Assistant [CNA] B) - [DATE]- Medium (Documented by CNA C) The documentation did not include details of the character of the Resident's bowel movements. Review of Resident #701's documented weights in the EMR revealed the Resident weighed 131.2 pounds on [DATE] and 138 pounds on [DATE]. An interview was conducted with CNA B on [DATE] at 2:29 PM. When queried regarding Resident #701, CNA B revealed they did not recall the Resident. CNA B was then queried regarding the facility process/procedure for monitoring/documentation of resident bowel movements, CNA B revealed they document If resident has a BM and the size in the EMR. CNA B was then asked how they determine BM size when documenting in the EMR, CNA B replied, It depends on the resident. When asked to clarify if they were saying there was no standardized documentation related to BM size in the facility, CNA B revealed there was not. When asked what a pea amount size of stool would be documented as, CNA B indicated any amount of stool, no matter how minute would be documented as small. When asked BM the size of three peas would be documented as, CNA B replied, Medium. Review of Resident #701's Health Care Provider Orders in the EMR revealed an order dated [DATE] which specified, Order Description: Complete type and cross lab work for blood transfusion on [DATE] . Frequency: Once . No documentation was present in the EMR related to the blood transfusion completion. An interview was conducted with the Director of Nursing (DON) on [DATE] at 3:48 PM. When queried regarding documentation regarding Resident #701's blood transfusion order dated [DATE] for type and cross match lab testing and lack of documentation related to the transfusion completion in the EMR, the DON reviewed the EMR and confirmed there was no documentation. The DON was then queried where Resident #701 had their transfusion and replied, Transfusion center at the hospital. When queried regarding facility policy/procedure related to communication and care coordination with the blood transfusion center, the DON revealed they were unsure if the facility had a policy/procedure. The DON was then queried if Resident #701's blood band (specific identification bracelet placed when blood sample is obtained and utilized for blood product transfusion) had been cut off, the DON revealed there was no way to know if the blood band identification bracelet had been removed at the facility. When queried if facility staff received education related to blood bank identification bracelets, the DON replied, No. A policy/procedure related to care coordination for blood product transfusion was requested at this time. On [DATE] at 4:10 PM, an interview was completed with the DON and Registered Nurse (RN) G. When asked, the DON and RN G stated the facility does not have a policy/procedure related to care coordination and blood [CONDITION(S)]. An interview was conducted with the DON at [DATE] at 4:47 PM. The DON was queried regarding facility policy/procedure related to documentation of bowel movement size and indicated staff document the frequency and size of resident bowel movements. When queried how facility staff know what a medium sized bowel movement is to document is, the DON stated, It's subjective. When asked the DON revealed there was no consistency and/or education provided to staff regarding bowel movement size. Review of Resident #701's Medication Administration Record (MAR) and Treatment Administration Record (TAR) for February 2022 revealed the following: - Last recorded BM ,d+[DATE]- please verify and initiate BM protocol if indicated . Once . (Start Date: [DATE]) - Senna [OTC] tablet; 8.6 mg . Administer at bedtime . (Start Date: [DATE]). The medication was not administered on [DATE] due to Drug/Item Unavailable. - Order Set- If no bowel movement within 72 hours; 2 Tablespoons (30 cc [cubic centimeters]) of 'Natural Laxative' . Once A Day - PRN . assign to bowel protocol flow sheet . (Start Date: [DATE]). There was no documentation of administration. - Order Set- If no results within 24 hours, after 'natural laxative' give 30 cc Milk of Magnesia . Once a day - PRN . (Start Date: [DATE]). The medication was administered on [DATE] and [DATE]. - Order Set- If no results within approximately 12 hours of above MOM (Milk of Magnesia) administration give Dulcolax suppository per rectum . Once A Day - PRN . q (every) day PRN if no results from MOM . (Start Date: [DATE]). Documentation indicated Resident #701 requested and received a suppository on [DATE] due to constipation and discomfort . - Order Set- If results of suppository are not satisfactory within 2 hours give Fleets enema per rectum . Once A Day - PRN . (Start Date: [DATE]). There was no documentation of administration. Review of Resident #701's MAR and TAR for [DATE] revealed the following: - Dulcolax ([MEDICATION(S)]) suppository 10 mg . rectal once a day PRN . (Start Date: [DATE]). The medication was administered on [DATE] with the comment, Constipation per (Nurse Practitioner) request . Not Effective . and on [DATE] at 9:09 AM per Resident request. - [MEDICATION(S)] powder 17 gram/dose . once a day . (Start Date: [DATE]) - Senna [OTC] tablet; 8.6 mg . Administer at bedtime . (Start Date: [DATE]) - Order Set- If no bowel movement within 72 hours; 2 Tablespoons (30 cc [cubic centimeters]) of 'Natural Laxative' . Once A Day - PRN . assign to bowel protocol flow sheet . (Start Date: [DATE]). There was no documentation of administration. - Order Set- If no results within 24 hours, after 'natural laxative' give 30 cc Milk of Magnesia . Once a day - PRN . (Start Date: [DATE]). There was no documentation of administration. - Order Set- If no results within approximately 12 hours of above MOM administration give Dulcolax suppository per rectum . q day PRN if no results from MOM . (Start Date: [DATE]). There was no documentation of administration. - Order Set- If results of suppository are not satisfactory within 2 hours give Fleets enema per rectum . Once A Day - PRN . (Start Date: [DATE]). Documentation revealed the enema was administered on [DATE] but was not effective. Review of Resident #701's EMR revealed a care plan titled, Resident has potential constipation (Problem Start Date: [DATE]). The care plan included the interventions: - Administer medications/enemas/suppository as ordered (Approach Start Date: [DATE]) - Document frequency and character of BM's (Approach Start Date: [DATE]) - Encourage dietary fiber intake (Approach Start Date: [DATE]) - Encourage physical activity (Approach Start Date: [DATE]) - Position resident upright as able on bed pan for BM's (Approach Start Date: [DATE]) - Position resident upright on toilet for BM's (Approach Start Date: [DATE]) - Provide privacy for BM's (Approach Start Date: [DATE]) Review of Resident #701's Health Care Provider Orders in the EMR revealed an order dated [DATE] which specified, Order Description: Complete type and cross lab work for blood transfusion on [DATE] . Frequency: Once . An interview was completed with RN E on [DATE] at 7:16 PM. When queried regarding Resident #701's condition on [DATE], RN E indicated they were not sure what happened that day. The progress note they wrote in Resident #701's EMR on [DATE] at 3:35 PM was reviewed with RN E at this time. After review, RN E revealed they had been the Resident's assigned nurse on the day shift. When queried what occurred, RN E stated, (Resident #701) looked sick and I was worried. (The Resident) didn't eat anything at all that day. When asked if the Resident's abdomen was distended, RN E revealed it was the first time I had (Resident #701) so I had nothing to compare to. With further inquiry, RN E stated, I just remember I called the doctor right away and did what I could to help (Resident #701). When asked why the Resident was not transferred to the hospital sooner due to their concerns, RN E revealed they contacted the Provider and obtained an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . When asked if an individual can have bowel movements when they have a bowel obstruction, RN E replied, Yes. When asked if the Resident was impacted on [DATE], RN E revealed they were unsure and did not assess for impaction. When queried regarding the specific time Resident #701 complained of feeling ill and when they completed their assessment before lunch as documented in their note, RN E revealed they were unsure of the specific time but indicated it was in the morning. RN E was then queried regarding facility policy/procedure related to the time frame for STAT X-Ray and diagnostic testing results and replied, Should be within four hours. When asked why documentation in Resident #701's EMR indicated the Resident was not transferred until after 9:00 PM, RN E was unable to provide an explanation. RN E was asked if Resident #701's X-ray was obtained when they were working and replied, I think so but was unable to state when the time the x-ray was obtained. When asked if they conveyed their concerns regarding the Resident's condition to the oncoming shift in report, RN E replied, We do report but did not elaborate further. On [DATE] at 9:36 PM, an interview was completed with Licensed Practical Nurse (LPN) D. When queried they recalled Resident #701 including their transfer to the hospital on [DATE], LPN D replied, Think that was the first time had (Resident #701). With further inquiry, LPN D stated, I had taken report and (Resident #701) was uncomfortable and in pain. LPN D was asked when they were notified of Resident #701's change in condition and stated, I start work at 6:00 PM and then get report. When queried what time they assessed Resident #701 related their documentation in the EMR (note dated 9:47 PM on [DATE]) and identification of Resident #701's change in condition, LPN D revealed that is a very busy time and their recollection of that time is not clear. With further inquiry, LPN D stated, I'm not sure when I assessed (Resident #701). When queried regarding Resident #701's abdominal X-Ray and the EMR note indicating they had to contact the diagnostic imaging company to obtain the results, LPN D replied, I guess it (X-Ray) hadn't came through. LPN D was queried regarding the facility policy/procedure related to Stat X-ray and replied, At night, we usually get nothing about imaging. When asked if it is normal to have to call for the results of STAT X-Rays, LPN D reiterated night shift do not typically receive diagnostic imaging results. LPN D was then asked the normal timeframe for receiving STAT X-Ray results and replied, It could be a day. When asked if the results are typically faxed or called to the facility, LPN D replied, They (imaging company) usually call. When queried regarding the length of time from Resident #701's symptom onset to when they were transferred to the hospital, LPN D indicated they were unable to specifically recall the timeframe of the events which occurred without reviewing the Resident's EMR. LPN D indicated they were working and would be able to review Resident #701's EMR and provide a response after review. On [DATE] at 7:26 AM, a follow up interview was completed with LPN D. When queried if they had an opportunity to review Resident #701's EMR, LPN D replied, Yes. When asked why Resident #701 was not transferred to the hospital until 9:47 PM per their note documentation, LPN D stated, I did not chart right away and should have put late entry in documentation. When asked what time the Resident was transferred, LPN D was unable to provide a time. LPN D relayed they spoke to the DON and the DON was contacting the EMS transportation company to obtain a copy of their documentation in order to determine the time Resident #701 left the facility. At 8:35 AM on [DATE], the timeframe from identification of change in condition and further decline in Resident #701's medical condition while at the facility was reviewed with RN G. When queried why the Resident was not transferred immediately when RN E's assessment findings were abnormal and indicated a potential bowel obstruction, the Resident's medical history, and Resident/Family request to be transferred, RN G indicated they were unaware the Resident/family wanted to be transferred. When asked why additional assessment of the Resident's abdomen and bowel sounds were not completed following RN E's initial assessment, RN G was unable to provide an explanation. When queried regarding the decline in Resident #701's medical condition and worsening of their bowel obstruction from functioning (as evidenced by the presence of bowel sounds) to non-functioning with complete blockage (as evidenced by absence of bowel sounds), RN G stated, I see what you are saying. RN G verbalized understanding of the concerns identified but did not provide further explanation. An interview was conducted with Therapy Staff F on [DATE] at 9:15 AM. When asked, Staff F revealed they worked with Resident #701 during their stay at the facility from [DATE] until [DATE]. Staff F was queried regarding the Resident and stated, They were doing really well. I had them walking with a cane and then they sent (Resident #701) out (to the hospital) and went downhill. When asked, Staff F was unable to recall any further information regarding the Resident's change in condition. On [DATE] at 9:57 AM, an interview was completed with Therapy Staff H. When asked if they worked with Resident #701 during their stay at the facility from [DATE] until [DATE], Staff H indicated they had. When queried regarding the Resident, Staff H replied, (Resident #701) was doing phenomenal until the bowel obstruction. When queried if they recalled the Resident's abdomen becoming distended prior to their bowel obstruction and transfer to the hospital, Therapy Staff H replied, (Resident #701) had a lot of fluid but did not elaborate further. An interview was completed with CNA C on [DATE] at 10:54 AM, When queried regarding Resident #701, CNA C expressed they were unable to recall the Resident. When queried regarding RN G stating the Resident had not eaten all day and meal intake documentation they entered indicating they ate 75 to 100 % of both their breakfast and lunch, CNA C was unable to provide an explanation. When queried regarding the facility process/procedure for documented meal intake, CNA C revealed staff collect the trays and document how much the residents eats as a percentage. When queried if they had collected Resident #701's tray on [DATE], CNA C was unable to recall. With further inquiry regarding Resident #701's intake on [DATE], CNA C revealed it was possible they had documented the intake incorrectly or on the wrong resident but were unable to recall. CNA C was then queried regarding documentation of BM size and stated, Large is more than the size of my hand. When asked what would be small in relation to a pea, CNA C revealed they would document a BM that was the size one to two peas as small and more than two peas as medium. When queried if they had received training regarding documentation of BM size for consistency and/or characteristics, CNA C stated, I have had to self-train myself. Review of Resident #701's diagnostic imaging Abdomen, 1 View revealed, Date of Service: [DATE] . Reported [DATE] 15:45 (3:45 PM) . Final [DATE] 16:42 (4:42 PM) . Clinical Information: Constipation . Abdominal distension . Impressions: 1. Massively dilated (up to 11.8 cm) large bowel loops in the central abdomen, with paucity of air within the distal large bowel loops and rectum; (Diagnosis) includes high-grade large bowel obstruction . Review of Resident #701's medical records obtained from their hospital admission on [DATE] included: - [DATE]: Emergency Documentation . Chief Complaint: Confirmed bowel obstruction . Abdomen rigid and distended with no bowel sounds . History of Present Illness . presenting today . for a bowel obstruction . complaining of abdominal pain, and distention, states had had episodes of nausea and vomiting that started today, unsure of last bowel movement . Gastrointestinal: Diffusely distended, tympanic . states stomach feels hard 'like a rock' . slightly [CONDITION(S)] (elevated heart rate) likely secondary to pain . physical exam significant for abdominal distention, concerning for an obstruction. Patient immediate OG (Orogastric tube- tube placed through the mouth into the stomach to allow for removal of contents) tube placement, after NG (nasogastric) tube was difficulty to place . discussed with surgery . plan for OR in the morning . feels slightly improved after OG tube . - [DATE]: History and Physical . patient complains of abdominal pain, distention, nausea/vomiting . Hx (history) of chronic [CONDITION(S)] (inflammation of colon) with possible toxic megacolon . taken to OR for peritonitis, large bowel obstruction and toxic megacolon exploratory laparotomy with open colectomy . removal of ileum with ileocolostomy . partial excision of stomach - [DATE]: Operative report . Operative Summary . The colon was significantly distended and ischemic appeared, corresponding with toxic mega colon (dilated colon with distension). A controlled [CONDITION(S)] was made at this time and suctioned out 2 L (Liters) of fecal material, decompressing the colon . An abdominal wound vac device was placed into the abdominal cavity . This completes the first stage of surgery . will return for a second look operation in 24 - 48 hours . - [DATE]: Operative report . Operative Summary . Re-opening . Completion Colectomy . small bowel resection . abdominal wound vac was removed . open abdomen was evaluated . decision was made to undergo a diverting loop [CONDITION(S)] . An interview was completed with Physician N on [DATE] at 11:19 AM. When queried regarding Resident #701, Physician N revealed they had spoke with the DON and RN G regarding the Resident and reviewed their medical record. When queried regarding Resident #701's bowel obstruction development and transfer to the hospital on [DATE], Physician N indicated Resident #701's bowel obstruction was related to their diagnoses. With further inquiry, Physician N indicated the Resident was hospitalized due to [CONDITION(S)] prior to being transferred to the facility. Physician N was then queried regarding medical/nursing management and/or increased monitoring/assessment of the Resident including diet, medications, and/or assessments if they were at increased risk related to their diagnosis, Physician N revealed they were unable to provide any specific information without reviewing the Resident's EMR. When queried regarding the timeframe between Resident #701's symptom onset and transfer, Physician N revealed they were not working the date the Resident was transferred. Physician N was then asked if they would have transferred the Resident sooner and stated they would have got an X-Ray prior to transferring to the hospital. When queried what a reasonable time frame for STAT diagnostic imaging results, Physician N stated, Everything longer with Covid but should be four hours. When queried regarding the length of time between Resident #701's onset in symptoms and transfer, Physician N was unable to provide an explanation. On [DATE] at 11:40 AM, a phone interview was completed with Surgeon L who was the on-call surgeon covering for Surgeon K who had completed Resident #701's bowel surgery. When queried regarding Resident #701's surgery and bowel obstruction including the reason for the obstruction, Surgeon L reviewed the medical record and stated, Not (caused) from adhesions. (Resident #701) had a narrowing (in bowel) already then inflammation added to it. When asked the obstruction was caused from constipation, Surgeon L indicated they were unable to answer that with the information they currently had to review but confirmed two liters of stool were removed from Resident #701's bowels. Record review EMS Prehospital Care Report for Resident #701 dated [DATE] specified the facility called Emergency Services for a BLS (Basic Life Support) transfer at 8:52 PM and the Ambulance arrived at the facility at 9:34 PM. The report further detailed, Impressions . Bowel Obstruction . Primary Symptom of: Abdominal rigidity . Abdominal distension, Epigastric pain, weakness . Constipation . Narrative Very distended and rigid abdomen with pt (patient) expresses pain in epigastric region Pt also has absent bowel sounds . Review of requested transfusion medical record documentation from [TRUNCATED]

This Citation pertains to Intake Number MI 617. Based on interview and record review, the facility failed to provide acceptable quality of care for one (Resident #1) of four residents reviewed, resulting in Resident #1 sustaining a laceration to the left leg and a ruptured hematoma from a laboratory blood draw, resulting in blood loss, a decreased hemoglobin level and hospitalization with a surgical intervention. Findings include: Record review of facility 'Guidelines for Admission Nursing Observation and Data Collection', dated 05/22/2018, revealed the purpose to complete and document a comprehensive assessment of the resident's current medical status, identify risk factors for additional complications or safety concerns and implementing a temporary plan of care to address problem areas. (3.) The observation and data collection shall include identification of risk factors through assessment, observation, and review of pertinent documentation that may contribute to additional complications, medical decline, or safety concerns . Record review of facility 'Anti-Coagulant Assessment Guideline' Policy, dated 05/22/2018, revealed the purpose was to provide guidelines for monitoring residents on anti-coagulant therapy. (1.) Each resident receiving anticoagulant drug therapy will be monitored for side effects. (4.) .most recent [MEDICATION(S)] lab will be reviewed . (5.) Residents on anticoagulants will be care planned to monitor for side effects of anticoagulant therapy. Record review of the facility 'Notification of Change in Condition' Policy, dated 05/23/2018, revealed the purpose was to ensure appropriate individuals are notified of change in condition. Sample reasons to notify the physician immediately but not limited to: (1.) Deterioration in health . life threatening conditions or clinical complications. (2.) Need to alter treatment significantly (commence new treatment). Resident #1: Record review of Resident #1's admission referral forms from the hospital, dated 01/09/2021 and located in the residents closed medical record, revealed resident was admitted to the hospital on 01/09/2021 for [MEDICATION(S)] toxicity (anticoagulant/blood thinner) and [CONDITION(S)] (CHF). Lab Partial Thromboplastin Time (PTT) and International Normalized Ratio (INR) levels were elevated. Upon discharge on 01/13/2021 to the nursing home, Resident #1's PTT level was 17.6 (normal range 9.3-11.3) and INR level was 1.74 (normal range 0.90-1.10)- both levels were elevated. Hemoglobin (blood oxygen level) was 11.4 on 01/13/2021. Record review of Resident #1's Closed nursing home medical record revealed a 19-day stay from admission on 01/13/2021 at 7:26 PM to discharge on 02/03/2021 back to the hospital emergency room . Record review of Resident #1 admission assessment, dated 01/13/2021 at 7:26 PM, revealed assessment information was obtained from the resident and the medical record. Admission assessment revealed [AGE] year-old female admitted with [CONDITION(S)] and no upper or lower extremity [CONDITION(S)] noted. The right lower leg had a contracture and was not able to bend. Isolation precautions assessment checked. Record review of Resident #1's 48-hour Baseline Care Plan, dated 01/14/2021 at 9:40 AM, identified anticoagulant medication usage. Record review of Resident #1's Comprehensive Care Plans Pages 1-14- with problem start date of 01/14/2021, revealed that there was no care plan for the monitoring of the hospital diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . There were no interventions or safety monitoring related to the anticoagulant use. Record review of Resident #1's physician's progress note, dated 01/14/2021 at 1:47 PM, revealed: this [AGE] year-old female admitted for skilled nursing facility after hospitalization for pulmonary vascular congestion and [CONDITION(S)] with slow ventricular response switched to [MEDICATION(S)] (blood thinner that reduces blood clotting www.[MEDICATION(S)].com). Record review of Resident #1's nursing progress note, dated 01/17/2021 at 12:26 AM, noted bruises in healing stages . Record review of Resident #1's admission Minimum Data Set (MDS), dated [DATE], revealed an elderly female with a Brief Interview of Mental Status (BIMS) score of 8 out of 15, cognitive impairment noted. Active medical diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #1's progress note, dated 01/19/2021 at 2:36 AM, revealed, Tele-health system notified of lab results. Record review of Resident #1's progress note, dated 01/19/2021 at 12:33 PM, revealed residents' right hand and fingers swollen, large hematoma to right wrist proximal to hand. Resident can move fingers and has decreased range of motion to right wrist. No history of falls. Resident denies anyone causing injury or being rough with her, denies any injury occurring to her wrist, denies hitting wrist on any equipment or furniture. Resident states she had her blood drawn on 01/19/2021 where hematoma has occurred. Documented by phlebotomist blood draw in right arm. X-ray order given and done. An interview on 3/30/2021 at 2:20 PM with Registered Nurse (RN) J revealed that the hematoma was on Resident #1's right arm. RN J stated that the resident had hospital ID bands that were up to her elbow. We cut those off because of the swelling. She had right arm swelling from below the elbow to the fingertips. The hematoma was located on the right wrist area above the wrist joint. The hematoma was cool to the touch, soft, black in color. She had full range of motion in fingers with limited motion in the wrist. Called Doctor applied an Ace wrap bandage for compression with ice on/off every 2 hours. She did not have any falls or injuries. She said that she had blood drawn there. We looked up lab draws and identified blood drawn from that hand. Blood had infiltrated the skin. Orders that nurse go with lab phlebotomist for this resident to monitor. Every time I took care of her, I saw the hematoma. She was a good patient. She was compliant and kept her arm elevated up on pillows. I would estimate the hematoma to be a 2-inch circle that was black-dark blue in color. Record review of Resident #1's progress note, dated 01/20/2021 at 1:27 PM, revealed that the Nurse Practitioner (NP) was notified of x-ray results and ordered ace wrap to right hand and remove at bedtime. Cold compress every two hours as resident tolerates. Elevate right hand on pillow Nutrition progress note, dated 01/21/2021, revealed a lab of 01/18/2021 with a hemoglobin of 11.1. Record review of Resident #1's progress note, dated 01/21/2021 at 1:37 PM, revealed that Resident #1 stated hematoma from a recent blood draw. Record review of Resident #1's physician's progress note, dated 01/21/2021 at 5:53 PM, noted a large purple lump on right wrist . most likely secondary to blood draw, resident being on [MEDICATION(S)] (blood thinner) . Record review of Resident #1's progress note, dated 01/29/2021 at 1:27 PM, revealed, On 1/29/2021 noted nurse aide went to help transfer resident into bed and noticed bleeding. Nurse noted large skin tear to left lower extremity. Pressure applied, area cleansed and Steri strips applied, 4 X 4 (gauze), ABD pad, Krelix (gauze wrap). An interview on 3/31/2021 at 11:28 AM with Certified Nurse Assistant (CNA) D revealed the Resident #1 was sitting up in a wheelchair. CNA D stated that she and the resident transferred with the use of a walker. She stood up with the walker, and the back of her leg grazed the metal wheelchair pedal attachment piece, the hole that the pedals attach to the wheelchair. CNA D stated that the resident did not have any pedals on the wheelchair. She sat on the bed and I went to pick up her legs to assist her into bed and my gloves touched her pant leg and they were covered in blood. She had on pants and tubigrips (Geri sleeve). She did not have any feeling in that leg. She did not complain of any pain prior to the transfer. She did not realize she was even bleeding until I touched the pant leg. I called the nurse. It was a pretty good-sized gash,a deep laceration that gushed blood. No, she did not bang anything or fall. She just stood up to the walker and pivoted to the bed. Record review of Resident #1's care plan ADL's (Activity of Daily Living) interventions revealed transfer and gait status: 1 PA (person Assist) with gait belt and walker, may request 2 PA if pt. (patient) fatigued. An interview on 03/30/2021 at 1:57 PM with Licensed Practical Nurse LPN H revealed that she was working the floor on 100 unit. Resident #1 was on 300 hall. LPN H went to Resident #1's room to assist with the incident. The incident already occurred before she got there. Resident #1 was already on the bed. The wound from the leg was bleeding from a large wound with a flap. The flap wound was cleaned, estimated 5 inches long and deep, it was cleaned, and I applied pressure and Steri strips. It was bleeding a lot. Record review of Resident #1's therapy notes, dated 01/29/2021 noted that the resident could be transferred with 1 or 2 people assisting, if resident is fatigued. Record review of Resident #1's nursing progress note, dated 01/30/2021 at 5:10 AM, revealed that Tylenol was given for right arm discomfort. Record review of Resident #1's nursing progress note, dated 01/30/2021 at 10:12 AM, revealed that the nurse noted bleeding and cut to tongue. Record review of Resident #1 physician's progress note, dated 01/31/2021 at 2:20 PM, noted right wrist hematoma. No measurements were noted. Record review of Resident #1's progress note by the Director of Nursing (DON), dated 02/2/2021 at 11:19 AM, revealed a 16 X 5 cm (centimeter) laceration sustained during pivot transfers . Record review of Resident #1's progress note, dated 02/2/2021 at 12:19 PM, described lower left extremity dressing change with moderate amount of serosanguineous (blood and serum fluid) from laceration and that the resident complained of throbbing to right wrist, large hematoma present . An interview on 03/30/2021 at 3:02 PM with Certified Nurse Assistant (CNA) E revealed that Resident #1 put her call light on, and CNA E went to answer it. The resident said that she was wet up by her shoulders. CNA E stated that she pulled the blanket back and discovered that the wet spot was the wound on her arm. CNA E stated that she moved the blankets back and it was a large dark spot and that her arm was bleeding. CNA E went and got the nurse. The CNA stated that a complete bed change was necessary. We changed all the bedding, sheets, blankets, and her pajamas were bloody from the arm bleeding all over. It was change of shift, like 5 minutes to 6:00 AM. CNA E stated the wet spot on the bed was as big as a cereal bowl. Record review of Resident #1's nurse progress note, dated 02/03/2021 at 6:14 AM and written by Licensed Practical Nurse (LPN), revealed that at 6:00 AM the aide called the nurse into resident's room to see resident's right wrist hematoma bleeding profusely. Writer cleaned the area and put a pressure dressing on, contacted the Telehealth system who ordered pressure dressing applied and to monitor for 30 minutes and call back with an update. An interview on 03/30/2021 at 5:54 PM with Licensed Practical Nurse (LPN) F, revealed that around 5:50 AM on 02/03/2021, CNA E called her into Resident #1's room. There was blood on the bed from her arm bleeding. the hematoma had ruptured, it was from the blood draw. The bleeding was a large dark spot. LPN F stated that she called the Telehealth system. It is the doctors on the phone service that the facility uses at night. It is a contracted service. The blood was basically pouring out of her. The aide and I were holding pressure on it. I left CNA E to hold pressure on the arm. I called Telehealth system to ask for transfer orders to the hospital. I was told no. I was told to apply a pressure dressing and just watch the resident. I went back into the resident's room, and it was bleeding through the pressure dressing. I went to get more supplies to replace the dressing and the first shift Registered Nurse (RN) G, had come into work. I asked RN G to help me. RN G went to the room and she was shocked at how much blood was coming out of her arm. RN G told me she would stay with the resident. I called Nurse Practitioner (NP) for the facility. She is the Nurse Practitioner for resident's doctor. She did not answer the phone. I left a detailed message to explain the situation. I went back to the resident's room. RN G said she would take over the care. Later the next day or so, RN G told me that she asked NP for orders to send Resident #1 out to hospital and NP said no. I left at 6:40 AM that morning and Resident #1 was still in the facility bleeding. I did a progress note about it. Record review of Resident #1's nurse's progress note, dated 2/3/2021 at 7:20 AM and written by Registered Nurse (RN) G, revealed that she spoke with the physician and received an order to change the pressure dressing and have staff apply manual pressure for 30 minutes. Pressure dressing changed; area is still actively bleeding a steady stream of bright red blood . An interview on 03/30/2021 at 6:20 PM with Registered Nurse (RN) G revealed she got to work at 6:00 AM, and that she worked the first shift. RN G stated that right as she got there (to work) and was waiting for Licensed Practical Nurse (LPN) F the night nurse, LPN F poked her head out of a room and asked for some help. RN G stated that she went into the resident's room. It was Resident #1's room. RN G was told Resident #1 put her call light on because she thought she had wet herself. RN G stated the blood was up to her chest area. She did not realize she was bleeding. The lights were on and the blood was all over the resident, all over the nurse's isolation gown, and all over the bed. It (blood) was a steady stream of blood pouring out. The wound was a hole that had opened up in the hematoma. It was dark purple in color. RN G went got and ABD bandage, Krelix (gauze) and Cobain (wrap). Prior it was wrapped in an ace wrap. No dressing on it. So, she put a pressure dressing on it. She tried to call Nurse Practitioner (NP) for residents' doctor, but call went to voice mail. I told LPN F to call Telehealth system services and was told to apply a pressure dressing and leave it for 30 minutes and then re-assess in 30 minutes. RN G stated that she checked the resident's vital signs and stayed with her. RN G took off the pressure dressing in 30 minutes and reassessed the wound. It was bleeding through the dressing and it was still bleeding a steady stream of blood. RN G cleaned up the wound site, applied another pressure dressing and elevated on the pillow. RN G stated she sent the doctor a text message. The doctor called within minutes and he told me to not send the resident to the hospital. She explained the situation and bleeding through the dressing, and he instructed me to re-enforce the pressure dressing and have someone hold manual pressure on the area for 30-45 minutes. RN G stated that she reinforced the dressing. and went and got the aide to sit and hold the resident's arm. RN G stated that she showed the aide were to hold the pressure. RN G stated that she checked the vital signs again. Resident #1 denied pain to the site and called her son with an update. The son asked if doctor was going to see her that day. RN G texted the physician again and asked. The physician stated that he would see the resident, but did not tell her when. RN G called the family back to update them. After 30 minutes RN G went back to check on resident and it was starting to bleed through the pressure dressing. RN G called doctor again. RN G explained that it was still bleeding, and he said again not to send her to the hospital. He said that the hospital would not do anything different. RN G reinforced the dressing again and instructed the aide to continue to hold pressure to the wound. RN G stated that she did an I-stat chem8 (instant lab) with a hemoglobin level. It came back at 8.5. RN G called the family again. At that point Registered Nurse C the Assistant Director of Nursing (ADON) came to the room. We removed pressure dressing. It looked like it had stopped bleeding and while we were looking at it started to spurt blood. It was a stream that spurted out and stopped with each heartbeat of the resident. We re-applied the pressure dressing. RN/ADON C got on the phone with physician or Nurse Practitioner and got an order to send the resident out to the emergency room . This occurred a little after 8:00 AM (2 hours after the bleeding began). RN G stated that she left RN/ADON C with Resident #1, called the family, called the hospital with report and sent the resident to the hospital. Record review of Resident #1's progress, note dated 2/30/2021 at 8:50 AM and written by Registered Nurse/Assistant Director of Nursing (ADON) C, revealed, Hematoma to right wrist opening and bleeding. Upon entering aide holding pressure to resident arm with pressure dressing on. Pressure dressing saturated with bright red blood. Pressure dressing changed and bleeding pulsating out in a rapid flow. New pressure dressing applied arm elevated on pillow and writer applied pressure on top of dressing. Warm cloth applied to resident right hand as circulation decreased to fingers and fingertips cold to the touch with complaints of tingling . An interview on 3/30/2021 at 12:00 PM with Registered Nurse (RN/ADON) C revealed that she gets to work about 6:30 AM as the first manager there. RN C stated that she came in and RN G was there. RN G stated that she had a problem. The hematoma on Resident #1's arm was bleeding. RN G said that she had placed a pressure dressing once already and sent the aide to apply pressure with her hands. RN C stated that she went to check the dressing. The pressure dressing was on and was bleeding through the bandage. A second pressure dressing was applied. When RN C first removed the dressing there was no bleeding. It looked like a large blood clot protruding through the skin. Then like with her (Resident #1) heart beat the blood shot out with each heartbeat. RN G had a bunch of supplies in the room. We applied a new pressure dressing. RN C stated that she called the doctor and explained to him what she had seen and he said to send her out at that time. The resident was alert and oriented. She told me she thought she had wet the bed but could not understand how she got the urine up to her shoulder. She was legally blind and could not see the right arm hematoma. When she was down on 100 Hall, she had a lab draw and the hematoma appeared after the blood draw. (That was 15 days prior to the rupture) Record review of Resident #1's Hospital Emergency Department (ED) record for the date of 02/03/2021 at 10:45 AM revealed: [AGE] year-old female was sent to the ED for a large hematoma to the dorsum of the right wrist that ruptured and is now bleeding extensively. Patient is on oral anticoagulant (blood thinner) After a blood draw, she developed a hematoma to the site it is progressively gotten more swollen and reddened and very tender. It broke open this morning with extensive bleeding Patient was admitted during previous admission related to acute CHF (Chronic Heart Failure) and fluid retention and [MEDICATION(S)] toxicity (blood thinner elevated levels). ED lab work revealed a hemoglobin level of 8.0 (low), Prothrombin Time (PT) 13.7 (high), and INR 1.33 (high) on 02/03/2021 at 11:10 AM. Physician noted review of laboratory data and testing: Patient has dropped 3 g (grams) of hemoglobin since last testing which was one month ago her blood pressure is 94/50. General surgery has evaluated the patient . ED note dated 02/03/2021 at 4:03 PM: Upon reassessment patient's blood pressure did drop. She received 500 cc normal saline which did recover her pressure to 86/50. Repeat hemoglobin was obtained. Patient's hemoglobin had dropped to 6.9 with a drop in hematocrit as well Patient will receive 1 unit of packed cells (Packed Red Blood Cells/blood) as well as 1 unit of FFP (Fresh Frozen Plasma). Further hospital record review revealed that Resident #1 had surgery for [MEDICAL RECORD OR PHYSICIAN ORDER]

This Citation pertains to Intake Numbers MI 336, MI 431, MI 556, and MI 320. Based on observation, interview and record review, the facility failed to provide appropriate assessment and monitoring for 3 residents (Resident #3, Resident #5, Resident #11) and ensure that wound care was completed for 2 residents (Resident #3, Resident #11) of 4 residents reviewed for wounds. These deficient practices resulted in 1) Resident #5 developing a red excoriated buttock and groin wound without routine assessments or wound measurements to ensure an appropriate treatment was provided; 2) Resident #3 had a treatment ordered for the coccyx, but lacked assessment of the wound; and 3) Resident #11 was admitted to the facility with reddened toes and a blister on the right first toe, but due to a lack of assessment, monitoring, and treatment, developed black eschar (dead tissue found in a full-thickness wound) encompassing the right and left first toe bilaterally. Findings Include: Resident #5: A record review of the Facesheet, progress notes and Minimum Data Set (MDS) assessment indicated Resident #5 was admitted to the facility on [DATE] with Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the progress notes, indicated Resident #5 was discharged to the hospital on [DATE] with a change of condition, including decreased oxygen saturation levels 68% (normal ,d+[DATE]%); a low blood pressure ,d+[DATE] (normal approximately ,d+[DATE]) and poor appetite. A note dated [DATE] at 12:00 AM written by Nurse HH provided, Resident hollering out . pale cyanotic skin color . slurring her words . lethargic . 02 (oxygen) turned up to 6 liters/minute . mask applied at 10 liters and 02 came up to 100% . order to transport to ER . An interview with Confidential Person II on [DATE] at 1:26 PM provided, The hospital said she had sores the size of a silver dollar when she came in (from the facility on [DATE]). The nurse said it was the worst case she had seen. She died in the hospital. They said her heart stopped. A review of a hospital note by Physician NN, dated Admission [DATE]; [DATE] Reason for Consult, Sacral pressure ulcer . Chief complain: Shortness of breath/altered mental status; Comment: . brought to the emergency room . change in mental status . She was found to have low blood sugar. She responded to IV glucose. Patient had mental status improvement. She was found to be in acute hypoxic [CONDITION(S)] .Wound care was asked to see the patient regarding sacral pressure ulcer . Skin: redness; Ecchymosis (bruising) right shoulder; Comments: Generalized [CONDITION(S)] (redness) non-blanchable to sacral area; old cystic tracts with no drainage to the sacral area; [CONDITION(S)] consistent with Stage 1 decubitus. A review of the electronic medical record for Resident #5 revealed there were 3 Skin assessments, in the medical record: [DATE], [DATE] and [DATE]. There was also an Admission Skin Assessment, dated [DATE]. The Admission Skin Assessment, was completed and signed by Nurse U after the initial admission to the facility from the hospital on [DATE] and identified the following: a cast on the left lower leg, +3 pitting [CONDITION(S)] (swelling from fluid) in the lower legs, redness on the buttocks and front perineal area and bruising on the left posterior forearm, right upper, inner arm and near the bilateral axilla (armpits). There were no measurements. The Skin Assessment (Shower Sheet), dated [DATE] was blank except for the resident's name and room number and signed by Certified Nursing Assistant JJ. The assessment included Front and Back pictures of a Human body and said, Instructions: Identify the part of the body or area of the body injured. Be as specific as possible. The Skin Assessment, dated [DATE] was blank except for the resident's name and room number and signed by Certified Nursing Assistant JJ. The Skin Assessment, dated [DATE] was signed by Certified Nursing Assistant KK and included the resident's name and room number and the following: Red, blotchy areas on upper chest, abdomen, right upper inner axilla, right posterior upper arm, back and right thigh and buttocks/coccyx area and swelling bilateral lower legs. The document also said, Sheets changed; Hair washed. None of the Skin Assessments, were signed by a Nurse. On [DATE] at 2:18 PM, the Director of Nursing was asked for skin assessments for Resident #5. The DON said the nurse was to assess the resident's skin weekly. On [DATE], the Director of Nursing provided 2 nurses notes for Resident #5: [DATE], by Nurse U, Skin Integrity Events,- Rash/[CONDITION(S)] Skin Event, Redness to groin, Present on Admission: No . Fold of groin . irregular shape, oblong in folds of groin . Red . excoriations . grouped clustering of [CONDITION(S)] . Burning . red excoriation . No exudate (drainage) . When did rash first occur: [DATE] . Onset: Gradual . Did rash spread over time: Yes, per resident, rash is spreading . Interventions: Washed with soap and water, dried completely, cream applied. [DATE], by Nurse U, Skin Integrity Event, Skin tears, . Right forearm, 2.5 cm length, 0.5 cm width . Blood loss: small amount . Treatment: transparent dressing . A review of the Medication Administration Records (MAR's) and Treatment Administration Records (TAR's) for [DATE], [DATE] and February 2020 provided the following: [DATE]: Weekly skin assessment: 0= no impairment, 1= new impairment, 2= old impairment, Once a day on Thu(rsday), Start [DATE]-[DATE]. The order was initialed as completed [DATE], [DATE] [DATE]. There was no documentation of follow up to the resident's wounds as identified on the Admission Skin Assessment. 2 entries were marked No new issues and 1 was marked 0 no impairment. There was no further assessment or identification of healing or worsening of the resident's wounds. [DATE]: Weekly skin assessment, was initialed as completed on [DATE] 0 = no impairment, [DATE] 2= old impairment, [DATE] 0= no impairment and [DATE] 0= no impairment. There was no description or assessment for the entry [DATE] old impairment to describe the wounds. February 2020: Weekly Skin assessment, initialed on [DATE] 1 new impairment with a follow up note. A progress note dated [DATE] at 9:38 PM written by Nurse MM revealed, . Resident right heel is spongy . Shower provided to resident and when applying cream to groin afterward, resident stated cream was burning . Redness present under left breast. Resident skin around finger-tips dried and cracked . The resident's skin was not consistently assessed weekly after admission to determine if the wounds identified on admission were healing or worsening. The wounds were not measured or described to better enable treatment and healing. The nurses initialed that they completed a skin assessment, but did not provide assessment data or descriptions of the wounds as identified on admission. A review of a Care Plan for Resident #5 titled, Skin Integrity: At risk for skin breakdown related to impaired bed mobility and functional status due to weakness, dated [DATE] with Interventions: Conduct weekly skin assessment. Pay particular attention to bony prominences, dated [DATE]. A Discharge Summary, for [DATE] dated [DATE] completed by Nurse A revealed, discharged to the Hospital and did not return . Services provided during stay: Wound care . Nursing Observation . Cooperative with care: goals met; able to safely discharge . Resident #3: A review of Resident #3's medical record, revealed an admission into the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the Minimum Data Set assessment revealed the Resident had severely impaired cognition and needed extensive assistance with dressing, toilet use, and personal hygiene. A review of Resident #3's progress notes revealed a dressing for the coccyx area ordered but there was a lack of documentation of assessment and measuring of the area: -Dated [DATE] at 11:01 AM, NP (Nurse Practitioner) in on rounds labs reviewed, meds reviewed with no new orders, assessed coccyx requesting to apply allevyn coccyx dressing . A review of the NP progress note, dated [DATE] at 2:20 PM, lacks documentation of the coccyx area. Documentation of the physical exam for skin revealed, Skin: Inspection and palpation: Refer to nursing documentation for full skin assessment. The Assessment/Plan documented, Continue current treatment plan. A review of Resident #3's order for the coccyx treatment revealed, Cleanse buttock with NS (normal saline), pat dry cover with and Allevyn Patch, change Q (every) 72 hours and PRN (as needed) until healed. Every 72 Hours 08:00 AM, date started [DATE]. A review of Resident #3's Treatments Administration History for ,d+[DATE] revealed the following: -Order: Weekly skin assessment: 0=no impairment, 1=new impairment, 2=old impairment, frequency: once a day on Monday with a start date on [DATE]. The documentation on [DATE] revealed weekly skin results as 0 indicating no impairment. The documentation on [DATE] revealed weekly skin results as 2 indicating old impairment. There was no documentation in the progress note dated [DATE] of a narrative of the assessment of the skin. A review of Resident #3's medical record revealed a transfer to the emergency roiagnom on [DATE] and returned to the facility on [DATE]. A review of the wound management documentation revealed wound information of a pressure ulcer to the coccyx with additional location details of Coccyx/bilateral upper buttocks and documented as present on admission/re-entry. A review of the document Skin Integrity Events, dated [DATE] at 11:58 AM, revealed the description: pressure injury to coccyx/bilateral buttocks, length 8.2 cm, width 7 cm, present on admission. The measurements, dated [DATE] at 11:01 AM, were length 3 cm (centimeters), width 4.9 cm, depth no measurable, stage: unstageable-deep tissue, tissue type: Closed/resurfaced. Dated [DATE] at 10:29 AM, measurements were length 5 cm, width 8 cm, depth not measurable, Stage: unstageable-deep tissue, tissue type: closed/resurfaced and wound healing status documented as stable. Further review of the coccyx wound management revealed, dated [DATE] at 12:30 PM, measurements of length 3.8 cm, width 7 cm, depth not measurable, Stage II, tissue type: granulation tissue and documented wound healing status as Stable. On [DATE] an interview was conducted with Assistant Director of Nursing (ADON) A regarding Resident #3's wound to the coccyx area. A review of Resident #3's medical record of the coccyx wound with the ADON was conducted. The measurements of the coccyx wound were initiated upon re-admission into the facility on [DATE]. The ADON was queried regarding the wound before the Resident was transferred. The ADON stated, She went out on ,d+[DATE] and it (coccyx wound) was there on ,d+[DATE]. A review of the progress note dated [DATE] at 11:01 AM for the Allevyn dressing to coccyx was reviewed. Further review of the medical record indicated a lack of documented assessment or measurements for the coccyx area with the order of the dressing. When queried what the wound was, the ADON, after reviewing the NP's progress note, stated, I can't answer that because the Nurse Practitioner doesn't reference it (coccyx wound). The ADON was queried regarding facility policy for skin assessments and reported that skin assessments were done on admission and weekly on shower days and as needed and an event documentation would be opened for any wounds. A review of the events revealed a lack of an event documented for the coccyx wound on [DATE]. Resident #11: A review of Resident #11's medical record, revealed an admission into the facility on [DATE] with a readmission on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review, of the Minimum Data Set assessment, revealed the Resident had severely impaired cognition and needed extensive assistance for transfers, dressing toilet use and personal hygiene. On [DATE] at 2:36 PM, an interview was conducted with Confidential Person Q regarding Resident #11. The Confidential Person reported the Resident had sores on his big toes and complained of pain and stated, I kept asking for him to go to the Podiatrist. The Confidential Person reported they were unable to visit due to Covid-19 until the Resident had declined and family were allowed to visit for end of life visitation. The Confidential Person stated, He had skin tears up and down his arms. On the second day I noticed another area under his left arm underside that had steri strips (adhesive skin closure strips). This was new, it wasn't there the day before. When I asked the nurse about it, she didn't know of the new wound. The Confidential Person reported that the Resident's knees over the patella had black eschar and stated, His toes were partly gone and covered in black eschar and peeling. He complained back in December that his feet hurt and he couldn't walk, and expressed anger and frustration at the condition of his skin. The Confidential Person explained the Resident was admitted into the facility around [DATE] for rehabilitation services and did not have these skin issues nor he did not have black eschar covering his toes or all the skin tears. The Confidential Person reported the Resident declined over the course of residing at the facility and died on [DATE]th 2020. A review of Resident #11's progress notes, revealed the following: -Dated [DATE] at 10:05 PM, . Abrasions to left knee remain scabbed, dry and intact without s/s (signs/symptoms) of infection. Coccyx wound dressing clean, dry and intact. c/o (complaints of) tenderness while sitting upright. Bilateral feet/toes with no noted change. RUE (right upper extremity) has x 3 dressings which were not previously on resident. CNA reports resident has skin tears which occurred while transferring resident in w/c (wheelchair) to shower. Dressings dry and intact. Denies pain to sites. Per resident, 'I bumped my arm' . -Dated [DATE] at 2:08 AM, . Left knee abrasions remain scabbed, dry and intact without s/s of infection. Coccyx wound dressing clean, dry and intact. Bilateral feet/toes with no noted change . -Dated [DATE] at 11:08 AM, progress note by Physician OO, revealed, .Skin: Inspection and palpation: refer to nursing documentation for full skin assessment. Right chest permacath-dressing clean, dry and intact . The documentation lacked assessment of the coccyx wound, left knee wound, bilateral great toes or the skin tears to the right upper extremity. -Dated [DATE] at 6:55 PM, progress note by Physician OO, revealed, Chief Complaint F/U (follow up) . Skin: Inspection and palpation: refer to nursing documentation for full skin assessment. Right chest permacath-dressing clean, dry and intact . The documentation lacked assessment of the coccyx wound, left knee wound, bilateral great toes or the skin tears to the right upper extremity. -Dated [DATE] at 4:07 PM, Resident has a 0.3 by 0.2 skin tear on his left elbow that happened at [CONDITION(S)] . States it happened when they transferred him to the [CONDITION(S)] chair. -Dated [DATE] at 2:16 PM, progress note by Physician OO, revealed, Chief Complaint F/U . Skin: Inspection and palpation: refer to nursing documentation for full skin assessment. Right chest permacath-dressing clean, dry and intact . The documentation lacked assessment of the coccyx wound, left knee wound, bilateral great toes or the skin tears to the right upper extremity. -Dated [DATE] at 11:49 AM, progress note by Nurse Practitioner (NP) PP, revealed, Chief Complaint wound care . Wound Check. Reported by patient. Location: buttocks; right. Quality: non-healing. Duration: resent on admission .Notes: bilateral great toes eschar ulcers . Physical exam . Skin: Inspection and palpation: refer to nursing documentation for full skin assessment. Right chest permacath-dressing clean, dry and intact . Assessment/Plan 1. Pressure ulcer of buttock stage 2- Foam dressing change every ,d+[DATE] days and PRN (as needed) . 2. Ischemic foot ulcer-keep clean and dry . -Dated [DATE] at 3:36 PM, IDT/CAR Review of skin wounds: .Resident remains at risk for skin breakdown related to complex medical diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Goal is for resident to remain free from skin breakdown and for skin impairments to heal without complication . -Dated [DATE] at 7:36 AM, IDT/CAR. Resident has wound to coccyx, bilateral great toes, and right forearm . -Dated [DATE] at 2:32 PM, Resident's fall on [DATE] resulted in two skin tears, one on right dorsal hand 1 x 2 cm with skin flap and one on left elbow 3 x 1.5 cm with skin flap . A review of Resident #11's Skin Integrity Events, dated [DATE] at 10:41 PM, revealed, .Description Redness . Present on admission yes. Location of Rash/[CONDITION(S)] and Size of Affected Area: right great toe red 2 sites 1)1 x 1 (1 cm (centimeter) by 1 cm). 2)1 x 0.5, left 2nd toenail darkened, left great toe blister/red 1.5 x 1.6 . A review of Resident #11's care plan revealed a problem start date on [DATE], Category: Skin Integrity. At risk for skin breakdown R/T (related to): Impaired bed mobility and functional status r/t weakness secondary to [CONDITION(S)], on hemodialysis; skin exposure to body fluids d/t (due to) transient urinary incontinence, history of pressure ulcers. Goal of Resident's skin will remain intact. The approaches (interventions) were all dated for [DATE] and lacked revision of interventions to prevent further skin tears. A review of Resident #11's Podiatrist Visit Summary, dated [DATE], revealed, HPI (history of present illness): . displays clinical evidence of nail mycosis. Patient's nails are thickened and yellow with underlying debris. Nails exhibit irregular growth pattern, and are painful with palpation. Patient is unable to trim their own nails due to risk to their skin integrity . Skin right: .toes cool to the touch. 3 cm dry blister distal 1st toe, stable. Skin Left: .toes cool to the touch. Dry hematoma distal 2nd toe, stable . Vascular assessment right: Abnormal-Distal temperature cooling noted with absent digital hair growth, delayed capillary refill, and skin discoloration, Vascular assessment Left: Same as Right . A review of Resident #11's Wound Management for the Left big toe include: Wound Type: Arterial Ulcer Wound Location: Left big toe Date/Time identified: [DATE] at 10:31 AM Present on Admission/Re-entry? Yes Initial measurements documented in Wound Management, dated [DATE] at 10:31 AM, revealed, Length 2 cm, width 1.5 cm; Depth of tissue injury: Full thickness: Through dermis and down to subq (subcutaneous) tissue, muscle; Tissues Type: Necrotic Tissue, Percent of wound covered by eschar tissue: 100; comments: dry eschar. A review of Resident #11's Wound Management for the right big toe and the documented measurements include: Wound Type: Arterial Ulcer Wound Location: Right big toe Date/Time identified: [DATE] at 8:20 AM Present on Admission/Re-entry? Yes Initial measurements documented in Wound Management, dated [DATE] at 3:27 PM, revealed, Length 2 cm, width 2 cm, Depth of tissue injury: Full thickness: Through dermis and down to subq (subcutaneous) tissue, muscle, Tissues Type: Necrotic Tissue, Percent of wound covered by eschar tissue: 100. On [DATE] at 9:58 AM, an interview was conducted with the Director of Nursing (DON) regarding Resident #11's skin care and monitoring. A review of multiple skin tears was reviewed with the DON. The DON was queried regarding interventions to prevent skin tears and after each event of skin tears was the Resident's care plan reviewed and updated for preventative interventions. A review of the care plan with the category of Skin Integrity, revealed no updated interventions. When queried what the facility uses for skin tear prevention, the DON reported that sleeves were used. The DON was queried if Resident #11 received sleeves to assist in prevention of skin tears and after review of the medical record stated, There is only multiple treatments ordered. The DON reported their process was that skin events are reviewed in clinical meetings to assure that measurements were done and preventative measures were put in place and then MDS made sure all the interventions were put in (care plan) and indicated this was a more recent practice. The DON was queried regarding Resident #11's podiatry consult, and reviewed that the visit was for nail trimming and not for the lack of assessment for the toes covered in eschar tissue. The DON stated, The group that we have here only trim nails. We are looking at another group that will look at vascular wounds as well. The DON was queried why the wounds on the toes were not followed by wound care when upon admission on [DATE] it was documented as reddened and a blister on the great toes. The DON indicated that wounds were usually monitored weekly with measurements by the wound care nurse and NP done on wound rounds and stated, Typically he would have been seen on Tuesday, New Years, and indicated due to the holiday, the nurses would be doing the routine monitoring of wounds. When reviewed that the Resident was not seen by the Nurse Practitioner and Wound Care Nurse until [DATE] and assessed with [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of facility policy titled, Pressure/Stasis/Diabetic wound Guidelines, revised date [DATE], revealed, .Purpose: To provide weekly documentation of wound measurements and condition. Procedures: 1. Appropriate skin Event is completed by a RN/LPN in EHR (electronic health record). a. Complete event for each impaired area . 4. Re-assessment/measurement weekly or with significant change in wound noting the current treatment, medical interventions provided and comments as needed .

Based on observation, interview and record review, the facility was placed in Immediate Jeopardy due to the facility's systemic collapse of the Infection Prevention and Control program with failure to follow evidence-based practices for Infection Control, including analysis of surveillance data to identify trends and patterns and implement appropriate interventions, including Transmission Based Precautions and diagnostic testing to prevent the spread of respiratory infections. The failure to maintain infection control practices during a COVID-19 Infection Control Survey resulted in a likelihood for a serious adverse outcome for all residents, including infectious illness and death if appropriate Infection Prevention and Control Standards of Practice were not enacted. Immediate Jeopardy: During a tour of the facility on [DATE] at 10:25 AM, the Director of Nursing (DON) provided a list of 5 residents identified to be in Isolation Precautions (Transmission Based Precautions): Three Residents diagnosed with [REDACTED].#1, #3, (#4 hospitalized [DATE])), one Resident #2 with respiratory signs and symptoms including a cough and one Resident #25 diagnosed with [REDACTED]. While approaching the residents' rooms on the Isolation List, none of the residents had a sign on or near their room door identifying what type of precautions were in place and what type of Personal Protective Equipment (PPE) was to be worn to safely care for the residents to prevent the spread of infection to other residents, staff and visitors. The DON said the residents with Influenza needed Droplet Precautions, the resident with respiratory symptoms needed Droplet Precautions and the resident with [MEDICAL CONDITION] needed Contact Precautions. There was no visible PPE at the entrance to the resident's rooms. The DON said it was hanging behind the resident's door. When the DON was asked how staff would know what precautions to follow, she pointed to a small red magnet, approximately 3 inches by 3inches attached to the doorframe that said Stop see the nurse. There was no indication the resident was in Transmission Based Precautions. The Centers for Disease Control and Prevention- CDC- 2007 Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings, Last update: [DATE], . Droplet Precautions are intended to prevent transmission of pathogens spread through close respiratory or mucous membrane contact with respiratory secretions . Healthcare personnel wear a mask (a respirator is not necessary) . Patients on Droplet Precautions who must be transported outside of the room should wear a mask . and . Contact Precautions are intended to prevent transmission of infectious agents, including epidemiologically important microorganisms, which are spread by direct or indirect contact with the patient or the patient's environment . Contact Precautions also apply where the presence of . other discharges from the body suggest an increased potential for extensive environmental contamination and risk of transmission . Healthcare personnel caring for patients on Contact Precautions wear a gown and gloves for all interactions that may involve contact with the patient or potentially contaminated areas in the patient's environment. Donning PPE upon entry and discarding before exiting the patient room is done to contain pathogens . A review of the Infection Surveillance Line Listings (The facility only provided Antibiotic Usage Reports for February 2020) for February and [DATE] revealed 19 residents of an approximate Resident Census of 73 residents (26.0 %) were positive for respiratory symptoms including: fever, cough, congestion, sore throat, shortness of breath, decreased oxygen saturation levels, increased confusion, and lethargy. None of the 8 residents (#'s 5, 8, 9, 10, 11, 12, 13, 14) identified with respiratory symptoms in February 2020, were placed on Transmission Based Precautions to prevent the spread of infection. In addition, there was inconsistency in initiating Transmission Based Precautions for those 11 (#'s 2, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24) residents with positive respiratory symptoms, identified in [DATE] (not identified to have Influenza B). The residents with positive respiratory symptoms were not tested for Influenza until [DATE] or Covid-19 (a highly infectious respiratory virus) until Resident #4 was tested in the hospital for Covid-19 on [DATE]. Four additional Residents tested positive for Influenza B from [DATE]-[DATE] (Residents #'s 1, 3, 6, 7). Residents, who exhibited respiratory symptoms and who tested Negative for the Influenza A and B virus, were not consistently place on Transmission Based Precautions. Beginning on [DATE], the facility began collecting data for the residents exhibiting respiratory symptoms of illness but did not analyze the data or present it to the QAPI Committee and the Medical Director. The facility did not notify the Local County Health Department of the 19 residents with signs and symptoms of respiratory illness, that were not positive for Influenza, until [DATE]. The Immediate Jeopardy began on [DATE]. The Immediate Jeopardy was identified on [DATE]. The Administrator was notified on [DATE] of the Immediate Jeopardy that began on [DATE]. The IJ Abatement (Removal) Plan was approved on [DATE] with a Removal Date of [DATE]. Findings Include: On [DATE] at 10:25 AM, during a tour of the facility and review of residents placed in Transmission Based Precautions (without signage designating the necessary precautions or visible PPE), with the Director of Nursing (DON) she was asked where the Infection Control (IC) Nurse was; The DON said (IC Nurse A) was not present at the facility. On [DATE] at 11:25 AM, IC Nurse A called from the facility and said she had just arrived, but she would be working as a Staff Nurse on the 3rd Shift (midnight shift) that night. The IC Nurse said she sometimes had to work as a Staff Nurse instead of in her role as Infection Control Nurse, because of a lack of available nurses in the facility. The IC Nurse was asked for Surveillance data for February and [DATE] and Infection Control Policies and Procedures for review. Arrangements were made for an interview with the DON and IC Nurse on [DATE], due to the IC Nurses work schedule. On [DATE] at 7:05 AM, the DON and IC Nurse were interviewed. The February and [DATE] Infection Surveillance data was reviewed with the IC Nurse. Upon review, there were 8 Residents (#'s 5, 8, 9, 10, 11, 12, 13, 14) with identified respiratory symptoms (on the February 2020 Antibiotic Usage Report) including fever, cough, congestion, sore throat, shortness of breath, decreased oxygen saturation levels, increased confusion, and lethargy in February 2020. The IC Nurse was asked if any diagnostic testing had been performed to aid in identifying a specific infectious organism and she said the facility had not done that. When asked if the facility placed the residents in Transmission Based Precautions to aid in preventing the spread of illness to other residents, the IC Nurse said the residents had not been placed in precautions. IC Nurse A was questioned if data was collected for residents with signs and symptoms of illness who did not receive an antibiotic and said, Not in February. The IC Nurse was asked if an analysis of the February 2020 data had been completed to determine if there were any trends and she said she had reviewed each resident with the physician at the time the illness was noted, but there was no overall analysis that identified multiple residents had similar symptoms or that there was a potential outbreak of illness. The IC Nurse said there was no documented summary data, for the February 2020 Antibiotic Usage Report, reported to the Infection Control Committee. The Association for Professionals in Infection Control and Epidemiology (APIC), [DATE] provided, Surveillance of healthcare-associated infections (HAI) is the cornerstone of an effective infection prevention program. By definition, surveillance is a comprehensive method of measuring outcomes and related processes of care, analyzing the data, and providing information to members of the healthcare team to assist improving those outcomes and processes . CDC, Long-Term Care (LTC) Respiratory Surveillance Line List, [DATE], 'The Respiratory Surveillance Line List provides a template for data collection and active monitoring of both residents and staff during a suspected respiratory illness cluster or outbreak . Using this tool will provide facilities with a line listing of all individuals monitored for or meeting the case definition for the outbreak illness . Each row represents an individual resident or staff member who may have been affected . The information . capture data on the case demographics, location in the facility, clinical signs/symptoms, diagnostic testing results and outcomes . ' Information gathered on the worksheet should be used to build a case definition, determine the duration of outbreak illness, support monitoring for and rapid identification of new cases and assist with implementation of infection control measures . During the interview and review of [DATE] Infection surveillance on [DATE] at 7:05 AM, with IC Nurse A and the DON, there were 11 residents (#'s 2, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24) on the line listing with respiratory symptoms similar to the 8 residents in February 2020: including fever, cough, congestion, sore throat, shortness of breath, decreased oxygen saturation levels, increased confusion, and lethargy in February 2020. IC Nurse A said not all of the residents had been placed in Transmission Based Precautions and none of the residents had been tested for Covid 19, until Resident #4 was transferred to the hospital [DATE] and tested [DATE]. IC Nurse A was questioned if an analysis of the February and [DATE] infection surveillance data had been completed to determine if there were any trends and she said she had reviewed each resident with the physician at the time the illness was noted, but there was no overall analysis that identified multiple residents had similar symptoms or that there was a potential outbreak of illness. The IC Nurse said there was no documented summary data, for the February or [DATE] infection line listing indicating 19 residents had similar symptoms of a respiratory illness. Per the CDC, [DATE], Transmission-Based Precautions are the second tier of basic infection control and are to be used in addition to Standard Precautions (Standard Precautions are used for all patient care. They're based on a risk assessment and make use of common sense practices and personal protective equipment use that protect . from infection and prevent the spread of infection from patient to patient.) for patients who may be infected or colonized with certain infectious agents for which additional precautions are needed to prevent infection transmission . Source: Guidelines for Isolation Precautions. On [DATE] at 7:15 AM, during the interview with the DON and IC Nurse A, the IC Nurse said on [DATE] the facility began testing several residents for Influenza. IC Nurse A said Five additional residents (#'s 1, 3, 4, 6, 7) tested positive for Influenza B from [DATE] to [DATE]. The IC Nurse was asked if the residents were placed in Transmission Based Precautions and she said they were placed in Droplet Precautions and received treatment with [MEDICATION NAME]. The IC Nurse was asked if the residents in the facility, including those with signs and symptoms of respiratory illness or Influenza received the FLU and Pneumonia vaccinations and said she would need to check on that. The IC Nurse was asked for the Infection Control Program Plan and Surveillance Plan. CDC, [DATE], Prevention Strategies for Seasonal Influenza in Healthcare Settings . more than 200,000 persons, on average, are hospitalized each year for influenza related complications. Healthcare-associated influenza infections can occur in any healthcare setting and are most common when influenza is also circulating in the community. Therefore, the influenza prevention measures outlined in this guidance should be implemented in all healthcare settings. Supplemental measures may need to be implemented during influenza season if outbreaks of healthcare-associated influenza occur within certain facilities, such as long-term care facilities and hospitals . The core prevention strategies include: administration of influenza vaccine . adherence to infection control precautions for all patient-care activities and aerosol-generating procedures . A record review of the electronic medical record and scanned documents for the 73 residents living in the building, indicated 9 residents (12%) did not have any documented vaccination information for Influenza and Pneumonia. For the remaining 64 residents, 24 had received the Influenza vaccination for the ,[DATE] Influenza Season. Nine residents had documentation that they had received the vaccination prior to admission, but there were no details of where and when to confirm that it actually occurred. There were also many discrepancies between the Preventive Health tab documentation of vaccinations and what was recorded on the Minimum Data Set (MDS) assessments. In addition, of the 5 residents who were infected and tested positive for Influenza B (Residents #'s 1, 3, 4, 6, 7), there was no confirmation in the medical record of when and where they were given an Influenza vaccination. Resident #3 tested positive for Influenza B on [DATE] and was not started on the Anti-[MEDICAL CONDITION]-[MEDICATION NAME] until 4 days later [DATE]. Resident #6 tested positive for Influenza B on [DATE] and died on [DATE]. Resident #4 tested positive for Influenza B on [DATE] and was transferred to the Hospital on [DATE]. Per CDC Guidance, Influenza, [DATE] . There are prescription medicines that fight against flu viruses in your body . [MEDICAL CONDITION] treatment works best when started soon after flu illness begins. When treatment is started within two days of becoming sick with flu symptoms, [MEDICAL CONDITION] drugs can lessen fever and flu symptoms . they may also reduce the risk of complications such as . respiratory complications requiring antibiotics and hospitalization in adults. For people at high risk of serious flu complications, early treatment with an [MEDICAL CONDITION] drug can mean having milder illness instead of more severe illness . During the record review for vaccinations, all residents living in the facility were assessed for Pneumococcal (Pneumonia) vaccinations Pneumococcal conjugate vaccine PCV13 and Pneumococcal [MEDICATION NAME] vaccine (PPSV23). Seventeen residents had previously received either one of the vaccinations. There was no documentation that any resident had received both Pneumococcal vaccinations nor was there mention of monitoring to aid in ensuring the residents were offered both vaccinations. Per the CDC, Pneumococcal Vaccination, [DATE], 'Vaccines help prevent pneumococcal disease, which is any type of illness caused by Streptococcus pneumoniae bacteria. There are two kinds of pneumococcal vaccines available in the United States: Pneumococcal conjugate vaccine or PCV13, Pneumococcal [MEDICATION NAME] vaccine or PPSV23 . CDC recommends routine administration of pneumococcal [MEDICATION NAME] vaccine (PPSV23) for all adults [AGE] years or older. In addition, CDC recommends PCV13 based on shared clinical decision- making for adults [AGE] years or older who do not have an immunocompromising condition . and have never received a dose of PCV13. Clinicians should consider discussing PCV13 vaccination with these patients to decide if vaccination might be appropriate .' A record review of the electronic medical record revealed the following for Residents identified with respiratory signs and symptoms of illness on the February 2020 Antibiotic Usage Report: Resident #8: The record review of the Face Sheet indicated Resident #8 was admitted to the facility on [DATE] with Diagnoses: [REDACTED]. The Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had a Brief Interview for Mental Status (BIMS) score of ,[DATE] indicating moderate cognitive impairment and needed assistance with all care. The resident was treated for [REDACTED]. Resident #9: The record review of the Face sheet indicated Resident #9 was admitted to the facility on [DATE] with Diagnoses: [REDACTED]. A progress note dated [DATE] at 10:18 PM on admission revealed, Resident arrived at facility at 7 pm . (temperature) 98.4, sp02 93% on 2 liters (L) NC . (oxygen saturation normal ,[DATE]%). A progress note dated [DATE] at 4:21 AM by Nurse P provided, Resident currently wearing 5 liters NC (nasal cannula oxygen) to maintain 02 saturation in the 90's . The physician's History and Physical dated [DATE] at 2:49 PM by Physician E indicated Pneumonia- onset [DATE]. A progress note written by Nurse Q on [DATE] at 6:38 AM provided, . At 5:30 AM writer went to check on resident and noticed grayish skin tone. Writer checked sp02 81% on 5/L . The resident was sent to ER for respiratory distress. Continued review of the progress notes for Resident #9 revealed the resident was readmitted to the facility on [DATE]. A progress note dated [DATE] at 7:51 PM said the resident had several loose stools that day. A physician E progress note dated [DATE] at 1:33 PM revealed, . CT confirmed bilateral lower lobes infiltrate and pneumonia (diagnosed in the hospital) Treated with IV [MEDICATION NAME] and [MEDICATION NAME], IV steroids . The note said a nasal swab was positive [MEDICAL CONDITION] ([MEDICAL CONDITION]- a Multi-drug resistant organism), but there was no clarification if the resident was colonized [MEDICAL CONDITION] with no infection or if the pneumonia was caused from [MEDICAL CONDITION]. There was no sputum culture. A progress note for Resident #9 dated [DATE] at 12:17 PM, RR (respiratory rate) ,[DATE], pursed lip breathing, labored, using accessory muscles, diaphoretic (sweating), restless, (oxygen saturation) 96% on 4L per minute (oxygen) on left hand, right hand 47%. Resident unable to follow instructions to take deep breaths . resident transferred to ER . A progress note dated [DATE] at 2:37 PM, . Per (hospital nurse) resident admitted to ICU on ventilator with pneumonia which is worse since previous hospital stay. The Antibiotic Usage Report for February 2020 said the resident had low oxygen saturation an increased heart rate and shortness of breath and began on antibiotics [DATE]. The column titled Infection resolved said Dc'd (discharged ) Resident #10 A record review of the Face sheet indicated Resident #10 was admitted to the facility on [DATE] with Diagnoses: [REDACTED]. The most recent MDS assessment indicated the resident had full cognitive abilities and needed assistance with care. A note by Physician E dated [DATE] at 1:27 PM indicated the resident had symptoms of a cough, abnormal lung sounds and a fever. A progress note written by Nurse P dated [DATE] at 7:09AM provided, Resident called staff to room at 0445 am (complained of) sudden onset (shortness of breath). Vitals assessed and resident (had high blood pressure, increased heart rate, increased respiratory rate and a fever), vitals in chart. Wheezing noted in all fields posteriorly, and bilateral upper extremities had a noticeable tremor . The resident refused to go to the ER. The February 2020 Antibiotic Usage Report said the resident had positive bilateral infiltrates and shortness of breath 6 days after admitted d [DATE] with antibiotics from [DATE]-[DATE]. A column heading on the report was titled, Clinical signs of Infection present it was marked Yes and the column titled Infection resolved was blank. Resident #14: A record review of the Face sheet indicated Resident #10 was admitted to the facility on [DATE] with Diagnoses: [REDACTED]. The most recent MDS assessment revealed the resident had decreased cognitive abilities and needed assistance with care. A review of a hospital progress note dated [DATE] at 7:23 AM, indicated Resident #14 was admitted to the hospital on [DATE] after being discharged to home from a different facility on the same day. The resident was brought to ER because he developed shortness of breath. The note said, .On their arrival his oxygen was hypoxemic (a low level of oxygen in the blood). Patient was started on oxygen supplement . Patient has been diagnosed with [REDACTED]. A progress note dated [DATE] at 7:15 PM, Resident up in wheelchair for meals . Coughing was minimal . A review of the physician orders [REDACTED]. The Antibiotic Usage Report said the resident had shortness of breath, hypoxemia and [MEDICAL CONDITION]. A review of the physician orders [REDACTED].# 8, 9, 10 and 14 indicated there were no orders or a Care Plan for Transmission Based Precautions to aid in preventing the spread of infection, as each had similar respiratory symptoms of illness. The February 2020 Antibiotic Usage Report had columns titled Date of Culture and Is organism sensitive to antibiotic (each resident was receiving an antibiotic). The Date of Culture column included no information about antimicrobial cultures that would identify the causative infectious agent and whether the antibiotic treatment was appropriate, except for Resident #9'[MEDICAL CONDITION] nasal swab that was not definitive for respiratory infection. The column titled Is organism sensitive to antibiotic said N/A not applicable for each resident including Resident #9. A record review of the electronic medical record revealed the following for Residents identified with respiratory signs and symptoms of illness on the [DATE] Antibiotic Usage Report: Resident #16: A record review of the Face Sheet indicated Resident #16 was admitted to the facility on [DATE] with Diagnoses: [REDACTED]. The MDS assessment full cognitive abilities on admission. A review of the physician orders [REDACTED]. On [DATE] an order was written to Monitor resident for signs of infection: shortness of breath, shallow respirations, abnormal vitals or change in condition. Notify MD of fever over 100, [DATE] to [DATE]. An Influenza A & B test was ordered [DATE]. Sodium Chloride 0.9% solution: amount 500 ml, injection, Special Instructions: Start IV and infuse 0.9% NS (Normal saline solution) @ 100 ml/hour for 5 hours, Once-one time 3:30 PM. A record review of the progress notes revealed the following for Resident #16: [DATE] at 7:02 PM, . Resident has completed antibiotic therapy . Resident has not been short of breath. No coughing noted . A nurses note dated [DATE] at 3:01 PM . Low grade fever noted . New order to use incentive spirometer and monitor vitals every 4 x 24 hours. A nurse's note [DATE] at 6:00 PM, . Resident has had a low-grade fever this shift . increased respiratory rate, non-productive coughing noted . A nurses note [DATE] at 6:58 PM, . Nonproductive cough observed . A nurses Note [DATE] at 2:50 PM (1 day after the order was written) Influenza A & B test given with negative results. A nurses note dated [DATE] at 5:37 AM, Staff report multiple loose stool during the shift . A nurses note dated [DATE] at 1:48 PM, . Resident is having increased cough and confusion . Resident is alert and oriented x1 . A Care Conference note dated [DATE] . recent change in mental status from baseline. Presents with decreased attention span and concentration . A nurses note [DATE] at 3:46 PM, . currently watching TV in the sitting area . A Nutrition note dated [DATE], (Resident) with noted overall decline in status/increased confusion. Not eating the past couple of days, refusing meals . requires a lot of encouragement . A nurses note [DATE] at 9:26 PM, Resident showed considerable decline. Resident was unable to work with therapy . A nurses note [DATE] at 12:51 AM, Resident has been laying on the couch in front of the nursing area . A nurses note [DATE] at 1:47 PM, Resident went to dining room for restorative dining only staying for a short period . A nurses note [DATE] at 3:46 AM, . Resident has been confused, laying out on sofa with her belongings . A review of the physician orders [REDACTED]. There was no laboratory testing to determine what the resident's respiratory illness was. Resident #18: According to a review of the EMR on [DATE], Resident #18 was an [AGE] year-old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A progress note in the EMR reflected that on [DATE] Resident #18 developed confusion, bilateral wheezing in her lungs, bluish color of the lips, and an oxygen saturation of 91%. Resident #18 had also vomited. Resident #18 was sent to the emergency room of the local hospital where she was admitted to the intensive care unit (ICU). The hospital tested for Influenza, and reported that the test was positive for Influenza B and negative for Influenza A. A progress note dated [DATE] at 2:00 AM, stated that the writer had called the hospital and was told that Resident #18 had been admitted to the ICU because she aspirated and has Influenza A. Resident #18 was readmitted to the facility on [DATE] with orders for two more doses of [MEDICATION NAME], 48 hours apart, for upper respiratory. According to the hospital records in the EMR, the emergency room had suspected that Resident #18 has aspirated. The notes from the hospital indicated that Resident #18 had pneumonia. On [DATE] at 3:29 PM, it was documented in a progress note that Resident #18 continued to have a non-productive cough and congestion. Resident #18's oxygens saturation was recorded as 90% on 4 liters of oxygen per minute. A breathing treatment was administered by the nurse. The physician saw resident #18 on [DATE] and noted that she had reported muscle weakness but denied other respiratory symptoms. On [DATE] at 9:46 AM, a progress note provided, Resident was positive of Influenza B per hospital records . Resident admitted from hospital on droplet precautions that gave been discontinued with resident free of (signs and symptoms) for 24 hours . According to the Minimum Data Set Resident Assessment (MDS), dated [DATE], Resident #18 had received the Influenza vaccine outside of the facility for this year's Influenza season. No documentation was located in the EMR that identified when the vaccine was received or where the information was obtained. The MDS revealed that Resident #18's Pneumococcal Vaccination was up to date. The EMR did not provide documentation about which and when the two vaccines, or both, Prevnar 13 or Pneumococcal 23, was received by Resident #18. A review of the facility Antibiotic Usage Report for [DATE] indicated Resident #18 received antibiotic treatment from [DATE] to [DATE] for respiratory symptoms of low oxygen saturation, shortness of breath and chest pain. Per the report, the IC Nurse categorized the infection as CAI a Community Acquired Infection, when the symptoms including wheezing in bilateral lungs, low oxygen saturation 90% and increased confusion began prior to transferring the resident to the hospital on [DATE]. Resident #21: A record review indicated Resident #21 was admitted to the hospital on [DATE] with Diagnoses: [REDACTED]. The resident was discharged back to the hospital on [DATE] due to labored breathing, increased respirations, abnormal lung sounds bilaterally a temperature of 103.0, moaning and diaphoresis. The resident was readmitted on [DATE] with [DIAGNOSES REDACTED]. A record review of the progress notes for Resident #21 revealed the following: [DATE] at 12:22 PM, . Resident on 2 liters 02 NC, (oxygen saturation within normal limits). Resident had period of labored breathing at approximately 1130; resolved after scheduled breathing (treatment given) . [DATE] at 9:53 AM, Resident continues with fever of 99.5 . Rhonchi (abnormal lung sounds) noted to all lung fields, audible congestion noted . [DATE] at 12:05 AM, Chest single view results .No evidence of acute cardiopulmonary disease . [DATE] at 9:38 AM, Resident continues on contact/droplet precautions. (Bilateral upper lung) expiratory wheeze . Moist congested cough . dried thick pale green secretions removed from oral cavity . A review of the physician orders [REDACTED]. Influenza A & B swab ordered [DATE]. There was no order for Transmission Based Precautions. A review of Resident #21's Care Plans revealed a care plan dated [DATE], Resident has need for isolation related to active infectious disease related to fever. Influenza swabbed obtained. Placed on droplet isolation. There was no documentation of the results of the Influenza test and the Care Plan was not initiated until the resident's 2nd episode of respiratory infection. Per the Antibiotic Usage Report dated [DATE], Resident #21 received an antibiotic upon readmission from [DATE]-[DATE] for [MEDICAL CONDITION], fever and congestion. Resident #24: A review of the electronic medical record Face Sheet and MDS assessment indicated Resident #24 was admitted to the facility on [DATE] with Diagnoses: [REDACTED]. The MDS dated [DATE] revealed the resident had full cognitive abilities with a BIMS of ,[DATE] and needed assistance with care. A review of the progress notes revealed the resident had a potential respiratory exposure and was tested for Influenza on [DATE] that was negative. He fell on [DATE] and a chest x-ray ordered after the fall indicated the resident had slight bibasilar infiltrate (pneumonia). The resident started on antibiotics from [DATE]-[DATE]. A review of the Antibiotic Usage Report said the resident was placed on antibiotics on [DATE]-[DATE] for bibasilar infiltrates identified after a fall. A review of the physician orders [REDACTED].

Based on observation, interview and record review, the facility failed to reconcile MEDICATION ORDERS FOR [REDACTED]. Findings include: Resident #42: A review of Resident #42's medical record, revealed an admission into the facility on [DATE] with a re-entry on 7/1/19 with [DIAGNOSES REDACTED]. A review of the Minimum Data Set assessment (MDS) revealed that Resident #42 was cognitively intact and needed extensive assistance with transfers, dressing and toilet use and needed limited assistance with personal hygiene. On 7/17/19 at 10:20 AM, an interview was conducted with Resident #42 during the initial tour of the facility. The Resident was queried regarding any issues with her medications and stated, Yeah, they took my [MEDICATION NAME] away and I really need that. Before they take medication away they need to talk to the resident. I had noticed fewer pills and I wondered if they have taken any away. I have depression, it's been there forever. That is my biggest complaint is why they took my medication away. One day it just wasn't there. So I asked where it was, they said one of the doctors quit it. Cold turkey, I feel like I went thru some withdrawals. I am not as alert as I should be, it affects my whole life, I am tired in therapy, I can't do as much and that is why I am here, to do therapy. I can't sleep at night. When queried when the medication was taken away, the Resident stated, It was Sunday night I think when I noticed it. I asked about it every night that I don't see it in there. I let the nurse know. I have not seen it back in there yet. Yesterday I asked quite a few times if a script can be written for it. I talked to the doctor and he said the psychiatrist was the one to order it. I can't get to the psychiatrist right now. I don't want to have to wait that long. They can't just take it away. When queried if the Resident had a Resident Representative or power of attorney, the Resident stated, I make my own decisions. No one asked me about taking that medication away. Oh god, I would not have let them. No one talked to me about it, it just disappeared. They just stopped giving it to me. I have taken it for many years. A review of Resident #42's medical record revealed the following: -An order, dated 6/12/19, for Drug Name: [MEDICATION NAME], Amount to Administer: 200 mg (milligrams), Frequency: At Bedtime, Repeat: Every Day. The order had a start date on 6/12/19 and an end date on 7/12/19, order received by Nurse Z. -An order, dated 7/10/19, for Drug Name: [MEDICATION NAME], Amount to Administer: 200 mg (milligrams), Frequency: At Bedtime, Repeat: Every Day, Special Instructions: [MEDICAL CONDITION] The order had a start date on 7/10/19 and an end date on 7/12/19, order received by Assistant Director of Nursing (ADON) B. -A document titled, Patient Discharge Instructions, dated 6/12/19 that revealed under the area titled These are the medications you should be taking, listed [MEDICATION NAME] ([MEDICATION NAME] 100 mg oral tablet) 2 tab(s) By Mouth Every Bedtime for 30 Days. -A document titled, Discharge Summary *Final Report*, with a printed date on 7/1/19, revealed under the area titled, Medications (ordered list), listed [MEDICATION NAME] 100 mg tab, Dosage 200 mg, Frequency Q (every) Bedtime, Start date 6/28/2019, Discontinued Date (no date given). -A progress note, dated 7/17/19 at 3:59 PM, created by Social Worker Y, revealed, Resident w/expressed concerns regarding DC of [MEDICATION NAME] by MD on 7/10. Resident was prescribed [MEDICATION NAME], Trazadone and [MEDICATION NAME] in the community under the supervision of her CMH (Community Mental Health) provider-see initial SS (Social Services) note. Resident with c/o (complaints of) unregulated sleep cycles/sleep deprivation. Resident reports poor sleep for two consecutive nights 7/15 and 7/16. Resident further reports visual hallucinations and other mood instability with a lack of sleep, further verbalized hx/o (history of) 5 days without sleep causing mania. Matter discussed w(with)/ADHS and Psych PA (Physician Assistant). Trazadone prescribed for Depression and mood stability with an added benefit/component of possible sleep regulatory. Psych PA endorsed to ADHS to start Trazadone 200 mg HS for Depression/mood stability. Discussed matter w (with)/resident and resident receptive to P[NAME]. On 7/18/19 at 8:50 AM, an interview was conducted with the Director of Nursing (DON) regarding the medication [MEDICATION NAME] discontinued for Resident #42. The DON was unaware of why the Trazadone was discontinued and stated, It could have been for a pharmacy recommendation. I don't know. On 7/18/19 at 8:55 PM, an interview was conducted with the Assistant Director of Nursing (ADON) B regarding the order to discontinue the [MEDICATION NAME] for Resident #42. The ADON indicated she had edited the order for [MEDICATION NAME] to include the special instructions of [MEDICAL CONDITION] and stated, She (Nurse Z) never wrote why the medication was to be given. The only thing that changed was the word [MEDICAL CONDITION]. When queried why the medication was discontinued, the ADON stated, It automatically gets d/ced (discontinued) due to the hospital discharge order. The order was for just the 30 days. We can't give it after that without an order. The new order was not put in until today after psych services had seen her and got it reordered. When queried if staff had contacted the doctor about the medication being stopped and validate the appropriateness of the sudden discontinuation of the medication and after the Resident had complained about not receiving the medication, the ADON stated, The doctor received the pharmacy recommendation. A review of the medical record with the ADON revealed no progress note indicating the physician had been notified by staff of the sudden discontinuation of the medication or the Resident's complaint of the medication not being given. When queried regarding the facility policy on notifying the Resident or Responsible party of medication changes, the ADON stated, Yes, usually they are notified. On 7/18/19 at 9:06 AM, an interview was conducted with Doctor I and ADON B regarding the discontinuation of the [MEDICATION NAME] for Resident #42. When queried why the medication was not reinstated with the recommendation, the ADON stated, On the 10th of July, I put the recommendations in for the Doctor. Dr. I stated, I will have to see about the communication and why it was dropped. I usually don't stop it like that. That is not a medication to be stopped. Usually we do a gradual dose reduction. It should not have been stopped like that. I didn't talk to her (Resident #42) about it, the other physician was covering. I was away. When I came back, I talked with her. I did not know why the medication was stopped and wanted to check with psych services to see why the medication was stopped before I restarted it. The ADON stated, The medication was stopped because of the order to d/c (discontinue) in 30 days, so it automatically was stopped. A review of the documentation with the ADON revealed no documentation that the doctor was notified to restart the medication after the Resident complained. Doctor I stated, They did contact me afterwards and I told her I would check on that. That should not have happened with out the dose reduction. The Doctor indicated he would investigate why the medication was stopped. Doctor I returned and an interview was conducted on 7/18/19 at 12:15 PM, regarding the [MEDICATION NAME] discontinued for Resident #42. The Doctor indicated the Resident had been admitted then went back to the hospital for further surgery and returned back to the facility. The discharge orders after the return to the facility on [DATE] listed the [MEDICATION NAME] to be continued and did not have a stop date listed for the medication. The Doctor indicated that upon the new admission (return to the facility after surgery), the medications and the new orders needed to be put into the computer. The Doctor was queried, when the Resident comes back from the hospital after having surgery, the facility was to redo the discharge orders and medications upon the re-entry into the facility? The Doctor indicated that was the procedure the facility was to follow. The Doctor stated, This would have prevented the medication from being stopped. The discharge instructions had the medication [MEDICATION NAME] listed without a stop date, had the Nurse redone the orders upon admission, the Doctor stated, Right, the medication would not have been stopped. A review of the facility policy entitled, Resident Rights Guidelines, reviewed on 5/23/19, revealed, . 2. Our resident have a right to . b. Be given the information necessary to participate in decisions which affect them both individually and corporately . t. Be consulted and encouraged to have input into their care plan which guides the services delivered to the resident . A review of the document provided by the facility entitled, Pharmacy Services Policies and Procedures for Nursing Facilities, from the pharmacy services of the facility, revealed, Medication Orders . B. Any dose or order that appears inappropriate considering the resident's age, condition, allergies [REDACTED]. C. The prescriber is contacted by facility staff to verify or clarify an order (e.g., when the resident has allergies [REDACTED]. Section III- Medication Monitoring. Medication Monitoring and Management. Procedures. A. The interdisciplinary team reviews the resident's medication regimen for efficacy and actual or potential medication-related problems . 2) The resident is evaluated before initiating, withdrawing, or withholding medication(s), or using non-pharmacologic approaches. a. The extent of the evaluation will vary according to the resident's current condition, but may include: 1. An appropriately detailed evaluation of mental, physical, psychosocial, and functional status, including comorbid conditions and pertinent psychiatric symptoms and diagnoses, and a description of resident complaints, symptoms, and signs. 2. Resident's goals and preferences .

Based on interview and record review, the facility failed to monitor and notify the physician each time the insulin was held for a diabetic resident (Resident #34) of two residents reviewed for Diabetes management resulting in the hospitalization for a hypoglycemic event. Findings include: Resident #34: According to the Face Sheet, printed on 7/18/2019, Resident #34 was an [AGE] year-old male admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. According to the Medications Administration History: 3/1/2019 - 3/31/2019 (MAH), printed on 7/19/2019, the insulin ordered for Resident #34 on 3/6/2019, the date of his admission to the facility, was a long acting insulin, [MEDICATION NAME] 53 units twice a day, morning and night, to be given by injection and sliding scale regular (fast acting) insulin injection coverage, based on the results of the blood sugar check, three times a day before meals. The sliding scale insulin began on 3/7/2019 and started at a blood sugar result of 151 to 200, give 2 units; 201 to 250, give 4 units; 251 to 300, give 6 units; 301 to 350, give 8 units; 351 to 400, give 10 units; and if the blood sugar reading was over 400, the nurse was to call the physician for orders. The progress note indicated that Resident #34 was admitted at 6:40 PM. The MAH reflected that Resident #34's blood sugar was 160 when checked between 6:00 PM and 10:00 PM. The comment for 3/6/2019 was that Resident #34 Refused the [MEDICATION NAME]on 3/6/2019 at 6:00 PM to 10:00 PM. There was a progress note for 3/6/2019 that indicated that Resident #34 also refused his dinner, but his spouse had told the nurse that he had something to eat at the hospital. According to the facility policy on Withheld Medications, dated (MONTH) (YEAR), If a medication is withheld for any reason the prescriber must be notified. Potential reasons medications might be held included blood sugars parameters. The policy continued, stating, After discussion with the prescriber, document conversation in nurse's notes, and transcribe any new orders. **Note: It is nursing judgment or facility policy, (taking into consideration the severity the drug and all contributing factors) when a prescriber should be notified. This was the only policy provided by the facility. On 3/7/2019, the 8:00 AM blood sugar was recorded as 208 on the MAH. Also recorded for 3/7/2019 was the administration of 53 units of [MEDICATION NAME]and 4 units of regular insulin on that morning. On 3/7/2019 the Meal Intake was recorded as 25% at breakfast, with a substitute offered and refused. The morning snack was recorded as not received due to his sleeping. The blood sugar was recorded as 198 at 12:00 PM, with regular insulin coverage of 2 units and the Meal Intake at lunch was recorded as 60%. The afternoon snack was recorded as 75% consumed. The 4:00 PM blood sugar was recorded as 248 with 4 units of regular insulin coverage administered. The dinner intake for 3/7/2019 was recorded as Refused Meal; Substitute Refused. The 6:00 PM to 10:00 PM blood sugar was recorded as 221 and the long acting [MEDICATION NAME] insulin, 53 units, was recorded as administered. The bedtime snack was recorded as Did not receive snack due to sleeping at 6:16 PM. On 3/8/2019, the 6:00 AM to 10:00 AM blood sugar was recorded as 140, with the 53 units of [MEDICATION NAME] held per family because Resident #34 refused breakfast. The 8:00 AM to 10:00 AM blood sugar was recorded as 194, with no regular insulin coverage given and no comment on the MAH. A progress note indicated that the afternoon blood sugar was charted on the morning blood sugar, with the morning blood sugar being 140 with no coverage was required. The progress note also stated that the afternoon blood sugar was 194 with 2 units of regular insulin coverage given before lunch. The intake of meals for breakfast, morning snack, lunch, and afternoon snack for Resident #34 were not recorded on 3/8/2019. The 4:00 PM to 6:00 PM blood sugar was recorded as 222 on 3/8/2019 with 4 units of regular insulin coverage. The 6:00 PM to 10:00 PM blood sugar was recorded as 192 and the 53 units of [MEDICATION NAME]was administered. Dinner was recorded at taken 65% and no snack received at bedtime because Resident #34 was asleep at 6:23 PM. On 3/9/2019 both the 6:00 AM to 10:00 AM and the 8:00 AM to 10:00 AM blood sugars were recorded as 115 for Resident #34. Resident #34 received 53 units of [MEDICATION NAME] insulin. Meal intake was recorded as 100 % of breakfast, 100% and 75% of the morning snack, and 75% of lunch. Resident #34 had a blood sugar of 123 recorded for 12:00 PM to 1:00 PM with no regular insulin coverage. On 3/9/2019, the blood sugar recorded for 4:00 PM to 6:00 PM was 79. The blood sugar recorded for 6:00 PM to 10:00 PM was 81. The amount of supper recorded as taken was 70%. No bedtime snack was recorded as consumed because Resident #34 was sleeping at 6:01 PM. The nurse recorded in the comment section of the MAH that the [MEDICATION NAME]was held per the physician. On 3/10/2019 Resident #34's blood sugars were recorded as 83 for 6:00 AM to 10:00 AM and the 8:00 AM to 10:00 AM. [MEDICATION NAME] 53 units were administered at 8;00 AM to 10:00 AM. No breakfast, lunch, or morning snack were recorded on the Meal Intake report for 3/10/2019. The afternoon snack was recorded as 0. On that day, Resident #34 consumed 75% of his supper and 0% of his bedtime snack according to the Meal Intake report. On the MAH, blood sugars were recorded as 4:00 PM to 6:00 PM 146 and 120 at 6:00 PM to 10:00 PM with 53 units of [MEDICATION NAME] administered for the evening dose at 6:00 PM to 10:00 PM. On 3/11/2019, Resident #34's blood sugars were recorded as 80 for 6:00 AM to 10:00 AM and not at all for 8:00 AM to 10:00 AM. there was a note in the Comment section of the MAH that the [MEDICATION NAME] was not administered due to low blood sugar. There was no progress note for 3/11/2019. The Meal Intake report indicated that Resident #34 had consumed 65% of his breakfast, none of his morning snack because he was sleeping, 100% of his lunch, 0% of his afternoon snack, 100% of his dinner, and 0% of his bed time snack. On the MAH, blood sugars were recorded at 4:00 PM to 6:00 PM as 150 and 176 at 6:00 PM to 10:00 PM with 53 units of [MEDICATION NAME] administered for the evening dose at 6:00 PM to 10:00 PM. There was no indication that the attending physician had been notified when the [MEDICATION NAME]was held on the morning of 3/11/2019. On 3/12/2019, Resident #34's blood sugars were recorded as 75 for 6:00 AM to 10:00 AM and 93 for 8:00 AM to 10:00 AM; there was a note in the Comment section of the MAH that the [MEDICATION NAME] was not administered due to Resident #34's refusal. There was no progress note for 3/12/2019 pertaining to the blood sugars or the refusal of the [MEDICATION NAME] insulin. The Meal Intake report indicated that Resident #34 had consumed both 75% and 100% of his breakfast, none of his morning snack because he was sleeping, 100% of his lunch, his afternoon snack was not recorded, 40% of his dinner, and he refused his bed time snack. On the MAH, blood sugars were recorded at 4:00 PM to 6:00 PM as 142 and 175 at 6:00 PM to 10:00 PM with 53 units of [MEDICATION NAME] administered for the evening dose at 6:00 PM to 10:00 PM. There was no indication that the attending physician had been notified when the [MEDICATION NAME]was refused on the morning of 3/12/2019. On 3/13/2019, Resident #34's blood sugars were recorded as 95 for 6:00 AM to 10:00 AM and 95 for 8:00 AM to 10:00 AM, Resident #34 was administered 53 units of [MEDICATION NAME]for the 6:00 AM to 10:00 AM dose. The Meal Intake report indicated that Resident #34 had consumed 100% of his breakfast, 10% of his morning snack, 10% of his lunch, 0% of his afternoon snack, 0% of his dinner, and 0% his bed time snack. On the MAH, blood sugars were recorded at 12:00 PM to 1:00 PM as 127, 4:00 PM to 6:00 PM as 142 and 147 at 6:00 PM to 10:00 PM with 53 units of [MEDICATION NAME] administered for the evening dose at 6:00 PM to 10:00 PM. There were no progress notes entered for 3/13/2019. On 3/14/2019, the nurse had documented that when she entered into Resident #34's room at 5:00 AM to administer medication, she had observed him foaming at the mouth and non responsive. The nurse had recorded that the blood sugar was 24 and the physician was called and ordered [MEDICATION NAME] to be administered. The blood glucose was retested and was found to be 25 when the ambulance was contacted. When Resident was leaving at about 5:43 AM, the blood sugar was found to be 140. The hospital records from the emergency room diagnosed Resident #34 with [DIAGNOSES REDACTED], was slow to respond to commands, and had appropriate responses when aggressively stimulated. According to the progress notes, Resident #34 was readmitted to the facility on [DATE]. During an interview with Dr. I on 7/18/19 at 12:15 PM, he stated that he usually prescribes sliding scale insulin for the first three to four days following admission until the resident is stable. Dr I stated that he was aware that sliding scale insulin is on the Beer's Criteria of Potentially Inappropriate Medications for Older Adults, published by the American Geriatrics Society in (YEAR). Dr I also stated that he uses sliding scale insulin for residents who were non-compliant with their dietary restrictions for Diabetes management. When asked if Resident #34 was non-compliant, he said no, he is blind, he eats whatever he is served. Dr I also stated that he had adjusted Resident #34's long acting insulin several times. Since Dr I was not informed of Resident #34's refusals and holds of the insulin doses, concerns about how much he was consuming, and the low blood sugars, he had no opportunity to evaluate the management of Resident #34's diabetes from 3/6/2019 to the time of the hypoglycemic event on 3/14/2019.

This Citation pertains to Intake #MI 214 Based on observation, interview and record review, the facility failed to prevent significant medication errors for 2 residents (#6 and #40 ) of 8 residents reviewed for medication errors, resulting in Resident #6 receiving repeated doses of Nicotine patches without removing the old patches, increased confusion and hospitalization and Resident #40 receiving an Intravenous (IV) antibiotic at a faster rate than the physician ordered, which could lead to adverse effects including fluid overload. Findings Include: Resident #6: On [DATE] at 2:50 PM, Resident #6 was observed sitting in a wheelchair in her room and stated, I was in the hospital about ,[DATE] days ago. A level was too high and it was very dangerous. The resident was asked if she was receiving a Nicotine patch and stated, Not anymore. They found 3 of those on me. A record review of a nurses note written by Nurse GG on 9//,[DATE] at 1:15 PM provided, CNA (Certified Nursing Assistant) advised this nurse that she found 2 nicotine patches on resident along with 1 patch that was somewhat folded and stuck between resident and resident gown. One patch was on shoulder, one on lower waist. Per the Nurse Practitioner, all patches are to be removed .Resident is confused reported resident found with 3 nicotine patches on. Family complains of increased confusion. A review of the physician orders indicated there was an order dated [DATE] to administer a Nicotine patch every 24 hours [MEDICATION NAME] (on the skin) to Resident #6, but there was no order to remove the previous patch or to document the location that the patch was placed on the resident's body. The order was discontinued on [DATE]. A new physician's order was documented on [DATE], Nicotine 24 hour patch off before next dose. A review of the Face Sheet and Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #6 was admitted to the facility on [DATE] with Diagnoses: [REDACTED]. The MDS revealed the resident had mild cognitive deficits. A review of the progress notes indicated Resident #6 was admitted to the hospital on [DATE] and readmitted on [DATE] related to increased confusion. On [DATE] at 11:20 AM, an interview with Nurse R revealed, It was me. I was the one who had put those patches on, not the Friday patch but the other 2. I had looked high and low and could not find the old patches. I searched her and couldn't find the patches. There was no place to document where the patches were placed. I couldn't find them. Then (Unit Manager G) called and told me about it and said they found the multiple patches on the resident. A review of the physician progress notes [REDACTED]. On [DATE] at 1:15 PM, during an interview with Physician FF, he was queried about the resident's hospitalization after the medication error with 3 Nicotine patches and stated, I am aware of that. It should have been documented where it was applied. On [DATE] at 2:05 PM an interview with Nurse Manager G revealed, The CNA (S) came and told me they found 2 nicotine patches on the resident's back and 1 stuck to the nightgown. The resident stated, she gets sweaty at night and sometimes they fall off. We implemented new orders to verify they removed the previous patch and documented the site of administration. I put in a progress note. I talked to her daughter about the steps we took to correct it. Resident #40: A review of the Face Sheet and Minimum Data Set (MDS) assessment dated [DATE], indicated Resident #40 was admitted to the facility on [DATE] and readmitted on [DATE] with Diagnoses: [REDACTED]. The MDS indicated the resident had full cognitive abilities. On [DATE] at 3:18 PM, Resident #40's empty [MEDICATION NAME] (an antibiotic) (1.5 grams/500 milliliters of normal saline) Intravenous (IV) bag was observed hanging in the resident's room. The [MEDICATION NAME] bag was dated [DATE] and expired on [DATE]. There was no date or time located on the bag, that indicated when the [MEDICATION NAME] was administered to Resident #40. On [DATE] at 3:23 PM, an interview was conducted with Nurse X regarding Resident #40's order for [MEDICATION NAME]. The Nurse explained the initial order was confusing as it read every 36 hours for 4 days. He reported Resident #40 did not receive his first dose of [MEDICATION NAME] on his shift. He reported he received it on [DATE] at 1:57 AM. On [DATE] at 5:04 PM, the empty [MEDICATION NAME] bag that was observed earlier in the day was still hanging in Resident #40's room, with no date and time of administration. On [DATE] at 8:30 AM, Nurse O was observed during medication administration for Resident #40. The Nurse prepared IV [MEDICATION NAME] , 1.5 milligrams (mg) in 500 milliliters (ml) of 0.9% sodium chloride solution. A Medication Administration Record [REDACTED].administer 1.5 gm .at 125 ml an hour . On [DATE] at 8:33 AM, upon entering Resident #40's room, the resident was observed to have redness and a large amount of [MEDICAL CONDITION] (fluid retention/swelling) in his right arm. Nurse O said the resident had a blood clot in the right arm. The Central Line IV catheter was also in the right arm. Nurse O connected the IV tubing to the resident's Central Line and set the electronic IV pump to 200 ml an hour. The Nurse was asked why she was administering the medication at a dose different from the order and stated, It says to run it at 200 ml an hour on the IV bag. Nurse O pointed to a white label on the 500 ml bag of IV fluids containing the [MEDICATION NAME]. When queried why it was different than the physicians order, she stated, Pharmacy sets the dose and rate. That is what we follow. On [DATE] at 9:00 AM, a review was completed of Resident #40's [MEDICATION NAME] orders, it revealed the following: [MEDICATION NAME] in 0.9% sodium chloride, solution; 1.5 gram/150 mL (milliliters); every 36 hours; administer at a rate of 125 mL/hr (hour). It can be noted the [MEDICATION NAME] order changed six times from [DATE]-[DATE], but the administration rate of 125/mL/hr was consistent with all 6 of the order changes. On [DATE] at 12:32 PM, Resident #40's next dose of [MEDICATION NAME] was observed in the 300-hall medication storage room. The bag was labeled to infuse at a rate of 200 mL/hr (when it was ordered for 125 mL/hr) and the bag is further labeled 1.5 grams /500 mL (when the order was for 1.5 grams/150mL). Further review of the physician orders revealed Resident #40 had a 1500 ml/day fluid restriction related to heart failure. The 500 ml bag of fluids was not calculated into the daily restriction. On [DATE] at 1:00 PM, during an interview with Physician FF regarding the [MEDICATION NAME] order for Resident #40, the Physician explained he was not aware that there was a discrepancy in the infusion rate and fluids and stated, The pharmacy usually sets the rate for the IV Vanco administration. When asked about the order for Vanco IV at 125 ml/hour, but the 500 ml IV bag said 200 ml/hour, the Physician said, We usually put that in a smaller bag with less fluid. We will check on that. On [DATE] at approximately 3:20 PM, an interview was conducted with the DON (Director of Nursing) regarding Resident #40's [MEDICATION NAME] order. The DON was alerted to the incorrect infusion rate and fluid volume that was administered during his medication pass and the additional [MEDICATION NAME] bag stored in the medication room for this resident with the incorrect rate and volume. The DON reported she was not aware of this and will consult with Pharmacy for clarification. The DON agreed there was an inaccuracy in the current prescribed [MEDICATION NAME] order for Resident #40. The DON was queried as to her expectations of nursing staff with dating and timing IV (intravenous) bags. The DON stated her expectation is that the nursing staff date and time the bag at time of infusing. On [DATE] at 3:50 PM the DON stated, The [MEDICATION NAME] order was corrected. A review of the facility policy titled, Preparation and General Guidelines, Medication Administration, dated revised ,[DATE] provided, The Medication Administration Record [REDACTED]. Prior to administration of any medication, the medication and dosage schedule on the resident's MAR indicated [REDACTED].If a medication with a current, active order cannot be located in the medication/cart drawer, other areas of the medication cart, medication room and facility are searched .Medications are administered in accordance with written orders of the prescriber .

This citation pertains to MI Based on observation, interview and record review, the facility failed to ensure appropriate securement during facility provided transport for one (#701) sampled resident for accidents from a total sample of three. An Immediate Jeopardy arose when facility staff failed to utilize the lap belts that were accessible to them on the bus, to properly secure Resident #701 during transport, resulting in Resident #701 being propelled forward during a sudden stop, landing on the floor of the bus, and sustaining a [MEDICAL CONDITION], unnecessary pain and the potential for agitation and emotional distress. The Immediate Jeopardy (IJ) was identified on 11/29/17 at approximately 4:00 PM. The Administrator was notified of the Immediate Jeopardy on 12/12/17 at approximately 9:10 AM. The Administrator was instructed to provide a plan of correction to remove the immediacy. The IJ was removed on 11/30/17 based on the providers implementation of the plan removal as verified onsite on 12/12/17. Finding include: On 12/11/17 at 1:35 PM, an interview was conducted with Employee B about the incident that occurred on 11/29/17. Employee B explained they (701 unsecured) and (704 and 705 secured and uninjured), Bus Occupant E and Employee A) were in route back to the facility from an outing with Resident's in Flint, MI. Employee A was inside the bus securing the Residents, as Employee B was on the outside of the bus assisting Resident's onto the bus. Employee A was operating the bus and as they were approaching an intersection and the vehicle in front of them abruptly slammed on breaks and Employee A subsequently, slammed on breaks to avoid a vehicular accident. Employee B reported she heard a loud noise and looked back and saw Resident #701 and Bus Occupant E on the floor of the bus. Bus Occupant E was observed lying flat on the bus floor and Resident #701 was observed lying on their right side. Employee B reported Resident #701 and Bus Occupant E wheelchairs were locked down but they did not have on the lap belt. Employee B explained the shoulder straps were observed but the mechanism it attaches to was not on the bus. Employee B stated they inquired about where the lap belt was and was directed to, Not worry about it. The employee continued that they were never shown how to properly load the Residents' onto the bus. Resident #701 suffered a broken leg in two places and Bus Occupant E broke their nose from the incident. On 12/11/2017 at 1:57 PM, an interview was conducted with Nurse C who responded to the incident, to transport the other two Residents that were not injured back to the facility. Nurse C reported they received a phone call from Employee A who informed them of the incident that occurred on the bus. Nurse C communicated this information to the Director of Nursing (DON) and Administrator. Nurse C stated when arriving on the scene Resident #701 and Bus Occupant E were no longer there. Nurse C stated she was trained by the Maintenance Director on how to properly secure Residents on the bus for transport (it can be noted this training occurred after the incident on 11/29/17). On 12/11/17 at 2:08 PM, an interview was conducted with Maintenance Director D about the incident that occurred on 11/29/17. The Maintenance Director reported he assumed Employee A trained her staff on how to properly secure Residents on the bus during transport. Maintenance Director D learned how to use the securement equipment on the bus after the incident occurred. Maintenance Director D explained monthly seat belt checks are completed on the bus, but this did not include the securement system for Resident wheelchairs. The Maintenance Director was not aware that facility staff did not know how to properly use it. After the incident, he checked the bus and found that all the equipment needed to secure the Resident's wheelchair were on the bus. An observation of two sets of the wheelchair securement equipment (metal brackets for track, harnesses and lap belts) were made on the facility bus. The Maintenance Director also provided a demonstration of how to secure a wheelchair. Maintenance Director D has trained facility staff that will be transporting on how to appropriately secure Resident wheelchairs on the bus. On 12/11/17 at approximately 2:40 PM, a record review was completed of the facility form entitled Vehicle Peer Review Inspection Report, dated 10/27/17. Next to the statement, Seat belts working properly, the letter Y is circled (denoting yes). On 12/11/17 at 2:50 PM, Resident #701 was observed lying in bed and right leg was observed to be in an immobilizer. Resident #701 was queried about the incident that occurred during facility transport from an activity on 11/29/17. The Resident reported when they were loaded into the bus only their wheelchair brakes were locked in place and they did not have on a seatbelt. Resident #701 reported Employee A was driving the bus and they were going through an intersection, when the car in front of them slammed on brakes, which caused Employee A to slam on brakes as well. When the Employee slammed on brakes Resident #701 flew out of their wheelchair, hit the steel part on the back of bus seat and landed on their right side. The Resident reported they broke their leg, above and below the knee and surgery cannot be completed due to their age and other mitigating factors. Resident #701 stated that she will not be able to walk again. She added that Bus Occupant E fell on their face in the aisle way and broke their nose. On 12/11/17 at 3:10 PM, an interview was conducted with Resident #704 in regards to the incident on the facility bus. Resident #704 reported as Employee A was operating the bus someone cut them off and the driver had to slam on brakes to avoid smashing into the car in front of them. Resident #704 stated they were sitting in a seat on the bus and had on their seatbelt, but the abrasiveness of the stopped caused them to launch forward and grab the front of the seat. Resident #704 reported Resident #701 and Bus Occupant E were in the back of the bus, in their wheelchairs, that were strapped down tot eh bus floor. Resident #704 explained they were not strapped to their wheelchairs and when Employee A slammed on brakes, they were thrusted forward out of their wheelchair and onto the floor. Bus Occupant E broke their nose and Resident #701 fell to the side in the back of the bus. On 12/11/17 at 3:35 PM, an interview was conducted with Resident #705 in regards to the incident on the facility bus. Resident #705 reported the bus stopped really quickly and when Employee A did this, Resident #701 and Bus Occupant E fell to the floor. They were both in the back of the bus, in their wheelchairs. Resident #705 reported the bottom of both wheelchairs were strapped down but Resident #701 and Bus Occupant E were not strapped into their wheelchairs. On 12/11/17 at 3:45 PM, a review was completed of Resident #701's electronic medical records and revealed that the Resident was originally admitted into the facility on [DATE] and readmitted (after the incident) on 12/5/17 with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment completed on 11/7/17 indicated the Resident was cognitively intact. On 12/11/17 at approximately 4:00 PM, a review was completed of Resident #701's Diagnostic Report from their hospital stay. Under impression it stated, Comminuted (fracture where bone is crushed into numerous pieces) periprostetic fracture (broken bone that occurs around the components or implants of a total hip replacement) of the distal femur .right distal femur fracture, no surgical intervention . On 12/11/17 at 6:00 PM, Employee A was queried about the incident that occurred on 11/29/17. Employee A reported at an intersection the vehicle in front of them slammed on brakes, causing her to slam on brakes in order to avoid an accident. Employee A stated Resident #701 and Bus Occupant E wheelchairs were secured with the S Hooks but their lap belts were not on as there were no lap belts present on the bus. Employee A explained the lap belts have not been present on the facility bus in many months. Employee A explained she informed the Administrator and Maintenance Director that the lap belts could not be located on the bus. The Employee explained they were never properly trained on how to appropriately secure the Resident's wheelchairs on the bus. She stated they watched a five minute video on the facility training site, but there was never a demonstration provided by facility staff, to ensure their understanding. On 12/12/17 at 8:50 AM, the Administrator was queried about the training provided to facility staff on securing Residents during transport on their bus. The Administrator explained the staff watch two videos and then sign that they understand how to safely transport Residents. There is no live demonstration or return demonstration for the securement of residents during transport of the bus. The Administrator was asked if Employee A and B received the training previously described. The Administrator stated both employee received the in-service for the bus. It was reported facility staff are not required to have a special license to operate the bus, as the occupancy level is not high enough. The Administrator reported the Maintenance Director was instructed to check the bus after the incident and it was reported that all the pieces to the securement equipment was on the bus and accessible to Employee A and B. On 12/12/17 at 9:40 AM, a review was completed of an email written by Nurse C on 12/1/17 at 9:50 AM, after a visit was completed with Resident #701 at the hospital. The email stated, .During the visit the resident stated that she has two breaks in her leg, and she is not able to have surgery to fix it .(Employee A) had not been driving fast but the car in front of them had stopped so suddenly that (Employee A) had to hit the brakes hard. (Resident #701) also stated that the only bad part was that she did not have a seatbelt on to stop (Resident #701) from coming out of (their) chair . On 12/12/17 at 9:50 AM, a review was completed of the statement completed by Bus Occupant E that was taken by the DON on 12/1/17 at 11:00 AM. The statement revealed the following, Last one to get on the bus, staff member buckled my feet down and I said What about up here (pointed to stomach) & staff said no it's on & they left back to facility & all of a sudden (Employee A) slammed on the brake and I went flying out of my seat on my face, I just laid on the floor forever .The woman next to me got hurt too .I scraped by body all up, I slid on my face . At 11:45 AM on 12/12/17, the Maintenance Director was queried about the last time the facility bus was utilized. It was reported the bus has not left the facility since the incident that occurred on 11/29/17. At 11:51 AM on 12/12/17, Employee B was queried about the monthly usage of the facility bus prior to this incident. Employee B reported there are about eight outings planned for the Residents during each month. Employee B was queried on the usage of the securement equipment during transport prior to this incident. The employee reported since they have been in the Activities Department they have never used the lap belts during transport of the Residents. Only the S hooks were utilized to secure the Residents on the bus, as they were informed the lap belts were not on the bus. Employee B reported they have not utilized the bus since the incident. On 12/12/17 at 12:00 PM, a review was completed of facility documents entitled, Resident Transportation Policy, revised July 2010, the policy stated, .All residents being transported in the campus van must wear seatbelts. Any resident being transported in a wheelchair must use the safety harness and wheelchair straps in strict accordance with the manufacturer's instructions . On the second page of the policy is a signature sheet where Employee A and B signed on 7/17/14 and 6/15/17 respectively, indicating their understanding of the aforementioned policy presented to them. The signature page stated, I (Employee name) have watched the two bus training videos on (the facility training site) and understand the information that was presented to me. On 12/12/17 at 12:05 PM, a review was completed of the facility policy entitled, Resident Transport Safety Procedures, effective 5/22/17, the policy revealed the following, .Make sure all residents are secured with safety belts before operating the vehicle . The facility submitted a Plan of correction to remove the immediacy: 1. Resident 710 has received care for her fractures. Social Work has followed up with resident 701 to monitor for signs and symptoms of emotional distress or agitation. Social Work has also followed up to give emotional support so resident 701 feels comfortable and secure on future bus outings. NHA or designee will ensure proper securement is in place on future bus outings. Nursing staff monitoring pain for resident 701. The bus has been taken out of services as of return to the facility on [DATE]. Driver has been terminated. 2. All residents have the potential to be at risk. Bus has not left campus since incident. Any current or future staff that operate the bus will have proper education prior to operating the bus with return demonstration to ensure understanding and compliance. Will discuss any concern with any residents that express any apprehension of going on future bus outings. Policies and procedures were reviewed and deemed appropriate. All staff that have been identified to operate the bus and any future staff have been educated on proper safety policies and procedures when operating the bus and have completed return demonstration of securement of residents ( both in seats and wheelchairs). NHA and designees completed the education. 4. Audits on use of bus safety belts is completed upon leaving the facility. Audits will be completed any time the bus leaves the campus x 8 weeks. NHA or designee will ensure compliance with this. 5. All results will be reported to QAPI. Date of compliance: 11/30/17

This Citation Pertains to Intake # MI 133 Based on interview and record review, the facility failed to assess and respond in a timely manner to a change in condition for one (#714) of one Residents reviewed for assessment and monitoring, of a total sample of 15, resulting in a delay in medical treatment, adverse outcomes, and deterioration in medical status. Findings include: Record review on [DATE] at 3:30 PM revealed Resident #714 was originally admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the initial Minimum Data Set (MDS) assessment dated [DATE] revealed the Resident was severely cognitively impaired and required extensive assistance to perform Activities of Daily Living (ADL's). Additional review at this time revealed the Resident was discharged from the facility, and sent to the hospital for emergency treatment, on [DATE]. Review of facility provided investigation pertaining to Resident #714 on [DATE] at 4:45 PM included documentation of Computed Tomography (CT) scan results from Hospital H dated [DATE] at 6:23 PM revealed the following results: Findings: The left hip is dislocated, with the prosthetic hip dislocated superiorly .There are multiple osseous fragments within the left hip joint, largest measuring 8.6 mm. There is lucency seen through the posterior acetabulum, most consistent with an acute non-displaced fracture. Fractures of the proximal femur, with involvement of the greater trochanter . Impression . Superior left hip dislocation. There is a [MEDICAL CONDITION] wall of the acetabulum. There is a [MEDICAL CONDITION] femur, with involvement of the greater trochanter. There is limited evaluation of the proximal femur fracture, secondary to artifact from hip prosthesis. There are multiple displaced fracture fragments within the hip joint. Large fluid collection in the subcutaneous tissues overlying the left hip . The possibility of infection cannot be excluded . Correlate clinically. Review of an interview completed by the Director of Nursing (DON) dated [DATE] with Physician G revealed the following, I reviewed the radiology reports (for Resident #714) . it (hip) is badly infected. The interview form was not signed or dated by Physician G. Additional review of the facility investigation pertaining to Resident #714's injury of unknown origin at this time revealed the facility was unable to determine the cause of the injury. On [DATE] at 9:00 AM, an interview was conducted with Confidential Family Member MM. When queried regarding Resident #714, Confidential Family MM stated, (Resident #714) ended up dying [MEDICAL CONDITION]. They had such an awful infection. I close my eyes and I can still hear (the Resident) crying out and screaming before they died . It was awful and the facility wouldn't even give us (Resident #714's family) answers about what happened. On [DATE] at 9:15 AM, review of Resident #714's medical record revealed the following documentation: [DATE] at 10:51 PM: Resident arrived to facility at approx 1600 via ambulance with EMT. Resident transferred into building on stretcher. Resident observed to be confused and in pain upon movement Resident medications entered into matrix, Dr. notified of arrival. Resident sustains Incision to L (left) hip, well approx (approximated) with 22 staples. [DATE] at 7:02 AM: Incision and staples on L Hip, no s/s (sign/symptoms) of infection, no redness. Well approximated. Duoderm on coccyx area.[MEDICAL CONDITION] precautions in place. ABT (antibiotic) will begin in AM [DATE] . [DATE] at 12:12 PM: Reviewed with IDT this morning resident admitted back to the facility with a surgical incision to left hip area has staples in place resident also on antibiotics and on isolation precaution [MEDICAL CONDITION] will cont (continue) to monitor for any side effects of medication and notify Dr with any changes or concerns. [DATE] at 12:37 PM: This nurse in with (Physician CC) to asses area to buttock hip and knee area to butt slightly red from moisture will implement a barrier cream to protect skin and also order a low air loss mattress residents hip incision intact with staples no redness noted to site resident was yelling out while repositioning and changing brief but hard to tell with dementia whether (the Resident) was more frightened or in pain is currently on ATC (around the clock) pain medication resident does have a new stage II area to left inner knee some drainage noted tx (treatment) implemented per physician will cont (continue) to monitor for any changes or concerns. [DATE] at 10:49 AM: Continue to monitor incision healing well. continue iv-abx tol (tolerated)-well no side effects noted. Nursing PICC (Peripherally Inserted Central Catheter) line in place infuses well, no redness or swelling noted at site. tx (treatment) continue to wound tol (tolerated)-well at this time. [DATE] at 6:44 AM: Observed swelling, redness, warmth with serous drainage at incision site of 18 mm (millimeters) x 1 mm. Temp 96.0 (o-oral) The top 6 mm has redness measuring 2mm. 1 mm at distal end of incision has the serous drainage, Cleansed with ns (normal saline), patted dry, applies ABD pad and taped. Notified Dr. via text of situation and waiting for response on further instruction. Reported to on coming staff nurse of situation. [DATE] at 9:33 AM: Reviewed with IDT this am. Resident started on IV fluids and is having concerns at surgical incision site. Dr. aware and new orders received. Will continue to monitor resident for concerns and notify Dr. [DATE] at 7:20 AM: 8 x 10 ABD Pad saturated with serous fluid from incision. Cleansed with ns, patted dry. Applied new ABD pad and reported to oncoming nurse and Wound Specialist Nurse condition. Will continue to monitor. Safety measures in place. [DATE] at 11:25 AM: Wound care continues for left inner knee pressure injury and left hip incision as ordered. Foam cushion placed between legs to help prevent further skin breakdown. Drainage from incision site serosang, surrounding skin pink/light red. Resident afebrile. Continue to monitor. [DATE] at 5:29 PM: Per conversation with physician about increased drainage add order for [MEDICATION NAME] to left hip incision daily. Clean with NS or wound cleaner, pat dry, apply thin layer of [MEDICATION NAME] to incision and cover with ABD secured with tape or an island drsg (dressing). Physician will assess on [DATE]. [DATE] at 11:25 AM: Nurse in with (Physician CC) to assess area to left inner knee area healed at this time cont (continue) treatment to left hip incision will cont to monitor area for any changes or concerns. [DATE] (No Time): Scanned documentation by Physician CC indicated serous drainage from left hip surgical incision with plan of care for Bactriban to site daily. [DATE] at 1:24 AM: Patient is confused this evening. Shows no behavioral signs of pain, just some confusion. (Resident) is currently resting in bed with his dressings intact . Changed dressing on the left hip with NS and applied [MEDICATION NAME] to the site as the previous dressing was saturated. Record review of facility documentation entitled SBAR: Physician/NP/PA Communication Tool (Dated [DATE] at 4:03 PM revealed the following documentation: Description: Drainage has changed in consistency and type since assessment on [DATE]. Physician made aware and requested (Resident #714) be sent to ER for evaluation and treatment as needed. Pertinent Medical History: Resident admitted to facility after surgery to fix left femur fracture. Was on Vanco but Resident was pulling our Midline so physician discontinued order. Any Other Data: Physician assessed and stated Resident needed to be sent to ER for evaluation for possible hematoma (collection of blood) in the lift hip area . Vital sign documentation included Temperature 96.3 (route not specificied), Pulse 70, Respirations 16, Blood Pressure ,[DATE], SPO2 Saturation 95%. Additional review at this time, revealed diagnostic laboratory testing that would indicate systemic infection occurred on [DATE]. This testing demonstrated an elevated White Blood Cell (WBC) count of 11.8, indicating infection. On [DATE], urinalysis testing was completed to evaluate the presence of a urinary tract infection. Review further at this time revealed Resident #714's antibiotic for [MEDICATION NAME] was discontinued and the last dose the Resident received was on [DATE]. Review of nursing documentation revealed the Resident removed their midline and Physician CC did not reorder antibiotic therapy for the Resident. Review of Resident #714's care plans at the time of their transfer to the hospital revealed that the Resident did not have a care plan pertaining to infection or risk for infection related to surgical procedure. An interview was completed with the Director of Nursing (DON) on [DATE] at 10:40 AM. When queried regarding Resident #714's surgical site including assessment and treatment of [REDACTED].#714) had an infection, we sent them out (to the hospital) when it got bad. The DON additionally stated, The Doctor looked at it and we followed the orders. When queried if the treatment ordered was appropriate and if timely interventions were implemented to treat the infection, the DON replied, We followed what we were supposed to do. On [DATE] at 10:20 AM, an interview was completed with Nursing Assistant W. When queried regarding Resident #714, Nursing Assistant W stated, (Resident #714) had such an infection in their leg. It would drip through the dressing and on to the floor within a few minutes. It keep getting worse and worse (the drainage). (The Resident's) pain kept getting worse and worse too. On [DATE] at 10:30 AM, an interview was completed with Nursing Assistant V. When queried regarding Resident #714, Nursing Assistant V stated, I remember the drainage from (Resident #701's) leg incision. We brought (the Resident) out to the nurses station to sit and the draining leaked through the dressing and onto the floor in just a few minutes. On [DATE] at 11:40 AM, an interview and record review was completed Physician CC. When queried regarding Resident #714's surgical incision, Physician CC stated, The wound dehisced and started oozing. With further inquiry, Physician CC stated (Resident #714) was sent here (from the hospital) on Vanco ([MEDICATION NAME], IV antibiotic medication) but we weren't sure why (the Resident) was even on it. Review of the medical record with Physician CC at this time revealed infection documentation that indicated the Resident had a respiratory infection [MEDICAL CONDITION] colonization. When queried [MEDICAL CONDITION] colonization and respiratory infection, Physician CC replied, I spoke to the Infectious Disease Doctor and they didn't know why (Resident #714) was receiving it (Vanco) either. When queried regarding nursing documentation within the Resident's medical record that indicated signs and symptoms of infection, Physician CC stated, I saw the Resident on [DATE] and I thought it was okay. Surgical incisions drain. When queried further regarding the length of time since surgery, the incision dehiscing, and the increased redness and drainage around the surgical incision site, Physician CC stated, The drainage was serous when I saw it. Serous drainage is normal. As a Physician, I don't think it is possible for the infection to get that bad that quickly. When asked about documentation of serosangous drainage by nursing staff, Physician CC did not provide a response. When queried regarding diagnostic testing completed to assess Resident #714 for infection, Physician CC reviewed the medical record and stated, There was nothing ordered but we knew the Resident had an infection when they came here. When queried further regarding discontinuation of antibiotics, no diagnostic testing to determine infection, and the signs/symptoms of incision infection first documented on [DATE], Physician CC replied, I am a Medical Doctor that was my determination. Physician CC further stated, We did start Bactriban topically on the site. Record review at this time revealed Bactriban was started on [DATE]. When queried how effective Bactriban would be for a systemic infection, Physician CC did not provide a response. Physician CC then stated, We were trying, everyone makes mistakes sometimes. On [DATE] at 3:50 PM, an interview was completed with the facility Administrator. When queried regarding the Resident #714's surgical site incision including assessment and timely care, the Administrator stated, I was not here when that happened. Would have to talk to (the DON). Review of facility policy entitled, Guidelines for Change in Resident Condition (No Date) on [DATE] at 6:00 PM revealed, 1. Upon assessment of resident change in status, the licensed professional nurse will initiate the appropriate 'Event' in the Electronic Health Record (EHR) in order to fully reflect and document the nursing process. 2 The nursing assessment will be entered into EHR Event, and progress notes added as needed, which may include vital signs. 3. Notification of the resident physician and responsible party will be documented in EHR reflecting date and time of notification. A policy/procedure pertaining to wound care/monitoring was requested but not received by the conclusion of the survey.

This citation pertains to intake MI 271: Based on interview and record review, the facility failed to provide adequate supervision and implement fall safety devices for one (#401) of two sampled residents reviewed for accidents from a total sample of four, resulting in falls, lacerations, abrasions, a hematoma, a contusion, post-concussio[DIAGNOSES REDACTED], and neck fractures. Findings include: On 8/1/14 at 11 AM, the clinical record and Accident/Incident (A/I) reports for resident #401 were reviewed. The resident was admitted on [DATE] with [DIAGNOSES REDACTED]. The 3/21/14 MDS noted that the resident required limited assistance with toileting which increased to the need for extensive assistance, per the 5/15/14 MDS. Both MDS' noted that the resident was cognitively intact, required limited assistance with transfers, bed mobility, and ambulating in the resident's room. The MDS' also noted the resident was "not steady, only able to stabilize with staff assistance" when moving on and off the toilet and surface-to-surface transfers (between bed, chair, and wheelchair). The Care Area Assessment on the 5/15/14 MDS noted "He (resident) does require frequent cueing/supervision as he does demonstrate impulsive decisions and judgement at times...." The clinical record for resident #401 revealed a hospital History and Physical report noting that the resident was admitted into the hospital from 3/11/14 to 3/14/14 for "....weakness and near syncope. He has had several falls over the past week, once presenting to the emergency department for a scalp laceration." On 3/14/14, upon admission into the facility, a Nursing Admission Assessment and an "At risk for fall/injury" care plan noted a goal: "Resident will have reduced risk of fall related injury by utilizing fall precautions." Interventions included "low bed," "instruct resident on use of call light," and "Educate/remind resident to request assistance prior to ambulation." A/I reports for resident #401 noted the following: 1). On 3/18/14-The resident fell from the wheelchair, no injury, corrective measures to prevent reoccurrence-instructed to use call light. 2). On 3/25/14-"Patient participating in therapy....was instructed to sit and rest....Patient took upon himself to stand....fell ." Per nurses notes, the therapist was standing next to the resident "....with back turned....hit head and elbow...." 3). On 4/10/14-Found the resident on floor by the bed with blood on back of his head and a 4 centimeter (cm) laceration. The corrective actions included: "re-enforce education." The resident was sent to the hospital and returned with head staples. The hospital discharge summary dated 4/10/14 noted an instruction for the facility: "Please use bed alarm." 4). On 5/16/14-Found on bathroom floor, no injury, had "poor safety awareness and generalized weakness." The resident was enrolled into hospice care on 5/22/14. Hospice progress notes dated 5/22/14 and 6/12/14 documented: "unsteady gait" and "increased leg weakness." There was no documentation of an alarm sounding to alert staff of attempts to self-transfer. 5). On 6/14/14-Nurse aide "heard resident holler for help." Found resident on bathroom floor with a forehead abrasion and redness. The corrective action: "Offer toileting assist after meals." There was no documentation of an alarm sounding. 6). On 6/16/14-Found on bathroom floor, no injury, no mention of an alarm sounding to alert staff. Hospice progress notes dated 6/20/14 documented: "Staff stating patient is much weaker." 7). On 6/21/14-Found sitting on the floor at bedside, stated he slid out of bed, no injury, no mention of an alarm sounding, corrective action-"resident to be up in geri-chair when out of bed." 8). On 7/7/14-Alarm was sounding, found resident on floor at bedside with a blue bruise to the lower back area, corrective action-concave mattress (raised-edge mattress to prevent rolling out). There was no documented indication why this intervention was not implemented after one of the previous falls out of bed. 9). On 7/14/14-"(Nurse aide 'B') put resident on toilet-went to closet and then heard a crash and found resident on floor." Per nurses notes dated 7/14/14: "(Nurse aide 'B') assisted resident to toilet, then went to his closet to get clean clothes for him. She heard a crash in the bathroom and found resident on floor....large laceration....left side of head. Large amount of blood. Resident alert and answers questions." A witness statement dated 7/16/14 by nurse aide 'B' (who was unavailable in person or by phone) noted that she was getting clothes from the closet, heard the resident fall "with the toilet riser underneath his leg and I saw a lot of blood and his finger was smashed....he wasn't even scared at all and he said 'it's ok babe, go get help.' " A witness statement dated 7/14/14 by nurse 'A' noted, the "resident was lying on the floor....in a fetal position....it was pretty bad and he said 'ok, I'm ok.' I was concerned about his neck, so (I) stabilized it." Nurse 'A' said during a phone interview on 8/1/14 at 3:15 PM: The resident was "lying on the left side with blood on the floor under his head and a flap of skin hanging. He was alert when he was sent out to the hospital." A review of hospital records dated 7/14/14 for resident #401 revealed the following: The resident fell off the toilet, hit his head, and had an "8 cm laceration to scalp with flap, left index finger laceration, and left forearm abrasion." The resident was "oriented x 4 (to person, place, time, and situation), alert, cooperative, and interactive." A CAT scan report of the cervical spine dated 7/14/14 noted: fractures at C1 and C2 (broken neck). The clinical impression (dated 7/15/14): "concussion," "abrasion, contusion," "hematoma," "laceration 8 cm scalp, post-concussio[DIAGNOSES REDACTED]....C1 fracture, C2 fracture." Per nurses notes dated 7/15/14 at 6:30 PM for resident #401: "Arrived back from (the hospital). Resident is confused and restless. He is wearing (a neck) collar. The bandage on his head is saturated with a large amount of blood....the laceration was measured 9 cm....14 staples....the left index finger....anterior laceration 3 1/2 cm....posterior laceration measures 3 1/2 cm. The finger is purple in color....3 cm skin tear on the left posterior forearm....Resident's left eye is black/purple in color. Resident denies pain and does not want anything for pain." Per 7/16/14 nurses notes: 2 AM-"Resident still denies pain, restless at times." 2:30 AM-"Resident has increased anxiety and color is dusky." 3:30 AM-"Resident is without respirations or a heart beat." "....pronounced (dead) at 5 AM." On 8/1/14 at 4:45 PM, the Director of Health Services and Executive Director did not respond when asked why resident #401, with a known history of falls and impulsive behavior, was left alone, unattended on the toilet and why there was no indication of fall safety alarms being care planned and implemented, as requested by the hospital, after the fall on 4/10/14. This citation pertains to intake MI 191: Based on interview and record review, the facility failed to implement fall safety devices for one (#402) of two sampled residents reviewed for accidents from a total sample of four, resulting in falls, abrasions, a laceration, and pain. Findings include: On 8/1/14 at 1 PM, the clinical record and Accident/Incident (A/I) reports for resident #402 were reviewed. The resident was admitted on [DATE] with [DIAGNOSES REDACTED]. The minimum data set ((MDS) dated [DATE] noted that the resident had moderately impaired cognition, and required extensive assistance with transfers and bed mobility. The resident was prescribed Norco (narcotic pain reliever) 5/500 milligrams (mg) 1 tablet every "4 hours PRN (as needed)" on admission. Per nurses notes dated 10/30/13, a "bed alarm" was ordered related to confusion. There was no mention of an alarm for the wheelchair. The notes indicated that the resident had a left hip surgical incision. A/I reports and notes for resident #402 revealed the following: 1). On 11/5/13-Resident was found sitting in front of wheelchair with legs wrapped around the toilet, no injury, corrective action-"chair alarm sensor pad (to detect and alert staff of unassisted transfer attempts)." There was an order dated 11/5/13 for Norco 5/500 mg 1 tablet prior to therapy daily along with the PRN order. On 11/11/13, an order noted to increase the Norco to 2 tablets before therapy. On 11/12/13, per conference notes: "Poor safety awareness related to cognition loss." Per nursing data collection records dated 11/20/13: "Resident complaining of pain in left hip during therapy. Per physician progress notes [REDACTED]." Nurses notes dated 12/4/14 and progress notes dated 12/10/13 and 12/13/13 documented that the resident had "hematomas on the (left) hip" per an ultrasound report, and "Left hip swelling, redness, warm. Currently not ambulating. Pain in left hip" and "Left hip incision cellulitis...." 2.) On 12/16/13-The resident was found on the floor with his legs crossed at the ankle that caused pain when uncrossed. The Fall Circumstance Investigation form noted: "signs/symptoms of fracture....Root cause: Rolled out of bed." The corrective action: Add posey rolls (cushions around the bed perimeter to prevent rolling out). A stat (immediate) left hip x-ray report dated 12/16/13 noted that the x-ray was negative for re-fracture. Per progress notes dated 12/17/13 and nurses notes dated 12/20/13, resident #402 was lethargic, had a decreased level of consciousness, and was hospitalized from [DATE] thru 12/20/13 for dialysis and a "work-up for infection." Resident #402 returned to the facility on [DATE] at 6:30 PM. Fall safety interventions on the Nursing Admission assessment dated [DATE] included, "low bed" and alarms to "chair and bed." There was no mention of posey rolls or fall safety floor mats. At 11:30 PM: 3). Resident found on the floor. Per nurses notes: "Resident fell out of bed face down....laceration right lower lip....excoriation of bilateral knees...." There was no mention of the posey rolls being in place at the time of the fall, an alarm sounding to alert staff, or the bed being in its' lowest position. The fall circumstance form noted: "No bedside mat available or found." There was an order dated 12/21/13 for "posey bed pillows while in bed. An order dated 12/22/13 noted: "Monitor bruise to right chin/cheek area every shift for signs/symptoms of change. Monitor abrasion to right lower lip every shift for bleeding or signs/symptoms of infection." On 8/1/14 at 4:45 PM, the Director of Health Services and the Executive Director did not respond when asked why resident #402, who had a history of [REDACTED]. They did not respond when asked how the facial injuries occurred to that extent if the resident's bed was low during the fall. On 8/1/14 at 4:30 PM, per review of the facility's "Falls Management Program Guidelines" dated 3/2008: "(The facility) strives to maintain a hazard free environment, mitigate fall risk factors and implement preventative measures....identified risk factors should be evaluated for the contribution they may have to the resident's likelihood of falling. Care plan interventions should be implemented that address the resident's risk factors." ( )

This citation pertains to intake number: MI 187. Based on observation, interview and record review the facility failed to supervise and provide thin liquids by teaspoon as prescribed by the physician for one (#301) of three Residents assessed to require supervision and assistance with meal set up from a total sample of three, resulting in a burn to the left lateral thigh. Findings include: On 3/27/14 at 11:00 a.m., the full investigation into the facility reported incident for Resident #301 was requested. Nurse "G" stated, the facility Administrator and Director of Nursing were not in the facility. A copy of the facility's investigation was provided. On 3/27/14 at 11:15 a.m., an "Accident/Incident Report," and the medical record for Resident #301 was reviewed and revealed the following: "Name of Person Involved: (Resident #301). Date of Occurrence: 3/8/14. Time of Occurrence: 8 p.m. Describe exactly what happened: Patient spilled coffee on her lap. Blister formed on left lateral thigh. Reported by: (Certified Nursing Assistant, CNA "A"). Reported to: (Nurse "D"). List Witnesses: (CNA "B," and CNA "C")." On 3/27/14 at 11:30 a.m., CNA "C" was queried via phone regarding the incident with Resident #301 and stated, "She was dressed in her pajamas. I went down to Town Square to get her coffee. She loved coffee. I put cream in her coffee and walked to the nurse's medication cart and poured water in her cup. I gave her the coffee then continued passing snacks on down the hall. They said (Resident #301) spilled her coffee on her(self). The nurse put salve on it to keep it pain free. It was a blister on the left hip/thigh area. It was the size of a golf ball." On 3/27/14 at 11:55 a.m., CNA "A" was queried via phone regarding the incident with Resident #301 and stated, "It was evening time. Someone was passing snacks. We heard (Resident #301) say 'Ow, Ow." She had a night gown and a robe on. There was coffee between the chair and her leg (left). There was a puddle. It was really hot (the robe) when we were lifting the nightgown and robe up. We tried to lift the clothing up so it wouldn't burn her anymore and that's when the nurse poured water on her leg. She put cream on it. She was in a lot of pain." When queried regarding what the left thigh looked like, CNA "A" stated, "It was really red. It looked like a blister was starting. She was in a lot of pain. I think the nurse tried to give her pain medication but she spit it out." On 3/27/14 at 12:15 p.m., Nurse Practioner, NP "E," was queried regarding the incident with Resident #301 and stated, "It happened on a weekend (3/8/14). I was not here. The DON wanted me to look at it. There was some coffee that spilled on it but they had cooled the coffee. They wanted me to evaluate whether it was a burn vs water blister. I thought it (the area) may be due to friction." Review of a progress note written by NP "E," dated 3/10/14 (two days after the incident) revealed "Asked to see resident (#301) has water filled blister left posterior thigh/hip/buttock area. No redness or warmth. Blister is intact." On 3/27/14 at 12:25 p.m., Resident #301's physician, Physician "F," was queried regarding the incident and stated, "It was reported and I saw it. It was a blister so we treated it. I know there was controversy whether it was a burn or a blister. It was just coincidental (the blister and the coffee spill found at the same time). It was not a second or third degree burn." On 3/27/14 at 12:30 p.m., CNA "B" was queried via phone regarding the incident with Resident #301 and stated, "I was sitting at the nurses desk doing paperwork. We just got her (Resident #301) changed. A co-worker was passing snacks. We heard an 'Ow. Ow. Ow.' We went over there. Her housecoat was still warm to the touch. I was assuming the coffee was pretty hot. She had a fleece house coat and pajamas, and it (coffee) went all the way through and burned her. We looked at her leg, it was really red and looked like it was going to blister. It did almost instantaneously." When queried regarding Resident #301's skin condition prior to the incident CNA "B," stated, "That was her shower night. She had her shower around 7 p.m.. Then she was dressed. We put PJ's (pajama's) and a house coat on. She then sits in her lounge chair. I didn't see anything (skin alterations) to that area (during her shower)." According to the facility Accident/Incident report the incident occurred at 8 p.m., and CNA "B" indicated that Resident #301's skin was intact at 7 p.m. the same evening. Review of Resident #301's "Medication Record, Treatment Orders," dated 3/1/14 through 3/31/14 revealed that Resident #301's "Weekly skin assessment," for 3/8/14 revealed "0 (zero)" meaning "no impairment." The assessment was signed by Nurse "I." Review of the Facility 5 day Investigation Report from Incident date 3/9/14 for Resident #301 revealed "Area to the left lateral thigh was assessed and noted to have a 10 by 3 cm (centimeter) dependent fluid filled blister..." Review of Resident #301's "Other Skin Impairment Assessment," dated 3/9/14, revealed "Dependent fluid filled blister. Left lateral thigh. Pain: no pain. Tx (treatment) Silvadene (brand name of medication used for the prevention of infection in patient's with second and third degree burns). Exudate: 'S' indicating 'serous.' Surrounding tissue: 'Pink.' Measurements for the area, dated 3/21/14, revealed "Length 15.1 cm. Width 8.3 cm. Pain: yes." On 3/27/14 at 1:20 p.m., Resident #301 was observed sitting near the nurse's desk in a gerichair with her foot rest raised. Resident #301 was taken to her room by Nurse "G" and Nurse "I" for a wound observation. Resident #301 was confused and unable to answer questions appropriately. Nurse "G" and Nurse "I" assisted Resident #301 to a standing position. As Nurse "G" removed the dressing, Resident #301 stated, "Owww! Don't pull it. Don't pull it." The wound to Resident #301's left thigh was observed. Nurse "G" described the wound as, "There is yellow slough (an area of dead tissue separated from surrounding living tissue) on the wound base surrounded by pink granulation (new healthy tissue). The periwound (the tissue surrounding the wound) is dry and intact. There is a small amount of serosanguinous drainage (watery drainage that is composed of both blood and serum) from the site." Measurements of the area were taken by Nurse "G" and revealed that the wound was "14 cm by 8.5 cm" that ran down the length of the left lateral thigh. Indicating that the wound size had increased from a 10 cm by 3 cm.. On 3/27/14 at 1:40 p.m., Registered Nurse, RN "D" was queried regarding the incident with Resident #301 and stated, "I came in early that evening. I usually work midnights. I was at the med cart. I seen her (Resident #301) squirming in her chair. I was not sure what she was doing. The CNA's said she spilled coffee on herself. They pulled the garments away and I poured cold water on it (the area). It was red. I treated it with Silvadene. At first I didn't see blistering but later there was. She was in pain only when you touched the area." Review of Resident #301's physician orders [REDACTED]. Physician order, dated 3/9/14, no time, revealed "Apply Silvadene cream to burn TID (three times a day). Physician order, dated 3/9/14 at 1730 (5:30 p.m.) revealed, "Clarification: Silvadene cream to Blister Left hip daily." Physician order, dated 3/12/14, revealed "Cleanse wound with NS (normal saline), then apply Aquacel (a sterile dressing used to cover acute and chronic wounds that are excreting pus or other fluids) foam to wound every five days and PRN (as needed)." Physician order, dated 3/20/14, revealed "Apply Santyl (a debriding agent that removes dead skin from wounds and burned areas) to left thigh and change every three days. Indication: Left hip wound." On 3/27/14 at 2:15 p.m., Nurse "I" was queried regarding the documentation of Resident #301's skin on 3/8/14 and stated, "We go in on shower days and check the skin. Zero means there was nothing there (no skin alterations)." Review of Resident #301's face sheet revealed an admission into the facility on [DATE] with [DIAGNOSES REDACTED]. The Resident's Minimum Data Set Assessment, dated 3/5/14, revealed that the Resident's cognition was severely impaired and required extensive assistance for most activities of daily living. The Resident required supervision (oversight, encouragement or cueing) for eating (how resident eats and drinks). Resident #301's "Nurse's Notes" were reviewed and revealed a note dated 3/6/14 at 1600 which read "Hospice to admit and treat. ST (Speech Therapy) to eval- diet clarification pureed with thin liquids via tsp (teaspoon)-no straws." Resident #301's Physician Order, dated 3/6/14, revealed "Diet clarification: puree diet with thin liquids via tsp. No straws." On 3/27/14 at approximately 3:00 p.m., Nurse "G" and an Executive Director where queried regarding the incident with Resident #301. Nurse "G" stated that she was aware of the incident but did not take part in the investigation. Nurse "G" was unable to provide any information in regards to the investigation and facility's conclusion to the incident. On 3/28/14 at 10:50 a.m., Resident #301's family member was queried via phone regarding the incident and stated, "We were told it (the area) was because of the coffee. We (all three daughters) were not there. My sister (name) was the one that received the call." On 3/28/14 at 11:52 a.m., Resident #301's family member (primary contact) was queried via phone and stated, "They told us that area was because of the coffee spill. It was in the evening. I wanted to see it (the area). I got a little peak while they were assisting her to the bathroom, the dressing was coming off and it looked bad. She did complain of pain to me Tuesday, that it hurt (the area)." Review of Resident #301's care plan titled, "Nutrition/Hydration plan of care," updated 2/26/14, revealed "Diet A/O (as ordered) by MD (physician). Assist resident with meal set up, feeding, cueing, and encouragement prn. Coordinate care with... SLP (Speech Language Pathology). " ( )

This citation pertains to Intake MI 549 This citation contains two deficient practice statements: Deficient practice statement #1: Based on interview and record review, the facility failed to ensure that a pressure sore was cleansed and covered with a protective dressing to prevent contamination, for one (#601) of two residents reviewed for pressure sores, from a total sample of four, resulting in the wound worsening and becoming an infected, gangrenous (gangrene) stage IV pressure sore (extensive tissue loss exposing bone, tendon or muscle), with osteo[DIAGNOSES REDACTED] (infection of the bone and muscle) which required transfer to the emergency room , surgical debridement (surgery to cut away dead and infected tissue), hospitalization , and intravenous antibiotic therapy. Findings include: On [DATE] at 3:45 P.M., a complainant who wished to remain anonymous was interviewed by telephone and reported that Resident #601 had not received appropriate care and treatment of [REDACTED]. The complainant stated that the resident subsequently expired from complications from the wound infection. On [DATE] at 11:30 A.M., Resident #601's clinical record was reviewed with the Director of Nursing (DON), and revealed that Resident #601 was transferred to hospital for surgical debridement of an infected stage IV pressure sore on [DATE], after a stay of 20 days in the facility. Hospital records documented that the resident spent 11 days in hospital following surgical debridement for an infected pressure ulcer before being readmitted into the facility. The DON was interviewed at this time with regard to the following documents: Review of a face sheet documented that Resident #601 was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. A "Resident Transfer Form" (ambulance record) dated [DATE] (no time noted) revealed Resident #601 was transferred to the hospital for "wound debridement", noting, "wound was preexisting and has worsened." A second face sheet documented the resident was readmitted back into the facility on [DATE],after 11 days in hospital, and was referred to Hospice care three days later, on [DATE]. A Minimum Data Set Assessment ((MDS) dated [DATE], documented that resident #601 had moderately impaired cognition, needed extensive physical assistance of two staff for mobility in bed and transfers to the wheelchair, dressing and hygiene, and was frequently incontinent of bowel and bladder. Review of a nursing admission assessment dated [DATE] at 9:00 P.M., revealed Resident #601 was admitted with one area on the coccyx, and one area on each buttock documented as "unstageable." Review of a admission nursing note, dated [DATE] at 4:00 P.M., revealed no documentation of pressure ulcers. Review of a nursing note dated [DATE] at 2:10 P.M., revealed documentation of only one pressure sore, "stage II pressure ulcer, approx 2.5 centimeters (cm) round irregular with depth of 0.2 cm. wound edges at border pink, no drainage. denies pain to wound." When asked, the DON was unable to explain the discrepancy between the three "unstageable pressure sores" documented on the [DATE] nursing admission assessment form and the one "Stage II pressure ulcer" documented on the following day's nursing note, on [DATE]. Review of facility "Pressure/ Stasis/Ulcer Assessment Form(s), Complete Weekly" for resident #601 revealed documentation, dated [DATE] (one day after admission) that the resident had two pressures ulcers, noted in the "initial identification" as: 1. "Right (R) buttock: length 5.3 cm, width 2 cm, depth 0.1 cm. Stage: E (unstageable - depth cannot be determined)". Treatment: [MEDICATION NAME] (a topical moisture barrier/skin protectant). ("Protects from minor skin irritation associated with diaper rash. Do not use on deep or puncture wounds," http:daily med.nih.gov, reviewed on [DATE] at 9:00 A.M.). The sections documenting "physician notified", and "family notified" were left blank (no documentation). The rest of the form was blank. There was no other documentation on the form to indicate that weekly wound assessments, due [DATE], and [DATE], were done ("complete weekly"), 2. "Left (L) buttock: length 2.3 cm, width 2 cm, depth 0.1 cm. Stage: E (unstageable - depth cannot be determined)". Treatment: [MEDICATION NAME]. The sections documenting "physician notified", and "family notified" were left blank (no documentation). The rest of the form was blank. There was no other documentation to indicate that weekly wound assessments were done ("complete weekly")(due on [DATE] and [DATE].) On [DATE] at 11:30 A.M., The DON was queried, and was unable to provide any documentation that Resident #601's wounds were assessed, monitored, cleansed, or covered with a dressing to protect from fecal contamination and promote healing between [DATE], until [DATE], when the Resident was transferred to the emergency room for an infected stage IV (open to muscle/fascia or bone) pressure sore on the coccyx (tailbone). Record review with the DON at this time revealed no description of any pressure sore for resident #601 after [DATE]. The DON was unable to provide additional documentation upon request. On [DATE] at 11:30 A.M., the DON was queried, and was unable state whether Resident #601 had one stage II pressure sore, or three unstageable pressure sores on [DATE], and was unable to provide any documentation to accurately describe the wound or document changes to the wound/ wounds prior to transfer to the hospital on [DATE]. On [DATE] at 11:30 A.M., review of Resident #601's treatment records (TAR) and TAR "Comments" for June and [DATE] with the DON revealed blank (no initials documenting a nurse had performed it) weekly skin assessments due on [DATE], and [DATE] and a notation that the resident was in hospital for the weekly assessment due on [DATE]. There was no documentation on the TAR indicating that Resident #601's wounds were cleansed, or that a dressing was applied to Resident #601's pressure sore(s) to protect from fecal contamination or to promote healing. There was inconsistent documentation of a moisture barrier application "calazide paste ([MEDICATION NAME]) (a topical barrier paste not to be applied to deep wounds) to buttock each (q) shift and as necessary (PRN)." On [DATE] at 11:30 A.M., Review of Physician's orders with the DON revealed no orders to cleanse Resident #601's pressure ulcer (s) or to apply a dressing to promote healing and protect from contamination. An admission order dated [DATE] prescribed, "apply calmazide ([MEDICATION NAME]) to buttock q shift and PRN." When queried about whether a moisture barrier paste was an appropriate treatment for [REDACTED]. We have a protocol in our Skin Care Policy for what treatments to use for each type of wound. " When queried whether the wound should have been cleansed on a regular basis, and covered to protect it from contamination with feces (bowel movement), the DON stated, "I would have liked that to happen. I would have thought it should have been cleansed each shift and covered with something." When queried, the DON stated that Resident #601 was incontinent of bowel and bladder and wore an incontinence brief. and said, "The nurses should have called the doctor for a new treatment order once the wound started getting deeper, and one of them should have noticed that there was no order to cleanse the wound or apply a dressing, and called the doctor to get one." The DON was unable to provide any additional documentation upon request. On [DATE] at 11:30 A.M., Review of Resident #601's Nursing Care Plans with the DON revealed no nursing care plan for pressure sores. A "Skin" care plan, dated "[DATE] - present" documented only, "hip incision", but contained no interventions(staff instructions) or documentation of a pressure sore. An Interim (temporary, post admission) care plan, dated [DATE] documented Resident #601 was at risk for skin breakdown due to "past history", "mobility impairment", and "incontinence/moisture". The interim "Skin Plan of Care", dated [DATE] revealed no instructions for wound cleansing, dressings, or wound treatments. The care plan noted, "provide treatments per physician order." When queried, the DON stated that Resident #601 should have had a Pressure Sore Care plan containing nursing interventions to promote healing and prevent worsening. The DON stated, "The electronic care plan process, used at that time, was not working, as the staff nurses who were responsible for creating and updating the plans could not access the system." A facility "Clinically At Risk Individual Monitoring Sheet" for Resident #601, dated [DATE] (two days after admission), documented, "admitted with large wound on buttock. Area of deep tissue injury with open area on coccyx and right buttock." A weekly follow up, dated [DATE], did not describe the wound, but documented the following "intervention update", "Roho mattress (specialty pressure reduction device)." On [DATE] at 12:30 P..M., the DON was requested to provide documentation this was implemented as planned. On [DATE] at 2:45 P.M. the sales representative "D" for the medical supply company was interviewed by telephone and reported that an "air float mattress" was ordered by the facility on [DATE] (the day Resident #601 was sent out to the hospital) and delivered the same day. It was unclear why the speciality mattress was not implemented as discussed on [DATE]. When queried, the DON was unable to provide documentation that a pressure relieving cushion was provided for use in Resident #601's wheelchair. When queried about this, the DON stated, "She really didn't get out of bed much." On [DATE] at 12:00 P.M., physician progress notes [REDACTED]. A physician progress notes [REDACTED]. (pressure sore)", but there was no description of the wound, or treatment plan noted. A physician progress notes [REDACTED]. A physician progress notes [REDACTED]." The treatment plan was documented as, "Pt (patient) sent to ER (emergency room ) for severe decub." On [DATE] at 12:30 P.M., Resident #601's hospital records were reviewed with the DON. A hospital Consultant Physician report dated [DATE] at 4:45 p.m.( for a hospitalization admission date of [DATE]) revealed the following, "The patient was found to have a large ulcer that is very foul smelling, way down in the bone with fluid collection and excessive drainage which is brown green. In her bottom, she does have an ulcer of about 4 x 5 cm, stage II on the left gluteal area. The one on the right area, on the sacrum/ischium bone, she has a very foul-smelling necrotic large ulcer, deep down, that is a stage IV, and I do feel that it is down in the bone with involvement of the bone as well. When I pressed on the edge of the ulcer, a bubble, and a quite significant amount of greenish foul-smelling material came through with air as well. Impression: large infected stage IV decubitus ulcer on the right gluteal ulcer down to the sacrum (bone), most likely with involvement of the bone, and osteo[DIAGNOSES REDACTED] (infection of bone and muscle) with the possibility of fistula (tunneling completely through into a hollow body cavity) that cannot be excluded. Plan: The patient is currently on IV (intravenous) [MEDICATION NAME] (antibiotic used for drug resistant organisms) and IV [MEDICATION NAME] (antibiotic used for drug resistant organisms). On [DATE] at 12:30 P.M., resident #601's hospital records were reviewed with the DON, and revealed a report dated [DATE], which documented the following surgery for [REDACTED]. It was found to be 10 cm x 10 cm and extended down into the sacrum as well as through the gluteal muscles. The ulcer involved the full thickness of the skin, subcutaneous tissue and the deep fascia. A large amount of necrotic tissue was present which extended all the way down to the sacrum itself as well as involved the gluteal muscles." A hospital laboratory culture, dated [DATE], revealed the pressure sore tissue removed during Resident #601's surgery was infected with Eschericia coli (E. coli) and [MEDICATION NAME] faecium, both bowel flora (germs found in human feces). The surgery pathology laboratory report, dated [DATE] noted, "necrotic tissue of sacrum. The tissue is markedly necrotic and gangrenous." On [DATE] at 2:45 P.M., the DON was interviewed, and was unable to explain why Resident #601's pressure ulcers were not assessed, measured, described or appropriately treated for [REDACTED]. The DON was unable to explain why the wound was not monitored, and why there was no documentation of the wound becoming worse. The DON was unable to explain why there was no documentation that the physician was notified that the wound was showing signs of infection until the day of discharge on [DATE]. The DON stated, "I'm scared of what I'm finding." The DON stated that the previous wound care nurse had been terminated because, "lots of things were falling through the cracks." Review of the facility policy entitled, "General Wound and Skin Care Guidelines", (no date indicated), revealed the following statements: "Dress chronic wounds using clean technique." "Cleanse wounds using a non-toxic agent prior to making wound assessment and applying a new dressing." "Select a dressing that keeps the wound bed moist and the periwound area dry." "Reevaluate dressing and skin integrity every shift" "Reevaluate the wound's response to the prescribed treatment, Make recommendations for changes PRN. Inform MD of changes in wound status." "Know the indications and contraindications for the wound products used." "Document type of wound, location, stage (if applicable), length, width, depth, base, drainage, periwound tissue, and treatment of [REDACTED]." "Assess for signs and symptoms of infection and treat as applicable." "Assess and document progress toward healing at least every 7 days or with significant change in appearance of the wound." "Basic wound treatment: cleanse, fill all dead space (to prevent infection, abscess, sinus cavities, etc), absorb drainage, maintain moist wound bed, cover and protect." ( ) Deficient Practice Statement #2: Based on interview and record review, the facility failed to ensure that wounds were consistantly monitored, cleansed and treated, and soiled dressings changed regularly per physician's orders, for one (#602),of two residents observed for pressure sores out of a total sample of four, resulting in the potential for wound infection and exacerbation of wounds. Findings include: On [DATE] at 12:45 P.M., wound care was observed for resdient #602, performed by staff nurse "C", assisted by the DON. A gauze dressing dated [DATE] was observed on resident #602's left foot. When queried, the DON reported that the dressing should have been changed on [DATE], as, "it was supposed to be changed daily (qd)" Nurse "C" failed to change gloves and sanitize or wash hands between treating Resident #602's three pressure ulcers, located on the medial halix, lateral side and heel of the left foot, and failed to change gloves and wash hands after applying the wound treatment ointment and before putting on the clean dressings. The nurse treated the heel wound after treating the medial and lateral wounds. When queried, The DON reported that Resident #602 was receiving [MEDICATION NAME] (an antibiotic used to treat drug resistant microorganisms) intravenously to treat infections in the left foot wounds. When queried, the DON stated, "Each wound should have been treated separately. He should have changed gloves and sanitized hands between wounds.He should have cleansed and treated the heel wound first as it was the one isn't infected." The medial halix wound presented as a circular wound covered with dried black eschar (necrotic tissue) surrounded by inflammed puffy red skin. The lateral foot wound presented as an oval wound covered with dried black eschar, and surrounded by inflammed puffy red skin. The heel wound presented as a flat wound, covered with dry brown eschar, surrounded by flaky dry pale skin. On [DATE] at 1:25 P.M., Resident #602's clinical record was reviewed with the DON and revealed the following: A face sheet documented that Resident #602 was admitted into the facility on [DATE], and readmitted on [DATE] after a transfer to the hospital. [DIAGNOSES REDACTED]. A Minimum Data Set Assessment (MDS)dated [DATE], documented Resident #602 had moderately impaired cognition and needed extensive assistance for bed mobility and transfers to the wheelchair. The MDS documented that Resident #602 had three unstageable pressure sores present upon admission. A hospital Infectious Disease Consultant Physician report, dated [DATE] (the day prior to Resident #602's readmission to the facility), documented the following: "open ulceration to the left heel and two other ulcerations to the left foot. Infectious disease consult for antibiotic management. Impression: left heel ulceration and infection, rule out osteo[DIAGNOSES REDACTED] (bone infection). A wound consultant report for Resident #602 dated [DATE], documented the follwoing diagnoses, "osteo[DIAGNOSES REDACTED] ( infection of muscle and bone) secondary (resulting from) foot wounds (left)." A physician progress notes [REDACTED]. "[MEDICATION NAME] for four more weeks." Review of Physician Orders for Resident #602 revealed the following prescriptions, "[MEDICATION NAME] 3.375 grams (gm) Intravenously (IV) q (every) 8 hours - infection", dated [DATE], and , " change dressing qd (daily), wash with mild soap and water. Dry dressing medial and lateral foot wounds. Add santyl to heel wound. cover with dressing and kerlix (wrap)", dated [DATE]." Review of Treatment Records TAR, and nursing notes for Resident #602 (,[DATE] and ,[DATE]) with the DON revealed there was no documentation to indicate that an admission skin assessment was done since readmission on [DATE]. When queried, the DON was unable to provide any documentation to indictate that weekly skin assessments were performed (due [DATE], [DATE], [DATE].) The DON stated, "The order to do weekly skin assessments didn't get transcribed (recorded) over to the TAR." The DON was unable to provide documentation to indicate that facility "Pressure/ Stasis/Ulcer Assessment Form(s), Complete Weekly" were completed for Resident #602 since readmission on [DATE]. Review of the TAR and clinical record with the DON revealed no documentation to indicate that Resident #602's dressing was changed ([DATE] "dry dressing L foot, change daily") on [DATE], [DATE], [DATE], [DATE] and [DATE]. When queried about this, the DON stated, We realized things were falling through the cracks. That's why we just hired a new wound care nurse." ( )