Every finding on record at The Rivers Health & Rehabilitation Center of Gross

This citation pertains to Intake 2674204. Based on observation, interview, and record review the facility failed to provide adequate supervision to prevent elopement of one cognitively impaired resident (R901) of three residents reviewed for elopement risk. Findings include: A Facility Reported Incident documented, On 11/12/2025, (R901) had exited the building at 10:14 PM and was returned to their room at 10:26 PM. This data was from camera review. R901 had been located by a laundry associate at 10:20 PM who had just punched out for the end of their shift. R901 stated (R901) was going to visit (their) friend but was agreeable to return to the building. A review of the facility Safety Event-Elopement report dated 11/13/25 documented nursing discovered the resident was off the unit at 10:07 PM.On 11/24/25 at 7:40 AM and 8:01 AM, Security Desk Staff A reported someone was to be seated at the desk 24 hours a day and if a break is needed a substitute staff person needs to be in place. Staff A was asked about cameras which revealed the exits of the facility were visible with a camera view. A camera was observed mounted to the ceiling at the entry to the hallway to the first-floor nursing unit. Staff A was asked about a list of residents with known wandering or elopement risk and revealed a bulletin board behind the security desk on which pictures of known elopement risk residents. On review it was noted two of the pictured residents on the board had been discharged months earlier. A picture of R901 was not on the bulletin board. Staff A was unsure of who kept the bulletin board up to date.At 9:15 AM, Certified Nursing Assistants (CNA) F and G reported they were aware of R901's tendency to wander and end up down the hall around the elevator. Both CNAs worked on the floor where R901 resided.At 9:30 AM, Licensed Practical Nurse (LPN) H reported R901 easily moved around by walking fast but would sometimes use their wheelchair. LPN H reported R901 was adamant about getting out and in the last couple of months was more apt to walk to the elevator, get on and go downstairs, but was easily redirected once located. LPN H reported security staff along with nursing staff were aware of R901's wanderings. LPN H further reported R901 would play like they were relaxing on the couch in lobby area by the elevator but would actually be looking for staff in the hallway and wound say, you caught me then redirected to return to the floor or move away from the elevator. When asked about R901's cognition, LPN H reported R901 knew their name, what type of place they were in. At 9:50 AM, the unit clerk reported R901 had been more actively wandering to the elevator and downstairs in the last thirty days or so prior to the elopement and knew staff were watching them.At 10:30 AM, the Director of Nursing (DON) was asked about their knowledge of the elopement and staff present at the security desk and confirmed security staff had stepped away, leaving the security desk unattended, at the time R901 exited the facility. The DON also confirmed the front door was not alarmed and R901 pushed it open when it did not open automatically.At 2:33 PM, Security Staff N reported, when you go on break, you have to make sure someone watches the desk. Staff N further noted residents do walk into the lobby about once a week and ask to go out or just look out the window or sit on one of the couches. At 3:46 PM, LPN R acknowledged they were the assigned nurse for R901 on the night shift 11/12/25. LPN R reported R901 was mostly in the lounge and did a lot of singing and watching TV. LPN R reported they had not witnessed R901 walk down the hall to the elevator. LPN R reported they thought it was around ten minutes after the elopement code was called that R901 was back on the floor.At 4:13 PM, CNA V reported they were aware R901 liked to roam around and had last seen R901 in the activity room between 9:30 PM and 10 PM on 11/12/25. CNA V noted they were giving another resident a bath around 10 PM which was about the timeframe LPN R was passing meds to the same resident. At 4:29 PM, the Administrator reported their knowledge of the elopement was from viewing the cameras. The Administrator reported R901 exited at 10:14 PM, while security was in the restroom. The Administrator reported the timing of the elopement code and the location of R901 by the laundry aide were about the same time. It was further noted the cameras for the second-floor hallway were not in operation and it looked like R901 had arrived in the lobby around 10:12 PM. R901 stopped looked out the front doors and then pushed them out of the way and walked out. On 11/25/25 at 10:11 AM, a phone message was returned by Security Staff O. Staff O reported it was about 9:45 PM to 10 PM when they went to the bathroom after being unable to reach any staff via the phone. When they returned to the lobby a female staff alerted them a resident was missing. LPN R came down shortly after so Staff O went to the office and reviewed the camera footage. Staff O reported they saw R901 come around the furniture in lobby and stood before the front doors and when they did not open R901 pushed the door open. Staff O noted R901 had come down from the second floor at two different times during the same evening R901 had eloped. A review of the record for R901 revealed R901 was admitted into the facility on [DATE]. diagnoses included Schizophrenia, Dementia and Insomnia. A review of the Minimum Data Set (MDS) assessment dated [DATE] documented a 5/15 Brief Interview for Mental Status (BIMS) score which indicated severe cognitive impairment. The MDS further documented that R901 had wandering behavior. A review of the most recent care plans documented, I have a variety of interests that include spending time with others, going outside, watching movies and listening to music. Wandering halls and into other rooms, usually easily redirectable. Attempting to leave facility unattended. Placed in Elopement Books throughout facility and at security. Category: Behavioral Symptoms: Start Date: 06/17/2025. Last Reviewed/Revised 09/09/2025 08:44 AM; Problem: I scored 12 or greater on elopement assessment. Category. Behavioral Symptoms. Start Date 06/17/2025. Last Reviewed/Revised 06/17/2025. Approach: Observe for whereabouts and redirect as needed. Start Date 09/21/2025; Problem: I display poor short- and long-term memory deficits. I am alert and oriented x 1-2, with periods of increased confusion. Able to make simple needs known. Category Cognitive Loss / Dementia Start Date 06/17/2025 Last Reviewed/Revised 06/17/2025 04:02 PM; MDS date 09/09/25. A review of the Elopement Risk assessment dated [DATE] documented a score of 22. This indicated high risk and that greater than 12 was considered at high risk. A review of the progress notes indicated some increase in elevator use activity since 04/15/25. A note dated August 8th, noted redirected several times from the area around the elevator. Additional dates noted were: 10/27/25, 09/30/25, and 09/12/25. Social work documented similar concerns on review in notes dated 09/11/25 and 09/09/25, with frequent attempts and redirection noted, these single notes included Wandering halls and into other rooms, usually easily redirectable. Attempting to leave facility unattended. Placed in Elopement Books throughout facility and at security. Approach: Attempt distraction with an activity, snack, conversation, etc. Start Date; 09/09/2025, Approach: Placed picture in Elopement Books throughout facility and at security. Start Date 09/09/2025, Approach: Observe whereabouts and redirect as needed. Start Date 09/09/2025.A review of the undated facility policy titled, Resident Elopement revealed, It is the facility's policy to provide residents with a safe and secure environment and identify residents at risk for unplanned exit from the facility. Residents who enter the facility may display behaviors that are unsafe particularly since they are entering an environment that is unfamiliar. Residents with cognitive loss or impaired judgement may attempt to leave the premises, known as exit seeking behavior. Residents are most vulnerable in the early admission period; however, residents with progressive cognitive disorders can begin displaying exit seeking behaviors at any time . Monitoring doors: All exit doors on each unit will be checked to ensure they are locked and secure every shift. Door security of exit doors will be documented on every shift per nursing assignment sheet. The designated staff will initial off on the assignment sheet. Maintenance/or designee will check all doors in the building twice daily. Any deficient door(s) will be reported to the Maintenance Director immediately. If the alarm system is not in working order, staff will be required to check all doors hourly until the alarm system is up and running .

Based on observation, interview, and record review, the facility failed to assess and treat a wound for one resident (R68) of one reviewed for wound care and failed to ensure appropriate positioning while in bed for one resident (R11) of one reviewed for positioning. Findings include: R68 On 8/18/25 at 10:55 AM, R68 was observed to have a pink foam dressing between the elbow and wrist that had leaked dried blood on the upper border of the dressing. The dressing was not dated. R68 was dressed in a short-sleeve shirt. A review of the medical record revealed R68 was admitted on [DATE] with the following relevant diagnoses: Non-ST elevation myocardial infarction (heart attack), atrial fibrillation (rapid heart rate), and diabetes, type 2. Their [NAME] Data Set assessment revealed an intact cognition. On 8/19/25 at 9:00 AM and 12:27 PM, the pink foam dressing remained in the same condition as the previous observation. R68 was wearing a short-sleeved shirt. On 8/19/25 at 3:31 PM, R68 was interviewed regarding the dressing, they revealed it occurred when an unknown staff member had touched a large blood blister on their arm, and it began to bleed. The unknown staff member applied a pink foam dressing to their arm that has not been changed since initially applied. On 8/20/25 a review of the R68's shower sheets revealed on 8/12/25, a shower was given by Certified Nurse Assistant (CNA) H and they had indicated a change in skin condition R68's right forearm corresponding with the location of the dressing. A review of the Electronic Medical Record (EMR) revealed no documentation regarding the wound by nursing or medical staff. Further review revealed a progress note by the Rehabilitation Nurse Practitioner (NP) dated 8/12/25 which indicated the following: SKIN – No skin lesions or rashes noted in exposed upper/lower limbs. A progress note dated 8/19/25 by the NP revealed the following: SKIN – No skin lesions or rashes noted in exposed upper/lower limbs. On 8/20/25 at 3:55 PM, an interview with Wound Care Nurse (WCN) C revealed they were unaware of any skin issues with R68. They further revealed that when any caregiver notes a change in a resident skin condition, they are to be notified, and staff are to initiate treatment (cover/protect with appropriate dressing) and notify them. Staff are then to document their findings in the nursing progress notes, if a CNA notices the change, they are to notify their nurse. On 8/20/25 at 4:10 PM, the Director of Nursing (DON) confirmed that when a staff member notices a change in skin condition, the nurse for the resident should be notified. The nurse then puts a treatment in place and notifies the wound care nurse. A review of the policy titled, Skin Management Facility Guidelines revised April 2023, revealed the following: . 10. A weekly meeting will be conducted by the Interdisciplinary Team as necessary. Residents reviewed for skin alterations .3. The presence of any pressure ulcer, wound, or other skin condition is documented weekly on the pressure ulcer or skin report forms. R11 On 8/18/25 at 12:31 PM, an observation was made of R11 being in bed and positioned a quarter to a third of the way down from the top of the mattress. Mats were observed on both sides of the bed. On 8/19/25 at 11:35 AM and 12:11 PM, R11 was in bed and was observed positioned a quarter to a third of the way down from the top of the mattress and close to the edge of the bed nearest the door with their right elbow being very close to being off of their bed. Mats were observed on the floor on both sides of the bed. On 8/19/25 at 12:43 PM, R11 was observed in bed with the head of the bed elevated approximately thirty degrees and their tray table in front of them eating their lunch. R11 was interviewed and asked if they would like to be repositioned in bed and sitting up straighter. R11 stated, sure. On 8/19/25 at 12:48 PM, Certified Nursing Assistant (CNA) A who was walking by R11's room, was interviewed about R11's current positioning in bed. CNA A stated, I'll get another Aide (CNA) and we will reposition [R11]. On 8/20/25 at 10:39 AM, Unit Nurse Manager/LPN (Licensed Practical Nurse) B was interviewed regarding positioning expectations for R11. LPN B indicated R11 tends to slide down from the top to the middle of their bed and lay close to the side of their bed. LPN B said R11 was a fall risk and had a history of falls and their expectation was for staff to be checking on the resident regularly to ensure they were appropriately positioned. On 8/20/25 at 11:30 AM, the Director of Nursing (DON) was interviewed regarding their expectations for positioning of dependent residents in bed and during meals while in their bed eating. The DON confirmed during a meal the resident should be in a seated position with the tray table positioned directly in front of them. The DON further indicated R11 was a fall risk and should be positioned appropriately in bed as needed. A review of R11's care plan revealed an intervention which documented R11 should be assisted with turning and repositioning as needed to avoid pressure ulcers and falls. A review of R11's electronic medical record (EMR) revealed R11 was originally admitted to the facility on [DATE] with diagnoses that included Dementia and COPD (Chronic Obstructive Pulmonary Disease-lung disease). R11's most recent minimum data set assessment (MDS) dated [DATE], revealed that R11 had a severely impaired cognition and required partial to moderate assistance for bed mobility and all other activities of daily living (ADLs) other than eating. On 8/19/25 at 2:14 PM a policy regarding positioning was requested from the facility and not received by survey exit.

This citation pertains to Intake:1359931Based on observation, interview, and record review, the facility failed to prevent a fall for one resident (R14) of three residents reviewed for falls. Findings include:A review of information submitted to the State Agency (SA) revealed R14 sustained a fall due to their assigned Certified Nursing Assistant (CNA) providing care alone resulting in a transfer to the hospital for an evaluation.On 8/18/25 at 9:25 AM, R14 was observed lying in bed with two fall mats observed on both sides of their bed. Attempts to interview the resident were to no avail due to their cognition.A review of R14's medical record revealed they were admitted into the facility on [DATE] with diagnoses that included Dementia, Chronic Obstructive Pulmonary Disease, Heart Failure, and Diabetes. Further review revealed the resident was cognitively impaired and required extensive assistance of two staff for bed mobility.Further review of the medical record revealed the following care plan: Problem Start Date: 02/13/2024 Category: ADLs (activities of daily living) Functional Status/Rehabilitation Potential. [R14] requires assistance with ADL's due impaired mobility, B/L AKA (bilateral above knee amputation), and dx (diagnosis) of dementia .Approach Start Date: 11/18/2024. Assist me with two-person bed mobility .On 8/19/25 at 10:38 AM, an attempt to contact R14's assigned nurse, Licensed Practical Nurse (LPN) L the date of the fall was to no avail. On 8/19/25 at 12:04 PM, CNA M was interviewed via phone regarding R14's fall and explained while attempting to change the resident when they became agitated and combative. CNA M further explained the resident let go of their grab bar and fell to the floor. A review of the medical record revealed the following progress note authored by LPN L: 6/12/25 at 7:05am. Resident experience a fall during care. Writer had previously informed the CNA that resident might refuse care due to [their] combative behavior. The CNA was well aware of this, as she witnessed the resident slap the writer during an earlier interaction. I told the CNA that it was in best interest to leave the resident alone. Res and CNA exited the room. Writer notified everyone on the 2nd floor that she was going on break. Writer went to her car. 20 minutes later the CNA was knocking on my window. Stating that [R14] fell on her. The CNA reported that the resident was holding onto the bed rails and actively resisting being turned. During this struggle, the resident fell on top of her. Upon assessment, the resident was found with blood actively gushing from area just above the right amputation swite (site). All surgical staples remained intact; however, tissue was noted hanging from the tip of knee. (An old slightly opened sore was noted on the top surface of knee as well). The wound care specialist was immediately contacted. After an evaluation, the specialist was determined it was in the resident best interest to be sent out for further medical care A review of one-on-one in-service documentation dated and signed by CNA M noted the following, Topic of Inservice: ADL Care. DON (Director of Nursing) met with employee to discuss the concerns with the care provided to [R14]. Per the nurse on duty pt (patient] was combative .the CNAs did the care which resulted in a fall out of bed during positioning. Outcome of in-service: Moving forward employee will attempt to redirect resident or allow then to calm down before providing care.On 8/20/25 at 10:58 AM, the DON was interviewed regarding the fall of R14 and acknowledged that there was one CNA providing care to the resident, and the resident required two. A review of the facility's Fall Management Guidelines revealed the following, 2. Residents identified at risk for falls will have a care plan developed and implement fall prevention interventions as needed based on their assessment .

Based on observation, interview, and record review, the facility failed to provide staff with education regarding (R68's) Wearable Cardioverter Defibrillator (WCD- a device that continuously monitors the heart and can automatically deliver a shock to restore normal rhythm if it detects life-threatening arrhythmias) for 3 of 3 direct care nursing staff. Findings include:On 8/18/25 at 9:34 AM R68 was sitting in their wheelchair. Upon inquiry R68 revealed they had a WCD vest due to recently having a heart attack. They further revealed that it had not been activated (no shock given) since they first began to wear it. R68 revealed there are two batteries one is always charging the other is on the device and the vest is only removed for showers.A review of the Electronic Medical Record (EMR) revealed R68 was admitted on [DATE] with the following relevant diagnoses: Non-ST elevation myocardial infarction (heart attack), atrial fibrillation (rapid heart rate), and diabetes, type 2. R68's Minimum Data Set assessment revealed an intact cognition. A review of the EMR revealed a physician order as follows: Monitor function of WCD every shift. Confirm battery is fully charged on vest as well as the spare on the charger. Notify MD with concerns. Twice A Day 07:30 - 11:30 AM, 07:30 PM - 11:30 PM.On 8/19/25 at 9:30 AM an inquiry regarding the function of the WCD vest was made to Licensed Practical Nurse (LPN) F. LPN F revealed the device alerts them and staff if the heart rate drops too low. LPN F further revealed the resident will get a message when battery is low and it can be heard when near the resident room, not at the nursing desk. LPN F did not know the device would deliver a shock if R68's rhythm became dangerously irregular or what the risks were for the resident. On 8/19/25at 9:45 AM, LPN J was queried and did not know what the device was or what it was used for.On 8/20/25 at 9:27 AM, an inquiry with LPN E revealed they did not know how to monitor the function of the device but knew they had to push a button on the front of the device and a message indicating battery was charged and resident name would appear. LPN E was unaware a shock would be delivered if the device was activated. On 8/20/25 at 2:30 PM, Staff Educator (SE) K was interviewed and revealed they was not invited to an in-service meeting with the company providing the device. SE K further revealed they were familiar with the device, had extensive conversation with R68 and knew there was paperwork with instructions in the resident's room. On 8/20/25 at 10:50 AM the Director of Nursing (DON) was queried about how the staff were educated on the WCD vest and/or other equipment that staff may be unfamiliar with. The DON indicated that the company providing the vest, came to the facility and gave about an hour in-service. The DON further indicated that a sign-in sheet was not provided so there is no documentation of who was educated and if those staff members were care givers for R68.

Based on observation, interview, and record review, the facility failed to ensure a medication error rate of less than five percent for one (R2) of three residents reviewed during medication pass. Findings include:A review of the electronic medical record (EMR) revealed R2 was admitted on [DATE] with the following relevant diagnoses: Traumatic Subdural Hemorrhage (stroke), Diabetes, Convulsions (Seizures), Atrial Fibrillation, and Schizoaffective Disorder. The Minimum Data Set assessment revealed severe cognitive impairment. R2 also requires maximum to substantial assistance for all activities of daily living and mobility. On 8/19/25 at 9:19 AM, during a medication observation for R2, it was noted the resident was on two extended-release medication, Depakote and Keppra which should not be crushed. An inquiry as to how those medications would be delivered, Licensed Practical Nurse (LPN) F revealed if a capsule, they would crush the other tablets, then empty capsule contents into the medicine cup and then mix with applesauce per resident preference. Further inquiry regarding if extended-release medications should be crushed or capsule opened, LPN F hesitated and after several minutes stated no. LPN F then identified the Depakote and Keppra and removed them from the dispensing cup with their ungloved finger/hand. The tablets were then laid on the cart top near the opened packages and LPN F crushed the remaining medications, mixed with applesauce and dispensed to resident leaving the extended-release medication unattended on the medication cart outside the room and proceeded to enter the resident's room. LPN F return to the medication cart, gather the packages and two medications and place them in the cart trash bag.Further inquiry regarding what is done with discarded medications, LPN F indicated she would take the two meds out of the trash after medication pass was completed and put them in the drug buster container in the medication room. On 8/19/25 at 10:00 an interview with Unit Manager (UM) G indicated extended-release medications should not be opened or crushed and the order should indicate the same. A review of the Electronic Medical Record (EMR) revealed an order for levetiracetam (Keppra) 500 milligrams (mg) one tab that should not be crushed. Further review of the EMR revealed an order for valproex (Depakote) 500 mg 1 tab that should not be crushed. The container indicated the drug name and dose with a notation do not crush.An interview with the Infection Control Nurse (ICN) K revealed, when a nurse is required to remove a medication that either the resident does not want, does not fall within parameters outlined by the physician or was put in the medication cup in error, the nurse should have a glove on or use a clean spoon to retrieve it.On 10/20/25 at 12:00 PM an interview with the Director of Nursing (DON) indicated when R2's dietary downgraded on 4/14/25 was implemented, the pharmacy should have been notified to change any non-crushable medication to another form, i.e., liquid. Prior to the dietary downgrade, R2 took their medications whole in applesauce, after the downgrade medications were crushed in applesauce. The DON further revealed that nurses should be aware that extended-release medication capsules/tablets should not be opened or crushed and that there is a DO NOT CRUSH list of medication available to them. They further revealed if a nurse comes upon an order for a non-crushable medication for a resident who requires crushing, the physician should be notified. A Medication Administration Policy was requested on 8/19/25 at 12:24 and was not received by survey exit.

Based on observation, interview and record review the facility failed to properly label medication in one of two medication carts. Findings include:On [DATE] at 10:00 AM, Licensed Practical Nurse (LPN) L was observed administering medication from the second floor medication cart and the following medications were observed to be without an open date; Lispro Insulin Pen, Tobramycin Eye Drops, and a bottle of Enulose liquid. Also observed was vial of Novolog without a resident label or an open date and a bottle of Latanoprost Eye Drops with an expired date of 5/31. Under the dated label was a sticker indicating it should be discarded 42 days after opening. On [DATE] at 10:13 AM, an interview with LPN L revealed all multi-use prescription medications should have a resident identifier as well as an open date.On [DATE] at 10:15 AM, an interview with Unit Manager (UM) B revealed that the medication carts are reviewed each week for unlabeled, undated medication and those that are found are discarded in the sharps container or a drug busting solution to prevent use. UM B further revealed all multi-use prescription medications should have a resident label and be dated when opened.On [DATE] at 10:50 AM, an interview with the Director of Nursing (DON) revealed all medication in the medication carts should be dated when opened and should have a resident identifier. Any prescription item without a resident identifier or open date should be discarded.A policy for Medication Storage was requested on [DATE] at 12:34 PM and was not received by survey exit.

Based on observation, interview and record review, the facility failed to ensure that call lights were in reach for one dependent resident (R11) of five reviewed for call light accessibility. Findings include: On 8/18/25 at 12:25 PM, R11 was observed lying in their bed with no call light anywhere in sight. R11 was interviewed regarding the location of their call light and was unaware of its location. On 8/19/25 at 11:42 AM, 12:11 PM, 1:15 PM, and 2:16 PM, R11's call light was observed to be on the floor by the side of the bed farthest from the door. R11 indicated that they were unaware of the location of their call light. On 8/20/25 at 10:45 AM, Unit Nurse Manager (UNM)/LPN (Licensed Practical Nurse) B was interviewed regarding their expectations for call light placement when residents were in their rooms in bed. UNM B indicated that the call light should be accessible to the resident and clipped to the resident when in bed. On 8/20/25 at 11:50 AM, the Director of Nursing (DON) was interviewed regarding their expectations for call light placement when residents were in their rooms in bed. The DON indicated that the call light should be clipped to the resident and within their reach. A review of R11's electronic medical record (EMR) revealed that R11 was originally admitted to the facility on [DATE] with diagnoses that included Dementia and COPD (Chronic Obstructive Pulmonary Disease) (lung disease). R11's most recent minimum data set assessment (MDS) dated [DATE], revealed that R11 had a severely impaired cognition and required partial to moderate assistance for all activities of daily living (ADLs) other than eating. A facility policy titled Accommodation of Needs with no date, was reviewed and stated the following, Procedures 4. Ensure that the resident has the call system within reach and can use it if desired.

This citation relates to Intake # MI00148495. Based on interview and record review, the facility failed to notify the responsible party and physician of x-ray findings timely for one Resident (R901) of three residents reviewed for change of condition. Findings include: On 12/04/24 at 11:08 a.m, R901's Family Member, FM B, reported they were concerned R901 received a diagnosis of a new left knee fracture which occurred during their stay at the facility, from 11/04/24 to 11/22/24. FM B stated they learned about the new knee fracture when they accompanied R901 to their orthopedic surgical follow-up visit on 11/22/24, which was for a left hip fracture that occurred on 10/30/24 from a fall FM B reported the orthopedic surgeon found the new left knee fracture during the visit, showed them the x-ray with the new fracture, and asked if R901 had fallen, or how the second fracture had occurred. FM B reported R901 was emergently transferred to an acute care hospital directly from the orthopedic surgeon's office on 11/22/24, where they underwent a second surgery to stabilize the new left knee fracture. FM B reported they noticed R901's left knee began swelling on 11/14/24 and 11/15/24 at the facility, which they reported to nursing management, including the Unit Manager, Registered Nurse (RN) A. FM B stated they knew something was not right. FM B learned R901 had a blood clot on 11/18/24 at the facility, although their leg remained swollen until 11/22/24, when they had the orthopedic surgery follow-up appointment. FM B reported they asked the facility nursing staff what had occurred after the appointment on 11/22/24, when they went to pick up R901's belongings, and no one explained the cause or the injury to them. Review of R901's Minimum Data Set (MDS) assessment, dated 11/10/24, revealed R901 was admitted to the facility on [DATE], with diagnoses including hip replacement, anemia, diabetes, and dementia. R901 required maximal assistance with toileting, bed mobility, and transfers. The Brief Interview for Mental Status (BIMS) assessment revealed a score of 15/15, which showed R901 was cognitively intact upon admission to the facility. Further review of R901's Electronic Medical Record (EMR) on 12/04/24 revealed no documentation of any falls, accidents, or incidents during R901's stay, which was confirmed was from 11/04/24 to 11/22/24. Surveyor requested any accident and incident reports including falls related to this resident, and none were provided. Review of R901's hospital discharge record history and physical, beginning 10/31/24, revealed R901 was admitted on [DATE], with a fracture of the left intertrochanteric (hip) fracture, which was surgically fixated (stabilized) by nailing on 11/01/24. R901 was discharged from the hospital to the facility for care and rehabilitation on 11/04/24. The report further revealed R901 was WBAT (Weight Bearing as Tolerated) on their left lower extremity upon discharge, with physical and occupational therapy ordered. Review of Electronic Medical Record (EMR) revealed R901's left knee X-ray report, dated 11/19/2024 at 10:29 a.m, revealed R901 had a new distal (lower) displaced fracture of the left femur (long upper leg bone). The report described the fracture as Knee .left. Results: There is a displaced obliquely oriented (diagonal fracture often from a direct blow or forceful twisting motion) fracture of the distal left femoral metadiaphysis (the part of the femur located near the knee joint) . Further review revealed the X-ray report was faxed to the facility on [DATE] at 10:34 a.m., and initialed by the ordering provider, Nurse Practitioner, (NP) E, and undated. Review of R901's facility census revealed R901 was discharged to the hospital on 11/22/24 following the orthopedic appointment. Review of R901's orthopedic consult, dated 11/22/24, revealed, On post-op (operation) appointment, patient (R901) found to have a new (underlined) left femoral shaft fracture with left leg pain and inability to bear weight. Has been hurting for over one week, does not remember mechanism (cause of injury). Review of R901's progress note, dated 11/20/24 at 8:46 a.m., by Licensed Practical Nurse (LPN) C, revealed R901 complained of left leg pain of 7/10 (with 10 the highest pain), requiring as needed pain medication (not scheduled), with pain relief. Review of R901's progress note, dated 11/20/24 at 11:48 p.m., by LPN C, revealed R901 continued to keep their left leg externally rotated inward due to pain (level unspecified) whenever their leg was moved. There was no documentation of physician communication. Review of R901's progress note, dated 11/22/24 at 7:49 a.m., by LPN C revealed R901 continued to keep their left leg internally rotated due to pain (level unspecified) whenever their leg was moved. There was no documentation of physician communication. Review of R901's progress notes, dated 11/18/24, revealed R901 was diagnosed with a blood clot in their left leg, and Eliquis (an anticoagulant) was started. Review of R901's EMR from 11/19/24 to 11/22/24 revealed no documentation or interventions related to R901's distal femur (knee) fracture, including physician or resident/representative notification, a referral to an orthopedic physician, or an emergent hospital transfer. Review of R901's provider progress note, dated 11/18/24 at 6:37 p.m., by NP E revealed they visited R901 with a chief complaint of left knee edema (swelling). There was no mention of an x-ray being ordered in the progress note. Review of R901's EMR including physician orders with the daytime unit manager, Registered Nurse (RN) A, the Acting Director of Nursing (DON), revealed there was no x-ray order found. There was a referral found in the facility documents for the x-ray to R901's left knee after NP E's visit on 11/18/24. On 12/04/24 at approximately 1:45 p.m., RN A was asked about R901's x-ray report dated 11/19/24, showing the new distal femur (knee) fracture. RN A reported they or any nursing management had not been made aware R901 had a new knee fracture on 11/19/24, and they were not aware an x-ray had been requested by NP E. RN A reviewed the medical record and found no evidence of the physician or nursing documentation regarding the x-ray results. Further review of R901's nursing progress notes from 11/18/24 through 11/22/24 with RN A showed R901 reporting increased pain and staff noted rotation of their left leg. RN A explained if they had known about the fracture, they would have sent R901 out emergently for orthopedic follow-up and acute pain management. RN A confirmed there was no physician or provider documentation showing any awareness of the 11/19/24 x-ray results for a new distal femur (knee) fracture. On 12/04/24 at 2:15 p.m., R901's x-ray report was reviewed with Physical Therapist (PT) D, who confirmed R901's left distal femur (knee) fracture was a new fracture, after review of initial hospital documentation and their records. PT D clarified R901 made limited progress in therapy, and required maximal assistance with two people to transfer during their rehab stay and upon discharge. On 12/04/24 at 3:01 p.m., LPN C was asked about their documentation showing R901 had increased pain and their left leg being rotated inward on 11/20/24 and 11/22/24. LPN C reported they had not been made aware of any acute fracture on 11/19/24, and only knew R901 had new blood clot, and was being treated with Eliquis, so they believed their pain and condition was from the blood clot. When asked if they reported this to the physician, as no physician communication was documented respective to R901's increased pain and leg rotation, LPN C stated they had communicated with NP E on 11/22/24. On 12/04/24 at 3:57 p.m., NP E was asked during a phone interview about R901's 11/19/24 x-ray report which they ordered, showing a new knee (distal femur) fracture, NP E confirmed they initialed the x-ray however could not recall when they reviewed the x-ray report dated 11/19/24, as their initials were not dated. NP E recalled they were focused more on R901 having a blood clot, due to the swelling in their left leg. Review of R901's MAR (Medication Administration Record) report from 11/19/24 through 11/22/24, reviewed with the Nursing Home Administrator (NHA) and RN A, showed R901 received prn (as needed) Hydrocodone-acetaminophen (opioid pain medication). The medication was administered on 11/14/24 for pain of 7/10 in their left hip, on 11/15/24 for 7/10 pain in their left leg, on 11/16/24 for pain of 6/10 in their back, on 11/18/24 for 4/10 pain in their knee, on 11/19/24 for 7/10 pain in their left leg, and on 11/22/24 for pain in their left leg. On 12/04/24 at 4:20 p.m., the concerns were reviewed with the NHA and RN A, including R901 or their representative not being notified of an acute knee fracture on 11/19/24, increased pain and discomfort, lack of timely orthopedic consultation and/or emergent hospital transfer, and process concerns related to the x-ray not being made available to NP E timely, and nursing management not being made aware. Both reported they understood the concerns and confirmed they had already begun working on corrections during the survey to prevent a recurrence. Review of the policy, (Facility) Notification of Changes Policy, undated, revealed, It is the policy of this facility that changes in a resident's condition or treatment are immediately shared with the resident representative, according to their authority, and reported to the attending physician or delegate (hereafter designated as the physician). The resident and/or representative will be educated about treatment options and supported to make an informed choice about care preferences when there are multiple care options available. All pertinent information will be made available to the provider by the facility staff. Nursing and other care staff are educated to identify changes in a resident's status and define changes that require notifications of the resident and/or their representative, and the resident's physician, to ensure the best outcomes of care for the resident .A need to alter treatment significantly means a need to stop a form of treatment because of adverse consequences .or commencing a new form of treatment to deal with a problem (for example, the use of any medical procedure . The objective of the notification policy is to ensure that the facility staff makes appropriate notification to the physician and delegated non-physician practitioner and immediate notification to the resident and/or the resident representative when there is a change in the resident's condition, or an accident that may require physician intervention. The intent of the policy is to provide appropriate and timely information about changes relevant to a resident's condition .The nurse will immediately notify the resident, resident's physician, and the resident representative for the following .: A need to alter treatment significantly .

Based on observation, interview, and record review, the facility failed to maintain the dish machine to ensure dishware was sanitized. This deficient practice had the potential to affect all residents that consume food from the kitchen. Findings include: On 8/20/24 at 8:55 AM, dietary staff was observed cleaning soiled dishware in the facility's dish machine. At that time, a plate simulating dishwasher tester was sent through the dish machine to check the sanitizing properties of the facility's high temperature dish machine. The maximum temperature recorded on the plate simulator was noted to be 124 degrees Fahrenheit. The plate simulating dishwasher tester was sent through the dish machine a second time, and the maximum temperature was noted to be 125 degrees Fahrenheit. Dietary Staff continued to use the dish machine. On 8/20/24 at 9:10 AM, Dietary Manager (DM) O was queried about the dish machine, and stated that he was aware of the issue and had put in a work order for maintenance last week. No explanation was given as to why staff continued to use the dish machine, when it was not properly sanitizing. On 8/20/24 at 9:35 AM, Maintenance Supervisor P was queried about the dish machine, and stated that DM O had contacted him about the dish machine temperatures. Maintenance Supervisor P stated that because they rent the dish machine, that he told DM O he would have to call the company for service. Review of a work order dated 8/14/24 noted: Description: Dish machine not getting hot. According to the 2017 FDA Food Code section 4-703.11 Hot Water and Chemical, After being cleaned, EQUIPMENT FOOD-CONTACT SURFACES and UTENSILS shall be SANITIZED in: (B) Hot water mechanical operations by being cycled through EQUIPMENT that is set up as specified under SS 4-501.15, 4-501.112, and 4-501.113 and achieving a UTENSIL surface temperature of 71 C (160 F) as measured by an irreversible registering temperature indicator; P According to the 2017 FDA Food Code section 4-501.112 Mechanical Warewashing Equipment, Hot Water Sanitization Temperatures, (A) Except as specified in (B) of this section, in a mechanical operation, the temperature of the fresh hot water SANITIZING rinse as it enters the manifold may not be more than 90 C (194 F), or less than: Pf (1) For a stationary rack, single temperature machine, 74 C (165 F); Pf or (2) For all other machines, 82 C (180 F). Pf.

This citation pertains to Intake MI00146468. Based on interview and record review, the facility failed to notify the responsible party and obtain x-ray results timely for one resident (R123) of one resident reviewed for a change in condition, resulting in the responsible uninformed about a fall until hours later and a delay in treatment. Findings include: A review of the record for R123 revealed a progress note dated 06/10/24 at 10:30 AM by Unit Manager D which documented, Writer was reported to by oncoming staff that resident was lowered to the floor by CENA (Certified Nursing Assistant, CNA) on midnight shift while doing peri care, resident was reaching and grabbing onto CENA and CENA had to lower resident to floor for safety. Resident has abrasion on left shoulder and left side of torso, x-ray ordered to rule out any injury, (Director of Nursing) DON notified, spouse notified. investigation process and complete. Patient is resting well, no s/s of distress or discomfort. family at bedside. The previous progress note identified in the electronic medical record was dated 06/09/24 at 12:58 PM. No notification of the responsible party was documented until 06/10/24 at 10:30 AM. A review of the Nurse Practitioner (NP) note dated 06/10/24 at 6:07 PM documented, .Chief Complaint: fall at facility on 6/10 .Assessments/Plans: Unspecified fall .resident was lowered to floor by staff on 6/10 x-ray ordered to (rule out) r/o injury . A review of the Nurse Practitioner (NP) note dated 06/12/24 documented, . x-ray positive for left clavicle (fracture) FX spouse notified and desires transfer to the hospital for evaluation .resident was lowered to floor by staff on 6/10/24 . On 08/21/24 at 2:27 PM, Licensed Practical Nurse (LPN) E reported R123 was total care, non verbal, and two person for care. LPN E was asked what indicates the need to send a resident to the hospital and reported if the resident was on a blood thinner, if there was a fall with acute pain, a change in vital signs or the resident was not at baseline. LPN E was also queried about any issue with x-ray when ordered stat and reported x-rays were not truly stat and could take four hours or even the next day to result or get a technician out to the facility. On 08/21/24 at 2:46 PM, [NAME] Clerk G reviewed the order for the X-Ray for R123. It was noted the order was sent early afternoon on 06/10/24. Clerk G noted x-rays are usually ordered at the time of the fall and R123's fall actually happened on midnights (11PM - 7AM). Clerk G reported the x-ray was ordered stat and generally the technician will come in two hours or at least the same day. On 08/21/24 at 4:57 PM, LPN H reported that R123 had been sent out prior to their afternoon shift on 06/12/24. On 08/21/24 at 5:00 PM, Unit Manager (UM) D and Wound Nurse I were asked about R123's fall. UM D reported they found about the fall when they came into to work on 06/10/24. UM D was asked about the x-ray company and timeliness and reported there was a delay and the report did not arrive until the 06/12/24. UM D reported they had contacted the responsible party about the fall once they found out about it and the night nurse assigned had not called the family or notified the Director of Nursing as should have been done. UM D further reported the responsible party was called when the result of the x-ray was received on 06/12/24. A progress note dated 06/11/24 at 2:44 PM, by LPN E documented, .localized swelling (left) Lt shoulder clavicle region, also noted mild swelling and bruising around Lt eye .x-ray results pending . On 08/22/24 at 8:57 AM, LPN E confirmed they did see increased swelling to the face on 06/12/24. A progress noted dated 06/12/24 at 3:56 PM, by LPN H documented, 3:40 PM sent to (hospital name) for evaluation of left clavicle, due to abnormal x-ray report. On 08/22/24 at 9:17 AM, NP F reported they felt it was safe for R123 to stay at the facility until the x-ray results were reviewed. NP F reported R123 was stable from a clinical standpoint and once the x-ray result was received on 06/12/24, R123 was sent out to the hospital. The decision for R123 to remain was based on clinical presentation and R123 lacked any a change in vital signs, obvious pain, or deformity from the clavicle fracture. NP F reported a stat x-ray can take 24 hours and the expectation is the result is called to the faciity if acute like a fracture and also faxed to the facility. On 08/22/24 at 10:26 AM, R123's fall was reviewed with the Director of Nursing (DON). The DON reported they heard about the fall when notified by the management team later in the morning. The DON confirmed they were not called by the midnight nurse or CNA and the expectation is that all falls, injury or not, are reported to the DON when they occur. The DON was asked about the timing of the call to the responsible party and reported the midnight nurse should also have called the responsible party (like they documented they did). The DON was also asked about the timing of the x-ray and result received. A review of the x-ray result documented it resulted on 06/10/24 at 9:52 PM and documented a mild displaced fracture of the mid to distal left clavicle. The DON was asked why the result had not been reported until 06/12/24. It was noted the result was not received until 06/12/24 at 10:45 AM and the x-ray company should have called and faxed the result to the facility prior to that time. The DON further reported that staff should have called on 06/11/24 when no result had been received. On 08/22/24 at 3:01 PM, CNA K confirmed they worked the midnight shift with two nurses and another CNA on 06/09/24 into the morning of 06/10/24. CNA K reported they had to put R123 on the floor and had to do it by themselves as no one came when they called out for help. CNA K reported they and another aide helped to get R123 back into bed. A review of the record for R123 revealed R123 was admitted into the facility on [DATE]. Diagnoses included Hemiplegia and Hemiparesis following cerebral infarction affecting right dominant side, Heart Disease and Muscle Spasm. A review of the Minimum Data Set (MDS) assessment dated [DATE] indicated moderately impaired cognition, a range of motion impairment on both upper and lower extremities, total dependence to roll left and right, and total dependence all for all activities of daily living (ADLs). The .require assist with ADLs care plan dated 12/04/23 documented assist me with bed mobility and two person total assist with hoyer lift transfers as needed .follow therapy recommendations . A review of the Continuity of Care Document revealed no vitals signs were documented as completed from 06/09/24 at 6:39 PM until 7:03 AM on 06/10/24. The weight documented on 06/05/24 was 212.9 pounds. A review of the facility contract with the x-ray company documented, .(company name) will promptly transcribe the full written report and electronically send and or fax a copy to the facility . The contract did not specifically address orders for stat x-rays or provide designated time frames for delivery of the report. A review of the facility policy titled, Fall Management Guidelines revised April 2023 revealed, .After each fall the nurse will assess for pain and document the findings .The licensed nurse will document the incident on .nurse's notes .as soon as practicable communicate the fall to the attending physician and the responsible party/legal representative and document in the medical record .any fall with injury that is significant, fractures needing sutures hospitalization , must be called to the Director of Nursing as soon as practicable . A review of the facility policy titled, Change of Condition revised April 2023, revealed, An acute change in condition is a sudden, clinically important deviation from a resident's baseline in physical, cognitive, behavioral or functional domains. Clinically important means a deviation that without intervention, may result in complications or death .Document in the medical record all interventions to address the change in condition .x-ray: new or unsuspected finding (such as) fracture .

Based on observation, interview, and record review, the facility failed to facilitate and assist in obtaining eye glasses in a timely manner for one resident (R2) of one reviewed for ancillary services, resulting in R2 experiencing impaired vision. Findings include: On 8/20/24 at 10:35 AM, R2 was interviewed regarding their care and services at the facility and indicated that they had provided the facility with a prescription for eye glasses over a month ago and had not heard anything since then about obtaining new eye glasses. R2 stated, I don't know what's going on. It was observed that R2 was not wearing eye glasses. On 8/21/24 at 11:22 AM, a follow up visit was conducted with R2 and they were further interviewed about their eye glasses. R2 stated, I can't see well. R2 was observed to not be wearing eye glasses. On 8/21/24 at 11:30 AM, R2's responsible party (RP) A was interviewed by phone regarding R2's eye glasses and indicated that a prescription was provided to the facility following R2's eye appointment in July 2024. RP A stated, I haven't heard anything about [R2's] eye glasses since then. A review of R2's electronic medical record (EMR) revealed the following document from [Outpatient Vision Clinic Provider], Report of consultation: Report: New Eyeglasses: Glasses RX (Prescription) .7/11/24. Further review of R2's EMR revealed that R2 was originally admitted to the facility on [DATE] with diagnoses that included, Chronic obstructive pulmonary disease (COPD) (Lung disease) and Congestive heart failure. R2's most recent quarterly minimum data set assessment (MDS) dated [DATE] revealed that R2 had impaired vision, an intact cognition, and was independent to requiring partial assistance for all activities of daily living (ADLs). On 8/21/24 at 12:14 PM, Social Services Director (SSD) B was interviewed regarding assistance provided to R2 with obtaining their eye glasses. SSD B indicated they sent R2's eye glass prescription to the [Facility eye glass provider] on 8/14/24. SSD B stated, I told them to put a rush on it. SSD B was further interviewed and asked if facilitation of obtaining eye glasses for R2 should have been done more timely. SSD B stated, Yes, to be honest with you I forgot about it. On 8/21/24 at 12:21 PM, the Administrator (NHA) was interviewed regarding their expectations regarding assisting residents with ancillary services such as obtaining eye glasses. The NHA stated, I would expect it to be done within a week or two. A facility policy titled, Ancillary Services with no date, was reviewed and stated the following, Policy: The Facility will take such steps as necessary to ensure that the residents will be provided with .vision .to have meaningful access, adequate and effective care. Ancillary services are medical services provided in the facility to ensure that the residents will continue to have [services] during their stay in long term care setting. Procedure: 2) The IDT (Interdisciplinary Team) will coordinate any resident needs to obtain and schedule ancillary services needed. 5) Follow-up as needed .

This citation pertains to Intake MI00146468. Based on interview and record review, the facility failed to implement interventions to prevent a fall from the bed for one resident (R123) of two reviewed for falls, resulting in a fracture, facial trauma, skin abrasions and bruising. Findings include: A review of the record for R123 revealed a progress note dated 06/10/24 at 10:30 AM by Unit Manager D which documented, Writer was reported to by oncoming staff that resident was lowered to the floor by CENA (Certified Nursing Assistant, CNA) on midnight shift while doing peri care, resident was reaching and grabbing onto CENA and CENA had to lower resident to floor for safety. Resident has abrasion on left shoulder and left side of torso, x-ray ordered to rule out any injury, (Director of Nursing) DON notified, spouse notified. investigation process and complete. patient is resting well, no s/s of distress or discomfort. family at bedside. The previous progress note identified in the electronic medical record was dated 06/09/24 at 12:58 PM. No documentation of the fall by the midnight shift was found in the progress notes. A progress note dated 06/10/24 at 3:24 PM, by Wound Care Nurse I documented, .Resident suffered a fall from previous shift and was assessed for any injuries as follows. (right) RT back abrasion, buttocks and hip abrasions, (left) LT clavicle bruise, LT eye swollen and slightly bruised . A review of the Nurse Practitioner note dated 06/10/24 at 6:07 PM documented, .Chief Complaint: fall at facility on 6-10 .resident was lowered to floor by staff on 6-10, x-ray ordered to (rule out) r/o injury . A review of the Nurse Practitioner (NP) note dated 06/12/24 documented, .Review Of Systems: Musculoskeletal: Positive for: Joint Pain-Shoulders .Assessments/Plans: Pain in left shoulder, x-ray positive for left clavicle (fracture) FX spouse notified and desires transfer to the hospital for evaluation discuss in detail with (interdisciplinary team) IDT we will transfer to hospital for evaluation and ortho consult .(vital signs stable) VSS .Patient with (paralysis of one side) Hemiplegia and Hemiparesis following (stroke) cerebral infarction, has developed non fixed contracture of ankle bilaterally, patient is non ambulatory .phone call placed to spouse at 11 am- message left spouse was called again at 1320 . On 08/21/24 at 2:27 PM, Licensed Practical Nurse (LPN) E reported R123 was total care, non verbal, and two person for care. LPN E reported they had heard the midnight CNA had turned the resident by themselves and the resident fell out of the bed. LPN E was asked what indicates the need to send a resident to the hospital after a fall and reported if the resident was on a blood thinner, if there was a fall with acute pain, a change in vital signs or the resident was not at baseline. On 08/21/24 at 2:46 PM, [NAME] Clerk G noted R123's fall actually happened on midnights (11PM - 7AM). On 08/21/24 at 4:57 PM, LPN H reported that R123 did not usually exhibit signs of pain. On 08/21/24 at 5:00 PM, Unit Manager (UM) D and Wound Nurse I were asked about R123's fall. The nurses reported R123 did not exhibit outward signs of pain other the skin abrasions and bruising on assessment. UM D reported they found about the fall when they came into to work on 06/10/24 and that an agency CNA did provide care with one person instead of required two. UM D reported the normal two nurses and two CNAs were present. UM D and Wound Nurse I confirmed all agency staff received orientation to the floor and a binder is available for care plan needs and questions. This binder was observed with Wound Nurse I and present at the nurse station with care sheets filed by room number. Wound Nurse I further reported the book is not difficult to find and staff are oriented to where the information can be found. UM D was asked about the x-ray company and timeliness and reported that there was a delay and the report did not arrive until the 06/12/24. UM D reported they had contacted the responsible party about the fall once they found out about it and the the night nurse assigned had not called the family or notified the Director of Nursing as should have been done. UM D further reported the responsible party was called when the result of the x-ray was received on 06/12/24. On 08/22/24 at 8:57 AM, LPN E reported they did see R123 the morning after the fall and recalled as surprised by the fall and injuries and it was not well communicated in report. The next day LPN E noted no acute change in behavior or vitals except for the obvious injuries. LPN E confirmed they did see increased swelling to the face on 06/12/24. A progress note dated 06/11/24 at 2:44 PM, by LPN E documented, .localized swelling (left) Lt shoulder clavicle region, also noted mild swelling and bruising around Lt eye . A progress noted dated 06/12/24 at 3:56 PM, by LPN H documented, 3:40 PM sent to (hospital name) for evaluation of left clavicle, due to abnormal x-ray report. On 08/22/24 at 9:17 AM, NP F reported they felt it was safe for R123 to stay at the facility until the x-ray results were reviewed. NP F reported R123 was stable from a clinical standpoint and once the x-ray result was received on 06/12/24, R123 was sent out to the hospital. The decision for R123 to remain was based on clinical presentation and R123 lacked any a change in vital signs, obvious pain, or deformity from the clavicle fracture. On 08/22/24 at 10:26 AM, R123's fall was reviewed with Director of Nursing (DON). The DON they heard about the fall when notified by the management team later in the morning on 06/10/24. The DON reported it was a normal night with two CNAs and two nurses per floor and root cause of the fall was that the agency CNA did not follow the plan of care. The CNA was alone for incontinence care. The DON confirmed they were not called by the midnight nurse or CNA and the expectation is the all falls injury or not are reported to the DON when they occur. On 08/22/24 at 2:51 PM and 2:52 PM, phones call were made to the midnight nurses for R123. The calls were not returned. 08/22/24 02:54 PM CNA J was asked about the night R123 fell out of bed. CNA J reported it was busy and it was them and another aide. CNA J reported the only time the other aide asked for assistance was when she came and asked for help to get R123 off the floor. CNA J reported they were not the assigned aide for R123 that night but had said to the other aide to ask if help was needed. CNA J reported they believed R123 was a two person because of their size and and that they shook when moved. On 08/22/24 at 3:01 PM, CNA K confirmed they worked the midnight shift with two nurses and another CNA on 06/09/24 into the morning of 06/10/24. CNA K reported they had to put R123 on the floor and had to do it by themselves as no one came when they called out for help. CNA K reported that the nurse assigned to R123 never came. CNA K reported they had asked the assigned nurse, who was in the day room on a computer, to come and assess R123 after the fall but they did not and it was the other nurse and aide who helped to get R123 back into bed. CNA K further noted they had not seen the assigned nurse enter the room of R123 all night. CNA K reported on query that R123 was a two person for incontinence care and that they had not requested an assist. CNA K also reported they had many years of experience as an aide and were not given a login to document on residents. CNA K further reported that a care guide was not given and only had what another aide wrote out for them about the residents. A review of the record for R123 revealed R123 was admitted into the facility on [DATE]. Diagnoses included Hemiplegia and Hemiparesis following cerebral infarction affecting right dominant side, Heart Disease and Muscle Spasm. A review of the Minimum Data Set (MDS) assessment dated [DATE] indicated moderately impaired cognition, a range of motion impairment on both upper and lower extremities, total dependence to roll left and right, and total dependence all for all activities of daily living (ADLs). The .require assist with ADLs care plan dated 12/04/23 documented assist me with bed mobility and two person total assist with hoyer lift transfers as needed .follow therapy recommendations . A review of the Continuity of Care Document revealed no vitals signs were documented as completed from 06/09/24 at 6:39 PM until 7:03 AM on 06/10/24. The weight documented on 06/05/24 was 212.9 pounds. A review of the undated Resident's Care Guide revealed under the heading # of person assistance the lines for one person and two person were not checked. A review of the facility policy titled, Fall Management Guidelines revised April 2023 revealed, Each resident is assisted in attaining/maintaining his or her highest practicable level of function by providing the resident adequate supervision, assistive devices, and or functional programs as appropriate to minimize the risk for falls. Residents will be evaluated by the interdisciplinary team for their risk of falls. A care plan is developed and implemented based on this evaluation with ongoing review .When a fall occurs the nurse should assess the patient for injury .After each fall the nurse will assess for pain and document the findings .The licensed nurse will document the incident on .nurse's notes .as soon as practicable communicate the fall to the attending physician and the responsible party/legal representative and document in the medical record .any fall with injury that is significant, fractures needing sutures hospitalization , must be called to the Director of Nursing as soon as practicable .

Based on observation, interview and record review, the facility failed to ensure the dressing for a Peripherally Inserted Central Catheter (PICC) intravenous (IV) was changed timely for one resident (R27) of one whose line was reviewed. Findings include: On 08/21/24 at 9:06 AM, the PICC line dressing on the left upper arm of R27 was observed with Licensed Practical Nurse (LPN) L. An antibiotic medication was infusing. The dressing was dated 8/12/24. LPN L reported the dressing would need to be changed. On 08/21/24 at 11:02 AM, the Infection Control Nurse was asked about the PICC line dressing and reported R27 had been out to the hospital and the dressing did not get changed when R27 came back and it should have been changed Monday. On 08/22/24 at 10:26 AM, the Director of Nursing (DON) reported the dressing should have been changed every seven days per protocol. A review of the record for R27 revealed R27 was admitted into the facility 08/12/24 and readmitted [DATE]. Diagnoses included Osteomyelitis (bone infection) of the left ankle and foot. A review of the physician order dated 08/16/24 documented, .PICC dressing change every 7 days. Maintain sterile technique. Frequency: Once A Day on Mon 1: 03:00 PM - 11:00 PM. Special Instructions: Change upon admit and every 7 days thereafter . A review of the facility policy titled, IV Therapy Central Lines PICC Lines revised March 2024 revealed, .Manage Central Venous Catheters as follows: Use sterile transparent or gauze dressing over all central lines; [NAME] the dressing with date and initials when site care is performed; Visually assess the site every day for signs of complications or infection; Perform site care per physician order or as necessary. Change the dressing, Luer lock caps {for multi-lumen catheters}, and IV tubing down to the cannula hub .

Based on observation, interview, and record review, the facility failed to label medications when opened in two of three medications carts reviewed. Findings include: On [DATE] at 4:45 PM, the second floor cart one front medication cart was observed with Licensed Practical Nurse (LPN) H. An Incruse inhaler did not a have a date opened on the box not the actua inhaler. An identifier was not included on the inhaler; A Breo Ellipta had no identifier on the actual inhaler; and a Latanoprost eyed dropper was not dated when opened on the vial. On [DATE] at 8:37 AM, the first floor back cart was observed with LPN M. A Fluticasone propionate/salmeterol ,d+[DATE] inhaler did not have an identifier on the actual inhaler; A Trelegy inhaler ,d+[DATE].5 was not dated when opened on the acutal inhaler and did not have an identifier on the actual inhaler; A second Trelegy Inhaler was not dated on the actual inhaler and did not have an identifier on the actual inhaler; A Fluticasone/Salmeterol inhaler ,d+[DATE] and an Incruse inhaler was not dated when opened on the actual inhaler and did not have an identifier on the actual inhaler. On [DATE] at 8:53 AM, the first floor cart two medication cart was observed with LPN N. A Trelegy inhaler did not have a resident identifier on the actual inhaler. On [DATE] at 10:51 AM, the Director of Nursing was asked about label and dating of inhalers and reported the open date should be applied to the actual container when opened and ensure returned to the original box from the pharmacy so the name will be known. A review of the undated facility policy titled, Medication Administration revealed, .Before giving medication to a resident check to be sure it is not expired. Medication containers for insulin, eye, nasal, ear and topical medications will be dated when opened . The policy did not indicate to label an inhaler when opened. A review of the facility policy titled, Medication Ordering and Receipt dated [DATE] did not specifically address the labeling and dating of inhalers or eyedroppers. A review of the information at Drugs.com revealed: for the Incruse, Store at room temperature away from moisture, heat, and light. Keep the inhaler device in the sealed foil tray until ready to start using it. Throw the inhaler away 6 weeks after opening, or when the dose indicator shows a zero whichever comes first; for the Trelegy, Trelegy Ellipta should be discarded in the trash 6 weeks after first use OR when the counter reads 0 which means you are out of medicine, whichever occurs first; For Fluticasone/salmeterol, Discard Fluticasone Propionate/Salmeterol 1 month after opening the foil pouch or when the counter reads 0 (after all blisters have been used), whichever comes first; for the Lantanoprost, Once a bottle is opened for use, it may be stored at room temperature up to 25 C (77 F) for 6 weeks.

This citation pertains to Intake MI00137133. Based on observation, interview, and record review, the facility failed to promote a dignified existence and value residents' private living space, for three residents (R29, R36, and R272), and potentially affecting all residents residing on the first floor, resulting in resident feelings of frustration and disrespect and the potential for diminished quality of life. Findings include: Resident #29 On 7/11/23 at 10:37 AM, Certified Nursing Assistant (CNA) K was observed to walk into R29's room. CNA K did not knock or announce herself before entering. CNA K said something to the effect of what's wrong/what's the matter to the resident, whom was observed sitting on the edge of their bed, and loudly slammed the resident's door shut behind her. On 7/12/23 at 8:29 AM, R29 was observed sitting in their wheelchair in their room, with their back facing the doorway. CNA K was observed to walked into the resident's room without knocking or announcing herself. A review of R29's Minimum Data Set (MDS) assessment dated [DATE] revealed that the resident was admitted into the facility on [DATE] with medical diagnoses including Dementia, Stroke, and Arthritis. Further review revealed the resident is moderately cognitively impaired, with moderate difficulty hearing as well as impaired vision. Resident #36 On 7/11/23 at 10:51 AM, upon approaching R36's closed door, a sign was noted that read, Please knock before entering, thank you! R36 was then interviewed in their room and indicated that they are legally blind. When queried regarding any concerns about living at the facility, R36 stated, The staff here are very rude. I have a sign on my door to please knock. I like my privacy, and peace and quiet. R36 continued and indicated that it was very important to them that they know when people are coming into their room. The resident stated, Because I am visually impaired. I don't like anyone sneaking up on me basically. I want to know when people are in my room. I think it's basic professionalism whether I [am able to] see or not .I need you to tell me who you are and what your function is. That's extremely important to me. R36 continued and explained that at a resident council meeting recently, issues were brought up about toilets in the residents' bathrooms not flushing properly. R36 recalled that a day shortly after the meeting, I was laying in bed with my eyes closed. There was a knock on my door, someone came in and went in my bathroom and started flushing my toilet. I said, 'You need to tell me who you are.' A male voice said, I thought you were sleeping.' I told him you need to tell me who you are regardless, even when you knock. I've had other residents come into my room. Basic professionalism, it eases my concerns. On 7/11/23 at 11:03 AM, R36 activated their call button to request staff assistance with their cell phone. At this time, CNA L knocked on R36's door and walked in. CNA L did not say anything and proceeded to walk over to the resident. The resident looked around and stated, Who are you? (CNA L)? CNA L then replied, Yes. A review of R36's Minimum Data Set (MDS) assessment dated [DATE] revealed that the resident was admitted into the facility on [DATE] with medical diagnoses including End Stage Renal Disease and Diabetes. Further review revealed the resident is cognitively intact with severely impaired vision (defined in Section B of the MDS as, No vision or sees only light, colors or shapes; eyes do not appear to follow objects). Resident #272 On 7/11/23 at 9:52 AM, this surveyor stood and interviewed R272 as they waited for their active call light to be answered by staff. R272 indicated that they had just been admitted to the facility yesterday (7/10/23) and wished to be helped back into bed. R272 was tangential while speaking but knew the day/date, and was oriented to person and place when queried. R272 had on a neck brace and sat in their wheelchair. The door to R272's room was only slightly cracked open. The Wound Care Nurse (WCN) proceeded to come into R272's room without knocking or introducing themself. The WCN turned R272's call light off by pressing a button on the wall, and did not speak directly to the resident nor inquire about what the resident needed. This surveyor had to ask the staff member their name and role. The WCN then mentioned something (unable to hear clearly) about needing to come back anyway to do a skin assessment. The WCN then left the room without having addressed the resident. R272 looked at this surveyor and stated, Who was that .Was that the doctor or something? Would've been nice if he said who he was. On 7/11/23 at 10:12 AM, CNA K opened R272's door and entered the room without knocking or announcing herself. CNA K was observed with a wireless earbud in her right ear. CNA K did not say anything to the resident as she set a fresh water down on their table. CNA K did not address the resident prior to leaving the room. R272 had still not been helped back to bed. As CNA K was leaving the room, this surveyor asked her what her name was and if anyone had informed her that the resident wanted to get back into bed. CNA K gave her first named and stated, No not at this moment. I'm passing [NAME]. I'll put [R272] back to bed in a minute. CNA K did not speak with the resident nor ask if the resident did indeed wish to be helped back into bed. On 7/11/23 at 10:15 AM, Speech Language Pathologist (SLP) N knocked on R272's door and introduced themself to the resident. R272 stated to SLP N, Sure would be nice to know who all these other people were that came in here. On 7/12/23 at 9:34 AM, CNA K was observed to walk into R272's room without knocking on the door or announcing herself. On 7/12/23 at 8:08 AM, Licensed Practical Nurse (LPN) M was observed at a medication cart near room [ROOM NUMBER]. LPN M was in the middle of medication pass and was observed to have a wireless earbud in they're left ear. On 7/12/23 at 12:27 PM, Registered Nurse (RN) E was interviewed. RN E indicated that the Director of Nursing (DON) was not available on-site for the survey, therefore, he was filling in for her. RN E was asked what is expected of staff when they are about to enter a resident's living space. RN E stated that staff are supposed to knock, wait for a response, introduce themselves and what they are about to do. When queried about staff wearing wireless earbuds in patient care/living areas, RN E stated that staff are not supposed to be wearing earbuds in their ears. RN E explained that doing so would interfere with hearing the resident and/or the call light system. RN E added that he does confront staff about it when he sees it, and that the Nursing Home Administrator (NHA) is big on staff not having them in. RN E stated that education of staff on the matter is on-going. A review of the facility's policy/procedure titled, Resident Rights and Responsibilities, undated, revealed, .4. A patient or resident is entitled to privacy, to the extent feasible, in treatment and in care for personal needs with consideration, respect and full recognition of his or her dignity and individuality .10. A patient or resident is entitled to know who is responsible for and who is providing his or her direct care .

This citation pertains to Intake MI00137133. Based on observation, interview, and record review the facility failed to ensure that food was served in a palatable manner and at the preferred temperature for five confidential group residents of eight residents reviewed for food palatability, resulting in dissatisfaction during meals. Findings include: On 7/10/23 at 12:45 PM, a review of resident council group meeting notes for the months of April 2023 through June 2023 revealed the following, June 27, 2023, Food not hot when it reaches residents rooms. Breakfast meal is coldest. On 7/11/23 at 1:42 PM, a group meeting was conducted with five confidential group residents. All five group residents expressed dissatisfaction with the temperature of the food being served to them. All five group residents indicated that the food was cold when it reached their room. Multiple group residents stated, The eggs are cold. One group resident stated, The oatmeal is watery. On 7/12/23 at 8:30 AM, on the first floor of the facility, an observation was made of breakfast trays being served to residents in their rooms on open carts, without a plate warmer under the food plate, and the plastic lid covering the plate had a circular opening in the middle of the lid. On 7/12/23 at 8:32 AM, Dietary Manager (DM) D temperature tested the food on a random breakfast plate and the results were the following, Eggs: 117.5 degrees Fahrenheit; Bacon: 97.5 degrees Fahrenheit; Grits: 131 degrees Fahrenheit. DM D was interviewed regarding their expectations for hot food temperatures upon arrival to a resident's room and stated, I like to see it at 145 degrees Fahrenheit or above. DM D voluntarily tasted the bacon and stated, It tastes good. On 7/12/23 at 8:35 AM, the surveyor taste tested the breakfast meal and the results revealed that the eggs and bacon tasted cold which negatively impacted the palatability of the food. On 7/12/23 at 1:00 PM, a facility policy titled Food Temperatures Revision Date: May 2023 was reviewed and stated the following, Policy: Food will be maintained at proper temperature to insure food safety. Procedures: .hot food served to the resident will be no less than 135 degrees Fahrenheit.

This citation pertains to Intake MI00137133. Based on observation, interview, and record review, the facility failed to timely respond to a resident's call light and request to be helped back into bed for one resident (R272), resulting in an extended wait, resident frustration and expression of discomfort, and ultimately, the resident initiating an attempt to self-transfer. Findings include: On 7/11/23 at 9:35 AM, R272's call light above their door was observed to be flashing red. An unidentified female staff member in maroon scrubs came out of a stairwell and entered the resident's room. The call light was turned off and the staff member exited the resident's room at 9:38 AM. On 7/11/23 at 9:38 AM, upon entering R272's room, the resident was observed sitting in their wheelchair. R272 had on yellow non-slip socks and a yellow band on their wrist that read, Fall Risk. R272 stated that they want to go back to bed and also indicated that they had informed the staff member who just exited the room. R272 was asked if the staff member who just helped them had said she was coming back? R272 stated, I don't know, I've dealt with their sh*t before .She said she would go get my nurse. The resident indicated that the staff member had helped them off the toilet and into their wheelchair. R272 was queried regarding waiting for their call light to be answered and stated that it, Feels like forever even when you're waiting just a couple minutes. R272 then attempted to propel themselves closer to their bed. On 7/11/23 at 9:44 AM, R272's call light was activated. At 9:52 AM, R272 continued to wait for their active call light to be answered by staff. R272 indicated that they had been admitted into the facility yesterday (7/10/23). R272 was tangential while speaking but knew the day/date, and was oriented to person and place when queried. R272 had on a neck brace. The door to R272's room was only slightly cracked open. The Wound Care Nurse (WCN) proceeded to come into R272's room without knocking or introducing himself. The WCN turned R272's call light off by pressing a button on the wall, and did not speak directly to the resident nor inquire about what the resident needed. This surveyor had to ask the staff member their name and role. The WCN then mentioned something (unable to hear clearly) about needing to come back anyway to do a skin assessment. The WCN then left the room without having addressed the resident. R272 looked at this surveyor and stated, Who was that .Was that the doctor or something? Would've been nice if he said who he was. At 9:57 AM, R272 reiterated their wish to go back to bed. At 10:07 AM, R272 asked this surveyor to transport them to the front of the building and, Tell them this poor sucker needs attention. At 10:10 AM, R272 was asked how waiting for so long made them feel. R272 replied, They make it seem like there's nothing they can do. They just make you wait. Sometimes seems like they just plain forget. At 10:12 AM, CNA K opened R272's door and entered the room without knocking or announcing herself. CNA K was observed with a wireless earbud in her right ear. CNA K did not say anything to the resident as she set a fresh water down on their table. CNA K did not address the resident prior to leaving the room. R272 had still not been helped back to bed. As CNA K was leaving the room, this surveyor asked her what her name was and if anyone had informed her that the resident wanted to get back into bed. CNA K gave her first named and stated, No not at this moment. I'm passing water. I'll put (R272) back to bed in a minute. CNA K did not speak with the resident nor ask if the resident did indeed wish to be helped back into bed. At 10:15 AM, Speech Language Pathologist (SLP) N knocked on R272's door and introduced herself to the resident. R272 stated to SLP N, Sure would be nice to know who all these other people were that came in here. This surveyor exited the room at this time. A review of R272's active physician orders revealed: Transfer status: 1 person extensive assist (start date) 07/10/2023. At 11:17 AM, R272 was observed to still be sitting up in their wheelchair in their room. R272 stated, Everyone gets so busy here, people forget. When queried about their comfort level, R272 stated, I would be more comfortable sitting on a camel's back in the desert. I'm not comfortable at all. R272 began to state that they were thinking about putting themselves back into bed now that someone was in the room with them. R272 then positioned their wheelchair up to the edge of their bed and began putting their hands on the armrests to lift themselves up. R272 was asked to please wait so that a facility staff member could be retrieved to assist them with a safe transfer. At 11:22 AM, Licensed Practical Nurse (LPN) G was found at the nearby nurses' station and entered R272's room to help R272 into bed. On 7/12/23 at 12:27 PM, Registered Nurse (RN) E was interviewed. RN E indicated that the Director of Nursing (DON) was not available on-site for the survey, therefore, he was filling in for her. RN E was asked what is expected of staff when a resident makes a care request, such as wanting to get back into bed. RN E stated that staff should be taking and completing resident requests as they are happening except during meal tray pass. RN E stated that even then, staff should be informing the resident that they will be right back. RN E indicated that he would not expect a request to go unfulfilled if multiple staff had been asked. A review of the facility's policy/procedure titled, Resident Rights and Responsibilities, undated, revealed, .4. A patient or resident is entitled to privacy, to the extent feasible, in treatment and in care for personal needs with consideration, respect and full recognition of his or her dignity and individuality .5. A patient or resident is entitled to receive adequate and appropriate care .

Based on observation, interview, and record review, the facility failed to implement an individualized care plan for heel boots for one sampled Resident (R8) out of one reviewed for care plan for pressure ulcers, resulting in the potential for development of ulcer. Findings include: On 7/11/23 at 9:33 AM, R8 was observed in their room sitting in a wheelchair. On 7/12/23 at 9:17 AM, R8 was observed in bed laying on their backside. R8's feet were laying flat on the bed, heel boots were not observed on R8's feet or sitting in the room. A review of R8's medical record revealed, that R8 was admitted to the facility on [DATE] with diagnosis of Hemiplegia following a cerebral infarction affecting right dominant side. A review of R8's Minimum Data Set assessment dated [DATE], noted R8 with an impaired cognition and the need for total assistance with activities of daily living. A review of R8's care plan noted, Start Date: 04/27/2023 Category: Pressure Ulcer/Injury PROBLEM: [R8] is at risk for further pressure ulcers R/T (related to) impaired mobility and fragile skin. Resident was admitted with Right heel unstageable ulcer. right heel unstageable ulcer is healed. I have an open area on my RT (right) buttock. have an open area on my LT (left) heel. The area on my LT heel is resolved. GOAL: I will have risks related to compromised skin integrity addressed and complications minimized; and/or skin condition/wounds will exhibit signs of improvement. Start Date: 04/27/2023. APPROACH: Use Heel Lift Booties to relieve pressure on the heels when in bed. On 7/12/23 at 10:02 AM, a wound care observation was completed with the Wound Care Nurse (WCN) and Wound Doctor. R8 observed in bed without boots. WCN was asked if R8 was to have boots on and stated, When (name of R8) allows it. WCN was asked, would refusals be documented and stated, Yes. Documentation for refusing heels boots was not found in R8's medical record. On 7/12/23 at 1:23 PM, the WCN was asked if R8 care plan should reflect the refusal of the boot applications. The WCN explained a progress note should be added and a refusal care plan. On 7/12/23 at 1:25 PM, the Director of Nursing was asked about the observation of R8 being in bed without the heel boots and explained that a progress would be need to be added when R8 refuses the boots and in the point of care. A review of the facility's policy titled Pressure Ulcer & Skin Care management dated, August 2022, noted, Policy: A resident who enters the facility without pressure ulcers does not develop pressure ulcers unless the resident's clinical condition demonstrates that they were unavoidable; and a resident having pressure ulcers receives necessary treatment and services to promote healing, prevent infection and reduce the risk of new pressure ulcers developing

Based on observation, interview, and record review, the facility failed to consistently implement interventions to maintain or improve strength and range of motion (ROM) affecting one resident (R50) of one reviewed for rehabilitation/restorative care, resulting in the potential for further functional decline in strength and mobility. Findings include: On 7/11/23 at 2:23 PM, R50 reported that they were not receiving their restorative services on a consistent basis. R50 stated, They have a Restorative Certified Nursing Sssistant (RCNA) but they pull them to help on the floor. R50 indicated that they desired to receive their restorative services on a consistent basis. On 7/11/23 at 3:33 PM, a ninety day review of restorative services received by R50 indicated that R50 received restorative services on 7/11/23, 5/25/23, 5/12,23, 4/23/23, 4/18/23, 4/17/23, and 4/14/23. The dates of 6/13/23, 5/30/23, and 5/29/23, indicated the following: Not performed. No information given. No other dates related to restorative services being provided for R50 were indicated during the ninety day review period. On 7/11/23 at 3:39 PM, a review of R50's most recent care plan revealed no restorative goal/interventions being present on the care plan On 7/11/23 at 3:43 PM, a review of R50's electronic medical record (EMR) revealed that R50 was most recently admitted to the facility on [DATE] with diagnoses that included Malignant neoplasm of unspecified part of bronchus or lung (Tumors in the lungs) and Hypertension (High blood pressure). R50's most recent annual minimum data set assessment (MDS) dated [DATE] revealed that R50 had an intact cognition and required extensive two person assistance or was totally dependent for all activities of daily living (ADLs) other than eating. On 7/12/23 at 10:47 AM, RCNA A was interviewed regarding restorative services being provided to R50. RCNA A stated, Stated sometimes I get pulled to the floor. RCNA A indicated that staffing on R50's unit was, Challenging. On 7/12/23 at 12:09 PM, the Director of rehabilitation services (DRS) B was interviewed regarding restorative services for R50. DRS B indicated that a restorative program was developed and recommended for R50 to maintain their strength and range of motion. DRS B indicated that a restorative goal should be placed on the resident's care plan by the nurse. DRS B provided documentation of an Occupational Therapy OT Discharge Summary signed and dated 5/6/2023 which stated the following recommendation, D/C [Discharge] to the LTC [Long term care] setting. Refer to restorative program. On 7/12/23 at 12:16 PM, the Director of Nursing (DON) was interviewed regarding their expectations for implementing and care planning a resident's restorative program. The DON indicated that a referral for a resident's restorative program comes from therapy, is implemented on the resident's care plan, and the RCNA is responsible for implementing the restorative program with the resident. The DON further indicated. Sometimes the RCNA gets pulled to the floor to help and then the other CNAs are expected to assist with restorative care as best as possible. On 7/12/23 at 12:47 PM, a facility policy titled Restorative Nursing Services No date, was reviewed and stated the following, Policy: .Restorative nursing ensures residents retain skills learned in therapy once discharged ; or can be used to build residents to a higher level so they can begin therapy services again. 1. Nurses Role .Must understand the importance of allowing restorative aide(s) to perform sessions without being pulled to the floor .3. Restorative Aide's Role Carries out each resident's restorative program. Maintains restorative documentation .3. Levels of Restorative Nursing 3. Functional Maintenance Program The resident receives services delivered by the CNAs .The goal is to prevent a decline and maintain function achieved with rehab/or restorative services. Incorporate everything that it takes to keep the resident at their highest functional level in their everyday life. Restorative Programs .Passive/Active ROM.

Based on observation, interview, and record review, the facility failed to maintain maintaining the catheter drainage tubing and bag in a sanitary condition, for one sampled resident (R169) of one sampled resident reviewed for catheter care, resulting in the potential for infection. Findings include: On 7/10/23 at 10:30 AM, R169's was observed lying in bed, the bed was in a low position. The catheter bag was observed attached to the left side of the bed, lying directly on the floor. On 7/11/23 at 1:40 PM, R169's was observed sitting on the left side of the bed, the bed was in a low position. The catheter bag was observed attached to the left side of the bed, lying directly on the floor and halfway under the bed. A record review of the Minimum Data Set (MDS) assessment dated [DATE] revealed, that R169 was admitted to the facility on [DATE] with the diagnoses of Diagnoses Hypertension, Urinary Tract Infection last 30 days. R169 had a Brief Interview of Mental Status (BIMS) of 11, indicating an impaired cognition. A review of R169's care plan noted, PROBLEM: [R169] requires an indwelling urinary catheter R/T (related to) urine retention. Start Date: 07/07/2023. Revised: 07/11/2023. GOAL: Resident will have catheter care managed appropriately as evidenced by: not exhibiting signs of urinary tract infection or urethral trauma. Start Date: 07/07/2023 APPROACH: Do not allow tubing or any part of the drainage system to touch the floor. On 7/11/23 at 2:47 PM, the Infection Preventionist (IP) was asked if catheter bags should be touching the floor. The IP responded no, they should not. On 7/12/23 at 1:28 PM, the Director of Nursing (DON) was asked the expectation for R169's catheter bag and explained that the resident now has a barrier, and that expectation is that it doesn't touch the floor. A review of the facility's policy titled, Indwelling Catheter Care, dated October 2022, did not address the above concern.

This citation pertains to intake # MI 666. Based on observation, interview and record review, the facility failed to complete and/or document ordered wound care treatments for two residents (Resident # 703 and Resident #708) of two reviewed for wound care, resulting in the worsening of a pressure ulcer, and the likelihood of the continued worsening of a wound and unnecessary pain. Findings include: Resident #703 On 08/09/2021 at 09:51 AM, Confidential Witness A was interviewed via telephone. According to Confidential Witness A, Resident #703 had developed a wound within the facility. Confidential Witness A stated, We (the family) had no idea how bad that wound was. When we got to the hospital, we seen it. I was horrified. (Resident #703) needed two surgeries to debride (surgical remove nonviable tissue) that wound! A record review of the Minimum Data Set (MDS) assessment dated [DATE] revealed that Resident #703 had a Brief Interview for Mental Status (BIMS) score of 09, indicating a moderate impaired cognition, and needed extensive assistance with bed mobility, transfers and toileting needs. Resident #703 was admitted to the facility on [DATE] with the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A record review of the skin assessments for Resident #703 revealed the following: 05/14/2021 (including admission skin assessment), 05/25/2021, 06/01/2021, 06/15/2021-no open areas or new wounds noted. 06/23/2021-small wound to coccyx area and right buttocks skin excoriated noted. [MEDICATION(S)] (a barrier cream to prevent further skin breakdown) applied. Wound care made aware . 07/06/2021-Open skin/wounds to R (right) upper back and coccyx and buttocks with on going treatment . A record review of the progress notes for Resident #703 revealed the following: 05/14/2021 11:29 PM [Recorded as Late Entry on 05/15/2021 01:11 AM] Received .No skin breakdown noted . 06/16/2021 02:40 PM Resident is alert and able to make needs known to staff. Receives extensive assist in transfer .Observed skin excoriation (red/irritated skin from excess moisture) to rt (right) buttocks and small open skin to coccyx (just above buttocks) area, [MEDICATION(S)] applied; repositioned in bed. Wound care nurse informed. No s/s (signs and symptoms) of acute distress noted Safety maintained. 06/29/2021 09:17 AM Resident is an extensive 1 person asst (assist) with transferring and transferring. Resident is incontinent of B/B (bowel and bladder) kept clean and dry [MEDICATION(S)] cream was applied to buttocks during brief change . 07/02/2021 06:18 AM WOUND CARE ROUNDS: RESIDENT SEEN BY WOUND MD (Medical Doctor) ON 6/30/21 FOR WOUNDS TO RIGHT FOREARM AND COCCYX AREA. WOUND TO RESIDENT FOREARM HAS BEEN RESOLVED, COCCYX AREA MEASURES WITH BRIDGING 4.0 X 2.0 X UTD (undetermined tissue damage). TREATMENT REMAINS IN PLACE. 07/04/2021 03:23 PM .Writer called by nursing assistant to check resident back, writer observed wound to R (right) upper back under with bath towel and minimal drainage noted. Wound cleanse with NS (normal saline) and cover with dry dressing. Treatment in placed until seen by wound care nurse. Repositioned in bed. On coming nurse made aware. Safety maintained. 07/06/2021 06:36 PM [Recorded as Late Entry on 07/07/2021 01:44 AM] Resident is alert and able to make needs known to staff. Receives extensive assist in transfer. Assisted by staff in the shower. Observed wound to R upper back and coccyx/buttocks with on going treatment .B/L (bilateral) heel slightly pinkish in color, L (left) heel dry small flat blister noted. Repositioned in bed. Will monitor. Safety maintained. 07/07/2021 04:30 PM WOUND CARE ROUNDS: RESIDENT WAS SEEN BY WOUND DOCTOR FOR WOUND TO COCCYX AREA, MEASUREMENTS ARE 5.0 X 6.0 CONTINUE WITH CURRENT TREATMENT. RESIDENT HAS NEW EXCORIATION WOUND TO R SHOULDER BLADE OVER BONY PROMINENCE MEASUREMENTS ARE 4.5 X 3.8 X 0.0, NEW ORDER FOR XEROFORM AND [NAME] (SIC) FOR AIRLOSS MATTRESS. RESIDENT WAS EDUCATED BY MD ON .LACK OF BED MOBILITY AND THAT .NEEDS TO TRY AND REMAIN OFF BACK. RESIDENT STATED THAT .UNDERSTANDS AND HAS HEARD MULTIPLE TIMES. 07/14/2021 03:43 PM WOUND CARE ROUNDS: RESIDENT WAS SEEN BY WOUND MD FOR WOUNDS TO COCCYX AND R SHOULDER BLADE. COCCYX MEASUREMENT WITH BRIDGING IS 3.0 X 6.7. R SHOULDER MEASURES 3.5 X 3.8. ADVISED TO CONTINUE WITH TREATMENTS. RESIDENT HAS VERY LIMITED BED MOBILITY AND HAS TROUBLE WITH BEING REDIRECTED ABOUT REPOSITIONING SELF. 07/21/2021 03:41 PM WOUND CARE ROUNDS: RESIDENT WAS SEEN BY MD TODAY FOR WOUNDS TO COCCYX/BUTTOCKS AND R SHOULDER. COCCYX MEASURES WITH BRIDGING 7.5 X 7.0 X UTD AND R SHOULDER MEASURES 2.4 X 2.4. ADVISED TO CONTINUE WITH CURRENT TREATMENTS. RESIDENT HAS BEEN EDUCATED BY FACILITY STAFF AND WOUND MD R/T INCREASING BED MOBILITY AND NUTRITIONAL INTAKE. A record review of the wound notes entered by Wound Licensed Practical Nurse (LPN) C revealed the following: 07/02/2021-THE WOUND BASE HAS TAN-COLORED SOFT ESCHAR (nonviable tissue) APPRECIATED WITH PARTIALLY ADHERENT EDGES. THIS IS ALSO A SATELLITE AREA SHOWING OPEN ARE SHALLOW IN NATURE. EDGES ARE SMOOTH AND ATTACHED. SCANT SEROUS (clear) EXUDATE (drainage). NO ODOR NOTED. NO TUNNELING OR UNDERMINING. 07/09/2021-THE WOUND BASE HAS TAN-COLORED SOFT ESCAR (SIC) APPRECIATED WITH PARTIALLY ADHERENT EDGES. THERE ARE NOW TWO SATELLITE AREAS SHOWING GRANULATION TISSUE. BOTH ARE SHALLOW IN NATURE. EDGES ARE SMOOTH AND ATTACHED. SCANT SEROUS EXUDATE. NO ODOR NOTED TO EITHER SITE. 07/15/2021-THE WOUND BASE HAS TAN COLORED SOFT ESCHAR APPRECIATED WITH PARTIALLY ADHERENT EDGES. THERE ARE NOW TWO SATELLITE AREAS SHOWING GRANULATION TISSUE BOTH ARE SHALLOW IN NATURE. EDGES ARE SMOOTH AND ATTACHED. SCANT SEROUS EXUDATE. NO ODOR NOTED TO EITHER SITE. NO TUNNELING OR UNDERMINING. 07/22/2021-THE WOUND BASE HAS TAN COLORED SOFT ESCHAR APPRECIATED WITH PARTIALLY ADHERENT EDGES. THERE ARE NOW TWO SATELLITE AREAS SHOWING GRANULATION TISSUE BOTH ARE SHALLOW IN NAUTRE (SIC). EDGES ARE SMOOTH AND ATTACHED. SCANT SEROUS EXUDATE. THERE IS NOW A MILD ODOR NOTED. THE AREA OF INJURY HAS INCREASED. THE AREAS ALSO DISPLAY INCREASED [CONDITION(S)] (redness) AND DIMINISHED BLACHABILITY (skin doesn't turn from white, back to pink when lightly pressed, indicating lack of blood flow to the area, which is an abnormal finding). NO TUNNELING OR UNDERMINING. A record review of the Treatment Administration Record (TAR) for Resident #703 revealed the following: May 2021 [MEDICATION(S)] ([MEDICATION(S)]-[MEDICATION(S)]) [OTC] ointment; 0.44-20.6 %; Amount to Administer: small amount; topical every shift Initiated 05/15/2021. The treatment was not documented as being completed on the following shifts: Shift 1-05/15/2021-05/17/2021, 05/20/2021, 05/29/2021 and 05/30/2021-05/31/2021. Shift 2-05/15/2021-05/17/2021, 05/20/2021, 05/23/2021 and 05/25/2021-05/31/2021. Shift 3-05/15/2021-05/16/2021, 05/19/2021-05/20/2021 and 05/23/2021-05/30/2021. June 2021 [MEDICATION(S)] ([MEDICATION(S)]-[MEDICATION(S)]) [OTC] ointment; 0.44-20.6 %; Amount to Administer: small amount; topical every shift. Initiated 05/15/2021 (see revision on 06/16/2021). Apply [MEDICATION(S)] to buttocks every shift. Initiated 06/16/2021. The treatment was not documented as being completed on the following shifts: Shift 1-06/05/2021, 06/12/2021-06/13/2021, 06/16/2021-06/17/2021, 06/24/2021, 06/27/2021 and 06/29/2021-06/30/2021. Shift 2-06/01/2021, 06/03/2021-06/05/2021, 06/07/2021-06/10/2021, 06/12/2021-06/17/2021, 06/19/2021, 06/21/2021, 06/24/2021, 06/26/2021-06/28/2021 and 06/30/2021. Shift 3-06/01/2021-06/08/2021, 06/12/2021-06/17/2021, 06/19/2021, 06/21/2021-06/24/2021, 06/26/2021 and 06/30/2021. July 2021 CLEANSE COCCYX AREA WITH NS (Normal Saline), PAT DRY APPLY SANTYL AND COVER WITH SRY (SIC) DRESSING. Initiated 07/05/202. The treatment was not documented as being completed on the following shifts: 07:30 AM-11:00 AM-07/05/2021-07/12/2021, 07/14/2021, 07/18/2021-07/19/2021, 07/21/2021-07/22/2021. Apply [MEDICATION(S)] to buttocks every shift. Initiated 06/16/2021. The treatment was not documented as being completed on the following shifts: Shift 1-07/03/2021-07/14/2021 and 07/18/2021-07/22/2021. Shift 2-07/01/2021-07/15/2021 and 07/18/2021-07/22/2021. Shift 3-07/01/2021-07/15/2021, 07/13/2021, 07/15/2021 and 07/20/2021-07/21/2021. A record review of the skin care plan for Resident #703 revealed the following: Problem (initiated 05/17/2021)- .At risk for skin breakdown r/t (related to) decreased mobility and fragile skin .I now have a wound to coccyx area due to my decreased bed mobility and fragile skin. Goal-Patient will have risks related to compromised skin integrity addressed and complications minimized; and/or skin condition/wounds will exhibit signs of improvement. Approach-Administer medications and supplements as ordered. Assist with turning and positioning as needed. Encourage adequate nutrition/hydration. Keep skin clean and dry. Skin/Wound care treatment as ordered. There were no updates after 05/17/2021 to the care plan. On 08/10/2021 at 12:09 PM, the Director of Nursing (DON) and Wound LPN C were interviewed in regard to the development and worsening of Resident #703's coccyx wound and stated, (Resident #703) declined in their functioning. We got a low air loss (a mattress utilized to assist in offloading pressure automatically off the skin) bed. The DON stated, (Resident #703) had a lot of comorbidities (chronic health complications) and didn't like to be sit up in the wheelchair. (Resident #703) needed lots of encouragement. Wound LPN C was asked about the interventions listed in the nurses notes for Resident #703 being educated on repositioning themselves with a BIMS score of nine (impaired cognition) and how effective was the education. Wound LPN C did not provide an explanation. At this time, the TAR was reviewed with the DON and Wound LPN C. They were both asked about the missing documentation of the wound treatments being completed. Wound LPN C stated, I was transitioning (into new wound nurse role), that was my fault. I forgot to sign them out. Wound LPN C was asked about the other shifts (that she did not work) and days that were not filled in as being completed. Wound LPN C did not provide an explanation. On 08/10/2021 at 2:05 PM, the Nursing Home Administrator (NHA) was interviewed in regards to the lack of completion of wound care and documentation for Resident #703. The NHA stated, Honestly, we have been so staff challenged. The staff have to choose between documenting and patient care. We have been focusing on wound care and staffing. Resident #708 On 08/09/2021 at 12:44 PM, Resident #708 was observed to be up in the dining room. Resident #708 had a wound bandage with a large brown substance that had soaked through the bandage observed on their left lateral calf. The date on the bandage read, 8/6/21. Resident #708 was asked about their wound and stated,, Most of the time it gets done. they didn't do it today though. Guess they forgot. Resident #708 further explained that they had another wound on their left ankle. A record review of the MDS assessment dated [DATE] revealed that Resident #708 had a BIMS score of 10, indicating a moderate impaired cognition, and needed extensive assistance with bed mobility and transfers. Resident #708 was most recently admitted to the facility on [DATE] with the diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] A record review of the August 2021 TAR for Resident #708 revealed the following treatment order initiated on 08/05/2021: cleanse left lateral leg wound with NS (normal saline), pat dry. apply [MEDICATION(S)] SOAKED 4x4 and cover with kerlix daily and PRN (as needed). On Monday, Wednesday and Friday. The treatment was not signed out as being completed on 08/09/2021. A review of the facility policy titled Pressure Ulcer & Skin Care Management effective: January 12, 2020 revealed the following: Policy-A resident that enters the facility without pressure ulcers does not develop pressure ulcers .and a resident having pressure ulcers receives necessary treatment and services to promote healing .and reduce the risk of new pressure ulcers developing .

Based on observation, interview, and record review, the facility failed to properly maintain infection control practices per Centers for Disease Control (CDC) guidance during a COVID-19 (a severe and highly contagious respiratory infection) Infection Control Survey, resulting in 16 residents and 22 staff members contracting COVID-19. The facility was unable to identify the cause of the COVID-19 outbreak, failed to methodically track, trend, and follow infection control principles/ practices after the initial staff tested positive on 10/23/2020, failed to follow Droplet Precaution guidelines by allowing eight Residents to gather in the common area/TV room with four Residents not wearing masks over their nose and mouth, failed to utilize full PPE (personal protection equipment) during resident care, failed to perform hand hygiene and change PPE while removing food trays from rooms of residents under isolation. This deficient practice resulted in sustained spread of COVID-19 to a total of 38 residents and staff and the likelihood for continued transmission of COVID-19 to all facility residents and staff, and decline in overall health, serious illness, and/or death. The Immediate Jeopardy (IJ) started on 10/23/2020 and was identified on 11/18/2020. The Nursing Home Director of Clinical Operations was notified of the Immediate Jeopardy on 11/18/2020 at 4:49 PM and was asked for a plan to remove the immediacy. The IJ was removed on 11/19/2020, based on the facility's implementation of the removal plan as verified onsite on 11/19/2020. Although the immediacy was removed, the facility's deficient practice remained widespread with actual harm that is not immediate jeopardy. Findings include: On 11/18/20 at 8:45 AM, during the entrance into the facility, the Infection Control Nurse A indicated that the facility had a census of 42 with a total of 38 positive COVID-19 cases including the facility's Administrator. Sixteen COVID-19 Residents were transferred to another facility, however, symptomatic Residents were transferred to the hospital. The Infection Control Nurse also indicated that the Director of Nursing (DON) started a week ago. Additionally, the Infection Control Nurse returned to work on 11/17/2020 after being off with COVID-19. On 11/18/20 at 9:25 AM, during a tour of the second floor an observation was made of Droplet Precaution signages on every door except for room [ROOM NUMBER] (a single bedroom). Additionally, eight Residents (on Droplet Precaution) were observed sitting in a common area/TV room with four Residents not properly wearing masks over their nose and mouth. An unknown staff was also observed in the common area/TV room feeding an unknown resident. This unknown staff was not wearing full PPE (gown and gloves) while assisting this Resident. On 11/18/20 at 9:54 AM, the Unit Manager B was interviewed and asked about Droplet Precaution signage on every door except for room [ROOM NUMBER]. Unit Manager B stated, The entire second floor is on Droplet Precaution. The Unit Manager B was asked if the resident in room [ROOM NUMBER] was on Droplet Precaution and the Unit Manager B stated, Yes, they are all on Droplet Precautions. The Unit Manager B was asked if the Residents in the common area/TV room were also on Droplet Precautions. The Unit Manager B stated, Yes. But it's not truly Droplet Precaution. We are just watching them. It's ok for them to be in the TV room. On 11/18/20 at 10:05 AM, an interview was conducted with the Infection Control Nurse A, the Unit Manager B, the Director of Nursing (DON), and the facility's Corporate Director of Clinical Operations were interviewed and queried about the Droplet Precaution signage on every door except for room [ROOM NUMBER], and eight Residents (on Droplet Precaution) were observed sitting in a TV room with four Residents not properly wearing masks over their nose and mouth. Unit Manager B stated, They have a right to not wear a mask. The DON was asked their expectation of Residents on Droplet Precaution congregating in the TV room and the DON stated, Some of the Residents on the second floor have behavioral or memory issues. This is on their care plan. It's hard to redirect them. On 11/18/20 at 11:15 AM, an interview was conducted with the Infection Control Nurse A to review their COVID-19 positive cases surveillance and tracking. The first positive case identified was noted to be the Admission Coordinator C. Infection Control Nurse A stated, On 10/23/20, I saw (Admission Coordinator C) and (they) did not look good. (Admission Coordinator C) said (they) were feeling sick. I performed a quick test and it was positive (COVID positive) . (Admission Coordinator C) was sent home. The Infection Control Nurse was asked what infection control processes were changed after the Admission Coordinator C tested positive. The Infection Control Nurse A stated, We didn't do anything different because (Admission Coordinator C) office is upfront. (Admission Coordinator C) only had interactions with other staff and not residents. Infection Control Nurse A was asked if they tracked the staff Admission Coordinator C had contact with. Infection Control Nurse A stated, The only thing we did different started on 10/28/20 with deep cleaning, wiping all surfaces, the breakroom, and deep cleaning residents rooms upon discharge. Infection Control Nurse A was asked if they placed residents on precautions and traced Admission Coordinator C contacts. Infection Control Nurse A stated, We did not place residents on precautions. We started the deep cleaning. Infection Control Nurse A was queried if they provided staff education, optimized the use of PPE, and determined which residents received direct care from staff that had contact with Admission Coordinator C. Infection Control Nurse A stated, No. But I started thinking maybe we should do something. That's why we initiated the deep cleaning on the 28th (10/28/20) .I tested positive on the 30th (10/30/20). Infection Control Nurse A was queried when they started contact tracing and they said, The 30th was on a Friday so not much was done because it was the weekend. I was then working from home since I was positive (COVID-19). The facility started transferring residents out and placing residents on Droplet Precautions on November 1st and November 2nd. During the record review of the COVID-19-line listing for October through November 2020 revealed the following results identified: Staff 10/23/2020-One staff member tested positive (Admission Coordinator C) 10/30/2020-Three staff member tested positive (Certified Nurse Assistant (CNA), Security, Infection Control Nurse A) 11/5/2020-One staff member tested positive (RN) 11/6/2020-One staff member tested positive (Nurse Manager B) 11/9/2020-Two staff member tested positive (CNA, Physical Therapy) 11/10/2020-Four staff members tested positive (2 CNA, RN (Registered Nurse), Housekeeper) 11/12/2020-One staff member tested positive (LPN (Licence Practical Nurse) 11/13/2020-Five staff members tested positive (CNA, 2 LPN, Housekeeper, Administrator) 11/16/2020-Two staff members tested positive (CNA, Dietary Server) 11/17/2020-One staff member tested positive (Floor Care) 11/18/2020-One staff member tested positive (unknown) Residents 11/1/2020-Two residents tested positive 11/2/2020-One resident tested positive 11/6/2020-One resident tested positive 11/7/2020-Six residents tested positive 11/8/2020-One resident tested positive 11/9/2020-One residents tested positive 11/10/2020-One resident tested positive 11/15/2020-One resident tested positive 11/16/2020-Two residents tested positive On 11/18/2020 at 12:40 PM, CNA D was observed in an unsampled Resident's room (Droplet Precaution) assisting with lunch. The CNA was without their gown and gloves. CNA D was queried if it was their policy to wear full PPE (including gown and gloves) while in a Droplet Precaution room. CNA D stated, I did not know that I was supposed to wear a gown and gloves while feeding a resident. I was never told that. Droplet Precaution signage was on the door with pictures of eye covering, mask, gown, and gloves. On 11/18/2020 at 12:46 PM, observed a hand sanitizer wall pump on the second floor with a sticker noted Betco Alcohol Free Hand Sanitizer (current recommendation per CDC guidelines is 60% alcohol). On 11/18/2020 at 12:57 PM, Nurse E was observed to enter a resident room while wearing only a procedural mask. Nurse E was queried if it was their process to wear an N95 mask when providing care to a resident on Droplet Precaution. Nurse E stated, Oh yes. I'm supposed to wear my N95. It's at the desk. I'll go get it. I hope I'm not in trouble. On 11/18/2020 at 1:04 PM, Housekeeper E was observed entering and exiting room [ROOM NUMBER] and then room [ROOM NUMBER] without changing PPE. On 11/18/2020 at 1:07 PM, CNA F was observed going in and out of rooms, picking up lunch trays without changing PPE and without gloves. On 11/18/2020 at 1:11 PM, an unsampled resident was observed on the second floor in the hallway without face covering. Two staff were in the hall, however, the resident was not redirected. On 11/19/2020 at 10:15 AM, Admission Coordinator C was interviewed and queried regarding testing positive for COVID -19 on 10/23/2020. Admission Coordinator C stated, I was told I had a sinus infection by my doctor . I went to the doctor that Saturday before. On the 17th (10/17/2020) I started having a pressure headache . My doctor didn't think it was COVID because we get tested weekly (at the facility) . I had a stuffy nose .My doctor was treating me for a sinus infection. By Friday I felt so (bad) . I saw (Infection Control Nurse A) and (they) asked if I was ok, I said no I feel terrible . 10/23 we did a PCR (nose swab) and a rapid COVID -19 test and both came back positive. Admission Coordinator C was queried it they notified their manager or the Infection Control Nurse that they had been feeling sick for over a week before testing positive and they said, No, I did not tell anyone I went out to dinner on October 12 for my birthday. I started feeling sick afterwards. On 11/19/2020 at 11:02 AM, Nurse Manager B was interviewed regarding testing COVID positive on 11/3/2020. Nurse Manager B stated, On that weekend before getting sick, my (family) had a small party at home. One of our friends came to visit us wearing a mask. This friend said they were not feeling well .on Tuesday I started having chills and I had a fever of 101.7. I had a curbside testing here and was positive on the rapid test. My last day at work was November 2. On 11/19/2020 at 11:48 AM, the DON and Director of Clinical Operations were interviewed regarding the COVID outbreak, tracing, and notification of feeling sick. The Director of Clinical Operations stated, New admits are on the first-floor observation rooms for 14 days .the whole 2nd floor is on isolation because of the positive cases. We recommend that staff wear face shields . We provide surgical mask and N95 mask. We do not mandate the wearing of N95s, we recommend it. They must wear a mask, but it is not mandatory to wear an N95 mask .all staff knows that if they are not feeling well they need to let us know. The DON stated, We send out blast text that if you're not feeling well, contact immediate supervisor, and don't come into work. We offer curbside testing so they don't have to come in the building .even if staff is sick and goes to the doctors, we would expect them to let us know. Director of Clinical Operations was queried regarding their expectation of residents on Droplet Precautions gathering in the TV room without masks and they said, The expectation is for residents on Droplet Precautions should not be in the TV room and should remain in their room. A review of the facility's Pandemic/Infection Control dated 10/26/2020 noted the following: Due to the increased risk of mortality from infectious disease in the frail elderly, infection control measures to prevent the introduction or spread of the infectious virus is a priority .Training clinical staff in the modes of transmission of the [MEDICAL CONDITION] .Training residents .non-clinical staff on the symptoms of influenza and standard infection control precautions (handwashing, respiratory hygiene/cough etiquette .Isolation of infected residents .use of appropriate barrier precautions during resident care .Screen all employees for infectious disease-like illness before coming on duty .If an outbreak of pandemic influenza occurs with the facility, strict adherence to standard and transmission-based precautions and other infection control measures will be implemented. Abatement Plan The following interventions either have been implemented or will immediately be implemented effective today to address the alleged non-compliance: All individuals entering facility will continue to be screened for COVID-19 prior to entry and denied entry if necessary. All staff will continue, at a minimum, to wear face masks while in the facility. Facility will continue COVID testing for all staff at required intervals Upon learning of a confirmed case of COVID in a staff member, facility will: - Exclude the individual from the workplace - Interview individual to identify and trace close contacts within the facility and assess any identified close contacts for exposure risk to determine further appropriate action, if any. - Prohibit access to common areas of the facility to individuals on droplet precautions in a manner consistent with the relevant care plan -Notify the appropriate agencies as required -Notify all staff and residents / resident families as required -Post required notice of existence of positive case at facility entrance for the applicable time period -Sanitize areas of the facility as necessary

This citation pertains to intake MI 012 Based on interview and record review, the facility failed to ensure that one sampled resident (#703) of three reviewed for abuse and neglect was free from verbal abuse, involuntary seclusion, and mistreatment resulting in feelings of fear and mental anguish. Findings include: On 3/15/16 at 9:30 a.m., an interview with resident #703 revealed that a Certified Nursing Assistant (CNA) staff C was involved in behaviors she felt were abusive behavior. Resident 703 reported that, an incident happened that the facility was made aware of, and further added that staff C had been reported to the facility's unit manager, D. Resident #703 reported the following concerning CNA C, I could tell by what the CNA was stating, that you could tell she was upset. She (CNA C) began to change me from my soiled brief and had to leave the room for something, and left me exposed with feces in my brief. I waited and waited, then 15 minutes went by, then longer. Resident 703 continued, stated that CNA C left her in a soiled brief (feces) and threw the call light far from the resident's reach on the floor, then closed the door to her room (resident #703 was in a private room at the end of the hallway). Resident stated she waited for an hour then started to yell out and no one responded. 'I had to call my daughter and had her call the front desk. The next thing resident #703 stated she knew, the CNA came forcefully flying into the room angry and told the resident that she was sick of her, and sick and tired of looking at her white face. Resident #703 reported, then, CNA C threw the soiled brief with feces in it onto the floor and further angrily addressed resident #703 with accusations that resident #703 was determined to have CNAC fired, and with that stormed out of the room closing the door on the resident again and leaving the call light on the floor. Resident #703 further explained that the unit manager, staff D came into the room five minutes later after I had placed the initial phone call and resident #703 told staff D that she had a problem with her (CNA C) and that she wanted to have another CNA. Resident #703 revealed that, The CNA came in the room the second time and continued with her verbally assaulting words. (The resident stated she felt threatened). Later, I heard that the CENA quit. I did not have her work with me after that event, not sure what happened with her until I heard that she was fired. On 3/15/17 at 2:17 p.m., the clinical record for resident #703 was reviewed and revealed an admission date of [DATE] and a re-admission date of [DATE], with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) dated , 2/21/17, revealed that resident #703 was cognitively intact and was dependent on the facility for activities of daily living. Resident #703 was coded as able to move her upper and lower extremities but was limited, and was unable to independently walk and was confined to her electric wheelchair. On 3/15/17 at 10:20 a.m., the Director of Nursing was interviewed and queried if she was aware of the reported aforementioned concerns that resident #703 revealed. The DON responded, I was not aware of this incident . When the DON was queried if the incident was investigated or reported to the state? The DON stated, I didn't know about it. The DON was queried, Would a nurse call to let you know if a CNA was being reassigned? The DON responded, No, that is a nurses' call. On 3/15/17 at 2:00 p.m., the facility's administrator (and abuse coordinator) was interviewed and queried if she was aware of the allegation of verbal abuse and neglect of resident #703? The administrator responded, this was the first that I heard about it. On 3/15/17 at 10:35 a.m., staff D was interviewed and queried regarding the reported verbal abuse and that resident #703 was left in her soiled brief, staff D responded, I was at the nurse's station and we received a call from her daughter. The daughter was saying she (resident #703) was trying to call for help and that no one was answering her and the daughter said she was calling for an hour. This was a month ago on Midnights (7-7) I also work 3-11. Not sure which shift but basically it was the evening. I went into the room right away. I was asking her what happened, she told me that the CNA was helping her and she closed the door behind her and she said that the call light fell on the floor. I told the CNA and asked if she accidentally closed the door on the resident (#703). I asked the CNA to go to her and said she needed to finish changing her. Then they exchanged some words. The CNA said 'I can't change her anymore because she won't let me.' I went back into her room and asked the resident what happened, what is going on, the resident said she didn't do it (left her soiled) and closed the door. She said she did not want her as her CNA. I switched the aides after telling the resident I can switch the aides. As soon as she was changed, I asked her if she was okay right now!. Staff D further reported that resident #703 stated, I just didn't like that we were having this argument. Staff D further added, I really do not know what they were saying to each other. She looked upset. This resident always has this smile on her face. I can remember her arms across her chest. I saw a change in her normal expressions. Staff D was queried, Do you know what a catastrophic reaction was? Staff D responded, It is really hard to explain. Can you remind me? Staff D was queried, if the resident felt like she was not being taken care of and if she looked upset or revealed anything that CNA C might have done? Staff D responded, She just mentioned she did not want to be with this aide. When queried if she reported this incident to anyone, responded, I think I mentioned it to the Director of Nursing (DON). Staff D was then queried as to when she spoke with the DON? Staff D revealed, I left a message right before I left my shift. This happened in the evening time, maybe around 9:00 p.m On 3/15/17 at 5:00 p.m., the policy and procedure titled, Abuse and Neglect Policy and Procedure dated, October 2016, revealed the following: - Each resident shall be free from abuse, neglect, mistreatment, exploitation and misappropriation of property. Abuse includes physical harm, pain mental anguish, verbal abuse (derogatory terms), sexual abuse, mistreatment, or involuntary seclusion from any source, - Resident care and treatment shall be monitored by all staff, on an ongoing basis, to ensure residents are free from abuse, neglect or mistreatment. It is the responsibility of all staff to provide a safe environment for our residents.

This citation pertains to intake MI 850. Based on observation, interview and record review, the facility failed to identify, develop, implement and/or document interventions and apply appropriate care to prevent pressure ulcers for three residents (#304, 302 and 301) of six residents reviewed for pressure ulcers from a total of 13 sampled residents resulting in the development and worsening of a facility acquired Stage 3 coccyx pressure ulcer with necrosis for Resident #304; the development of a right heel deep tissue injury (DTI) for Resident #302; and the worsening of a Stage 3 coccyx pressure ulcer for Resident #301. Findings include: Resident #304 On 9/7/16 at 8:30 a.m., during the initial tour, Resident #304 was observed lying on his back with the head of the bed (HOB) elevated. Resident #304 was flailing his arms around and appeared restless. Resident #304 was unable to respond or acknowledge being spoken to. Resident #304 was wearing air boots to both of his feet and pillows were under his sheets next to his upper body on both sides of his body. Resident #304 was also on humidified oxygen to support his breathing via a [MEDICAL CONDITION] (a surgically opened area to the throat). On 9/7/16 at 12:05 p.m. until 4:30 p.m., Resident #304 was observed lying on his back and was not repositioned during this time period. Resident #304 was observed positioned between two pillows, cradling him to the middle of the bed. On 9/7/16 at 1:30 p.m., Nurse A was requested to allow this surveyor an observation for wound care to be done and responded, the afternoon nurse does that. When queried, what if it is as needed, Nurse A could not offer a response. When queried further about what type of wound care does Resident #304 receive and what type of wound does he have, Nurse A could not offer a response and stated, she did not know. On 9/7/16 at 3:52 p.m., during a review of Resident #304's clinical record revealed an admission date of [DATE], with [DIAGNOSES REDACTED]. A Minimum Data Set (MDS), dated [DATE], scored Resident #304's cognition as severely impaired. Additionally, the MDS scored Resident #304's ability to move in his bed as completely dependent on staff. Further review revealed that Resident #304 entered the facility with his skin intact and no pressure ulcers were identified when he was admitted per the MDS. The initial Nursing Evaluation/Data Collection Sheet for Admission, dated 7/24/16 at 5:00 PM, revealed the following: resident's skin condition as follows: 1. LUA PIV (Left Upper Arm PICC line Vascular an access device used for intravenous fluids) 2. Left wrist skin tear, 3. Anterior right hand skin tear, 4. right great toe nail missing, 5. left great toe (blank) 6 redness to rectal peri area, 7 [MEDICAL CONDITION], 8. Bruise to right arm anterior. There were no further nursing notes in resident #304's clinical chart identifying any wounds; either the development or care provided. A care plan for skin wounds and pressure ulcers dated 8/12/16 revealed the following: I'm at risk for skin breakdown r/t (related to) decreased mobility and cognition, Goal: My skin will remain intact. Interventions: Assess me for presence of risk factors. Treat, reduce, eliminate risk factors to extent possible. Change my position frequently, Keep clean and dry as possible. Minimize skin exposure to moisture, provide incontinence care after each incontinent episode. Nurses do a weekly skin assessment and address any skin issues pay particular attention to bony prominences. Continued review of Resident #304's clinical record revealed a physician's orders [REDACTED]. [MEDICATION NAME] Ointment: Bilateral Buttocks, Apply topically per plan of treatment QS (every shift) and as needed after cleaning with soap and water, restore wound cleanser: Coccyx: Apply topically per plan of treatment to wound. Silver [MEDICATION NAME] 1% Cream: Coccyx: Apply topically per plan of treatment QD(everyday) and PRN (as needed) [MEDICATION NAME] Island Dressing 2 x 3.75: Coccyx apply topically per plan of treatment every day and as needed. Review of resident #304's TAR for August did not reveal any treatment plans addressing application for wound care. On 9/8/2016 at 8:20 a.m., Resident #304 was observed lying with shoulders twisted facing the door, while the buttocks and coccyx were lying flat on the mattress. Resident #304 appeared to be fidgeting and restless with repetitive movements of both arms into the air as though trying to grab something. On 9/8/2016, at 8:25 a.m., a review of the Wound Care Log: (TAR-Treatment Administration Record), for the month of September 2016, revealed a Weekly skin assessment shower day as 09/07/16, and where a signature or initial to acknowledge the task as being done, was left blank. Resident #304 was observed to not receive a shower on 09/07/16, during the day from 8:30 a.m., until 4:30 p.m Further review of Resident #304's clinical record also revealed physician orders [REDACTED]. A review of the nursing notes dated 9/7/16 revealed no documentation concerning any changes to the skin. The August Wound Care TAR was blank, with the weekly skin assessment shower day the only information written. An Admission Pressure skin care care plan, no date, identifies treatment as to follow facility skin care protocol and turn every 2 hours and PRN. All previous TAR's did not reveal that resident #304 had any pressure ulcers and the current TAR's did not reveal that resident currently had a stage 3 pressure ulcer (although the current pressure ulcer is necrotic). A Weekly head to toe skin checks, dated 8/3/16, revealed the following documentation for skin observations: previously identified areas? 'yes,' bruise? 'yes' rashes? 'no' skin intact? 'no', 8/9/16 coccyx bilateral buttocks contact [MEDICAL CONDITION], previously identified? 'yes', bruises? 'yes', resident favors lying on his back, 8/16/16 skin intact, no open area to coccyx 1.5 cm by 1.5 cm previously identified? 'yes', no bruises, 8/22/16 open area on coccyx skin intact? 'no', previously identified? 'yes' no measurements. On 8/9, no nursing notes on any wounds or the care thereof, on 8/16, no nursing notes on any wounds or the care thereof. There were no Braden Scales done (measurement to determine risk of developing a pressure sore), On 8/22/16, no nursing notes on wound or the care thereof. On 9/8/16 at 11:11 AM, during a wound care observation and interview with nurse B the following was observed and heard: I'm filling in for the wound care nurse and The wound care nurse has not been here for three weeks. Additionally, nurse B stated she just started doing wounds recently. Nurse B reviewed the TAR for September, when queried when did the new wound care information get entered into the TAR, nurse B stated that she did it late yesterday (9/7/16) after the wound care doctor came out. The TAR revealed the following ; Right ankle cleanse w/nss (with normal saline) apply hydrogel and dry dressing QD. Per nurse B, the TAR further read, he has a pressure ulcer stage 2 to his right ankle. Nurse B added, I just did his care plan for the first time today, he did not have one before. Nurse B then handed me a copy of the Wound Care Team Consult dated 9/7/16 and stated that it was the only one. When queried if there were any other wound care documents, nurse B stated, no. When nurse B was queried, if there were any other measurements or wound notes, nurse B responded, no. The 'new' care plan written 9/8/16, revealed the following: Right ankle posterior pressure ulcer stage 2, coccyx right buttock pressure ulcer stage 3. Labs total protein 6.3 [MEDICATION NAME] . Diagnosis: [REDACTED]. TX (treatment) as ordered by physician low air loss mattress 9/7/16. My goal - wound will heal without infection. Nurse B additionally provided one wound care form filled by the facility's Wound Care Consults, dated 9/7/16 at 2:03 PM, with the following assessments: Coccyx/right buttocks 6.5 by 6.0 by 1.2 centimeters, necrotic (dead and when there is necrotic tissue, that would indicate a 'stage 4' pressure ulcer) base, moderate serous drainage, irregular edges, mild [DIAGNOSES REDACTED], right posterior ankle 1.5 by 10 cm with a pink base minimal serous drainage, heels intact. Diagnosis 1. Pressure ulcer stage three coccyx/ right buttock and 2. pressure ulcer stage two right posterior ankle, Recommendations: 1. [MEDICATION NAME] everyday and as needed coccyx/right buttocks, 2. Hydrogel everyday and as needed to right ankle, 3. Insert Foley catheter to aide in wound healing, 4. Frequently reposition and 5. low air loss mattress. The following was observed during wound care, resident #304 was lying supine (on his back), the bed was not in lowest position, asked, is bed supposed to have been in lowest? Nurse B responded, yes' then proceeded to put the bed in the lowest position. No low loss air mattress was being utilized. Nurse B Set-up wound cleanser, 4 x 4' s' gauze, and a borderless dressing, along with Silver [MEDICATION NAME] 1% to put on wound (used to expedite wound healing). Wound dressing removed. Nurse B provided wound measurements: current measurement is 6.5 centimeters width (cm) by 6.0 cm length by 1.2 cm deep. Brief is thick with urine saturation and strong odor of urine. No Foley. Per nurse B, usually I have a CENA (Certified Nursing Assistant) over on the other side for safety. Left equipment on the table to go and retrieve CENA C. Re-washed hands for 5 seconds. CENA C did not wash her hands. When queried about how thick resident #304's brief is and smell of urine, per CENA C, I just changed him, he is a heavy wetter. CENA C ( resident #304's back observed with dark red lines and blotches) removed soiled brief, washed hands for three seconds re-gloved and returned to assist. Buttocks on both sides of butt cheeks were red around with scattered wounds that were opened. A dark area size of half of a dollar with an opening was observed on coccyx which was staged as a stage 3 however appeared unstageable (stage three involves skin, subcutaneous and muscle tissue). Nurse B proceeded to Wash wound and did not re-glove or re-wash hands before measuring or washing wound. The 'Necrotic base' observed in center of coccyx, was opened and had a measurement of 0.5 depth, width was 4.5 cm by 5.0 cm. After measuring, nurse B proceeded to the 4 x 4 gauzes and reached in obtaining several gauzes with soiled hands, then obtained [MEDICATION NAME] and applied the [MEDICATION NAME] to the 4 x 4' s', while handling the 4 x 4' s', nurse B touched the inside of the dressings with her soiled hands. Nurse B then stated that she had to grab another tongue (wooden stick used to scoop medications) and proceeded out of the room to obtain a tongue. Nurse B re-entered resident #304's room and re-washed her hands for 5 seconds. The right hip had Redness that covered the entire hip which appeared to be excoriation. Upon applying ointment, resident began to scoot away from the source of touch from the wound. Nurse B stated, after I am done, I will go and ask the nurse for something for pain. Observation of feces was on rectum at the beginning of the wound care, nurse B stated she was going to clean him after the wound dressing because she did not want to get anything on him. Nurse B took her gloves off and re-washed hands for 5 seconds. When this writer pointed out the excoriation to nurse B, she stated she was going to call the physician and get an order for [REDACTED]. Resident was restless and thrashing throughout the wound care. Observations of skin tears on left arm and right hand were multiple. Nurse B did not address those wounds, and there were no arm protectors on resident. Left arm, near mid to elbow, was a large skin tear with reddened area surrounding the wound. When asked what type of care is the resident receiving for the skin tears, nurse B could not offer any response. When nurse B was explained to that she had to allow a wound observation of resident #304's heel, she then began to obtain the necessary supplies. Nurse B was not ready to provide wound care for the right heel at the time of the observation for the wounds. When nurse B was ready to proceed, nurse B touched resident #304 to reposition him and proceeded to re-wash her hands for 3 seconds only. Nurse B gloved her hands then gathered the Hydrogel, wound cleanser, 4 x 4' s', and Kerlix, tape. Nurse B with the same gloved hands, lifted the bag out of trash receptacle to re-position the bag in the trash receptacle. Nurse B then took her gloves off and washed her hands for 6 seconds and then nurse B re-gloved her hands. Resident 304's boot was removed to the right heel, with same gloves, nurse B reached into her pocket to remove scissors to cut off the old dressings and proceeded to do so. The right heel was observed to have had two sores; one directly behind the ankle area, which was recently staged (9/7/16) as a pressure ulcer stage two (involving skin and subcutaneous tissue and pain), and one to the lateral malleus/ankle. There were two toes (last two) to the right foot that had sores to the top of the toes. A small wound to exterior ankle measured 0.1 depth by 1.5 cm by 1.5 cm's was not staged by the facility. Nurse B was observed removing the old dressing, then cleansed and measured the ankle wound without re-washing or re-gloving her hands. Additionally, nurse B did not mention the second wound which was scabbed and red. When the second wound was pointed out to the nurse, and was asked about that wound, she was unable to explain when and how the ankle wound occurred, nor did she identify the excoriation and was unaware of the excoriation until it was pointed out to her. Nurse A had entered the room and it was at this time that this writer brought to her attention that it was not observed that the resident was turned or repositioned on 9/7/16. Nurse A was on the day shift the day before (9/7/16) and was queried if she knew when the resident was turned and repositioned yesterday, she was unable to confirm when and if the resident was turned or repositioned. On 9/8/16 at 1:45 PM, an interview with the facility's Director of Nursing (DON) revealed when queried about the development of resident #304's pressure ulcers, that there were no care plans developed, that the wound was not being monitored and that the cross contamination of not washing hands appropriately and touching other items without re-washing was being performed. The DON responded, I realize that there were no skin assessments for this resident's pressure ulcer and that there were no in-services on handwashing. On 9/8/16 at 5:10 PM, a review of the facility's policies titled, Pressure Ulcer and Skin Care Management, with no date, revealed A resident who enters the facility without pressure ulcers does not develop pressure ulcers unless the resident's clinical condition demonstrates that they were unavoidable; and a resident having pressure ulcers receives necessary treatment and services to promote healing, prevent infection and reduce the risk of new pressure ulcers developing. Procedure: 1. A licensed nurse checks the resident's body for the presence of pressure ulcers, wounds and other skin conditions: Weekly on residents .2. The licensed nurse documents that the body check was completed on the resident's weekly head to toe skin record. 3. The presence of any pressure ulcer, wound, or other skin condition is documented weekly on pressure ulcer or skin report forms (wound/skin healing record and or non-pressure skin condition report), 4. A licensed nurse completes a pressure ulcer risk assessment using the Braden scale: At admission or readmission to the facility, Weekly for four weeks after the initial admission Braden scale is complete .and with significant change of status assessment. 8. The interdisciplinary team: Develops the care plan using the clinical conditions and risk factors identified, Includes in the care plan measurable objectives and timetables to meet the resident's needs as identified in the resident's assessment, Considers and includes interventions for pressure ulcer prevention and treatment to provide an aggressive program of consistent interventions by all staff involved, Implements treatment procedures in accordance with professional standards of practice, Evaluates and revises the care plan based on the response, outcomes, and needs of the resident and Determines if the resident refuses's treatment; is so re-evaluates and attempts other interventions. Procedure for Handwashing with no date, revealed, 2. Apply on squirt of soap. Using friction, rub hands together, cleaning under nails and between fingers thoroughly. Wash up to your wrist as well. Do this for at least 20 seconds. When to wash hands (at a minimum) Before and after each resident contact, after touching a resident or handling his or her belongings, whenever hands are obviously soiled, after contact with any body fluids, and after handling any contaminated items (linens, soiled diapers, garbage, etc.) ( ) Resident #302 On 9/7/16 at 9:15 am, Resident #302 was observed sitting up in a wheelchair adjacent to his bed. Resident #302 was observed to make facial grimacing and when queried, Resident #302 stated, My heel (right) is so sore that I can't touch it with a powder puff. I told the nurses and aids about it two weeks ago but they haven't done anything about it. I asked to see that doctor about it (Right heel pain) but nothing. Resident #302's right foot was covered with a sock. There was no protective heel covering intact and the right heel was observed resting on the floor. When asked to rate the level of pain on a scale of 1 through 10, Resident #302 stated, While resting on the floor it is a five, but when I stand on it, it is a 10! On 9/7/16 at 11:00 am, clinical record review revealed that Resident #302 was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. According to the Admission Nursing assessment dated [DATE], Resident #302 was alert, able to verbalize his needs, required one person physical assistance for bed mobility and 1-2 person physical assistance for transfers. Review of the Admission Nursing Assessment regarding the skin, revealed no documentation or indication on the diagram that Resident #302's heels had any skin concerns. The Initial Care Plan (undated) noted there were no interventions related to skin care or the prevention of pressure sores. On 9/7/16 at 11:30 am and at 1:30 p.m., Resident #302 was observed to sitting up in the wheelchair, next to his bed, with his right heel touching the floor. There was no protective covering or device intact. On 9/7/16 at 3:30 p.m., the Interim Wound Care Nurse and Nurse 'S' were queried regarding the right heel pain that Resident #302 voiced. The Interim Wound Care Nurse and Nurse 'S' reviewed Resident #302's clinical record. There were no nursing skin assessments that would indicate that licensed/registered nursing staff assessed Resident #302's skin. There were no bath sheets to indicate that Resident #302's skin was monitored by Certified Nurse Assistants on bath days (Thursday day shift and Sunday afternoon shift). In addition, the Interim Wound Care Nurse acknowledged there were no nursing notes or wound care notes that addressed Resident #302's complaints of right heel pain nor was there any documentation regarding the condition of Resident #302's right heel. On 9/7/16 at 4:00 p.m., the Wound Care Team assessed Resident #302's right heel and noted a fluid-filled blister that measured 3.3 centimeters (cm)by 1.7 cm. On 9/8/16 at 8:00 am, a skin assessment was performed by the Interim Wound Care Nurse. At this time, Resident #302's right heel was observed. The Interim Wound Care Nurse stated, The fluid-filled blister is gone. It is now a red bruise. In addition, Resident #302's right heel wound was observed to be dark red, near purple in color at the 1-3 o'clock position and the circumference of the area was approximately the size of a golf-ball (larger than 3.3 cm x 1.7 cm). On 9/8/16 at 5:00 p.m., the Interim Director of Nursing (DON) was queried regarding the findings related to the onset of Resident #302's right heel wound. The DON acknowledged that nursing staff did not implement interventions to prevent an acquired right heel wound nor did nursing staff perform skin assessments to monitor Resident #302's skin for any changes in order to update or change interventions to prevent the right heel wound. ( ) Resident #301 On 09/07/16 at 2:15 p.m., during a review of the medical record for Resident #301 the following was revealed: Resident #301 was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS (minimum data set) assessment dated [DATE] indicated intact cognition with a 15 out of 15 BIMS (brief interview of mental status) score and the need for extensive assist with bed mobility and transfer. The stage three pressure ulcer size was noted as 4.2 cm (centimeters) long by 3.2 cm wide by .5 cm deep. The pressure ulcer/skin care plan dated 09/02/16 indicated,Approach: Frequently reposition, low air loss mattress. On 09/07/16 at 8:45 a.m., during the initial tour and at 12:48 p.m., and 4:50 p.m., Resident #301 was observed in bed. A Low Air Loss (LAL) was not present on the resident's bed. The September 2016 TAR (treatment administration record) revealed, Coccyx: cleanse normal saline, apply santyl to wound base, cover with 4x4, ABD pad. The treatment was not documented as done on 09/05/16 and 09/06/16 for the 7-3 shift nor a prn (as needed) treatment. On 09/08/16 at 1:15 p.m., Resident #301 and their spouse were queried if the LAL was in place prior to this time and stated, No. It was just put on today. I had to sit up in my wheelchair which is not comfortable for me. Resident #301 was also queried if they had a wound and stated, I had gone to my regular doctor and he said I had a bed sore. I don't know how I got it. I was pretty active before all this. Resident #301 was then queried about wound care at the facility and stated, It used to be changed only every three or four days. On 09/08/16 at 2:56 p.m., the wound care physician consult noted dated 09/07/16 indicated, coccyx, 3.5 cm by 1.2 cm by .9 cm necrotic (non viable tissue) base, minimal slough (non viable tissue), moderate drainage, irregular edges, santyl every day to coccyx, frequently reposition, low air loss mattress. ( )