Every finding on record at The Villa at the Bay

This citation pertains to intake 3008577.Based on interview and record review, the facility failed to ensure staff competencies were performed for 5 staff members reviewed. Findings include: Review of three Certified Nursing Assistant (CNA) employee files showed CNA T, CNA NN, and CNA OO did not have any documented skills competencies. Review of two Licensed Practical Nurse (LPN) employee files showed LPN BB and LPN N did not have any documented skills competencies. In an interview on 7/16/26 at approximately 10:00 AM, the Nursing Home Administrator (NHA) reported, if the staff competencies were not provided, they did not have them.

This citation pertains to intake #2991669.Based on observation, interview, and record review, the facility failed to follow menus prepared in advance for six Residents (#41, 47, 48, 49, 50 & 51) of six residents prescribed a pureed diet.Findings include:On 4/22/2026, the State Agency (SA) received a complaint which read in part, Complainant states that (Resident #41 [R41]) is on a puree diet and the staff have given him mashed potatoes for two meals per day for a year. Complainant states that (R41) has asked for a different meal option, but they haven't given him anything else to eat. Complainant states that (R41) chooses not to eat the mashed potatoes because they make him sick to his stomach because he has had them for too long.On 4/28/26 at 12:44 PM, R41 was in the north dining room waiting for lunch. R41 stated the food was getting better but he still got a lot of mashed potatoes.During a tour of the south dining room on 4/28/26 at 12:50 PM, R47 and R48 were observed to be eating a pureed diet. R47 was being assisted with her meal and did not voice any comments. R48 was not happy with her meal. She pointed to her plate (a puree diet) and said, It is all mush. The same mush every day. I can chew. The plate contained pureed peas, pureed mashed potatoes, and pureed chicken.On 4/28/26 at 12:55 PM, R41 had received his pureed lunch in the north dining room and it included pureed peas, pureed mashed potatoes, pureed chicken and ice cream as a dessert. The other residents in the dining room received chicken soft tacos, refried beans, and corn and a dessert of churros.During an interview on 4/28/26 at 2:45 PM, the Dietary Manager (DM) F presented the planned menus titled, Week At a Glance as well as the pureed diet extension for the meal. The pureed diet was listed as pureed chicken soft tacos, pureed refried beans, pureed chef choice vegetable (not corn) and pureed churros. DM F was asked why the menu did not include what was planned and he replied that the cook had not followed the menu. DM F said, Instead of pureed refried beans he made mashed potatoes.During an interview on 4/28/26 at 2:50 PM, Dietary Staff H was asked what was prepared and served for the pureed lunch meal. Staff H described the meal preparation. The cook had pureed chicken, but he had not followed the pureed chicken soft tacos recipe. Staff H had not prepared pureed refried beans but made mashed potatoes. Staff H had pureed peas for the chef choice of vegetable. It was also confirmed those residents prescribed a puree diet including Resident #49, Resident #50 and Resident #51, did not get the planned pureed churros dessert but an ice cream cup.The menu prepared by a Registered Dietitian included a variety for the pureed diets and included corresponding recipes for each pureed item. The menu and recipes were reviewed with DM F and it was agreed the menu and recipes for the residents on a pureed diet had not been followed.

This citation pertains to intake #2991669.Based on interview and record review the facility failed to provide timely pharmaceutical services, for one Resident (#40) of three sampled residents reviewed for pharmacy services. Findings include:Resident #40 (R40)On 4/22/2026, the State Agency (SA) received a complaint which read in part, Complainant states that she is prescribed Zubsolv. Complainant states that the medication is for opioid dependence . Complainant states that she runs out of the medication often and the staff have to go to a local pharmacy to locate the medication. Complainant states that she starts to have withdrawals when she is not on it, which includes sweating, nausea, anxiety, and diarrhea.The medical record for R40 indicated an admission date of 9/25/25 with diagnoses of pain in right ankle and joints of right foot, major depressive disorder, and chronic pain syndrome. Physician orders on 10/27/25 included Zubsolv Sublingual Tablet 5.7-1.4 MG (milligrams). Give 1 tablet sublingually three times a day for pain dissolve under tongue.The medical record also included a nurses progress note on 4/1/26 at 11:35 (AM) which read, . Zubsolv . awaiting delivery from pharmacy. An additional nurse progress note dated 4/12/26 at 12:09 (PM), read . Zubsolv . On order from pharmacy.During a phone interview on 4/28/26 at 3:17 PM, Pharmacist I stated the medication Zubsolv for R40 had to be pulled from the pharmacy back up on 4/1/26 and 4/12/26 and sent to the facility. Usually, they will pick it up.During an interview on 4/28/26 at 4:42 PM, the medication administration record was reviewed with the Director of Nursing (DON) and the Nursing Home Administrator (NHA). The Zubsolv medication was observed scheduled for 8:00 AM, 1:00 PM and 8:00 PM each day. Zubsolv was signed as not available on 4/1/26 at 8:00 AM and on 4/12/26 at 8:00 AM. The DON presented records indicating a facility staff member picked up the medication Zubsolv from the local pharmacy on 4/1/26 at 4:18 PM, and it was given as the 1 PM dose. On 4/12/26 at 3:15 PM the facility personnel again picked up the Zubsolv from the local pharmacy and it was administered at approximately 3:30 PM as the 1 PM dose. The medication was unavailable at 8 AM on both 4/1/26 and 4/12/26.The facility pharmacy policy titled, Medication Administration - General Guidelines read in part, Medications are administered as prescribed in accordance with good nursing principles and practices.Medications are administered within 60 minutes of scheduled time.

This deficiency pertains to intake #2644019Based on interview and record review, the facility failed to prevent the involuntary seclusion of one Resident (#1) of three residents reviewed for involuntary seclusion. This deficient practice resulted in feelings of frustration and the potential for feelings of isolation, depression, psychological and emotional distress, and impaired mental health. Findings include: Intake complaint #2644019 was received by the state agency on 10/15/25. The complainant alleged Resident #1 (R1) was living in a secured unit in the facility where residents with dementia reside despite R1 not having a dementia diagnosis. The intake alleged, in part: . [R1] is in the dementia unit even though she doesn't have dementia.staff won't let her leave the unit. Review of the Electronic Medical Record (EMR) disclosed R1 was admitted to the facility on [DATE] and had a primary diagnosis of lymphedema. A dementia diagnosis was not found in the EMR. R1 was assigned to a room on the facility's south unit. The EMR did not contain a care plan for placement in a secured unit nor did the EMR contain documentation of the clinical criteria for placement of R1 in a secured unit. Documentation was not located regarding R1's input and involvement in placement on a secured unit.A quarterly Minimum Data Set (MDS) assessment dated [DATE] documented R1 had a Brief Interview for Mental Status (BIMS) score of 15 reflecting R1 was cognitively intact. Further review of the MDS revealed R1 did not display behaviors and was not at risk for elopement from the facility. The MDS documented R1 sometimes felt socially isolated.On 10/22/25 at 11:25 AM, staff C confirmed the facility was comprised of three units: a north unit, a central unit, and a south unit. Staff C said the south unit consisted of residents who had dementia. Staff C indicated the south unit had a digital key code system, and the code was required to exit the south unit. Staff C said only the staff had access to the code to leave the south unit, and a staff member would be required to enter the code to exit that unit.The door to the south unit was visualized on 10/22/25 at 11:28 AM. Entrance to the south unit was accessed by pushing a button next to the door of the unit. Once inside the door to the south unit, a key-coded, electronic securement system was observed next to the door. The system contained a series of pressable keypads containing numeric digits.Licensed Practical Nurse (LPN) A was interviewed on 10/22/25 at 11:30 AM. LPN A was asked the reason a key-coded system was placed next to the door to exit the south unit. LPN A explained a series of numbers had to be pressed on the keypad to unlock the door and exit the unit. LPN A said, It's for the safety of the residents here [south unit] - they all have dementia of some sort. LPN A asserted the staff had the numeric code to exit the south unit, and staff had to enter the code for anyone who wanted to exit the unit. LPN A said, They [the residents on the south unit] can't exit without a chaperone. LPN A said the doors to the south unit are maintained closed and secured for the safety of the residents on the south unit. LPN A confirmed the doors to the other units were left open and did not utilize or require access codes for egress from the other units.On 10/22/25 at 11:35 AM, R1 was observed and interviewed in her room on the south unit. R1 responded appropriately to questioning and presented as alert and oriented. During the interview, R1 said, I never wanted to be on a dementia unit - I don't have dementia. I just wanted a private room. I wish I could be on north [north unit] in a private room. R1 said she previously resided on the north unit. She said she told staff she wanted her own room, so she was moved to the south unit. She said she never told staff she wanted to move to the south unit from the north unit. R1 said she ambulated to the bathroom with her walker but utilized a wheelchair for locomotion outside of her room. R1 said she attended activities routinely throughout the week and left the unit independently in her wheelchair after a staff member entered the door code so she could exit the unit. R1 said after a staff member let her off the south unit, she independently propelled her wheelchair to attend activities or other areas of the facility. R1 said, They won't give me the code to leave [the south unit].R1 said there were two occasions when she was told by staff she could not leave the unit but could not recall when it occurred. She said she was told on those two occasions that she had to stay in the unit.Registered Nurse (RN) B was interviewed on 10/22/25 at approximately 12:00 PM. RN B confirmed the south unit was considered the facility's dementia unit. RN B said R1 did not have the code to get off the unit and confirmed R1 needed to find a staff member to exit the unit. RN B said R1 independently propelled her wheelchair to activities without staff accompaniment when staff open the door for her to exit the unit. RN B said R1 was the only resident currently on the unit who was not cognitively impaired. When asked if it was appropriate for R1 to be on the unit that otherwise exclusively housed cognitively impaired or demented residents, RN B said, She [R1] could be on north [unit].The Administrator (NHA) and Director of Nursing (DON) were interviewed on 10/22/25 at approximately 1:30 PM. The NHA and DON confirmed the residents on the south unit had dementia and cognitive impairment. When asked the clinical indication for placing R1 on a unit requiring key-coded egress, the NHA said R1 was placed on the south unit because R1 wanted a private room. When asked if a private room had become available on another unit, the DON said R1 had been offered private rooms on the north unit but R1 had declined the offers. The DON was asked for documentation of R1's declination of the alleged offers or any documentation R1 had been offered a room on another unit. The DON replied that she didn't think there was documentation but said she would verify. When asked if there was documentation to support the resident's involvement in the decision for placement on the south unit, the DON said, I'll have to look. The DON and NHA were asked if R1 had a care plan to be on the south unit, and if the care plan contained interventions to direct staff on appropriate steps to take while an alert and oriented resident resided on a unit with key-coded egress that housed residents with dementia and cognitive impairment. The DON and NHA said they did not know if there was a care plan for R1 to be on the south unit.The DON and NHA were asked for the criteria for residents to be on the south unit. They responded they had a policy and said the policy would be provided. When asked if R1 had been supplied with the code to independently leave the unit, the DON said staff had to enter the door code for R1 to exit the unit. The DON said R1 left the unit independently and said, She [R1] can go wherever she [R1] wants to go in the facility at any time.The DON was asked to provide the documentation of R1's clinical criteria for placement on the south unit, a care plan with interventions for egress from the south unit, documentation on the decision to place R1 on the south unit, documentation of R1's voluntary involvement in being placed on the south unit, any additional information regarding R1's placement on the south unit, and a policy for placement criteria for residents on the south unit. R1 was re-interviewed on 10/22/25 at 2:52 PM. R1 reiterated she wanted a private room. R1 asserted she did not belong on the south unit and said she had never been offered a private room on the north unit. The facility provided a policy on 10/22/25 at 2:55 PM titled Guideline Regarding Our Special Care Secured Unit dated 3/14/17. The guidelines read, in part: . Our Special Care Unit is a Memory Care Unit. This unit is secured by a keypad in which: Our resident do not have access to. It is our practice to have our facility staff enter in the security pin for all visitors exiting the unit. It is not our practice to share this door security code with any one person that is not an employee of our facility.This security provides a specialized need for cognitively impaired persons. Our unit includes but is no [sic] limited to targeted activities and other programs specifically designed for the care of people with progressive memory and functional loss.The policy further read, in part: . This special care unit provides comprehensive care plan management that supports the need for a secured unit that includes an interdisciplinary team approach together with the resident and representative. Our units are designed for the following reasons: o It is the home of individuals whom suffer from progressive memory loss, o Provides a safe community, o Individuals who live within this secured environment become familiar with consistent care givers whom represent their safety and well-being.The facility did not provide documentation of the clinical criteria for placing R1 on the secured unit. The facility did not provide documentation for the decision for placement of R1 on a secured unit. The facility did not provide a care plan with interventions for R1 residing on a secured unit. The facility did not provide documentation of R1's involvement in the decision for placement on a secured unit.

Intake: MI00150656 This citation has two separate deficiencies. Based on interview and record review, the facility failed to provide all necessary care and services for one resident (R128) of one resident reviewed for quality of life, resulting in R128 not maintaining his highest practicable well-being, being hospitalized three times and endangering his life. Findings include: Review of R128's Electronic Medical Record (EMR) revealed admission to the facility on [DATE] with diagnoses including multiple right rib fractures and alcohol dependence with withdrawal. R128 was his own responsible party for medical and financial decisions. Review of R128's Discharge Summary from [Hospital Name] dated 3/4/25 read, in part, .Patient is a pleasant 78 y.o. (year old) male who tripped over a tv cord the morning of admission (3/2/25) and had right sided chest wall pain. He was diagnosed with multiple right sided rib fractures, however refused hospital admission .He then went home and slipped and fell on the ice of his driveway and returned having never made it inside his house. This time he did strike his had [sic] and had questionable LOC (loss of consciousness). On second presentation to the ED (emergency department), he was only complaining of right sided chest wall pain. He was found to have fractures to R (right) ribs 7, 8, 9. He was admitted to the ICU (intensive care unit) given the severity of his rib fractures to monitor his vital signs and oxygenation .He demonstrated some signs of alcohol withdrawal, mainly tremors. This was treated satisfactorily with oral Librium (medication used to treat anxiety or alcohol withdrawal) .He is being discharged to [Facility Name] in stable condition .He will be sent on a 3-day taper of oral Librium to prevent DT's (delirium tremens) while at the facility .Medications: chlordiazepoxide (Librium) 75 mg (milligrams) to be given evening of 3/4/25, 50 mg BID (twice a day) to be given on 3/5/25, 25 mg BID to be given on 3/6/25 . Review of R128's Physician Note dated 3/5/25 read, in part, .Overall the patient remained stable although he did develop concerns of minor alcohol withdrawal in which he was discharged to [Facility Name] for subacute rehab with oral Librium taper. Upon arrival to [Facility Name] the patient was stable with mild tremor. Librium was not stocked in the back up medications and the patient did not come with any from the hospital therefore I did place him on Ativan 1 mg x (times) 1 with .5 mg Q4hrs as needed .He has mild tremor and anxiety .Assessment: Alcohol withdrawal syndrome without complication - with chronic alcohol abuse and acute alcohol withdrawals. Mild with tremor and agitation. Vitals stable. Continue Ativan taper as ordered with PRN Ativan x 7 days. Continue thiamine and folic acid as ordered. Monitor closely, vitals every shift x 3 days . Review of R128's Medication Administration Record (MAR) for March 2025 revealed two Physician Orders for Librium which read as follows, Librium 25 mg 1 capsule by mouth two times a day for ETOH for 1 day (3/5/25) and Librium 25 mg 2 capsule by mouth two times a day for ETOH for 1 day (3/4/25). During review it was confirmed that R128 did not receive either order of his Librium medication. Review of R128's Progress Notes read, in part, 3/4/25 08:22 This writer received a phone call from primary nurse at 0020. Primary nurse stated that resident became extremely agitated for no apparent reason and was trying to rip the TV off of the wall. PRN Ativan was given. Resident is a heavy ETOH user, prior to hospitalization and admission and is suspected to be going through withdrawals. NP (Nurse Practitioner) was notified this morning. She would like resident to have Ativan this morning 1 mg if Librium did not come in. 3/5/25 12:04 Med with (R128) to get food preferences. (R128) was very out of it had trouble answering my questions . 3/5/25 17:53 Pt (patient) medicated throughout shift for agitation and pain . 3/7/25 08:11 .Sending out to hospital due to ETOH and elevated blood pressure, complaining of chest pain and stating that he is having a heart attack . 3/7/25 15:25 Resident stated that he feels like he is dying, and can't breath. Resident appears to have tremors, increased anxiety and agitation, denies auditory or visual hallucinations. PRN Ativan given . 3/7/25 16:38 Resident extremely agitated stated he was calling the police, there was people trying to take over his home, stated he would walk home in his pajamas if he had to. Appears to be having delusions and agitation related to alcohol withdrawal. NP contacted. Gave one time order for Ativan .5mg and lisinopril 20mg. Asked that vitals be rechecked in 1 hour and texted to her. Primary nurse notified. 3/7/25 20:56 This writer was notified that the resident was yelling at staff exit, having episodes of delirium. Upon assessment the residents blood pressure was elevated, immediate action was taken blood sugar obtained. Resident was oriented only to person, slurred speech, right sided facial drooping, ataxia NIH performed with positive results. NP notified with an order to send out . 3/7/25 22:17 Resident was walking on his own, very unsteadily, and he tried to go out the back door. He was pushing on the handle making the alarm go off. He also tried to set off the fire alarm .He was given .5mg Ativan, on 4 different occasions .he said Don't touch me, I'm going to get my gun .he called 911 and told the operator that he was being held against his will .he was going to kill everyone, one by one .police officers came . 3/7/25 23:13 .Per nurse patient is detoxing from alcohol, has been having high blood pressure despite several Ativan doses. He tried eloping several times, threatened to kill people. Nurse states that the new nurse that is coming on shift does not feel comfortable in taking care of this patient and thus is requesting the patient go back to the hospital . 3/8/25 14:21 Resident returned from [Hospital Name] . 3/8/25 18:08 Resident was observed to be having aggressive behaviors. Attempted to his glass door with oxygen tank. Threatening staff. Resident was extremely agitated and having delusional thoughts. He called 911 and told the police he was being held against his will . Review of R128's Physician Note dated 3/7/25 read, in part, .This patient is being seen today in follow up ER visit that occurred last night. The patient developed increased anxiety and hypertension and was sent to [Hospital Name] .the patient was given additional dose of linisonpril 20mg, oxycodone 5mg, and Librium 50mg and discharged back .Assessment: Alcohol withdrawal syndrome without complication .extended Ativan taper as ordered with continued PRN Ativan .Addendum: Staff requested repeat evaluation on the afternoon of 3/7/25 as the patient was requestioning to go to the ER. Upon exam, the patient notes he needs to go to the hospital because he is dying. He notes he is having anxiety and shortness of breath .Approx (approximately) 1 hour later the staff did call me again stating the patient called 911 himself stating he wanted the police to take him to the hospital .At 2000 the staff called and stated the patient was having acute right facial droop, hypertension, slurred speech, weakness with ataxia. At this point EMS was called and the patient was transferred to the hospital .Assessment: Alcohol withdrawal syndrome without complication . Review of R128's Physician Note dated 3/10/25 read, in part, The patient is being seen today in follow up from 2 ER visits over the weekend. The patient has been having acute alcohol withdrawal in which he developed agitation and delirium .the patient was treated for increased alcohol withdrawal and discharged back .upon arriving back records reveal the patient became agitated and was threatening to shoot staff with a gun and was aggressive therefore staff requested the patient go back to the ER. The patient was kept in the ER overnight in which he was noted to have persistent delirium and started on Risperidone .25mg twice daily and his symptoms did improve. The patient was brought back to [Facility Name] on 3/8/25 . Review of R128's ED summaries read, in part, Admit 3/7/25 01:16 He is brought to the ED by EMS (Emergency Medical System) from [Facility Name] .It is a bit unclear why the patient is here in the ED this evening .vital signs on arrival are significant for elevated blood pressure .We did call the [Facility Name]. Nursing staff spoke with their nurses .I did review his discharge summary from trauma surgery several days ago. It was noted that he was discharged with 3 days of Librium to finish his taper. Nursing staff at [Facility Name] did confirm that he has not been taking this, therefore maybe this is contributing to his elevated blood pressures .I have also ordered him a dose of Librium . Admit 3/8/25 00:04 Returns to the emergency department, his current skilled nursing facility where he was residing for rehabilitation purposes reports that they are unable to care for him, there is no clear report as to what exactly is occurring that is precluding them from caring for him, they alleged that it may be because of alcohol withdrawal .He has been seen in the emergency department 3 times in the past 24 hours . An interview was conducted with RN U on 5/22/25 at 11:39 a.m. RN U recalled R128 and said, It was kind of wild and crazy those few days, I remember him (R128) going through active detoxing. His behaviors were crazy. RN U confirmed he was not provided any additional resources or education for detoxing residents. An interview was conducted with Former Director of Nursing (DON) V on 5/22/25 at 12:06 p.m. DON V stated that R128 was suffering from severe withdrawals and having delusions and behaviors. DON V confirmed R128 never received Librium as the facility could not fill that order from the hospital and instead was given Ativan. DON V confirmed R128's behaviors continued, and the facility felt they could no longer care for the resident no longer felt comfortable doing so and discharged him 3 separate times to the emergency department. DON V stated the staff were not provided any additional education for residents who are suffering from withdrawal symptoms. An interview was conducted with Certified Nurse Aide (CNA) Q on 5/22/25 at approximately 10:30 a.m. CNA Q recalled R128 and said, I remember him having a lot of behaviors, he was taking oxygen tanks and throwing them at the exit doors, he called police, he was very scary and threatening us. I heard that he was having alcohol withdrawal. CNA Q recalled not having proper training on how to properly care for residents who are having withdrawal symptoms. Review of R128's Care Plans read, in part, Date Initiated: 3/6/25 Recent history of substance abuse; Goal: Resident will be in safe environment during stay at facility; Interventions: Complete review using medical record and resident/family interview, Education to resident on potential injury related to ordered medications and interaction with substances abuse, Establish resident goals, Notify MD (Medical Director) if resident appears impaired (prior to administering medications), Social Services referral of emotional support, Use calm and empathetic approach for communication . An interview was conducted with Regional Clinical Registered Nurse (RN) L on 5/22/25 at 11:29 a.m. who confirmed the facility does not have an alcohol withdrawal or assessment. 45123 Based on observation, interview, and record review, the facility failed to provide standards of care for hypoglycemia and diabetes management for one Resident (#5) of 18 residents reviewed for quality of care. Findings include: Resident #5 (R5) The medical record for R5 revealed an admitted to the facility on [DATE] with a primary diagnosis of diabetes mellitus. R5 had a BIMS assessment score of 15 out of 15 indicating intact cognition. On 5/20/25 at 11:12 AM, an observation was made of R5 in their room sitting on the side of their bed without any pants on. R5 was asked how they were doing and if they had any recent falls and replied, Yes, I had low blood sugar and I bumped my leg on my walker (four-wheeled walker). R5 was observed with a bandage on their left leg. R5 stated that orange juice does not work well if their sugar is low, and milk works best for them. Review of R5's medication administration record (MAR), dated 5/2025, revealed an order for lispro solostar 100 unit/ml (milliliter) pen-injector. Inject as per sliding scale: if 0 - 199 = 0; 200 - 250 = 2; 251 - 300 = 3; 301 - 350 = 4; 351 - 500 = 5; 501 - 999 = 6 Call physician if BS [blood sugar] if (sic) greater than 500. Review of fasting blood glucose sugar levels (FSBS), dated 4/27/25 through 5/19/25, revealed the following: - 4/27/2025 7:23 AM, 44.0 mg/dL (milligrams/deciliter) - no progress note. - 4/27/2025 7:38 AM, 64.0 mg/dL - no progress note. - 4/28/2025 8:06 AM, 38.0 mg/dL - no progress note - no follow-up FSBS. - 4/30/2025 7:24 AM, 56.0 mg/dL - no progress note - no follow-up FSBS. - 5/5/2025 11:34 AM, 47.0 mg/dL - no progress note. - 5/5/2025 11:47 AM, 54.0 mg/dL - no progress note - no follow-up FSBS. - 5/9/2025 11:57 AM, 69.0 mg/dL - no progress note - no follow-up FSBS. - 5/17/2025 12:22 AM, 42.0 mg/dL - no progress note - no follow-up FSBS. - 5/18/2025 11:58 AM, 55.0 mg/dL - no progress note - no follow-up FSBS. - 5/19/2025 11:47 AM, 58.0 mg/dL - no progress note. - 5/19/2025 11:59 AM, 58.0 mg/dL - no progress note - no follow-up FSBS. Review of R5's progress notes, dated 4/27/25 through 5/19/25, lacked any notification to the physician of a low blood glucose level and no follow-up on the intervention or status of R5. On 5/21/25 at 12:15 PM, an interview was conducted with the Director of Nursing (DON) regarding their expectation for nursing encountering a resident with blood glucose levels below 70 mg/dL. The DON replied, I would expect to see a progress note communication on the physician notification, the interventions, and the repeat FSBS until the blood sugar was within normal limits. Review of policy titled, Diabetes Management, dated 6/29/17, read in part, Purpose: To develop a practice in which our facility consistently provides care for the resident with diabetes. Guidelines .Nursing Evaluation / Symptoms: Blood glucose monitoring .Results <70 or >400 indicate hypo or hyperglycemia require immediate follow up. Determine with the physician / extender if the individual has specific parameters to monitor .Nursing intervention .Evaluate signs and symptoms of diabetes complications .Notify the physician of any findings .

Based on observation, interview, and record review, the facility failed to readily identify, promote healing, and prevent the development of pressure injuries for two Residents (#26 & R42) out of three residents reviewed for pressure ulcer care. This deficient practice resulted in R26 developing a stage 3 pressure ulcer that worsened into a stage 4 pressure ulcer, and R42 developing infection and the deterioration of pressure wounds. Findings include: Resident #42 (R42) The medical record for R42 revealed an admitted to the facility on [DATE] with a primary diagnosis of pneumonia. R42 had a Brief Interview for Mental Status (BIMS) assessment score of 15 out of 15 indicating intact cognition. On 5/20/25 at 12:04 PM, an observation was made of R42 in their room and lying in bed with a pillow under their left side and both heels touching the bed. R42 was asked when the last time staff had turned and repositioned them and replied, Since last night. R42 was asked if they had a pressure ulcer and replied, Yeah, on my buttocks. R42 did not have a personal protective equipment (PPE) cart outside of their room door and no used PPE was observed in the trash cans in their room. R42 was asked how often they normally get turned and repositioned and replied, Usually every three to four hours. R42 was noted not to be wearing puffy boots while in bed. Review of R42's Quarterly Minimum Data Set (MDS), dated [DATE], read in part, .Section E: Behaviors .Rejection of care: Behavior not exhibited .Section G: Functional abilities and goals .Substantial/maximum assistance for toileting, upper body dressing, personal hygiene, and rolling left to right .Section M: Skin conditions .Resident has a stage 1 or greater, a scar over bony prominence, or a non-removable dressing/device (checked) .Risk of pressure ulcer development check yes .Unhealed pressure ulcers checked yes .Number of stage 2 pressure ulcers - two. Number of these stage 2 pressure ulcers that were present upon admission/reentry - two . Number of stage 3 pressure ulcers - one. Number of these stage 3 pressure ulcers that were present upon admission/reentry - one . Number of stage unstageable pressure ulcers - three. Number of these stage unstageable pressure ulcers that were present upon admission/reentry - zero . Number of venous and arterial ulcers - two . Review of R42's Braden assessment for determination of developing pressure ulcer risk, dated 4/15/25 at 3:10 PM, revealed that R42 was at, very high risk. Review of R42's active wound summary list, dated 5/21/25, revealed the following: 1.) Wound site: buttocks/hip left, date identified 1/17/25, type: pressure, classification: ulceration, clinical stage: unstageable, and measured 0.70 length (L) cm (centimeters) x 0.50 width (W) cm x 0.00 depth (D) cm, 2.) Wound site: left flank lower wound, date identified 12/16/24, type: pressure, classification: ulceration, clinical stage: unstageable, and measured 2.40 L cm x 3.00 W cm x 0.10 D cm, 3.) Wound site: left flank upper wound, date identified 3/25/25, type: pressure, classification: ulceration, clinical stage: stage 3, and measured 2.70 L cm x 4.20 W cm x 0.20 D cm, 4.) Wound site: left buttocks 2 medial, date identified 1/17/25, type: pressure, classification: ulceration, clinical stage: unstageable, and measured 2.00 L cm x 1.30 W cm x 0.30 D cm, 5.) Wound site: left heel, date identified 5/20/25, type: pressure, classification: ulceration, clinical stage: unstageable, and measured 3.50 L cm x 4.60 W cm x 0.00 D cm, 6.) Wound site: right buttock, date identified 2/27/25, type: pressure, classification: erythema, clinical stage: healed stage 2, and measured 2.00 L cm x 1.50 W cm x 0.00 D cm, 7.) Wound site: sacrum, date identified 9/13/24, type: pressure, classification: ulceration, clinical stage: stage 3, and measured 8.00 L cm x 2.50 W cm x 0.70 D cm. Review of R42's task for behavioral monitoring for refusals of care, dated 4/21/25 through 5/20/25, revealed no refusals of care and no behaviors observed. Review of R42's care plan, dated 5/2/25, read in part, .Focus: The resident is on antibiotic therapy r/t (related to) cellulitis to buttocks. Goal: The resident will be free of any discomfort or adverse side effects of antibiotic therapy .Interventions: Administer antibiotic medications as ordered by physician .Focus: The resident has pressure ulcer (to) coccyx, sacrum, buttocks, (and) left scapula region. Goal: The resident's skin risk for further alteration in skin integrity will be minimized by staff allocated interventions. Interventions .Assess/record/monitor wound healing (q week) [every week] Measure length, width, and depth where possible. Assess and document status of wound perimeter, wound bed and healing process .The resident needs to turn/reposition at least every 2 hours, more often as needed or requested .Weekly treatment documentation to include measurement of each area of skin breakdown's width, length, depth, type of tissue and exudate . On 5/22/25 at 11:55, an observation was made of R42's wound dressing changes in their room with the Director of Nursing (DON), the Regional Clinical Registered Nurse (RN) L, and Licensed Practical Nurse (LPN) K to measure, assess, and complete wound dressing changes on R42's buttocks area. Findings include: 1.) Pressure ulcer, stage 3 to left buttocks (next to intergluteal cleft), facility acquired and measured 8.00L cm x 3.00W cm x 0.20D cm, 2.) Pressure ulcer, stage 3 to left buttocks (lateral side), facility acquired and measured 0.75L cm x 1.00W cm x 0.10D cm, 3.) Pressure ulcer, stage 3 to left lower buttocks facility acquired and measured 2.00L cm x 1.00W cm x 0.50D cm with tunneling, 4.) Pressure ulcer, unstageable to left heel, facility acquired and measured 3.50L cm x 4.60W cm x 0.00D cm. On 5/22/25 at 12:30 PM an interview was conducted with the DON who was asked if the documentation for the wound summary should reflect the actual presentation of the wound weekly after being assessed and replied, Yes, I don't know why it doesn't. We need to do a better job with documentation of wound assessments and measurements. (R42's) Pressure ulcers should not have developed or worsened. 49302 Resident #26 (R26) Review of R26's electronic medical record (EMR) revealed admission to the facility on [DATE] with diagnoses including dementia and aphasia (difficulty expressing thoughts). Review of Section C (Cognitive Patterns) of R26's most recent Minimum Data Set (MDS) Assessment, dated 3/21/25, revealed R26's cognitive skills for daily decision making were, severely impaired. On 5/20/25 at 1:35 PM, a phone interview was conducted with R26's son and Durable Power of Attorney (DPOA) R regarding his overall satisfaction with care received at the facility. DPOA R stated deterioration of a wound on R26's right buttock contributed to her overall decline and eventual enrollment with hospice services. Review of progress note dated 2/28/25 written by Nurse Practitioner (NP) S read, in part: Chief complaint/Nature of Presenting Problem: Progressing pressure ulcer, hospice discussion . History of Present Illness: [R26] is being seen today due to [a] progressing pressure ulcer. The staff notes [R26's] pressure ulcer is a stage 4 [extending through all layers of skin, exposing muscle, tendons, or bones], and [R26] overall continues to decline over time . hospice was recommended . Review of a R26's Wound Summary documentation read, in part: Site: right ischial tuberosity . Type: Pressure . Source: Facility Acquired . Date identified: 1/6/25 . Clinical stage: stage 3 . Review of R26's skin assessments revealed the most recent documented assessment prior to identification of the stage 3 pressure wound on 1/6/25 occurred on 12/18/25, an 18 day lapse between routine skin assessments. Review of R26's most recent Braden Scale for Predicting Pressure Sore Risk, dated 7/1/24, revealed a score of 12, indicating high risk of pressure ulcer formation. Review of R26's EMR revealed the following progress note written on 2/14/25 at 11:04 AM: .wound to ischial tuberosity has worsened in condition and is now a stage 4 . On 5/22/25 at 1:33 PM, a group interview was conducted with the Nursing Home Administrator (NHA), Director of Nursing (DON), and Regional Clinical Registered Nurse (RCRN) L regarding wound prevention and care expectations. The DON stated skin assessments should be completed on a weekly basis and documented in the EMR system. All parties agreed identification of the pressure ulcer on R26's right ischial tuberosity should have occurred prior to development into a stage 3 wound. Review of R26's plan of care revealed a focus initiated which read: [R26] has actual and potential for impairment to skin integrity r/t [related to] limited mobility, incontinence, dementia, hydrocephalus, venous insufficiency. An intervention, initiated on 6/11/24, read: Weekly skin assessment. Review of the facility policy titled, Skin Alteration Documentation, revised 2/11/19, read, in part: .patients without skin issues will have skin observed daily during cares and observations weekly by licensed nurses .

Based on interview and record review, the facility failed to adhere to the applicable components of the process for transferring or discharging residents including the notice of bed-hold policy and the written notice of transfer or discharge to both the resident, resident's representative, and the representative of the Office of the State Long-Term Care (LTC) Ombudsman, with the reason for a transfer for five Residents (#1, #42, #50, #54, and #75) of five residents reviewed for transfers out of the facility. Findings include: Resident #50 (R50) During an interview on 05/20/25 at approximately 12:20 AM, R50 stated she had been transferred out to the hospital a while ago. The medical record for R50 revealed three transfers dated 12/16/24, 12/23/24, and 1/4/25. The medical record did not indicate a written notification of transfer, or a bed hold policy was given to R50 or a responsible party for any of the transfers. Resident #54 (R54) During an interview on 05/20/25 at approximately 11:50 AM, R54 indicated he had been transferred out to the hospital during his stay at the facility although he was not sure of the date. The medical record for R54 revealed a transfer to the hospital on 1/9/25 with a readmission on 1/13/25. The medical record did not indicate a written notification of transfer, or that a bed hold policy was given to R54 or his responsible party. On 05/21/25 at 3:41 PM, the Director of Nursing (DON) stated she did not believe there was a system in place to send written transfer notifications to the resident and resident representative. Further follow up with the Regional Clinical Consultant Registered Nurse (RN) L revealed no documentation of bed hold policy presentations or written notification of transfers had been given to transferred residents or their responsible parties. During an interview on 5/22/25 at 10:45 AM, Clinical Consultant RN L confirmed there was not an Ombudsman log to alert the Office of the State LTC Ombudsman of the transfers. 45123 Resident #1 (R1) During an interview on 5/20/25 at 11:32 AM, R1 indicated they had been sent out to the local hospital during their stay at the facility but were unsure of the exact date. The medical record for R1 revealed a transfer to the hospital on 12/7/24 with a readmission on 12/9/24. The medical record did not indicate a written notification of transfer or a bed hold policy was given to R1 or their responsible party. Resident #42 (R42) During an interview on 5/20/25 at 12:04 PM, R42 stated that they had been admitted to the local hospital for pneumonia a couple months ago. The medical record for R42 revealed two transfers dated 2/23/25 and 3/18/25. The medical record did not indicate a written notification of transfer or a bed hold policy was given to R42 or their responsible party. Resident #75 (R75) The medical record for R75 revealed three transfers dated 1/24/25, 2/19/25, and 2/24/25. The medical record did not indicate a written notification of transfer or a bed hold policy was given to R75 or their responsible party. Review of policy titled, Bed Hold and Return Guideline, dated 4/25/19, read in part, Purpose: It is the practice of that residents who were transferred to the hospital or go on a therapeutic leave are provided with written information about the State's bed hold duration and payment amount before the transfer .Residents and their representatives will be provided with bed hold and return information at admission and before a hospital transfer or therapeutic leave . Review of policy titled, Transfer and Discharge Guidelines, dated 11/28/17, read in part, Purpose: This guidance supports safe discharges and transfers for all residents, regardless of initiating party. Guideline: The facility will provide proper and timely notice to a resident who will be discharged as required by regulations and laws .Notifications: The interdisciplinary team designee will meet with the resident and resident representative as applicable to review the discharge/transfer notice and its contents .A copy of the discharge notice is sent to the State Office of Long-Term Care Ombudsman. The Ombudsman office may offer additional support and advocacy to the resident .

Based on observation, interview, and record review, the facility failed to ensure meals were served in accordance with the posted menu. Findings include: A confidential resident council meeting was conducted on 5/21/25 at 11:00 AM. When discussing meal choices at the facility, 8 of 14 confidential participants stated the facility frequently did not follow the posted meal plans. Confidential Resident (CR) #9 stated: They [facility] never give us a decent menu and never follow the menu they give us . It's an everyday occurrence. When asked if the inconsistencies happen at a particular meal, CR-9 replied, It's a surprise. 40383 On 5/20/25 at 12:25 PM, Resident #7 (R7) and Resident #16 (R16) stated they were not satisfied with the meals served at the facility. R7 stated the kitchen did not serve what was on the menu. On 5/21/25 at 8:29 AM, the meal assembly tray line was observed in the kitchen. Dietary Manager (DM) N stated the menu cycle being served was not correct as another manager had been in charge. The menu was titled Week 2 and was dated 5/11/25 through 5/17/25. The menu items were served for the Week 2 plan despite being on the Week 3 menu cycle. On 5/22/25 at 12:56 PM, R7 received her lunch and pointed to her meal and stated, See this is not on the menu. They messed up again. They never serve what is on the menu. Every meal is wrong. R7 said she and her roommate were looking forward to roast beef the day before according to the menu and instead We got noodles with tomatoes. R7 presented a copy of the menu which had been passed out to all residents. The menu was dated for 5/18/25 through 5/24/25 and was labeled Week 3. Therefore, the menu the kitchen was using was Week 2 and dated for the previous week, and the residents had the Week 3 menu and did not get the expected meal. On 5/22/25 at approximately 2:00 PM, DM N agreed he had not given the residents the correct menus nor had he changed the date on the posted menu. He had recognized the error in the menu distribution and had posted the menu which was being served in both dining rooms. When the posted menus were reviewed the dates had not been corrected and no menu items were listed for the lunch meal on 5/22/25, and that lunch menu had been blacked out. During a group interview on 5/22/25 at approximately 2:00 PM, the Nursing Home Administrator, and the Director of Nursing acknowledged the residents had said the menus have not been followed. Review of the facility policy titled, Food & Nutrition Services Food Preparation, undated, read, in part: .cycle menus are planned by a dietitian at least two weeks in advance . the menu spreadsheet for the week is dated and available in the kitchen. The general menu is posted at visible places throughout the healthcare community . The menu of the day will be posted on each unit in a designated place where it will be readily available to clients, staff, and visitors .

Based on observation, interview, and record review, the facility failed to consistently provide meals in a timely manner and/or consistently provide a nourishing snack to all 82 residents. This deficient practice resulted in the potential for residents to not have a hot meal or to have more than 16 hours between a substantial evening meal and breakfast the following day, decreased oral intake, and the potential for weight loss. Findings include: On 5/20/25 at 12:46 p.m., an interview was conducted with Resident #27 (R27) who was sitting in the dining room waiting for the lunch meal service to be delivered. R27 expressed frustration with having to wait such a long time for their meal. It's late and it's always been late. It was bad on the weekend this time too. It's constantly being served to us late, yesterday it was 1:45 p.m. before we got out meal, and it wasn't very good either. Around 1:00 p.m. R27 was observed going back to her room and stated she refuses to eat a meal that is this late. R27 was noted to not eat a lunch on 5/20/25. On 5/21/25 at 9:17 a.m., an interview was conducted with Resident #3 (R3) who was laying in her bedroom. R3 stated the meals had been delayed for quite a few days and expressed frustration in having to wait for meals to be delivered. It has been awful, by the time I get my breakfast, it will be time for lunch. 40383 During the lunch meal observation on 5/20/25 at 1:16 PM, the second food cart carrying the meals arrived to the 100 (North) hall. At 1:23 PM on the same day, the last tray on the 100 (North) hall food cart was taken out of the cart and delivered. During the lunch meal observation on 5/21/25 at 12:55 PM, the first food cart arrived to the 100 (North) hall. The second food cart arrived to the 100 (North) hall at 1:07 PM. The third food cart arrived to the 100 (North) hall at 1:15 PM, and the last tray on the third cart was taken out of the cart and delivered at 1:17 PM. The posted mealtimes were presented on 5/21/25 at 2:31 PM as follows: Breakfast served: South wing (300 hall) - 8 AM - 8:20 AM North wing (100 hall) - 8:30- 8:40 AM Center wing (200 hall) - 8:45-9 AM Lunch served: South wing (300 hall) - 12 PM - 12:20 PM North wing (100 hall) - 12:30- 12:40 PM Center wing (200 hall) - 12:45-1 PM Dinner served: South wing (300 hall) - 5 PM - 5:20 PM North wing (100 hall) - 5:30- 5:40 PM Center wing (200 hall) - 5:45-6 PM During an interview on 5/21/25 at 12:45 PM, Resident #7 (R7) who resides on the North Hall stated she was dissatisfied with the meal arrival times. R7 said, We are getting breakfast after 9:00 (AM) and most of us are up at 6 or 6:30 (AM) and we have to wait . Lunch and dinner you never know (when the meals will arrive.) R16, who resides on the North Hall agreed saying mealtimes were sporadic and not served on a schedule. R16 stated, It would be nice if the meals were on time. During an interview on 5/21/25 at 12:49 PM, R22, a resident of the North Hall, said meals are sometimes late with breakfast arriving around 9:30 AM or whenever they bring it to us. R22 said dinner usually gets delivered at 6:30 at night. When asked if R22 received an evening snack, she replied, No, we have to ask (for a snack), and (we) do not always get one. During an interview on 5/21/25 at 1:20 PM, Dietary Manager (DM) N acknowledged the lunch trays that day were late. DM N was not familiar with the regulations on meal service hours and was unaware there must be no more than 14 hours between a substantial evening meal and breakfast the following day, except when a nourishing snack is served at bedtime, then up to 16 hours may elapse between a substantial evening meal and breakfast the following day if a resident group agrees to this meal span. DM N had not met with the residents and did not know of anyone who had met with the residents to determine if the residents would agree on a 16-hour meal span. 49302 A confidential resident (CR) council meeting was conducted on 5/21/25 at 11:00 AM. When discussing evening snacks, 6 of 14 confidential participants stated they were frequently not offered a snack during the evening hours. CR-2 stated, We have to ask them [the facility] for snacks . sometimes they come back and sometimes they don't. A lot of times they don't show back up. Review of snacks offered in a 30-day look-back period revealed CR-2 was not offered an evening snack on 13 different occasions. CR-8 stated, We haven't been getting breakfast until well after 9:00 AM . We're getting really hungry by the time breakfast is coming around. Review of snacks offered in a 30-day look-back period revealed CR-8 was not offered an evening snack on 7 different occasions. Review of Resident Council minutes dated 1/27/25 revealed the following question: How would you rate the quality of snacks provided between meals? The resident council selected poor as a response. Review of Resident Council minutes dated 3/3/25 revealed the following note: Snacks and water passes needed more at night. 7 of 14 confidential participants also voiced dissatisfaction regarding the timeliness of meals. CR-9 indicated residents frequently wait 30 minutes after the posted mealtimes for delivery of food trays. On 5/21/25 at 8:38 AM, breakfast meal service was observed on the secured dementia unit. On 5/21/25 at 8:40 AM, Certified Nursing Assistant (CNA) T was observed placing a breakfast tray in front of Resident #29 (R29) and continued to deliver trays to other residents. At 9:02 AM, CNA T was observed sitting next to the resident to assist with feeding, 22 minutes after initial placement of the tray. Review of Section GG in R29's Minimum Data Set (MDS) Assessment, dated 3/23/25, revealed R29 required total dependence for eating. Review of the posted meals time revealed service time for breakfast on the dementia unit (south wing) was 8:00 - 8:20 AM. On 5/21/25 at 12:20 PM, the lunch service was observed on the secured dementia unit. R29 was observed seated at a central table in a wheelchair. On 5/21/25, the mobile lunch carts arrived on the secured unit at the following times: At 12:24 PM, the first lunch cart arrived on the secured unit. At 12:32 PM, the second lunch cart arrived on the secured unit. At 12:36 PM, the third lunch cart arrived on the secured unit. On 5/21/25 at 12:43 PM, CNA T was observed placing a lunch tray in front of R29. At 12:52 PM, R29 was observed receiving dining assistance, 9 minutes after the tray was placed in front of her and 32 minutes after initial arrival in the dining room. Review of the posted meals time revealed service time for lunch on the dementia unit (south wing) was 12:00 - 12:20 PM. Review of Resident Council minutes dated 12/16/25 revealed the following prompt: Rate the following questions on a scale of 1-5 (1 being poor & 5 being excellent) .How has tray passing been? 2 out of 5. Review of Resident Council minutes dated 1/27/25 revealed the following question: Are you happy with the times that meals start and complete? The resident council selected poor as a response. Review of the facility policy titled, Meal Frequency and Preferences, issued 9/1/21, read, in part: Meal service schedules establish mealtimes that are appropriate for residents and optimize staff's ability to assist resident during meals. Residents are served in an efficient manner that emphasizes customer service . meal schedules are posted in resident care areas and dining rooms . residents needing assistance will be served last. When the tray is delivered the server will prepare the tray, sit by the bedside and assist the resident as needed . Review of the facility policy titled, Meal HS [at night] Snacks issued 9/1/21, read, in part: .Bedtime (a.k.a. HS) snacks will be provided for all residents . Nursing Services is responsible for delivering the individual snacks to the identified residents and for offering evening snacks to all other residents .

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety by: - storage of expired foods, - food preparation equipment not cleaned properly after use, - utensils and pans not properly cleaned and stored, - sanitizing solution not properly prepared, and - unit nourishment room had storage of outdated beverages and resident foods. This deficient practice has the potential to result in food borne illness among any and all 82 residents. Findings include: On [DATE] at 9:49 AM, the kitchen was toured with Dietary Manager (DM) N. The following observations were made: - Vanilla yogurt was in the walk-in refrigerator dated [DATE] - [DATE]. DM N stated the activity department dated this container and the first date would be the date the yogurt was opened, and the second date would be the date it should be used by. DM N said he would dispose of the yogurt as it was about a month past the use by date. - A gallon jar of picante sauce was in the reach-in refrigerator marked as opened ,d+[DATE] and expired on ,d+[DATE]. - A nearly empty gallon jug of vanilla and a nearly empty gallon jug of molasses were stored under the prep counter and both had dark black drip trails of product on the outside of the containers and both lids were covered in brown product residue. DM N said of the vanilla container, That looks disgusting and referred to the jug of molasses as definitely unacceptable. - The hand crank can opener blade was covered with a brown sticky goo-like substance. When questioned, DM N said the substance on the blade was probably dirt and paper from opening cans. DM N said, It (the can opener) should go back every night (to the dishwasher). It did not get cleaned. - Quarter steamtable pans were observed to be stacked wet. DM N observed the moisture when the pans were separated and stated, It can create bacteria doing that (when pans are not air dried.) - The utensil bins were observed with seven serving scoops, measuring cups, and other service utensils with visualized bits of dried particles of food adhering to them. The bin itself was observed with loose crumbs and dried debris on the bottom of the bin which contacted the utensils stored in the bin. - A small pan of knives was observed on the clean rack. The knives were found lying in bits of paper and food debris. Several pieces of equipment were observed not clean. - The microwave had spattered brown hardened remnants of what appeared to be food on the door, walls and ceiling of the interior. - The mixer was covered indicating it was ready for use. After the mixer was uncovered, it was observed with a large white dried on glob of what appeared to be a batter on the undercarriage. The whisk beater attachment also contained white dried on residue . DM N suggested the dried-on glob was cake batter from production the previous evening indicating it had not been cleaned thoroughly after use. - The large meat slicer was also covered indicating it was ready for use. The slicer was uncovered and discovered to have bits of dried meat on the blade which had not been adequately cleaned after use. The three-compartment sink was filled and ready for use. The sink labeled for sanitizing was tested and registered as having no sanitizer. DM N was unsure if the employees had filled the sink with the proper hose or if the sanitizing system was not functioning correctly. The North nourishment refrigerator was observed with the following: - A container of a type of salad marked with the first name of a resident, but no label and no date the item was prepared or should be used by. - A 14-ounce container of sour cream marked with the first name of a resident, but no opened date or use by date. - A small 4-ounce container of pudding was not covered. This container was dated [DATE]. - A gallon pitcher of orange juice without a label, and without a prepared date or use by date. - There were three opened Med Pass supplement containers without an opened date or use by date. During the tour of the North Nourishment room on [DATE] at approximately 10:30 AM, Registered Nurse (RN) E stated the items (stored in the refrigerator) all should be dated. The related portions of the FDA Food Code 2017 are as follows: - ,d+[DATE].17 Ready-to-Eat, Time/Temperature Control for Safety Food, Date Marking. (A) Except when PACKAGING FOOD using a REDUCED OXYGEN PACKAGING method as specified under S ,d+[DATE].12, and except as specified in (E) and (F) of this section, refrigerated, READY-TO_EAT, TIME/TEMPERATURE CONTROL FOR SAFETY FOOD prepared and held in a FOOD ESTABLISHMENT for more than 24 hours shall be clearly marked to indicate the date or day by which the FOOD shall be consumed on the PREMISES, sold, or discarded when held at a temperature of 5 C (41 F) or less for a maximum of 7 days. The day of preparation shall be counted as Day 1. - ,d+[DATE].11 Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils. (A) EQUIPMENT FOOD-CONTACT SURFACES and UTENSILS shall be clean to sight and touch. (B) The FOOD-CONTACT SURFACES of cooking EQUIPMENT and pans shall be kept free of encrusted grease deposits and other soil accumulations. (C) NonFOOD-CONTACT SURFACES of EQUIPMENT shall be kept free of an accumulation of dust, dirt, FOOD residue, and other debris. - ,d+[DATE].13 Nonfood-Contact Surfaces. NonFOOD-CONTACT SURFACES of EQUIPMENT shall be cleaned at a frequency necessary to preclude accumulation of soil residues. - ,d+[DATE].11 Hot Water and Chemical. After being cleaned, EQUIPMENT FOOD-CONTACT SURFACES and UTENSILS shall be SANITIZED in: (A) Hot water manual operations by immersion for at least 30 seconds and as specified under S ,d+[DATE].111; (B) Hot water mechanical operations by being cycled through EQUIPMENT that is set up as specified under SS ,d+[DATE].15, ,d+[DATE].112, and ,d+[DATE].113 and achieving a UTENSIL surface temperature of 71oC (160oF) as measured by an irreversible registering temperature indicator; P or (C) Chemical manual or mechanical operations, including the application of SANITIZING chemicals by immersion, manual swabbing, brushing, or pressure spraying methods, using a solution as specified under S ,d+[DATE].114. Contact times shall be consistent with those on EPA-registered label use instructions - ,d+[DATE].12 Cleaning, Frequency and Restrictions. (A) PHYSICAL FACILITIES shall be cleaned as often as necessary to keep them clean.

Based on interview and record review, the facility failed to maintain an operable emergency electrical power system to ensure electrical power to life support systems in the event of a power outage, affecting all 82 residents in the facility. Findings include: Review of the facility's incident report, read, in part, An ice storm hit the region Saturday evening 3/28 .[Facility Name] lost power temporarily the evening of 3/28 and went to generator power. Power restored within a few hours but eventually went back down the morning of 3/29 and the building returned to generator use. The generator stopped working around 7 p.m. on 3/30, and the building lost power completely .The MAR/TAR (Medication Administration Record/Treatment Administration Record) was attempted to be printed out utilizing the backup computer, but the battery was not able to run both the laptop and printer at the same time . The generator was repaired and power restored via generator at 1 p.m. on 4/1/25 .grid power was finally restored at 5:40 a.m. on 4/2/25 . One resident who required 10 L (10 liters) of oxygen was sent to the hospital for the duration of the outage. The facility was afraid they would not be able to properly care for this resident without power. An interview was conducted with the Nursing Home Administrator (NHA), Director of Nursing (DON) and Regional Clinical Registered Nurse L on 5/22/25 at 3:10 p.m. The three staff members confirmed that the facility failed to follow their emergency procedures guide in obtaining a back up generator in the event the facility's current generator is out of operation. The three staff members confirmed that during the frequent times that the generator would cease to function properly, residents requiring oxygen were switched to portable oxygen tanks, residents who are on specialized air mattresses were converted to standard mattresses, and eventually they were able to reach the emergency kits which were behind locked doors and inaccessible at the beginning of the power outage to pass out some flashlights to staff while others used their personal phones as flashlights. The NHA also stated that they were unable to access residents' electronic medical records (EMRs) during this time as the computer back up battery was not functioning. Review of the facility's Electrical Power Outage Policy & Procedure read, in part, .The facility has an emergency backup generator that runs electrical power to the entire facility. Aside from the power transfer time from utility to emergency power, the facility will not experience any disruptions of operations .If the back-up generator fails during the outage, reference the Emergency Generator Power System Failure policy found within the policy section of the Disaster & Emergency Preparedness binder. Review of the facility's emergency Generator Power System Failure policy read, in part, .If a generator/Emergency Power Supply System should fail during a test, or during actual operations, or at other times, it will be repaired as quickly as possible. (If it cannot be returned to service and pass the monthly test within a few hours, a backup generator will be brought in and connected for use until the primary generator can be repaired and pass the test). Review of the facility's Severe Weather: Blizzard-Snow-Ice Storm Policy and Procedure read, in part, .Make sure emergency power supply is operable . Review of the facility's Cold Weather Emergency-Loss of Heat or Extreme Cold Policy and Procedure read, in part, .In the event that there is decreased heat in the building and especially in the residents rooms because of a power outage, the maintenance department will implement the use of the emergency generator so that we will be able to provide heat by use of the emergency generator. The emergency generator will provide electricity to the entire facility .

Based on interview and record review, the facility failed to utilize their emergency plan to allow residents to directly communicate and alert staff members of their needs during a power outage and generator failure affecting all residents residing at the facility. This deficient practice resulted in resident helplessness and potential decreased emergent response times. Findings include: During an interview on 5/22/25 at 12:56 PM, Resident #7 (R7) stated, Oh yes, we remember the ice storm. They (the facility) had just so many flashlights and we were left in the dark. They did not have enough flashlights. It was coal black. The electricity went out and then the generator went out. There were no bells or whistles to call for the staff. We were on our own. It was bad. During an interview on 5/22/25 at 1:01 PM, R5 stated during the ice storm there were no flashlights, no bells, no whistles. We were out of luck. During an interview on 5/22/25 at 1:04 PM, Registered Nurse (RN) E recalled the ice storm and said We thought that flashlights for all would be a good idea, but there was not enough for everyone we found out. The call system was out. 34568 An interview was conducted with the Nursing Home Administrator (NHA), Director of Nursing (DON) and Regional Clinical Registered Nurse L on 5/22/25 at 3:10 p.m. The three staff members confirmed that the facility failed to follow their emergency procedures guide in obtaining a back up generator in the event the facility's current generator is out of operation. The three staff members confirmed that during the frequent times that the generator would cease to function properly, residents requiring oxygen were switched to portable oxygen tanks, residents who are on specialized air mattresses were converted to standard mattresses, and eventually they were able to reach the emergency kits which were behind locked doors and inaccessible at the beginning of the power outage to pass out some flashlights to staff while others used their personal phones as flashlights. The NHA also stated that they were unable to access residents' electronic medical records (EMRs) during this time as the computer back up battery was not functioning. The NHA confirmed that residents did not receive flashlights or bells/whistles to be able to communicate with staff. The NHA also confirmed she was unable to initially be present during the beginning stages of this ice storm event so no one had access to the door with all the emergency supplies. Review of the facility's Initial Actions read, in part, Communication Failure: .Distribute Bells and whistles to staff and identified residents to use as audible emergency notice and/call light needs. Review of the facility's Access to and Security of Facility During Emergencies read, in part, To ensure that keys to locked rooms are available during emergency situations, the person in charge during the administrator's absence shall have access to keys of all locked rooms or areas . Review of the facility's Emergency Equipment read in part, The facility has designated certain equipment for use during emergency conditions. All such equipment is located in the following areas: Maintenance Office .the maintenance department will be responsible for maintaining emergency equipment and ensuring that it is operable at all times .Emergency equipment, as a minimum, consists of the following: A) Flashlights B) Ropes C) First Aid Kits D) Portable fire extinguishers E) Radios F) Batteries .

Based on interview and record review, the facility failed to ensure accurate advanced directive information for four Residents (#17, #57, #62, #278) of four residents reviewed for advance directives (legal document that allows a person or their representative to identify medical care preferences if they should be unable to do so). Findings include: Resident #17 (R17) On 5/20/25 at 12:38 PM while conducting a review of R17's Electronic Medical Record (EMR), the responsible party was identified as a legal guardian. R17's (State)-POST (Physician Orders for Scope of Treatment) advance directive indicated full code/full treatment was to be administered in the event of a life threatening emergency. The form was signed by R17, instead of their legal guardian. Resident #57 (R57) On 5/20/25 at 1:51 PM, during a review or R57's EMR, the admission record indicated R57 had a designated legal guardian. A (State)-POST advance directive signature dated 3/24/25 was written as a V.O. (Verbal Order) by a Licensed Practical Nurse for R57's guardian's acknowledgment of the document. No other signatures were present as witnesses. Resident #62 (R62) A review of R62's EMR on 5/20/25 at 1:16 PM revealed there was a Designated Power of Attorney (DPOA, legal document that allows a person to appoint someone to make financial and/or health decisions on their behalf, even if the person becomes incapacitated) for healthcare in place. R62 was deemed by two physicians to be unable to participate in medical treatment decisions on 9/27/24. R62's (State)-POST advance directive for full code/full treatment was signed by R62 on 10/29/24, instead of their DPOA. Resident #278 (R278) On 5/21/25 at 1:00 PM, a review of R278's admission record indicated there was a designated guardian as their responsible party. On 5/21/25 at 1:12 PM, the EMR was reviewed and a record was found for a (State)-POST advance directive which indicated R17 was to be a full code. The document had a verbally acknowledged signature for R17's guardian on 5/8/25. On 5/20/25 at 3:10 PM, during an interview, MDS (Minimum Data Set) Nurse C stated, since the facility does not currently have a social worker it has been a team effort to take on social services' roles. The MDS nurse stated all staff are responsible for getting advance directives completed and signed by the residents. The MDS nurse stated residents can sign unless they have a been deemed incapacitated, and/or have a guardian. Review of the facility's policy titled Advanced Directives and Care Planning Guidelines indicated in part G .ii Define and clarify medical issue, review the resident's condition and existing choices and present information regarding relevant health care issues to the resident or resident representative as appropriate to determine continuation or modification of choices of care. iii Evaluate the resident for decision-making capacity and based on evaluation if the resident is determined not to have decision-making capacity, facility staff will invoke the health care agent or legal representative . According to the Department of Health and Human Services Policy and Planning Administration Michigan Physician Orders For Scope of Treatment, June 10, 2022 .Completing the MI-POST . (2) A valid MI-Post must be signed by both: (a) The patient, or the patient representative. (b) The attending health professional. Any verbal or telephone signatures are for medical orders only and must then be signed by the attending health professional within 10 calendar days. MI-Post Approved FAQ (Frequently Asked Questions) .Who can sign the MI-POST on behalf of the patient? The MI-POST must be signed by the person for whom it is completed. If he/she lacks capacity (or competency), a patient representative may sign the form. The patient representative refers to the Patient Advocate documented in a Designation of Patient Advocate/Durable Power of Attorney for Healthcare (DPOA-HC) form or, if no DPOA-HC has been executed, a court-appointed guardian with authorization to make healthcare decisions. The MI-POST form should reflect the patient's wishes .

Based on observation, interview, and record review, the facility failed to provide scheduled showers for two sampled Residents (#18, #73) and three Confidential Residents (CR#6, #9, and #14) of 18 Residents reviewed for Activities of Daily Living (ADLs). Findings include: During the resident council meeting conducted on 5/1/25 at 11:00 AM, three Residents who wished to remain confidential stated that they do not receive showers on a consistent basis and expressed subsequent feelings of frustration. Confidential Resident (CR)-14 reported getting less than one shower per week and sometimes going up to two weeks without a shower. CR-14 indicated each resident was scheduled to receive two showers per week. CR-6 stated they received, Maybe one shower per week. CR-9 explained, If they're [facility] short of help, they always come in and say we can't do showers today. 45123 Resident #18 (R18) During an interview on 5/20/25 at 11:38 AM, R18 was observed in their room lying in bed. R18's hair was uncombed and appeared greasy. R18 was asked when the last time they received a shower and replied, I was supposed to get one last Sunday, but they (facility staff) told me they could not give me a shower because of short staffing. Once I went 18 days without a shower. The medical record for R18 revealed an admitted to the facility on [DATE] with a primary diagnosis of type 2 diabetes mellitus. R18 had a Brief Interview Mental Status (BIMS) assessment score of 9 out of 15 indicating moderately impaired cognition. The medical record for R18 also included the documentation for Bathing/Showering Monday PM and Thursday AM and PRN [as needed]. Shower/bathe self: The ability to bathe self, including washing, rinsing, and drying self (excludes washing of back and hair) from the last 90 days as follows: - 2/24/25 Not applicable - Not attempted and the resident did not perform this activity prior to the current illness, exacerbation, or injury. - 2/27/25 Not applicable - Not attempted and the resident did not perform this activity prior to the current illness, exacerbation, or injury. - 3/6/25 - No offer of a shower or shower received. - 3/13/25 Not applicable - Not attempted and the resident did not perform this activity prior to the current illness, exacerbation, or injury. - 3/20/25 - No offer of a shower or shower received. - 3/24/25 Not applicable - Not attempted and the resident did not perform this activity prior to the current illness, exacerbation, or injury. - 3/27/25 Not applicable - Not attempted and the resident did not perform this activity prior to the current illness, exacerbation, or injury. - 3/31/25 Not applicable - Not attempted and the resident did not perform this activity prior to the current illness, exacerbation, or injury. - 4/3/25 - No offer of a shower or shower received. - 4/7/25 - No offer of a shower or shower received. - 4/10/25 - No offer of a shower or shower received. - 4/14/25 Not applicable - Not attempted and the resident did not perform this activity prior to the current illness, exacerbation, or injury. - 4/17/25 Not applicable - Not attempted and the resident did not perform this activity prior to the current illness, exacerbation, or injury. - 4/21/25 - No offer of a shower or shower received. - 4/24/25 - No offer of a shower or shower received. - 4/28/25 - No offer of a shower or shower received. - 5/1/25 - No offer of a shower or shower received. - 5/5/25 - No offer of a shower or shower received. - 5/8/25 Not applicable - Not attempted and the resident did not perform this activity prior to the current illness, exacerbation, or injury. - 5/12/25 - Refused shower. - 5/15/25 - No offer of a shower or shower received. - 5/19/25 Not applicable - Not attempted and the resident did not perform this activity prior to the current illness, exacerbation, or injury. This data indicated that R18 had not received scheduled showers for 23 out of 25 shower opportunities. R18 did not receive a shower from 4/23/25 through 5/11/25 (19 days). 40383 Resident #73 (R73) On 5/20/25 at 11:38 AM, R73 was observed in the hallway shouting in a loud voice, I have been asking to take a shower for about 10 days. Registered Nurse (RN) E responded to R73, Your day is tomorrow but (the shower aid) can try to squeeze you in (today). You are on Wednesdays and Saturdays (referring to R73's schedule for showers). R73 responded, I have not had a shower on either one for a while. The medical record for R73 revealed an admitted to the facility of 4/11/25 with a primary diagnosis of osteomyelitis in the left ankle and foot, an inflammation of the bone caused by infection. R73 had a Minimum Data Set (MDS) assessment dated [DATE] which noted a BIMS assessment score of 15 out of 15 indicating intact cognition. During an interview on 5/20/25 at 12:09 PM, R73 was observed in his room placing cool wet washcloths on his shoulders and complaining about an uncontrollable itch he was experiencing across his entire upper torso. He stated if he could have a shower that may help his itching. R73 said he would do it himself if they let him as he had not had a shower in a long time. The medical record for R73 also included the documentation for Shower/bathe self: The ability to bathe self, including washing, rinsing, and drying self (excludes washing of back and hair) from the last 30 days as follows: - 4/28/25 Not applicable - Not attempted and the resident did not perform this activity prior to the current illness, exacerbation, or injury. - 4/29/25 Not applicable - Not attempted and the resident did not perform this activity prior to the current illness, exacerbation, or injury. - 5/4/25 Not applicable - Not attempted and the resident did not perform this activity prior to the current illness, exacerbation, or injury. This data indicated R73 had a shower on 4/28/25, 4/29/25, and 5/4/25. No showers were documented from 5/4/25 until the resident was requesting a shower on the morning of 5/20/25. During an interview on 5/22/25 at 1:14 PM, the Director of Nursing (DON) acknowledged scheduling of showers is done but the communication from the computer to the CNAs (Certified Nurse Aides) was missing. The DON confirmed R73 did miss his shower for at least 10 days as R73 had reported. The DON stated many showers had been missed. The facility policy titled Activities of Daily Living (ADLs) dated effective 5/7/2020 and without a revision date, read in part: .In accordance with the comprehensive assessment, together with respect for individual resident needs and choices our facility provides care and services for the following activities: Hygiene: Bathing dressing, grooming and oral care .

Based on observation, interview, and record review, the facility failed to complete assessments to ensure safe self-administration of medication for three Residents (R60, R61, and R230) of 18 residents reviewed for right to self-administer medications. Findings include: Resident #60 (R60) The medical record for R60 revealed an admitted to the facility on [DATE] with a primary diagnosis of respiratory failure. R60 had a Brief Interview Mental Status (BIMS) assessment score of 9 out of 15 indicating moderately impaired cognition. On 5/21/25 at 9:10 AM, an observation was made of R60 asleep and resting in their bed. R60 had a medication cup on their bedside table with six oral pills and a clear plastic cup with a light brown substance which measured approximately 6 ounces. On 5/21/25 at 9:18 AM, an interview was conducted with Licensed Practical Nurse (LPN) O after they entered R60's room. LPN O was asked how long the medications had been sitting on R60's bedside table and if R60 had a physician order to self-administer medications. LPN O replied, The medications have been there for ten or fifteen minutes. I am not sure if (R60) has an order to self-administer. I would have to check. LPN O was asked what kinds of medications were left in the medication cup on the bedside table and replied, I would have to review the medication administration record to be exact. Review of R60's medication administration record (MAR) entry, dated 5/21/25 revealed the following medications were signed out at approximately 8:35 AM: - Cholecalciferol (vitamin D) 1000 units, one tab. - Multi-vitamin, one tab. - Amlodipine (blood pressure medication) 5 milligrams (mg), one tab. - Acetaminophen (tylenol) 650 mg, two tabs. - Tramadol (controlled pain medication) 50 mg, one tab. - House high calorie supplement (protein liquid identified in the clear plastic cup), 6 ounces. During a follow-up interview on 5/21/25 at 11:40 AM, LPN O indicated there was no assessment completed for R60 to self-administer medications, and stated there was also no physician order to self-administer medications. Review of R60's most recent quarterly nursing evaluation, dated 12/21/24, revealed under Section N: Preferences #4: Self-medicates/desires to self-medicate? No. Resident #61 (R61) The medical record for R61 revealed an admitted to the facility on [DATE] with a primary diagnosis of dementia. R61 had a BIMS assessment score of 8 out of 15 indicating moderately impaired cognition. On 5/20/25 at 11:27 AM, an observation was made of R61 lying in their bed. R61 had a medication cup on their bedside dresser that contained a white power substance. R61 was asked about the white powder inside the medication cup and just shrugged their shoulders. On 5/20/25 at 12:14 PM, an interview was conducted with Certified Nurse Aide (CNA) H regarding the contents of the medication cup in R61's room. CNA H replied, I don't know. It could be antifungal powder. I bet midnights [the midnight shift nurse] left it there though. On 5/20/25 at 12:20 PM, an interview was conducted with LPN D who was asked about the medication cup with the white powder on R61's bedside dresser and replied, I am not sure. It could be a couple of different things. I would have to review (R61's) treatments. LPN D was asked if R61 had an assessment to self-administer medications or if the medication cup containing the white powder should be left on R61's bedside dresser and replied, No, it should not be there, and I don't think there is an assessment. Review of R61's most recent quarterly nursing evaluation, dated 12/30/24, revealed under Section N: Preferences #4: Self-medicates/desires to self-medicate? No. Review of R61's treatment administration record (TAR), dated 5/21/25 revealed no ordered skin treatment/prevention such as creams or powders. Resident #230 (R230) The medical record for R230 revealed an admitted to the facility on [DATE] with a primary diagnosis of heart failure. R230 had a BIMS assessment score of 8 out of 15 indicating moderately impaired cognition. On 5/20/25 at 12:02 PM, an observation was made of R230 lying in her bed resting. R230 was asked how they were doing and replied, It's too early to tell. R230 was asked about the nystatin cream on their bedside dresser and replied, I use that daily. The hospital sent it with me, so I had some to use. On 5/20/25 at 12:22 PM, an interview was conducted with LPN D who was made aware R230 had a tube of nystatin cream on their bedside dresser and replied, As far as I know (R230) does not have an assessment to self-administer medications. I will have to check to see if there is even an order for that. Review of R230's most recent quarterly nursing evaluation, dated 5/19/25, revealed under Section N: Preferences #4: Self-medicates/desires to self-medicate? No. Review of R230's MAR/TAR, dated 5/19/25 through 5/21/25 revealed no physician order for the nystatin cream. On 5/21/25 at 12:15 PM, and interview was conducted with the Director of Nursing (DON) who was asked if any of the current residents in the facility had a physician order to self-administer medications and replied, No. The DON was asked if medications, including controlled substances, should be left at the bedside unattended for residents to take at their leisure and replied, No. The DON was asked if all medications needed a physician order and replied, Yes. Review of policy titled, Self-Administration of Medications, dated 2/2021, read in part, Policy Statement: Residents have the right to self-administer medications if the interdisciplinary team has determined that it is clinically appropriate and safe for the resident to do so. Policy Interpretation and Implementation: 1. As part of the evaluation comprehensive assessment, the interdisciplinary team (IDT) assesses each resident's cognitive and physical abilities to determine whether self -administering medications is safe and clinically appropriate for the resident . 3. If it is deemed safe and appropriate for a resident to self-administer medications, this is documented in the medical record and the care plan. The decision that a resident can safely self-administer medications is re-assessed periodically based on changes in the resident's medical and/or decision-making status . 5. Residents who are identified as being able to self-administer medications are asked whether they wish to do so . medications are stored in a safe and secure place, which is not accessible by other residents . 9. Any medications found at the bedside that are not authorized for self-administration are turned over to the nurse in charge for return to the family or responsible party . Review of policy titled, Medication Storage, dated 05/2022, read in part, Policy: The facility shall store all medications and biologicals in a safe, secure, and orderly manner. General Guidelines: 1. Medications and biologicals shall be stored in the packaging, containers or other dispensing systems in which they are received. Only the issuing pharmacy is authorized to transfer medications between containers . 5. Medications for external use, as well as poisons, shall be clearly marked as such . Review of policy titled, Controlled Substance Accountability Guideline, no date, read in part, .Controlled Substance Administration. Chapter 4: Controlled substances are administered with great care .

Based on interview and record review the facility failed to follow their grievance procedure and make prompt efforts to resolve grievances regarding complaints of missing items for three Residents (#5, #11 and #22) of three residents reviewed for inaction of grievances. Findings include: Resident #5 (R5) The medical record for R5 included a face sheet indicating an original admitted [DATE]. The Minimum Data Set (MDS) assessment dated [DATE] included a Brief Interview for Mental Status (BIMS) assessment score of 15 out of 15 indicating intact cognition. On 5/22/25 at 10:14 AM, R5 complained she had many things that were missing. R5 said, I am missing two black tops, and I told staff but (heard) nothing. I guess the tops just disappeared. I am also missing an orange top. R5 stated she has tried to follow up and has asked staff about the items, but she has been told we don't know. R5 stated, Sometimes it gets upsetting. During an interview on 5/22/25 at 10:15 AM, Registered Nurse Consultant (RN) L discussed grievances of missing items and reviewed the facility grievance log back through 2023. There was no record of any logged concerns for missing items for R5. During an interview on 5/22/25 at 10:23 AM, RN E stated she remembered R5 missing some clothing. RN E said, Yes, I filled out a missing item slip (for the items). I feel like that was a while back. Resident #11 (R11) The medical record for R11 included an MDS assessment dated [DATE] indicating an admitted [DATE] and included a BIMS assessment score of 11 out of 15 indicating moderately impaired cognition. During an interview on 5/21/25 at 2:06 PM, RN B stated he had overheard R11 declaring she was missing a sweater. RN B said, There seems to be a lot of missing items lately. Resident #22 (R22) The medical record for R22 included a face sheet indicating an admitted [DATE]. The MDS assessment dated [DATE] included a BIMS assessment score of 14 out of 15 indicating intact cognition. During an interview on 5/20/25 at 1:01 PM, R22 stated the facility had lost several items of her clothing and they were still looking for them. R22 explained, I have notified several staff members that I am missing gray sweat pants, a blue sweatshirt and a brown long sleeve shirt. During an interview on 5/21/25 at 3:03 PM, RN Consultant L reviewed the facility grievance log and did not find any grievances for the missing items reported by R11 or R22. During an interview on 5/22/25 at 10:01 AM, the Interim Environmental Services Supervisor (Staff) M acknowledged she was aware R22 was missing a pair of pants and a hoodie and was keeping an eye out for them. Staff M stated, We have not yet seen them, but it has been a while. Staff M did not have a record of the missing items for R22 but stated they had been verbally reported. Staff M discussed the missing item process stating sometimes there was a written report describing missing items and then a search would begin. Staff M said, If we are struggling to locate items, we talk to administration. The facility policy titled Grievance Guidelines dated effective 11/28/2017, read in part, It is the practice of this facility that each resident has the right to voice grievances to the facility or other agency or entity that hears grievances . The facility will ensure prompt resolution to all grievances, keeping the resident and resident representative informed throughout the investigation and resolution process. The facility grievance process will be overseen by the Administrator/designee who will be responsible for receiving and tracking grievances through their conclusion, lead necessary investigations .communicate with residents throughout the process to resolution and coordinate with other staff .The facility will provide a mechanism for filing a grievance/complaint .and will provide an ongoing system for monitoring and trending grievances and complaints. The policy included a GRIEVANCE/CONCERN FORM, a GRIEVANCE INVESTIGATION form and a GRIEVANCE RESOLUTION RESPONSE form. No grievance forms included in the above policy were found or presented for the missing items described by R5, R11, or R22.

Based on interview, and record review, the facility failed to revise and update care plans to reflect resident status for one Resident (#54) of 18 Residents reviewed for care plans. Findings include: Resident #54 (R54) R54 was admitted on [DATE] with diagnoses including stroke, quadriplegia, dysphagia (difficulty swallowing) following a stroke, protein-calorie malnutrition and anemia. The Minimum Data Set (MDS) assessment dated [DATE] indicated R54 had a feeding tube in place on admission and while a resident. The MDS assessment dated [DATE] indicated a feeding tube was not in place. A physician order dated 4/21/25 read, Contact Digestive Health to notify them of removal of PEG tube (percutaneous endoscopic gastrostomy tube inserted directly into the stomach providing an alternative for individuals who cannot swallow or received adequate nutrition orally.) and if any other follow up is needed, Patient/guardian decline replacement at this time. A physician order for Regular diet, Pureed texture, Honey-Thick consistency was in place and noted as last revised 11/8/24. During an interview on 5/21/25 at 4:24 PM, Licensed Practical Nurse (LPN) O stated R54's feeding tube had been out (removed) several months ago. He was not getting any food or fluid through a PEG tube. The current care plan for R54 was reviewed and included a nutritional risk focus due to the history of stroke, and conditions of dysphagia, malnutrition and many other nutritional concerns including, need for pureed textures and thickened liquids since advanced from NPO (nothing by mouth) status. The goal section for this care plan focus included, The resident will tolerate tube feed regimen without s/s (signs/symptoms) intolerance. Date initiated: 3/18/2024 The target date to accomplish this goal was listed as 7/6/2025. The interventions for this focus and goal included, Maintain NPO (nothing by mouth) status unless cleared for oral intake by ST/SLP (Speech Therapist/Speech Language Pathologist) Date initiated: 3/18/2024. The facility policy titled Careplan (SIC) Standard Guidelines dated effective on 11/28/2017 read in part, . The interdisciplinary team will continue develop (SIC) a resident/client centered care plan that includes problem, need, or strength statements, measureable (SIC) goal statements and resident/client specific interventions . The care plan is to be revised to reflect the current status of the resident. The care plan will be reviewed through out the resident's stay upon admission, quarterly and with changes in condition .

Based on observation, interview, and record review, the facility failed to ensure restorative nursing services were provided to increase range of motion and/or to prevent further decrease in range of motion (ROM) for one Resident (#54) of one resident reviewed for limited range of motion. Findings include: Resident #54 (R54) R54 was admitted on [DATE] with diagnoses including stroke, quadriplegia, cerebral palsy, and traumatic brain injury. The Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) assessment score of 15 out of 15, signifying R54 was cognitively intact. On 5/20/25 at 11:51 AM, R54 was observed in his bed with severely contracted hands. R54 was able to open his fists slightly and said no staff helped him work on his hands and it, Probably would be a good idea. The physician order dated 2/9/25 included, Splint to L (left) hand off while awake and on at night every day and evening shift for hand splints. R54 stated he did not always like to wear the splint but sometimes he wears it. During an interview on 05/22/25 at 9:48 AM, Certified Occupational Therapy Assistant (COTA) Q discussed the restorative therapy program following a physical therapy (PT) or occupational therapy (OT) regimen. COTA Q said, We fill out a referral to nursing, if we think the resident would be good (benefit from a) restorative (program). They (the nursing department) take it from there. COTA Q reviewed the therapy notes for R54 and reported, We finished up with (R54) in February. The date of his last therapy OT and PT was 2/17/25 . hand splints were recommended, and a ROM program was recommended. The medical record OT Discharge Summary dated 2/27/25 included, Discharge Recommendations: OOB (out of bed) for meals. ROM Restorative program . During an interview on 5/22/25 at 9:17 AM, the Director of Nursing (DON) stated the facility did not have a restorative program and did not have a restorative nurse or a restorative Certified Nurse Aide (CNA). The DON said, It is something we would like to establish. The facility policy titled, Restorative Nursing Services dated as revised on 7/2017 and presented on 5/21/25 at 1:00 PM read in part, Residents will receive restorative nursing care as needed to help promote optimal safety and independence . Residents may be started on a restorative nursing program upon admission, during the course of stay or when discharged from rehabilitative care.

Based on observation, interview, and record review, the facility failed to provide proper infection control measures pertaining to indwelling catheters (a tube inserted into the bladder to accommodate emptying of the bladder) for one Resident (#8) of two residents reviewed for indwelling catheters. This deficient practice resulted in the potential for infections and illness. Findings include: Resident #8 (R8) Review of R8's electronic medical record (EMR) revealed an admitted [DATE] with diagnoses including neuromuscular dysfunction of bladder. R8's 4/5/25 Minimum Data Set (MDS) assessment revealed a Brief Interview for Mental Status (BIMS) score of 14/15 indicating no cognitive impairment. R8 was also marked on the MDS for the use of an indwelling catheter. On 5/21/25 at 2:07 p.m., R8 was observed being assisted by staff to go outside to the smoking shed which is across the facility parking lot. R8 was being pushed by an unidentified staff member in her wheelchair. R8's indwelling catheter urinary collection bag was observed underneath the wheelchair seat, not in a privacy bag, and dragging on the pavement ground with auditory sound of the bag hitting the pavement. The drainage tube tip was also noted to be hitting the pavement as R8 was being assisted. On 5/22/25 at 1:40 p.m., R8 was observed asleep in her wheelchair, in the dining room. The indwelling catheter urinary collection bag was observed uncovered and on the floor with the drainage tube tip touching the ground. On 5/22/25 at 3:00 p.m. an interview was conducted with the Director of Nursing (DON). The DON confirmed indwelling urinary catheter bags should remain off the floor and in a privacy bag. Review of the facility's Catheter Care (Indwelling Catheter) policy did not identify that urinary catheter bags should remain off the floor.

Based on observation, interview, and record review, the facility failed to ensure sanitary storage, labeling, and cleaning of respiratory equipment for three Residents (#23, #42, and #61) of 3 residents reviewed for respiratory services. Findings include: Resident #23 (R23) Review of R23's electronic medical record (EMR) revealed initial admission to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease (COPD) and chronic respiratory failure with hypoxia (low levels of oxygen in body tissues). Review of R23's admission Minimum Data Set (MDS) assessment revealed a Brief Interview for Mental Status (BIMS) score of 6, indicative of severe cognitive impairment. Review of R23's EMR revealed the following physician's order, initiated 5/8/25: Continuous O2 [oxygen] via (NC/MASK) [nasal cannula] at 2 L/m [2 Liters per minute]. On 5/20/25 at 10:52 AM, an unoccupied wheelchair was observed at the foot of R23's bed with undated oxygen tubing connected to a portable oxygen tank. The tubing was observed laying in the wheelchair seat with no protective covering. R23 was observed sleeping in bed, wearing an undated nasal cannula attached to a concentrator. On 5/21/25 at 12:45 PM, an unoccupied wheelchair was again observed at the foot of R23's bed with oxygen tubing connected to a portable oxygen tank. The tubing was observed laying in the wheelchair seat with no protective covering. Additional undated oxygen tubing was observed attached to a concentrator and resting on the floor. On 5/22/25 at 8:46 AM, undated oxygen tubing was observed attached to a concentrator resting on the floor in R23's room. The nasal cannula prongs were observed in direct contact with an unkempt soaker pad located on the bed. On 5/22/25 at 8:49 AM, an interview was conducted with Registered Nurse (RN) B regarding respiratory equipment storage and labeling expectations. RN B stated some residents have an order in their Treatment Administration Record (TAR) to ensure oxygen tubing gets changed on a weekly basis. RN B stated the expectation is for all oxygen tube to be dated, changed weekly, and stored in a bag when not in use. Review of R23's EMR revealed no order for weekly oxygen tubing changes. 45123 Resident #42 (R42) The medical record for R42 revealed an admitted to the facility on [DATE] with a primary diagnosis of pneumonia. R42 had a BIMS assessment score of 15 out of 15 indicating intact cognition. During an interview on 5/20/25 at 12:04 PM, R42 was observed in their room lying in bed. R42's undated nebulizer was observed lying on top of their bedside table in one piece with visible condensation in the medication cup. R42 was asked when the last time the nebulizer was rinsed out by staff and replied, It has been like that since last night. The medical record for R42 revealed a physician order which read, Ipratropium-Albuterol inhalation solution 0.5-2.5 (3) mg/ml (milligram per milliliter), 1 vial inhale orally four times daily. On 5/22/25 at 12:15 PM, R42's undated nebulizer was again observed lying on top their bedside table in one piece with visible condensation in the medication cup. Resident #61 (R61) The medical record for R61 revealed an admitted to the facility on [DATE] with a primary diagnosis of dementia. R61 had a BIMS assessment score of 8 out of 15 indicating moderately impaired cognition. During an interview on 5/20/25 at 11:27 AM, R61 was observed lying in their bed. R61 had an oxygen concentrator next to their bed with a nasal cannula attached to the concentrator dated 3/24/25. R61 was receiving oxygen at 2 liters via nasal cannula. R61 was asked about the oxygen equipment being maintained by the facility staff and was unable to answer if the oxygen tubing was changed regularly. R61 stated that they had the flu about a month ago. R61 also had a nebulizer hanging off the back of the oxygen concentrator that was dated 3/24/25. On 5/20/25 at 12:14 PM, an interview was conducted with Certified Nurse Aide (CNA) I who was asked what the date read on R61's oxygen tubing. CNA I stated the nurses are responsible for changing the tubing and confirmed the date was 3/24/25. CNA I replied, That date does not seem right. On 5/20/25 at 12:16 PM, an interview was conducted with CNA H who was asked about R61's oxygen tubing and replied, I am not really sure, that is a nursing thing. On 5/20/25 at 12:20 PM, an interview was conducted with Licensed Practical Nurse (LPN) D who was asked how frequently oxygen tubing and nebulizers were changed. LPN D replied, It is changed every week. Normally there is an order on the treatment administration record for the tubing and nebulizer to be changed every week on Sunday. Review of R61's treatment administration record (TAR), dated 3/1/25 through 5/20/25, revealed no order for R61's oxygen tubing or nebulizer to be changed weekly. On 5/22/25 at approximately 11:30 AM, a request was made to the Nursing Home Administrator (NHA) for a respiratory care policy. The NHA stated that the facility did not have a respiratory care policy.

This citation pertains to intake numbers; MI00150212, MI00150215, and MI00150297. Based on interview and record review, the facility failed to ensure 1. New admission orders were double checked, 2. Appropriate assessments and wound care were provided, and 3. Timely notification of a change in condition were completed per professional standards for one Resident (#3) of three residents reviewed for new admissions, resulting in R3 being transferred to the emergency department with post-surgical infection, respiratory distress, low blood pressure, sepsis, and subsequent death. Findings include: Resident #3 (R3) Review of complaint intake number MI00150212 to the State Agency (SA), dated 2/11/25 revealed, R3 was transfer to a local hospital by emergency medical services (EMS) in critical condition after a four-day admission from the facility due to his colostomy not being cared for resulting in stool contaminating surgical incision and drains. R3 now had positive blood cultures for VRE (vancomycin-resistant enterococcus) and was in septic shock. Supporting evidence of neglect by the facility can be substantiated by local hospital documentation. Review of complaint intake number MI00150215 to the SA, dated 2/11/25, revealed, on 2/5/25, R3 was discharged from the hospital in stable condition to the facility to recover. On 2/9/25, R3 was admitted to the local hospital in critical condition. R3's oxygen was extremely low, he had low blood pressure, his binder that was over his incision had feces in it, his incision also had feces in it. R3 was in septic shock, he had positive blood cultures, and he was in critical condition. Hospice had been consulted, there was a concern that R3's care was neglected while he was at the nursing home. Review of complaint intake number MI00150297 to the SA dated 2/13/25 revealed on the early morning of 2/9/25, R3 was transferred to a local hospital by EMS. At the time of R3's transfer, his oxygen was in the 40's. R3's abdominal binder that was covering his incision, drains and colostomy bag was off as well as his colostomy bag. He was covered in stool. R3's gown was soaked in feces and fluids and his surgical wounds were packed with stool. R3's blood pressure was also 66/40. R3 was in septic shock before arriving to the local hospital. R3's PICC (peripherally inserted central catheter) line was dirty and dislodged. R3 was treated like garbage by facility staff and his condition was horrific. Review of R3's emergency department (ED) records, dated 2/9/25, read in part .History of Present Illness .presents to the ED for evaluation of low oxygen saturation. He is brought in by EMS. He was brought from the [facility name] .will open his eyes and answers some questions however he is moaning, seems to be in a good amount of pain. According to EMS, they did not get much of a history from the nursing staff over at the [facility name]. Apparently, they checked on him this morning and he had an oxygen saturation of 43% .He does have audible rhonchorous (coarse, low-pitched, rattling sounds heard in the lungs during breathing) breath sounds heard at bedside. He moans and complains of pain basically diffusely with palpation .Patient came into the ED saturated in fluid and feces. His gown is almost completely soaked in fluid .He has an abdominal binder in place. When this is removed his ostomy bag is off and he has a large amount of brown stool covering his abdomen under the binder. He has palpable edema noted to his abdomen as well. With any manipulation he does have fluid expressed from the drain sites .He has a right upper extremity PICC line. When nursing staff went to clean for and wipe around the PICC .it then almost immediately fell out, certainly did not look like it was in the right spot I will place a central line in the patient's left groin. norepinephrine (medication to support low blood pressure) is running through his peripheral IV in the left upper extremity while central line being inserted .Lactic acid (a lab value that measures the lactic acid in the bloodstream) is elevated at 3.2 (normal level is < 2), procalcitonin (a lab value that is a protein hormone used to detect and monitor bacterial infections) is elevated at 5.62 (normal range is between 0.05-2.0 and > 2.0 indicates severe infection), high-sensitivity troponin (a protein found in heart muscle that leaks into the blood when the heart is damaged) is elevated at 148 (normal level is between 0-14) and BNP (a hormone in the blood that indicates how well the heart is pumping) is 5114 (normal level is < 450 in adults over the age of 75) .I did order him 40 mg of IV Lasix (a diuretic to help eliminate excess body fluid) .He will admit the patient to the ICU (intensive care unit) He is obviously in critical condition .Final Impression/Diagnosis: Acute sepsis (life threatening complication of an infection), acute hypotension, acute hypoxic (an absence of enough oxygen in the tissues to sustain bodily functions) respiratory failure .acute lactic acidosis (a metabolic condition that occurs when the body builds up too much lactic acid in the bloodstream) . Review of R3's ED nursing note, dated 2/9/25, read in part .The patient came in altered. This patient had an ostomy bag that was stuck and not attached anymore under an abdominal binder and covered in feces. This patient had 2 (brand name surgical) drains with one that was coming out and the sutures were coming undone. The patient had drainage from both drain sites and his abdominal staples sites. The patient had not been cleaned up in a while .Patient had a PICC line that he came in with and when ED staff went to check patency, the PICC line dislodged and appears to possibly have broken off .When I called the [facility name], the nurse that card for the patient, [facility nurses name], told me she did not know much about the patient. When I told her the patient had an ostomy, she was surprised to find out he had an ostomy. She stated that the CNAs (certified nurse aides) take care of all of that, including the wound changes. I let this nurse know our findings and how critical this patient appears. I would like to express my concerns about the care this patient received . Review of R3's hospital history and physical, dated 2/9/25, read in part .He was in shock (a condition that occurs when organs don't get enough blood), hypotensive (low blood pressure), altered mentation, cold to touch, abdominal pain/guarding, hypoxia (low oxygen saturation) - 43% per history, and wet cough .He had a PICC line he was supposed to be getting antibiotics through that was mostly out. Abdominal binder was in place covering his ostomy from last admission and drains - there was extensive stool saturating between skin and binder, stool in wounds, ostomy was off. SNF (skilled nursing facility) may not have known he had an ostomy I was told .Patient said he has eaten very little, maybe none .purulent drainage from midline incision. Mucosa of ostomy initially pale . Review of R3's hospital records, dated 2/9/25 through 2/12/25, revealed the following: a.) Underwent a blood transfusion b.) Received IV blood pressure support medications c.) Had an insertion of a central line in the groin area for cardiac monitoring and IV medication administration d.) Had a nasogastric tube inserted for nutritional purposes e.) Was found to have new wound infection in his abdominal cavity that was stool covered and with VRE (vancomycin resistant enterococcus) bacteremia f.) Had lower abdominal staples removed to allow for drainage g.) Possible PICC line infection h.) Urinary catheter with urinary tract infection i.) Weight gain of 11 pound 7 ounces from 2/6/25 - 2/9/25 j.) Severe protein calorie malnutrition k.) admitted to the ICU l.) Surgical consultation m.) Infectious diseases consultation n.) Went from a full code to Hospice services o.) Death occurred on 2/12/25 Review of R3's face sheet revealed an admission to the facility on [DATE], with diagnoses including, hypertension, perforation of intestine (a hole in the intestine), and colostomy (a surgical procedure that creates an opening [stoma] in the abdominal wall to divert stool [fecal material] from the colon [large intestine] directly into a bag or pouch). Review of Minimum Data Set (MDS) assessment, dated 2/9/25, revealed Section GG of the MDS assessment revealed R3 was dependent on staff for all activities of daily living cares including eating, oral hygiene, toileting, upper and lower body dressing, and personal hygiene. R3 was also dependent on staff for all mobility such as rolling from left to right, sit to lying position, and lying to sitting position. Review of R3's progress note dated 2/9/25 at 6:33 AM, read in part, R3 was transferred to [local hospital] at 6:00 AM. Vital signs; blood pressure 77/30, respirations 16, pulse 100, oxygen saturation 46% at 2 liters per minute [via nasal cannula] increased to 5 liters per minute oxygen saturation came up to 93%, unresponsive. Pupils non-reactive. R3 was moaning most of the night shift. R3 was moaning this am [morning] . Review of R3's hospital discharge paperwork, dated 2/3/25, read in part .Cefazolin 6 g (grams) per 24 hours continuous infusion (or 2 g IV [intravenous] q [every] 8 hours . Review of R3's progress note, dated 2/5/25 at 9:35 PM, read in part Resident admitted from (local hospital) . Unable to use any or all devices. Needs assistance with devices .Medication review: A medication reconciliation/review occurred. Findings and actions: Clarified with (local hospital). Review of R3's progress note dated 2/5/25 at 10:26 PM, read in part Received report .Cefazolin last given at 5:00 PM (at local hospital) . Review of R3's new admission phone report form, dated 2/5/25, read in part .Arrived by: EMS (emergency medical services) 1800 ish (approximately 6:00 PM) . Antibiotics: cefazolin - PICC (peripheral inserted central catheter) Q (every) 8 hours last dose 17:00 (5:00 PM) . Review of R3's order recap, dated 2/5/25 through 2/9/25, revealed an order added by Registered Nurse (RN) D on 2/5/25 for cefazolin sodium injection solution reconstitute 2 GM (grams). Use 50 ml (milliliters) intravenously three times a day until 3/7/25 (every 8 hours, last dose at 5:00 PM), and was scheduled to be given at 1:00 AM, 9:00 AM, and 5:00 PM. Order was verified by the same nurse who added the initial order. Review of R3's order recap, dated 2/5/25 through 2/9/25, revealed an order added on 2/6/25 at 10:33 AM for cefazolin sodium injection solution reconstitute 2 GM. Use 2 gram intravenously, every 8 hours, for of cervical hardware infection until 3/7/25, and was scheduled to be given at 6:00 AM, 2:00 PM, and 10:00 PM. Order was added by the Nurse Practitioner (NP) F and verified by Licensed Practical Nurse (LPN) B. Review of R3's medication administration record (MAR), dated February 2025, revealed R3 did not receive a 6:00 AM dose. R3 should have received a dose of antibiotics at 1:00 AM based on the last dose he received prior to being discharge from the local hospital per written orders. R3 did not receive antibiotics for 19 hours, based on the last dose he received at the local hospital. R3 missed two doses of his antibiotics on 2/6/25 at 1:00 AM and at 9:00 AM. On 2/19/25 at 10:15 AM, an interview was conducted with RN D who was asked about the new admission process for entering medication orders. RN D replied, The admitting nurse or the nurse manager adds the orders from the admission paperwork and then a second nurse is to verify that the orders are correct. RN D was asked why the antibiotic order from R3 was not verified with a second nurse. RN D replied, I do not recall, maybe at that time there was not anyone to verify the orders were correct. On 2/19/25 at 3:49 PM, an interview was conducted with LPN B who was asked if she remembered R3. LPN B replied, I remember R3 coming in. R3 had a PICC line, and I think R3 missed his first dose of antibiotics because the order got put in wrong with administration times. On 2/20/25 at 12:15 PM, an interview was conducted with NP F who was asked about R3's antibiotic orders. NP F replied, New admission orders should be verified by another nurse and double checked. It was noted by facility staff that R3 did not receive any antibiotic therapy since admitting to the facility despite having the medication in back-up and a new order was placed. On 2/20/25 at 2:00 PM, an interview was conducted with the Regional Nurse Consultant G who was asked about the admission process. The Regional Nurse Consultant G replied, We recognized a problem and have started a past non-compliance, but it is not completed yet. Nurses are to double check orders with a second nurse to verify the order input is being added correctly. R3 should not have missed any doses of antibiotics. Review of R3's admission phone report document, dated 2/5/25, revealed that R3 had recent abdominal and cervical surgery. R3 had two (name brand surgical) drains in his abdominal cavity, a colostomy in his LUQ (left upper quadrant), an abdominal surgical incision with staple, a PICC line in his RUE (right upper extremity), was receiving IV antibiotics with the last dose indicated, a c-collar (a device to help secure the neck), a urinary catheter, was on oxygen at 3 liters via nasal cannula (soft plastic device to deliver oxygen through the nose), had edema in his upper and lower extremities, was on narcotic (controlled substance used to treat moderate to severe pain) pain medication, and wore an abdominal binder at all times. Review of R3's care plan, dated 2/7/25, read in part Focus: The resident has an ostomy to (Specify where) r/t (related to). Goal: Resident will have no complications with ostomy through the review date. Interventions: Monitor for signs or symptoms of pain with ostomy or stools and notify physician as needed. Review of R3's physician order, dated 2/5/25, revealed an order for ostomy care to check bag and empty, cleanse skin and pat dry if any leakage every shift. Review of R3's treatment administration record (TAR), dated 2/5/25 through 2/9/25, revealed no documented checking or emptying on 2/5/25 during the night shift. On 2/19/25 at 2:54 PM, an interview was conducted with LPN H who was asked about R3 and the care that was provided on the night of 2/8/25. LPN H stated there was a nurse call-in that night. Nurse-to-nurse reports are not really that great or helpful. LPN H was asked about ostomy care on the night of 2/8/25. LPN H replied, I should have taken more time to do a head-to-toe assessment on him on 2/8/25. The North end is very heavy with as needed narcotic medications and all I had time to do was pass as needed narcotics. I did not look at his ostomy and I don't recall having to do anything with the (brand mane surgical) drains either, because it would have come up on the TAR. I feel terrible that his ostomy opened underneath his binder. I only gave him pain medication and reassessed his pain. On 2/19/25 at 3:18 PM, an interview was conducted with RN I who was asked about the care she provided to R3. He was too heavy acuity. I took care of him on 2/8/25 during day shift until 6:30 PM. He was very sleepy. I attempted to do a dressing change on him, and he refused. I drew labs on him and put them in the refrigerator because I could not take them to the lab, and I am not sure if the driver was out or why they were not taken to the lab or if they were. RN I was asked if she attempted to try again later to complete the dressing changed. RN I replied, No. RN I was asked if she recalled R3's colostomy. RN I replied, He had a midline abdominal incision with staples below his umbilicus that had purulent (discharging pus) drainage. He had a colostomy and an abdominal binder that had some yellow serosanguinous (fluid that contains clear, watery liquid and blood) on the binder. I don't recall what the stoma looked like. RN I clarified that she did not report the purulent drainage to the physician. Review of R3's TAR, dated 2/5/25 through 2/9/25, revealed that R3 had labs drawn by RN I on 2/8/25 at 1:12 PM. On 2/20/25 at 11:30 AM, an interview was conducted with LPN C who was asked about R3 and the care provided on 2/9/25. LPN C replied, I got called in early on 2/9/25 and arrived around 3:00 AM. I got report from LPN 'H' that R3 was moaning, and he gave R3 some pain medication. LPN C was asked if she did any kind of assessment or observed R3's colostomy/stoma. LPN C replied, I probably did not document an assessment on his drains and abdominal area. I did not pull the abdominal binder off or look at it. I had to finish up night shift medications. I went in to see him at 6:00 AM to hook up his IV and his PICC line looked funny, and I had the certified nurse aide (CNA) come into do his vitals. I sent him out at 6:00 AM to the local hospital. That was the first time I took care of him. All I was told was that R3 was in pain and received pain medication and I got no other report on the other residents. R3's oxygen was very low at 46% and (nasal cannula) was only in one nostril. I did not listen to lungs. R3 had quite a bit of edema and I am not sure how we were monitoring that. I normally work the back half. Review of R3's hospital discharge paperwork, dated 2/5/25, revealed discharge instructions for surgical (brand name) drains to remain in place and care instructions that included keeping the skin around the drains dry and covered. There were also instructions for emptying along with how to compress the bulb of the drains for proper function. Instructions also included recording the amount of output in a 24-hour period and to contact the provider if you have less than 30 ml (milliliters) of output. The instructions also stated to monitor daily for signs and symptoms of infection. Laxative instructions were to take one capful of polyethylene glycol 3350 milligrams (mg), mixed in 4-8 ounces of beverage every morning. If in 2 to 3 days your bowel movement is too soft: Reduce polyethylene glycol 3350 mg to 1/2 capful mixed in 4-8 ounces of beverage every morning. R3's MAR/physician orders had no polyethylene glycol order written. Review of R3's care plan, dated 2/7/25, read in part .I have alteration in skin integrity d/t (due to) placement of (Specify: Drain) post-surgical procedure. Goal: The resident will have no complications with drain sites through the review period. Interventions: Observe and record fluids drained from drain sites . R3 had no other interventions noted for monitoring abdominal surgical incision with staples and staples were not counted to ensure wound did not dehisce (to split open or burst along a natural line or seam). On 2/18/25 at 4:00 PM, an interview was conducted with Family Member (FM) E, who stated, No one voiced any concerns to me. Talked to the staff at the facility while (R3) was there and stated everything was fine. I was assured by staff at the facility that (R3) would be taken care of. (R3) was transferred to the local hospital on 2/9/25 and the facility never called me to let me know (R3) was declining. I was called by the local hospital from the ICU doctor that (R3) had been admitted and was in critical condition. I was planning on going to see him at the facility on 2/10/25. FM E was tearful and hurt during the phone interview and felt very frustrated with the facility staff by the lack of care and communication. FM E stated that she was led to believe R3 was being taken care of and that he was going to be fine. On 2/21/25 at 1:15 PM, an interview was conducted with FM J who was asked about R3 and if they had visited them at the facility while he was there. FM J replied, Yes. I went to see R3 on 2/7/25 on a Friday. R3 was asleep when I arrived, but I called out his name and he opened his eyes. He looked like he was in bad shape. I noticed a banana that had been cut up, appeared to be there for a while and I asked him is he wanted me to go get him something to eat. He said yes, so I checked with the nurse first and they said it was ok. I brought him back a hamburger and a shake. He only took two pea sized bites of the burger and was unable to suck out of the straw. I lifted up R3's gown to see his drains and they were both expanded and not compressed, and I thought that did not look right. His gown was soiled with some blood on it and needed to be changed. R3 was unable to talk to me like he was the last time I saw him the last week in January around the 25th when he carried on a conversation and had a little sense of humor. I noticed that he could not reach his banana or his drink. He need assistance with feeding because he does not have the dexterity to pinch has hands together to grasp a cup. He was having difficulty sitting himself up to reach the cup. All R3's belongings where just lined up along the windowsill and not put away. I felt like I walked into a dump. On 2/21/25 at 2:17 PM, an interview was conducted with FM K who was asked about R3 and if they visited them at the facility while he was there. FM K replied, Yes, I went to see him on 2/6/25 it was a Thursday. I gave him yes or no questions because he had a hard time with his breathing. I noticed his nasal cannula was only in one of his nostrils and he seemed a little confused when I talked to him. I went to get the nurse, and she came in and checked his oxygen saturation. I had my wife on the phone, and she asked me what the oxygen saturation level was, and the nurse told me it was in the 50's. My wife was freaking out! The nurse went to get a second nurse, and they stayed for a while and rechecked his level and it had come back up. The second nurse seemed to just kind of brush it off like it was not a big deal. No one was checking on him prior to me going to get someone. When he was at the hospital either we as family would assist him in eating or the hospital staff would assist, because he was unable to feed himself. Review of R3's tasks and task list, dated 2/5/25 through 2/9/25, revealed no bed baths or showers were provided during R3's stay at the facility. R3's food acceptance for 2/6/25 was recorded as zero during lunch and no breakfast was recorded. R3's food acceptance for 2/7/25 was recorded for dinner only between 1-25 %. R3's food acceptance for 2/8/25 lacked any documentation. R3's task list indicated that staff was to record food acceptance for each meal offered. No documentation that R3 had low or poor intake to the physician was found. Review of R3's physician order, dated 2/5/25, revealed oxygen was to be delivered continuous via nasal cannula or mask at 2 to 6 liters per minute. R3's oxygen order had no directions for how nursing was to titrate to a certain oxygen saturation level or record how many liters R3 required. Review of R3's physician order, dated 2/5/25, revealed an order for IV PICC: Document signs and symptoms of infection one time a day every 7 days for per protocol. Nursing staff did not measure the initial length of R3's PICC line and had no way of assessing proper placement. Review of R3's MAR, dated 2/5/25 through 2/9/25, revealed on 2/6/25 PICC line dressing change was marked as 9 (see progress notes). Review of R3's progress note, dated 2/6/25 at 1:56 PM, read in part .Dressing is clean, dry and intact. Progress note completed by LPN B. There were no other notes in the EMR indicating the PICC line dressing change was completed as ordered. Review of R3's care plan dated 2/7/25, read in part, .Focus: The resident has actual impairment to skin integrity (SPECIFY location) r/t [related to]. Goal: The residents will have no complications r/t documented skin impairment through the review dated (5/7/25). Interventions: Evaluate and treat per physicians' orders (2/6/25). Evaluate resident for S/SX [signs and symptoms] of possible infections (2/6/25). Monitor IV site q/shift [every shift] and complete dressing change as ordered (2/7/25) . R3 had no interventions to monitor length of the PICC line tubing extending from the insertion site to ensure proper placement. Review of policy titled, Infusion Therapy: Clinical and Pharmacy Services Policies and Procedures for Long-Term Care, dated 05/2022, read in part, Policy: Midline and Central Line IV catheters (CVADs [central venous access devices]) will be flushed to maintain patency; to prevent mixing of incompatible medications and solutions; and to ensure entire dose of solution or medication is administered into the venous system. General Guidelines: 1.) Prior to procedure, assess catheter type for flushing protocols .Types of peripheral catheters .d.) Peripherally Inserted Central Catheter (PICC) .(5) Length of catheter is specific to resident. This length needs to be documented in the medical record .(6) Catheter length is measured for baseline comparison .(8) This is a very fragile catheter and can be broken easily .(12) Anchor catheter to skin to prevent accidental removal . Review of R3's electronic medical record, dated 2/5/25 through 2/9/25, revealed no documented initial admission weight, and no weight obtained on 2/7/25. R3 had one weight recorded on 2/6/25 which was the exact same weight documented in his hospital discharge paperwork. Review of policy titled, Weight Monitoring Guideline, dated 7/1/19, read in part, Purpose: The facility measures and records weights to ensure accuracy and provide information for the evaluation of clinical status unless clinically contraindicated with physician justification. To provide guidance on timely consultation and weight parameters .Guidelines: Residents will be weighed; documentation will be recorded in (EMR): Upon admission and re-admission. Hospital weights should be verified and compared to facility admission and/or re-admission weight. Daily for three days . Review of R3's skilled daily nursing assessments, dated 2/6/25 through 2/8/25, revealed no documented skilled nursing assessment on 2/6/25. On 2/7/25 R3's assessment created by LPN H revealed a note identified as a late entry added on 2/8/25 which used the same vital signs from 2/8/25, with lungs clear and no shortness of breath and surgical wound well approximated. On 2/8/25 the nursing assessment created by RN I revealed R3 had left side weakness, edema; 3+ (noticeable deep, last more than 1 minute) arms, hands, legs, and feet. R3's lung sounds were with rhonchi present, had a cough, had increased or purulent sputum, and had abnormal lung sounds. R3 had shortness of breath when lying flat. R3 had a surgical wound that was an abdominal midline incision with staples wound approximated intact with purulent serosanguinous drainage from the site. There was no documentation showing the left sided weakness, purulent drainage, or edema was reported to the physician. On 2/20/25 at 12:15 PM, an interview was conducted with the Nurse Practitioner (NP) F, who was asked if she was notified of R3's decline and transfer to the hospital. NP F replied, No one called me about anything with R3 and I was on-call the weekend he was sent out. I was not notified that R3 had declined, had respiratory distress, or was moaning in pain all night. I ordered labs on 2/7/25 and they were drawn but never sent to the lab. I can't tell you what happened Friday night into Saturday morning. NP F was asked what kinds of assessments the nursing staff should have been completed on R3. NP F replied, The nursing staff should have been assessing vital signs, weights, and monitoring his ostomy, drains, and surgical sites for signs of infection. NP F stated that the only thing she knew was one day R3's (name brand surgical) drain was not draining, and she assisted nursing staff to get it back working and recalled the abdominal binder being saturated. Review of policy titled, Charting and Documentation, dated 7/2017, read in part Policy Statement: All services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional or psychosocial condition, shall be documented in the resident's medical record. The medical record should facilitate communication between the interdisciplinary team regarding the resident's condition and response to care. Policy Interpretation and Implementation .2. The following information is to be documented in the resident medical record: a. Objective observations .d. Changes in the resident's condition .7. Documentation of procedures and treatments will include care-specific details, including .c. the assessment data and/or any unusual findings .f. notification of family, physician or other staff . Review of facility policy Notification of Changes Guideline, dated 7/24/19, read in part Purpose: It is the practice of this facility that changes in a resident's condition or treatment are immediately shared with the resident and/or the resident representative, according to their authority, and reported to the attending physician .The resident and/or their representative will be educated about treatment options and supported to make an informed choice about care .All pertinent information will be made available to the provider by the facility staff .Overview of Components of the Guideline: 1.) Requirements for notification of resident, the resident representative and their physician .2.) A significant change in the resident's physical, mental, or psychosocial status. (i) A significant change includes deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications .Procedure: 1.) The nurse will immediately notify the resident, resident's physician and the resident representative (s) for the following (list is not all inclusive). If the resident's physician is not available contact the Medical Director .e. A decision to transfer or discharge the resident from the facility .

Based on observation, interview, and record review, the facility failed to implement and maintain interventions to prevent the development and progression of pressure ulcers for two Residents (R9, R18) of four residents reviewed for pressure ulcers. This deficient practice resulted in the development of one unstageable pressure ulcer and the potential for development of new/additional pressure ulcers. Findings include: Resident #18 (R18) Review of R18's Electronic Medical Record (EMR) revealed admission to the facility on [DATE] with diagnosis including right tibia fracture, right fibula fracture and nutritional deficiency. Review of R18's most recent Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 12, indicative of moderate cognitive impairment. Further review of the MDS, section M, revealed R18 was marked at risk of developing pressure ulcers and had three unstageable-suspected deep tissue pressure ulcers. Review of R18's Skin and Wound Evaluation dated 7/9/24 read, in part, .Type: Pressure .Stage: Deep Tissue Injury: Persistent non-blanchable deep red, maroon or purple discoloration .Location: Right heel. Acquired: In-house Acquired .Exact Date: 5/22/24 .Staged by: (blank) .Wound Measurements: .8 cm2 (centimeters squared) by 1.3 cm by .9 cm .Wound bed: Eschar 100% .Additional Care: Heel Suspension/Protection device, Mattress with Pump, Turning/Repositioning program . On 7/15/24 at 2:18 p.m., an interview was attempted with R18 who was lying in her bed after eating her lunch meal. R18 could not recall if she had a pressure ulcer. It was observed that R18's had an air mattress with the air pump attached to the footboard of her bed. R18's air pump was not turned on nor was it plugged into the outlet located on the wall during this interview. On 7/16/24 at 8:45 a.m., an interview was attempted with R18 who was lying in her bed eating her breakfast meal. R18 stated that she was not wanting to eat her breakfast at this time. R18's air mattress pump was not turned on nor plugged into the outlet located on the wall during this interview. On 7/16/24 at 9:00 a.m., an interview was conducted with the Director of Nursing (DON). When asked, the DON stated R18's right heel pressure ulcer was facility acquired due to a brace that was placed on R18's right leg after surgery. The DON stated the pressure ulcer was healing at this time, being treated with betadine as it was not open, and R18 was to have an air mattress with pump as an intervention. The DON was notified that the air mattress had not been turned on or plugged in during previous observations. On 7/16/24 at 1:00 p.m. a wound observation was conducted with Registered Nurse/Unit Manager (RN/UM) S and RN T for R18's right heel. RN T placed a barrier down with all supplies needed for R18's wound care and proceeded to wash their hands. RN S and RN T placed clean latex gloves on their hands but did not don any further Personal Protective Equipment (PPE) to treat R18's wound. When asked if further PPE was needed, RN S stated R18's wound is closed and has never opened, so they did not need further PPE. RN T removed R18's blue puffy boot to expose R18's right foot and heel. RN T began to wash R18's foot with a clean wet washcloth and soap when R18 stated, Ouch that hurts! RN T then used a sterile cloth to wipe betadine over R18's right heel where the pressure ulcer was located. During the pressure ulcer care, RN S stated they were not going to do measurements. Near the bottom of the right heel R18 had an observed dark, thick purple scab approximately the size of a quarter, with bright pink tissue surround the scab. A follow-up interview was conducted with the DON who clarified R18 has an unstageable pressure ulcer with eschar on the right heel which was facility acquired. When asked if R18's air mattress pump was always supposed to be on, the DON confirmed that it should be. The DON stated she is unsure why R18's pump had been turned off and unplugged. Review of R18's Wound Assessment Details Report dated 7/16/24 read, in part, Braden Score:15 (At Risk) .Wound: Right heel .Source: Facility Acquired .Date Identified: 7/16/24; Identified by: RN S .Size (cm) 2.75 x 2.00 x unknown .area 5.5 cm2 .Current Plan and Comments: Bilateral puffy boots, Air Mattress, Turn Schedule, Nutritional Supplements, Betadine . Review of R18's Care Plan read, in part, .5/22/24 Right heel deep tissue Pressure injury .interventions: air mattress (date initiated: 5/13/24) . 41978 Resident #9 (R9) Resident #9 was admitted on [DATE] with diagnoses including heart failure, neurogenic bladder, obstructive uropathy, and chronic obstructive pulmonary disease (COPD). Review of R9's MDS assessment, dated 4/4/2024 revealed R9 was dependent on staff for toileting and personal hygiene and required substantial/maximal assistance for mobility, including rolling left and right. Further review of the MDS assessment revealed R9 was at risk for pressure ulcers. An observation on 7/15/2024 at 10:50 a.m. revealed R9 lying in bed, supine ( lying on back) with the head of the bed elevated at approximately 45 degrees. The control panel for R9's air mattress was not lit up which indicated the mattress was not actively functioning. Further observation revealed CNA U enter R9's room at which time CNA U was queried as to whether R9's air mattress should be turned on. CNA U stated she was unsure and confirmed the mattress was indeed not functioning. CNA U stated she did not know how to operate the control panel for the mattress. This Surveyor observed CNA U tracing the power cord from the air mattress panel to the power outlet at the head of R9's bed and stated the air mattress was not plugged in. CNA U plugged the air mattress cord into the outlet and confirmed the air mattress was then functioning. CNA U could not state how long the mattress was not functioning. Review of R9's care plan revealed the following, in part: The resident has actual impairment to skin integrity MASD (moisture associated skin damage) r/t limited mobility incontinence. Date Initiated: 11/30/2023 . The resident needs pressure relieving/reducing mattress, pillows to protect the skin while in bed. Date Initiated: 7/11/2024.

Based on observation, interview, and record review, the facility failed to provide appropriate pressure ulcer care and services to prevent the development of multiple new facility-acquired pressure ulcers for six Residents (#38, #31, #21, #53, #62, and #70) out of seven residents reviewed for pressure ulcers. This deficient practice resulted in harm for Resident #38 with the development of multiple Stage 2 pressures ulcers, and delayed wound healing, wound deterioration, increased risk of infection, and discomfort for the residents with facility-acquired pressure injuries. Findings include: Resident #38 During an observation and interview on 8/21/22 at 12:30 p.m., Resident #38 was observed positioned on his back in bed. Long whiskers and stubble were observed on Resident #38's upper lip, both sides of his face and neck. The Resident stated, They did not do a good job (shaving him). When asked about life in the facility, Resident #38 said the food was terrible, and commented that he had lost weight. Resident #38 said he could sometimes eat on his own, but that staff did not assist him to eat, and if unable to eat independently, no staff dining assistance was offered. When asked about staff assistance with repositioning in bed, Resident #38 said that he was not routinely repositioned in bed, and he did have sores on his bottom (buttocks). Resident #38 said the facility did not have enough staff to provide necessary care to the residents. Resident #38 was alert and oriented and conversed appropriately during the entirety of this interview. Review of Resident #38's Minimum Data Set (MDS) assessment, dated 7/5/22, revealed Resident #38 was admitted to the facility on [DATE], with a recent re-admission on 6/29/22. Active diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #38 scored 14 of 15 on the Brief Interview for Mental Status (BIMS) reflective of intact cognition, and no communication deficits were noted. Section E0800. Rejection of Care - Presence and Frequency documented 0 Behavior not exhibited. Resident #38 required extensive - two-person assistance with bed mobility, and extensive - one person assistance with transfers, dressing, toilet use, personal hygiene. Supervision with setup help only for eating was documented, with a mechanically altered diet. Resident #38 independently performed intermittent self-catheterization and was always continent of bowel and bladder. The MDS documented two Stage II pressure ulcers, with one present upon admission/entry or reentry. During an observation and interview during Resident #38's wound care on 08/22/22 at 10:05 a.m., Registered Nurse (RN) GG' and Licensed Practical Nurse (LPN/Unit Manager) KK were present in the room. [MEDICATION(S)] 0.25 ml's (milliliters) was administered prior to the dressing change/wound care. LPN/Unit Manager KK confirmed a nurse was assigned weekly to provide wound care, but it was not consistently the same nurse assigned each week. RN GG reported working as a floor nurse on Wednesday the previous week on the Front North Hall where Resident #38 resided. RN GG stated, It (sacral wound) was not black last Wednesday, and I was doing his dressing change, and it was an every three day change - with hydrogel, and I came into do the dressing change and it had become black since last Wednesday . Yesterday we noticed the odor (from the sacral wound) . RN GG said she went to RN U who was wound care certified, to find out what the wound dressing order should be changed to. RN GG said she and RN U were reading the directions on the dressing they thought would be appropriate. LPN/Unit Manager KK said Physician MM was coming to look at the wound that day. Resident #38 was observed to be extremely thin, with every rib clearly delineated on his back. The large sacral wound appeared black, and unstageable. Resident #38 was unresponsive to verbal and physical stimuli at the end of dressing change. RN GG and LPN KK both said the first dose of [MEDICATION(S)] was today. During an interview on 8/22/22 at 1:05 a.m., RN U confirmed she was currently Wound Care Certified and stated, I do not practice (wound care) - that is not my job in this facility. They ask me questions and I will answer them the best I can. RN U confirmed RN GG had changed Resident #38's sacral dressing last week, because there was not a specific wound care nurse in the facility that day. RN GG showed RN U the picture of the wound, and RN U said she put her hand on her forehead and stated, Oh MY!. RN U confirmed a consistent wound care nurse was not overseeing the wounds in the facility. RN U said she believed a consistent wound care nurse had not been scheduled in the facility since before the COVID-19 pandemic. During a repeat interview on 8/22/22 at 4:45 p.m., RN U confirmed participation on the IDT (Interdisciplinary Team) Committee, but clearly noted that she did not interject on all IDT wound ordered developed by the facility IDT. RN U confirmed Physician MM never refused to sign an order provided to him by the IDT team and confirmed Physician MM may not be the author of the wound care orders. The orders may be developed by another nurse or the IDT team, with or without input from RN U' with a current Wound Care Certification. Review of Resident #38's Skin/Wound Documentation, including photographs of the coccyx, sacral area, and buttocks, revealed the following facility acquired wound documentation: 5/4/22, NEW, Stage II (2) Pressure injury to coccyx (Wound #4), L (length)1.04 cm (centimeters) x W (width) 0.47, Goal of Care - Healable, Progress - New. A Risk VS Benefits form was completed on 5/6/22, detailing risks related to noncompliance of .increase in wound size, hospitalization , infection, pain, infection, death . The Physician was notified on 5/6/22. 5/11/22, Stage 2 Coccyx Pressure injury, in-house acquired, improving. Measurements were listed as L 0.0 x W 0.0 x Area 0.0. No open wound was observed on the Wound Evaluation photograph. No treatment or wound bed documentation were completed on the Wound Evaluation. 5/16/22 Wound Dressing Order: Derma thin to Coccyx, one time a day, every three day(s) for Coccyx for 2 Weeks. 5/18/22, Stage 2, Coccyx Pressure injury, in-house acquired, Improving. Measurements show increase in wound size (deterioration of wound) of L 0.61 cm, x W 0.21 cm, Area, < (less than) 0.1 cm. The Wound Evaluation noted the wound dressing was missing (not present on the wound) when wound care was initiated on this day. 5/21/22, Stage 2, Coccyx Pressure injury, in-house acquired, L 0.2 x W 0.1, 21 days old, improving. The wound dressing was again documented as missing prior to application of a new dressing. 6/1/22, Stage 2 Coccyx Pressure injury, in-house acquired, L 1.01 cm, x W 0.78 cm, Progress - Stalled (had increased in size), Healable, Not compliant with repositioning. 6/8/22, Stage 2 Coccyx Pressure injury, in-house acquired, L 2.85 x W 1.86 cm, Area 3.23 cm, one month old, Progress - Stable (more than doubled in size). 6/15/22, Stage 2 Coccyx Pressure injury, in-house acquired, L 5.51 cm x W 3.22cm, Area 12.64 cm, Progress - Deteriorating, Goal of Care - Healable. 6/22/22, Stage 2 Coccyx Pressure injury, in-house acquired, L 4.89 cm x W 0.76 cm, Area 0.65 cm, Wound dressing was documented as missing prior to application of a new dressing. Additional Care included Mattress with Pump, Nutrition/Dietary supplementation, and Turning/repositioning program. Progress - Improving. Notes: Zinc. The Wound Evaluation form documented on this day, 6/22/22, showed the initial coccyx wound, with two additional pressure injuries on Resident #38's left buttock. No reference to the new, in-house acquired pressure injuries (appeared to be Stage 2) were documented on the Wound Evaluation form, or Version 1 of the Skin Observation form dated 6/22/22. 6/29/22, Stage 2 Coccyx Pressure injury, in-house acquired, L 0.99 cm x W 0.54 cm improving. The dressing appearance said None, and no dressing was applied. The Wound Evaluation form did not list the Buttock wounds, but the Skin Observation form, version 1 detailed one new left buttock wound, not two on the left buttock as observed in the photograph on the previous 6/22/22 Wound Evaluation of the Coccyx. 7/6/22, Stage 2 Coccyx injury, in-house acquired, L 1.51 cm x W 1.21 cm, Progress - Deteriorating, Dressing was missing at time of wound observation. Primary Dressing: Foam. Skin Observation, Version 1 does not document left buttock wounds. 7/13/22, Stage 2 Coccyx Pressure Injury, in-house acquired, L 0.97 cm x W 0.76 cm, Progress - Deteriorating (coccyx wound decreased in size), large, reddened area on left buttocks not documented on Wound Evaluation or Skin Observation. 7/20/22, Wound Evaluation details Stage 2 Coccyx Pressure Injury, in-house acquired. Observation of the wound photo shows a sacral area wound, and a left buttock wound. Both may have been considered left buttocks previously. The dressing was again documented as missing, with the Progress - Stalled. 7/26/22, Wound Evaluation form details Stage 2 Coccyx Pressure Injury, in-house acquired, but observation of the wound photo shows deterioration with slough and increase size of the sacral wound, and deterioration of the left buttock wound. The Stage 2 Pressure injury has increased in size to L1.35cm x W 1.18 cm. The wound was found with the dressing missing, and a [MEDICATION(S)] dressing was applied. Resident #38's physician was notified. 7/27/22, New Wound Order, Wash buttock with soap and water, pat dry, apply skin prep around open areas, dab hydrogel to slough cover with two-by-two bordered foam. Cover left and right open areas with 4x4 comfort foam cut in half, one time a day every 3 day(s) for wound care . 8/6/22, Wound Evaluation photograph observed, Stage 2 pressure injury, enlarged sacral wound, left buttock wound, and right buttock wound. The dressing appearance was none (none present), with stable progress, although the number of wounds shows an increase per the Wound Evaluation form. Resident was documented as experiencing pain at the wound site(s). 8/10/22, Wound evaluation form shows marked increase in coccyx pressure ulcer. Slough and exudate visible on the larger sacral wound. No other documentation present on this wound assessment form. No wound description, or treatment detailed by staff. 8/17/22, Wound Evaluation form shows large dark butterfly-shaped wound now identified as a Pressure - Kennedy Terminal Ulcer in the same sacral position as the previous wound evaluations. The Wound Evaluation form did not detail the wound bed, peri wound skin, or treatment on 8/17/22. Progress - Deteriorating. The Skin Observation form determined this wound to now be unstageable due to obscured full-thickness skin and tissue loss. The date of the change to a Kennedy ulcer was not completed. The wound bed, evidence of infection, other wound descriptions, exudate, peri wound, and pain were not completed. Form noted: Slow to Heal: wound healing is slow or stalled but stable, little/no deterioration, although there was a marked change in the appearance and size of this sacral wound. Progress noted as Deteriorating. 8/21/22 15:03 (3:03 p.m.) New Wound Order, Dakin's quarter strength wet to dry dressing BID (twice a day). Use wet to dry saline till Dakin's arrives. Cover with ABD and tape, two times a day for wound care . Review of Resident #38's Skin and Wound Evaluations V5.0 on 8/3/22, 8/10/22, and 8/17/22 revealed a Stage 2 Pressure Injury on Resident #38's right buttock was facility acquired and documented as New on all three separate evaluation forms. None of the three Skin and Wound Evaluation forms were completed in their entirety but contained blank sections with no information. On 8/17/22 the right buttock pressure injury was noted as resolved. Review of Resident #38's Skin and Wound Evaluations V5.0 on 6/29, 7/6, 7/13, 7/20, 7/27, 8/3, 8/10, and 8/17/22 revealed the facility documented a Left Buttock Stage 2 pressure injury as Present on Admission on 6/29, although facility Skin and Wound photographs showed two left buttock pressure injuries present on 6/22/22, prior to transfer from the facility to an acute care hospital. The left buttock pressure injury was documented as resolved on 8/17/22. Review of Resident #38 Progress Notes revealed the following, in part: 8/19/22 14:02 (2:02 p.m.), Dr. called and notified about area on buttock with areas deteriorating. Santyl was ordered and to be changed Q (every) 48 hours and covered with 7-inch sacral bordered adhesive . 8/21/22 15:45 (3:43 p.m.), [Physician MM] was called and updated on change of condition of resident. Wound on buttock has an odor . Review of Resident #38's physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . The 6/15/22 Progress Note referenced skin issues, but the .presacral pressure sore complicated by his poor nutritional status. Turn on sides every 2 hours . was not clearly identified in the physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] Review of Resident #38's Turned and Repositioned POC (Point of Care) task documentation for 14 days beginning 8/9/22 through 8/22/22, revealed documentation showing Resident #38 was Turned and Repositioned every 2 hours was NOT present on the following days: 8/9, 8/10, 8/11, 8/12, 8/13, 8/14, 8/15, 8/16, 8/17, 8/18, 8/19. 8/20, 8/21, and 8/22/22. Only two refusals were documented - on 8/9/22, at the same time (10:12 a.m.), that yes repositioning was checked, and on 8/17/22 at 14:15 (2:15 p.m.), when checked as repositioned yes on 14:16 p.m. (2:16 p.m.). Review of Resident #38's Skin Care Plan revealed the following, in part: The resident has potential for reoccurring pressure ulcer and actual pressure areas r/t immobility, refusal to turn off backside, poor nutrition, nonadherence to POC (plan of care) with turning and reposition, heelzup (sic) cushion, pillow under heels at times, PO (oral) intake. Coccyx, left buttock, coccyx, left forearm abrasion, right buttock, 8/17/22 Unstageable to coccyx/sacral/rt (right) and lt (left) buttock . Date Initiated 07/10/2020. Interventions included the following, in part: Assess/record/monitor wound healing (q week) (every week). Measure length, width, and depth where possible. Assess and document status of wound perimeter, wound bed, and healing progress. report improvements and declines to the MD . .Encourage to elevate heels off bed on pillow as he refused heel up cushion. Date Initiated: 03/09/2021. If the resident refuses treatment, confer with the resident, IDT and family to determine why and try alternative methods to gain compliance. Document alternative methods. Date Initiated: 7/10/2020 . Monitor nutritional status. Serve diet as ordered, monitor intake and record. Date Initiated: 7/10/2020 . The resident needs (encouragement/reminders/assistance) to turn/reposition at least every 2 hours, more often as needed or requested. Not always compliant with turning off backside. Date Initiated: 7/10/2020 . Weekly treatment documentation to include measurement of each area of skin breakdown's width, length, depth, type of tissue and exudate. Date Initiated: 7/10/2020 . All Skin Care Plan interventions were initiated on 7/10/20, except for the one noted above on 3/9/21. No new care plan interventions were identified with the development of new pressure ulcers in 2022. Resident #38's Care Plans also included, in part: During feeding, assist according to resident preferences. Stop and return if becomes agitated. Date Initiated: 10/7/2019 . The resident's triggers for resisting care of turning and repositioning. Date Initiated: 6/22/022. No method of de-escalation of Resident #38's resistance to turning was noted in the care plan. Dining: Needs assistance with meals. Date Initiated: 10/19/2020. During an interview on 8/22/22 at 3:45 p.m., Physician MM was asked about Resident #38's pressure injuries. Physician MM said, in the presence of the Director of Nursing (DON), that he was not a wound care physician, but a wound care clinic was available locally. When the DON was asked if this resident was provided wound care clinic appointments, or visits, the DON said Resident #38 did not participate in the local wound clinic. When Physician MM was asked if he wrote (authored/created) the orders for the wound care treatments in the building, Physician MM stated, No, I sign off what the IDT sends me (for the order). When asked if he had ever declined or revised an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . He signed the orders that were sent to him. During an interview on 8/22/22 at 4:40 p.m., the DON acknowledged he was not an expert in wound care, even though he had vast clinical nurse experience. When asked about the development of wound care orders for facility residents, including Resident #38, the DON confirmed the IDT determines the wound care order for the residents, and then submits those orders, which are always signed off and approved by Physician MM. The DON confirmed that Physician MM had never refused signing an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on 8/29/22 at 9:53 a.m., the DON was asked about the Wound Evaluation forms that documented Resident #38's wound dressing, was missing, absent, or none. The DON surmised the wound dressing could have fallen off, or it was not performed. The DON confirmed Resident #38 had been hospitalized between 6/24/22 and 6/29/22, and the left buttock wound was considered acquired in the acute care hospital. The DON was asked to review the photograph of Resident #38's left buttock on 6/22/22, and he acknowledge the presence of two Stage 2 pressure injuries to Resident #38's left buttock prior to his hospitalization on [DATE], making them both facility acquired pressure injuries. Resident #53 During an observation on 8/22/22 at 5:25 p.m., RN GG entered Resident #53's room with this Surveyor. Resident #53's bilateral (both) heels were in contact with the bed mattress, and the left foot was in contact with the footboard. Observation of the outside lateral (outer aspect) heel on the right foot found a darkened read area that appeared unblanchable. The blue bolster used to position the Resident #53's heels off the bed was pushed up under his knees. RN GG pushed the dark blue bolstered down to position both heels off the bed mattress and stated, [Resident #53], you are way too low in the bed my dear. During an observation on 8/23/22 at 7:48 a.m., Resident #53's bilateral heels were touching the dark blue bolster cushion used to attempt to keep bilateral heels off the bed mattress. RN LL, upon entrance to the room, did not comment or act to reposition the cushion, until the resident complained about his heels on the bolster and requested the bolster cushion be moved up to remove pressure from the heels. Review of Resident #53's Care Plan revealed the following, in part: Focus: The resident is resistive to care wearing heel free boots r/t bilateral heels wounds. Date Initiated: 7/13/2022 . Interventions: Educate resident/family/caregivers of the possible outcome(s) of not complying with treatment or care. Date Initiated: 7/13/2022. Focus: The resident has (stage 2) pressure ulcer (rt bunion, lt buttock) r/t shoe, limited mobility. Deep tissue to right heel . The resident needs (assistance) to turn/reposition at least every 2 hours, more often as needed or requested. Date Initiated: 6/15/2022 . Interventions: Heels up . Refusal to wear heel free boots. Encourage to elevate heels. Date Initiated: 7/18/2022. Review of Resident #53's August 2022 Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Start Date: 7/12/2022. Review of the facility Skin Protection Policy, dated 7/7/2021, revealed the following, in part: Interventions for prevention, removing and reducing predicting factors and treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . Elevating heels (offloading) all pressure for residents that cannot turn and reposition themselves. Or, for residents that have diminished sensory perceptions of the lower extremities that may affect an independent ability to turn, reposition and off load pressure. Offloading devices may vary, may include pillows, and should be selected based on resident comfort and positioning needs. There should be protection of the Achilles area to avoid unintended pressures applied here when offloading lower extremities .Inspection of skin daily with cares and weekly by a license nurse, Specified turning and repositioning, exercise program and/or active and passive range of motion, Skin care, and Pressure, friction and shear reduction . Turning and Repositioning Observation (tissue tolerance) Pressure is the primary cause of pressure injuries. An effective turning and repositioning schedule can help reduce the risk of developing a pressure injury. Tissue tolerance (the ability of the skin and its supporting structures to endure the effects of pressure without breakdown), may vary. Therefore, it is important to individualize each resident's turning and repositioning schedule . If a skin concern or change is observed: The Notification of Change Guideline will be followed: Physician consulted, and orders will be transcribed for treatment .The dietician will be notified . With changes in skin integrity and/or development of a new wound, and with a deterioration in wound assessment Resident #31 A review of Resident #31's MDS assessment, dated 6/24/22, revealed an admitted [DATE] and diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #31 scored 7 of 15 on the BIMS reflective of severe cognitive impairment. Section E0800. Rejection of Care - Presence and Frequency documented 0 Behavior not exhibited. Resident #31 required extensive - two-person assistance with bed mobility, transfers, dressing, toilet use, and personal hygiene. The MDS documented one unstageable pressure ulcer present, no pressure ulcers that were present upon admission/entry or reentry. Review of Resident #31's Skin/Wound Documentation, including photographs of the right lower back dated 4/26/22 which indicated a new (Minutes old) area In-house Acquired with dimensions of Area: 7.22 cm, Length: 4.99 cm and Width: 2.47 cm. The document presented titled Full QA Report revealed the following facility acquired wound documentation of 4/27/22: Skin issue type: Pressure Ulcer(s), Wound Present: House acquired, Prior History: No. On 8/22/22 at 4:55 PM, an observation of Resident # 31's lower back pressure ulcer and treatment was observed with Physician MM, RN II, LPN KK and CNA Y. During an interview on 8/23/22 at 4:59 PM, the DON stated as of 3/18/22, Resident #31 did not have any pressure areas. The DON stated the facility had been treating and monitoring the house acquired pressure area on the lower back and it was still unhealed. Resident #62 A review of Resident #62's MDS assessment, dated 8/3/22, revealed an admitted [DATE] and diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #62 scored 15 of 15 on the BIMS reflective of intact cognition. Section E0800. Rejection of Care - Presence and Frequency documented 0 Behavior not exhibited. Resident #62 required extensive - two-person assistance with bed mobility, dressing, and toilet use, and one person assist with personal hygiene. The MDS documented one stage three pressure ulcer present, and was present upon admission/entry or reentry. The 8/3/22 MDS also documented no other open [CONDITION(S)] were present in section M1040 D. During an interview on 8/21/22 at 2:16 PM, Resident #62 was laying on her back in bed visiting with three family members. She said she had pressure areas on her bottom and had to be turned every two hours. Resident #62 stated, They (nursing staff) are working the best they can, but are short of staff . I can't turn myself . I try to turn with the railing, but my shoulders are sore, and I can't do it. She said the staff did not have time to help her and I got sores. During a wound care observation for Resident #62 on 8/22/22 at 5:16 p.m., RN II donned clean gloves following wound cleansing and hand hygiene, and applied zinc oxide cream to the right buttock pressure injury on Resident #62 with the gloved right index finger. Using the same right, gloved index finger RN II moved to the left buttock and applied zinc oxide to both wounds with potential contamination from one wound to another. During an interview on 8/22/22 at 5:22 p.m., RN II acknowledged she did use the same potentially contaminated gloves to apply zinc oxide to all three pressure injuries on Resident #62. RN II stated, I didn't even think about it, they (wounds) are all in the same area, so I just did them all. During an interview on 8/23/22 at 4:41 PM, the DON reported Resident #62 was admitted with one sacral area pressure sore 7/28/22 and then 7/31/22 had 2 more on left buttocks. The DON was not certain of the cause of the lesion citing possibly pressure or injury. He stated her skin was not in good condition. The three areas remained unhealed. physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] 8/1/22 Sacral Ulcer: I reinforced need for turning and positioning to off load ulcer. No mention of the two open areas on the left buttock documented as facility acquired 7/31/22. 8/7/22 Sacral Ulcer - on going. No mention of the two open areas on the left buttock. 8/15/22 Sacral Ulcer - on going. No mention of the two open areas on the left buttock. 8/22/22 Sacral Ulcer - on going. No mention of the two open areas on the left buttock. Resident #62's care plan dated 7/28/22 included: The resident needs (assistance) to turn/reposition at least every 2 hours, more often as needed or requested. Resident #70 The medical record of Resident #70 revealed an initial admitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS assessment of 8/10/22 included a BIMS score of 15 out of 15 indicating intact cognition. Section E0800. Rejection of Care - Presence and Frequency documented 0 Behavior not exhibited. Resident #70 required total staff dependence for bed mobility, locomotion, eating, dressing, personal hygiene, and toilet use every day. The MDS documented one stage two pressure ulcer present, and was present upon admission/entry or reentry. The Skin and Wound Evaluation V5.0 completed on admission 8/4/22 at 12:43 PM revealed no skin issues (including pressure areas) except for a documented bruise on the left shin. During an interview on 8/23/22 at 9:00 a.m., Resident #70 was asked about repositioning for the prevention and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . They are understaffed and they don't have the staff to do that. We pay (the price) for them not having enough staff when we are not properly cared for. They have no idea how much pain we are in. Resident #70 said he did not have any pressure ulcers when he was admitted to the facility, and he was in pain. Resident #70 said he had not been given any pain medication prior to being gotten out of bed and that was confirmed by RN AA. Resident #70 was observed wincing with the removal of each pillow, and bolster and he continued to wince through peri-care clean up. CNA HH obtained a water basin and began peri care for the Resident. CNA HH cleaned Resident #70's penis with a wet soapy washcloth, but did not clean the right or left groin creases. Resident #70 was rolled onto his right hip, and CNA HH swiped down the gluteal fold and produced residual brown fecal matter on the washcloth. CNA HH used approximately five wet washcloths to remove fecal residue from Resident #70's gluteal crease. No fecal residue was observed on the wound. No evidence of a bowel movement was present on the used brief upon removal. CNA HH said Resident #70 needed to be turned over so she could clean under his scrotum and in the front groin creases. CNA HH used multiple wet washcloths to clean fecal residue from both groin creases and under scrotum where brown residue was observed on each cloth used to wipe the area. Resident #70 said he had his last bowel movement last night and was not always aware of when he had a bowel movement, but the residual fecal matter found in all creases appeared to be stool from inadequately cleaned areas from the previous bowel movement. No frank presence of fecal matter was present - just residual in all creases. CNA HH grabbed a green brief and was beginning to place it on the resident, when this Surveyor asked if Resident #70's peri area was going to be dried before application of the brief. All creases were red, and under the groin area appeared red, but no type of cream was applied to the area for skin protection. LPN AA used a tongue depressor to apply zinc oxide ointment to the right buttock pressure injury, acquired more zinc oxide on the tongue depressor and moved to the left buttock with no open wounds, moved back to the right buttock and continued to spread the zinc over all the buttock including the open area, moved back to the left buttock and spread the zinc, and then moved back to the right side - using the same tongue depressors for spreading of zinc oxide back and forth between the right and left buttock. During an interview on 8/23/22 at 4:42 p.m., family friend VV of Resident #70 asked to speak with a Surveyor. Friend VV was asked about the care provided by the facility to Resident #70. Friend VV stated, He has an open wound on his tailbone (coccyx) where he sits. He is supposed to be getting turned every two hours, and he is not getting turned every two hours . I don't believe he had the pressure injury when he came here. I try to get here every day, and I am usually here four to five hours, and they do not reposition him every two hours. They have literally sat waiting and waiting in pain when they are up in their chairs, and they don't have enough staff. A review of the CNA task titled Turned and Repositioned for 8/9/22 through 8/23/22 revealed Resident #70 was never turned and repositioned every 2 hours (12 times) in a 24 hour period. Of the 14 days reviewed, Resident #70 had documentation of 4 days he was turned 3 times, 8 days he was turned 2 times and 2 days he was only turned one time. Resident #70's care plan dated 8/4/22 included: The resident needs 2 person assist to turn/reposition at least every 2 hours, more often as needed or requested. A review of Resident #70's Skin/Wound Documentation, including photographs of the coccyx and left buttock area, and revealed the following facility acquired wound documentation: dated 8/18/22 which indicated a new (Minutes old) area In-house Acquired with dimensions of Area: .36 cm, Length: .8 cm and Width: .63 cm. During an interview on 8/23/22 at 5:22 PM, the DON confirmed there was a new pressure area on the left buttock discovered on 8/18/22. Resident #21 Review of Resident #21's MDS assessment revealed Resident #21 was admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER]

Based on observation, interview and record review, the facility failed to ensure a catheter was properly secured for one Resident (#31) of three residents reviewed for catheter care. This deficient practice resulted in actual urethral opening damage. Findings include: Resident #31 On 8/29/22 at 3:45 p.m., Certified Nurse Aide (CNA) T was observed performing catheter care for Resident #31. During the care being provided, there was no securement device or tape observed in place to assist in preventing the catheter from pulling on the urethral area and/or becoming dislodged. As CNA T performed cleaning of the catheter at the head of the penis, Resident #31 had observable wincing and asked CNA T to be careful and stated that it was painful. The urethral opening was observed to be enlarged and extended downward on the posterior portion of the head of his penis. The area of impairment on the urethral opening was approximately one 16 French (Fr) catheter tubing width. CNA T stated the urethral opening had been as it appeared since she started working at the facility in April 2022. CNA T stated the catheter was often without a securement device of any kind. CNA T acknowledged there should be something to secure the catheter from pulling downward on Resident #31's urethra and stated occasionally she has seen tape securing the catheter to Resident #31's leg. CNA T continued with the catheter care and had to remove one leg from Resident #31's pants and brief to allow for his legs to open and finish his care. During this portion of the observation the catheter tubing was observed pulling downward on the urethral opening and again Resident #31 asked CNA T to .be careful. On 8/29/22 at 5:07 p.m., during an interview, Licensed Practical Nurse (LPN) BB was asked if CNA AA had reported Resident #31 lacked a catheter securement device. LPN BB stated that issue was not reported to her. On 8/29/22 at 5:10 p.m., during an interview, the Director of Nursing (DON) was asked if he would expect CNA AA to have reported an abnormal finding like a missing catheter securement device for a resident. The DON confirmed he would expect CNA T to have communicated the missing securement device to her direct supervisor. A review of the current care plan for Resident #31 for the presence of a urinary catheter located in the Electronic Medical Record (EMR) revealed a securement device should have been in place to prevent dislodgement. the following intervention was active: Monitor that indwelling catheter is secure by tape or leg strap to to prevent pressure/pulling on catheter. (Initiated on 3/20/22) On 8/30/22 at approximately 9:05 a.m., toileting assistance was observed performed for Resident #31 by Assistant Director of Nursing (ADON) Registered Nurse (RN) U and the Director of Nursing (DON). The DON observed the area of impairment and acknowledged the abnormal appearance. The DON stated he was not aware of the area of impairment. The DON acknowledged the area was consistent with either a urethral erosion (pressure caused) or urethral tear. Review of an admission Minimum Data Set (MDS) assessment for Resident #31, dated 3/24/22, revealed a catheter was in place at the time of the assessment. This same assessment indicated there were skin tear(s) and open lesion(s) present for this assessment but none of the areas of skin impairment documented in the EMR, noted anything on the urethra. Review of the admission skin assessment for Resident #31, dated 3/18/22 revealed no evidence of urethral opening impairment. Review of a face sheet for Resident #31, revealed admission to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a Consult Report for Resident #31, dated 3/16/22 at 1:55 p.m., read in part: .A Foley catheter has been placed in the emergency room (ER), but he has been able to void on his own prior to this ER admission . The consult note revealed no evidence of any urethral abnormality or diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] Review of the admission Nursing Evaluation for Resident #31, dated 3/18/22, at 4:52 p.m., revealed multiple areas of skin impairment, but none were identified as a urethral skin impairment. The assessment rated Resident #31 as being continent of bladder with no urinary symptoms or concerns. Review of a Progress Note for Resident #31, dated 3/19/22 at 2:45 p.m. read in part: Foley Catheter Change Size: 14 FR (french)/30 cc (cubic centimeter) Balloon .Foley inserted due to resident (#31) having no void on (night shift) and being straight (catheterized) for 500 cc out . There was no reference to any abnormality or impairment at the time of this note. Review of the EMR order for the catheter revealed the following: 3/19/22 2:06 p.m. Foley Catheter Change Size: 14 FR/30 cc Balloon Review of a Progress Note dated 4/11/22 at 1:52 p.m. revealed the following: this nurse alerted to resident having cloudy urine. upon assessment urine looks very turbid. its a tan color. resident noted to be very sleepy and harder than normal to wake up. this nurse changed residents catheter using sterile technique. resident tolerated procedure well. new catheter is 16 Fr with 30 cc. obtained a urine sample to send for testing. Review of a Progress Note dated 4/16/22 at 5:53 p.m. revealed the following: Lab called with a critical lab regarding (urinalysis) that was sent to (local hospital). They had sent results previously for the culture that said it was [MEDICATION(S)] resistant but now have changed that to susceptible . Review of Progress Notes provided by the facility for the time period 4/25/22 - 8/26/22 revealed notes addressing 5 falls on 4/25/22, 5/29/22, 6/25/22, 7/16/22, and 8/14/22. Multiple falls alone would have been important for Resident #31 to have some sort of securement device for his catheter in place at all times to prevent pulling, tearing, or dislodgement. The securement device would also have been important to be in place during care being provided to avoid catheter from being pulled on at the urethral opening. No skin assessment or wound assessment could be found in the EMR to acknowledge when this urethral skin impairment started. On 8/23/22 at 11:23 a.m., during an interview, the DON was asked what the expectation of the staff was in regard to documentation of skin impairments. The DON stated his expectation was that the urethral skin impairment would be documented somewhere. The DON stated this was so the facility would not have to claim an impairment if they didn't cause it. On 8/30/22 at 11:45 a.m., during the exit conference, the DON was asked if he could provide any evidence the urethral skin impairment was existing prior to Resident #31's admission to the facility on [DATE]. The DON handed this Surveyor copies of the progress notes referenced above. None of which addressed when the urethral skin impairment came into existence. On 8/30/22 at 4:12 p.m., an email was received from the DON which contained the urethral skin impairment wound assessment. The impairment was rated as a Medical Device Related Pressure Injury and was listed as in-house acquired. The area measured 0.67 cm (centimeters) by 0.34 cm. Cath (catheter) secure in place to avoid pulling of Foley cath onto meatus (urethral opening) of penis (LPN BB). A review of the facility policy, Skin Protection Guideline, dated 7/7/21, read in part: Purpose: To provide evidenced based practice standards for the care and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] To ensure residents that admit and reside at our facility are evaluated and provided individualized interventions to prevent, reduce and treat skin breakdown. EVALUATION Our facility applies a process to identify residents with or at risk for developing a pressure injury: -Upon admission / readmission -Transfer out / in -With significant changes in condition -Routinely through the MDS Assessment process . .An admission evaluation helps identify residents at risk of developing a PU/PI, and residents with existing PU/PIs. Because a resident at risk can develop a PU/PI within hours of the onset of pressure, the at-risk resident needs to be identified and have interventions implemented promptly to attempt to prevent PU/PI: -Skin should be examined as soon as possible upon admission, re-admission or return -Where possible, prioritize completion of the skin evaluation within the first 2 hours The admission evaluation helps define those initial care approaches. In addition, the admission evaluation may identify pre-existing signs suggesting that tissue damage has already occurred, and additional tissue loss may occur . .Monitoring of Skin Integrity: -Skin will be observed daily during care by the nursing assistants -Should there be a change in skin integrity, the nurse will be notified for continued evaluation -Weekly skin observation by a licensed nurse -This may be completed during a scheduled shower or bath day and / or as determined by preference through the care planning process -If a skin concern or change is observed: -The Notification of Change Guideline will be followed -Physician consulted and orders will be transcribed for treatment -Refer to the Skin and Wound Care Formulary -Resident / resident representative informed -The plan of care will be modified based upon root cause analysis investigation findings for additional prevention and healing approaches -Routinely through the RAI process and as needed the plan of care will be reviewed for continued effectiveness together with the resident and resident representative .

This citation is linked to intake # MI 301. Based on observation, interview, and record review, the facility failed to ensure pressure ulcer assessments, preventative measures, and monitoring were in place for four Residents (#10, #16, #17, and #18) of four residents reviewed for pressure ulcers. This deficient practice resulted in the actual development of unstageable, Stage 2, and/or State 3 pressure ulcers and the potential for undetected and/or worsening pressure ulcers which could lead to pain, infection, and a decreased quality of life. Findings include: On 10/4/21, a complaint was filed with the State Agency (SA) which alleged the facility staff failed to provide adequate and appropriate care to prevent and/or treat pressure sores. Resident #10 During a phone interview on 6/22/22 at 12:57 PM, Resident Representative O stated Resident #10, after being admitted to the facility, experienced a fast decline including weight loss and development of pressure areas. A review of the medical record for Resident #10 revealed an admitted [DATE] and a date of discharge of 9/7/21. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #10 was severely cognitively impaired, needed extensive two-person physical assistance with bed mobility, was not ambulatory, and had no unhealed pressure areas. However, Resident #10 was coded to be at risk for developing pressure ulcers/injuries. On 8/26/21, a Skin Observation - V1 sheet revealed Resident #10 had no skin issues observed, only a hip incision described as healing' without signs or symptoms of infection. On 8/31/21, a Skin Observation - V1 sheet revealed Resident #10 had a skin tear on his coccyx, a right heel unstageable pressure ulcer, and a left heel stage 2 pressure ulcer. Further documentation titled, Pressure Ulcer Unavoidability revealed the right heel pressure ulcer measured 3.5 cm (centimeters) by 3.7 cm and the left heel pressure ulcer measured 5.5 cm by 5.0 cm. This document described the risk factors as limited mobility due to hip fracture with replacement. Interventions were listed as low air loss mattress, prevalon boot and float heels (heels should not rest on surfaces such as a mattress). During an interview on 6/24/22 at 2:30 PM, the Director of Nursing (DON) stated, There is not any part of me that is claiming the area was unavoidable. That was just the name of the report. The DON said, I don't think if his (Resident #10) heels were off the bed it (pressure ulcers) would not have happened. On 9/2/21, the Skin and Wound Evaluations for Resident #10 revealed the coccyx was classified as a pressure type wound stage 1 and measured 4.9 cm by 2.5 cm. The right heel was noted as in-house acquired and measured 3.4 cm by 5.0 cm. The left heel was noted as in-house acquired and measured 3.4 cm by 5.1 cm. A Braden assessment presented for Resident #10 was dated 9/2/21 and no initial Braden assessment was found. During an interview on 6/24/22 at 1:48 PM, the DON stated, I would want them (licensed nurses) to do a Braden on admission. Risk is generated off of the Braden (assessment). The DON stated the expectation was every 7 days there is a total skin observation. Resident #10 had a nursing skin assessment on 8/17/22 and not again until 8/26/22. The DON agreed there was a gap in the skin assessments for Resident #10. Resident #18 A review of the medical record for Resident #18 revealed an admitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #18 was moderately cognitively impaired, needed extensive two-person physical assistance with bed mobility, was not ambulatory, had one stage two pressure area, and was coded is at risk for developing pressure ulcers/injuries. On 6/23/22 at 8:15 AM, Resident #18 was observed on his back with his feet pressing against the foot board. His calves were on pillows and a foam floating mat in the bed, but his heels were resting on the mattress. During an interview on 6/23/22 at 8:24 AM, Certified Nurse Aide (CNA) D was asked about the positioning of Resident #18's feet up against the foot board and his heels on the mattress. CNA D stated, The heels should be off of the mattress as he has a sore. On 6/23/22 at 11:07 AM, Resident #18 was observed sleeping on his back and his heels again were resting on the mattress. CNA D again observed the resident and adjusted his leg positioning, but the pressure area remained resting directly on the foam pad so that a pillow had to be added by CNA D to assure Resident #18's feet were floating and off of the mattress. On 6/23/22 at 1:02 PM, Resident #18 was observed on his back with his heels rubbing on the mattress. The Skin Observation -V1 dated 5/5/22 indicated Resident #18 had no skin issues. On 5/9/22, a skin incident report revealed a stage 3 pressure ulcer was house acquired and measured 1.0 cm by .9 cm on Resident #18's right lateral malleolus (outer boney prominence of ankle). The Skin Observation -V1 dated 5/11/22 indicated Resident #18 had an open area on the right outer ankle. On 5/11/22 a Physician Note read in part, Asked to evaluate sore over his right ankle lateral malleolus. He has a 2-3 mm ulceration with surrounding mild redness directly over his malleolus consistent with a pressure injury. Discussed with nursing positioning to avoid pressure . The active care plan printed 6/22/22 for Resident #18 included: The resident has moderate risk for impairment to skin integrity r/t (related to) limited mobility, incontinence initiated 1/19/2018. The interventions included in part: Ensure that heels are elevated while resident is lying in bed. Date Initiated: 1/19/2018 . encourage small frequent position changes while in chair and in the bed. Date Initiated 1/30/2018. Also listed on this care plan was a problem: The resident has actual impairment to skin integrity right lateral malleolus r/t limited mobility Dated Initiated: 5/24/22. Interventions for this problem included: Ensure that heels are elevated while resident is lying in bed. Date Initiated: 5/24/22 and The resident needs pillows to float heels to reduce pressure on heels, ankles. Date Initiated: 5/24/22 and Turn (resident name) to side-back-side to reduce pressure areas. Date Initiated 5/24/22. Resident #17 A review of the medical record for Resident #17 revealed an admitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #18 was cognitively intact, needed extensive two-person physical assistance with bed mobility, was not ambulatory, had one stage two pressure area, and was coded is at risk for developing pressure ulcers/injuries. On 6/23/22 at 8:44 AM, Resident #17 was observed to be resting flat on his back in bed with his covers over his head, his feet against the foot board, and heels on the mattress. On 6/23/22 at 10:12 Resident #17 was again observed in bed on his back, with his feet touching the foot board, and heels not floating. On 6/23/22 at 11:14 AM, Resident #17 was again observed lying on his back. He remained in the same position and his left foot was up against the foot board and heels on the mattress. On 6/23/22 at 11:59 AM, Resident #17 was observed lying on his back with his left foot on the mattress and against the foot board. His heels were resting on the mattress. On 6/23/22 at 1:09 PM, Resident #17 was observed lying in bed on his back with his left foot pressing against the foot board. His heels were resting on the mattress. On 6/23/22 at 2:38 PM, CNA I indicated the rooms in her assignment and included Resident #17. CNA I was asked if she had turned Resident #17 at any time during her shift. She answered no. It was observed there was now a pillow at the foot of the bed. CNA I said she did not know about it or put it there. CNA I read the task list for Resident #17 which included a pressure relieving device should be in the bed. When asked what a pressure relieving device was, CNA I did not know. Then (at 2:40 PM), CNA M stated, The mattress is smaller than the bed frame and he (Resident #17) keeps sliding into the foot board, someone just added a pillow to prevent him from sliding into the foot board. The Nursing Evaluation upon admitted d 6/2/22 indicated Resident #17 had no skin integrity concerns. On 6/8/22, a skin incident report revealed a pressure ulcer was house acquired on Resident #17's right bunion area of foot. The active care plan printed 6/22/22 for Resident #17 included: The resident has (stage 2) pressure ulcer (rt bunion) r/t shoe Date Initiated 6/15/22. The interventions included in part: The resident needs (assistance) to turn/reposition at least every 2 hours, more often as needed or requested. Date Initiated: 6/15/22 . The resident requires (Pressure relieving/reducing device) on (bed/chair). Date Initiated: 6/15/22. Resident #16 A review of the medical record for Resident #16 revealed an admitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #16 was moderately cognitively impaired, needed extensive one-person physical assistance with bed mobility, was not ambulatory, had one stage two pressure area, and was coded is at risk for developing pressure ulcers/injuries. On 6/23/22 at 10:14 AM, Resident #16 was observed with his heels directly on the mattress (not floating) as he sat in bed watching TV. On 6/23/22 at 11:15 AM, Resident #16 was observed again sitting in bed with his feet at the end of the bed touching the foot board and again not floating. On 6/23/22 at 11:22 AM, Registered Nurse (RN) K was asked to observe Resident #16 and upon seeing his feet up against the foot board stated, Yes that would be a risk (for pressure ulcer injury). RN K and CNA L repositioned Resident #16 adding pillows under his heels and had him lay on his side. Resident #16 was compliant and had no complaints. The Skin Observation -V1 dated 4/27/22 indicated Resident #16 had no skin issues. On 5/4/22, a skin incident report revealed a stage 2 pressure ulcer was house acquired on Resident #16's coccyx. The Skin Observation -V1 dated 5/4/22 indicated Resident #16 had skin breakdown on his coccyx. The active care plan printed 6/22/22 for Resident #16 included: The resident has potential for reoccurring pressure ulcer (coccyx) r/t immobility, refusal to turn off of backside Date Initiated 7/10/20. The interventions included in part: : Encourage to elevate heels off of bed on pillow as he refused heel up cushion. Date Initiated: 3/9/21 . The resident needs (encouragement/reminders/assistance) to turn/reposition at least every 2 hours, more often as needed or requested. Not always compliant with turning off of backside. Date Initiated: 7/10/20 . The resident requires (Pressure relieving/reducing device) on (bed/chair). Date Initiated: 7/10/20. The care plan for Resident #16 also included a problem of resident being resistive to care. The facility policy on pressure ulcer assessment, care, and treatment was requested and the Skin Protection Guideline dated as effective on 7/7/21 was presented by the Director of Nursing (DON). This document read in part: Purpose: . To ensure residents that admit and reside at our facility are evaluated and provided individualized interventions to prevent, reduce and treat skin breakdown . Our facility applies a process to identify residents with or at risk for developing a pressure injury: upon admission .The process includes evaluating: . Implementation, monitoring and modifying interventions to stabilize, reduce or remove underlying risk factors . The first step in the prevention of PU/PI (Pressure Ulcer/Pressure Injury) is the identification of the resident at risk . This is followed by implementation of appropriate individualized interventions and monitoring for the effectiveness of the interventions. An admission evaluation helps identify residents at risk of developing a PU/PI . The admission evaluation helps define those initial care approaches . Although the requirements do not mandate the use of any specific assessment tool . Our facility utilizes the BRADEN scale . an evidence based tool that provides a scale to identify potential categories that would contribute to conditions for breakdown . An individualized plan of care will be developed based on known predicting factors for skin breakdown . Turning and Repositioning Observation: Pressure is the primary cause of pressure injuries. An effective turning and repositioning schedule can help reduce the risk of developing pressure injury.

Based on observation, interview, and record review, the facility failed to assess, monitor, and implement interventions to prevent the development and worsening of facility acquired pressure injuries for three Residents (#22, #66, #126) out of five residents reviewed for pressure injury. This caused actual harm to Resident #126 who developed an avoidable stage 4 pressure injury to the sacrum and a stage 4 pressure injury to the heel, which resulted in continued deterioration in overall function, reduced quality of life and pain. Resident #66 sustained harm due to worsening of their sacral pressure injury, and Resident #22 was put at increased risk for worsening of their facility-acquired pressure injury due to the systemic breakdown in pressure injury prevention and management. The immediate jeopardy began on 2/22/21, when Resident #126 was documented to have developed a deep tissue injury (DTI) to her heel, which worsened into a stage 4 pressure ulcer, and no assessment or tracking of the wound was completed. The Administrator was notified of the immediate jeopardy on 5/19/21 at 11:45 a.m. While the immediate jeopardy was removed on 5/19/21 at 4:00 pm, non-compliance remained at the lower scope and severity of potential for harm that was not immediate jeopardy due to the other residents affected by the deficient practice, and until sustained compliance had been verified. Findings include: Resident #126 On 5/16/21 at 12:24 p.m., Resident #126 was observed laying in her bed, moaning and calling out. Resident was asked how she was doing but did not respond. There was a very strong odor coming from Resident #126's room. A Personal Protective Equipment (PPE) cart was observed beside her door. On 5/16/21 at 12:34 p.m., Licensed Practical Nurse (LPN) K was asked why Resident #126 was in isolation and she reported that Resident #126 was in isolation for C-diff (a gastrointestinal infection). On 5/16/21 at 12: 50 p.m., Resident #126 was observed laying on her back in her room. There was a very strong odor coming from her room. Resident #126 was intermittently moaning and calling out. On 5/17/21 at 11:31 a.m., Resident #126 was observed laying on her back in her room, and moaning. A review of Resident #126's medical record revealed she admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of her 2/16/21 Minimum Data Set (MDS) assessment revealed she scored 5/15 on the Brief Interview of Mental Status (BIMS) assessment indicating severely impaired cognition. Further review of this MDS revealed she admitted with one Stage 2 pressure ulcer, one Stage 3 pressure ulcer, and one Unstageable pressure ulcer. A review of Resident #126's History and Physical dated 2/11/21 on admission to the facility revealed, . had a large sacral decubitus ulcer with eschar . also has decubitus ulcers of the upper left back and left hip . A review of Resident #126's medical record revealed no wound assessments or measurements of the left hip and left upper back pressure ulcers. There was no documentation on when these wounds healed. A review of a 3/10/21 progress note from Infectious Disease revealed, . Wound assessments: Wound #2 left, posterior heel is an unstageable pressure injury obscured full-thickness skin and tissue loss necrotic adipose (dead fat tissue) is exposed . Wound #3 Left, Medial Sacral is an unstageable pressure injury . there is a moderate amount of sanguineous (fluid containing blood and seroud fluids) drainage noted which has a strong odor . Wound #4 Left, inferior sacral is a pressure ulcer . Wound #5 Sacral most distal, most left lateral is a chronic unstageable pressure injury . This indicates that there was multiple open areas to the sacral area, and was not considered to be all one wound. A review of a progress note for Resident #126 dated 3/25/21 revealed, On 3/1/21 nursing found unstageable pressure wound on left heel. MD aware as well as ID (Infectious Disease) who ordered PRAFO boot for heel. Resident was admitted with a wound on her sacrum for which has been taking pro-stat (protein supplement used for wound healing) since admission on 2/12/21. PRAFO boot (a boot that elevates the heel) ordered 3/3/21. Repositioned every two hours and feet have been careplanned to be elevated. She has been using an air mattress since admission . Resident is responsible for own medical decisions, attempted to contact her niece but no answer and unable to leave message. A review of a progress note written by Infectious Disease for Resident #126 dated 4/19/21 revealed, Her (Resident #126) sacral wound is deteriorating. A decision needs to be made re: (regarding) goals of care. To heal this she will need a diverting [CONDITION(S)], surgical debridement, and possibly a skin flap . A review of an Infectious Disease progress note for Resident #126 dated 4/10/21 revealed, Wound #1 Heel left post heel prominence is an acute Stage 3 . Wound #2 Left Posterior (toward the back) heel is an unstageable pressure injury . the patient reports a wound pain level of 5/10 . the wound is deteriorating . this is very close to bone . Wound #3 Left medial (toward the middle) sacral is an unstageable pressure injury . necrotic tendon, necrotic muscle, and necrotic adipose tissue are exposed . the wound is deteriorating . there is loose stringy necrotic tissue hanging from the wound . debridement is limited by pain and this wound is very close to bone . Wound #4 Left inferior (toward the back) sacral is a stage 3 pressure ulcer . Wound #5 sacral most distal (furthest from center of body), most left lateral (toward side) is a chronic Stage 3 pressure injury . Psychiatric: Cannot assess. Shows poor insight into need for offloading. Oriented conversationally, very poor memory,, not sure why she is here today .Pain Level: 'I cannot give you a number. I just hurt!' . A discussion needs to be made with the patient if she is her own decision maker and otherwise with the family regarding goals . IF this is a palliative (end of life care) wound, she does not need management here, can be managed by your excellent wound care staff at the (name of Facility) . I am very happy to discuss with you and the patient. I tried with her, but really don't this she comprehends what I am proposing . A review of a progress note for Resident #126 dated 3/26/21 revealed, Addendum: Wound to left heel first noted on 2/22/21. A review of Resident #126 Wound assessments for the Sacral (noted as coccyx in facility documentation) revealed the following: The first assessment was not completed until 3/7/21, despite Resident #126 being admitted on [DATE]. The 3/7/21 wound assessment revealed the sacral (coccyx) wound was 4.5 by 6.5 by unknown centimeters, undermining and tunneling was unknown. A review of the 5/17/21 wound assessment revealed it had increased to be 8.60 by 4.00 by 2.50 centimeters, with undermining and tunneling present. Strong odor, was also documented on this assessment. There was only one wound being documented on the sacral (coccyx) region. A review of Resident #126's wound assessments for the Left heel wound revealed the first assessment was dated 3/24/21, despite the DTI being identified on 2/22/21. The 3/24/21 assessment revealed its size as 3.20 by 2.70 by unknown depth in centimeters. A review of the 5/12/21 assessment revealed it was 5.00 by 3.00 by depth unknown with, dressing is moist. Drainage noted . On 5/19/21 at 10:02 a.m., an interview was conducted with the Director of Nursing (DON) and the Administrator. When asked why no wound assessments were completed for Resident #126 between her admission on 2/11/21 and 3/25/21, the DON stated, We know the gap and that's why Identified the dates yesterday. We missed that. When asked why the heel pressure ulcer first identified in an evaluation as a DTI was not assessed until 3/25/21, the Administrator reported it was a lack of assessment and education. When asked where the documentation was of the two pressure ulcers on the hip and left back that Resident #126 admitted with and when they would have healed, the DON stated, We missed (Name of Resident #126) . I don't know exactly when the scapula and hip healed. When asked if staff had been educated on assessing and staging wounds, the DON and Administrator confirmed that they had been educated in March (3/26/21 and 3/27/21). The DON confirmed that he did not become aware of Resident #126's heel pressure ulcer until 3/24/21. The DON was asked to provide information as to why multiple shifts of pressure ulcers treatments had not been completed for Resident #126. On 5/25/21 at 10:35 a.m., an interview was conducted with LPN AA. When asked about why she had documented that she had done the wound care on 5/18/21 when it had been observed being done by RN M, LPN AA stated, It was brought to my attention. I noticed the nurse hadn't documented that she used the saline (solution) instead of the dakins (an antiseptic soluition to clean wounds). I went to the TAR (Treatment Administration Record) to try to back date a progress note and that happened. When asked how long the saline solution was being used instead of the ordered Dakins, LPN AA stated, Now we have it. LPN AA was unable to say how often the saline had been used instead of the Dakins prior to 5/18/21. When asked if using the saline as opposed to the ordered Dakins could delay wound healing, LPN AA stated, Well, the Dakins helps keep the bile burden down. When asked about the odor coming from the wounds, LPN AA stated, She has an odor because of the C-diff. But it could be the wounds. A review of Resident #126's TAR revealed she cumulatively missed 4 treatments to her heel, and 10 treatments to her sacrum. On 5/25/21 at 2:26 p.m., the DON was asked about the treatments that were not documented as being completed for Residents #126 and #66. The DON stated that prior to 5/19/21 if there wasn't a check mark on the TAR, then it (treatment) probably wasn't done. Resident #66 A review of Resident #66's medical record revealed he admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of his 5/2/21 MDS assessment revealed he scored 15/15 on the BIMS assessment indicating intact cognition. A review of this MDS also revealed he admitted to the facility with 3 unstageable pressure ulcers. A review of a physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] .He has a very large, surgically debrided sacral decubitus ulcer and bilateral heel pressure sores with dry necrotic skin eschars (dark scab composed of dead tissues) . A review of Resident #66's Wound Assessments revealed the following: The Sacrum wound was first assessed on 4/27/21 and was 10 cm by 13.5 cm by 2.0 cm deep, with undermining present. A review of the 5/12/21 assessment of this wound revealed it increased to 12.2 cm by 11.5 cm by 4.0 cm deep, with heavy serosangenous drainage. This suggests that the wound worsened during his stay at the facility. A review of Resident #66's physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . It remains as big as my fist and down to the bone . A review of Resident #66 TAR revealed that between 5/1/21 and 5/16/21 when he discharged 18 shifts of wound care to the sacral wound were missed. The intervention for the Left heel boot on at all times except for transfers . was not completed for 10 shifts during the same time period. The treatment orders for the left heel were not completed on 12 shifts as well during this period of time. A review of the facility policy titled Skin Management Guideline dated 11/28/17 revealed, . It is the practice of this facility to properly identify and evaluate residents whose clinical conditions increase the risk for impaired skin integrity, and pressure ulcers; to implement preventative measures; and to provide appropriate treatment modalities for wounds according to industry standards of care . all residents admitted to the facility will be evaluated for actual and potential skin integrity issues . If a resident is admitted with or there is a new development of a pressure ulcer or lower extremity ulcer the following procedure is to be implemented: . Consult with the Physician/NP . 3. Notify Supervisor/Designee as assigned . 10. Initiate the Wound Initial Documentation Observation in PCC which will include: type of wound, location, date, stage (pressure ulcers only) or indicate partial or full-thickness . length, width, and depth . The weekly wound documentation . should only have ONE WOUND per observation . 11. When a a pressure ulcer is present, daily wound monitoring should include: an evaluation of the ulcer, if no drainage is present. An evaluation of the status of the dressing, if present . Whether pain, if present, is being adequately controlled. Document on any changes or concerns in the nurses notes and re-evaluate prior steps 1-9 as appropriate. Resident #126 On 5/18/21 at 11:00 a.m., wound care for Resident #126 was observed by Registered Nurse (RN) M and assisted by Licensed Practical Nurse (LPN) AA. Resident #126 was in isolation for [CONDITION(S)] (bacteria which spreads by contact with a contaminated object or surface). No hand hygiene was performed by RN M prior to entering Resident #126's room. RN M applied a cloth, yellow gown which was hung inside of the room. Wound care supplies contained within a purple basket were brought inside the isolation room from the medication storage room and then placed down on top of a paper towel on Resident #126's over bed table. The wound care supplies were not dedicated to Resident #126 to prevent cross-contamination. RN M left Resident #126's room on two separate occasions to retrieve additional wound care supplies. Hand sanitizer was used instead of hand washing as required with Resident #126's isolation precautions. Resident #126's room contained a very strong, foul odor which permeated outside the doorway. Resident #126 appeared very thin and was laying on her back with the head of the bed elevated approximately 30 degrees and heard continuously moaning in discomfort. Resident #126 was positioned on her right side for the wound care and supported by LPN AA. Resident #126 moaned and grimaced when positioned on her right side. When RN M left the room on two occasions, Resident #126 was not lowered to her back, but instead, remained turned on her right side. RN M lowered Resident #126's brief to access the wounds. Stool was present which presented a separate odor. The stool was not removed and skin cleansed prior to the continuation of wound care. RN M rolled the brief to contain the stool. RN M was asked to clarify the location of Resident #126's wounds since the electronic medical record referenced coccyx but the observation of the wound dressing indicated sacral location. RN M said the location was sacral and not coccyx. RN M removed the large dressing, while wearing the same pair of gloves, with one hand without attention placed to Resident #126's loose sacral skin. A very strong odor emitted from the wounds once the dressing was removed. A large amount of wound drainage was noted to the removed dressing and to the bed linens beneath Resident #126. Two large, deep wounds each approximately the size of an egg, were identified. A bridge of skin separated the two large openings. The superior wound base showed yellow tissue and both wounds indicated advanced tunneling to the wound borders. No wound measurements were taken at this time. When asked about the progression of the wounds, LPN AA said the bottom wound developed first and tunneled which created the second wound (superior wound). The wound edges showed clear wound separation. While wearing the same pair of gloves, RN M sprayed saline onto a 4 x 4 dressing and wiped the superior sacral wound, then the inferior sacral wound, and lastly a third wound located to the bottom right of the inferior wound. A separate 4 x 4 dressing was not used to clean each wound separately; therefore, the risk for cross-contamination occurred. When asked about the physician ordered (brand name hypochlorite antiseptic solution used to kill bacteria and viruses) not observed being used, LPN AA indicated it was not available. When asked about the third wound observed, RN M said, Oh, that's probably from (adhesive) dressing removal. [MEDICATION(S)] skin loss was noted to the third wound which was approximately the size of a quarter. After wiping the wounds using the same soiled 4 x 4 dressing, RN M packed the superior and inferior sacral wounds separately with dry dressings using two sterile cotton-tipped swabs. Resident #126 said, That hurts. I feel that!. Resident #126 displayed guarding during the dry wound packing. RN M then applied one large dressing which covered all three wounds. Review of Resident #126's Treatment Administration Record (TAR), 5/12/2021 physician order date, showed (brand name) hypochlorite solution 1/4 strength 0.125% was to be applied to sacral wound bed topically every day and evening. The wound was to be cleansed and packed with Kerlix soaked in hypochlorite solution. On 5/19/21 at 8:30 a.m., Resident #126's left upper heel wound care performed by LPN K and assisted by Certified Nurse Aide (CNA) Q was observed. Once LPN K explained wound care need, Resident #126 shouted, Oh my God! Resident #126's was positioned on her back with the head of the bed up 45 degrees. Resident #126's bilateral feet were noted up against the footboard contained within (brand name) heel protector boots. Once the left boot and wrapped gauze were removed, a very strong odor was noted. A large amount of purulent wound draiange was noted to the bed linens underneath Resident #126's foot. A large opened wound was noted above the left heel. A large amount of wound slough was noted to the inferior portion of the wound bed. Once the slough was removed with cleansing, musculoskeletal tissue was noted. Resident #126's during cleansing repeatedly said, Ouch! and moaned throughout the wound care. When asked, LPN K confirmed wound measurements were performed on Wednesday (that day). When asked why LPN K was not measuring the wound said, I can't measure since I don't have access to the phone. When asked for clarification, LPN K explained the phone provided the ability to photograph and measure the wound. When asked for wound staging, LPN K replied, I don't know, I'm not really good at staging. After the wound was dressed, LPN K asked CNA Q for a pen. CNA Q lowered Resident #126's leg, reached underneath her isolation gown, and retrieved a pen from her left scrub pocket while wearing the same soiled gloves. LPN K retrieved the pen and dated/initialed the dressing to the foot. Upon further skin assessment, Resident #126's sacrum dressing was found unsecured on the right side with a large amount of bloody wound drainage noted to the dressing and scrunched up bed linens. Resident #126's loose back skin was noted to be creased and wrinkled. Resident #126's repeatedly said, Help me! while CNA Q held her on her right side. Stool was noted within her brief once lowered. Resident #126's right arm skin protectant sleeve was found inside of her gown. During an interview on 5/25/21 at 10:40 a.m., LPN AA confirmed Resident #126's physican ordered hypochlorite solution had not been used for an unknown period of time. LPN AA said the solution was intended to lessen the bioburden (bacteria). When asked about Resident #126's foul smelling wounds and use of saline instead of the hypochlorite solution, LPN AA said it may have contributed to Resident #126's poor wound healing. Resident #22 Review Resident #22's MDS assessment, dated 3/5/21, reflected the following Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #22's required one staff person assistance for bed mobility, transfers, locomotion, and toileting. The BIM showed a score of 3 out of 15 which reflected severe impaired cognition. Resident #22's was at risk for pressure ulcers but did not have any skin breakdown at the time of the MDS assessment. On 5/25/21 at 10:09 a.m., RN O performed Resident #22's wound care. Without the performance of hand hygiene, RN O applied a pair of clear gloves and then moved Resident #22's wheelchair and over bed table where wound care supplies were previously placed. RN O removed Resident #22's white cotton sock. No dressing noted to the wound. Outer left ankle bony prominence was bright pink color. No skin opening noted. RN O used a brown paper towel, instead of a gauze, to cleanse the wound with a substance found within a medicine cup. RN O then removed her gloves, used hand sanitizer, and then left Resident #22 who was sitting in her wheelchair next to the window to wash her hands within the bathroom. Once RN O returned, a clean pair of gloves were applied before placement of the dressing. When asked if a dressing should have been in place at the start of the wound care, RN O said, Yeah, it should have. Review of Resident #22's Wound Assessment Details, 5/19/21, read in part, Site: left lateral malleous .Status- Active Type Pressure-Source Facility-acquired-Date identified 4/12/2021. Clinical Stage Stage 2 . The accepted Abatement plan included the following actions taken, to be verified by onsite revisit survey: Identified resident #126 continues to reside at the facility. Currently plan of care indicates resident having a pressure injury to sacrum and left heel. Care plan has been reviewed and updated accordingly. On May 19, 2021 evealuation was scheduled for weekly skin assessment on resident #126 and was completed. Evaluation has been completed and entered under skin evaluation. Current wounds have been assessed and measured in Wound rounds. Treatments were reviewed for appropriateness. Care plan was reviewed and updated as appropriate. 73 additional residents reside in the facility, all residents have had a head to toe skin evaluation and were entered into the medical record. Residents with both facility and community acquired wounds have received assessments of wounds that include measurements. Treatments and care plans have been reviewed and updated as appropriate. Licensed nursing staff have been educated on skin observation technique and on guideline for routine, soiled, or contaminated dressings. Education was initiated on May 19, 2021. This facility employs 23 licensed nurses, currently 9 licensed nurses have completed the education . All remaining licensed nurses will received [sic] education prior to working their next shift. Skin evaluation and wound care management education will be provided to new hires and will occur annually for licensed nursing staff. QAPI (Quality Assessment Performance Improvement) team has reviewed the education and training plan for licensed nursing staff. This team will ensure that all licensed nurses are educated. Policy and procedure were reviewed on May 19, 2021 an deemed appropriate. The Medical Director has reviewed and provided input in the formulation of this abatement plan. The DON/ designee will coduct random observations 5 times per week for completeness of treatment documentation, weekly skin evaluations, and documentation of weekly wound measurements. The results of these audits will be reviewed by the facility Quality Assurance Performance Improvement committee for patterns, trends, and continued recommendations for process monitoring and continued improvement. The Administrator is responsible to ensure these actions are taken.

Based on observation, interview, and record review, the facility failed to implement an effective pain management program for one Resident (#126) who exhibited signs, symptoms, and verbalizations of pain, out of two reviewed for pain management. This deficient practice resulted in Resident #126 experiencing untreated pain throughout the day and during extensive wound care for multiple pressure ulcers. Findings include: Resident #126 On 5/16/21 at 12:24 p.m., Resident #126 was observed laying in her bed, moaning and calling out. Resident was asked how she was doing but did not respond. There was a very strong odor coming from Resident #126's room. On 5/16/21 at 12: 50 p.m., Resident #126 was observed laying on her back in her room. There was a very strong odor coming from her room. Resident #126 was intermittently moaning and calling out. On 5/17/21 at 11:31 a.m., Resident #126 was observed laying on her back in her room, and moaning. On 5/18/21 at 11:27 a.m., Resident #126 was observed moaning in her room. Registered Nurse (RN) M was observed to go into her room and stated I'll be back in just a minute to Resident #126 and left the room. A review of Resident #126's medical record revealed she admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of her 2/16/21 Minimum Data Set (MDS) assessment revealed she scored 5/15 on the Brief Interview of Mental Status (BIMS) assessment indicating severely impaired cognition. Further review of this MDS revealed she admitted with one Stage 2 pressure ulcer, one Stage 3 pressure ulcer, and one Unstageable (unable to stage due to slough, dead tissue) pressure ulcer. A review of Resident #126's History and Physical dated 2/11/21 on admission to the facility revealed, . had a large sacral decubitus ulcer with eschar (thick black scab) . also has decubitus (pressure) ulcers of the upper left back and left hip . A review of a progress note written by Infectious Disease for Resident #126 dated 4/10/21 revealed, Wound #1 Heel left post heel prominence is an acute Stage 3 . Wound #2 Left Posterior heel is an unstageable pressure injury . the patient reports a wound pain level of 5/10 . the wound is deteriorating . this is very close to bone . Wound #3 Left medial sacral is an unstageable pressure injury . necrotic tendon, necrotic muscle, and necrotic adipose tissue are exposed . the wound is deteriorating . there is loose stringy necrotic tissue hanging from the wound . debridement is limited by pain and this wound is very close to bone . A review of Resident #126's care plan revealed a behavior care plan, The resident has a behavior problem r/t (related to) yelling out initiated 2/17/21. This care plan included an intervention dated 2/17/21 of, PAIN: Evaluate resident for changes in pain levels and if appropriate request a scheduled pain medication from Physician. A review of Resident #126's Pain Care plan dated 2/19/21 revealed the following, The resident has(actual/potential) (acute/chronic) pain r/t pressure ulcers, CVA (stroke), PVD (peripheral vascular disease, GERD (gastroesophageal reflux disease) .Anticipate the resident's need for pain relief and respond immediately to any complaint of pain (2/19/21). Monitor/record/report to Nurse any s/sx of non-verbal pain: Changes in breathing .(grunting, moans, yelling out, silence) . (2/19/21). A review of Resident #126's progress note dated 5/14/21 revealed, Interviewed resident .She stated no to SOB (shortness of breath) and a little to pain when asked. Would not give a number . A review of a progress note for Resident #126 dated 5/7/21 revealed, Lots of yelling tonight. when I went in to see what she needed she said she didn't need anything. A review of Resident #126 progress note dated 5/12/21 revealed, Resident has been yelling out more frequently, during care and while at rest. Spoke with MD who ordered to increase acetaminophen to three times a day and stop prn (as needed) A review of Resident #126's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Give 1000 mg by mouth three times a day for pain -Order Date-05/12/2021. At the time of the survey entry the Resident had no PRN or as needed pain medication orders. Further review revealed no orders or instructions to medicate the Resident prior to her wound treatments. A review of the facility policy titled, Pain Management dated 11/28/17 revealed, It is the facility practices to observe residents for pain upon admission, quarterly, with a significant change in condition that may cause an onset or increase in pain and any time it is suspected a resident is in pain. Residents are observed for pain regularly during daily care and interactions . Suggestive Signs and Symptoms of pain: . Bracing, guarding or rubbing . signs, groans, crying, labored breathing .facial grimacing . Pain scales: Cognitively impaired: Use of the PAINAD scale . Risk factors: .gastrointestinal conditions . pressure ulcers . During an observation on 5/18/21 at 8:08 a.m., Certified Nurse Aide (CNA) EE placed Resident #126's breakfast tray in front of her while she layed in bed. Resident #126 was calling out in pain when the head of the bed was elevated between 45 and 90 degrees. CNA EE said, You have to sit up. I don't want you to choke. Resident #126's bed remained elevated when CNA EE exited her room. When the head of the bed is elevated, it puts additional pressure on the sacral region and other bony prominences which may contribute to increased pain/discomfort. On 5/18/21 at 11:00 a.m., wound care for Resident #126 was observed by RN M and assisted by Licensed Practical Nurse (LPN) AA. Resident #126 was in isolation for [CONDITION(S)] (bacteria which spreads by contact with a contaminated object or surface). Resident #126's room contained a very strong, foul odor which permeated outside the doorway. Resident #126 appeared very thin and was laying on her back with the head of the bed elevated approximately 30 degrees and heard continuously moaning in discomfort. Resident #126 was positioned on her right side for the wound care and supported by LPN AA. Resident #126 moaned and grimaced when positioned on her right side. When RN M left the room on two occasions, Resident #126 was not lowered to her back, but instead, remained turned on her right side. RN M removed the large dressing, while wearing the same pair of gloves, with one hand without attention placed to Resident #126's loose sacral skin. A very strong odor emitted from the wounds once the dressing was removed. A large amount of wound drainage was noted to the removed dressing and to the bed linens beneath Resident #126. Two large, deep wounds each approximately the size of an egg, were identified. A bridge of skin separated the two large openings. The superior wound base showed yellow tissue and both wounds indicated advanced tunneling to the wound borders. RN M sprayed saline onto a 4 inch (in.) x 4 in. dressing and wiped the superior sacral wound, then the inferior sacral wound, and lastly a third wound located to the bottom right of the inferior wound. When asked about the third wound observed, RN M said, Oh, that's probably from (adhesive) dressing removal. [MEDICATION(S)] skin loss was noted to the third wound which was approximately the size of a quarter. After wiping the wounds using the same soiled 4 in .x 4 in. dressing, RN M packed the superior and inferior sacral wounds separately with dry dressings using two sterile cotton-tipped swabs. Resident #126's said, That hurts. I feel that!. Resident #126 displayed guarding during the dry wound packing. RN M then applied one large dressing which covered all three wounds. Review of Resident #126's Treatment Administration Record (TAR), 5/12/2021 physician order date, showed (brand name) hypochlorite solution 1/4 strength 0.125% was to be applied to sacral wound bed topically every day and evening. The wound was to be cleansed and packed with Kerlix soaked in hypochlorite solution. On 5/19/21 at 8:30 a.m., Resident #126's wound care performed by LPN K and assisted by CNA Q was observed. Once LPN K explained wound care need, Resident #126 shouted, Oh my God! Resident #126's was positioned on her back with the head of the bed up 45 degrees. Resident #126's bilateral feet were noted up against the footboard contained within (brand name) heel protector boots. Once the boot and wrapped gauze were removed, a very strong odor was noted. A large amount of purulent wound draiange was noted to the bed linens underneath Resident #126's foot. A large opened wound was noted above the heel. Resident #126's during cleansing repeatedly said, Ouch! and moaned throughout the wound care. Upon further skin assessment, Resident #126's sacrum dressing was found unsecured on the right side with a large amount of bloody wound drainage noted to the dressing and scrunched up bed linens. Resident #126's loose back skin was noted to be creased and wrinkled. Resident #126's repeatedly said, Help me! while CNA Q held her on her right side. Stool was noted within her brief once lowered. Resident #126's right arm skin protectant sleeve was found inside of her gown.

This citation pertains to intake number MI 807. Based on interview and record review, the facility failed to ensure that one (Resident #1) of four residents reviewed for quality of care received timely reporting of significant deterioration in vascular perfusion to a wound (identified by facility staff as a deep tissue injury) located on the dorsum (top) of his right foot. This deficient practice resulted in delayed assessments and interventions by the facility's wound care nurse and the resident's attending physician, delayed transfer of the resident to a local hospital for emergent assessment by a vascular surgeon, subsequent surgical intervention by the vascular surgeon, and the development of [MEDICAL CONDITION] requiring intravenous administration of antibiotic therapy. Findings include: The medical facesheet revealed Resident #1 was admitted to the facility for skilled nursing care on 11/6/2018 with [DIAGNOSES REDACTED]. Review of the Minimum Data Sets assessment ((MDS) dated [DATE], revealed Resident #1 was mildly cognitively impaired (BIM score 10/15), and required extensive assist from one to two facility staff members with activities of daily living (ADLs). Review of physician orders, dated 11/7/2018 at 17:04 (5:04 pm), specified Resident #1 would continue to wear a right knee brace to his right lower extremity and a CAM (controlled ankle motion; an orthopedic device prescribed for treatment and stabilization of injuries of the foot or ankle which permits removal for care and inspection/assessment) boot to his right foot. The physician's orders [REDACTED]. Review of the Treatment Administration Record (TAR), initiated 11/7/2019, revealed facility staff were to document entries to the TAR for the day, afternoon, and night shifts. Review of the physician orders [REDACTED]. Apply skin prep, protective dressing and wrap with kerlix every day (day shift). Review of the admission assessment dated [DATE] at 16:30 (4:30 pm), revealed that Resident #1 received skin assessment, performed by Registered Nurse (RN) A, to his right foot which included . has deep purple bruises to right foot secondary to fall with fracture. No open areas noted. Pulses present. RN A performed assessment to the right foot again on 11/14/2018 at 10:36 am, and documented continues to have bruised areas on the right foot and lower leg . WCC (wound care nurse) informed of areas and will assess. Wound care inspections continued, as ordered by Resident #1's attending physician, from 11/7/2018 through 11/9/2018. Resident #1 returned to a local hospital for the dates of 11/10/2018 and 11/11/2018. Beginning 11/12/2018, Resident #1 continued with orders for use of the right knee brace and use of the CAM boot to his right foot. The physician's orders [REDACTED]. Documentation on the TAR revealed missed inspections for the following: 11/15/2018 day and evening shifts, 11/16/2018 day shift, and 11/24/2018 night shift. After review of this documentation by the Director of Nursing and Wound care nurse / Registered Nurse (RN) K, they could not account for these missed assessments and acknowledged on 1/3/2019 at 3:50 pm, If it's not documented, it wasn't done. Review of the wound care progress note dated 11/21/2018 at 16:27 (4:27 pm), revealed RN E documented Right foot dark purple wound encrusted; no drainage. There was no documentation that the wound care nurse or Resident #1's attending physician had been notified of the significant change in the Resident's wound. During an interview on 1/2/2019 at 1:50 pm, Resident #1's attending Physician D, said, He had a full thickness wound that developed at this facility secondary to chronic ischemia and pressure. He had eschar (unstageable wound), but it wasn't recognized as such by the staff here. I didn't send him to the hospital, initially. Within a few days he was sent to the hospital. He was evaluated at the hospital and placed on three antibiotics. He was seen by a vascular surgeon . We should have picked it up earlier; it had an eschar component. Would it have made a difference; I don't know. During an interview on 1/2/2019 at 2:55 pm, Wound care nurse/ RN K said, He (Resident #1) came with deep tissue injuries of his right lower extremity; he came to us after he had a fracture and surgery. I saw him for the first time on 11/14/2018; he'd been here a week. He was identified with eschar on 11/27/2018, by me, during my weekly evaluation. It was on the dorsal area of his right foot. No one reported to me that there was an area of eschar on the dorsal part of his foot; it was missed. I don't know why it wasn't found earlier. It didn't happen overnight. I didn't check with staff after it (eschar) was found to see if they just weren't able to assess it correctly . I wasn't aware he didn't have assessments done on his right lower extremity, as ordered, every shift . I found that staff were stuffing additional dressings in the CAM boot to prevent pressure of the boot to his foot; I educated them to stop that, since it was causing even more pressure. I made them remove the additional dressings. Wound care nurse/ RN K confirmed Resident #1 was sent to a local hospital for evaluation on 11/28/2018. During an interview on 1/3/2019 at 3:05 pm, RN I said, I saw ABD dressings (thick dressings used to absorb drainage from wounds) stuffed beneath the CAM boot, between the CAM boot and the Resident's (#1) foot; I didn't do it, but I did see it done. Staff were doing it to protect the surface of his right foot from rubbing against the CAM boot. Review of the hospital discharge summary dated 12/12/2018 (untimed), revealed that Resident #1 was diagnosed with [REDACTED]. Resident #1 underwent right lower extremity vascular surgery with catheterization with angiogram and angioplasty; he had improved blood flow with this.

BASED ON OBSERVATIONS, INTERVIEWS AND RECORD REVIEWS, THE FACILITY FAILED TO PROVIDE ADEQUATE SUPERVISION TO PREVENT AN ELOPEMENT FOR ONE (#1) OF FOUR RESIDENTS REVIEWED FOR SAFETY RISK DUE TO IMPAIRMENTS WITH COGNITION AND MOBILITY FROM A FACILITY POPULATION OF 109 RESIDENTS. THIS FAILURE RESULTED IN IMMEDIATE JEOPARDY TO THE HEALTH AND SAFETY FOR RESIDENT #1. THE IMMEDIATE JEOPARDY BEGAN ON 8/4/11 AT APPROXIMATELY 12:45 A.M. WHEN RESIDENT #1, WHO WAS diagnosed with [REDACTED]. THE FACILITY WAS UNAWARE OF RESIDENT #1'S WHEREABOUTS/SAFETY UNTIL 8/4/11 AT APPROXIMATELY 12:45 A.M. WHEN REGISTERED NURSE (RN) "B", WHILE DOING HER BED-CHECK ROUNDS, FOUND THAT RESIDENT #1 WAS NOT IN HIS BED OR IN HIS USUAL AREAS (DINING ROOM AND FOYER/LOBBY). RN "B" ALERTED ALL STAFF TO BEGIN A HEAD COUNT THROUGHOUT THE FACILITY WHILE RN "B" WENT OUT THE FRONT DOOR OF THE FACILITY TO SEARCH FOR RESIDENT #1. IT WAS THEN THAT RN "B" NOTICED A POLICE CAR WITH THEIR LIGHTS ON NEAR THE END OF THE FACILITY DRIVEWAY ALONGSIDE HIGHWAY 131 WITH RESIDENT #1 SITTING IN THE CAR. THE FACILITY ADMINISTRATOR WAS NOTIFIED OF THE IMMEDIATE JEOPARDY ON 8/8/11 AT 5:05 P.M. THE IMMEDIATE JEOPARDY WAS REMOVED ON 8/8/11 AT 5:35 P.M. BY FACILITY ACTIONS, AS FOLLOWS: 1. PROVIDE STAFF SUPERVISION OF FRONT AND BACK DOORS FROM 6:15 A.M. UNTIL 11:30 P.M. THE FRONT AND BACK DOORS WILL BE ALARMED FROM 11:30 P.M. UNTIL 6:15 A.M. THIS WILL BE IN PLACE UNTIL OTHER SATISFACTORY ARRANGEMENTS HAVE BEEN MADE. 2. CONSULT WITH A LOCAL ALARM COMPANY ON 8/9/11 TO DISCUSS DOOR ALARMS THAT ARE CODE CONTROLLED AND WILL BE IN USE 24 HOURS PER DAY. THE SURVEYOR CONFIRMED BY OBSERVING FACILITY SUPERVISION OF THE FRONT AND BACK DOORS BETWEEN 6:15 A.M. AND 11:30 P.M. AND, DURING A TELEPHONE INTERVIEW WITH RN "B" ON 8/9/11 AT 5:30 A.M., COULD OVERHEAR A DOOR ALARMING WHEN DAY SHIFT STAFF ENTERED. VERIFICATION WAS MADE THAT ALL EXIT DOORS WITH ALARMS SOUNDED WHEN TRIGGERED BY A WANDERGUARD BRACELET AND OBSERVATION WAS MADE OF FACILITY STAFF'S RESPONSE TO THE ALARM SYSTEM WHEN THREE RANDOM DOORS WERE OPENED. ALTHOUGH THE IMMEDIATE JEOPARDY WAS ABATED, THE FACILITY'S DEFICIENT PRACTICE WAS NOT CORRECTED, AND CONTINUES AT A PATTERN LEVEL WITH THE POTENTIAL FOR MORE THAN MINIMAL HARM PENDING THE FACILITY'S ABILITY TO: 1. DEMONSTRATE THEIR ABILITY TO PROVIDE ADEQUATE SUPERVISION TO MEET THE SPECIAL NEEDS OF THE RESIDENTS WHO ARE AT RISK FOR WANDERING AND ELOPEMENT. 2. VERIFICATION BY THE STATE AGENCY. FINDINGS INCLUDE: DURING THE SURVEY FROM 8/8/11-8/9/11, RESIDENT #1'S MEDICAL FILE WAS REVIEWED. HIS FACE SHEET REVEALED THAT HE IS AN [AGE] year-old MAN, admitted to the facility on [DATE], WITH [DIAGNOSES REDACTED]. HIS physician's orders [REDACTED]. A REVIEW OF RESIDENT #1'S MOST RECENT MINIMUM DATA SET (MDS), dated [DATE], REVEALED THAT HIS COGNITIVE SCORE ON THE BRIEF INTERVIEW FOR MENTAL STATUS (BIMS) WAS 10 OUT OF A POSSIBLE SCORE OF 15. IT FURTHER INDICATED THAT HE HAD NOT EXHIBITED WANDERING BEHAVIOR. HE WAS ABLE TO TRANSFER AND WALK IN HIS ROOM INDEPENDENTLY WITH SETUP HELP ONLY, BUT REQUIRED SUPERVISION AND SETUP HELP TO WALK IN THE CORRIDOR AS WELL AS REQUIRING ONE PERSON PHYSICAL ASSIST TO MOVE BETWEEN HIS ROOM AND ADJACENT CORRIDOR. HIS BALANCE WHILE WALKING, TURNING AROUND WHILE WALKING, AND TRANSFERRING SURFACE-TO-SURFACE (BETWEEN BED AND CHAIR) WERE ALL CODED "1" MEANING NOT STEADY, BUT ABLE TO STABILIZE WITHOUT HUMAN ASSISTANCE. A WALKER WAS CHECKED AS A MOBILITY DEVICE NORMALLY USED BY RESIDENT #1. A REVIEW OF RESIDENT #1'S CARE PLAN FOR IMPAIRED MOBILITY RELATED TO WEAKNESS, POOR BALANCE, MOOD AND BEHAVIOR INSTABILITY, AND HISTORY OF FALLS (INITIATED 2/8/11 AND MOST RECENTLY REVIEWED/UPDATED ON 8/1/11) CONFIRMED THAT HE "MAY BE UP AD-LIB WITH WALKER, SOMETIMES FORGETS WALKER, GIVE CUES/REMINDERS AS NEEDED TO USE WALKER AND KEEP WALKER WITH HIS REACH." A REVIEW OF RESIDENT #1'S MOST RECENT SOCIAL SERVICE PROGRESS NOTE` DATED 7/26/11, REVEALED "HE HAS SHORT TERM MEMORY DEFICITS, IS MODERATELY IMPAIRED FOR DECISION MAKING SKILLS." A REVIEW OF HIS MEDICAL FILE, INCLUDING NURSE PROGRESS NOTES, SHOWED NO EVIDENCE OF BEHAVIORS SUCH AS ELOPEMENT ATTEMPTS OR EXIT-SEEKING BEFORE THE 8/4/11 INCIDENT. DURING AN INTERVIEW WITH THE DIRECTOR OF NURSING (DON) ON 8/8/11 AT 12:00 NOON, SHE SUMMARIZED THE FINDINGS OF THE FACILITY INVESTIGATION AS FOLLOWS: "THE MIDNIGHT SHIFT NURSE (RN "B") CAME IN AT 10:30 P.M. AND GOT A REPORT FROM THE PREVIOUS SHIFT UNTIL ABOUT 11:00 P.M. THE CNAS (CERTIFIED NURSE AIDES) STARTED THEIR ROUNDS RIGHT AWAY AT 10:30 P.M. THEY SAW (RESIDENT #1) IN HIS BED SLEEPING AT 10:40 P.M. AT 11:35 P.M., ONE OF THE AIDES SAW HIM SITTING ON HIS WALKER OUTSIDE HIS ROOM. IT'S NOT UNUSUAL FOR (RESIDENT #1) TO BE UP AT NIGHT. AT 11:55 P.M., THE NURSE AND BOTH AIDES SAW HIM PASSING BY THE NURSES STATION. HE FREQUENTLY HANGS OUT IN THE DINING ROOM. BETWEEN 12:10 A.M. AND 12:45 A.M., THE TWO AIDES TOOK THEIR BREAKS, ONE AT A TIME. AT 12:45 A.M., (RN "B") STARTED MAKING HER ROUNDS. WHEN SHE GOT TO (RESIDENT #1'S) ROOM, HE WAS NOT IN HIS BED. SHE CHECKED THE DINING ROOM AND THE LOBBY AND COULDN'T FIND HIM. SHE THEN TOLD BOTH CNAS TO START A HEAD COUNT AND TO ALERT THE OTHER TWO WINGS TO START A HEAD COUNT. (RN "B") THEN WENT OUT THE FRONT DOOR TO LOOK FOR HIM AND SAW POLICE CARS WITH THEIR LIGHTS FLASHING ON THE ROAD JUST PAST OUR DRIVEWAY. SHE FLAGGED THEM DOWN AND FOUND THAT (RESIDENT #1) WAS IN THE POLICE CAR. (RESIDENT #1) TOLD US THAT HE WENT OUT THE BACK DOOR AND THAT IS WHERE HIS WALKER WAS FOUND." THE DON CONTINUED, "HE HAS A WANDERGUARD ON NOW. THERE WAS NO INDICATION FOR IT BEFORE." THE ADMINISTRATOR WAS ALSO PRESENT AT THIS INTERVIEW ON 8/8/11 AT 12:00 NOON AND STATED, "THERE WAS NO HINT THAT HE MIGHT ELOPE. ALL OF THE DOORS ARE ALARMED AT NIGHT EXCEPT THE FRONT DOOR AND THE BACK DOOR. STAFF USE THEM TO COME AND LEAVE AND FOR BREAKS." AT 12:35 P.M. ON 8/8/11, A TOUR AND RE-ENACTMENT OF THE INCIDENT WAS HELD WITH THE SURVEYOR, THE ADMINISTRATOR AND THE DON, STARTING AT RESIDENT #1'S ROOM (ROOM 119-BED A) ON THE NORTH WING. RESIDENT #1'S ASSUMED ROUTE WAS TRACED FROM HIS ROOM, PAST THE NURSES STATION WHERE HE WAS LAST SEEN, THROUGH THE DINING ROOM AND THEN THE LOBBY, DOWN A SHORT HALL TO THE TIME CLOCK AND BACK DOOR, WHERE RESIDENT #1'S WALKER HAD BEEN FOUND. THE TOUR CONTINUED OUTSIDE TO AN EMPLOYEE PARKING LOT, AROUND THE WEST SIDE OF THE BUILDING (CENTER AND SOUTH WINGS), DOWN THE FACILITY DRIVEWAY TO A SIDEWALK ALONGSIDE HIGHWAY 131 (SPRING STREET) UNTIL IT INTERSECTS WITH ANDERSON STREET. THIS INTERSECTION WAS WHERE THE POLICE CARS WERE SEEN BEFORE THEY ENTERED THE FACILITY DRIVEWAY WITH RESIDENT #1 IN THEIR CAR. A GARDEN WAS OBSERVED AT THE INTERSECTION JUST TO THE NORTH OF ANDERSON STREET. WHEN ASKED IF RESIDENT #1 HAD CROSSED ANDERSON STREET, THE ADMINISTRATOR STATED, "WE DON'T THINK SO. WE FIGURED HE STOPPED HERE AT THE FLOWER BED BECAUSE THEY HAVE AUTOMATIC SPRINKLERS TURNED ON AT NIGHT; HE WOULD NOT HAVE LIKED GETTING WET." THE DISTANCE FROM THE BACK DOOR OF THE FACILITY TO THE INTERSECTION OF HIGHWAY 131 AND ANDERSON STREET WAS ESTIMATED TO BE ABOUT ONE-HALF OF A BLOCK AND TOOK LESS THAN TWO MINUTES TO WALK. THE GEOGRAPHY OF THE RETURN ROUTE BELIEVED TO HAVE BEEN AMBULATED BY RESIDENT #1 WITHOUT HIS WALKER INCLUDED A DOWNGRADE HILL. DURING AN INTERVIEW WITH THE DON ON 8/8/11 AT 3:05 P.M., SHE WAS ASKED FOR RESIDENT #1'S ASSESSMENT FOR HIS ELOPEMENT RISK. THE DON STATED, "WE DON'T ASSESS EVERYBODY THAT COMES INTO THE FACILITY, JUST IF WE FEEL THAT THERE'S A NEED FOR IT FOR SOME REASON--IF WE HAVE SOME INDICATION THAT THEY MIGHT TRY TO ELOPE. NO, WE DON'T HAVE ONE FOR HIM." AT 3:35 P.M., IT WAS VERIFIED BY THE DON THAT THE FRONT AND BACK DOORS ARE NEVER LOCKED AND DO NOT ALARM UPON OPENING, UNLESS, SHE STATED, "...A RESIDENT WEARING A WANDERGUARD GETS NEAR THEM." RESIDENT #1 WAS INTERVIEWED ON 8/8/11 AT 4:10 P.M. HE REMEMBERED THE NIGHT OF THE INCIDENT AND WAS WILLING TO TALK ABOUT IT. HE STATED, "MY MIND GOT KIND OF MUDDLED. NO, I DIDN'T CROSS THE STREET. I GOT TO THE SPRINKLERS AND I THOUGHT, 'I DON'T WANT TO GO THERE.' I TURNED AROUND TO GO BACK. IT WAS DOWNHILL AND I THOUGHT I MIGHT FALL. THAT'S WHEN THE POLICE CAME. I HAD A JACKET ON AND PANTS LIKE THESE (JEANS). MY SHOES WEREN'T FASTENED; I THOUGHT I MIGHT TRIP. NOW I HAVE TO WEAR THIS (WANDERGUARD OBSERVED ON LEFT WRIST)." REGISTERED NURSE (RN) "B" WAS INTERVIEWED BY TELEPHONE ON 8/9/11 FROM APPROXIMATELY 5:05 A.M. UNTIL 5:30 A.M. IN RELATING THE EVENTS OF 8/4/11, SHE STATED, "HE (RESIDENT #1) WAS FULLY DRESSED; HE OFTEN SLEEPS IN HIS CLOTHES. HE'S IN HIS BED WITH HIS SHOES ON RIGHT NOW. PRIOR TO 11:00 P.M. THAT NIGHT, HE CAME PAST THE NURSES DESK. HIS FAVORITE PLACE TO SIT IS IN THE FOYER (LOBBY) OR THE DINING ROOM. I HAD PASSED MEDS AND DID A MIDNIGHT NEURO CHECK; THEN I STARTED MY BED-CHECKS. I HAD TO GO AROUND (RESIDENT #1'S) BED TO CHECK HIS ROOMMATE. HE (RESIDENT #1) WASN'T ANYWHERE. I WENT THROUGH THE DINING ROOM AND FOYER. I PUT THE LIGHTS ON AND STILL DIDN'T SEE HIM. I GOT CONCERNED BECAUSE THE LAST TIME I SAW HIM WAS 11:00 P.M. I TOLD THE CNAS TO START A HEAD COUNT AND TO ALERT THE OTHER TWO WINGS TO START A HEAD COUNT. I WENT OUT THE FRONT DOOR TO LOOK FOR HIM. I SAW POLICE CARS ON THE HIGHWAY WITH THEIR LIGHTS FLASHING. THE POLICE OFFICER DID A (TURN-AROUND) AND PULLED INTO OUR DRIVEWAY. THEY FOUND HIM AT ANDERSON STREET. HIS WALKER WAS LATER FOUND BY THE TIME CLOCK. I WAS JUST SO GLAD HE WAS OKAY." DURING THIS TELEPHONE INTERVIEW, ON 8/9/11 AT APPROXIMATELY 5:30 A.M., AN ALARM WAS HEARD OVER THE PHONE. RN "B" STATED, "DID YOU HEAR THAT? THAT'S THE DOOR ALARM; DAY SHIFT MUST BE COMING IN," OFFERING EVIDENCE THAT THE REMOVAL PLAN HAD BEEN PUT IN PLACE. A REVIEW OF RESIDENT #1'S NURSING NOTES FROM 8/4/11-8/8/11 SHOWED THAT HE DID NOT SUFFER ANY INJURY DURING THIS INCIDENT. A WANDERGUARD WAS PLACED ON HIS LEFT WRIST ON 8/4/11. HIS CARE PLAN FOR ALTERATION IN BEHAVIOR/ MOOD/PSYCHOSOCIAL WELL-BEING, INITIATED 2/16/11, WAS UPDATED ON 8/5/11 TO INCLUDE THE INTERVENTION "WANDERGUARD PLACED ON LEFT WRIST AND MONITORED FOR PLACEMENT AT THE BEGINNING AND END OF EACH SHIFT. REPORT ABSENCE OF DEVICE TO CHARGE NURSE PROMPTLY." ( )