Every finding on record at The Oaks at Woodfield

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 06/08/2026 at 9:18AM during the initial kitchen tour with Assistant Manager A, salmon packaged in separate plastic bags with a prep date of 5/20/26 and use by date of 5/26/26 was observed in the walk-in cooler. During this observation, Assistant Manager A stated it was taken out of the freezer this weekend and continued to throw out the salmon. On 06/08/2026 at 9:28AM interior walls of microwave were observed to be visibly soiled with food debris. During this observation, Assistant Manager A said oh gosh when she saw the dirty microwave and stated that they clean it every day. On 06/08/2026 at 9:34AM two cans of baked beans with dents on the seams were observed on the can rack in the dry storage room. During this observation, Assistant Manager A was interviewed on the process of eliminating dented cans from storage and she stated the dented cans are thrown out, and they receive credit for them, then she proceeded to throw out the dented cans. In addition, Assistant Manager A stated she will re-check cans during stock on Tuesdays and Fridays. During this time, Assistant Manager A observed another dented can that contained hot fudge and proceeded to throw out that can as well. On 06/08/2026 at approximately 11:45AM interviewed Assistant Manager A on whether there is a log or documentation on thawing of foods, particularly for the salmon that was found in the walk-in cooler earlier this morning, and she stated there wasn't any documentation or logs for thawing. During this time, Assistant Manager A presented a labeling sticker that is used to date mark food and said that staff probably didn't replace the sticker when the salmon started to thaw. According to the 2022 Food Code, 3-501.18 Ready-to-Eat, Time/Temperature Control for Safety Food, Disposition, Time/temperature control for safety refrigerated foods must be consumed, sold or discarded by the expiration date. According to the FDA 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. According to the FDA 2022 Food Code, 3-101.11 Safe, Unadulterated, and Honestly Presented, Food shall be safe, unadulterated, and, as specified under S 3-601.12, honestly presented.

Based on observation, interview, and record review, the facility failed to have an active plan for reducing the risk of Legionella and other opportunistic pathogens of premise plumbing (OPPP). This deficient practice has the increased potential to result in allowing waterborne pathogens to exist and spread in the facility's plumbing system with an increased risk of respiratory infection among all residents in the facility. Findings include: On [DATE] at approximately 1:00PM the environmental tour was conducted with Maintenance Director B. When interviewed on chlorine residual testing, he stated the chlorine test strips are expired, and he will have more coming in today. The chlorine test strips were observed to have an expiration date of 6/2023. During this observation, Maintenance Director B was interviewed on what range the chlorine is kept at and he stated it's usually pretty low, and it's tested monthly. Record review of facility's chlorine logs show multiple free chlorine results at zero, dated [DATE], [DATE], [DATE], and [DATE]. According to the Centers for Disease Control and Prevention, Controlling Legionella in Potable Water Systems dated [DATE]rd, 2025, Ensure disinfectant residual is detectable throughout the potable water system.

Based on observation, interviews, and record review, the facility 1) Failed to ensure that medications and related supplies were properly labeled, stored, and discarded upon expiration and, 2) Failed to secure chemical medication destroyers, chemical sanitation cloths, and alcohol based hand rubs out of residents' reach. These deficiencies were identified in two of two medication carts, one of two medication rooms, and in three of three resident units reviewed for medication storage.Findings include: On 06/10/2026 at 9:16AM, an observation of the resident living room / nursing station area on unit 300 revealed that on top of the nurse's station at mid chest level (~ approximately 4 feet high) were two large bottles of RX (prescription) medication destroyer with a label that read: always store in a secure location and out of reach of children; warnings: if ingested, contact poison control. if solution comes into contact with eyes, flush with cool water for 15 minutes and consult position immediately. Also locate at the nurse's station at midthigh level (~ approximately 3 feet high) was an 8-ounce bottle of purple spray with a label perineal and skin cleanser. On 06/10/2026 at 9:20AM, during an observation and interview with the ADON she was asked if the RX (prescription) medication destroyer and perineal and skin cleanser should be stored in the resident common areas and within reach. ADON said no they should not be and said they should be kept in the secure medication room behind the desk. ADON took the items and stored them in the medication room. According to a review of the safety data sheet (SDS) for (brand name) perineal care: individual protection measures, such as personal protective equipment; Eye/Face Protection Avoid contact with eyes. General Hygiene Considerations: Do not get in eyes. Keep away from food and drink.On 06/10/2026 at 09:23 AM, during a walkthrough of resident unit 100 an observation of 75 count (brand name) sanitation wipes with bleach and 160 count (brand name) germicidal sanitation wipes both were on top of nurse's station at mid chest level (~ approximately 4 feet high). Also observed on resident's hall handrail was one 8-ounce pump style bottle of ABHR, with warning label: do not use in eyes. Observed in the living room area of 100 hall on a side table (~ approximately 2 feet high) between the couch and chair was one 160 count (brand name) germicidal sanitation wipes and one 8-ounce pump style bottle of ABHR. According to a record review of the brand name sanitation wipes SDS warnings: avoid skin or eye contact; keep out of reach of children and unauthorized personnel.; 7.1. Precautions for safe handling Precautions for safe handling Hygiene measures: Ensure good ventilation of the workstation. Wear personal protective equipment: Do not eat, drink or smoke when using this product. Always wash hands after handling the product.On 06/10/2026 at 09:26 AM, during a walkthrough or resident unit 200 an observation of 8-ounce pump style bottle of ABHR was sitting on top of a personal protection equipment (PPE) cart at knee height (~ approximately 2 feet high) within residents reach in residential hallway. Also observed on top of a cart at mid chest level (~ approximately 4 feet high) were two 8-ounce pump style bottles of ABHR, with warning labels: do not use in eyes. On 06/10/2026 at 09:30 AM, during a requested walkthrough of the facility with the ADON she verified locations and removed all the chemicals mentioned in above-mentioned observations. When queried the ADON said none of these should be within the resident's reach. On 06/10/2026 at 09:50 AM, during medication storage with the ADON, observed in medication room on unit 200 in the IV-treatment cart were two 24 gauge IV start needles with the expiration date of 03/01/2025. ADON said she didn't know where they were from, and she took them to discard. Additionally, an observation of medication cart on 200 (front hall) revealed one resident Novolog insulin pen label on a bag that contained another resident's Humalog Kwik pen inside. ADON said she didn't know how that happened and that only one of the residents was in that part of the unit. Observed a bottle of Timolol maleate eye drops with peeled label stored in a bottle with a resident label and date 05/04/2026. When asked how they would be identified when they were removed from the bottle, ADON and Nurse I said they could not be easily. Observed 3 separate residents' Lanaprost eye drops with open dates: 04/19; 04/23 and 04/27. Nurse I was asked how long the eye drops are good for once opened and she looked it up and said 45 days. The ADON was asked if according to the expiration schedule any of these were still ok to use, she responded no. the ADON Verified that the latest dated one 04/27 would have expired on 06/08/2026. Continued observation on the 300 unit and the medication cart was observed a loose Albuterol inhaler with black marker labelled 311A (no name) opened 05/05/2026. ADON and Nurse J agreed that was not a sufficient resident identified label and could easily lead to an error. On 06/10/2026 at ~03:00 PM When asked EDC said they had no specific policy on chemical storage and was asked for safety data sheets for each; they were not supplied by facility but were obtained online after the survey. A record review of the (facility pharmacy) expiration dates revealed: Timolol maleate eye drops expired 30 days after opening; Lanaprost eye drops expired 6 week/42 days after opening. A record review of the facilities policy titled Medication storage in the facility revealed: Policy: medications and biologics are to be stored safely, securely, and properly, following manufacturer's recommendations or those of the supplier. The medication supply is accessible only to licensed facility personnel, pharmacy personnel, or facility personnel lawfully authorized to administer medications. With Procedures: C. All medications dispensed by the pharmacy are stored in the container with the pharmacy label; G. Potentially harmful substances are clearly identified and stored in a locked area separately from medication; H. Outdated, contaminated, or deteriorated medications and those in containers that are cracked, soiled, or without secure closures are immediately removed from inventory, disposed of.; expiration dating: c. Certain medications or package types, such as four solutions, multiple dose injectable vials, ophthalmic, nitro glycerin tablets. once opened require an expiration date shorter than the manufacturers to ensure purity and potency; d. The medication administration personnel will check the expiration date of each medication before administering it; e. No expired medication will be administered to a resident. F. Call expired medications will be removed from the active supply and destroyed in the facility.

Based on observation, interview, and record review, the facility failed to ensure that 1) Call lights were answered in a timely manner, 2) Residents' preferences were respected, and 3) Residents were treated with dignity during the provision of care for one resident (Resident #28) and a confidential group of residents reviewed for dignity with care. Findings include: During the Facility's Monthly Resident Council Meeting held on 6/8/26 at 3:15 PM, twelve (12) residents of a confidential group of residents were present. At the meeting, the council raised the call light response time as an issue. They indicated that it has been an ongoing concern. Ten (10) confidential group of residents raised their hands when asked about the wait time experienced when they activated their call button. 10 indicated by raising their hand, experiencing an average of over 15-minute wait time for staff to respond to their call light. Eight (8) of twelve (12) residents continued to raise their hands when asked whether they had recently experienced a wait time of over 30 minutes after activating the call light. Among the 8 residents in the confidential group, two (2) residents expressed that staff do not seem to focus on providing quality care. When the surveyor asked if they could provide more specific details about the concern, one described the nursing staff as on their phones, talking to someone, or talking to each other about themselves and their personal issues. Another resident expressed that staff are not really focused on the residents here when providing care. The majority of the confidential group of residents indicated that this has been an issue raised for several months during monthly Resident Council Meetings, where they have expressed concerns about delayed responses to call lights or about call lights not being placed close to them or within their reach. or simply staff turning them off and leaving, saying they will return but do not return to address their immediate need. One said: Nothing seems to be done by the facility to resolve the issue. A review of the Resident Council Meeting Minutes dated 3/2/26, 4/20/26, and 5/11/26. The following are details of the concerns: Call light/Waiting (3/2/26)-Concern: healthcare resident council inconsistency on all shifts to put call light within reach and when returning to room. Facility action as resolution was noted: Satisfactorily- Huddles being completed with staff daily to re-educate on this topic. Also on agenda for discussion 3/8 and 3/19 CRCA meeting. There were no audits or interviews found to confirm with residents. No follow-up was documented for resolution. Call Light 4/20/26 - Concern: Healthcare resident council reports that assigned aides are not in the dining room at the assigned time; also, aides don't arrive promptly to get their residents from the dining room after meals,, causing extended wait times for residents. Resolved by re-education of staff. No audits or interviews were found to confirm with residents. No follow-up was documented to confirm resolution. Call Light/Waiting 5/11/26 - Concern: Health Care Resident Council is noticing that aides are turning off resident call lights and stating they will return to complete the needed task. There were no audits or interviews found to confirm with residents. No follow-up was documented to confirm resolution. The Resident Council (RC) Minutes were discussed during the meeting, and it was confirmed that they remain unresolved. The Council Meeting ended on 6/8/26 at 4:09 PM. According to the Executive Director and the Administrator during the QAPI (Quality Assurance and Process Improvement) meeting held on 6/10/26 at 3:15 PM, they indicated that, there were different call light concerns each month, and they are resolved each time. A review of the Facility's policy was done on 6/10/26 at 2:30 PM: The Guidelines for Answering Call Lights Policy, date reviewed by the facility, 12/10/2025, revealed, Purpose Statement: The purpose of this policy is to respond to the resident's request and needs. Procedure: .5. Answer the call lights as quickly as possible .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 appropriate staff are available to assist. .13. If nothing else is needed, return the call light to within reach of the resident. Resident Rights Guidelines, date reviewed: facility on 12/08/2025. Purpose Statement: The purpose of the policy is to ensure resident rights are respected and protected and to provide an environment in which they can be exercised. Precedure: .2. Our residents have the right to. a. Be treated with dignity and respect. Resident #28 (R28): A record review of R28's face sheet and Minimum Data Set (MDS) assessment indicated R28 was admitted to the facility on [DATE] with diagnoses that included: after care following digestive surgery, acute appendicitis, sepsis (extreme response to infection), presence of colostomy (surgical opening for stool to pass externally), paraplegic (paralysis of lower body) and urinary tract infection. The MDS assessment dated [DATE] indicated the resident was cognitively intact with a Brief Interview for Mental Status (BIMS) score of 15/15 and required assistance with care. On 06/08/2026 at 2:35PM, during an interview with R28 and family member E, R28 said she has a long wait time for her call light to be answered and that mornings were especially slow response. R28 said she had requested to be out of bed and dressed for the day before breakfast so that she can eat breakfast in the dining room. R28 said that she has repeatedly asked staff to get her up and that today (05/08/2026) she was not dressed until 1:30PM. Family member E concurred with the time R28 stated. R28 further stated they put me in bed naked today after my bath and said they would be right back R28 and family member E concurred that it was approximately 45 minutes before anyone returned to get her dressed. R28 further stated I ending up eating my lunch naked in my bed, so it did not get cold while she waited. On 06/09/2026 at 8:25AM, during medication administration observation of the resident she was resting in bed in green gown. R28 said she no one got her dressed as requested, and they had brought her breakfast to her room, so she had eaten it in her room today (06/09/2026). On 06/10/2026 at 9:03AM, Observed R28 call light on and entered her room to follow up, R28 was in bed in her night gown and stated they are still not getting me up for breakfast R28 said that she had made the request to the CNA's and said it is hard to remember who was who among the staff to recall, when asked. When asked, R28 said her call light had been on for about 10 minutes before SA entered her room. SA exited room of R28 at 9:05AM and continued observation of R28's room from hall. On 06/10/2026 at 9:08AM, observed MDS D enter R28's room and overheard him ask R28 'what she needed', and overheard R28's response I am still waiting to get out of bed and heard MDS D who replied, I will let your CNA know. Observed MDS D exit R28's room with R28's meal tray and observed the call light was no longer on in the hall. Observation of R28's room continued from the hall. On 06/10/2026 at 9:19AM, during the continued observation of R28's room from hall, no staff came and at 9:19AM R28's call light was turned back on and visible from the hall. On 06/10/2026 at 9:23AM, observed ADON stop at R28's door and overheard her ask 'what she needed help with' and overheard R28's response I am still waiting to get out of bed, and no one came back. Observed ADON and CNA K don (apply) personal protective equipment (PPE) enter R28's room. According to the interviews and observations R28 had used call lights and made requests for assistance to staff without assistance provided from approximately 8:53AM until 9:23AM. On 06/10/2026 at approximately 10:30AM, Family Member E was asked if she could confirm the staff that bathed R28 on 06/08/2026 and she said she was unsure because the day was such a blur now and she does not know names, maybe the therapy or CNA. On 06/10/2026 at 11:13 AM, during an interview with Occupational therapist (OT) F she said that she assisted R28 with the shower on 05/08/2026 as part of occupational therapy. OT F said that since R28 has diagnoses of paraplegia she had to do everything at bed level, and that R28 had to be in bed to get dressed, so she was in bed naked. OT F said she stepped out to let the nurse know that R28 had her shower and needed cream for dermatitis before getting her dressed. When asked if 45 minutes was acceptable for a resident who was waiting naked in bed and was upset about that they had to eat lunch that way was appropriate and she said no, that is unfortunate and that she was not sure what the delay was from, and stated I guess if I would have known it was going to take so long, I would have gone ahead and gotten her dressed. On 06/10/2026 at 11:50AM, Executive Director (ED) C approached SA and offered that she had talked to OT and then did an investigation. ED C said she asked R28 and Family member E how long R28 had waited and they said, 'they couldn't remember because so many things were going on that day'. ED C said Nurse G reported 'that it was about 20 minutes until she treated resident and not 45 minutes.'The medication administration records (MAR), and treatment administration records (TAR) were requested from ED C for R28 on 06/08/2026. On 06/10/2026 at 2:59PM, received a return phone call from Nurse G and during the interview she said it was about 20 minutes after she was informed of the requested care, that she provided that care to R28, that she was prepped and administered an IV medication prior to that. Nurse G said she applied R28's cream but did not get R28 dressed, that the CNA and the OT got R28 dressed. On 06/10/2026 at 3:05PM, ED C was asked how often residents are assessed for preferences and care planning. ED C said they get an assessment with in 5 days of admission, if they have a significant change and quarterly. She was asked how the care plan was updated and she said it was updated from conversations and interactions, they are not documented in progress notes unless the social worker or interdisciplinary team reviewed them. She said she was made aware today (06/10/2026) when she interviewed the resident and that she updated her care plan, that if R28 had told staff they should have updated the care plan, and if R28 had requested it to staff and it was not addressed that was a problem. According to a record review of the MAR/TAR it indicated that treatment or medication was completed and did not have time stamp associated. When requested the specific time stamped MAR/TAR for R28, she said it was not available. According to a review of R28'd plan of care (POC) medical record: 'activities of daily living (ADL's) bathing dated 06/08/2026 at 12:04PM R28 received a shower.' A record review of R28's care plan revealed: Dated 05/27/2026 Focus: Resident has impairment in functional status. with Interventions: Provide assistance as needed with self-care and mobility functional tasks. Not found in care plan residents' preference was to be up and dressed for breakfast in the dining room daily. According to a record review of the facility policy labelled call lights the Policy: guidelines for answering call lights: procedure: 5. Answer the call light as quickly as possible; 10. Provide this service the resident requested and turn the call light off; 11. If the service is unable to be provided do not turn the call light off until the appropriate staff is available to assist.No specific policy was provided on Dignity to review as requested. According to a record review of the facilities policy titled Residents rights guidelines:Procedure. 2. Our residents have the right to.; a. Be treated with dignity and respect; b. Be given the information necessary to participate in decisions which affect them both individually.; t. Which means they're probably be consulted and encouraged to have input into their care which guides the services delivered.;

This Citation pertains to Intake Number 3011265.Based on interview and record review, the facility failed to ensure that neurological assessments (neuro checks) were completed per Standards of Practice after unwitnessed resident falls and/or witnessed falls with a head injury for 1 resident (Resident # 80) of 3 resiudents reviewed for falls, resulting in the potential for head injury without necessary Neuro assessments. Findings Include: Accidents Resident #80: A record review of the Face sheet electronic medical record (EMR) indicated that Resident #80 was originally admitted to the facility on [DATE] and with several readmissions and diagnoses: Dementia, anxiety, depression, epilepsy, heart disease, Chronic pain syndrome, COPD, GERD, history of falls. The resident died on [DATE]. A record review of an Event Report dated [DATE] indicated Resident #80 fell at the facility on [DATE] at 9:20 AM: At 9:20 AM after transfer to the wheelchair with aide assistance, the resident leaned forward and fell, landing on knees and striking the right eye on the tray table. Redness noted to the right eye. At approx. 1:40 PM Resident verbalizes pain during range of motion in right lower extremity. X-ray order for right hip pain. x ray shows fracture Evaluation Notes: Patient w/BIMS 0 (with Brief Interview for Mental Status/BIMS score of 0/15 = severe cognitive loss). Further review of the medical record indicated there were no documented Neurological assessments after the resident hit her face on the tray table. On [DATE] at 3:37 PM, the Director of Nursing/DON was interviewed about Resident #80's fall she said she recalled the resident fell in the hallway near the 200 hall in the common area. She said Resident #80 leaned forward and fell, fractured hip and hit her face. On [DATE] at 9:30 AM, the DON provided a copy of a paper document titled, Neurological Checks the entry Date/Time of Fall was dated [DATE] for Resident #80. The entry Baseline at Initial Assessment was not dated or timed. There was no assessment for the left eye and the right eye identified Redness above right eye. There was no mention of a Neurological assessment for the resident's eyes, to identify if they were reacting to light and accommodation; the size of the pupils; or if the resident's mentation was changed, or if she could follow commands. The remainder of the Neurological Checks document included vital signs only: blood pressure, heart rate, temperature, respirations and oxygen saturation. In addition, there was a column titled, Any changes from Baseline? all lines were blank with no reference to a specific dated/timed Neuro assessment. The DON said usually the Neuro assessments would be completed in the computer, but they were not. Reviewed with the DON that the Neurological Checks document for Resident #80 was lacking assessment information used to monitor the residents neurological status. She said that was all there was documented. A review of the Care Plans for Resident #80 revealed the following: ADL's (Activities of daily living): Resident requires staff assistance to complete self-care and mobility functional tasks completely and safely, start date [DATE]. Falls: Resident at risk for falling r/t (related to): (altered) balance, weakness, diagnosis of dementia, history of falls, start date [DATE]. There was no mention of ensuring a Neurological assessment after falling and hitting the resident's face or head.

This citation pertains to Intake Number 3011265. Based on interview and record review, the facility failed to ensure an appropriate, complete and thorough investigation was conducted for one (1) resident (Resident #77) of 3 residents reviewed for discharges when Resident #77 became unresponsive while receiving a shower done by a family member with unknown training for performing safe Activities of Daily Living (ADL) and no other nursing staff member was present to witness the unusual event resulting in R77 hitting her head on the grab bar, exhibiting a significant change in condition during the shower and being immediately transferred to the hospital for evaluation.Findings include: Resident #77 (R77):A review of R77's progress notes dated [DATE] at 1:27 PM described: Resident R77 was receiving a shower by daughter when she became unresponsive. The resident hit her head on the grab bar. The resident was breathing with a faint pulse. Resident's face and lips cyanotic. The resident was transferred from a wheelchair to bed. When the resident was transferred to bed, she returned to consciousness but continued to close her eyes while the staff was talking to her. Resident's BP was 75/54. The resident's pulse continued to be faint and irregular. The resident was placed in the Trendelenburg position. EMS was contacted. Family at the bedside is visibly upset. ADHS was present at the time, and the resident was taken to the nearby hospital (hospital name mentioned).According to the facility face sheet, R77 was [AGE] years old, admitted on [DATE], and was discharged on [DATE].R77 had a list of diagnoses and received treatment for Type 2 Diabetes Mellitus with hyperglycemia, essential hypertension, gastro-esophageal reflux disease without esophagitis, adjustment disorder, and anxiety disorder, in addition to other diagnoses. R77's Brief Interview for Mental Status (BIMS) Score, assessed on [DATE], was 14/15. A score of 14 means that the person is cognitively intact. The Minimum Data Set (MDS), GG section, assessed on [DATE], coincided with the Care Plan for ADLs created on [DATE] at 11:11 AM and indicated that Resident (77) requires staff assistance to complete self-care and mobility functional tasks safely and completely. GOAL: Resident's functional needs will be met safely by staff. R77 did not have a care plan specifying that the family can provide R77's ADLs, particularly showers.An attempt to call the family member via phone was made on [DATE] at 3:30 PM. Family returned the call on [DATE] at 3:39 PM and stated that they were present during the incident. When asked who they were? Family #1 stated, My sister and I were giving mom a shower, and, according to Family #1, they did not receive any training or an in-service from the facility on how to provide showers. Staff asked them if they could give it, so they did. They were not aware of any training requirement. They were alone with their mother when it happened, and no staff was available when their mother started to pass out. There were no other staff present during the shower when she slumped over and hit her head on the shower bar. Family #1 further described that they activated the call light immediately but could not leave to yell for help, and it took a very long time for staff to respond. Family #1 said, It was the maintenance man who came first on the scene, and no nurse or aide responded to the call. When staff finally responded, they laid her flat on the floor, and an ambulance was called. We held her in the shower chair, so she did not fall, but she was moved to the ground by staff to assess her breathing and pulse. She was on the floor when the ambulance came. Family #1 was unsure whether CPR was performed. She is not medical, but she was blue on the lips and her face. Maybe they performed CPR. I really don't know.According to an interview with the Director of Nursing (DON) on [DATE] at 10:30 AM, the DON stated that the resident had syncope and was sent to the hospital on (DATE). It did not deem an investigation necessary because the event is a medical condition. The surveyor asked who diagnosed that the resident had a syncopal episode? Is the syncopal episode concluded from an investigation of what happened? The DON remained quiet and did not answer. The surveyor asked, How did R77 bump her head, and what caused the cyanosis of the lips and face? Was any staff member present during the syncopal episode? Did a provider or a physician give this diagnosis? where there staff statements obtained in this particular event? Did she fall? Was she on the floor? Why was she transferred to the chair? Was she on the floor, then to the chair, then to the bed? The DON stated. There was no soft file or investigation because it did not warrant one.Regional Staff on [DATE] at 12:15 PM insisted that the incident was a medical change in condition and did not need any investigation.Executive Director was interviewed on [DATE] at approximately 3:45 PM along with the Administrator. The Executive Director stated that she was not aware of this incident and, when checked, was off at the time. When asked if this incident was deemed an investigation, she agreed, yes. She would. The Administrator revealed that she received a report stating that R77 had a change in condition and was sent to the hospital. She did not know the details about the shower done by the family where she passed out and called emergency 911. She agreed that it would be deemed an incident report and a call to the Executive Director.A call was made to the Nurse-in-charge of R77 (during the [DATE] incident) on [DATE] at 3:31 PM. The surveyor left a voicemail, but there was no reply. The surveyor learned from the facility Executive Director that the Nurse-in-charge was terminated and is no longer employed by the facility.Physical Therapy notes dated [DATE] to [DATE] were reviewed. Upon review of the Rehab notes, no notes were found, nor was there any indication that the family received ADL care training, specifically bathing/showering, in the rehab record or in R77's progress notes. on 3/26,26 Rehab notes revealed discontinued service on [DATE]: Not assessed prior to sudden hospitalization. Occupational Therapy (OT) notes dated [DATE] to [DATE] were reviewed. No notes were found, nor was any indication written that the family received ADL care training, specifically bathing/showering, in the rehab record or in R77's progress notes. on 3/26,26 Rehab notes revealed discontinued service on [DATE]: Not assessed prior to sudden hospitalization. The OT progress notes dated [DATE] , R77 Functional Skills Assessment revealed: Bathing- Shower/bath self: Partial/moderate assistance. Functional Skills Assessment-Functional Mobility: Tub/Shower Transfer=Supervision or touching assistance. The OT Progress Notes continued . Assessment and Summary of Skilled Services: Skilled Interventions Provided Skilled Treatment interventions included instructing and training the patient in compensatory strategies, energy conservation techniques, safety precautions, safe transfer techniques, and the use of assistive device(s) to decrease fall risk and maximize ADL independence. Discharge (D/C) Destination: Acute Care Hospital. D/C Reason: Discharge to Hospital.An interview with Rehab by the surveyor on [DATE] at 2:30 PM confirmed that the family did not receive any training to perform R77's Activities of Daily Living (ADLs).On [DATE] at 10:30 AM, the Activities of Daily Living (ADL) Policy was requested, and the Executive Director stated that the facility did not have an ADL policy.Fall Management Program Guidelines, undated, were reviewed on [DATE] at 4:00 PM.Purpose Statement: The purpose of this policy is for (Name of the Company) to strive to maintain a hazard-free environment, mitigate fall risk factors, and implement preventative measures. (Name of the Corporation mentioned) recognizes even the most vigilant efforts may not prevent all falls and injuries .Policy for Abuse was reviewed on [DATE] at 4:05 PM.Purpose StatementThe purpose of this policy is to: (Name of Company mentioned), has developed and implemented processes, which strive to ensure the prevention and reporting of suspected or alleged resident abuse and neglect.Policy: Abuse, Neglect, and Exploitation Procedural GuidelinesProcedure:1. (Name of Company mentioned), has implemented processes in an effort to provide a comfortable and safe environment.2. The Executive Director and Director of Health Services are responsible for the implementation and ongoing monitoring of abuse standards and procedures3. Definitions: ABUSE is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. Abuse also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain, or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse, including abuse facilitated or enabled through the use of technology. Willful, as used in this definition of abuse, means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm.f) Investigationi. The Executive Director is accountable for investigating and reporting.ii. Exercising caution in handling evidence that could be used in a criminal investigation. (e.g., not tampering or destroying evidence)iii. Investigating different types of alleged violationsiv. Identifying and interviewing all involved persons, including the alleged victim, alleged perpetrator, witnesses, and others who might have knowledge of the allegations.v. Focusing the investigation on determining if abuse, neglect, exploitation, and/or mistreatment has occurred, the extent, and the cause.vi. Providing complete & thorough documentation of the investigation.

Based on interview, and record review the facility failed to ensure that staff records for Covid-19 vaccination education, and acceptance or declination of the vaccination were documented and maintained for 2 staff members Certified Nursing Assistant (CNA) L and Nurse M of 3 staff members reviewed for Covid-19 vaccinations. Findings Include: Infection Control: On 6/10/2026 at 10:09 AM, during an interview with Infection Control Practitioner O she said she said she had worked as the ICP at the facility for 2 years and was responsible for the Immunization program for residents and staff. She said staff were assessed on hire for vaccination status and she said the MCIR Michigan Care Improvement Registry was reviewed to determination staff vaccination status. The ICP O said staff were offered Covid-19 vaccinations through a pharmacy or at their providers office. During the interview with ICP O on 6/10/2026 at 10:30 AM, a request was made to review 3 staff L, M, and N for Covid-19 vaccination screening, proof of offering the vaccination, education for the vaccination and acceptance or declination of the vaccination. On 6/10/2026 at 11:55 AM, during an interview with the Administrator, she said she sent an email to the facility pharmacy requesting copies of the Covid-19 vaccination forms for Staff L and M as she said the facility did not keep a copy of the forms for the two staff. A copy of Covid-19 vaccination record and Declination of Covid-19 Vaccination signed 2/10/26 was received for Staff N. The Administrator said education for the Covid-19 vaccination was hanging on the wall in the staff breakroom for their review. A Vaccination Information Statement/VIS document was not noted as being provided to Staff N. On 6/10/2026 at 12:14 PM, the Administrator provided a copy of the email to the facility pharmacy requesting Covid-19 vaccination information for Residents L and M. Prior to exit of the survey on 6/10/2026 at 4:30 PM, there was no additional employee vaccination information received from the facility. A review of the Facility Assessment dated 2/2/2026 identified a section titled Facility Resources Needed to Provide competent Support and Care for our Resident Population Every Day and During Emergencies; there was no mention of an Infection Control Practitioner or Infection Preventionist. Further review of the document revealed it did not mention staff or resident vaccinations. There was one entry titled, Infection Prevention and Control: Identification and containment of infections, prevention of infections. There was no additional information. A review of the facility policy titled, Infection Prevention and Control Program (IPCP), dated reviewed 11/19/25 provided, Purpose Statement: the purpose of this policy is to: 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 and infections. Is based on the facility assessment. There was no mention of staff vaccinations.

Based on observation, interview, and record review, the facility failed to ensure that appropriate skin care was provided for one resident (Resident #40) and that appropriate Activities of Daily Living (ADL) care for one resident (Resident #77) was provided by trained nursing staff during showers for 6 residents reviewed for skin and ADL care. Findings include: Resident #40 (R40):According to the facility Face Sheet, R40 was admitted to the facility on [DATE] with a diagnosis of Hypertensive Heart Disease with CHF, Pneumonia, Difficulty Walking, and Mild Cognitive Impairment in addition to other diagnoses.On [DATE] at 3:05 PM, R40 was observed to be alert and oriented, with a Brief Interview of Mental Status (BIMS) Score of 13/15 per CMS-generated data submitted by the facility. A score of 13-15 means that the individual's cognitive function is intact. A review of R40 's Care Plan for skin care dated [DATE], indicated:1. Moisture-Associated Skin DamageInterventions:Keep skin clean and dry.Observe for pain/itching/ discomfort and treat as ordered.Observe MASD for decline or s/sx of infection,Notifying the physician as needed.Treatment as needed.2. At risk for skin breakdown related to morbid obesity and impaired mobility Treatments as ordered.On [DATE] at 3:05 PM, R40 was observed in her room sitting up on her bed. When asked how she was, R40 was concerned and complained of redness, itching, and discomfort in her abdominal skinfold areas, under her breast, and sometimes in her privates. R40 stated she has been complaining of her issue to the nurses and has not been seen by a doctor for it. R40 expressed that sometimes it becomes unbearable that she could not sleep. She would ask the Nursing Assistant (CNA) assigned to her to apply it to her folds and under her breast, and it gives her so much relief that she reports that she is able to sleep. She was previously treated for her fungal infection in the areas mentioned when she was home, and she wanted to take precautions to prevent it from happening again.A review of R40's medication list was conducted on [DATE] at 11:30 AM. R40's Medication and treatment record dated [DATE] has no prescribed medications, no skin treatments, and no preventative skin care orders. No vaginal cream treatments were noted.On [DATE], at 9:45 am, while waiting for the Certified Nurse Aide to provide skin care, R40 showed the surveyor two tubes of cream kept in her bedside table drawer. R40 revealed that the aides apply them on her abdominal folds and under her breast when she's having discomfort. She further described her discomfort as burning, painful, and itchy. R40 stated she needed them last night and slept better last night after the nurse applied it on her foldsAt 10:15 AM on [DATE], the CNA came to perform her skin check with the surveyor; the abdominal fold area was intact but red. There was a raised reddened area that she had pointed ([NAME] -size) under her right breast and the adjacent abdomen touching the breast that was red. The raised area was red, and it was apparently of a similar shape because the skin was rubbing against each other. R40 commented, That area burns! The CNA confirmed they were applying the cream per the R40's request and commented further that she must have brought them from home.The nurse confirmed at 10:30 AM that R40 had no skin or topical cream ordered for her. The nurse on duty explained that she is just initiating an assessment for R40 self-medication. The nurse confirmed that she did not have the order to keep her own and apply the cream without the doctor's go-ahead. R40 must have brought the vaginal cream and the skin cream from home because no skin care was ordered for her. While in R40's room, the nurse pointed out that the Desitin cream is available over the counter, but the vaginal cream is a prescription treatment. None were listed in her physician's orders.According to the Director of Nursing (DON), on [DATE] at 10:00 AM, there was no skin care or vaginal cream ordered for R40. An assessment and an order allowing her to self-medicate are needed to have R40 keep them at bedside.According to the DON and the Executive Director, on [DATE] at 2:30 PM, the company did not have a policy for ADL (Activities of Daily Living ) Care.Resident #77 (R77):A review of R77's progress notes, dated [DATE] at 1:27 PM, described: Resident R77 was receiving a shower by daughter when she became unresponsive. The resident hit her head on the grab bar. The resident was breathing with a faint pulse. Resident's face and lips cyanotic. The resident was transferred from a wheelchair to bed. When the resident was transferred to bed, she returned to consciousness but continued to close her eyes while the staff was talking to her. Resident's BP was 75/54. The resident's pulse continued to be faint and irregular. The resident was placed in the Trendelenburg position. EMS was contacted. Family at the bedside is visibly upset. ADHS was present at the time, and the resident was taken to the nearby hospital (hospital name mentioned).According to the facility face sheet, R77 was [AGE] years old, admitted on [DATE], and was discharged on [DATE].R77 had a list of diagnoses and received treatment for Type 2 Diabetes Mellitus with hyperglycemia, essential hypertension, gastro-esophageal reflux disease without esophagitis, adjustment disorder, and anxiety disorder, in addition to other diagnoses. R77's Brief Interview for Mental Status (BIMS) Score, assessed on [DATE], was 14/15. A score of 14 means that the person is cognitively intact. The Minimum Data Set (MDS), GG section, assessed on [DATE], coincided with the Care Plan for ADLs created on [DATE] at 11:11 AM and indicated that Resident (77) requires staff assistance to complete self-care and mobility functional tasks safely and completely. GOAL: Resident's functional needs will be met safely by staff. R77 did not have a care plan specifying that the family can provide R77's ADLs, particularly showers.An attempt to call the family member via phone was made on [DATE] at 3:30 PM. Family returned the call on [DATE] at 3:39 PM and stated that they were present during the incident. When asked who they were? Family #1 stated, My sister and I were giving mom a shower, and, according to Family #1, they did not receive any training or an in-service from the facility on how to provide showers. Staff asked them if they could give it, so they did. They were not aware of any training requirement. They were alone with their mother when it happened, and no staff was available when their mother started to pass out. There were no other staff present during the shower when she slumped over and hit her head on the shower bar. Family #1 further described that they activated the call light immediately but could not leave to yell for help, and it took a very long time for staff to respond. Family #1 said, It was the maintenance man who came first on the scene, and no nurse or aide responded to the call. When staff finally responded, they laid her flat on the floor, and an ambulance was called. We held her in the shower chair, so she did not fall, but she was moved to the ground by staff to assess her breathing and pulse. She was on the floor when the ambulance came. Family #1 was unsure whether CPR was performed. She is not medical, but she was blue on the lips and her face. Maybe they performed CPR. I really don't know.According to an interview with the Director of Nursing (DON) on [DATE] at 10:30 AM, the DON stated that the resident had syncope and was sent to the hospital on (DATE). It did not deem an investigation necessary because the event is a medical condition. The surveyor asked who diagnosed that the resident had a syncopal episode? Is the syncopal episode concluded from an investigation of what happened? The DON remained quiet and did not answer. The surveyor asked, How did R77 bump her head, and what caused the cyanosis of the lips and face? Was any staff member present during the syncopal episode? Did a provider or a physician give this diagnosis? where there staff statements obtained in this particular event? Did she fall? Was she on the floor? Why was she transferred to the chair? Was she on the floor, then to the chair, then to the bed? The DON stated. There was no soft file or investigation because it did not warrant one.Executive Director was interviewed on [DATE] at approximately 3:45 PM along with the Administrator. The Executive Director stated that she was not aware of this incident and, when checked, was off at the time. When asked if this incident was deemed an investigation, she agreed, yes. She would. The Administrator revealed that she received a report stating that R77 had a change in condition and was sent to the hospital. She did not know the details about the shower done by the family where she passed out and called emergency 911. She agreed that it would be deemed an incident report and a call to the Executive Director.Physical Therapy notes dated [DATE] to [DATE] were reviewed. Upon review of the Rehab notes, no notes were found, nor was there any indication that the family received ADL care training, specifically bathing/showering, in the rehab record or in R77's progress notes. on 3/26,26 Rehab notes revealed discontinued service on [DATE]: Not assessed prior to sudden hospitalization. Occupational Therapy (OT) notes dated [DATE] to [DATE] were reviewed. No notes were found, nor was any indication written that the family received ADL care training, specifically bathing/showering, in the rehab record or in R77's progress notes. on 3/26,26 Rehab notes revealed discontinued service on [DATE]: Not assessed prior to sudden hospitalization. The OT progress notes dated [DATE] , R77 Functional Skills Assessment revealed: Bathing- Shower/bath self: Partial/moderate assistance. Functional Skills Assessment-Functional Mobility: Tub/Shower Transfer=Supervision or touching assistance. The OT Progress Notes continued . Assessment and Summary of Skilled Services: Skilled Interventions Provided. Skilled Treatment interventions included instructing and training the patient in compensatory strategies, energy conservation techniques, safety precautions, safe transfer techniques, and the use of assistive device(s) to decrease fall risk and maximize ADL independence. Discharge (D/C) Destination: Acute Care Hospital. D/C Reason: Discharge to Hospital.An interview with Rehab by the surveyor on [DATE] at 3:30 PM confirmed that the family did not receive any training to perform R77's Activities of Daily Living (ADLs).On [DATE] at approximately 2:30 AM, the Activities of Daily Living (ADL) Policy was requested, and the Executive Director stated that the facility did not have an ADL policy.

Based on observation, interview and record review the facility failed to develop and implement a comprehensive care plan for 1 resident (Resident #85) of 19 residents reviewed, resulting in Resident #85 lacking Care Plan interventions for a neck brace, which could lead to the resident lacking necessary care and services. Findings Include: Resident #85: Care Plans A record review of the Face sheet and electronic medical record indicated Resident #85 was admitted to the facility on [DATE] with diagnoses: history of falls with facial fracture, sixth cervical vertebral fracture, fracture of first thoracic vertebra, wedge compression fracture of second thoracic vertebra, fracture nasal bones, maxillary fracture, dementia, hypothyroidism, anxiety, and hypertension. On 6/08/2026 at 10:19 AM, Resident #85 was observed sitting in a Broda chair in the dayroom on the 100 Hall. The resident was observed to have large purple bruising on both sides of her face, and she was wearing a neck brace. The neck brace had a large round dark red stain approximately 2 cm x 2cm on the lower left front of the neck brace. She was resting with her eyes closed. On 6/8/2026 at 10:20 AM Nurse N was interviewed about Resident #85, and she said the resident had been at the facility for a Couple days. The nurse was asked about the resident's neck brace, and she said she thought it was dried blood on the front of the brace, but she would have to look into it. On 6/8/2026 at 2:00 PM, Nurse N was interviewed and said a new neck brace was ordered for Resident #85. A review of the physician orders for Resident #85 identified, Cervical collar, may remove for skin checks Twice a day, start date 6/3/2026. A review of the Care Plans for Resident #85 provided the following: Resident has impairment in functional status related to C6 and facial fractures, hypertension, dementia, start date 6/3/2026. Skin integrity: At risk for skin breakdown related to impaired mobility, start date 6/3/2026. There was no mention of checking the skin under the neck brace. There was no mention of the neck brace. Falls: Resident is at risk for falling related to impaired mobility, start date 6/3/2026. There was no mention of wearing a neck brace due to the prior falls and fractures. Pain: At risk for pain related to facial and C6 fractures, start date 6/3/2026. There was no mention of wearing a neck brace. The resident's Care Plans did not mention the neck brace. On 6/10/2026 at 1:34 PM the resident was observed in her room lying in bed awake; a new soft neck brace was in place. Nurse N was interviewed and she said the new neck brace was provided the day before (6/9/2026).

This citation pertains to intake Number 2743538.Based on interview and record review, the facility failed to ensure that licensed nursing staff possessed an active Cardiopulmonary Resuscitation (CPR) certification, resulting in the potential to not meet the needs of residents requiring CPR.Findings include:On [DATE] at 03:10PM, a list of staff that were terminated in the last 90 days was requested. On [DATE] at 08:45AM, the list of terminated staff was reviewed.On [DATE] at 08:46AM, the Cardiopulmonary Resuscitation (CPR) card was requested for Licensed Practical Nurse (LPN) F. On [DATE] at 12:16PM, the Executive Director (ED) A approached this surveyor and stated that they could not provide a copy of the CPR card for LPN F. ED A: was asked if they request CPR cards for nurses upon hire? ED A stated, yes, we do. We identified a break in the hiring process, and we ensure that the CPR cards get uploaded in the system now. We go over this every month in a staff meeting. We do have sufficient staff present to perform CPR at all times. ED A was asked how this was missed? ED A stated, our tracking system wasn't what it needed to be. ED A was asked if they have a policy for CPR requirements? ED A stated, not necessarily, we just follow the regulation and that states that the facility must have an adequate amount of trained staff present. ED A was asked if they found any negative outcomes during the auditing process. ED A stated, no, we did not identify any negative outcomes. A request was made for the job descriptions for licensed nurses. At this time ED A provided a Past Non-Compliance (PNC) for CPR cards.On [DATE] at 01:05PM, ED A provided the job descriptions for licensed nurses.Record review of the job description for Licensed Practical Nurse (LPN) revealed: Qualifications:-Must possess, at a minimum, a nursing degree or diploma from an accredited college or university. Must have and maintain a current, valid, LPN license and current, valid CPR certification required.On [DATE] at 02:16PM, an interview was conducted with Employee Services (ES) G. ES G was asked if they were aware at the time of hire that this nurse did not possess an active CPR certification? ES G stated, no, I was not aware. ES G was asked if LPN F notified her that she did not possess an active CPR card.? ES G stated, no, she did not make us aware. ES G was asked if that is part of the hiring process to ensure they have the correct items needed for the role? ES G stated, yes, I check to make sure they have the necessary items to be eligible for hire. ES G was asked how did this get missed? ES G stated, I don't have an answer, it was just missed. ES G was asked what they are doing as a facility to ensure this doesn't happen again? ES G stated, we have a new checklist system that will help make sure things don't get missed again.On [DATE] at 12:16PM, during the onsite survey, Past Non-Compliance (PNC) was cited after the facility implemented actions to correct the non-compliance which included: 1. All current nurses were audited to ensure CPR cards are on record and current. No residents were affected.2. All current nurses were audited to ensure CPR cards are on record and current. No residents were affected.3. The facility reviewed their onboarding process for new hires to ensure compliance with CPR certification. 4. The employee services staff member is auditing weekly x4 and monthly x3 to ensure compliance.5. Date of compliance: [DATE].

Based on interview and record review the facility failed to develop a person-centered, comprehensive care plan for 4 residents (# 8, #28, #45, #47) of 16 residents reviewed. Findings include: Resident #8: Advance Directives A record review of the Face Sheet and Minimum Data Set/MDS assessment indicated Resident #8 was admitted to the facility on [DATE] with diagnoses: history of a stroke, right-sided weakness, dementia, depression, anxiety, peripheral vascular disease and hypertension. The MDS assessment dated [DATE] indicated the resident had full cognitive abilities with a Brief Interview for Mental Status/BIMS score of 13/15 and the resident needed assistance with all care. A record review of the electronic medical record revealed Resident #8 wished to be a Full code (meaning full resuscitation if her heart stopped and she quit breathing). The Face sheet was flagged Full Code and the physician orders indicated Full code. The Care Plan for Resident #8 identified the following: Social Aspects: . She has chosen the following advanced directives, Code status, dated 11/1/2018; with Interventions including: Code status as ordered, dated 11/1/2018. The Care Plan did not mention the specific Code status the resident had chosen, Full Code. Resident #28: Advance Directives A record review of the Face sheet and Minimum Data Set/MDS assessment indicated Resident #28 was admitted to the facility on [DATE] with diagnoses: Diabetes, depression, hypothyroidism, hypertension, asthma GERD and chronic pain. The MDS assessment dated [DATE] revealed the resident weighed 94 lbs. and was cognitively intact with a Brief Interview for Mental Status/BIMS score of 15/15. A record review of the electronic medical record indicated the Face sheet was flagged with DNR (do not resuscitate) and there was a physician order for Code status: DNR, dated 2/15/2023. A review of the Care Plans for Resident #28 identified the following: Resident/resident representative have chosen advanced directives, dated 7/28/2020. There was no mention what the resident's preference for Advance directives was. Resident #47: Advance Directives A review of the Face sheet and Minimum Data Set/MDS assessment indicated Resident #47 was readmitted to the facility on [DATE] with diagnoses: Spina bifida, heart failure, history of intestinal obstruction, diabetes, history of a stroke with right sided weakness, anxiety, kidney disease, ileostomy and Stage 4 pressure ulcer on coccyx. The MDS assessment dated [DATE] revealed the resident had full cognitive abilities with a Brief Interview for Mental Status/BIMS score of 15/15 and she needed some assistance with all care. A record review of the electronic medical record revealed the Face sheet for Resident #47 said DNR. The Care Plan for Resident #47 identified the following: Social Aspects: Resident has elected for comfort care and has chosen Hospice services, dated 3/11/2025. It did not mention what the resident's Code Status preference was. On 5/07/2025 at 12:37 PM, Social Services staff K was interviewed about the process for obtaining the residents' preferences for Code status and she said nursing staff completed the advance directives assessment form and Social Services ensured they were completed and in the information was in the chart. When asked who created the person-centered Care Plan for the resident, she said either Social Services or the MDS Nurse would complete the Care plan. On 5/07/2025 at 3:56 PM, MDS Coordinator L was interviewed about the residents' Care Plans for their specific preferences for Code Status and she said the Social Services staff completed the Code status Care Plans. 37771 Resident #45: A review of Resident #45's medical record revealed an admission into the facility on [DATE] and readmission on 3/1/25 with diagnoses that included stroke, cognitive communication deficit, hemiplegia and hemiparesis of left non-dominant side and pressure ulcer. Further review of the medical record revealed the Resident was on hospice services. On 5/6/25 at 1:45 PM, an observation was made of the Resident lying in bed sleeping. An interview was conducted with Family Member S regarding Resident #45's care at the facility. The Family Member reported that she was unaware of the Resident having any wounds but reported that the Resident stays mostly in bed, sleeps a lot and health was declining. The Resident had an air mattress that was set at the highest setting for comfort at 5 and alternating air circulation. There was no data on the air bed controller to indicate directive for staff on the air mattress settings. On 5/8/25 at 11:34 AM, a review of Resident #45's care plan revealed a Category: Skin Integrity. At risk for skin breakdown r/t (related to) need for staff assistance with turning and repositioning with an approach dated 1/18/24 Low Air Loss mattress to bed as ordered. A review of Resident #45's orders revealed no order for an alternating pressure mattress. On 5/8/25 at 1:02 PM, an interview was conducted with the Regional Clinical Coordinator (RCC), Nurse B regarding Resident #45's air mattress that was on the Resident's bed. The care plan with the low air loss mattress and lack of directive for settings for the alternating pressure mattress was reviewed. The RCC indicated that the Resident should be ordered the APM air mattress and care planned for the APM air mattress. The RCC was unsure of where the settings for the air mattress could be found by staff and indicated that the settings were set to Resident comfort.

Based on observation, interview and record review, the facility failed to ensure safe and secure medication storage and ensure that supplies was labeled and not expired for two medication rooms and four medication storage carts and treatment carts reviewed for storage of drugs, biologicals and supplies. Findings include: On [DATE] at 2:32 PM, an observation was made with Nurse G of the 200 Hall medication storage room. An observation was made of Assure Prism glucose control solutions, two boxes with one box open and the other box sealed, both boxes expired on [DATE]. There was not an open date on the control solution bottles or on the box. The medication room was reviewed for other, not expired control solutions but there were none found in the medication room. When asked, Nurse G indicated they should be dated when opened. A review of the med cart ,d+[DATE] was conducted with Nurse G. The Nurse was asked if there was the glucose control solution in the medication cart, but it was not found. The Nurse asked the other nurse if there was any in the other 200 Hall medication cart and the Nurse indicated there was none. An observation was made of the medication cart for the 215 to 223 rooms. There were medications in bubble packaging that the Nurse indicated appeared to be from back up. There was no name or room number to identify whose medications they were. The Nurse indicated they should be labeled and stated, It could be from back up, but I don't know who they belong to. The medication was two tablets of memantine, a metoprolol tartrate, and atorvastatin. When asked if the medication is not used what do you do with them, the Nurse stated, I would use it because it's been already signed out for the resident. On [DATE] at 3:30 pm, an observation was made with Nurse R of the 300 Hall medication room with the treatment cart in the room. An observation was made of a betadine solution opened, without an open date, and had a white powder residual on the outside of the bottle. The Nurse was asked what it was but was unsure what the white powder residue was and reported it could be nystatin powder. The Nurse reported that it should be dated when it was opened. A heel protective dressing was opened and laying in the drawer. The Nurse removed it and stated, It's been opened. Three triad hydrophilic wound dressing were opened and not dated. When asked when they were opened, the Nurse stated, I don't know, they should be dated. When asked for glucose control solutions, the Nurse was unable to find any in the medication room or the 300 medication cart. A review of the medication cart revealed glucose test strips opened and not dated with an open date. When asked about facility policy of dating the glucose test strips when opened, the Nurse reported the vial should be dated when opened. On [DATE] at 4:10 PM, an interview was conducted with Regional Clinical Coordinator RCC, Nurse B regarding glucose monitoring solutions. At 4:14 PM, Central Supply Staff Q looked for the test solution for the glucometers but was unable to find any except for the expired control solutions found earlier. The RCC was asked about calibration of the glucose monitors. The RCC reported that the machines are not calibrated unless they were getting an error or as needed and reported that they should have some solution available. On [DATE] at 10:30 AM, an observation was made during medication administration with Nurse H on the 200 hall unit. There were two medication carts and a treatment cart that was positioned near the nurse's station. Upon return to the nursing station area after observing Nurse H performing medication administration, an observation was made of keys on the treatment cart that were on the top of the cart on a pole. The Nurse was asked what the keys were for, and the Nurse explained they were the keys to open the treatment cart. The Nurse was asked if that was where the keys were normally kept. The Nurse reported that the keys are usually with the cart and sometimes they put them on the side of the cart. An observation was made of the keys visible on the top of the cart. The Nurse indicated that due to having only one set of keys, both nurses need to access the cart, and the keys were left with the cart for the two nurses. A review of the contents of the treatment cart revealed multiple treatments in the cart that were prescription medications. The items included Bio Freeze, antifungal treatments, ammonia lactate, arthritic pain gel, Lotrimin, zinc oxide ointments, Triamcinolone acetonide cream, Nystatin powder, and triple antibiotic ointment. Other items in the cart included wound dressings, wound cleansers, wound/treatment supplies and needles. On [DATE] at 11:04 AM, an interview was conducted with the Director of Nursing (DON) regarding the storage of the treatment cart keys on the top of the cart. The DON indicated that they were made aware of the keys left on the treatment cart and reported they were going to have another set of keys made so each nurse will have access to the treatment cart with their medication cart keys that they keep with them. 37666 FACILITY Medication Storage and Labeling On [DATE] at 2:00 PM, Nurse Aide E was overheard and observed asking Nurse H for the keys to enter the medication room that was located behind the nurse's desk. Nurse Aide E said he wanted to get an ice pack. Nurse H was observe standing in the hallway and tossing Nurse Aide E her keys to the medication room. Nurse Aide E was observed opening the door to the medication room and he went in by himself. Nurse H was asked if Nurse Aides were allowed to go into the medication room unattended and she said they were allowed to go in to get an ice pack. The Surveyor and Nurse H entered the medication room and Nurse Aide E was observed taking an ice pack from the medication freezer. The medication refrigerator had a location for a lock on it, but it was not in place; it was unlocked. Inside the refrigerator there were a variety of medications, including insulin pens and vaccinations. They were not in a locked area. On [DATE] at 2:10 PM, upon exiting the medication room with Nurse H and Nurse Aide E, Nurse G approached the nurses' desk and Nurse H handed her a set of keys to the medication cart and medication room, as Nurse G had been on break. Nurse G was asked if Nurse Aides were allowed to go into the medication room on their own and she said they go in to get ice packs. On [DATE] at 2:33 PM, during an interview with Nurse Supervisor I, she was asked if Nurse Aides were allowed to go into the medication room and she stated, Only if they are with a nurse.

The facility failed to inform and offer transportation to and from dialysis appointments, as part of the services at no cost, for one resident (R#55), of 2 residents reviewed for dialysis services. Findings include: Resident #55 (R55): Dialysis R55 was [AGE] years old, admitted to the facility on [DATE] with the diagnosis of Acute Renal Failure, Non-ST Elevation (NSTEMI) Myocardial Infarction, Stage 4 Chronic Kidney Disease, Chronic Obstructive Pulmonary Disease, and Dementia (unspecified) in addition to other Diagnoses. Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview of Mental Status (BIMS) Score of 15/15. A score of 15 means R55 is cognitively intact. R55's Care Plan indicated that the plan was to discharge home after the rehab program. He was scheduled for dialysis every Tuesday, Thursday, and Saturday. R55's CarePlan indicated a coordinated care with dialysis transported by the family. R55 on 5/6/25 at 12:30 PM was observed in his room talking to his son while waiting for the second son to arrive. It was R55's second son's turn to drive R55 to dialysis before the 1:30 PM appointment. Son #1 was there as backup to ensure he made it on time. While waiting, R55 expressed that he would love to have a shower soon. He has not received a shower since he was at the facility, and he did not receive a shower while admitted at the hospital for 2 weeks. R55 stated he would prefer a shower in the shower room with water sprinkling on his head instead of a bed bath. On 05/06/25 at 12:32 PM, R55's son was concerned about why the facility did not provide transportation for his father's dialysis appointment. His brothers and he have to arrange and ensure that R55 is transported to and from dialysis 3 times a week. R55's son asked why other facilities have a transport service and not this one. The hospital, before discharge, made sure that we agreed to transport our dad to dialysis before we were accepted to this facility. If we were offered a choice, we would have used their transportation. No one discussed this service, and the facility did not provide it. Otherwise, we would have chosen to use their transport services. R55's dialysis documentation record and nursing notes were reviewed in R55's: Tuesday, 4/29/25 Monday, 5/1/25 Saturday, 5/3/25 Tuesday, 5/6/25 Although the nurses' notes indicated that R55 went to dialysis on all four days, a missing dialysis visit documentation for May 3, 2025, was noted. On 05/08/25 at 10:58 AM, Licensed Practical Nurse (LPN) AW stated that Resident (#55) left at 9:30 for dialysis today. She indicated that it was the family's choice to transport R55. Our transportation Service is free of charge if the family prefers to use it. The Social Services Director #1 in an interview on 5/7/25 at 02:34 PM, revealed that transportation related to dialysis was part of the bundled payment, which means they are included in the services with no extra fees. We provide transportation to and from the dialysis center and don't require the family to find the transportation. When asked who makes that conversation with the family, Social Services Director #1 was not sure who does but explained the bundled payment protocol that Medicare and Managed Care insurances have the transportation included as services. On 5/8/25 at 2:49 PM, a conversation with the Administrator and the Administrator in Training (AIT) was conducted regarding R55 dialysis transport. The Administrator confirmed that everything related to dialysis, including transportation, should be covered with no extra charge. The Administrator was unaware that it was not the family's choice to drive R55 to and from dialysis. She was unaware of the issue. There should have been a conversation upon admission that did not happen. The Administrator admitted that they assumed it was the family's choice upon admission. The Administrator did not know what was said at the hospital before transfer. It should have been explained to the family that the facility can transport dialysis. The Guidelines for Dialysis dated 5/11/16 were reviewed on 5/8/25 at 12:00 PM. Purpose Statement: The purpose of this policy is to provide communication to Dialysis Providers and monitoring of residents receiving dialysis. Policy: Guidelines for Dialysis Procedure: 1. The campus shall have the information regarding the Dialysis Provider schedule and requirements such as but not limited to: a. Location, b. Date and time of service to be provided. c. Required documentation from campus. 2. The campus shall be responsible for arranging or providing transportation to and from the Dialysis Provider .

Based on observation, interview and record review the facility failed to ensure that residents received timely Activities of Daily Living (ADL) care and ensure that residents' preferences were followed for bathing for three residents (R24, R28, R55) of four residents reviewed for ADL care, resulting in residents receiving bed baths instead of showers, not receiving showers on scheduled days, long nails and long facial hair. Findings include: Resident #24 R24 is [AGE] years old and recently admitted to the facility on [DATE] with diagnoses that include cellulitis of the right and left lower leg, diabetes and osteomyelitis. R24 has a brief interview for mental status (BIMS) score of 15, indicating they are cognitively intact. On 05/06/25 at 10:42AM, R24 was asked if they received their showers on time. R24 stated they don't get their showers regularly and often times they get a bed bath. R24 was asked if they prefer a shower over a bed bath and they replied yes. R24 was noted to have a greasy appearance to their hair. On 05/07/25 at 01:41PM, record review revealed that R24 had a shower on 5/2/25(Friday), 4/26/25(Saturday) and 4/21/25(Monday). On 4/25/25 and 5/5/25, both scheduled shower days, no bathing was recorded. On 4/28/25, a scheduled shower day, a partial bed bath was recorded. All bathing recorded outside of scheduled days, was recorded as a partial bed bath. On 05/07/25 at 01:50PM, record review revealed an order for showers every Monday and Friday. Record review revealed a care plan titled Profile Care Guide contained an approach for showers, twice weekly and as needed/requested. On 05/07/25 at 02:10PM, an interview was conducted with certified nursing assistant (CNA) D. CNA D was asked if they have provided care for R24. CNA D stated they have helped R24 with showering. CNA D was asked if R24 has ever refused a shower. CNA D stated that R24 has not refused to take a shower for them. CNA D stated the CNA's are providing showers for the residents they are taking care of. I always try to get my residents to take a full shower. The only time I would give a bed bath is if they refused a shower. CNA D was asked if they knew the difference between a bed bath and a partial bed bath. CNA D stated they weren't sure, but they think that during a partial bed bath everything except the resident's hair gets washed. On 05/07/25 at 03:03PM, R24 was observed sitting in their room watching the television, R24 was noted to have greasy hair. Review of the policy titled, Guidelines for Bathing Preference, revealed: Procedure: 1. The resident will be advised of Trilogy's guidelines for residents to self-determine their plan of care and schedule during their stay on campus. 2. The resident shall determine their preference for bathing on admission. a. Day of the week. b. Time of day, morning or evening. c. Type of bathing- tub bath, bed bath or shower. 37666 Resident #28: Activities of Daily Living A record review of the Face sheet and Minimum Data Set/MDS assessment indicated Resident #28 was admitted to the facility on [DATE] with diagnoses: Diabetes, depression, hypothyroidism, hypertension, asthma GERD and chronic pain. The MDS assessment dated [DATE] revealed the resident weighed 94 lbs. and was cognitively intact with a Brief Interview for Mental Status/BIMS score of 15/15. On 5/06/2025 at 11:59 AM, Resident #28 was observed sleeping in bed. Her feet were lying outside her blanket and her toenails left and right foot were very long and jagged. Her left toenail was hanging over the end of the left great toe. A review of the physician orders for Resident #28 revealed an order to Clip nails on shower days, Once a day on Wed., Sat. A review of the electronic medical record indicated Resident #28 had received 3 showers from 4/7/2025 to 5/6/2025. A review of the Care Plan for Resident #28 identified the following: Showers/Bathing: Twice weekly per schedule and as needed/requested. Offer/encourage to allow staff to shave facial hair, trim nails, dated 1/5/2023. On 5/7/2025 at 9:00 AM, Resident #28 was observed eating breakfast in bed. Her feet were outside the blanket and her toenails were long and jagged on each foot. The resident was asked if she had recently had her toenails clipped and she said she had not. She said it bothered her to have them clipped. The resident said her feet were bumping the footboard of the bed at times. When asked if she was tall, she said, No, I'm short. Asked her if her toenails were bumping into the bed because they were quite long and she said Maybe. On 5/08/25 at 2:38 PM, Resident #28 was observed in her bed, awake, talkative and had a visitor. The Assistant Director of Nursing/ADON C and Corporate Nurse B were present also and observed the resident's toenails were very long and jagged. The resident was asked about having her toenails clipped and she said she had a bad experience with toenail clipping sometime in her life and was afraid. Corporate Nurse B said she thought the Wound nurse last trimmed the resident's nails and that it went well. She said she would arrange for someone to clip the resident's nails; the resident was again complaining of her feet touching the foot board of the bed. Corporate Nurse B and the ADON C assisted the resident with repositioning up in bed. 22348 Resident #55 (R55): Activities of Daily Living During the initial tour, R55 on 5/6/25 at 12:30 PM was observed talking to his son in his room. R55 expressed that he would love to have a shower soon. He has not received a shower since being admitted to the facility. And during his 2-week stay at the hospital before coming to the facility on [DATE]. When asked if he was given a bed bath, R55 emphasized that he would prefer a shower in the shower room with water sprinkling on his head instead of a bed bath. A review of R55 Electronic Medical Record was [AGE] years old, admitted to the facility on [DATE] with the diagnosis of Acute Renal Failure, Non-ST Elevation (NSTEMI) Myocardial Infarction, Stage 4 Chronic Kidney Disease, Chronic Obstructive Pulmonary Disease, and Dementia (unspecified) in addition to other Diagnoses. Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview of Mental Status (BIMS) Score of 15/15. A score of 15 means R55 is cognitively intact. R55's Care Plan indicated that the plan was to be discharged home after the rehab program. R55 required assistance with Activities of Daily Living (ADLs). R55's care plan indicated for Showers: Twice weekly per schedule and as needed/requested. Regarding transfers, R55's care plan dated 4/26/25 revealed that it requires one person to assist with transfers and may walk with a front-wheeled walker in the room and facility with one person's assistance. Walking/Mobility devices: Wheelchair. On 5/6/25 at 3:45 PM, the Administrator printed R55's Point of Care History showing the following: 4/30/25 at 12:58 PM Shower was signed off as given. 5/1/2025 at 9:49 AM Partial Bed Bath signed off as given. 5/5/2025 at 12:46 PM Partial Bed Bath signed off as given. 5/6/2025 at 8:48 AM Partial Bed Bath signed off as given. On 05/06/25 at 2:42 PM, A review of the shower schedule revealed that R55 is scheduled on Wednesday and Saturday. R55 and son both reported that no showers were received as noted above. On 5/7/25 at 3:45 PM, R55 said he preferred water spraying on him like a regular shower. R55 thought the permacath (was pointing at the port) dressing was an issue, but he had a shower today for the first time. He said, It felt good. He indicated that he received bed baths but preferred a real shower. On 5/7/2025 at 2:50 PM, R55 was observed with facial hair growth all over. The surveyor asked if he preferred to grow his beard. He said no. He shaves every other day at home. He needed his shaver from home and did not think they would shave him at the facility. No one offered to shave him. R55 commented that since it had gotten long, he now thinks he needs an electric shaver. R55 was asked if he received three bed baths ( 5/1/25, 5/5/25, and 5/6/25) and one shower on 4/30/25 during your stay? R55 stated, No, I did not get any shower in the shower room. I only received bed baths, but can't recall the dates specifically. R55 was very excited to report that he finally received a shower today.

Based on interview and record review, the facility failed to ensure that weights were obtained, monitored as ordered, and recommended for 2 residents (#28 and #55) of three residents reviewed for nutrition. Findings Include: Resident #28: Nutrition A record review of the Face sheet and Minimum Data Set/MDS assessment indicated Resident #28 was admitted to the facility on [DATE] with diagnoses: Diabetes, depression, hypothyroidism, hypertension, asthma GERD and chronic pain. The MDS assessment dated [DATE] revealed the resident weighed 94 lbs. and was cognitively intact with a Brief Interview for Mental Status/BIMS score of 15/15. On 5/7/2025 at 1:15 PM, during an interview with Resident #28 she was observed sitting in bed eating her lunch. She appeared very thin. A record review of the electronic medical record/emr weights for Resident #28 identified the following weights: 1/12/2025 98.9 lbs. 2/19/2025 94.2 lbs. 3/2/2025 88 lbs. (flagged in red print) 3/12/2025 93.6 lbs. 3/26/2025 93.4 lbs. 4/15/2025 95.2 lbs. A review of the physician orders for Resident #28 revealed Order Set WT- Monthly Weight, Once a Day on the 5th of the Month, 6:00 AM- 10:00 PM, start date 6/25/2024. Resident #28's weights were obtained inconsistently; the resident lost 6.2 lbs. from 2/19/2025 to 3/2/2025 and 10 lbs. from 1/12/2025 to 3/2/2025. The weights were obtained by the 5th of the month as ordered one time (3/2/2025). On 5/07/2025 at 1:29 PM, during an interview with Registered Dietitian/RD J, she said the staff weigh the residents and she reviews the weights weekly when she is in the facility. RD J said the electronic medical record/emr weight program, flags out of range weights. Reviewed Resident #28 had red weights with one weight of 88 lbs. on 3/2/2025. The resident was reweighed 10 days later. The RD said she had documented an assessment on 3/3/2025 and there was a dietary recommendation related to significant weight loss. The RD recommended weekly weights. The resident did not have weekly weights obtained. On 5/8/2025 at 2:30 PM, Resident #28 was observed sitting up in her bed talking to a visitor. Corporate Nurse B and Assistant Director of Nursing C also entered the room. During conversation with the resident, she mentioned she was upset because she said she was told she weighed 88 lbs. she said she never weighed below 100 lbs. and she was very bothered by this. A review of the facility policy titled, Clinical Services- Weight Monitoring, dated reviewed 12/20/2024 provided, Weight monitoring is essential to the well-being of the residents we serve and requires a multidisciplinary approach . Review of missing weights: a. Monthly; b. Weekly weights as ordered; c. Daily weights as ordered . Review of error weights, daily . Re-weights as needed . Weely review of 5% weight changes . 22348 Resident #55 (R55): Nutrition A review of R55 Electronic Medical Record (EMR) was [AGE] years old, admitted to the facility on [DATE] with the diagnosis of Acute on Chronic systolic (congestive) heart failure CHF, Acute Kidney Failure, Non-ST Elevation (NSTEMI) Myocardial Infarction, Stage 4 Chronic Kidney Disease, Chronic Obstructive Pulmonary Disease, and Dementia (unspecified) in addition to other Diagnoses. R55 requires Hemodialysis three times a week on Tuesdays, Thursdays, and Saturdays. R55's Minimum Data Set (MDS) Assessment, dated May 1, 2025, revealed a Brief Interview of Mental Status (BIMS) Score of 15/15. A score of 15 means R55 is cognitively intact. R55's Care Plan indicated that the plan would be discharged home after the rehab program. R55 required assistance with Activities of Daily Living (ADLs). R55's goals for weight monitoring care plan indicated: 1) No further unwarranted significant weight gain will occur, 2). Meet Nutritional Needs and maintain appropriate weight and labs for dialysis. Approach: Obtain weight as ordered. A Physician's Order was noted for: Daily Weight Special Instructions: DX: CHF Once A Day 06:00 AM - 10:00 PM Date order started: 4/27/2025 and end date: 5/26/2025. R55's Vitals and Weights Recorded were the following: 05/07/2025 04:21 PM Weight: 164.2 lbs / Routine BMI: 24.25 05/06/2025 10:07 AM Weight: 169 lbs / Routine BMI: 24.95 05/05/2025 09:56 AM Weight: 164.8 lbs / Routine BMI: 24.33 05/04/2025 10:30 AM Weight: 165.4 lbs / Routine BMI: 24.42 05/03/2025 - - *No Entry Found 05/02/2025 10:04 AM Weight: 161.8 lbs / Routine BMI: 23.89 05/01/2025 11:58 AM Weight: 161.6 lbs / Routine BMI: 23.86 04/30/2025 03:44 PM Weight: 164 lbs / Routine BMI: 24.22 04/29/2025 - - *No Entry Found 04/28/2025 - - *No Entry Found 04/27/2025 12:00 PM Weight: 159.8 lbs / Admission BMI: 23.6 04/26/2025 06:58 PM Weight: 154.6 lbs / Admission BMI: 22.83 Review of the nurse's notes did not reflect any weights recorded on the days missing 4/28/25, 4/29/25, and 5/3/25.

Based on observation, interview and record review, the facility failed to ensure that hospice records/communication were part of the medical record for two Residents (#45 and #47) of two reviewed for hospice services. Findings include: Resident #45: A review of Resident #45's medical record revealed an admission into the facility on [DATE] and readmission on 3/1/25 with diagnoses that included stroke, cognitive communication deficit, hemiplegia and hemiparesis of left non-dominant side and pressure ulcer. Further review of the medical record revealed the Resident was on hospice services. On 5/6/25 at 1:45 PM, an observation was made of the Resident lying in bed sleeping. An interview was conducted with Family Member S regarding Resident #45's care at the facility. The Family Member reported the Resident had a couple strokes and his left side was affected. The Family Member indicated the Resident had started on Hospice services about a month ago. On 5/8/25 at 11:16 AM, a review of Resident #45's medical record revealed a lack of Hospice communication, progress notes from hospice, what hospice services visited the Resident, or what care was provided during visits. On 5/8/25 at 12:08 PM, an interview was conducted with the Assistant Director of Nursing (ADON) C regarding hospice communication documentation of hospice service visits. At the Nurses' Station, an observation was conducted with the ADON of the hospice folder for Resident #45. The folder had information about the hospice service and a care plan but lacked documentation of visits or care provided when hospice team members visited Resident #45. When questioned about hospice communication with the facility, the ADON reported that hospice information can be accessed through the portal so that Social Work staff can access the portal. When asked that no other staff can access the portal, the ADON stated, Right, just the social worker. 37666 Resident #47: Hospice and End of Life On 5/6/2025 at 11:14 AM, Resident #47 was observed sitting in a wheelchair in her room. She said she received Hospice services twice a week from a Hospice Nurse and Hospice Nurse Aide. A review of the Face sheet and Minimum Data Set/MDS assessment indicated Resident #47 was readmitted to the facility on [DATE] with diagnoses: Spina bifida, heart failure, history of intestinal obstruction, diabetes, history of a stroke with right sided weakness, anxiety, kidney disease, ileostomy and Stage 4 pressure ulcer on coccyx. The MDS assessment dated [DATE] revealed the resident had full cognitive abilities with a Brief Interview for Mental Status/BIMS score of 15/15 and she needed some assistance with all care. On 5/8/2025 at 9:00 AM, a nurse on the 200 Hall was asked if Resident #47 had a Hospice chart and she said the resident did have a Hospice chart. The nurse began looking through binders at the nurses' desk and said she could not locate the Resident's Hospice chart. A review of the electronic medical records/emr documents, progress notes other tabs, did not reveal any Hospice Notes. On 5/6/2025 at 9: 15 AM, the Administrator was asked if Resident #47 had a Hospice chart, and she said she would locate it. On 5/08/2025 at 9:56 AM, the facility provided a hard binder with several documents from the Hospice company in it for Resident #47, but there were no Hospice Nurse or Hospice Aide visit notes. This was reviewed with the Administrator, she said the notes are in the emr. Reviewed they were not located in the emr. On 5/8/2025 at 11:30 AM, the facility provided a binder with Hospice notes, including Nurse and Nurse Aide visit notes. Each document was printed with the date 5/8/2025. The Hospice note visit dates were from 3/11/2025 to 5/7/2025. On 5/08/2025 at 12:04 PM interviewed The Assistant Director of Nursing/ADON was interviewed about the Hospice Binder- all of the notes were printed 5/8/2025. They were not in the medical record. Reviewed on initial tour, the resident had voiced that she was struggling with staff not providing care like she did at home, she said she had talked to Hospice about it related to ileostomy care and wound care.

Based on interview and record review the facility failed to ensure that baseline care plans were completed within 48 hours of admission for two residents (Resident #2, Resident #40) of 20 residents reviewed, resulting in incomplete baseline care plans, falls, and unmet care needs. Findings include: Resident #2 (R2): R2 is [AGE] years old and was admitted to the facility on [DATE], diagnoses include right lower leg fracture, Alzheimer disease, dementia and metabolic encephalopathy. On 05/13/24 at 03:32 PM, record review revealed the R2 has had multiple unwitnessed falls since admission to the facility on [DATE]. Record review of R2's admission assessment from 10/24/23 revealed they were at high risk for falls with a score of 17. Record review of care plans revealed that a care plan and interventions were not put in place for falls until 11/27/23. On 05/15/24 at 03:47 PM, an interview was conducted with the Minimum Data Set nurse (MDS). MDS was asked why the resident wouldn't have had a care plan in place for falls on admission despite being high risk for falls. MDS stated they aren't sure why it wasn't put in place until a month later and that it was just missed. MDS was asked if the care plan for falls should have been present on the baseline care plan. MDS responded that it should've been on the baseline care plan. Review of the facility policy titled 48 Hour Baseline Care Plan Guidelines, revised and reviewed on 12/31/23 revealed: PROCEDURES 1. The 48-hour baseline care plan will be completed within 48 hours of resident admission. a. The admitting nurse will be responsible completing the baseline care plan with the admission nursing observation. b. The admitting nurse will then add information from 48-hour baseline care plan to the CareAssist profile. 2. The admitting nurse will add the following information to e-CareAssist profile -Transfer status -Diet -Safety (All fall interventions selected from Falls intervention section) -Ted Hose/Splits -Glasses, dentures, and hearing aides -Continence status -Showers (preferences) -Skin (Pressure prevention interventions) -Cultural preferences and trauma triggers -Other (Any information pertinent for CRCA's caring for resident) 3. The MDS coordinator or MDS nurse will review baseline care plan and profile on the next business day to ensure completion and accuracy. The 48 hour baseline care plan will be printed and provided to the resident or resident representative during the initial resident first meeting. 4. The 48-hour baseline care plan will serve as our temporary working care plan until the comprehensive care plan is developed per RAI guidelines. 5. Any changes to the residents care will be care planned accordingly until the comprehensive care plan is developed and then will be included on the comprehensive care plan. 37666 Resident #40: Pressure Ulcer/Injury A record review of the Face sheet and Minimum Data Set (MDS) assessment indicated Resident #40 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses: Alzheimer's dementia, rheumatoid arthritis, hypertension, weakness, anemia and dizziness. The MDS assessment dated [DATE] revealed the resident needed some assistance with all care including partial to moderate assistance with bed mobility, transfers and toileting. A review of the Readmission assessment dated [DATE] indicated the resident had redness on the right great toe. An Event Report dated 5/11/2024 for Resident #40 revealed the resident had redness on her right great toe and provided I will heal this with proper medication and care plan. A review of the Care plans indicated there was no Care plan mentioning the right great toe redness on readmission until 5/14/2024: over 72 hours later. Skin Integrity: Resident has a skin impairment (Redness of right great toe- present on admission), dated 5/14/2024. On 5/14/24 at 2:56 PM , Nurse D was interviewed about Resident #40. She said she had completed the admission assessment and nurses note for the resident. They indicated the resident had redness on the right great toe. There were no orders for treatment or monitoring and there was no Care plan to aid in healing the wound. There was no baseline care plan related to Resident #40's right great toe until 5/14/2024.

Based on observation, interview and record review, the facility failed to ensure appropriate interventions were in place and supervision was provided to prevent a fall with injury for one resident (Resident #52) and repeated falls for one resident (Resident #15) of 2 residents reviewed for falls, resulting in Resident #52 falling and sustaining a fracture and Resident #15 falling multiple times and injuring his face. Findings Include: Resident #15: A review of the Face sheet and Minimum Data Set (MDS) assessment for Resident #15, indicated the resident was admitted to the facility on [DATE] with diagnoses: Left leg above the knee amputation, diabetes, chronic kidney disease, atrial fibrillation, COPD, morbid obesity, depression, anxiety, dementia, chronic pain, weakness. The MDS assessment, dated 3/25/2024, revealed the resident had full cognitive abilities with a Brief Interview for Mental Status (BIMS) score of 13/15 and the resident needed some assistance with all care. A record review of the Incident and Accident reports for Resident #15 revealed the resident had several falls at the facility: 1/24/2024, 2/6/2024, 3/14/2024, 3/28/2024. During a review of the monthly Pharmacy Recommendations for Resident #15, Pharmacist B made recommendations on 1/25/2024 and 3/31/2024 to change the resident's medication for Depression as it may lead to falls: A fall review was performed for this resident for a fall that occurred on 1/24. After evaluation, please consider the following: (Resident #15) has an order for paroxetine (Paxil) and SSRI (Selective Serotonin Reuptake Inhibitor-for depression). This medication is on the Beers list of medications that are potentially inappropriate for the elderly. (Cleveland Clinic: The Beers Criteria for Potentially Inappropriate Medication Use in Older Adults is a list of medications that healthcare providers reference to safely prescribe medications for people above age 65 .). Paroxetine is considered highly anticholinergic and can cause sedation, orthostatic hypotension, confusion, and other side effects. Please consider switching to another SSRI such as escitalopram (Lexapro) or sertraline (Zoloft) which are more appropriate choices for the elderly population. If declined, please document. The resident continued to receive the medication. Resident #15 fell 3 more times after this: 2/6/2024, 3/14/2024 and, 3/28/2024. The Incident and Accident reports for Resident #15 identified the following: 1/24/2024 at 4:32 PM: Unwitnessed fall in bedroom . Resident observed on floor in front of wheelchair . Resident states he was trying to get clothes out of closet and slipped out of chair . 2/6/2024 at 10:32 AM: Resident fell in bathroom . transferring self . 3/14/2024 at 5:12 PM: Fall in bedroom .transferring self . mild pain . Mental Status: sleepiness . Resident was found on floor by staff. He stated that he was trying to get himself into bed and slid out of his wheelchair . 3/28/2024 at 4:44 AM: Resident fell off bed while brief change . abrasion . Slight redness to nose and small amount of blood from nostrils . Patient hit nose on floor, has small abrasion . On 3/31/2024 another Pharmacy Recommendation was initiated by Pharmacist B: A fall review was performed for this resident for a fall that occurred on 3/28. After evaluation, please consider the following: (Resident #15) has an order for paroxetine (Paxil), an SSRI that started on 3/21/24. This medication is on the Beers list of medications that are potentially inappropriate for the elderly. Paroxetine is considered highly anticholinergic and can cause sedation, orthostatic hypotension, confusion, and other side effects. Please consider switching to another SSRI such as escitalopram or sertraline (Zoloft) which are more appropriate choices for the elderly population. During an interview with the Director of Nursing on 5/15/2024 at 3:45 PM, she was asked about the Pharmacy recommendations for Resident #15 and said the recommendation on 1/25/2024 was missed and not followed up on until 4/16/2024. The DON was asked about Resident #15's continued falls, including falling and injuring his face and she said the resident had experienced several falls and the pharmacy recommendations were now enacted. A review of the Care plans for Resident #15 identified the following: Psychotropic Drug Use: Resident is at risk for developing adverse effects from the use of anti-depressant medications, date initiated 12/12/2023, with Interventions including: Notify MD of any adverse effects noted, date initiated 12/12/2023. A review of the facility policy titled, Falls Management Program Guidelines, dated 5/31/17 and reviewed 12/31/23, provided (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 . discuss risks and interventions with resident and/or responsible party . 22348 Resident #52 (R52): Accidents During the resident observation and interview on 05/13/24 at 11:00 AM, Resident #52 (R52) was lying in bed and had indicated that he fell in March and broke his hip (pointing at the left side). R52 revealed that he underwent surgery at the hospital. Although R52 denied pain at the time of the interview, he expressed being unable to get up and walk on his own after surgery. On 5/14/24 at 4:00 PM, the facility's incident report (I/A), dated 3/16/24, was reviewed. It noted on the description: On 3/16/24, at 10:50 AM, Resident in wheelchair in front of the nurse's station when nursing heard someone call for help and observed resident sitting on his bottom in front of his wheelchair. When writer asked resident how did he fall, resident verbalized he was trying to stand up. The Evaluation Section of the Event (incident) Report noted: .Resident discharge to the hospital post fall, readmitted to facility for rehab: Fall resulted in fracture? Yes Resident sent to hospital and returned Yes Resident sent to hospital and did not return No Incident reported to State Agency No Did Fall result in serious injury, harm, impairment, or death to the resident Yes . The Hospital Discharge Records were reviewed on 5/15/24 at 4:00 PM. R52 was at the emergency room (ER) at a nearby hospital on 3/16/24 for evaluation and was admitted on [DATE] for surgical intervention for a displaced intertrochanteric fracture of the left hip. R52 was discharged back to the facility on [DATE] with a discharge diagnosis of Hip Fracture. R52's discharge instructions included pain medications, post-surgical staples, and wound dressing care. A review of the Electronic Medical Record (EMR) on 5/14/24 at 11:00 AM revealed that R52 was admitted to the facility on [DATE]. He was at high risk for fall, and on 3/16/24, R52 sustained a displaced intertrochanteric fracture of the left femur as a result of a fall. Among R52's listed primary diagnoses, R52 had Parkinson's Disease, repeated Falls, and age-related physical debility in addition to other diagnoses. R54's Brief Interview of Mental Status (BIMS) Score, dated 2/28/24, was 13/15. A BIMS score of 13-15 suggests the patient is cognitively intact. A review of R52's Minimum Data Set (MDS) assessment, dated 2/28/24, revealed that R52 ambulated, walking 10 feet, required substantial maximum assistance with no functional limitation in the upper and lower extremities ROM. R52 required substantial maximum assistance with toileting, personal hygiene, and transfers. R52, on the 2/28/24 assessment, was occasionally incontinent with bladder elimination pattern but was frequently incontinent for bowel elimination pattern. In a review of R52's clinical record, dated 3/26/24, there was a change in R52's BIMS score of 09/15. A score of eight to twelve suggests moderately impaired. A significant change in R52's MDS dated [DATE] assessment revealed that R52 was dependent on staff with mobility, toileting, and most activities of daily living (ADL), especially personal hygiene. Ambulating ten feet did not occur, and a one-step assessment was not attempted. Another significant change noted was R52's status for bowel and bladder elimination patterns, which changed from occasional to frequent for both urinary and bowel elimination patterns. During the interview on 05/15/24 at 12:12 PM, Nurse C, indicated that she was the nurse caring for R52 on 3/16/24 when R52 had a fall. Nurse C further revealed that she had left R52 alone in the day room facing the nurse's station when he fell at 10:50 AM. He fell at least twice before this fall. Nurse C had indicated that R52's care plan was to place him in a common area so everyone can see and watch him when he tries to get up. Nurse C stated: R52 was showing signs of frequent restlessness and was trying to get up on his own. I placed him in the day room across from the nurse's station with the TV on. There were no other staff assigned to watch R52 at that time, and I then proceeded to pass my meds to the residents, hoping there would be other staff that would pass by to see him and keep an eye out. Nurse C confirmed that R52 was left unattended and unsupervised when she left him in the day room. When Nurse C was queried, she revealed that the call light was inaccessible or within reach. R52 did not have access to the call light in the day room. Nurse C clarified that there was no staff in the nurse's station at that time or nearby. Nurse C further described that R52's aide was attending to other guests (residents). There was only one nurse and one nursing aide assigned in the hall. The nurse aide provided patient care when the fall occurred. Nurse C further indicated that another resident yelled that someone was on the floor, and that's how she was alerted. Staff from other units came to help with assessing and transferred R52 to his room. Nurse C revealed that R52 was sent to the hospital after the X-ray. R52 complained of pain, and limited ROM of the left lower extremity was observed. The Physician was notified, and EMS was called to send him to the hospital. Nurse C indicated that R52 was sent to the hospital because the resident complained of pain in his left lower extremity and could barely move it. There was an obvious limited Range of Motion (ROM) due to extreme pain in the left lower extremity. Nurse C further indicated that she recalled that R52, upon post-fall assessment, did not show any problems with moving his right leg. After the X-ray was performed, R52 was sent to the hospital because of severe pain, and the X-ray results revealed a fracture. According to the Director of Nursing (DON), during an interview conducted on 3/16/24 at 11:00 AM, she recalled that the weekend supervisor called to inform her of R52's fall and that he was being sent to the hospital for a fracture. The facility did not report this to the state because R52 could tell what happened. The DON revealed that R52 was placed in the common area for easier eyes and clarified that it means staff can observe him by the nurse's station and more people walk by. When queried, the DON denied staff was present during the fall, and there were no witnesses. The DON stated: I'm not sure who was there to find him. On 5/14/24 at 3:59 PM, Nurse E confirmed that R52 fell sometime in March (2024), but Nurse E stated she could not recall the details because she was not the nurse assigned when it happened. Nurse E had indicated that R52 was at high risk for fall and that R52 had an unwitnessed fall and underwent surgical hip repair due to a fracture sustained after a fall. R52's Family G was interviewed on 4/15/25 at 3:30 PM. She stated that the goal for R52 was to go through rehabilitation (physical therapy and occupational therapy) to strengthen him so he can return home. Because of the fall which resulted to fracture, he was unable to come home sooner than planned. R52 previously was able to walk with assistance using a walker. R52's fall care plan was reviewed on 4/16/24 at 10:00 AM. Although R52's admitted was 2/23/24, the fall care plan was created on 3/12/24 and was last updated on 4/24/24. It revealed: Resident was at risk for falling r/t Parkinson's Disease, poor safety awareness, non-compliance with utilizing assistance, has a history of falling with left hip fracture. The following are the interventions/approaches: Care Plan Interventions/Approaches dated 3/12/24 (before the fall that resulted in fracture) c Therapy eval and treat as needed. Therapy to offer services after breakfast. c Staff to assist Resident with transfers. c Provide nonskid footwear. c Keep personal items and frequently used items within reach. c Keep call light within reach. c Encourage/assist resident to assume a standing position slowly. c Assure the floor is free of liquids and foreign objects. c Stay close to the resident in restroom as he allows. (action was added dated 3/15/24) Upon readmission after hospitalization , care plan approaches added: c Move to a room closer to the nurse's station. (updated 3/20/24) c Round on resident between 3-4 PM. (updated 4/24/24) c Dycem to wheelchair. (updated 4/24/24) Upon review of R52's Fall Care Plan on 4/16/24 at 10:05 AM, there was no indication to place R52 in the day room or common area unsupervised as one of the planned approaches, as Nurse C had mentioned to prevent R52 from falling. The Fall Care Plan for R52 was initiated on 3/12/24, nine days after the first fall on 3/4/24. It was also revealed that no other updates were noted from 3/12/24 when the Fall care plan was initiated, until R52 returned from the hospital. A review of R52's Fall Incident reports occurred on various dates described: . On 3/4/24, Resident fell on the floor in his room attempted to ambulate without the walker . . On 3/15/24, Resident was found alone sitting on buttocks on the bathroom floor with pants around the ankles with multiple skin tears. Fall in the bathroom after self-transfer . .On 3/16/24, Resident was found on the floor alone in the day room. There was no call light access in the day room. No staff was present at the nurse's station across the day room. No witnesses .Fall resulted in left hip fracture, hospitalization , and surgical repair . The facility's Fall Management Program Guidelines, dated 5/31/2017, were reviewed.

Based on observation, interview, and record review, the facility failed to ensure that weight loss was monitored, addressed with updated nutritional interventions, and notify the registered dietician of the weight loss for one resident (Resident #52) of two residents reviewed for weight loss of a total sample of 20 residents, resulting in the potential for continued rapid weight loss and compromised health condition. Findings include: Resident #52 (R52): During the observation tour and resident interview on 05/13/24 at 11:00 AM, Resident 52 (R52) verbalized that the food was not enough. When queried, R52 further revealed that he needed more food because it seemed like he was losing weight. During the interview, a friend, Mr. H, who often visited R52, indicated that he was not getting feeding assistance from staff or provided any assistive device during meals. The visitor, Mr. H, further revealed that because R52's hands shake as part of his Parkinson's, he drops and spills more food than getting them in his mouth. Mr. H stated, There are times he (R52) would need feeding assistance, but not all the time. He (R52) definitely could use some adaptive feeding utensils to minimize his hands from shaking during meals. A review of the Electronic Medical Record (EMR) on 5/14/24 at 11:00 AM revealed that R52 was admitted to the facility on [DATE]. He was at high risk for a fall, and on 3/16/24, R52 sustained a displaced intertrochanteric fracture of the left femur as a result of a fall. Among R52's listed primary diagnoses, R52 had Parkinson's Disease, repeated Falls, and age-related physical debility in addition to other diagnoses. R52's clinical record, dated 3/26/24, showed a significant decline in R52's MDS assessment compared to the admission assessment. On 3/26/24, after hospitalization and repair of left hip fracture, R52 was dependent on staff with mobility, toileting, and most personal hygiene and Activities of Daily Living (ADL). An ambulation assessment was not attempted. Another significant change noted was R52's status for bowel and bladder elimination patterns, which changed from occasional to frequent for both urinary and bowel elimination patterns. A record of his weight was reviewed: 2/24/24 Admission 164.6 lbs. (pounds) 2/29/24 167.8 lbs. 3/7/24 167.2 lbs. 3/14/24 167.0 lbs. 3/21/24 165.6 lbs. 4/8/24 163.8 lbs. 5/3/24 156.2 lbs. On 02/24/2024, the resident weighed 164.6 lbs. On 05/03/2024, the resident weighed 156.2 pounds, a -5.10 % weight loss. There was a difference of 6.91 percent (%) in weight loss from 2/29/24 to 5/3/24. R52 was observed eating lunch at the supervised dining area (Safe Eat Room) on 05/14/24 at 12:32 PM. R52 did not finish his meal (R52 ate less than 50%) but had asked for a bowl of vanilla ice cream for dessert. There were no adaptive utensils, such as divided plate during observation, as written in R52's meal ticket, but the beverages were served with sip lids and straws. R52 used regular silverware. When CNA I was queried, she revealed that R52 does not eat much, but the staff made sure we set (cut) up his food and monitored his food intake. On 5/14/24 at 12:00 PM, The nutritional/dietary notes were reviewed dated 3/4/24. It noted an RD (Registered Dietician) Review of notes revealed the admission weight was recorded as 167.8# on 2/29/24. BMI:22.76 (WNL). Weight remained stable. No RD entries following the initial nutritional notes were found. There were no nutritional progress notes found after the readmitted after hospitalization , with a new diagnosis of Left Hip Fracture upon return to the facility on [DATE]. R52's Nutrition Care Plan was reviewed on 4/15/24 at 4:00 PM, R52's care plan was initiated on 3/12/24 and noted last reviewed by facility staff on 4/2/24 at 11:54 AM. Problem: Resident has potential for alteration in nutritional status related to diagnoses, medication, fluid balance, diet, intake, physical activity and metabolic demands. All Approaches and interventions listed were dated 3/12/24. No updates were noted at the date and time of review despite weight loss and other significant changes such as Fall resulting in Left Hip Fracture, decrease ADL function, pain and weight loss. The following approaches were noted in the nutritional care plan: 1. Assist with meals as needed. (Approach start date 3/12/2024) 2. Obtained weight as ordered/needed. (Approach start date 3/12/2024) 3. Offer Alternative food and beverage items as needed. (Approach start date 3/12/2024) 4. Provide diet, supplement, medications, and adaptive equipment as ordered. (Approach start date 3/12/2024) No updates and additional approaches/interventions were added to address R52's weight loss as recorded above. On 5/14/24 at 10:30 AM, the Director of Nursing was asked about the weight loss policy or process and a copy of the weight record for R52. When queried, she explained that R52 did not trigger a weight loss because it did not have a red flag. It is triggered if the weight loss is significant, and R52 did not trigger a significant weight loss. The RD J(Registered Dietician) during the phone interview on 5/16/24 at 10:30 AM. RD J revealed that she did not get a red flag notification unless it was a significant weight loss. RD J explained that red flag means a 5% weight loss or more. RD J did not recall getting a call or email from the facility about R52's weight loss concerns. She evaluates residents every quarterly unless there are changes and concerns. RD J ensured the surveyor during the interview and stated, I will review the records and update the care plan with the team for R52. R52's Family G was interviewed on 4/15/25 at 3:30 PM. Family G stated that the goal for R52 was to go through rehabilitation (physical therapy and occupational therapy) to strengthen him to return home. Because of the fall, he ended up having a fracture and was unable to come home sooner than planned. Family G did not recall attending a care conference with the facility staff or team and discussing approaches to encourage his eating and food preferences. Family G denied attending a care conference on the date and time of the interview. The Facility Weight Monitoring Policy dated 1/1/21 was reviewed. Clinical Standard Operating Procedure noted: .Review of error weights, daily, in CCM a. Re-weights as needed b. Correct weights as needed c. Invalidate weights as needed . i. May be reviewed by DHS, ADHS, MDS .4. Weekly review of 5% weight changes in KeyStats a. May be delegated to DHS, ADHS, or MDS i. Open weight event for true 5% or greater weight changes 1. Refer true 5% weight changes to RD for evaluation . i. Open weight event for true 5% or greater weight changes 1. Refer true 5%weight changes to RD for evaluation .

This Citation pertains to Intake Number MI00142646. Based on observation, interview and record review the facility failed to ensure timely dressing changes for two residents (Reside#5, Resident #117) of four residents reviewed for wounds, resulting in missed dressing changes and the potential for worsening wounds. Findings include: Resident #5 (R5): R5 is [AGE] years old, was admitted to the facility on [DATE] with diagnoses that include a right humerus fracture, heart failure, dementia, dysphagia and hypertension. On 05/14/24 at 03:00 PM, an in person conversation was conducted with the complainant. The complainant stated that on 4/17/24 a wound dressing on the left shin was dated 4/7, complainant stated the bandage was leaking blood. The complainant said that based on the date on the dressing, it had not been changed in 10 days, The complainant stated that once the dressing was removed, there was green colored drainage present. On 05/15/24 at 09:04 AM, the Director of Nursing (DON) provided a physicians wound care order for R5's left lower extremity (shin) skin tear, the order had a start date of 2/22/24, the order was to change the dressing every five days, cleanse the wound with wound cleanser or normal saline, apply skin prep and cover with an Allevyn dressing and to change the dressing every five days. On 05/15/24 09:13 AM, an interview was conducted with the DON. The DON was asked when the skin tear dressing was last changed changed for R5. The DON stated that dressing was changed on the morning of 4/17/24. The DON was asked if they were aware that the dressing was dated 4/7 on the afternoon of 4/17/24. The DON stated they were aware that the dressing present on R5 on 4/17/24 was dated 4/7. The DON stated that it was an error on the nurses part and they meant to put 4/17 on the dressing. When asked why the dressing had a large amount of drainage in it if it was changed the morning of 4/17/24, the DON stated that those dressings are built to have some drainage in them. On 05/15/24 at 09:28 AM, two pictures, time stamped 4/17/24 at 2:52 PM and 4/17/24 at 2:54 PM were provided by the complainant. One picture showed the intact dressing on the left lower extremity of R5, the dressing was dated 4/7 and wound drainage was present near the edges of the dressing. The second picture revealed the exposed skin tear with the dressing removed, there was scant serosanguinous drainage(drainage with blood present) and a pocket of purulent drainage present. There was an order to change the dressing every five days. 22348 Resident #117 (R117): During the initial observation and interview on 05/13/24 at 11:43 AM, Resident #117 (R117) was lying in her room, alert and oriented to time, place, and person. R117 stated she was admitted for a short-term stay and is currently on antibiotic therapy after abdominal surgery. R117 showed a drain dressing on the right side of the abdomen with a slight old blood stain (dry, dark brown color) surrounding the tube. The drain tube was attached to a drainage bag attached to the bed. When queried, R117 did not know when the dressing was last changed. The wound dressing did not have a date written for when it was last assessed or when the dressing was changed. The drainage bag had yellowish-to-brownish fluid drainage in the canister. The breathing treatment- tubing and mask were placed on the side table next to the food tray and all other resident's personal items. The respiratory treatment mask and tubing were not secured in a clean bag, and no date label was found on the tubing or mask. The Infection Control Nurse L was in R117's room on 5/13/24 at 11:58 AM. Nurse L examined the wound drainage tube and dressing on the right side of the abdomen. Nurse L confirmed that the wound drain dressing was not labeled nor dated. Nurse L could not tell when it was last assessed or changed. Nurse L stated that this(referring to the R117's breathing treatment apparatus) should be put away appropriately in a sanitary way and labeled accordingly. Resident R117 Electronic Medical Record was reviewed on 5/14/24 at 1:00 PM. R117 was [AGE] years old and admitted to the facility on [DATE]. According to the facility's Admission Assessment performed on 4/29/24, R117 was admitted with a history of Peritoneal Abscess, Acute Renal Failure, and Gastroesophageal Reflux Disease or GERD in addition to other diagnoses. R117 was alert, oriented with person, place, time, and situation, and responded to questions appropriately. A weekly skin assessment or treatment was ordered. However, there was nothing specific for the care for R117's abdominal wound drain. There was no specific treatment order to monitor, assess, and change the wound drain dressing and document abnormal findings and observations specific to R117's Right Abdomen wound drain. R117's medication and active physician's orders list were reviewed on 5/14/24 at 1:05 PM, and no treatment order for the wound drain tube was found. There was no indication when the drain tube dressing would be assessed, and wound care instructions were not specified. Policy for wound dressing change was requested and reviewed on 5/16/24 at 11:10 AM. The Facility's Bruise, Rash, Lesion, Skin Tear, Laceration Assessment Guidelines dated 5/10/2016 was submitted for review in place for the requested Wound Dressing Change Policy. The purpose: Utilized to describe and monitor bruises, rashes, lesions, skin tears, and lacerations. The facility did not include in the policy a wound or post-surgical drain pertinent for assessment (daily or weekly on the wound status, such as an abdominal wound drain or a surgical site wound drain.) However, the policy had specific skin tear/ laceration guidance: 1. May complete Skin Tear/ Laceration Event in HER (Electronic Health Record) by an RN/LPN if the skin Tear/Laceration warrants documentation due to the extent and/or location. 2. Complete the event for each skin Tear/ Laceration. 3. One weekly follow-up assessment may be completed to ensure Skin Tear/ Laceration are resolved or in the process of healing. If further follow-up is needed, documentation may be placed in a progress note .

This Citation pertains to Intake Numbers MI00130541 and MI00131538. Based on observation, interview and record review, the facility failed to properly identify, monitor, and treat a skin condition for one resident (Resident #5) of three residents reviewed for pressure injury, resulting in the worsening and declining of the pressure ulcer, wound infection, resident suffering hospitalization and surgical wound debridement. Past Non-Compliance was given for this citation with a Compliance Date of 12/16/2022. Findings include: Resident #5: According to admission face sheet, Resident #5 was a [AGE] year-old female, admitted to the facility on [DATE], with diagnoses that included: Low back pain, Hypertensive (with elevated blood pressure) heart disease with heart failure, Chronic diastolic (congestive) heart failure, Longstanding persistent atrial fibrillation, Nonrheumatic mitral (valve) insufficiency (abnormalities of a valve in the heart that are not caused by or related to rheumatism), Nonrheumatic aortic (valve) insufficiency, Nonrheumatic tricuspid (valve) insufficiency, Type 2 diabetes mellitus without complications, Hyperlipidemia, Atherosclerotic heart disease of native coronary artery without angina pectoris, Vitamin B12 deficiency anemia due to intrinsic factor deficiency, Venous insufficiency (chronic peripheral), Bilateral primary osteoarthritis of knee, Osteoporosis, History of pulmonary embolism, History of transient ischemic attack (TIA), and cerebral infarction(stroke) without residual deficits, History of falling. The MDS assessment dated [DATE] revealed the Resident #5 had mild cognitive impairment with a Brief Interview for Mental Status (BIMS) score of 11/15. The resident needed one person assist with bed mobility, dressing, and personal hygiene, 2+ persons assist with transfers, and toileting. Resident #5 was discharged home with family on 8/26/22. On 2/16/23 at 1:03 PM wound care was observed with DON and Wound Care Nurse F. Care was performed by nurse F according to the provider's order and per standard of practice. Hand hygiene was appropriate. On 2/16/23 at 03:10 PM interview was conducted with Nurse F regarding Resident #5's wound care. Nurse F stated that she assumed the role of wound care provider in a facility in October 2022. She did not remember the resident in question and did not provide resident with wound care. On 02/16/23 pertinent documentation for Resident #5's care was requested from the facility and was reviewed. Skin Integrity Event (for Resident #5) dated 8/2/22 at 01:55 PM had the following documented: Coccyx and buttocks open areas, coccyx 2 cm x 2 cm and buttocks 1 cm x 1 cm. Round in shape, color pink surrounding skin white center; character- excoriations, pale spots surrounded by red halo; distribution- discrete, lesions remain separate; no exudate. When did rash first occur? -8/2/22. Onset of Rash or skin lesion- gradual. Interventions- treatment orders and educate on importance of following orders. Evaluation notes- Excoriated areas to buttocks are being managed with daily treatment. Resident denies pain on site. Current treatment is effective and staff is monitoring with each dressing change. Rash/Lesion showing signs of healing? - Yes. Further, Wound Management Detail Report for Resident #5 was reviewed and revealed the following documentation. Nursing note created on 8/9/22 at 09:42 AM indicated: Left buttocks wound, with length 2.2 cm and width 0.5 cm, depth 0.1 cm, light serosanguineous (pale red to pink, thin and watery) exudate amount, no odor, 100% of wound covered with epithelial tissue. Wound healing status is stable. Under comments- 100% pink epithelial tissue in wound base, scant serosanguineous drainage, peri wound dry intact. A&D (diaper rash cream) and allevyn (dressing) every 3 days. Nursing note created on 8/9/22 at 09:41 AM indicated: Right buttocks wound, with length 1 cm and width 1.5 cm, depth 0.2 cm, light serosanguineous (pale red to pink, thin and watery) exudate amount, no odor, 100% of wound covered with epithelial tissue. Wound healing status is stable. Under comments- Area measures 1 x 1.5 x 0.2 cm with area of bridging and area of 0.6 x 0.4 x 0.1 cm stage 2. 100% pink epithelial tissue in wound bed, scant serosanguineous drainage, no odor. A&D (diaper rash cream) and allevyn (dressing) every 3 days. Nursing note created on 8/17/22 at 05:40 PM indicated: Left buttocks wound, with length 2 cm and width 0.5 cm, light serous (clear, amber, thin and watery) exudate amount, no odor, 100% of wound covered with epithelial tissue. Wound healing status is improving. Under comments- Wounds to bilateral buttocks appear to be due to mechanical excoriation, chemical maceration, or a combination of both. Wound bed is healthy pink tissue, scant serous drainage on previous dressing. Surrounding skin is WNL (within normal limits), foam dressing is effective for protection to chemical maceration and allowing wound to heal without disruption. Nursing note created on 8/17/22 at 05:39 PM indicated: Right buttocks wound, with length 1 cm and width 1 cm, light serous (clear, amber, thin and watery) exudate amount, no odor, 100% of wound covered with epithelial tissue. Wound healing status is improving. Under comments- Wounds to bilateral buttocks appear to be due to mechanical excoriation, chemical maceration, or a combination of both. Wound bed is healthy pink tissue, scant serous drainage on previous dressing. Surrounding skin is WNL (within normal limits), foam dressing is effective for protection to chemical maceration and allowing wound to heal without disruption. Nursing note created on 8/22/22 at 05:16 PM indicated: Left buttocks wound, with length 4 cm and width 6 cm, light seropurulent (yellow or tan, cloudy and thick) exudate amount, sour and pungent odor was present, 40% of wound covered with epithelial tissue, 40% of wound had slough tissue, and 20% was covered by eschar. Type of tissue- necrotic. Wound healing status- declining. Under comments- Wounds merged and now are collectively 4 x 6 cm, friable red granulation tissue encircles areas of slough on right side and eschar on the left side. Odor has developed. Resident does not attempt to keep pressure off this area, states she cannot feel it. Drainage is scant, odorous, tan to green on old dressing. New treatment started: MediHoney with dry dressing daily. Review of Resident #5 Medication and Treatment Administration Records (MAR and TAR) for August 2022 revealed: 1) A and D Diaper rash cream (dimethicone-znox-vit a-d-aloe) [OTC] (over the counter) cream; 1-10%, 1 application, topical, once a day every 3 days. Start 8/9/22, discontinued 8/9/22. Nursing note indicate treatment was not administered due to be discontinued. 2) A and D Diaper rash cream (dimethicone-znox-vit a-d-aloe) [OTC] (over the counter) cream; 1-10%, 1 application, topical, once a day as needed. Start 8/9/22, discontinued 8/9/22. Treatment was marked as done on 2/9/22. 3) A and D Diaper rash cream (dimethicone-znox-vit a-d-aloe) [OTC] (over the counter) cream; 1-10%, 1 application, topical, once a day as needed. Special instructions: cleanse sacrum with normal saline or wound cleanser pat dry, apply skin prep peri wound, apply A&D ointment and cover with allevyn dressing as needed. Start 8/9/22, discontinued 8/22/22. For a period of 13 days no treatments were recorded as done under this order. 4) A and D Diaper rash cream (dimethicone-znox-vit a-d-aloe) [OTC] (over the counter) cream; 1-10%, 1 application, topical, Once a day every 3 days. Special instructions: cleanse sacrum with normal saline or wound cleanser pat dry, apply skin prep peri wound, apply A&D ointment and cover with allevyn dressing every 3 days. Start 8/9/22, discontinued 8/22/22. Treatment was marked as done on 8/9/22, 8/12/22, 8/15/22, 8/18/22, and 8/21/22. 5) Wound care- coccyx and buttock: cleanse wound with wound cleanser or normal saline, apply skin prep, and cover with foam (gentle or life) dressing change 5 days. Once a day every 5 days. Treatments were marked as done on 8/2/22, 8/7/22, 8/12/22, 8/17/22, and 8/22/22. 6) Cleanse coccyx wound with normal saline, pat dry. Apply MediHoney to entire wound bed with special attention to eschar on left side of wound bed. Cover with dry dressing (bordered gauze) and change daily and if soiled or dislodged. Once a day. Start day 8/22/22, discontinued 8/26/22. Provider's note dated 8/9/22 revealed: resident was seeing to evaluate wound on sacral area present on admission, guest denies any pain of wound area. Resident has been having daily wound care and reports she does try to reposition herself. She is diabetic. Further, the were wound measurements documented: 1. Right gluteal stage 3 pressure ulcer 1 by 1.5 by 0.2 (cm) 2. Right gluteal stage 2 pressure ulcer -0/.6 by 0.4 by 0.1 (cm) 3. Left gluteal stage 2 pressure ulcer 2.2 by 0.5 by 0.1 (cm) Wound care nursing note dated 2/22/22 at 05:16 PM indicated: Wounds merged and now are collectively 4 x 6 cm, friable red granulation tissue encircles areas of slough on right side and eschar on the left side. Odor has developed. Resident does not attempt to keep pressure off this area, states she cannot feel it. Drainage is scant, odorous, tan to green on old dressing. Nursing note dated 8/26/22 had the following: Resident (#5) was discharged home with 2 daughters with all of her belongings. Wound care education was gone over with both of them. On 2/16/23 at 03:10 PM during an interview, Wound Care Nurse F was asked what wound cultures were collected from Resident #5's wound and if wound infection was treated. Nurse F responded she was unaware of any antibiotic treatment prior to resident's discharge home with family. Record review of facility provided hospital records dated 8/30/22 at 11:17 PM revealed that Resident #5 was hospitalized on [DATE] after decline at home and underwent two surgical wound debridement procedures during her stay in a hospital- one on 9/4/22 and the other on 9/8/22. Review of Resident #5's Care Plan indicated under problem Skin Integrity- Resident has a pressure ulcer (2 open areas on buttocks observed on admission), with a start date 08/03/2022. Under Goal there was- Resident's ulcer will heal without complications. Under Approach section there were the following interventions: - Administer analgesics per MD order - Assess and record the condition of the skin surrounding the pressure ulcer - Encourage fluids unless contraindicated - 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 - Obtain a dietary consult - Pressure reducing cushion to chair - Pressure reducing mattress - Provide diet, supplements, vitamins and minerals as ordered - Treatment per MD order. Notify MD if treatment is not effective - Weekly skin assessment, measurement, and observation of the pressure ulcer and record All above interventions were initiated on 08/03/2022. No intervention was noted for frequent position change and offloading pressure from the coccyx area. No new interventions and updates were recorded after resident's wound enlarged and showed signs of infection on 8/22/22. Wound and Skin Care Policy was requested and reviewed. Policy dated 5/10/2017 indicated: The following general wound and skin care guidelines should be followed for all residents with potential and/or actual impairment in skin integrity. 2. Turn/reposition residents who are immobile according to their care plan requirements. 16. Reevaluate the wound's response to the prescribed treatment. Make recommendations for changes PRN. Inform MD of changes in wound status. Facility's provided Wound Risk Observation Guideline dated 11/2017, indicated: 1. A RN or LPN shall complete the Admission Nursing Observation and Data Collection which includes a Braden Scale of the risk factors predisposing the resident to skin impairment which includes the initial care plan interventions. 2. Recognized risk factors shall have care plan interventions/approaches identified and put in place to mitigate the risks to the extent possible. According to National Pressure Injury Advisory Panel, September 2016, 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 (yellow, brown, wet stringy dead skin) or eschar (brown or blackened dead skin tissue). If slough or eschar is removed, a Stage 3 or Stage 4 pressure injury will be revealed . According to International NPUAP/EPUAP (National Pressure Ulcer Advisory Panel/ European Pressure Ulcer Advisory Panel; a group of experts who serve as the authoritative voice in pressure injuries) defined pressure injury stages. (A) Stage I-nonblanchable erythema. (B) Stage II-partial thickness skin loss with exposed dermis. (C) Stage III-full-thickness skin loss. (D) Stage IV-full-thickness skin and tissue loss. (E) Unstageable pressure injury-obscured full thickness skin and tissue loss. (F) Deep tissue pressure injury-persistent non-blanchable deep red, maroon, or purple discoloration. (2016 NPUAP Pressure Injury Staging Illustrations from http://www.npuap.org/resources/educational-and-clinical-resources/pressure-injurystagingillustrations/. Used with permission of the National Pressure Ulcer Advisory Panel March 2018. (C) NPUAP.) Nursing and Patient Care Considerations: Prevent Pressure Ulcer Development- 1. Provide meticulous care and positioning for immobile patients. (a.) Inspect skin several times daily. (b.) Wash skin with mild soap, rinse, and pat dry with a soft towel. (c.) Lubricate skin with a bland lotion to keep skin soft and pliable. (d.) Avoid poorly ventilated mattress that is covered with plastic or impermeable material. (e.) Employ bowel and bladder programs to prevent incontinence. (f.) Encourage ambulation and exercise. (g.) Promote nutritious diet with optimal protein, vitamins, and iron. On 02/17/23 at 10:00 AM an interview was conducted with the DON and Corporate RN A regarding Resident #5's wound care. RN A stated that in December 2022 interdisciplinary team (IDT) conducted random audits and facility identified issues with skin management system charting and classifications. Further deep dive revealed that previously assigned team was not following processes and policies for identification, care and notification of new and worsening wounds. Facility administration immediately took actions and put new wound team in place and conducted process improvement and audits to solidify the new process. DON stated she was personally reviewing residents' charts and observing wound care. The DON explained they created a PIP (Process Improvement Plan) and reviewed the process change in QA (quality assurance), completed audits, and educated staff. Skin Program was reviewed to include all aspects of prevention, assessment and care. Clinical team, as DON stated, was re-educated on the policy and procedures related to the timely identification of risk factors related to onset of new wounds and worsening wounds, timely notification of the providers and responsible parties, wound infection prevention, assessment, and identification, with further re-evaluation of treatment plan. During the interview with wound care nurse F on 2/16/23 at 03:10 PM, she stressed that she received multiple education prior to assuming her role and emphasized how instrumental was support of the DON to her when she started. She also stated that she continued to educate nursing staff on importance of accurate assessment of wounds, timely communication of any changes and accurate charting. During wound care observation on 8/16/22 nurse F showed skills in wound care that were based on current standards of practice. Facility's provided education, assessment of residents, and audits were reviewed. On 2/17/23 at approximately 02:15 PM, a review was completed of the facility's timeline for their process change. - On 12/15/20212 facility's IDT conducted Quality Review and identified areas of opportunities related to the skin management program - On 12/15/2022 deficient practice was identified as it was related to management and assessment of wounds. - On 12/15/2022 new wound [NAME] was identified who was WCC (wound care certified). - On 12/15/2022 Skin Management training and education was initiated to all staff responsible for wound care - On 12/16/2022 staff responsible for wound care prior to quality review was provided 1:1 education - On 12/15/2022, this recognized issue was reported to QA - Compliance date of 12/16/22 During the abbreviated survey the facility was found to be out of compliance with their regulatory requirement. But they recognized the deficient practice, completed a process change, education, and audits prior to survey entry and during the survey they were found to be currently compliant. Therefore, Past Non-Compliance will be granted with a Compliance Date of 12/16/2022.

This Citation Pertains to Intake Numbers: MI 756 and MI 055. Based on interview and record review, the facility failed to ensure pressure ulcers were assessed, monitored, wound care provided and appropriate interventions were in place for two residents (Residents #4 and Resident #5) of five residents reviewed for pressure ulcers, resulting in Resident #4 developing 2 Deep Tissue Injuries - facility-acquired pressure ulcers: 1 on each heel and Resident #5 developing a Stage III facility-acquired pressure ulcer on the coccyx and 2 Deep Tissue Injuries-facility acquired pressure ulcers, one on each heel. Findings Include: Resident #4: A record review of the Face Sheet and Minimum Data Set (MDS) assessment indicated Resident #4 was admitted to the facility on [DATE] with Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS assessment dated [DATE] revealed the resident had severe cognitive decline and needed assistance with all care. Resident #4 was receiving Hospice services and died on [DATE]. An attempt to review the Hospice Notes indicated the notes were not in the resident's medical record. After several hours, the facility obtained copies and provided the records on [DATE]. A record review of the Hospice notes revealed the following: [DATE]: A note by Nurse W, . Patient eats pancakes and cream of wheat for every meal per her favorites, which has improved her food intake, but is a total feed (needs assistance with eating) . RN states no concerns at this time . Thin red line on top of right foot noted and redness to right heel. Skin intact in these areas. Staff aware to call with questions, concerns or change of status . [DATE]: A note by Nurse W, Bilateral heels red, skin intact. No other skin concerns at this time, red line to right foot has now resolved. A review of the Resident's Skin Care Plan provided, Skin Integrity; at risk for skin breakdown related to: fragile skin prone to skin tears/ecchymosis (bruising) with increased risk for skin alterations due to decreased mobility, incontinence . Resident not compliant with turn and reposition at times and float bilateral heels while in bed, dated [DATE] with Interventions: Conduct weekly skin assessment. Pay particular attention to bony prominences, dated [DATE]. The most recent intervention was dated [DATE] and none of the interventions mentioned the heels. A review of the resident's Weekly Skin Assessment, on the October, 2020 Medication Administration Record/Treatment Administration Record revealed, 0= No impairment, 1= New impairment, 2= old impairment; Once a day on Monday. The nurses documented 0 for No impairment on [DATE], [DATE], [DATE] and [DATE]. There was no mention of reddened heels, as noted by the Hospice nurse on [DATE] and [DATE]. A review of the Weekly Skin Assessment, on the November, 2020 Medication Administration Record/Treatment Administration Record for Resident #4 revealed, 0 for No impairment on [DATE], [DATE], [DATE] and [DATE] on [DATE] the nurse documented 2 for Old impairment. A review of a progress note for Resident #4, dated [DATE] at 3:17 PM, by Nurse X IDT (Interdisciplinary Team) assessment of bilateral heel DTI (Deep tissue Injury). Hospice aide notified nurse that resident's heels were breaking down . Right heel 1 cm diameter DTI, brown to purple in color. Surrounding skin is flaky and dry. Left heel is 2 cm x 2.5 cm DTI, purple to red non-blanching area over bony prominence. Resident is bed bound, malnourished and is a hospice patient . Hospice notified and will be providing pressure reducing booties. Allevyn (wound dressing) applied to bilateral heels . A review of two wound pictures, one of each of Resident #4's heels dated [DATE], revealed each heel had a large, reddened area with layers of peeling skin, from the inside out to a bordered darker red area. The right heel wound extended past the heel towards the middle bottom of the foot. The facility called them Deep Tissue Injuries. National Pressure Injury Advisory Panel; Evolution of Deep Tissue Pressure Injury, Friday, [DATE]; Deep tissue pressure injury remains one of the most serious forms of pressure injury. The pressure is exerted at the muscle-bone interface . The process leading to deep tissue pressure injury precedes the visible signs of purple or maroon skin by about 48 hours. Then about 24 hours later, the epidermis lifts and reveals a dark wound bed The lag between the Pressure event and the change in color of the skin makes the root cause analysis complex . National Pressure Injury Advisory Panel; Pressure Injury Stages, 2017 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 . A physician's progress note dated [DATE] provided, . The patient has no further breakdown other than her heel wound that was reported a week or two ago by her hospice nurse . On [DATE] at 11:15 AM, during an interview with the Director of Nursing, she was asked about Resident #4's reddened heels, as identified by Hospice Nurse W on [DATE] and [DATE]. The Director of Nursing said the facility staff had not identified any wounds until [DATE], left and right heel Deep Tissue Injuries. The Director of Nursing was asked if the wounds would have progressed that far if interventions had been put in place sooner and said she would check into it. On [DATE] at 2:19 PM, Nurse W provided a statement, I went and did a review of the chart for (Resident #4) on [DATE] . I reviewed my note and do see that I charted patient's heels were red. At this time, I updated the staff as well as the case manager for the patient. I did not know the patient's baseline, as I was filling in for the CM. No changes to care were implemented at this time as the case manager was updated to monitor areas . Further review of the Skin Care Plans for Resident #4 revealed 2 new Care Plans; one for each heel was created on [DATE], which included Interventions: Administer analgesics per MD order; Assess and record the condition of the skin surrounding the pressure ulcer; Observe for and report signs of pain related to pressure ulcer; Treatment per MD order .; Weekly skin assessment, measurement and observation of the pressure ulcer and record. The Skin Care Plan dated [DATE] was also updated with intervention, Pressure reducing boots to bilateral heels while in bed, dated [DATE]. There had been no new interventions, measurements, pictures or additional monitoring of Resident #4's heels after the initial identification of redness on [DATE] and again on [DATE]. Interventions were not put in place until the wounds continued to decline and were again identified on [DATE]. Resident #5: A review of Resident #5'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 bed mobility, transfers, dressing, toilet use and personal hygiene. The Resident had been transferred to the hospital on [DATE]. A review of Resident medical record revealed the following documentation of the origination of wounds: -Dated [DATE], Skin Integrity Events document revealed a description as Right distal great toe intact fluid filled blister. Upon admission the Resident presented to the facility with a right distal great toe fluid filled blister. -Dated [DATE], Skin Integrity Events document revealed a description as Purple area to right heel . Length 1.5 (centimeters), Width 1.5 (centimeters) . Present on Admission: No . Notification documented for Resident Representative: Yes on [DATE] at 5:08 PM. -Dated [DATE], Skin Integrity Events document revealed a description as Purple area to right heel . Length 2.5 cm (centimeters), Width 4 cm . Present on Admission: No . Notification documented for Resident Representative: Yes on [DATE] at 12:03 PM. -Dated [DATE], Skin Integrity Events document revealed a description as Skin impairment to L (left) buttock . Type of injury: Skin tear. Length 3 cm. Width 3.9 cm. Depth of Skin Tear: Shallow. Activity During Skin Tear/Laceration Occurrence: Other-Shearing . Present on Admission: No . Notification documented for Resident Representative: Yes on [DATE] at 12:03 PM. A review of Resident #5's progress notes related to wounds included the following: -Dated [DATE] at 1:45 PM, Resident . admitted into room [ROOM NUMBER] for therapy due to debility r/t (related to) leg pain . -Dated [DATE] at 8:03 PM, Skin assessment: Right distal great toe intact fluid filled blister. Resident has severe PVD and DM (diabetes) type 2. Resident has a hx (history) of non-compliance with standing due to pain with ambulation . Wound orders as follows: paint blister with [MEDICATION(S)] once daily for 14 days. Will continue to monitor. -Dated [DATE] at 12:35 PM, IDT (interdisciplinary team) assessment of blister to right great tow. Blister intact, no open areas, no drainage. No redness or swelling. Surrounding skin WNL (within normal limits). Will continue to monitor and open in wound tool and CAR (Care at Risk). -Dated [DATE] at 9:27 PM, Resident with intact fluid filled blister to RLE (Right lower extremity)-[MEDICATION(S)] treatment Rx (prescription) and foot cradle to assist with off loading pressure . -Dated [DATE] at 1:40 PM, This morning during shower, areas of concern noted on assessment. Open area skin tear to buttocks noted measuring approximately 3 cm x (by) 3.9 cm. Area cleansed with wound cleanser and alevin dressing applied. Purple area to L (left) heel measuring 2.5 x 4 cleansed and alevin heel dressing applied. Purple area to right heel measuring 1.5 cm x 1.5 cm, and alevin heel dressing applied. ADHS in the facility and notified of new areas and she stated that she would order an air mattress. (Doctor)covering for (Doctor) in the facility today and notified of new areas of concern. Unable to locate padded boots for heels. Heels elevated on pillows and resident positioned on his side with positioning wedge. -Dated [DATE] at 2:03 PM, Pressure reducing air mattress put on bed. Dressings to areas of impairment intact. Resident participating in feeding self today. -Dated [DATE] at 11:56 AM, IDT assessment of wounds to bilateral heels and buttocks. Bilateral heels have DTI (deep tissue injury) at pressure points, dark purple to black in color. Skin is intact and there is no drainage, swelling, or redness. Allevyn dressings and air mattress in place, heels floated with pillows and blankets. Added to wound rounds and CAR. Buttock wound is excoriated, red wound bed, scant drainage. This wound is not related to pressure, appears to be chemical maceration and excoriation. Treatment is in place, will continue to monitor. -Dated [DATE] at 12:04 PM, Discussed in CAR with IDT regarding wounds. Resident admitted to facility with DTI wound to toe, wound is stable. Bilateral heels noted to have each have DTI as well. Resident kicks pillows used to float heels when in bed causing heels to have contact with mattress. New order for air mattress placed, resident also has allevyn dressings in place to both heels to protect. Skin remains intact, there is no drainage or swelling noted. See wound tool and wound pictures for further descriptions . -Dated [DATE] at 10:12 AM, Nutrition Note/Wounds: . Wound management reviewed, PU (pressure ulcer) to L heel, PU to R heel, and PU to R 2nd toe present, tx (treatment) in place. Recommend new order for Prostat 30 ml (milliliters) BID (twice a day), and daily MVI (multivitamin) to aid in skin integrity/healing . -Dated [DATE] at 4:10 PM, Observed buttock wound with physician. Wound has increased greatly in size and skin is very fragile and is coming off during cleansing. Physician ordered to keep resident on either of his sides, rotating frequently. Keep allevyn dressing as treatment and reassess on Monday as this wound is not presenting as a typical wound. -Dated [DATE] at 7:05 PM, Physician note, Called (Daughter) back and discussed diagnosis, treatment plan, and prognosis. Discussed history and home care. Discussed [CONDITION(S)] and bowel issues, bp (blood pressure), sugars, skin concerns and [MEDICATION(S)], and code status. She states that patient would want to be a DNR (do not resuscitate) and 'there are papers somewhere'. Discussed discharge plan and she understands he needs 24 hour care and supervision, total care. Questions answered and she is in agreement with the treatment plan. -Dated [DATE] at 11:02 PM, Resident had an xtra (extra) Lrg (large) BM (Doctor) notified. Pressure ulcer to sacrum bleeding wound was cleansed with wound cleanser patted dry and allevyn dressing applied to sacrum. -Dated [DATE] at 3:02 PM, Resident turned and repositioned Q (every) 2 hours to alternating side lying positions. Alevyn dressing changed to sacrum after cleansing. Pressure area noted at coccyx with shearing of tissue surrounding wound on buttocks. Resident received ordered prostat and was fed both breakfast and lunch and ate 100%. -Dated [DATE] at 2:25 PM, IDT assessment of wound to buttock and coccyx. Wound has changed drastically since last review. Previous review showed wound on right gluteal area, approximately 3 cm by 2 cm, excoriated. No sign of pressure related wound. At review on Friday, resident had open reddened area to both gluteal areas, loss of top layer of skin. Review today shows coccyx area with slough, approximately 3 cm in length by 1.5 cm in width. This area is classified as pressure due to location and slough tissue is present. Resident has had several interventions in place, and wound is atypical in progression. Speaking with physician, it was noted that resident may be having an allergic reaction to allevyn dressing as evidenced by spread of wound to all areas that dressing was in contact with. Physician would like to have resident see wound care specialist as soon as possible. Orders changed from allevyn to [MEDICATION(S)] dressing, and santyl to slough area. Pressure reducing air mattress in place, dressing to coccyx and bilateral buttock area, and a wedge is being used to keep resident off of his back. See wound tool and picture attached to chart under resident documents. Will continue to monitor and follow in CAR. -Dated [DATE] at 8:07 PM, Physician note discussed with daughter (name) changes over the weekend and today. Discussed our concerns regarding an allergic reaction to the Allevyn causing the adverse skin breakdown and new suspected pressure area on coccyx, which is very concerning due to the fact patient has been on air mattress since Tuesday. Treatment has been changed and patient to see a wound specialist due to the unusual nature. Also, patient had acute [CONDITION(S)] today and required Foley cath as he is going home tomorrow. SW aware and is updating home care. Recommended to daughter to have patient seen by primary within a couple of days of discharge and to schedule an appointment with a urologist. She is not sure if he has one or not and I recommended discussing with PCP (primary care physician). Also, recommended he not utilize geri-chair until skin healed and discussed need for wound specialist. Also, she should not use mechanical lift until properly trained by homecare and should contact SW (social worker) at (facility) if homecare not in by Wednesday. Questions were answered and she is in agreement with treatment plan. She has my contact number and is to call if any concerns arise with transition home. -Dated [DATE] at 2:16 PM, Phone call made to (daughter) about residents decline. Spoke with her about newly developed wound, and concern that preventative measures were placed pressure reducing mattress, allevyn dressing, turning and repositioning, prostat and that he still obtained further skin breakdown. Discussed also about his need for Foley catheter placement after resident not being able to empty his bladder. Explained that they have several options 1. They are able to take resident home still as planned. 2. They are able to keep him here skilled d/t new wound and Foley placement 3. We can send him out to hospital for further work up that is unable to be completed while staying in house. Family has asked that resident be sent to hospital for a work up and to find a potential cause for his decline. Stating 'I don't want to get him home and have to send him rt back to the hospital' Physician in to see resident prior to transfer to hospital. A review of Resident #5's medical record revealed wound measurements and description of the coccyx wound that included: -Dated [DATE] documented on the Skin Integrity Event as a skin tear to the right buttock, length 3 cm, width 3.9 cm, depth of skin tear as shallow. -dated [DATE] documented on the Wound Management Detail Report as a pressure ulcer on the coccyx, length 6.5 cm, width 9 cm, depth can not be measured, exudate amount: moderate, exudate color and consistency: serosanguineous, Stage: Unstageable-slough and/or eschar, tissue type: Slough, Comments: Wound bed is friable granulation tissue, 3 cm x 1.5 cm area of grey yellow slough visible at 12 o'clock. Drainage is moderate, serosanguineous. Wound bridges across gluteal cleft and up towards coccyx. Entire wound bed is moist and bright red, skin is weepy and is coming off with cleansing. Dressing orders changed to santyl and [MEDICATION(S)] . A review of Resident #5's medical record revealed wound measurements and description of the left heel wound that included: -Dated [DATE], documented on the Skin Integrity Event as a purple area to L heel . Length 2.5 cm, Width 4 cm . Evaluation Notes: IDT assessment of wounds to bilateral heels and buttocks. Bilateral heels have DTI at pressure points, dark purple to black in color. Skin is intact and there is no drainage, swelling, or redness. Allevyn dressings and air mattress in place, heels floated with pillows and blankets. Added to wound rounds and CAR. Buttock wound is excoriated, red wound bed, scant drainage. This wound is not related to pressure, appears to be chemical maceration and excoriation. Treatment is in place, will continue to monitor. -Dated [DATE], documented on the Wound Management Detail Report as a pressure ulcer on left heel . Length 3 cm, Width 4 cm, Can depth be measured? No . Stage: Unstageable-Deep Tissue . Comments: Deep tissue injury to left heel, dark purple closed ulceration. No drainage redness or open areas. Surrounding skin WNL . -Dated [DATE], documented on the Wound Management Detail Report as a pressure ulcer on left heel . Length 3 cm, Width 4 cm, Can depth be measured? No . Stage: Unstageable-Deep Tissue . Comments: Wound bed is dark purple to black eschar attached firmly to base, no open areas, no drainage. No odor or swelling. Surrounding skin is intact and within normal limits. Allevyn dressing in place . A review of Resident #5's medical record revealed wound measurements and description of the right heel wound that included: -Dated [DATE], documented on the Skin Integrity Event as a purple area to right heel . Length 1.5 cm, Width 1.5 cm . Evaluation Notes: IDT assessment of wounds to bilateral heels and buttocks. Bilateral heels have DTI at pressure points, dark purple to black in color. Skin is intact and there is no drainage, swelling, or redness. Allevyn dressings and air mattress in place, heels floated with pillows and blankets. Added to wound rounds and CAR. Buttock wound is excoriated, red wound bed, scant drainage. This wound is not related to pressure, appears to be chemical maceration and excoriation. Treatment is in place, will continue to monitor. -Dated [DATE], documented on the Wound Management Detail Report as a pressure ulcer on right heel . Length 1.5 cm, Width 1.5 cm, Can depth be measured? No . Stage: Unstageable-Deep Tissue . Comments: Deep tissue injury to right heel, dark purple closed ulceration. No drainage redness or open areas. Surrounding skin WNL. Treatment in place. Will continue to follow in CAR . -Dated [DATE], documented on the Wound Management Detail Report as a pressure ulcer on right heel . Length 3 cm, Width 4 cm, Can depth be measured? No . Stage: Unstageable-Deep Tissue . Comments: Wound to right heel, deep tissue. Black to purple eschar firmly attached to base. No open areas, no drainage swelling or redness. Surrounding skin intact and within normal limits. Allevyn dressing to site. Will continue to monitor and follow in CAR . A review of the resident's Weekly Skin Assessment, for January, 2021 on the Medication Administration Record/Treatment Administration Record revealed, 0= No impairment, 1= New impairment, 2= old impairment; Once a day on Wed (Wednesday). The nurses documented 2 for old impairment on [DATE] and 3 on [DATE] and did not have a corresponding note. A review of Resident #5's hospital records revealed a transfer to the hospital emergency department (ED) on [DATE] at 3:59 PM with Chief Complaint: Tachycardia [pt (patient) resident at (facility name), per ems (emergency medical service-ambulance) pt was to be dcd (discharged ) from facility today, md (doctor) there wanted pt evaluated because of tachycardia, pt arrives with hr (heart rate) of 83, pt skin dry and flaky, ems states facility informed them that pt is developing wounds, pt denies any pain, states he feels normal, per ems facility stated pt with decreased urine output so Foley placed. The ED history and physical revealed, (Resident #5) presenting for tachycardia from subacute rehab facility. Patient was admitted here in ,d+[DATE] for significant peripheral vascular disease with decreased pulses in the right lower extremity and abdominal pain. He had an uncomplicated course without procedure required and was discharged to inpatient rehab and subsequently discharged to subacute rehab. A patient was scheduled for discharge home today. Facility noted patient with tachycardia in the context of recent decreased urinary output. They had placed a Foley catheter due to this, unclear whether this relieved any obstruction or improved urinary output. He is not currently on antibiotics. He likewise per chart recently started receiving wound care to a sacral decubitus ulcer as well as bilateral heel ulcers. These were not noted at time of discharge from this hospital . Physical Exam . Skin: Comments: Unstageable decubitus ulcer, bilateral heel ulcers . Further review of Resident #5's hospital record revealed the following: -Dated [DATE] at 4:16 PM, ED Triage Abuse Screening: Abuse Observations/Findings: Are there any potential physical indicators of abuse/neglect? [select ALL that apply]: Malnutrition, dehydration, failure to thrive, poor physical care, unattended medical problems [pt dry and flaky, per ems facility states pt developing pressure ulcers . Abuse: Healthcare provider suspects. Possible abuse reported or referred to: ED Social Worker . Referral Reason: Alleged/suspected neglect . -Dated [DATE], ED Course, .Patient is admitted to medicine service for AKI (acute kidney injury)/rehydration, infectious disease as well as wound care consultations. -Dated [DATE] at 9:09 AM, Pressure Ulcer Coccyx (buttocks) Mid, Stage III, Length 6.5 cm, Width 8 cm, Depth 0.4 cm, Drainage amount: Scant, Drainage Description: Tan; Serosanguineous, Odor: Positive. -Dated [DATE] at 9:09 AM, Pressure Ulcer Calcaneous [heel] left; Outer, Staging: Deep Tissue Injury, Site Assessment: Non-blanchable; Purple/maroon; Bulla intact, Length 4.5 cm, Width 3 cm, Depth 0 cm. -Dated [DATE] at 9:09 AM, Pressure Ulcer Calcaneous [heel] right; Outer, Staging: Deep Tissue Injury, Site Assessment: Purple/maroon; Bulla intact; Length 3.5 cm, Width 2.5 cm, Depth 0 cm. -Dated [DATE] at 9:10 AM, Service: Wound Care, .Assessment: Left lateral heel Deep Tissue Pressure Injury, non-blanching purple blood filled bulla. Present on admission. Right lateral heel Deep Tissue Pressure Injury, non-blanching purple blood filled bulla. Present on admission. Sacrum Stage 3 pressure injury, 50% gray/tan/yellow, 50% pink. Present on admission . -Dated [DATE], H&P (history and physical) Notes, Chief Complaint. Wound and ulcer of the both heel and also in the back getting worse . Physical Examination: .The patient has bilateral heel with deep tissue injury and unable to examine the sacral area, but as per the wound care management and photos, the patient has sacral ulcer stage III with clear margin . A review of the Resident #5's care plan revealed a problem start date on [DATE] for Skin Integrity At risk for skin breakdown, with a goal of Resident's skin will remain intact, and approaches of keep linens clean and dry, foot cradle to bed, avoid shearing skin during positioning, turning, and transferring, conduct weekly skin assessment. Pay particular attention to bony prominences, encourage and assist to turn and reposition for comfort and as needed, float heels as needed, keep resident as clean and dry as possible and minimize skin exposure to moisture, pressure reducing cushion to chair and mattress to bed, use lifting device as needed for bed mobility and use moisture barrier product to perineal area as needed. The approaches had a start date on [DATE]. There were no added interventions after the development of the wounds to the coccyx and bilateral heels. The Director of Nursing (DON) was queried on [DATE] at 2:50 PM regarding Resident #5's wound history. When asked why the Wound Management documentation referred to a pressure ulcer on the right 2nd toe, the DON reported that the wound was on the great toe and there was no wound on the second toe indicating the location was documented in error on [DATE]. The DON was asked for a care plan and all information on the Resident's wounds. On [DATE] an email was received with a Care Plan History for Resident #5. The Care Plan had a problem start date of [DATE] of Resident has a pressure ulcer to right second toe, created on [DATE] with a goal that revealed, Resident's ulcer will heal without complications, with a created date on [DATE] and approaches that were created on [DATE]. The Care Plan did not indicate the wounds on the coccyx or bilateral heel. On [DATE] at 8:57 AM, an interview was conducted with Resident #5's Family Member Y regarding Resident #5's care at the facility. The Family Member reported the Resident had been at the hospital for pain in his legs and his blood sugar was out of [NAME], then went to the facility for rehab and to get stronger, it was a matter of getting him walking. The Family Member reported the Resident had been sent back to the hospital on [DATE] and had wounds on his buttock and heels. The Family Member reported that the facility had told them the Resident had a slight skin tear, and when they were getting ready to take him home the facility told them they would need to set up a wound specialist for the Resident and stated, that was really concerning since he had a skin tear and they requested on [DATE] he be sent to the hospital to be evaluated. The Family Member reported that when the Resident got to the Emergency Department, they were made aware of the wounds to the butt area that was a hole that a child's fist could fit in, not a 'slight skin tear' but a hole and a large area of raw flesh that had skin coming off . They (the facility) did not tell (another family member) how bad it was. They never told us about the bruise on his leg or that he had blisters on his toes or that his heels were rotting away, both heels were blackened and leaking fluid. We didn't know anything about the wounds on the heels until he was in the Emergency ([DATE]). The Family Member reported the doctor had talked with the family on Friday, [DATE] regarding the 'skin tear' and declining in health but they still wanted to take him home and was scheduled to be released on the following Tuesday, [DATE] and on [DATE] the DON had told the family that he would need to see a wound specialist and after discussing it with the family they felt that something serious was going on that he would need to see a wound specialist. The family had the facility send Resident #5 to the hospital for evaluation. The Family Member reported they were not allowed to go into the facility to visit due to Covid but had visited from the window. The Family Member reported visiting 2 to 3 times a week and that siblings had also visited frequently and stated, One time I seen him sitting up eating a hamburger, that was in the beginning, after that he was always in bed sleeping and always laying on his back, and reported the resident was not turned from side to side that they could tell from observing from the window. The Family Member reported the Resident had gotten an infection in the coccyx wound that had gone into his blood stream and had passed away on [DATE]th. On [DATE] at 11:00 AM, an interview was conducted with Hospital Staff O from the hospital that Resident #5 had been transferred to on [DATE]. The Hospital Staff reported the Resident had a hospital stay from [DATE] to [DATE] and discharged home with family. The Hospital Staff reported a previous hospital stay from [DATE] to [DATE] and discharged to the facility. The Hospital Staff reviewed Resident #5's medical record and reported that upon discharge to the facility on [DATE], the patient (Resident #5) did not have wounds to the bilateral heels and back and buttock area. The Hospital Staff reported that upon transfer to the emergency department (ED) on [DATE], the patient had presented in the ED with wounds that had been acquired at the facility and stated, There is no documentation of the wounds when he left the hospital on the 15th ([DATE]) and that is why the doctor was concerned. The Hospital Staff reported the pressure ulcer to the back and buttock appeared to be one continuous wound and was documented as Unstageable in the ED and then on [DATE], the Wound Care Nurse had documented the buttock/back wound was a Stage 3 and the bilateral heels were Deep Tissue Injuries. On [DATE] at 8:55 AM, an interview was conducted with Family Member N regarding Resident #5's wounds. The Family Member reported that on Friday before coming home, she was told by the Doctor that he had a skin tear on his buttock and then called again on Monday and stated, They were unsure of him coming home. The Family Member indicated they had still planned on taking him home but when they were getting discharge instructions, they were told he would need to see a wound specialist and stated, We knew something was going on . It was a red flag, it was ore than a slight skin tear. We wanted an evaluation at the hospital before coming home. They said they would keep him there, trying to keep him. If he had a wound that needed a specialist, we wanted him evaluated at the hospital. The Family Member reported the Resident had been transferred to the hospital and the Emergency Department staff had shown the wound to the buttock and heels and stated, he didn't have these wounds when he went in (to the facility). The Family Member reported visiting the Resident at the window every day about 6:00 in the evening and stated, he was always in bed, always laying on his back. The Family Member reported a son had visited and seen him up in a wheelchair once that had been about a week

This Citation pertains to Intake Number MI 739. Based on observation, interview and record review, the facility failed to prevent physical and verbal staff-to-resident abuse for one resident (Resident #1) of seven residents reviewed for abuse resulting in Resident #1 experiencing rough care, verbal and aggressive behavior from the staff, restrained and feeling choked when staff hugged the resident and feeling fearful, distraught and yelling out for help during the altercation. Findings include: On 5/7/21 at 1:58 PM, an observation was made of Resident #1 in their room in a wheelchair. The Resident was dressed, clean and was propelling the wheelchair on their own. The Resident was wearing a boot on one leg and foot. When queried regarding any abuse incidents, the Resident did not elaborate on any incidents but reported sometimes staff does not put her boot on correctly and it causes pain. The Resident denied any injury caused by staff not putting the boot on correctly and reported sometimes it hurts. The Resident was pleasant and communicative but when asked again regarding and abuse allegations the Resident did not report any allegations of abuse. A review of the Facility Reported Incident revealed, .On 9/22/20 at 0937 (9:37 AM) (Resident #1) reported that the night prior, (CNA K) [her aide] had thrown her in her wheelchair, took her in the bathroom, ripped her pants down and had thrown her brief on the floor . (Resident #1) was interviewed and she stated that (CNA K) had answered her call light and when she had gotten her up out of bed [NAME] put her sock on the wrong foot and she had then pulled her around, put her feet down hard on the floor, grabbed her arms and set her down hard in her chair. She then wrapped her arms around her. She stated that she then told her she was smothering me and that her pin was [NAME] her. (Resident #1) stated that (CNA K) told her she was going to hug the meanness out of her . She had ahold of (Resident #1's) shoulder at that time. When she put her on the toilet (Resident #1) stated that she had ripped the brief off of her and onto the floor and also a second brief had ripped. She stated she had called for help and (CNA D) had come in. She stated that a week ago (CNA K) had ripped a remote out of her hand and that was why she had a band aid a bruise on her finger. In the interview with (CNA K) she acknowledged that she did answer (Resident #1's) call light at the beginning of her shift and (Resident #1) had been yelling and screaming, she had attempted to hug (Resident #1) but (Resident #1) continued to yell and scream and had acted like I was choking her and that (CNA D) was finishing up care with (Resident #1). (CNA K's) assignment was changed to not provide care to (Resident #1 for the rest of the night as that had been determined to be a trigger for (Resident #1's) behaviors. When questioned about the skin tear that was on (Resident #1's) hand (CNA K) acknowledged that she had taken the remote out of her hand so that (Resident #1) wouldn't hit her with the remote and that she had not meant to hurt her and had told the nurse, (Nurse T) right away. (CNA K) denied that she had anyone in the room with her for either incident, nor had she ever asked anyone to come in the room with her . (CNA D) was interviewed and stated that she had heard (Resident #1) yelling so she went down to help. She stated that she knows (Resident #1) gets this way but she can usually take care of her without a problem. When (CNA D) entered the room (Resident #1) was on the toilet. (CNA K) threw (Resident #1's) brief in the garbage and left the bathroom when (CNA D) said she would take over. (CNA D) was able to get (Resident #1) off the toilet and into bed without any further incident. (Nurse T) was interviewed and stated that (CNA K) had told her that the corner of the remote had hit her hand causing a skin tear. (Nurse T) stated that she had spoke with (Resident #1) that night and (Resident #1) had denied that it was anything other than an accident and that she felt safe and didn't want her son to be notified. (Nurse B) was interviewed and stated that (Resident #1's) call light had went on around 10 PM and (CNA K) had went down to (Resident #1's) room. She heard (Resident #1) screaming and seen that (CNA D) was going down there. She stated that after a few minutes (CNA K) had come back and had said that (Resident #1) had been yelling and screaming so she had hugged her but (Resident #1) had made it seem as if I were choking her. When I went down to take her pain pill she was calm, laying in bed and didn't mention any concerns . (Nurse M) was interviewed and stated that she had been doing report with oncoming nurse (Nurse B) when (Resident #1's) light had went on and (CNA K) had went down to answer the light. She heard (Resident #1) start to yell and then seen that (CNA D) was going to help her. (CNA K) came back to the nurses' station shortly after saying that she had hugged (Resident #1) and (Resident #1) had acted like (CNA K) was choking her. (Nurse M) asked (CNA K) if (Resident #1) had said that she was choking her but she said no, she didn't say that but she was just acting like it. (Nurse M) stated that (Nurse B) had indicated she was going down to give (Resident #1) her medication so she hadn't went back down to (Resident #1's) room after the incident . A review of the facility investigation interview with Resident #1, dated 9/22/20, regarding the incident with Resident #1 on 9/21/20 revealed the following: At approximately 10:05 am I spoke with (Resident #1) following her report of allegation of abuse to RN (Registered Nurse). (Resident #1) stated, '(CNA K) freaked out on me last night'. When asked 'what do you mean when you say 'freaked out'?' (Resident #1) stated 'I had to get up to go to the bathroom and she put my sock on the wrong foot. That's what started it. She pulled me around, put my feet down hard off the bed, she grabbed my arms, set me down hard in the chair the roughly transferred me to the toilet. She told me that she was going to 'hug the meanness out of me' and would not let me go. She was grabbing me hard on the shoulder. I told her that she was smothering me and that her pin was poking me. She did have ahold of my shoulder. She got mad and ripped my brief off, put another one back on and then ripped that off too. I had to yell for help and (CNA D) came running in. I always have problems with (CNA K). A week ago she ripped the remote out of my hand so hard that it hurt me. That's why I have this band aid. I have bruises from her fingers. She told me that she goes to a psychologist for her control issues. She just tries to tell me how to run my life, and the more she [NAME] at me the more agitated I get. I ask her to be quiet but she tells me she can say whatever I want. A couple of days ago she was in here and I tried to wheel out of the room for help and she pulled my back in by the wheelchair. Sometimes I use my good foot to push her hands away when she puts my boot on because she hurts me and doesn't stop when I tell her that hurts, and signed by Staff U. A review of the facility investigation interviews with staff, dated 9/22/20, regarding the incident with Resident #1 on 9/21/20 revealed the following: -Interview with Nurse T on 9/22/20 at 3:47 PM, revealed, On 9/7/2020 (CNA K) had told me that (Resident #1) had hit her hand on the corner of the bed remote. I went down to see (Resident #1) and asked her what had happened and she showed me the bed remote, pointing to the corner of it. She didn't report any allegations at that time, denied feeling unsafe, declined for her son to be called. (CNA K) did not report that she had 'ripped' the remote out of her hand. I had specifically asked the questions to ensure she felt safe and that nothing had happened. I did not tell her that she had to go to the hospital if she wanted to report (CNA K) or call the police. In the past I had told her that (Doctor's name) would send her to the hospital if her behaviors escalated but that was when (Doctor) had ordered that and it was a long time ago. I try to go in to answer (Resident #1's) light as much as I can but for some reason (CNA K) always wants to get her light. I know that (Resident #1) is supposed to be witnessed care and I try to be the witness as often as I can. -Interview with Nurse M, dated 9/22/20 at 4:23 PM, revealed, (Nurse B) and I were doing report. (Resident #1's) light went on and (CNA K) went down there to answer it. (Resident #1) started yelling. (CNA D) went down there. (CNA K) came back down the hallway sobbing kind of hurriedly. (CNA K) said she couldn't take it anymore and that (Resident #1) had been so mean to her stating that she had tried to hug (Resident #1) and she demonstrated how she had hugged her [standing to her side and wrapping her arms around her] but (Resident #1) had been hitting at her and yelling at her. (Resident #1) made a choking noise when (CNA K) hugged her. I have been in the room with (Resident #1) and (CNA K) and (CNA K) can do everything right and (Resident #1) will still yell at her and call her names, treating her like garbage and she is a good aide. She always says that (CNA K) can't do anything right. She did not come right out and say that (Resident #1) was saying she was choked but she made the noise indicative of choking. I didn't go back down there because (Nurse B) said she was going down there. -Interview with Nurse B, dated 9/22/20 at 4:00 PM, revealed, (Resident #1's) light went on at 10p. (CNA K) went down there and I could immediately hear (Resident #1) screaming. (Nurse M) and I were doing report. (CNA D) went down that way. (CNA K) came back a few minutes later really upset and crying stating that she went in there with a new attitude thinking it would be a fresh start and she tried to hug her but (Resident #1) had said she had tried to choke her. I tried to calm (CNA K) down and told (CNA K) she couldn't go in there again. I went down to give her a medication around midnight and she was calm at that time and didn't voice any concerns. (Resident #1) did not appear to have any injuries except for an old abrasion on her left leg. -Interview with CNA D, dated 9/22/20 at 2:20 PM, revealed, I was on the hall charting on residents at the end of my shift. Call lights were on. (CNA K) went into (Resident #1's) room to answer her call light. I heard (Resident #1) screaming 'Get off of me' over and over. I went in to see what was going on and when I went in (Resident #1) was on the toilet screaming and (CNA K) was in the bathroom crying. (CNA K) was not touching (Resident #1). (CNA K) threw the brief into the basket and pushed the shower chair that was in the bathroom. I asked (CNA K) what happened and she said she was trying to get her into her chair and (Resident #1) freaked out. I told (CNA K) I could take care of (Resident #1) from here and she left the room. (Resident #1) and I were okay. I got her off of the toilet, got her in bed, put her boot on and she was still agitated but had settled some and had allowed me to provide care without incident. I know we are supposed to have two people in the room to take care of (Resident #1). -Interview with CNA K, dated 9/22/20, revealed, It was not more than ten minutes into my shift and (Resident #1) had her light on. I went in and she immediately had an attitude. I could tell by the look on her face and she made a 'clucking' noise. I turned off her call light and she wanted to go the bathroom so I started getting her socks on her feet and she got upset when I put a sock on her foot that the boot goes on. I told her she needed to wear that one and then transferred her to the wheelchair. She was yelling and hollering at me. I tried to calm her down. I went behind her and gave her a hug from the backside trying to make her understand that I care about her. She was pinching and grabbing at me. I took her into the bathroom and she continued to yell and scream at me. Her brief tore while I was pulling it down so I got her another brief and threw that one away. (CNA D) came into the bathroom and said she had it from here. I tried to explain to her what had happened. As I left the room I bumped into the shower chair that was in the bathroom and I pushed it out of the way. It wasn't near (Resident #1) and didn't hit her. I never went back into the room. I did not have a witness when I was in there. I know she is witnessed care but I didn't ask anyone to help me because the nurses were giving report. I usually don't get someone. I know I should but sometimes (Resident #1) is good with me. I did tell (Nurse B) and (Nurse M) that I had tried to hug (Resident #1) and she was upset and she was acting like I choked her. No one has ever refused to be a witness for me . I hugged her because I wanted to let her know that I still care about her even when she is mean to me. I wanted to hold her. I feel like that sometimes I trigger her. She calls me all kinds of names and I know you guys said to not let it get to me and that she does that to a lot of people but it eats at me. I do tell (Resident #1) personal things and then (Resident #1) uses those things against me . There was a time to that I took the remote out of her hand because I didn't want her to throw it at me . I took the remote out of her hand and it made her get a skin tear. I told the nurse about the skin tear . On 5/13/21 at 2:14 PM, an interview was conducted with the Nursing Home Administrator (NHA) regarding Resident #1's investigation report for the facility reported incident. The NHA was queried regarding Resident #1's abuse investigation. The NHA reported the Resident was her own responsible party and was alert and oriented but had problems with orientation to time and had some behaviors towards staff. The NHA reported the Resident was witnessed care which meant that with any care provided, when the door was closed to provide care then two staff were to be in the room. The NHA indicated that witnessed care was to be provided on all shifts, for all care that included, showers, dressing, and up to bathroom. When queried why the Resident was on witnessed care, the NHA stated, The Resident has made allegations in the past, and it was to protect the Resident and staff, was in the Resident's plan of care for a long time, was not something new and could be found on the care tracker that CNAs used to know about the care required for the Resident. The staff statements in the investigation report were reviewed with the NHA. The NHA was queried when CNA K had been crying and upset and said she had tried to hug Resident #1 and CNA K indicated that the Resident thought she was choking her if that was an allegation of abuse and needed to be reported, the NHA reported it should have been reported. When queried if the Resident should have been assessed after yelling out for help, the NHA indicated the Nurses should have assessed her immediately. When queried if CNA K was pulled from working with other Residents, the NHA reported they did not have her take care of Resident #1 for the rest of the night but indicated she should have not continued to work. When queried if CNA K should have hugged the Resident, the NHA indicated that Resident #1 was not one who is really huggy, and the intervention for the Resident's behavior was to make sure she was safe and leave her alone, then reapproach or have someone else go in. The NHA reported that CNA K should have gotten assistance when she answered the light and the Resident needed to go to the bathroom and reported that CNA D should have gotten someone to go in with her for care. She's not to be alone with (Resident #1). The NHA indicated that CNA K had pushed the shower chair out of frustration and that CNA K should not have been doing Resident care when frustrated and stated, The two nurses (Nurse B and Nurse M) should have reported an abuse allegation that night. They were disciplined for not reporting and not following abuse policy. They should have assessed her immediately as well. They were educated on the Abuse Policy. When queried regarding the incident on 9/7/21 when CNA K had taken the remote from Resident #1 and caused the skin tear, the NHA indicated that the injury to the Residents hand should have been reported when the incident happened. On 5/13/21 at 3:38 PM, CNA D was interviewed regarding her witness statement for the incident on 9/20/20 with Resident #1 and CNA K. CNA D said CNA K had gone to answer Resident #1's call light, heard Resident #1 screaming, went down there and Resident #1 was crying and screaming, her and CNA K were arguing, seen CNA K hug the Resident on the toilet and stated, She hugged her like she was restraining her. She (Resident #1) was gurgling and yelling at the top of her lungs. CNA D continued and stated, (CNA K) was frustrated and got mad enough to throw the briefs and banged the shower chair. I took over, I got her into the bed. She (CNA K) was ticked off, crying and full of anger. She stormed out and went up the hall. The CNA reported she had told the Nurse what happened. When queried what she had told the Nurse, CNA D stated, (Resident #1) and (CNA K) were in a big [NAME]. The shower chair was thrown around. I just wanted to let you know. The CNA reported her shift was done and she had stayed to do some charting and left after the incident. The CNA stated, This is something I should have told them about, when queried who them were the CNA reported the Abuse Coordinator and stated, I told (Nurse B) and left it at that. On 5/14/21 at 11:29 AM and 11:41 AM, a phone call was made to CNA K but there was no answer, and a message was left to return the call but the CNA did not return the phone call prior to the exit of the survey. On 5/14/21 at 11:44 AM, an interview was conducted with Nurse B regarding the incident on 9/20/20 with Resident #1 and CNA K. When queried regarding the incident, the Nurse reported that CNA K had gone to Resident #1's room to answer the light and stated, She (CNA K) had come back crying. She tried to give (Resident #1) a hug. Bad move because (Resident #1) started screaming that she was trying to hurt her. That is what (CNA K) came back and told us, and reported she was getting report from the other Nurse (Nurse M). The Nurse continued, She was not one that liked hugs. I don't know why (CNA K) would do that. Some days (Resident #1) is nice and friendly, other days she screams at you. I didn't understand why (CNA K) would think that (Resident #1) was receptive to a hug. (Resident #1) did not like (CNA K). The Nurse stated, I should have reported it. I asked if everything was alright when I gave her medication. The Nurse was queried approximately when she had given the medication to Resident #1 and reported it had been about an hour later. When queried if anyone had gone down to assess the resident after the resident had been screaming, the Nurse stated, An Aide went down to finish toileting her, when queried regarding any assessment of the Resident, the Nurse stated, I just asked if she was OK. We should have gone down either (Nurse M) or myself, we were both there. The Nurse reported that it was an incident that should have been reported immediately to the Administrator. When queried if CNA K was pulled from working with Residents, the Nurse indicated the CNA was not to go into Resident #1's room for the rest of the shift but continued to work with other Residents and another CNA was assigned care of Resident #1. A review of the facility policy titled, Abuse and Neglect Procedural Guidelines, revised 8/29/2019, revealed, Purpose: (Facility Corporate) has developed and implemented processes, which strive to ensure the prevention and reporting of suspected or alleged resident abuse and neglect . c. Prevention i. Assure that prevention techniques are implemented in the campus. Identify, correct, and intervene in situations where abuse and/or neglect are more likely to occur. These may include but are not limited to, an analysis of: ii. Secluded areas of the facility. 1. Sufficient staffing on all shifts to meet the needs of the population served. 2. Assigned staff demonstrate knowledge of individual resident needs. 3. Identification of residents with needs and/or behaviors which might lead to conflict or neglect . 5. Staff is required to report concerns, incidents and grievances immediately to your manager and/or Executive Director and Director of Health Services . d. Identification . ii. Any person with knowledge or suspicion of suspected violations shall report immediately, without fear of reprisal . iii. The Shift Supervisor or Manager is identified as responsible for initiating and/or continuing the reporting process, as follows: iv. IMMEDIATELY notify the Executive Director. If the Executive Director is absent, they may appoint a designee . II. The Executive Director is responsible for: 1. Notification to the State Department of Health [per State guidelines] and other agencies, which include the Ombudsman, Adult Protective Services and/or local law enforcement agencies, as indicated. e. Protection i. Upon identification of suspected abuse or neglect, immediately provide for the safety of the resident and the person reporting to maintain anonymity as reasonable and necessary. This may include but is not limited to the following . iv. Suspend suspected employee[s] pending outcome of investigation . g. Reporting/response . ii. Ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment . are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury . to the administrator of the facility and to other officials [including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities] in accordance with State law through established procedures .

This Citation Pertains to Intake Number MI 392. Based on observation, interview and record review, the facility failed to, implement effective interventions to prevent a fall, and update the resident's Care Plans with new interventions after a fall, for 2 (#'s 701 and 702)) of 3 residents sampled for falls, resulting in Resident #701 falling and sustaining a serious face and head injury, including facial abrasions and a large, painful, raised, (greater than 1 ½ inches) hematoma on the right temple and a raised hematoma to the top of the head (occipital area), after falling from bed unattended, while having repeated seizures and Resident #702 having repeated falls with no new interventions to prevent further falls. Findings Include: Resident #701 A Record review on 11/20/17 at 11:30 AM revealed, Resident #701 was admitted to the facility on [DATE] with Diagnoses: [REDACTED]. Review of the Minimum Data Set (MDS) assessment dated [DATE], revealed the Resident had memory problems and required moderate 1 person assistance to perform Activities of Daily Living (ADL's), including transfers and ambulation. The resident received the following medications: [REDACTED]. A review of Resident #701's care plans revealed the following care plans and interventions related to falls, ADL's, Bleeding and Toileting: 1.Falls: Resident is at risk for falling . (Start Date: 8/2/17). Care plan interventions included: -Staff to assist resident with transfers as needed. (Start Date: 8/2/17) -Offer toileting assistance to resident upon rising, before and after meals and prior to bedtime. (Start Date: 8/13/17) -Staff Education was completed regarding toileting schedule. (Start Date: 10/31/17) 2.ADL's: Resident requires staff assistance to complete ADL tasks completely and safely. (Start Date: 8/2/17) -Observe for deterioration in ADL abilities and report if occurs. (Start: 8/2/17) 3.Bowel and Bladder (Start Date: 8/2/17) -Offer and assist with toileting as needed and /or per request. (Start: 8/2/17) The Fall Care Plan did not include Bedside Floor Mats, until 11/20/17. There was no Care Plan addressing seizures or seizure precautions to prevent injury. On 11/20/17 at 12:00 PM, Resident #701's Incident and Accident reports were reviewed. The resident had a history of [REDACTED]. 10/29/17 6:55 PM: On floor on buttocks at foot of bed, No Injury, Alert/wakefulness. Interventions: Toilet resident, evaluate continence. 11/1/17 1:28 PM: Resident observed on the floor next to (the) bed in (the) room. Observed a golf size protrusion on right side of forehead .Lethargic/drowsy .Dizziness/lightheadedness, headache, seizure. New Interventions: Bed in lowest position, defined parameter mattress. Doctor notified of seizure activity prior to activity. Evaluation Note: Resident had no major Injury from fall. Parameter mattress, and floor mats were placed next to bed. Care Plan reviewed and updated. On 11/20/17 at 12:20 PM, a review of the Progress Notes revealed the following: 10/30/17: IDT Note: Resident reviewed related to a fall last evening .In review of the root cause, resident needed to use the restroom. Resident is care planned for toileting schedule. Staff education was completed to inform staff of toileting schedule .Plan is to offer toileting schedule to anticipate needs . 11/1/17: 1:28 PM- .New orders obtained for x-ray and to hold Coumadin times one dose. Resident began to complain of head ache. Ice pack applied . 11/1/17: 4:48 PM-Resting in bed at this time. Ice pack remains applied at time to forehead. There was no additional assessment of the resident's condition or injury on 11/1/17. 11/2/17: IDT Note- .Resident has large bump on forehead, bruising noted to forehead, both eyes .Spoke with Daughter regarding Hospice . The next documented note was on 11/2/17 at 3:48 PM: .Bruises and swelling migrated to right side of face, neck and bilateral eyes. (Dr. A) at facility to see resident. Neuro checks WNL (within normal limits). An interview and observation was completed with Resident #701 and Confidential Person B on 11/20/17 at 12:58 PM. Resident #701 was observed lying in bed, awake with a large approximately 2 inch by 2 inch dark purple/yellow hematoma on the right forehead/temple. It was raised about 1 ½ inches. The resident had a dry abrasion above the hematoma with additional bruising above and around the raised area. There were floor mats on each side of the bed. Confidential Person B indicated the resident still had pain and a knot on the top of the head also. Resident #701 moaned and said Oww, when the area was touched. Confidential Person B stated, (The resident) had a seizure that morning (11/1/17) and fell around 12:00 noon When queried what Confidential Person B was told about the fall, they replied, Just that (the resident) fell . When queried if the facility discussed a toileting plan after the resident fell on [DATE], Confidential Person B stated, No. When further asked when the fall mats were added, Confidential Person B said the mats were added about 11/10/17. The Confidential Person was asked what measures the facility had in place to prevent the resident from falling and seriously injuring themselves and replied, Nothing. The breakfast tray was still sitting there at 2:00 PM. Not till the next day at 7:00 am the Doctor came in. They said they were going to do x-rays of the Hip. They never did (the resident's) head. On 11/20/17 at 1:30 PM, an Interview with CNA G, who was assigned to care for Resident #701 on the day of the survey provided, I just don't know what happened. The Fall Prevention Measures are Toilet, get (the resident) up, bring them to the living room, and just kind of watch (the resident). The fall pads were added about 2 weeks ago. An interview on 11/20/17 at 2:20 PM, with Certified Nursing Assistant C provided, (The resident) had a seizure that morning I repositioned (the resident) on the left side. (The resident's) right side was jerking during the seizure. The nurse called the doctor. I checked on (the resident) every 10-15 minutes. At 12:30 PM I went to lunch. At 12:35 PM the nurse called me to get (the resident) up from the floor .was on the right side of the bed on the floor, partially upright . When CNA was queried about a toileting plan they stated, I take (the resident) every so often. When queried how many resident's the CNA cared for on her assignment, she stated, Usually 12 residents. An Interview with Nurse F on 11/20/17 at 3:12 PM revealed, (The resident) was lying face down. I could see (they) weren't in bed from the nurse's desk. (The resident) was having seizures most of the day. About 1 hour before the fall I gave Ativan. Nurse F Indicated there was no one in the room with the resident while the resident was having seizures. An interview with the Director of Nursing (DON) on 11/20/17 at 3:30 PM revealed, Education was provided to staff on toileting after the resident fell on [DATE]. A review of the Employee Education, record dated 10/30/17, Profile Updated and Education/Fall, revealed 2 staff received education on this subject. Neither was caring for the resident on the day the resident fell again on 11/1/17. When the DON was queried why all staff caring for the resident wouldn't need to know this information, she stated, Those were the staff working that day. The DON was further queried on what preventive measures were put in place after the resident received a head injury on 11/1/17 and said the fall mats were not implemented right away, as they had to be ordered. The DON was queried why the intervention was not placed on the Care Plan until 11/20/17, the day of the survey and did not respond. Resident #702 A record review on 11/20/17 at 11:45 AM, revealed Resident #702 was admitted to the facility on [DATE] with Diagnoses: [REDACTED]. The MDS assessment dated [DATE], indicated the resident had full cognitive abilities and needed extensive 1 person assistance with transfers, toileting, dressing, hygiene and bathing. The resident did not walk. A record review on 11/20/17 at 12:05 AM, revealed the resident had fallen twice: 10/31/17 AND 11/16/17. In both instances the resident was found lying on the floor-once by the bed and once in the bathroom. The Fall Care Plan, dated 10/23/17 was updated on 11/1/17: Reeducation on use of call light and ask for assistance with all transfers, and 11/17/17: Reeducated on use of call light. The Toileting Care Plan, dated 10/23/17 revealed, Offer and assist with toileting as needed. The MDS indicated the resident needed extensive 1 person assistance with toileting and was frequently incontinent of bowel and occasionally incontinent of bladder. A toileting program had not been attempted. An interview with Resident #702 on 11/20/17 at 1:55 PM revealed, They won't let me, when queried if the resident transferred self. The resident replied, No, when asked if they had fallen during their stay in the facility. On 11/20/17 at 3:35 PM, an interview with the DON revealed, It would depend on why (the resident) fell . We would choose an intervention based on the reason they fall, when queried why the only updated intervention for Resident #702 is reeducation of the call light; because this intervention wasn't effective to prevent additional falls after the first time it was used. When queried what additional measures would be effective in preventing falls with potential injuries for Resident #702, the DON continued to repeat reeducation. On 11/20/17 at 3:50 PM, a review of the facility policy titled, Fall Management Program Guidelines, dated 5/31/17 provided, .Mitigate fall risk factors and implement preventative measures .Care plan interventions should be implemented that address the resident's risk factors .The resident care plan should be updated to reflect any new or change in interventions.

Based on observation, interview and record review, the facility failed to accurately assess, measure and stage a wound, ensure timely and appropriate treatment of [REDACTED].#'s 702 and 703) of 2 sampled residents reviewed from a total sample size of 12, resulting in the worsening of a pressure ulcer from a stage 2 (partial thickness loss of dermis) to a stage 3 (full thickness skin loss involving damage of subcutaneous tissue) and the development of a facility acquired stage 2 pressure ulcer, and delayed healing. Findings include: Resident #702 On 10/23/20 at 10:40 AM, resident #702 was observed in bed on back with the head of bed elevated approximately 75 degrees. On 10/23/17, at 11:00 AM, review of the face sheet revealed that the resident was admitted into the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment dated [DATE] revealed that the resident required extensive assistance with two people for most Activities of Daily Living ( ADL) including bed mobility and severely impaired cognition. On 10/24/17, at 8:00 AM, 9:10 AM, and 2:30 PM, resident #702 was observed in bed on back with the head of the bed elevated approximately 90 degrees. On 10/25/17, at 8:00 AM, resident #702 was in bed on back with head of bed elevated approximately 90 degrees. On 10/25/17, at 9:00 AM, a review of the resident's pressure ulcer care plan revealed the following: Resident has a history of pressure ulcer/injury to coccyx and hx (history) of L (left) gluteal pressure ulcer/injury . maintain the head of the bed at the lowest degree of elevation possible . On 10/25/17, at 9:15 AM, certified nurse assistant ( CNA) K was interviewed regarding care plans and ADL care for resident #702. CNA K stated, we can't get into matrix (electronic medical record that houses care plans and interventions). Nurse aide K logged into care tracker (a program for the aides to review how to care for the residents) and it revealed the following for resident #702; 1 PA (person assist) for ADL's, Hoyer with 2 PA for all transfers. There was no other information on care tracker that would tell the aides to turn and reposition for pressure reduction that was viewed. On 10/25/17, at 10:15 AM, resident #702 was observed in bed positioned on the left side with assistance of nurse J to evaluate coccyx/gluteal areas for healed pressure ulcers. Observations revealed areas of redness with open skin measuring approximately 1 and ½ inches circular equally on both sides of buttocks. There was no treatment on these areas. Nurse J fastened brief, repositioned resident #702 onto back, covered the Resident with blankets and elevated the head of bed. Resident #703 On 10/23/17, at 10:40 AM, resident #703 was observed sitting in a wheel chair in dining room. On 10/23/17, at 11:30 AM, a review of the face sheet revealed that the resident was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS assessment dated [DATE], revealed that the resident required extensive assistance with bed mobility, had intact cognition and a stage 2 pressure ulcer on admission. On 10/23/17 at 11:45 AM, a review of the resident's treatment order dated 9/16/17 revealed cleanse right gluteal wound with wound cleanser, pat dry, apply Santyl to wound bed, apply skin-prep to surrounding skin, and apply [MEDICATION NAME] dressing . once a day and prn . There were no other treatment orders or intervention changes for this wound. On 10/24/17, at 8:50 AM, the resident was observed sitting in bed leaning on back. Resident was queried on pain and resident #703 responded I am in pain, in my hip and back. At 3:00 PM, the resident was observed in bed on left side with nurse assistance exposing left gluteal region for view. The dressing was dated 10/22. The dressing was removed to revealed a large open area measuring approximately 1 inch by 1 inch by about 1.5 centimeter (cm) deep which appeared to have tunneling. The wound bed was beefy and red and the edges were not even. There was a 4 inch by 4 inch area of deep reddened tissue surrounding the open area. The dressing had a brownish green drainage that saturated an inner dressing that fell out onto the bed. On 10/24/17, at 3:30 PM, a review of skin integrity event dated 9/15/17 for resident #703 completed by nurse H, revealed right gluteal region . Length 4 cm Width 4 cm with no depth measurements. On 10/24/17, at 3:40 PM, a review of the resident's nurses notes by nurse H revealed the following; 9/29/17 . Resident presented upon admission with wound to right buttock measuring 4.5 cm x 3.5 cm x .5 cm Santyl ordered for wound treatment . 10/10/17 . Dressing to resident right buttock C/D/I (clear dry intact) resident takes prn pain medication for pain in back and butt., written by nurse F. On 10/24/17, at 3:45 PM, a review of resident #703's wound information all written by nurse G revealed the following: 1. 10/06/17 . Length 4.5 centimeters Width 3.5 centimeters Depth 0.1 centimeters . Exudate moderate (yellow or tan cloudy and thick) Wound odor Yes 2. 10/13/17 . Length 4 centimeters Width 3 centimeters Depth 0.1 . 3. 10/20/17 . Length 4.5 centimeters Width 3.5 centimeters Depth 0.1 . Stage II (stage 2) 4. 10/24/2017 4:39 PM . Length 4.5 centimeters Width 3.5 centimeters Depth 1 centimeters . Exudate light (pale red to pink thin and watery) . Stage III (stage 3) On 10/25/17 at 10:20 AM, the Administrator was interviewed on how the aides are alerted to changes in interventions for ADL care for residents and the Administrator responded, There are sheets on new admits they can fill out otherwise it's in the profile. When the administrator was alerted that every observation of resident #702 in bed and that the head of bed was elevated nearly 90 degrees each time, the administrator had no response. On 10/25/17 at 12:45 PM, observation of resident #703's bed mattress being removed and replaced with a pressure reduction air mattress. Resident #703 stated I got an air bed real quick she just mentioned she was going to get it. On 10/25/17 at 12:55 PM, the Director of Nursing( DON) was queried if the aides doing the ADL care are able to look at the care plans, the DON responded, No, Matrix is not linked to care tracker. On 10/25/17 at 1:30 PM, an interview with nurse G regarding resident #703's worsening wound, nurse G responded I measured it last night and it is deeper than 0.1. I am going to do Santyl 1 more week and if it doesn't respond I am going to have to start packing it. Nurse G was queried on the appearance of the wound including edges and surrounding tissue and that resident #703 is having pain in the wound, nurse G responded I called Doctor I and he is coming in tomorrow to look at it. The administrator who was present during this interview. On 10/25/17, at 2:00 PM, a review of the facility policy interdisciplinary team care guideline . effective date 06/15 revealed care plan interventions should be reflective of the impact the risk area, disease process have on the individual resident . problem area should identify the relative concerns . interventions should be reflective of the individual's needs and risk influence as well as the resident's strengths . On 10/25/17, at 2:10 PM, a review of facility policy titled, Pressure/stasis/diabetic wound condition guidelines . effective date 05/10/16 . to provide weekly documentation of wound measurements and condition . re-assessment/measurement weekly or with significant change in wound noting the current treatment, medical interventions provided . On 10/25/17, at 2:15 PM, The administrator was asked for a policy on care tracker and the policy for alerting aides/care team of changes in care plans/interventions and the administrator responded, they verbally talk with and report to aides and we don't have a policy on reporting to the care staff.

This citation has 2 deficient practice statements. This citation pertains to MI 945. Deficient practice #1 Based on observation, interview and record review, the facility failed to follow physician orders [REDACTED].#702) of 5 resident that were reviewed for falls from a total sample of 14, resulting in Resident #702 sustaining a left hip fracture that required a surgical repair. Findings include: According to the facility admission record dated 4/11/2014, Resident #702 was a [AGE] year old male originally admitted into the facility on [DATE] and readmitted on [DATE]. The annual history and physical dated 5/07/2015 reflected [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE] reflected a brief interview status of 6 indicating severe impairment and Resident #702 required assistance from staff for transfers, was nonambulatory and had 2 or more falls. The fall care plan dated 5/20/2015 reflected Resident #702 was at risk for falls due to dementia, history of falls, antidepressant medication use and need for extensive assistance with care. One of the interventions on the care plan was to place a personal alarm to the bed and the wheelchair. A review of the signed monthly physician orders [REDACTED]. A review of the facility form titled Fall Circumstance Assessment and Intervention dated 7/13/2015 reflected that Resident #702 was observed by Certified Nursing Assistant (CNA) Eon the floor on 7/07/2015 at 2:30 p.m., and complained of severe left leg pain, and was unable to move the left leg. Resident #702 was then transferred to the hospital. The investigatory report reflected Alarm not on at time of fall - cord to sensor pad alarm not connected to alarm box. Resident #702 self reported that he stood up to adjust his pants. The report reflected the wheelchair brakes were in the locked position. The facility investigation report identified the root cause of the fall as fall intervention not in place. .Sensor pad alarm was not connected to the pad and therefore did not alert resident to sit down. This resulted in a fracture. has been observed standing at other times and when he is alerted by his alarm he sits down. A review of hospital records dated 7/08/2015 reflected Resident #702 sustained a left hip fracture from the fall, surgical repair was completed on 7/08/2015 to assist with pain control and maintain function. The facility's physical therapy evaluation dated 7/10/2015 reflected prior level of functioning with bed mobility and sitting was supervision current level was maximum assistance with 2 person assist. Gait distance prior to fall was 10 feet, current level was unable. Wheelchair mobility prior to fall was modified independence, post fall with fracture dependent (100% assist.) Positioning, positioning assist prior to fall was modified independence post fall was dependent (100% assist.) On 3/30/2016 at 12:05 p.m. during a telephone interview with CNA C reported he had worked the day shift on 7/07/2015 and was assigned to Resident #702. CNA C reported he had changed Resident #702 pants several times that day, and that he was agitated that day he was fixated on his pants. CNA C reported that he left the facility at 2:00 p.m. and was not at the facility at the time of the fall. When queried if he had attached the alarm to the wheelchair after changing Resident #702's pants he reported he could not remember. When queried the last time and location he saw Resident #702 on that day, CNA C stated in his room, he was in his wheelchair just before 2:00 p.m. On 3/30/2016 at 2:35 p.m. during an interview with Licensed Practical Nurse (LPN) D she reported she was assigned to Resident #702 on 7/07/2015 and remembered visualizing him within 30 minutes of the fall but did not recall if the alarm was attached to the wheelchair. On 3/30/2016 at 2:45 p.m. during an interview with CNA E she reported working the afternoon shift on 7/07/2015, I went to answer someone else's call light and I heard yelling, he was on the floor on his left side, the first thing that hit me was, why didn't I hear his alarm?, I called the nurse down and saw the alarm box attached to the bed, not the wheelchair. CNA E further reported last July there was 1 alarm box that staff would move from wheelchair to bed depending on where the resident was, Now we have a lot of alarm boxes, he has one for both wheelchair and his bed now. CNA E reported she had received a verbal report from CNA C at shift change but they had not done rounds, and she did not recall being told in report that Resident #702 had been fixated on his pants or being agitated and she had not seen Resident #702 that day until after the fall. When observations were shared with CNA C of Resident #702 made on 3/29/16 - 3/30/2016 of Resident #702 consistently sitting near nurses station/common area CNA C reported staff try to keep him there for supervision purposes. During an interview with Director of Nursing (DON) B she reported on 3/30/2016 at 1:20 p.m., that she held all staff that were assigned to Resident #702 on 7/07/2015 accountable for his fall. Stating CNA C he should have checked to ensure the alarm was on the wheelchair. Nurses are overall responsible for residents safety and well-being, they all received disciplinary action and education. According to the facility policy titled Falls Management Program Guidelines with a revision date of 6/15 bullet point 5. Any orders received from the physician should be noted and carried out. During the entrance conference on 3/29/2016 at 8:30 a.m. with Administrator A and Director of Nursing B any past non-compliance packets were requested, none were presented by the facility related to Resident #702's fall throughout the survey that exited 3/31//2016. ( ) Deficient Practice #2 This citation pertains to intake MI 460 Based on observation, interview, and record review, the facility failed to supervise a resident with exit seeking behavior, and failed to implement interventions to prevent elopement, for one (#713) of 6 sampled residents reviewed for elopement precautions, out of a total sample of 14 residents, resulting in the resident exiting the building, and being brought back to the facility by a stranger who found the resident by the road. Findings include: On 3/30/16 at 3:00 pm, Resident #713 was observed in bed, with a staff sitter who was providing close, 1:1 supervision for the resident. Clinical record review on 3/30/16 at 3:30 pm revealed that Resident #713 was originally admitted into the facility on [DATE], and was readmitted on [DATE], with [DIAGNOSES REDACTED]. According to the Nursing Admission Assessment, dated 3/15/16, Resident #713 had cognitive impairment that effects safety/judgement, was independent with ambulation (wheelchair), and mental functioning varies over the course of the day. Review of an Event Report for Resident #713, dated 3/19/16, noted: Description: Resident elopement at 9:45 pm 3/19/16, You guys let me go .I had the papers. Where the resident was found? 5370 East Baldwin Road in parking lot by road. Who found the resident? Stranger driving by brought resident back to Assisted Living side of building. When was the resident last seen? 3/19/16 at 9:05 pm when accu check and coverage completed, resident refused all meds. Did resident exhibit any of the following behaviors prior to exit seeking? Anger regarding facility placement, verbalizing statements about leaving, Resident's wife visited around dinner time and resident thought she was here to pick him up, he wanted to put on his shoes and get coat to leave, he was not happy about staying to do therapy. Resident's wife left and resident tried to follow at first, resident was not easily redirected. Review of a One on One Inservice Record for Nurse H, dated 3/21/16, noted: Initiation of a wanderguard should be implemented when resident verbalizes or shows signs and symptoms of exit seeking, ie putting on shoes, coat, packing belongings or trying to get out exit doors. On 3/31/16 at 2:00 pm, Nurse H, who identified herself as the floor nurse working on the night Resident #713 eloped from the facility, was queried. Nurse H stated, His (Resident #713) wife was visiting at dinner time, and he was very agitated. His wife decided to leave, and he (Resident #713) tried to follow her out the door of his room. After a while, we were able to redirect him, and he seemed calm. I went into another room, and I heard his tab alarm going off. I came out of the room, and saw him at the exit door at the end of the hall with Certified Nurse Assistant (CNA) J. She (CNA J) was having a hard time with him (Resident #713). I kept him with me most of the night, and when I had to go into another room, I traded him off with (CNA J). At about 9:05 pm, he was in his room, and I gave him his insulin, and he seemed fine. I told him I would be back later, and I left him in his room. I went to check on another resident, and when I came out, (CNA J) asked me where he (Resident #713) was. I said, he's in his room, and she said, No, he's not. We checked the unit and couldn't find him, and that's when we started looking for him. We split up, and (CNA J) went over to the Assisted Living (AL) side to look for him. I heard a door alarm on the AL side, and when I went over there, I saw (CNA J) with Resident #713 in his wheelchair. At that time, I didn't know that he had gotten outside, and had just been brought back inside. At that time, it was about 9:42 pm. Nurse H stated that she was given a 1:1 inservice regarding the elopement incident and stated, The DON told me I should have put a wanderguard on him (Resident #713) when he started having exit seeking behaviors. On 3/31/16 at 10:00 am, The Director of Nursing (DON) was queried regarding the 3/19/16 elopement for Resident #713. The DON stated that Resident #713 had been assessed for elopement risk upon his admission on 3/15/16, and it had been determined that he was not at risk for elopement because he was not exhibiting exit seeking behaviors or verbalizing that he wanted to leave. The DON stated that Resident #713 did not try to leave the building until the night of the incident (3/19/16). The DON stated that Nurse H had administered insulin to Resident #713 on 3/19/16 at 9:05 pm. The DON stated that review of the facility's surveillance cameras showed Resident #713 propelling himself out the facility's front door on 3/19/16 at 9:25 pm. The DON stated that at that time, the front door did not lock until 10:00 pm, but that the facility now locks the front door at 8:00 pm. The DON further stated that review of the cameras showed Resident #713 being brought back into the facility on the Assisted Living side by a stranger on 3/19/16 at 9:42 pm. The DON stated that the stranger that brought Resident #713 back to the facility did not stay to give a statement, and they did not get her name. Review of the facility's Elopement Procedures, dated 9/2007, noted: Purpose: To prevent elopements by appropriately assessing resident risk factors, observing resident patterns, communication with family/responsible party, identifying the significance of risk factors, implementing prevention interventions and making environmental adaptations. Procedure: 1. Each resident will be assessed upon admission, at least quarterly and with change in condition for factors that may impact their off grounds privileges or risk for going to an unsafe area and to determine the supervision required to leave the facility grounds .3. A plan of care will be developed and implemented for each resident identified as having the potential to leave the facility unauthorized or requiring supervision for off grounds privileges . On 3/31/16 at 10:20 am, the Director of Nursing presented the following plan of correction, with a completion date of 3/25/16. Past Non-Compliance: Elopement Submission of this plan of correction is not an admission by The Oaks At Woodfield Health Campus that the deficiencies alleged in the survey are accurate or depict the quality of nursing care and services provided to the residents of this health care facility. This plan of correction is submitted in accordance with state and federal regulatory guidelines. #1: Resident was readmitted to the campus 3-29-16. Resident was assessed to be at risk for elopement. Wanderguard put into place upon re-admission. #2: All residents at risk for elopement have been re-assessed. The records of residents at risk have been reviewed for risk of elopement, interventions have been implemented. #3: Staff have been re- educated by DHS and designee on Missing Resident Procedure Guidelines. Staff education will be completed by 3-25-16. Exit doors will be locked at 8 PM. Wanderguard checks being completed on all residents at risk daily. One to one in-servicing completed with Nurse and Aide assigned at time of elopement. #4: Elopement drills and Wanderguard checks will be completed at random weekly for 6 weeks. Audit findings will be submitted to QA committee for follow up and further monitoring recommendations. The DHS or designee will be responsible for maintaining continued compliance. ( )