Every finding on record at Tuscola County Medical Care Facility

Based on observation, interview, and record review, the facility failed to maintain best practices in the food service area, resulting in the potential to spread food borne illness to all residents who consume food from the kitchen. Findings Include:On 12/9/25 at 10:15 AM, an initial tour of the kitchen was conducted with Dietary Manager (DM) C. The following observations were made: -A drain from the walk-in freezer drained into a hole in the floor. The tube was lower than the floor. -A drain that the DM reported she thought it was for the ice machine, was observed going into a cut out from the floor drain area and did not have an air gap. The drainpipe was below the level of the floor. There was another plastic tubing in the cut-out floor drainage area that was wrapped around the inside of the drain box in the floor. The tubing was below the level of the floor and debris was noted where the piping lay. -Osmosis system had a black tube inside slotted box drain in the floor. The black tube was below the level of the floor. -Nosey cups were stored in a plastic container with the lid secured. Multiple nosey cups were stored wet inside. The DM took them out to be cleaned. When queried regarding storage, the DM reported that the items should be air dried prior to storage or stacked. On 12/11/2025 at approximately 8:30am-9:00am during the kitchen tour with the Director of Food and Nutrition Services C, observed the ice machine drain line sitting directly inside the drain located in the kitchen. On 12/11/2025 at approximately 8:30am-9:00am observed built up residue on the meat slicer located in the kitchen. When interviewed on how often the meat slicer is cleaned, the Director of Food and Nutrition Services C stated it's cleaned after every use. On 12/11/2025 at 11:00am-Noon during lunch service with the Director of Food and Nutrition Services C, this surveyor temped chicken nuggets on the steam table with a Thermapen and the temperature was 106 degrees Fahrenheit. On 12/11/2025 at 11:00am-Noon when interviewed on what temperature the chicken nuggets should be during hot holding, the Director of Food and Nutrition Services C answered 135 degrees Fahrenheit or above. On 12/12/2025 at 9:00-9:40am during the kitchen tour of the Cortland House with the Director of Food and Nutrition Services C, observed ice machine drain line sitting inside the drain. According to the 2022 Food Code, 5-202.13 Backflow Prevention, Air Gap, An air gap between the water supply inlet and the flood level rim of the plumbing fixture, equipment, or nonfood equipment shall be at least twice the diameter of the water supply inlet and may not be less than 25 mm (1 inch). According to the 2022 Food Code, 4-601.11 Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils, Equipment food-contact surfaces and utensils shall be clean to sight and touch, the food-contact surfaces of cooking equipment and pans shall be kept free of encrusted grease deposits and other soil accumulations, nonfood-contact surfaces of equipment shall be kept free of an accumulation of dust, dirt, food residue, and other debris. According to the 2022 Food Code, 3-501.16 Time/Temperature Control for Safety Food, Hot and Cold Holding, Except during preparation, cooking, or cooling, or when time is used as the public health control, time/temperature control for safety food shall be maintained: At 57 degrees C (135 degrees F) or above. According to the facility's policy on hot holding, Compliance with Hazardous Analysis Critical Control Points (HAACP) guidelines will ensure that food will be kept out of the danger zone (between 41-135) during preparation and service.

Based on observation and interview, the facility failed to ensure appropriate backflow prevention was installed at plumbing fixtures, resulting in the potential for contamination of the water supply, affecting all residents. Findings include: On 12/11/2025 at approximately 12:41pm-1:24pm during the environmental tour with the Life Safety Officer B, observed a hose attached to a spigot without a backflow preventer at the cold water line located in the boiler room. On 12/11/2025 at approximately 12:41pm-1:24pm observed the water softener drain line sitting directly inside a drain. On 12/11/2025 at approximately 12:41pm-1:24pm observed a utility sink with a chemical feed downstream of an atmospheric vacuum breaker located in the housekeeping closets in Rooms 278, 206, 136, and 178. On 12/12/2025 at 9:00-9:40am observed a utility sink with an attached chemical dispenser downstream of an atmospheric vacuum breaker located in the janitor's closet in Cortland House. On 12/12/2025 at 9:00-9:40am observed a utility sink with an attached hose and a chemical dispenser downstream of an atmospheric vacuum breaker in the janitor's closet located in [NAME] House. According to 2018 Michigan Plumbing Code, 608.16.4.2 Hose Connections, Sillcocks, hose bibs, wall hydrants, and other openings with a hose connection shall be protected by an atmospheric-type or pressure vacuum breaker or a permanently attached hose connection vacuum breaker.According to the 2008 Cross Connection Manual on atmospheric vacuum breakers, AVBs shall not be installed where they will be under continuous pressure for more than 12 hours (i.e. no downstream shutoff valve).According to the 2008 Cross Connection Manual on chemical feeder backflow prevention, Another concern with a hose being run from a faucet to the dispenser is that many times a valve is installed on the hose downstream of an AVB, which is not allowed since AVBs cannot be subject to continuous pressure.According to the 2008 Cross Connections Manual on water softeners, Typical water softener installations may pose a public health threat mainly due to the waste discharge piping being terminated in a floor drain or sewage piping system thereby creating a submerged inlet cross connection.

Based on observation, interview and record review, the facility failed to ensure that residents' rights were being met by 1) Ensuring that call lights were within reach or easily accessible to residents and/or 2) Ensuring that call lights were responded to in a timely manner for four residents (R11, R74, R78 and R121) of four residents sampled for accommodation of needs and also a Confidential Group of Residents. Findings include:Resident #11 (R11): On 12/11/25 at 12:32 PM, an observation was made of Resident 11 sitting up in his wheelchair, propelling himself in his room. An observation was made of the Resident's call light positioned on the floor underneath the bed. The call light hung from the wall and the bed was positioned up against the wall. The call light was lying on the floor between the wall and the bed. The call light was not within reach for R11. The Resident was asked for help. A staff member was alerted to the Resident needing assistance from staff found in the hallway and was informed of the call light not in reach for the Resident. A review of R11's medical record revealed an admission into the facility on [DATE] and readmission on [DATE] with diagnoses that included heart disease, schizophrenia, anxiety disorder, dementia, bilateral hip and knee contractures and cerebral palsy. A review of the Minimum Data Set assessment revealed a Brief Interview for Mental Status score of 6/15 that indicated severely impaired cognition, and the resident was dependent on a helper for toileting hygiene, bathing, lower body dressing, and transfers. Resident #78 (R78): On 12/9/25 at 11:51 PM, an interview was conducted with Resident #78 (R78) who was dressed, lying in bed with her feet elevated up. The Resident answered simple questions and engaged in limited conversation. The Resident had asked to get up out of bed. The Resident was asked if she had used the call light. The Resident indicated she had a metal bell to ring by pointing to a call bell on the overbed table. An observation was made of no cord connected to the wall where the call light would be. The Resident was asked why she had the bell and not a call light. The Resident was unsure and reported the metal bell on her overbed table was what she used to call for help. The Resident reported she had already pushed the bell, but no one had come. The Resident was asked about how long ago she had used the call bell, but the Resident was unsure and indicated it had been a while and stated, No one came yet. At 11:53 AM, the Resident rang the call bell again and stated, It can take a while, or not at all indicating staff response time to the call bell. The Resident was asked how long she had to wait, and the Resident reported a long time sometimes, did not give a length of time but indicated yes when asked if she had to wait more than a half an hour and yes to more than an hour. An observation was made of no staff response to the call bell. The Resident reached over to the call bell and gave a rapid fire of the call light at 12:08 PM. The Resident reported she could not get up on her own and could not use her right side. An observation was made of no staff in the hallway. An observation was made at 12:15 PM of staff assisting R78's roommate into the room. At 12:33 PM, R78 was assisted out of bed and into the wheelchair. A review of Resident #78's medical record revealed an admission into the facility on 2/22/2020 with diagnoses that included stroke, vascular dementia, anxiety disorder, and contracture of right wrist. A review of the Minimum Data Set (MDS) assessment revealed a Brief Interview for Mental Status (BIMS) score of 5/15 that indicated severely impaired cognition, and the Resident was dependent on a helper for transfers. On 12/11/25 at 10:49 AM, an interview was conducted with Unit Manager (UM), Nurse A regarding R78's call bell. The observation of R78 using the call bell on 12/9/25 was reviewed with the UM. When asked if the Resident could use the call bell, the UM reported that the Resident was able to call for assistance with the call bell. When asked how the staff hear the call bell, the UM stated indicated staff would have to be in the area to hear it and stated, That's an issue with the bells. The UM manager reported she was unsure why the resident had a call bell instead of a call light. The Restorative Therapy Nurse (RTN) L reported she did not know why the Resident was changed either. The Resident's medical record was reviewed, and it was reported that the care plan was last updated in 2022 when the call bell was started. When asked if the call light versus call bell use was reassessed since 2022, the RTN stated, It depends on why it was taken away. The UM reported that if someone had a concern, then we would review it as a team and get everyone's opinion on it. When asked if a reassessment had been done since 2022, the UM stated, Not that I know of. The UM reviewed the medical record and reported that on 8/15/22 the Resident had threatened suicide and was having suicidal thoughts. The UM indicated the Resident no longer had concerns like that and no threats. It was reviewed with the UM and the RTN of the concern that it was approximately a half an hour or longer depending on when the Resident had first rung the call bell and no one was in the area to hear it with needs not met timely and lack of reassessment for call light use. Resident #121 (R121): On 12/9/25 at 3:07 PM, an interview was conducted with Resident 121 (R121) of the care received by the facility and any concerns they might have. The Resident reported that sometimes she must wait for call light response from staff and reported she has had her call light on for a long time. The Resident stated, I have to use a Hoyer lift to get me up. When I have to go to the bathroom, they just tell me to go in my diaper then they will clean it up. Sometimes it takes them a long time to get me cleaned up, so I am sitting in it for a long time. When asked if she used the call light to let them know, the Resident reported that she does use the call light and stated, sometimes fast to answer and sometimes not, and reported waits of thirty minutes or more as yes, many times. I have had messes in my pants waiting for them to get to me. The Resident was asked if they answer do they meet your needs at that time. The Resident reported at times they answer the call light, turn it off and they say they will be back, but they don't come back very soon. The Resident stated, It's hard to be in this position and then have to wait like that to get help, they don't know how it is on this side of things. A review of R121's medical record revealed an admission into the facility on [DATE] and readmission on [DATE] with diagnoses that included history of falling, anxiety disorder, depression, obesity, urinary incontinence, and knee, shoulder and bilateral hip joint replacement. A review of R121's MDS revealed a BIMS score of 15/15 that indicated intact cognition and needed substantial/maximal assistance with chair/bed-to-chair transfer and dependent on helper with toilet transfer. Confidential Group of Residents On 12/10/25 at 10:32 AM, a Confidential Group of Residents were interviewed. The group consisted of 18 Residents. The majority of Residents were able to answer questions and engaged in a group conversation. The Residents were asked about issues they had with the care received at the facility. The majority of Residents reported concerns with call lights not answered timely with wait times that would exceed 30 minutes or longer. The Residents reported that 30 minutes or more was too long to wait for staff to answer the call light. Eight of the Residents reported that the 3rd shift had more issues with getting the light answered and reported call light response time that would exceed 30 minutes. The Residents reported that staff would come in, turn the call light off and tell the Resident that they will be back then don't show up. Six of the Residents reported concerns with this issue. One Resident reported they had complained in Resident council but It was still happening. Four Residents reported issues with call light response times during mealtimes and unable to get to the bathroom timely and incontinence due to call light not responded to timely. A review of the facility document titled, Resident Rights, date reviewed 1/22/2025, revealed, .The Resident has a right to a dignified existence, self-determination and communication with and access to persons and services inside and outside the facility . 39. The resident has the right to be treated in a manner and in an environment that maintains of enhances each resident's dignity and respect in full recognition of his or her individuality . Resident #74: On 12/09/2025, at 10:30AM, Resident #74 complained that they often wait at least 30 minutes for staff to answer their call light. Resident #74 complained that staff use the excuse that they were busy with someone else or that they were short staffed. Resident #74 was asked how that made them feel and Resident #74 stated, makes me wonder if I'm going to get the help. On 12/10/2025, at 2:00 PM, a record review of Resident #74's electronic medical record revealed an admission on [DATE] with diagnoses that included Hypertension, Cerebral Palsy and Diabetes. and their most recent Brief Interview for Mental Status (BIMS) score revealed intact cognition.

Based on observation, interview and record review, the facility failed to ensure that food was palatable and maintained at a palatable temperature for one resident (Resident #68) of three residents reviewed for food palatability and a group of confidential residents. Findings include: Cold food complaints with a Confidential Group of Residents On 12/10/25 at 10:32 AM, a Confidential Group of Residents were interviewed. The group consisted of 18 Residents. The majority of Residents were able to answer questions and engaged in a group conversation. The Residents were asked about issues they had with the care received at the facility. The Confidential Group of Residents reported concerns with food being too cold to eat. Six of the Residents reported that food was not warm enough sometimes when they received the food in their room and other residents reported that sometimes the food that should be warmer was cold in the dining room as well. One resident reported getting eggs that were not at a good temperature to eat them. Other Residents reported issues with the eggs as well and discussed other food items that arrived too cold to enjoy eating them. Many of the Residents talked about the serving of vegetables received cold. The group reported having a meeting with a food committee once a month and expressed that issues with cold food had been brought up. One Resident stated, I can't understand why it can't be warmer. The consensus of the group reported that food does come warm but not consistently all the time. When asked about cold items being cold enough, Residents reported that the milk can be warm and three reported milk that smelled spoiled even when the date on the carton reflected that it should still be good. The Residents reported that the milk was an issue when served in the little carton containers. No residents had issues when the milk was served in a glass. One Resident reported issues with the ice cream and stated, If you are lucky, it's a little bit frozen, with three other Residents agreeing with the issue of the ice cream. Resident #68: On 12/09/2025, at 10:00 AM, Resident #68 was sitting in their room and complained their dinner of chicken nuggets the prior evening was colder than cold. Resident #68 further offered, they told me to go to the dining room for my meals because the food would be hotter. Resident #68 offered that even though they did go to the dining room the food temperatures were still cold. On 12/10/2025, at 12:30 PM, an observation of the second-floor dining meal service was conducted. The server was asked to prepare a sample tray and place it on the hall cart. There were four staff members sitting assisting residents with their meals. Certified Nursing Assistant (CNA) I was observed carrying trays from a cart in the kitchenette to the warming table across the dining room. Once the hot food was plated onto the tray, CNA I passed them. CNA I was walking in a fast motion. There was no other staff helping. CNA I was asked if they prepare the hall trays after the dining room trays were finished and CNA I offered, yes, and normally there is someone else helping but they were on break. A few moments later, another staff member entered the dining room and began assisting with trays and placed them on the medal hall cart. On 12/10/2025, at 12:45 PM, with the assistance of a staff member, a test tray was removed from the medal cart. The tray was taken down to the first-floor conference room from the second floor, which took approximately sixty-five seconds. The breaded chicken patty temperature revealed 121.8 degrees Fahrenheit. The egg roll temperature was 112.8 degrees Fahrenheit. The carton of milk temperature was 50 degrees Fahrenheit. On 12/10/2025, at 1:30 PM, a record review of Resident #68's electronic medical record revealed an admission [DATE] with diagnoses that included Hypertension, Heart failure and debility. A review of their most recent Brief Interview for Mental Status (BIMS) score revealed impaired cognition. A review of the facility provided policy Food and Nutrition Services Date Implemented: 11/23/2026 revealed . Residents have the right to make personal dietary choices regarding food and drink. Each resident receives and the facility provides: Food prepared by methods that conserve nutrient value, flavor, and appearance; food and drink that is palatable, attractive, and at a safe and appetizing temperature . An interview was conducted with Food and Nutrition Services Director C and Certified Dietary Manager (CDM) in training H on 12/12/25 at 10:40 AM. When queried regarding multiple resident complaints identified during the survey related to food temperatures, both Director C and CDM H verbalized they were not aware of any food temperature concerns. Director C and CDM H were informed of the temperature, both measured and palatability, of the food items on the test tray obtained. When queried what food temperatures are supposed to be for warm foods, Director C stated, Holding temp is 135 and the food should also be palatable to the resident. When queried regarding the milk on the obtained food tray not being cold and temperature being 50 degrees, an explanation was not provided.

Based on interview and record review the facility failed to ensure ongoing collaboration with hospice care for one resident (R56) of two residents sampled for hospice care, resulting in the absence of documentation of care provided by hospice. Findings include:Resident #56 (R56): R56 is [AGE] years old and admitted to the facility on [DATE] with diagnoses that include Alzheimer's disease, dementia, prediabetes and hypothyroidism. On 12/11/2025 at 3:00PM, record review of the Electronic Medical Record (EMR) revealed a physician's order for hospice care is present in the chart and dated 5/2/25. On 12/11/2025 at 3:05PM, record review of the EMR did not reveal any hospice documentation for R56. On 12/11/2025 at 3:13PM, Unit Manager (UM) A, provided the hospice binder for R56 that is stored at the nurse's station. On 12/11/2025 at 3:14PM, record review of the hospice binder was conducted. Record review revealed documents of Nurse and Certified Nursing Assistants (CNA) visits from 5/8/25 to 8/1/25. The documents contained the date, who provided the visit and what tasks were completed during the visit. There was no documentation of findings from assessments performed by the nurses during their visits. On 12/11/2025 at 3:16PM, UM A was asked if there is any additional hospice documentation available? UM A stated, The CNA documents when he/she comes to the facility for showers. Confirmed there was no documentation of CNA visits after 8/1/25. UM A was asked if the hospice nurses make notes from their visits? UM A stated, I have never seen them make notes, they come in to sign the care plans and that is it. On 12/11/2025 at 3:26PM, an interview was conducted with the Director of Nursing (DON). The DON was asked if the hospice nurses provide notes from their visits? The DON stated, yes, they do, they write them up and fax them over and we put them in the binder. The DON was informed that there is no nursing documentation in the hospice binder for R56. Review of the policy titled Hospice Care and Coordination of Care, revealed:2. Coordination of CareA. Hospice and TCMCC nursing staff will communicate changes in resident condition and needs.

Based on observation, interview and record review, the facility failed to implement and operationalize policies and procedures for pressure ulcer management for one resident (Resident #33) of five residents reviewed resulting in lack of comprehensive identification and assessment of wound etiology and lack of correct application of pressure reduction devices. Findings include:Resident #33:On 12/11/25 at 10:07 AM, Resident #33 was observed in their room lying in bed. The Resident was positioned flat on their back with bilateral Prevalon heel boots (soft, cushioned boot which floats the heels off of a mattress or surface for pressure reduction) in place. The boots were positioned incorrectly and Resident #33's heels were not in the open area designed for the heel in the boot. Resident #33's heels were positioned directly on the side of the boot. An interview was completed at this time. When queried if they were having any pain, Resident #33 replied in my feet. When asked to rate their pain on a scale of zero to 10, with 10 being the worst pain imaginable, Resident #33 stated, Three. When asked if they had any wounds, Resident #33 revealed they have a wound on their heel. Resident #33 was asked what the wound was caused from and indicated they did not know. An interview was conducted with Licensed Practical Nurse (LPN) J on 12/11/25 at 10:19 AM. When queried, LPN J verbalized they were Resident #33's assigned nurse. LPN J was asked if Resident #33 had a wound care treatment for their heel and indicated they did. When asked to observe the wound care treatment, LPN J stated, Wound Care (LPN K) changed the dressing today. LPN J was then asked if they had ever changed the dressing and/or seen the wound and replied, Yes. When queried regarding the wound, LPN J stated, Right over heel and like a dark bruise. When queried what they meant when they said the wound was right over Resident #33's heel, LPN J proceeded to show the location individual's foot. The wound location specified by LPN J was directly over the bony prominence of the heel. LPN J was asked when they last saw the wound and replied, Last week I think. Record review revealed Resident #33 was originally admitted to the facility on [DATE] with diagnoses which included heart failure, pacemaker, diabetes mellitus, and depression. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the Resident was cognitively intact and required substantial to total assistance for toileting, bathing, hygiene, dressing, and transferring. The MDS further detailed the Resident was at risk for pressure ulcer development and had no pressure ulcers, venous ulcers (wound caused by poor blood flow), arterial ulcers (wounds caused by poor oxygenated blood flow), and/or any other wounds. Review of Resident #33's care plans in the Electronic Medical Record (EMR) revealed a care plan entitled, (Resident #33) has potential for pressure injury development R/T (related to) decreased mobility, DM. (Initiated: 7/31/24; Revised: 11/18/24). The care plan included the following active and resolved interventions: - Resolved: Float heels in bed and r/c (chair) (Initiated: 2/24/25; Revised and Resolved: 12/2/25)- Blanket Cradle (Device to keep blankets off feet in bed) (Initiated: 11/18/25)- Side to side repositioning in bed (Initiated: 2/24/25; Revised: 4/24/25)- Prevalon boots while in bed & r/c (Initiated and Revised: 12/2/25) A second care plan entitled, The resident has diabetic/arterial ulcer of the right heel r/t Diabetes, Lack of sensation to affected area, Renal Disease, Vascular insufficiency (Initiated and Revised: 12/10/25). The care plan included the interventions:- Determine and treat cause: poor fitting shoes, poor blood sugar control, pressure area, infection (Initiated: 12/10/25)- Ensure appropriate protective devices are applied to affected areas (Initiated: 12/10/25)- Monitor pressure areas for color, sensation, temperature (Initiated: 12/10/25)- Avoid mechanical trauma: Constrictive shoes, Cutting and trimming corns and calluses, Adhesive tapes. (Initiated: 12/10/25) Review of Resident #33's paper medical record revealed two paper forms related to identification of the etiology of the right heel wound. The first form was titled, Arterial Ulcer and the second form was titled, Diabetic Wound. Both forms were signed by Physician G on 11/25/25 and indicated the etiology of Resident #33's right heel wound was mixed but did not detail what the mixed etiology was. Review of Diagnostic Imaging and Laboratory results in Resident #33's paper medical record revealed the Resident had an arterial doppler on 11/18/25 which specified, Bilat Dup (duplex) lower extremity Arterial (ultrasound) . Conclusion: Mild Peripheral Vascular Disease.Review of documentation in Resident #33's EMR revealed the following: - 11/13/25 at 6:57 PM: Health Status Note. LATE ENTRY. Writer noted a purple hued area noted to right heel while applying ace wraps in AM as ordered. - 11/13/25 at 1:29 PM: Skin/Wound Note. referred from nursing. has 2.5 x 2.5cm grey/purple discoloration noted to right heel, area firm to touch, no redness noted surrounding site, no open areas, right foot +3 edema, ace wraps present, foot warm to touch, cap refill wnl (Within Normal Limits) res denies pain to site, diabetic shoes in place, callus (thickened, hardened patch of skin that forms as a protective response to repeated friction, pressure, or irritation) noted during weekly assessment to right heel on 9/18/25, resident to float heels in bed. chronic cellulitis. has diabetes with current A1C (Hemoglobin[hbg] A1c- laboratory blood test which measures average blood glucose level for previous two to three months) of 6.6 (8/18/25). being referred to podiatry for further eval at this time. Note: Hbg A1c level of greater than 7% to greater than 8% indicates uncontrolled hyperglycemia in individuals with diabetes and a hbg A1c level of less than 7% is important for the prevention of diabetic ulcers ([NAME], et al., 2020 and [NAME], et al., 2019) - 11/17/25 at 2:50 PM: Skin/Wound Note. continues with 2.5 x 2.5cm purple/grey discoloration to right heel. also has 3 yellow/translucent circular firm areas on heel at this time next to purple discoloration. has pink blanchable area to tip of right 2nd toe with 2 yellow translucent spots noted. dressing changed as ordered, blanket cradle added. - 11/18/25 at 8:01 AM: Physician Acute Care Note. Chief complaints. heel skin changes. The patient has developed concerning lesions on right lower extremity, including a 2.5 x 2.5 centimeter grayish-purple discoloration of the right heel with slight purplish discoloration. Additionally. has a pink blanchable area at the tip of the right second toe with yellow translucent spots. Skin: 2.5 x 2.5 cm grayish-purple discoloration of the right heel with slight purplish discoloration. Pink blanchable area at the tip of the right 2nd toe with yellow translucent spots . Blood glucose was elevated at 191 - 11/20/25 at 1:28 PM: Plan of Care Note. Quarterly care plan summary. Nursing also stated that noted a purple hue on right heel, right and left callous (thickened, hardened skin from repeated pressure or friction) . Care plans reviewed. Problems, goals, and approaches reviewed, and updated in care plan. Current skin/pressure interventions for pressure ulcer prevention reviewed - 11/25/25 at 7:07 AM: Physician Acute Care Note. Chief complaints: Clinical assessment, medications review, heel ulcer and arterial doppler review. Present Illness. Recently found heel ulcer. Skin: 2.5 x 2.5 cm grayish-purple discoloration of the right heel with slight purplish discoloration. Pink blanchable area at the tip of the right 2nd toe with yellow translucent spots. - 12/4/25 at 11:27 AM: Wound Care Weekly Assessment. Right heel. Acquired. Type. diabetic/arterial. Wound Bed. skin intact, yellow discoloration with brown discoloration around edges. Length (cm- centimeters): 2.6. Width (cm): 4. Surrounding skin tissue appearance: a. Normal. b. Edematous. No redness surrounding site. Wound Progress: colored has changed from grey/purple discoloration to light yellow/tan color, no open areas noted, skin remains intact. - 12/8/25 at 2:09 PM: Wound Care Weekly Assessment. Right heel. admitted . Type. diabetic/arterial. Wound Bed. Cream colored discoloration to skin with dark brown edges. Length (cm): 2.3. Width (cm): 3.9. Surrounding Skin: Normal. Review of blood glucose monitoring documentation in Resident #33's EMR revealed no blood glucose levels were recorded on the Resident's Medication Administration Record (MAR) for November and December 2025 revealed no documentation of blood glucose level monitoring. A review of blood glucose levels documented in the vital sign documentation section of the EMR, revealed the last time Resident #33's glucose level was checked on 11/8/25. Prior to that, Resident #33's blood glucose levels were checked three to four times a day from 12/27/24 until 9/4/25.Further review of Resident #33's EMR revealed a care plan entitled, (Resident #33) has Diabetes Mellitus (Initiated: 8/14/24; Revised: 11/18/24). The care plan included the intervention, Monitor blood glucose as ordered, document and report abnormals to the physician (Initiated: 8/14/24). A review of Resident #33's Health Care Provider (HCP) orders in the EMR revealed the Resident did not have an order for blood glucose monitoring. On 12/11/25 at 2:26 PM, Resident #33 was observed in their room in bed. The Resident was positioned flat on the back with their eyes closed. Prevalon heel boots were in place on both of the Resident's feet. The boots were positioned incorrectly, and the Resident's heels were not floated in the open area of the boots. An interview was completed with Wound Care LPN K on 12/11/25 at 3:04 PM. LPN K was queried regarding the etiology of Resident #33's left heel wound and stated, Diabetic. When asked why the wound is classified as diabetic, LPN K stated, That was determined by the doctor. Resident #33's paper forms related to wound etiology were reviewed with LPN K at this time. When asked why both form specified the right heel wound was Mixed, LPN K replied, Because (Resident #33) had interventions in place for pressure prevention and could move their legs. LPN K was asked what mixed etiology meant and stated, More than one etiology to the wound. When queried what the etiologies were to Resident #33's wound, LPN K responded, Diabetes and arterial insufficiency. When queried why Resident #33's blood glucose levels were not being monitored, if part of the etiology of the wound was diabetes, LPN K did not provide an explanation. When queried if pressure was a potential etiology of the wound, LPN K indicated it was not as there were interventions in place for pressure prevention. LPN K was then asked if Resident #33 had seen a wound care physician/provider related to their wound and responded their Primary Care Provider (PCP), Physician G, oversaw the evaluation and treatment of the wound. When asked when the Prevalon heel boots were implemented, LPN K reviewed Resident #33's medical record and stated, 12/2/25. LPN K was then asked when the wound was first identified and stated, 11/13/25. When asked why the Prevalon boots were not implemented until 12/2/25 when the wound was identified on 11/13/25, LPN K stated, (Resident #33) had float heels in place. LPN K was asked if facility staff were educated regarding appropriate application of Prevalon boots and answered, Yes. When queried if the heel has to be positioned properly to provide pressure prevention and relief, LPN K responded they did. LPN K was informed of observations of the position of Resident #33's heels in the boots and was asked if they had a Prevalon boot to demonstrate the position of the Resident's feet in the boots. Restorative Manager Registered Nurse (RN) L obtained a Prevalon boot and joined the interview. Both LPN K and RN L were shown the position of Resident #33's heels/feet in the Prevalon boots and verbalized understanding. When queried if the Prevalon boots were providing pressure reduction when positioned incorrectly as demonstrated, both LPN K and RN L verbalized the boots do not provide pressure reduction when positioned incorrectly. When queried if they understood the concern related to pressure, both LPN K and RN L responded they did. When queried how they knew pressure was not the etiology and/or a contributing etiology to the Resident's right heel wound, LPN K did not provide an explanation. LPN K was then asked about the wound care treatment and dressing for the right heel wound and responded that the dressing is just foam. When queried what the wound bed felt like when palpated, LPN K revealed the wound bed was more firm than boggy. With further inquiry, LPN K stated, It started off more purple/gray and is now cream in the center with a purple/gray ring around the outside. An interview was completed with Physician G on 12/12/25 at 9:01 AM. When queried regarding the etiology of Resident #33's heel wound, Physician G responded that the wound etiology was arterial and diabetic and revealed they had ordered an arterial doppler study. Physician G was then asked why they classified the wound as arterial when the results of the doppler only showed mild PVD and stated, Does not appear to be arterial because of the arterial doppler. When queried regarding the wound etiology being documented as mixed when they just said it did not appear to be arterial, Physician G stated, Diabetic ulcer because (Resident #33 has) mild PVD, uncontrolled diabetes, and arterial flow worse in the left than the right. When asked if they were saying the doppler showed the blood blow in the left leg was worse than in the right leg when the wound was on the right heel, Physician G confirmed. When queried regarding if they had visualized and assessed Resident #33's right heel wound, Physician G replied, Once. I go off of what the wound nurse (LPN K) tells me. Physician G was then asked why they determined the wound was not caused by pressure considering the Resident was at risk for pressure ulcer development and stated, (Resident #33) has uncontrolled diabetes. When asked why Resident #33's blood glucose levels were not be monitored if they were concerned that the etiology of the heel wound was diabetic and their blood glucose levels were uncontrolled, Physician G replied, We are (monitoring blood glucose levels). Physician G was informed the most recent blood glucose level in Resident #33's EMR was on 11/8/25 and prior to that was on 9/4/25. When asked about the lack of blood glucose monitoring, Physician G revealed they thought facility staff were monitoring the Resident's blood glucose level and would check with the facility. When queried regarding Resident #33's Hbg A1c levels, Physician G stated, That can be deceptive. Physician G was then queried regarding Resident #33 being assessed as at risk for pressure ulcer development and Prevalon boots not being implemented until after the right heel wound developed but did not provide an explanation. Physican G was then informed of observations of Prevalon heel boots being positioned incorrectly and therefore not providing pressure relief and replied, I don't know about that. When asked if the right heel wound may have been caused by pressure, Physician G stated, That might be a possibility. On 12/12/25 at 11:37 AM, Resident #33 was observed laying in bed on their back with their eyes closed and mouth open. The Resident's brief was exposed and visible upon entering the room. An interview was completed with RN M on 12/12/25 at 11:55 AM. When queried if Resident #33's blood glucose levels were being routinely monitored, RN M reviewed the Resident's EMR and confirmed the Resident's blood glucose was not being monitored routinely and was last checked on 11/8/25. RN M was asked if Resident #33 moved their legs on their own and replied, Minimal. When queried if Resident #33 is able to reposition themselves in the bed, RN M stated, Not really. It is mainly us (staff) doing it. An interview was completed with the facility Administrator on 12/12/2025 1:43 PM. When queried regarding Resident #33's right heel wound including etiology and observations of Prevalon heel boots being positioned incorrectly, the Administrator did not provide further explanation. Review of facility provided policy/procedure entitled, Skin Care (Revised: 1/27/25) revealed, Pressure Injury or incidents involving skin. 1. Nursing staff will document their initial findings in EMR. Documenting using the clock method: In this method, the face of a clock is used as a measurement guide. The 12:00 reference position is towards the head of the body and 6:00 towards the feet, and measurements are thus obtained from 12:00 to 6:00 (length) and from 9:00 to 3:00 (width). Nursing or Wound Care Nurse will document on wound weekly in EMR. 2. Relieve pressure and/or causative measures to area when able 3. Evaluate pressure relief devices and interventions and initiate/change PRN (as needed). Citations:[NAME], M., Onar, L. C., [NAME], B., & Gumustas, S. A. (2019). Is high level of hemoglobin A1C an indicator for extended period of antibiotherapy in diabetic foot ulcers?. Northern clinics of Istanbul, 6(1), 21-27. https://doi.org/10.14744/nci.2018.25582Liu, L., [NAME], F., [NAME], E. J., [NAME], K., [NAME], S., [NAME], F., [NAME], P. Y., & [NAME], H. J. (2020). Burden of Uncontrolled Hyperglycemia and Its Association with Patients Characteristics and Socioeconomic Status in Philadelphia, USA. Health equity, 4(1), 525-532. https://doi.org/10.1089/heq.2020.0076

Based on interview and record review, the facility failed to ensure that daily posted nurse staffing data included delineation of licensed nursing staff and accurate documentation of actual hours worked, resulting in incomplete and inaccurate nurse staffing information. Findings include:On 12/10/25 at 2:49 PM, the facility posted nurse staffing hours were observed posted in the main hallway of the facility. The posted hours included a section for Licensed Nursing Staff but did not distinguish between the number and/or hours of Registered Nurses (RN) versus Licensed Practical Nurses (LPNs) who were working. An observation of the posted nurse staff information on 12/11/25 at 10:00 AM revealed the same form was used to post facility nurse staffing data and the number/hours of RNs and LPNs were not separate on the form. An interview was completed with the facility Administrator on 12/11/25 at 12:03 PM. When queried how an individual reviewing the posted nurse staff information knew if there was an RN in the building, the Administrator reviewed the facility posted staffing form and verbalized they could not because the posting does not distinguish between RN and LPN hours. When queried if they were familiar with the posted nurse staffing requirements, the Administrator responded they were not. F732 in the State Operations Manual (SOM) was reviewed with the Administrator at this time. After reviewing the SOM, the Administrator verbalized it was non-refutable that RN and LPN hours had to be separated on the form. The Administrator stated they were not aware it had to be like that and revealed they would change the form. When queried regarding the procedure for completion of the posted nurse staffing form, the Administrator responded that the form is completed at the beginning of each shift by the shift supervisor. When asked how the facility ensures the data accurately reflects nursing staff absences on the shift due to call-ins and/or leaving without working an entire shift, the Administrator verbalized the form did not provide accurate staffing information if a staff member left early and indicated they would ensure accurate information was posted and available to the public.

Based on observation, interview and record review, the facility 1) Failed to ensure analyzed observational data of personal cares with a continued spread of a Multi-Drug Resistant Organism (MDRO), 2) Failed to ensure proper Personal Protection Equipment (PPE) use, 3) Failed to ensure proper hand hygiene, 4) Failed to ensure proper wound care, 5) Failed to ensure proper perineal (peri) care for two residents (Resident #40, Resident $45) of two residents reviewed for peri-care and 6) Failed to prevent a wound infection for one resident (Resident #45) of three residents reviewed for wound care, resulting in the continued in-house spread of Proteus Mirabilis infections, staff not following enhanced barrier precautions and providing clean cares with the likelihood of the further spread of infections. Findings include: On 10/16/24, at 11:56 AM, a record review of the facility provided infection control line listing revealed the following case counts of In-House MDRO Urinary Tract Infections (UTI): 5/2024 Case List revealed 6 Urinary Tract Infections. 6/2024 Case List revealed 6 Urinary Tract Infections. 7/2024 Case List revealed 12 Urinary Tract Infections. 8/2024 Case List revealed 5 Urinary Tract Infections. 9/2024 Case List revealed 3 Urinary Tract Infections. 10/2024 Case List revealed 1 Urinary Tract Infections. \On 10/16/24, at 2:05 PM, a record review of provided Urinary Tract Infection Investigation documentation and culture results along with Infection Control (IC) Nurse O for five residents revealed the Urinary Tract Infections were caused by Proteus Mirabilis with Resident #46 having a Proteus Mirabilis urinary tract infection on 1/19/2024, 3/25/2024, 7/8/2024 and 8/15/2024. IC Nurse O was asked what the Urinary Tract Infection Investigation revealed and IC Nurse O offered, that they did research on Proteus Mirabilis and did staff education on preventing UTI's. IC Nurse O offered they did focused education on (nursing unit) where Proteus Mirabilis was found. IC Nurse O was asked to hypothesize the spread of the proteus mirabilis infection (MDRO) to Resident #45's wound and if there was any spread from Resident #46's MDRO urine infection with the same MDRO. The IC Nurse O offered that yes, (Resident #46) and (Resident #45) are on the same group so I did hand hygiene audits on those care givers but did not see breaches in those groups. IC Nurse O was asked if they watch the Nurses provide wound care or catheter care and IC Nurse O offered, the nurse managers due the wound care observations and that they didn't see any reeducation's provided by the nurse managers. IC Nurse O offered that they planned a jeopardy game for infection control education specific to spreading infections. IC Nurse O was asked if the MDRO proteus mirabilis could be spread by hand contact and IC Nurse O stated, not that I'm seeing but doesn't mean it isn't happening. IC Nurse O offered the summary on the line listing for July, 2024 which revealed: 5/12 urine cultures grew Proteus Mirabilis, a natural gastrointestinal flora Most common reason for its presence in urine is due to ascension from the GI tract, Foley catheters facilitate this . Notified medical director of observation and analysis, he state P. mirabilis is common GI pathogen responsible for UTI & diabetic wounds, not likely the result of transmission-stated, P. Mirabilis, E. coli infections are the result of the person's own GI bacteria. It is highly unlikely that that transmission of those bacteria to cause UTI could occur during the provision of care. After [AGE] years of practice, I've never heard of that happening. On 10/17/24, at 9:31 AM, CNA N was observed performing all am care for Resident #45. CNA N performed hand hygiene, donned a gown and gloves. CNA N opened up the closet door with their gloved hands, removed the basin, personals and clothing, walked through the closed privacy curtain touching the curtain with their left gloved hand. CNA N then entered the bathroom and filled the basin with water. CNA N entered the residents area after touching the privacy curtain. CNA N set the basin down on the bedside table, grabbed the bed remote and changed the position of the bed with the same gloves on. CNA N removed the covers, and the foot cushions underneath Resident #45's right foot. CNA N now walked back through the privacy curtain touching the curtain with both gloved hands and returned into the residents are with more washcloths. With the same gloves on, CNA N performed perineal care as Resident #45 was soiled with urine and a small amount of bowel movement. CNA N grabbed chamosyn cream out of the closet and applied cream to Resident #45's buttock area and placed a new incontinent brief on. Still with the same gloves on, CNA N adjusted the bed sheet and performed range of motion to the residents legs, positioned the wedge under the left leg and the pillow under the right foot. With the same gloves on, CNA N assisted the resident with new clothing, deodorant and finished with combing their hair. CNA N walked to the bathroom dried out the basin with paper towels, reentered the resident area and placed the personal items inside the basin, opened up the closet, placed the items inside. CNA N assisted Resident #45 with repositioning using the bed remote. CNA N doffed their gown and gloves and used hand gel for hand hygiene upon exit of the room . The privacy curtain was observed to have brown spots on it. On 10/17/24, at 9:46 AM, an observation of Nurse M was conducted of Resident #45's diabetes injections and their right foot wound care. Nurse M entered the room set down the supplies, performed hand hygiene, donned a gown and gloves. Nurse M gave the resident an injection to their right arm and then to their abdomen. With the same gloves on, Nurse M propped up Resident #45's right leg onto a cushion and removed their sock and dirty dressing from their right heel. The dressing had dark bloody drainage noted. Nurse N removed their gloves and discarded. Nurse M then entered their left pocket with their left hand, pulled out a pair of gloves and donned the gloves at the bedside without performing hand hygiene. Nurse M cleaned the wound and opened up the new dressing. Nurse M with their left gloved hand pulled aside the front of their gown, entered their right pocket with their gloved right hand, removed their black marker, wrote the date on the new dressing and then placed the black marker back into their right pocket. Nurse M then placed the new dressing over top of the wound on Resident #45's right heel. Nurse M placed the same sock onto the heel. Nurse M adjusted the residents blankets, tied up the garbage, doffed their gown and gloves and performed hand hygiene at the sink. Nurse M washed their hands for only a total of six seconds. Nurse M returned to the bedside to adjust the bed with the bed remote, grabbed their dirty garbage and exited the room. A review of Resident #45's lab results revealed Foot, Right, Wound Swab Collected 09/18/2024 . Moderate Escherichia coli Moderate Proteus Mirabilis Moderate Enterococcus species . Susceptibility . Proteus Mirabilis R (resistant) . On 10/17/24, at 10:06 AM, Infection Control Nurse (IC) O was asked to explain the facility expectations for proper perineal care and IC Nurse O offered, the expectation is to wash hands from dirty to clean care. IC Nurse O was asked if perineal care was considered dirty and IC Nurse O offered, yes, peri-care is dirty. IC Nurse O was alerted the observation of CNA N touched multiple surfaces with their gloved hands prior to peri-care and after peri-care for Resident #45. IC Nurse O asked the surveyor why CNA N wasn't stopped by the surveyor. IC Nurse O was also alerted of Resident #45's wound care observation with Nurse M. IC Nurse O was asked again to provide all environmental rounds, peri-care audits, hand hygiene audits, wound care audits and PPE audits to ensure staff compliance with infection control standards. On 10/17/24, at 11:17 AM, a record review of the provided Monthly Summary Data and provided environmental rounds along with IC Nurse O was conducted. The View Monthly Summary Data for June, July, August and September 2024 revealed 30 hand hygiene and 30 PPE audits for each month were conducted. There was no staff education provided for the Gown and Gloves audits that had failures each month. A review of the provided Environmental Room Attendants Checklist 10/10/24 revealed a checklist for Bedrooms, Bathrooms/Showers and Carts. There were check marks but no additional data that explained what the check marks meant. IC Nurse O clarified the environmental rounds check list was completed by the cleaning staff. IC Nurse O provided a typed document that revealed the following: During bi-weekly rounds we observe 12 wound care, peri-care and hand hygiene observations monthly x 12 months. In the last 24 months there were no observed concerns. During the educational fair all CENA's were observed for peri-care and hand hygiene observations. Concerns were addressed and real-time education was provided. General education followed for all direct care staff. IC Nurse O was asked if the peri-care observations were on actual residents and IC Nurse O stated, No, a mannequin. IC Nurse O was asked to clarify when and why there should be actual Resident peri-care audits of the staff and IC Nurse O stated, if there was a concern. IC Nurse O was asked to provide additional data for all staff/care audits, audits on cleaning reusable medical equipment, linen transportation, hand hygiene, wound care and peri-care. IC Nurse O stated, that was QAPI protected information and offered that the residents had their own medical equipment. IC Nurse O was again asked to provide audits on cleaning reusable medical equipment for all equipment other than glucometers. Prior to exit, there were no peri-care audits, wound care audits and audits on cleaning reusable medical equipment. Once the facility was alerted of exit, a document was offered of a printed spread sheet of numerous papers that were provided to show proof of audits of care although was not readable as it was all separated by page. During exit conference, the Administrator was alerted of the document share and was offered the opportunity to send any additional documents that clarified the data or proved audits of personal cares for ensuring staff were following Infection Control Standards. According to Centers for Disease Control and Prevention . Infection Prevention in Long-term Care Facility Residents .Healthcare-Associated Infections (HAI) . Long-term care facilities provide many services, both medical and personal care, to people who are unable to live without help. If you live in a nursing home, assisted living facility or other long-term care facility, you have a higher risk of getting an infection. There are steps you can take to reduce your risk . Keep your hands clean. Remind staff and visitors to keep their hands clean . According to National Library of Medicine, P. mirabilis has swarming motility and the ability to self-elongate and secrete a polysaccharide when in contact with solid surfaces; this allows for attachment and easy motility along surfaces (e.g. medical equipment) . Proteus is found abundantly in soil and water, and although it is part of the normal human intestinal flora . it has been know to cause serious infections in humans . Proteus infection can be avoided with proper sanitation and hygiene, such as adequate sterilization of medical equipment and surfaces . 37668 Resident #40: Record review revealed Resident #40 was admitted to the facility on [DATE] with diagnoses which included dementia, pressure ulcers (wounds caused by pressure), quadriplegia, and contractures. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the Resident was severely cognitively impaired and required maximum to total assistance to complete all Activities of Daily Living (ADL). Review of documentation in Resident #40's Electronic Medical Record (EMR) revealed Resident #40 had a current treatment in place to the top of their left foot. The treatment detailed, Everyday shift every Mon, Thu . cleanse with normal saline or sterile H2O, apply medihoney, cover with silicone dressing (mepilex) (Start Date: 9/16/24) Review of Resident #40's TCMCC Weekly Nursing assessment dated [DATE] specified, Left foot continues with open area 0.5 x 0.5 cm (centimeters), dressing was changed today and is currently dry and intact . A wound care observation was completed with Wound Care Licensed Practical Nurse (LPN) R on 10/17/24 at 10:01 AM. LPN R was observed removing the dressing on Resident #40's left foot pressure ulcer wound. LPN R was then observed removing their gloves and donning a new pair without performing hand hygiene after removing soiled gloves. 37666 A review of the Association for Professionals in Infection Control and Epidemiology: Guide to Preventing Catheter-Associated Urinary Tract Infections, first edition, April 2014 identified the following: . Urinary tract infections are one of the five most common types of healthcare-associated infection (HAI), and along with other device-associated infections (e.g., central catheter-associated bloodstream infections and ventilator-associated pneumonia) account for 25.6 percent of all hospital HAI's . Catheter-associated urinary tract infection (CAUTI) has been associated with increased morbidity, mortality, hospital cost, and length of stay. Bacteriuria also leads to unnecessary antimicrobial use, and urinary drainage systems can be reservoirs for multidrug-resistant bacteria and a source of transmission to other patients . The source of microorganisms causing CAUTI can be endogenous-typically via meatal, rectal, or vaginal colonization- or exogenous, such as via equipment or contaminated hands of healthcare personnel .Drainage System Safety- Sterile, continuously closed drainage systems became the standard of care based on an uncontrolled study published in 1966 demonstrating a reduction in the risk of infection in short-term catheterized patients with the use of a closed system. Recent data also include the finding that disconnection of the drainage system is a risk factor for bacteriuria. The catheter tubing should allow free flow of urine and kinking of tubing should be avoided. The urine bag should be kept below the level of the bladder and kept off the floor . Resident #17: Urinary Catheter or UTI A record review of the Face sheet and Minimum Data Set/MDS assessment for Resident #17 indicated an admission to the facility on [DATE] and readmission on 11/2/2023 with diagnoses: Multiple Sclerosis, Dementia, history of Lyme disease, diabetes, COPD, epilepsy, neuromuscular dysfunction of bladder and heart failure. The MDS assessment dated [DATE] revealed the resident had severely impaired cognitive skills and needed assistance with all care. A review of the physician orders for Resident #17 identified the following: Foley catheter. Change as needed for neurogenic bladder, start date 4/26/2024. On 10/14/2024 at 12:38 PM, Resident #17 was observed lying in bed. A urinary catheter/Foley catheter drainage bag was observed inside a black cloth bag sitting on the floor. The catheter bag was bent over in the middle, so the urine could not flow freely into the bag. A review of the Care Plans for Resident #17 revealed the following: The resident has Indwelling Catheter (Foley) in place r/t (related to): Neurogenic bladder, date initiated 8/30/2016 and revised 4/26/2024. On 10/17/2024 an intervention was added, The resident has (16 Fr (size)) Foley. Position catheter bag and tubing below the level of the bladder, date initiated and revised 10/17/2024; Keep in cloth bag for discreetness/cleanliness, date initiated and revised 4/26/2024. A review of the Infection Line Listing for May 2024 indicated Resident #17 was identified to have a Catheter Associated Urinary Tract Infection (CAUTI) on 5/13/2024. The infectious organism was Escherichia coli (E. coli) and the resident was treated with antibiotics. Resident #22: Urinary Catheter or UTI A record review of the Face sheet and Minimum Data Set/MDS assessment for Resident #22 identified a readmission to the facility on [DATE] with diagnoses: Diabetes, heart disease, heart failure, COPD, arthritis, Alzheimer's, and a history of falls. The MDS assessment dated [DATE] indicated the resident had a BIMS score of 9/15 with moderate cognitive decline and needed assistance with all care. A review of the physician orders indicated Resident #22 had a supra-pubic urinary catheter with a start date of 5/20/2024. On 10/14/2024 at 11:48 AM, Resident #22 was observed lying in bed resting. The urinary catheter tubing had cloudy colored urine in it. The urinary catheter bag was sitting inside a black cloth bag that was sitting on the floor under the bed and behind 2 mattresses that were sitting on the floor. Certified Nurse Aide/CENA P entered the room and said the resident had a history of UTI's/Urinary tract infections. The aide was assisting the resident A review of the Care Plans for Resident #22 revealed the following: The resident has history of) recurrent Urinary Tract infections, dated initiated 5/5/2023 and revised 5/29/2024 with Interventions including: Observe urine characteristics and report to physician as indicated, date initiated 5/20/2024 and revised 7/25/2024. There was no mention of keeping the urinary catheter bag and or the black cloth bag off the floor to aid in preventing contamination. The resident has a suprapubic catheter in place (related to): Neurogenic bladder, date initiated 7/26/2023 and revised 12/28/2023 with Interventions including: Catheter are per policy and procedure, dated 7/26/2023. There was no mention of maintaining the urinary catheter bag or the black cloth bag from touching the floor to prevent contamination. On 10/16/2024, Resident #22 was observed lying in bed and his urinary catheter bag was observed sitting inside a black cloth bag on the floor behind two mattresses stacked on the floor next to his bed. Nurse Q entered the resident's room and was asked about the catheter bag lying on the floor. The nurse moved the two mattresses slightly away from the side of the bed and the urinary catheter bag was observed inside a cloth black bag on the floor. The nurse said it should have been off the floor. He laid on his back on the mattresses on the floor and used two ties on the bag to lift it and tied it under the bed frame. On 10/17/2024 at 9:45 AM, Resident #22 was observed lying in bed waiting for wound care with Nurse R and Nurse Aide S. The urinary catheter bag was inside a black cloth bag and was tied on the end of the bed; hanging off the floor as the bed was raised to accommodate wound care. The black cover bag was very stained and soiled. The 2 mattresses that had been lying on the floor beside the bed were moved against the wall by the window during the wound care. Both mattresses were very soiled: brown with dirt stains. Both mattresses had tears, open areas and with ends that appeared shredded and tattered. The mattresses were previously leaning against the catheter bag. A review of the Infection Line Listing for May 2024-September 2024 identified Resident #22 as developing a urinary tract infection on 5/20/2024. The infectious organism was Escherichia coli and the resident was treated with antibiotics. The Infection Line List also listed Resident #22 as having urinary tract infections on 2/11/2024 with Enterobacter cloacae, 1/23/2024 with E. coli, 12/15/2023 with E. coli and Enterococcus faecalis. The Infection Line List identified Resident #22 as developing Clostridium (Clostridioides) difficile (C. diff) a severe infection with diarrhea that can lead to colitis, on 6/25/2024. Centers for Disease Control and Prevention- CDC: About C. diff: . Most cases of C. diff occur when you've been taking antibiotics for something else or not long after you've finished . That's because antibiotics that fight bacterial infections by killing bad germs can also kill the good germs. These good germs protect the body against harmful infection like C. diff infection . The Infection Line List for August 2024 indicated Resident #22 develop another urinary tract infection on 8/26/2024. The infectious organisms were Enterococcus faecium, Escherichia coli and Klebsiella pneumoniae. The resident was treated with antibiotics.

Based on interview and record review, the facility failed to develop person-centered comprehensive care plans for Code Status preferences for five residents (Resident #4, Resident #17, Resident #22, Resident #66, Resident #68) of 29 residents reviewed for care plans, resulting in the potential for residents not to receive individualized care, which could lead to a decline in condition, and/or a negative outcome. Findings Include: A record review of the facility policy titled, Comprehensive Care Plan, Care plan review and Care Plan Conferences, date implemented [DATE], date reviewed [DATE] and date revised [DATE], provided (The facility) will ensure that all residents have a Baseline Care Plan completed per the Baseline Care Plan Policy, and a comprehensive Care Plan in the e- chart within 7 days of completion of section Z of the Admission MDS assessment . The Care Plan will provide staff with guidelines on resident care needs . Resident #4: Advance Directives A record review of the Face sheet and Minimum Data Set/MDS assessment for Resident #4 indicated an admission to the facility on [DATE] and readmission on [DATE] with diagnoses: urinary tract infection, acute kidney failure, chronic kidney disease, diabetes, Parkinson's disease, obesity, Dementia and peripheral vascular disease. The MDS assessment dated [DATE] revealed the resident had moderate cognitive loss with a Brief Interview for Mental Status/BIMS score of ,d+[DATE] and the resident needed assistance with all care. On [DATE] at 4:13 PM, during a record review of the Advance Directives for Resident #4, the Code Status form dated [DATE] indicated the resident had No checked next to Cardiopulmonary Resuscitation (CPR), Use of Respirators, Ventilators, Tube Feeding, and Transfer to Acute Care Hospital. The Code Status form was signed by the resident's Durable Medical Power of Attorney on [DATE]. A review of the Comprehensive Care Plans for Resident #4 indicated there was no mention of the resident's Code Status preferences. Resident #17: Advance Directives A record review of the Face sheet and Minimum Data Set/MDS assessment for Resident #17 indicated an admission to the facility on [DATE] and readmission on [DATE] with diagnoses: Multiple Sclerosis, Dementia, history of Lyme disease, diabetes, COPD, and heart failure. The MDS assessment dated [DATE] revealed the resident had severely impaired cognitive skills and needed assistance with all care. A review of a Code Status form dated [DATE] identified several Code Status preferences by the resident: No was checked for the options Cardiopulmonary Resuscitation/CPR, Use of Respirators, Ventilators and Transfer to Acute Hospital. Yes was marked for Tube Feeding. The Other category listed Transfers to acute care hospital for tube feeding concerns and seizure activity as needed. The Code Status for was signed on [DATE] by the resident's Guardian. A review of the Care Plan for Resident #17 indicated there was no mention of the resident's Code status preferences for no CPR, no Use of a Respiratory/Ventilator or no Transfer to Acute Hospital. There was also no mention of the Other request to transfer to the acute care hospital for tube feeding concerns and seizure activity as needed. Resident #22: Advance Directives A record review of the Face sheet and Minimum Data Set/MDS assessment for Resident #22 identified an admission to the facility on [DATE] with diagnoses: Diabetes, heart disease, heart failure, COPD, arthritis, Alzheimer's, and a history of falls. The MDS assessment dated [DATE] indicated the resident had a BIMS score of ,d+[DATE] with moderate cognitive decline and needed assistance with all care. A review of the Code Status Form Do-Not-Resuscitate Order for Resident #22 revealed that the resident signed the form on [DATE]. A review of the Care Plans for Resident #22 revealed there was no mention of the resident's Advance Directives or Code status preferences. Resident #66: Advance Directives A record review of the Face sheet and Minimum Data Set/MDS assessment for Resident #66 indicated an admission to the facility on [DATE] with diagnoses: history of a stroke, left sided weakness, heart failure, Alzheimer's, and COPD. The MDS assessment dated [DATE] revealed the resident had full cognitive abilities with a BIMS score of ,d+[DATE] and needed some assistance with care. A review of the Code Status form for Resident #66 revealed it was signed by the resident's DPOA on [DATE]th, 2024. The form was marked Yes for: Cardiopulmonary resuscitation (CPR), Use of respirator, ventilator, tube feeding and transfer to Acute care hospital. A review of the Care Plans for Resident #66 indicated there was no mention of the resident's Advance Directives or Code Status preferences. Resident #68: Advance Directives A record review of the Face sheet and Minimum Data Set/MDS assessment for Resident #68 identified an admission to the facility on [DATE] and readmission on [DATE] with diagnoses: chronic kidney disease, heart failure, COPD, peripheral vascular disease, hypothyroidism, depression, anxiety, anemia, and obesity. The MDS assessment dated [DATE] revealed the resident had full cognitive abilities with a BIMS score of ,d+[DATE] and needed some assistance with all care. A review of the Code status form titled, Do-Not-Resuscitate Order indicated the resident signed the form on [DATE] for DNR/Do-Not-Resuscitate. A review of the Care Plans for Resident #68 revealed there was no mention of her Code Status preference. On [DATE] at 8:55 AM, Social Services/SS Director J was interviewed about Residents' Advance directives and code status preferences. The SS Director J said someone from Social Services reviewed the code status and advance directives with the resident or responsible party and nursing obtained an order for the code status. When asked if the residents' code status was Care Planned, she said she did not think it was care planned. Reviewed the resident's Care Plan with the SS Director and it did not mention the resident's code preferences.

Based on observation interview and record review the facility failed to follow facility policy for indwelling catheter use for five residents (R17, R22, R51, R52, R106) of six residents reviewed, resulting in physician's orders not having catheter size, dignity bags touching the floor and recurrent UTI's (urinary tract infections). Findings include: Resident #52 (R52): R52 is [AGE] years old and was admitted to the facility on [DATE] with diagnoses that include Alzheimer's disease, dementia, neuromuscular dysfunction of the bladder and history of urinary tract infections. On 10/14/24 at 10:27AM, observation revealed that R52 had an indwelling catheter, the urine collection bag was hanging below the bed, covered by a dignity bed and off the floor. On 10/16/24, record review of the admission MDS (Minimum Data Set) revealed that R52 was admitted with an indwelling catheter. On 10/16/24, record review of R52's care plan revealed a care plan for the indwelling catheter that was last revised on 12/27/2023. The interventions/tasks for the care plan state the resident has a 16fr Foley catheter, last revised on 12/18/2023. A review of the October 2024 TAR (Treatment Administration Record) for R52 revealed that the catheter was last changed on October 5th, 2024. No documentation was located that revealed what size catheter was used during the change. On 10/16/24, record review revealed a physician's order for the indwelling catheter, order date 01/03/2024. The order reads, Foley Catheter. Change PRN (as needed). as needed for end of life. The order does not contain the size of the catheter On 10/17/24, an interview with RN (Registered Nurse) K. RN K was asked how they would know what size catheter a resident has. RN K stated that the indwelling catheters are labeled with the size and that the physician's order also states the size the catheter is. RN K was asked who updates the care plans and orders with catheter size. RN K stated the nurse managers do that. Resident #106 (R106): R106 is [AGE] years old and admitted to the facility on [DATE] with diagnoses that include Alzheimer's disease, dementia, bladder-neck obstruction and neuromuscular dysfunction of the bladder. On 10/14/24 at 01:52PM, observation revealed that R106 had an indwelling catheter. The urine collection bag is covered by a dignity bag and the dignity bag is resting on the floor. On 10/16/24 at 10:26AM, record review of R106's physician's orders revealed that R106 has an order for an indwelling catheter for neuromuscular dysfunction of the bladder. The order is dated 01/26/2023 and reads, Foley Catheter. Change PRN. On 10/16/24 at 10:35AM, record review of R106's care plans revealed a care plan for an indwelling catheter, last revised on 08/15/2024. The interventions/tasks on the care plan state the resident has a 16fr indwelling catheter, last revised on 01/26/2023. On 10/16/24 at 10:40AM, record review of the October 2024 TAR for R106 revealed the catheter was changed on October 6, 2024 and it was documented that a 14fr indwelling catheter was used. Record review of the policy titled, Urinary Catheters: Insertion/Removal of Straight, Indwelling or Suprapubic Catheters, revised 11/27/2023 revealed: 1. The use of an indwelling urinary catheter will be in accordance with physician orders, which will include the diagnosis or clinical condition making the use of the catheter necessary, size of the catheter, and frequency of change (if applicable). 8. Keep urinary collection bags in a cloth bag/cover for discreteness and cleanliness. Maintain urinary collection bags below the level of the bladder per manufacturer ' s recommendations; typically, regular drainage bags are required to be placed below the level of the bladder while leg bags do not have the same restriction. Do not allow urinary collection bags or drainage tubing to rest on the floor. 11. When a catheter is changed, note the change in the resident's electronic medical record making sure to record the date, catheter type, and size. Update Indwelling Catheter Tracking Log (located in TCMCF Official Forms Folder) 37666 Resident #17: Urinary Catheter or UTI A record review of the Face sheet and Minimum Data Set/MDS assessment for Resident #17 indicated an admission to the facility on [DATE] and readmission on 11/2/2023 with diagnoses: Multiple Sclerosis, Dementia, history of Lyme disease, diabetes, COPD, epilepsy, neuromuscular dysfunction of bladder and heart failure. The MDS assessment dated [DATE] revealed the resident had severely impaired cognitive skills and needed assistance with all care. A review of the physician orders for Resident #17 identified the following: Foley catheter. Change as needed for neurogenic bladder, start date 4/26/2024. On 10/14/2024 at 12:38 PM, Resident #17 was observed lying in bed. A urinary catheter/Foley catheter drainage bag was observed inside a black cloth bag sitting on the floor. The catheter bag was bent over in the middle, so the urine could not flow freely into the bag. A review of the Care Plans for Resident #17 revealed the following: The resident has Indwelling Catheter (Foley) in place r/t (related to): Neurogenic bladder, date initiated 8/30/2016 and revised 4/26/2024. On 10/17/2024 an intervention was added, The resident has (16 Fr (size)) Foley. Position catheter bag and tubing below the level of the bladder, date initiated and revised 10/17/2024; Keep in cloth bag for discreetness/cleanliness, date initiated and revised 4/26/2024. Resident #22: Urinary Catheter or UTI A record review of the Face sheet and Minimum Data Set/MDS assessment for Resident #22 identified a readmission to the facility on [DATE] with diagnoses: Diabetes, heart disease, heart failure, COPD, arthritis, Alzheimer's, and a history of falls. The MDS assessment dated [DATE] indicated the resident had a BIMS score of 9/15 with moderate cognitive decline and needed assistance with all care. A review of the physician orders indicated Resident #22 had a supra-pubic urinary catheter with a start date of 5/20/2024. On 10/14/2024 at 11:48 AM, Resident #22 was observed lying in bed resting. The urinary catheter tubing had cloudy colored urine in it. The urinary catheter bag was sitting inside a black cloth bag that was sitting on the floor under the bed and behind 2 mattresses that were sitting on the floor. Certified Nurse Aide/CENA P entered the room and said the resident had a history of UTI's/Urinary tract infections. The aide was assisting the resident A review of the Care Plans for Resident #22 revealed the following: The resident has history of) recurrent Urinary Tract infections, dated initiated 5/5/2023 and revised 5/29/2024 with Interventions including: Observe urine characteristics and report to physician as indicated, date initiated 5/20/2024 and revised 7/25/2024. There was no mention of keeping the urinary catheter bag and or the black cloth bag off the floor to aid in preventing contamination. The resident has a suprapubic catheter in place (related to): Neurogenic bladder, date initiated 7/26/2023 and revised 12/28/2023 with Interventions including: Catheter are per policy and procedure, dated 7/26/2023. There was no mention of maintaining the urinary catheter bag or the black cloth bag from touching the floor. On 10/16/2024, Resident #22 was observed lying in bed and his urinary catheter bag was observed sitting inside a black cloth bag on the floor behind two mattresses stacked on the floor next to his bed. Nurse Q entered the resident's room and was asked about the catheter bag lying on the floor. The nurse moved the two mattresses slightly away from the side of the bed and the urinary catheter bag was observed inside a cloth black bag on the floor. The nurse said it should have been off the floor. He laid on his back on the mattresses on the floor and used two ties on the bag to lift it and tied it under the bed frame. On 10/17/2024 at 9:45 AM, Resident #22 was observed lying in bed waiting for wound care with Nurse R and Nurse Aide S. The urinary catheter bag was inside a black cloth bag and was tied on the end of the bed; hanging off the floor as the bed was raised to accommodate wound care. The black cover bag was very stained and soiled. The 2 mattresses that had been lying on the floor beside the bed were moved against the wall by the window during the wound care. Both mattresses were very soiled: brown with dirt stains. Both mattresses had tears, open areas and with ends that appeared shredded and tattered. The mattresses were previously leaning against the catheter bag. A review of the Association for Professionals in Infection Control and Epidemiology: Guide to Preventing Catheter-Associated Urinary Tract Infections, first edition, April 2014 identified the following: . Drainage System Safety- Sterile, continuously closed drainage systems became the standard of care based on an uncontrolled study published in 1966 demonstrating a reduction in the risk of infection in short-term catheterized patients wit the use of a closed system. Recent data also include the finding that disconnection of the drainage system is a risk factor for bacteriuria. The catheter tubing should allow free flow of urine and kinking of tubing should be avoided. The urine bag should be kept below the level of the bladder and kept off the floor . 39059 Resident #51: On 10/14/2024, at 4:33 PM, Resident #51 was lying in their bed. Their Foley catheter drainage bag was covered with a blue cotton bag. The blue cotton bag was resting on the floor. On 10/16/24, at 11:00 AM, a record review of Resident #51's electronic medical record revealed a readmission on 09/30/2024 with diagnoses that included Dysphagia, Multiple Sclerosis and Pneumonitis due to Inhalation of food and vomit. Resident #51 required extensive assistance with Activities of Daily Living and had intact cognition. A review of the physician orders revealed Foley Catheter, prn as needed Change indwelling Foley catheter as needed for Leakage, obstruction, breaks in system or S/S (signs and symptoms) of UTI (urinary tract infection) . Start Date 09/30/2024 . There was no size of the Foley catheter listed on the physician's order. A review of the Kardex revealed no direction as to when to change the blue cotton catheter bag cover or to keep the urinary catheter bag off the floor. A review of the care plan The resident has an indwelling catheter in place R/T (related to) Neuromuscular Dysfunction of Bladder Date Initiated: 03/14/2024 . Intervention/Task . Catheter care per policy & procedure. Date Initiated: 03/14/2024 CATHETER: The resident 16fr Foley 10 ml balloon. Position catheter bag and tubing below the level of the bladder. Revision on: 03/18/2024 Keep in cloth bag for discreteness/cleanliness. Date Initiated: 03/14/2024 . There was no intervention as to when to change the blue cotton catheter bag cover or to keep the urinary catheter bag off the floor. On 10/17/2024, at 8:30 AM, Resident #51 was lying in their bed. Their bed was in a low position. Their urinary catheter bag was inside a blue cotton bag which was resting on the floor. The overbed table leg was pushed against the catheter drainage bag touching the tubing. On 10/17/24, at 8:35 AM, an observation along with Nurse M was conducted of Resident #51's urinary catheter bag. Nurse M was asked if the blue bag covering the urinary catheter bag should be on the floor and Nurse M stated, no, that might have been midnight shift, pulled the bedside table back and raised the bed. Nurse M was asked how often the blue bags get replaced and Nurse M stated, I believe weekly and exited the room. On 10/17/24, at 10:06 AM, During Infection Control Task, Infection Control Nurse O was asked how often the blue cotton urinary drainage bag covers were laundered and IC Nurse O stated, as needed.

Based on observation, interview and record review, the facility failed to ensure that medications and medical supplies were stored and disposed of per professional standards of practice in two of five medication rooms resulting in expired medications and medical supplies, lack of refrigerated vaccine temperature monitoring per CDC recommendations, and the potential for residents to have procedures and testing completed with expired supplies and to receive expired medications with altered potency and efficacy. Findings include: A tour of the Second Redwood Medication Room was completed with Unit Manager Registered Nurse (RN) T on 10/17/24 at 8:34 AM. The following exited medications and medical supplies were present in the medication room: - ProSource NoCarb 15-gram Protein, 30 fluid ounce (oz) container, Expired: 9/28/24 - UTI-Stat, 30 fluid oz container, Expired 7/27/24 - 100 tablet bottle of Aspirin 81 mg tablets, Expired: 9/24 - Three bottles of Prevacid 15 mg tablets with 14 tablets per bottle for Resident #14, Expired 6/24 - Universal Viral Transport for Viruses (Covid) laboratory sample, Expired: 10/9/24 - 20 mL (milliliter) oral dispenser syringe, Expired: 7/30/24 - 24 g (gauge) IV (intravenous) Catheter BD Insyte Autoguard (for IV insertion and medication administration), Expired: 11/30/22 - Point-Lok Sharps Safety devices, quantity 12, Expired: 12/4/22 When queried regarding the expired medications and medical supplies, RN T confirmed the medications and supplies were expired and indicated they would dispose of them. A tour of the medication refrigerator in the medication storage room revealed vaccines were stored on the top shelf of the refrigerator along with other medications. A review of the temperature monitoring log for the refrigerator revealed temperatures monitoring documentation was completed once per day (24-hour period). When queried if vaccines are always stored in the medication refrigerator, RN T revealed vaccines are frequently stored in the refrigerator. When asked how often the temperatures are checked, RN T responded once daily. On 10/17/24 at 9:06 AM, a tour of the Second Hickory Medication Room was completed with the Assistant Director of Nursing (ADON). The following expired medications were noted in the medication room: - Bottle of 100 Vitamin E 200 IU (International Units) softgels - Bottle of 100 Acetaminophen 325 mg tablets - Bottle of Geri-kot (stool softener) 8.6 mg tablets, Expired: 4/24 - Four containers of Banatrol Plus (anti-diarrheal solution) 0.38 oz containers, Expired: 8/5/24 Review of facility policy/procedure entitled, Storage and Labeling of Medication and Biologics (Reviewed: 12/14/23) revealed, It is the policy of this facility to ensure all medications housed on our premises will be stored in the pharmacy and/or medication rooms according to the manufacturer's recommendations and sufficient to ensure proper sanitation, segregation, and security . 1. General Guidelines: a. All drugs and biological's will be stored in locked compartments (i.e., medication carts, cabinets, drawers, refrigerators, medication rooms) under proper temperature controls . 8. Expiration dates will be monitored to ensure that all medications are removed from distribution prior to expiration date. Nurses will check stock medications when removing them from storage are to ensure expired medications are not placed in the medication cart for use. The expiration date assures that the drug meets applicable standards of strength, quality & purity at the time of use. When the label shows only a month and a year, the implied expiration date is the last day of that month. 9. Out-dated stock medications / supplies will be disposed of in a pharmaceutical destruction container or returned to our contracted pharmacy for disposal if appropriate. Review of the Centers for Disease Control (CDC) Vaccine Storage and Handling Toolkit (Updated: 3/29/24) revealed, Vaccine Storage and Temperature Monitoring Equipment . Check and record storage unit minimum and maximum temperatures at the start of each workday. If your TMD (Temperature Monitoring Device) does not read minimum/maximum temperatures, then check and record the current temperature a minimum of two times per workday (at the start and end of the workday) . Reference: US Centers for Disease Control and Prevention. (2024, March 29). Vaccine Storage and Handling Toolkit. https://www.cdc.gov/vaccines/hcp/storage-handling/?CDC_AAref_Val=https://www.cdc.gov/vaccines/hcp/admin/storage-handling.html

Based on observation, interview and record review, the facility failed to ensure care that was dignified and respectful treatment for two residents (Resident #96 and Resident #114) of two residents reviewed, resulting in a lack of acknowledgement and/or response to Resident #96's verbalization of discomfort and Resident #114's request for assistance, and the likelihood for feelings for insignificance and psychosocial distress utilizing the reasonable person concept. Findings include: Resident #96: On 10/15/24 at 8:33 AM, Resident #96 was observed in the dining room of the locked dementia care unit of the facility. The Resident was sitting in their wheelchair at a table with a plastic cushion behind their back and was repeatedly saying, Oh my back, oh my back. There were other residents sitting at the table eating as well as a Certified Nursing Assistant (CNA) U. Two other staff members were present in the dining room within hearing distance of Resident #96. When asked if they were okay, Resident #96 responded, Oh my back but did not provide further explanation. The Resident was leaning forward and back and displaying non-verbal signs and symptoms of pain. When asked if they ate breakfast yet, Resident #96 indicated they did not know, and CNA U verbalized they already ate. Neither CNA U nor any of the other staff members in the dining room acknowledged the Resident's verbalization of back discomfort. Record review revealed Resident #96 was admitted to the facility on [DATE] with diagnoses which included Alzheimer's disease, dementia, intervertebral disc disorders (condition where the discs separating the spinal bones break down), osteoarthritis, and falls. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the Resident was severely cognitively impaired and required moderate assistance for bathing and personal hygiene. The MDS further revealed the Resident had received scheduled pain medication in the prior five-day period. Review of Resident #96's care plans revealed a care plan entitled, The resident has or is at risk for chronic pain r/t (related to) Arthritis (Initiated and Revised: 3/6/24). The care plan included the interventions: - Assess for pain using pain assessment tool appropriate for the Resident's cognitive status (Initiated: 3/6/24) - Monitor for presence of pain, effectiveness of intervention, adverse consequences . (Initiated: 3/6/24) Review of Resident #96's Medication Administration Record (MAR) and Health Care Provider (HCP) Orders revealed the Resident was receiving Ultram (opiate pain medication) 50 milligrams (mg) twice a day as well as Tylenol 8 Hour Arthritis Pain 650 mg three times a day. Documentation of pain on the MAR for 10/15/24 at 9:00 AM was zero out of 10 (indicating the Resident was experiencing no pain). Review of Resident #96's Progress Notes on 10/16/24 revealed no documentation related to the Resident complaining of discomfort on 10/15/24. Resident #114: On 10/14/24 at 11:27 AM, Resident #114 was not present in their room. On 10/15/24 at 8:33 AM, Resident #114 was observed in the dining room of the locked dementia care unit of the facility. The Resident's hair was uncombed and had a greasy appearance. When spoke to and asked questions, Resident #114 was pleasant, confused, and did not provide meaningful responses. Record review revealed Resident #114 was admitted to the facility on [DATE] with diagnoses which included Alzheimer's Disease, dementia, and hypertension. Review of the MDS assessment dated [DATE] revealed the Resident was severely cognitively impaired and required set up to supervision assistance to complete dressing and personal hygiene. On 10/14/24 at 4:10 PM, Resident #114 was observed sitting at a table in the dining room in a wheelchair. CNA V was sitting next to the Resident at the same table. Upon entering the dining room, and approaching Resident #114, the Resident was heard saying they wanted to lay down. An interview was conducted with Resident #114 at this time. When asked how they were, Resident #114 replied, I'm really tired and they won't let me lay down. Resident #114 gestured toward CNA V. CNA V was sitting directly next to Resident #114 but did not verbally respond to the Resident. When asked why Resident #114 was not able to lay down, CNA V did not provide a response and called CNA Y, who was also in the dining room, to come to the table. CNA Y was then asked why Resident #114 was not able to lay down and replied, We are going to eat dinner soon. When queried how that prohibited the Resident from laying down and why no one would assist them to go back to their room when they were asking, CNA Y did not provide a response. CNA V then stated they would take Resident #114 back to their room. CNA V was observed pushing the Resident out of their room in their wheelchair to their room. At 4:30 PM on 10/14/24, Resident #114 was observed in their room. The Resident was in bed, positioned on their side with their eyes closed. On 10/16/24 at 11:18 AM, Resident #114 was observed sitting in their wheelchair in the dining room. The Resident was pleasantly confused and did not provide meaningful responses to questions. Review of facility provided Resident Mealtimes document detailed dinner was served in Resident #114's unit at 5:00 PM for the first cart and 6:15 PM for the second cart. An interview was conducted with the Director of Nursing (DON) on 10/16/24 at 2:00 PM. When queried regarding expectations of staff in relation to acknowledgment and responding to a resident's verbalization of discomfort and/or care needs, the DON indicated they expect staff to acknowledge and respond to residents. Observations of Resident #96 were relayed to the DON at this time including non-verbal signs/symptoms of pain, verbalization of Oh my back, and lack of staff response. When asked their thoughts, the DON replied, I would have to look into that. When queried regarding Resident #96's pain level being documented as zero, no further explanation was provided. The DON was then informed of observations of Resident #114 asking staff to assist them to go to their room and lay down. When asked, the DON expressed the Resident is able to go to their room and lay down whenever they want. The DON was then questioned why staff did not acknowledge or assist the Resident and replied, I will look into that. Review of facility policy/procedure entitled, Resident Rights (Reviewed 1/15/24) revealed, Policy . The resident has a right to a dignified existence, self-determination . 6. The resident has the right to refuse treatment, deny or withdraw consent at any time . 39. The resident has the right to be treated in a manner and in an environment that maintains or enhances each resident's dignity and respect in full recognition of his or her individuality. 40. The resident has the right to choose activities, schedules, and health care .

Based on observation, interview and record review, the facility failed to ensure a safe environment to prevent skin tears and bruising for one resident (Resident #22) of 8 residents reviewed for accidents, resulting in Resident #22 suffering repeated skin tears and bruising. Findings Include: Resident #22: Accidents A record review of the Face sheet and Minimum Data Set/MDS assessment for Resident #22 identified a readmission to the facility on [DATE] with diagnoses: Diabetes, heart disease, heart failure, COPD, arthritis, Alzheimer's, and a history of falls. The MDS assessment dated [DATE] indicated the resident had a BIMS score of 9/15 with moderate cognitive decline and needed assistance with all care. On 10/14/2024 at 11:53 AM, Resident #22 was observed lying in bed; there were two handrails on the sides of the bed (grab bars). He was observed to have thick tan colored arm sleeves from his wrist to mid-upper arm on. Certified Nurse Aide/CENA P said the resident wore the sleeves to protect his arms because he repeatedly tried to climb out of bed. The aide said the resident would bump the rails and get skin tears on his arms. A review of the Incident and Accident Reports for Resident #22 revealed the following: Falls: Resident #22 had 2 falls over the last year- 5/27/2024, and 6/13/2024. 5/27/2024 at 2:15 PM- Resident found sitting on buttocks on floor beside bed, no injury, intervention to add 2 stacked mats beside the bed. The resident had recently completed antimicrobial treatment for C. Diff (a diarrheal infection) and a UTI (urinary tract infection). The report indicated the resident has confusion with UTI's. The resident's interventions were updated to include double stacked mattresses on the floor. 6/13/2024 at 11:40 AM- Resident #22 was found lying on floor next to his wheelchair with his bedside table tray in front of him. He had a laceration on his head 3 cm x 0.5 cm, hematoma 5.5 cm x 2.5 cm, bruise above left eye 7 cm x 3.5 cm. laceration left eye hematoma 1 cm x 1 cm. He was sent to the emergency room /ER and received 4 staples to the laceration on his head. The Incident and Accident Reports also identified Resident #22 as obtaining 13 skin tears and/or bruises from 11/23/2023- 10/3/2024. 11/23/2023 at 4:17 AM- 3.5 cm x 3.5 cm green purple bruise next to a skin tear right fore arm during transfer; The report provided, Predisposing Situation Factors: 'During Transfer'. 12/10/2023 at 5:57 PM- Back of right hand between 1st and 2nd digit open 0.5 cm V shaped skin tear. At sight of an existing bruise. 12/14/2023 at 10:40 AM- 0.5cmx1cm left hand between 1st and 2nd digits. The report stated, It happened when my hand brushed against the sling in the lift. 1/11/2024 at 2:42 AM- Right hand bruises 2.5 cm x 1.5 cm dark purple bruise back of right hand at base of thumb. 1/18/2024 at 4:30 PM- Skin tear right upper arm during care. 2/22/2024 at 2:02 AM- Dark purple bruise back of right hand 1cm x 2 cm. 2/29/2024 at 2:49 AM-Bruising to left upper arm, top of left hand and right wrist. Resident stated he thought it was from transfer to chair. 6/23/2024 at 10:27 PM- 0.3 cm x 0.3 cm open area right elbow near a scab, fell [DATE]. 6/26/2024 11:00 PM- Purple yellow bruise right ankle 5 cm x 2.5 cm. 6/29/2024 at 2:39 PM- Skin tear left bicep 0.5cm x 0.5 cm. 7/17/2204 at 10:30 PM- Skin tear 2 cm x 4 cm left upper arm with fresh blood; 9/20/2024 at 3:15 AM- Found on mattress on floor next to bed, with 3 new skin tears: between elbow and wrist on forearm 3 cm; on left elbow 1 cm; above left elbow 2 cm x 1 cm. on left arm from the rails. Per report, Resident injuries consistent with his likely using arms and bumping into hard surfaces attempting to self-transfer to mats. 10/3/2024 at 3:24 AM- LUE (left upper extremity) 3cm x 3cm dark purple bruise; (right forearm) purple bruise 4.5 cm x 6.5 cm with 1 cm dry scabbed area. A review of the Care Plans for Resident #22 identified the following: Requires assist with ADL (activities of daily living) needs (related to) Fatigue, weakness, dementia, date initiated 5/4/2023 and revised 9/16/2024 with Interventions including: Mobility handles per Dr's order for safety during care provision, to assist with bed mobility Observe for injury or entrapment related to mobility handle use, date initiated 8/28/2023; Assist with bathing, grooming, meals, dressing and personal hygiene as needed, date initiated 5/4/2023. Per the MDS assessment dated [DATE], the resident was identified to be dependent for all care except for eating. He was not able to transfer on his own and could not ambulate (walk). The resident is at risk for falls related to decondition, impaired safety awareness, impaired mobility, date initiated 5/4/2023 and revised 9/16/2024 with Interventions including: T/F (transfer): 1 assist with Hoyer & medium sling . date initiated 8/17/2023 and revised 3/26/2024. Resident #22 was identified to have many injuries (skin tears and bruises); some of the injuries did not have an identified cause, but several listed the resident attempting to exit the bed on his own or he had injuries from transfers with the mechanical lift. There was 1-person assigned to assist the resident with transfers with the lift; there was no mention on whether this was safe for one person to manage the mechanical lift and ensure the resident's safety, as the resident was dependent with transfers. The resident has potential for impairment to skin integrity related to fragile skin, date initiated and revised 6/8/2023 with 2 Interventions, Follow facility protocols for treatment of injury, date initiated 6/22/2023 and Dermasaver BUE (bilateral upper extremities) (at all times), off q shift & check skin, date initiated 8/17/2023 and revised 9/25/2024. The resident was ordered arm sleeves (Dermasavers), but continued to develop injuries. In some instances, the injuries were outside the area the Dermasaver covered. There was no mention of the resident climbing or attempting to climb out of bed, or if the Mobility bars were causing bruising or skin tears. On 10/16/2024 at 9:50 AM, during an interview with Quality Nurse H, he was asked about the injuries that Resident #22 had obtained. Quality Nurse H said he investigated the incidents, and the resident was confused and attempted to get out of bed at times and that is why he had the 2 mattresses on the floor. He said the resident had fragile skin and the Dermasavers for his arms were provided to protect them. There was no explanation for injuries potentially from the Mobility bars or during transfers, as some of the injuries were similar and in the same locations. A review of the facility policy titled, Skin care, date implemented 4/16/2003, reviewed 11/4/2021 and revised 2/18/24 provided, . Weekly Skin Assessment Procedure: . Skin assessment to be complete by unit nurses on their scheduled day . Fragile Skin/Skin Tears/Abrasions . There was no mention of investigating the causes for the injuries. A review of the facility policy titled, Falls and Fall Risk, date approved 11/25/2002, reviewed 12/27/22 and revised 1/10/24 provided Policy: The goal of the (facility) is to improve the prevention and management of resident falls by assessing/identifying the resident's risk for falls. Then incorporating a treatment/management program related to the individual resident's needs, monitoring/evaluating the effectiveness of interventions that have been employed . A Restorative Nurse will review current ADL documentation during the fall review to assess for changes in level of assistance utilized with transfers . All falls are recorded on an incident report . The policy was specific to falls, and did not address other injuries or potential causes for injuries.

Based on observation, interview and record review, the facility failed to update and follow care planned interventions for one resident (Resident #51) of two residents reviewed for tube feeding, resulting in the head of the bed being at 19 degrees during tube feeding with the likelihood of decreased tube feeding dose, aspiration and/or pneumonia. Findings include: Resident #51: On 10/16/24, at 11:00 AM, a record review of Resident #51's electronic medical record revealed a readmission on 09/30/2024 with diagnoses that included Dysphagia, Multiple Sclerosis and Pneumonitis due to Inhalation of food and vomit. Resident #51 required extensive assistance with Activities of Daily Living and had intact cognition. A review of the physician orders revealed . Jevity 1.5 Cal Liquid (Nutritional Supplements) Directions Give 60 ml enterally . Start Date 10/9/2024 . Ensure HOB is elevated 30 degrees for duration of feeding and 60 minutes after feeding complete Line up yellow markings on bed and headboard . Start Date 09/30/2024 . A review of the Kardex revealed . Resident Care . Yellow markings lined up R/T (related to) TF (tube feed) . A review of the care plan The resident requires tube feeding tube r/t Dysphagia, Resident has G-tube Date Initiated: 03/14/2024 . Interventions/Tasks . Current TF regimen: Jevity 1.5 45 ml until 1080 cc infused 400 mLs flushes for A shift and 400 mLs flushes for B shift Date Initiated: 09/12/2024 . HOB @ 30 degrees during & after T.F. for an hour, use wall timer Date Initiated: 03/15/2024 . Visualize hourly Date Initiated: 09/30/2024 Yellow marking lined up R/T T.F. Date Initiated: 09/30/2024 One hour after tube feed done, lower HOB Date Initiated: 09/30/2024 On 10/17/24, at 8:30 AM, Resident #51 was lying in their bed on their left side. Their tube feeding pump was running and the tubing was hooked to the resident. The head of the bed appeared low. A measurement of the bed frame and head of the bed revealed an angle of only 19 degrees incline. On 10/17/24, at 8:35 AM, an observation of Resident #51's head of the bed was conducted with Nurse M. Nurse M was asked if the head of the bed was high enough and Nurse M offered there used to be a yellow line on the head board to show the proper height but I don't see the yellow tape. There was a faint line on the headboard which appeared if there was tape at one point. The top of the mattress was below the faint line. Nurse M was asked if the top of the mattress should be above the faint line or the bed frame and Nurse M stated, I believe the bed frame and raised the head of the bed to allow the bed frame to be even with the faint line.

Based on observation, interview and record review the facility failed to follow physician's orders for oxygen administration for one resident (Resident #117) of one resident reviewed for oxygen administration, resulting in the oxygen flow rate being administered not matching the Kardex or care plan. Findings include: Resident #117 (R117): R117 is [AGE] years old and admitted to the facility on [DATE] with diagnoses that include COPD (Chronic Obstructive Pulmonary Disease), chronic pulmonary edema, anxiety and anemia. On 10/14/24 at 09:56AM, R117 was observed sitting in a reclining chair with oxygen being administered at 3LPM (liters per minute) via NC (nasal cannula). The oxygen tubing was dated 10/10. On 10/15/24 at 08:58AM, R117 was observed sleeping in bed, oxygen was being administered at 3LPM via NC. On 10/16/24 at 03:57PM, R117 was asked if they are on oxygen continuously. R117 stated they use oxygen all the time and currently use 3LPM. The oxygen concentrator was observed set to 3LPM and the humidification bottle was empty. On 10/16/24 at 03:59PM, an interview was conducted with CNA (Certified Nursing Assistant) L. CNA L was asked who sets the oxygen flow rate for residents. CNA L stated the nurses set the rate, CNA L also stated that the aides are not allowed to set the rate or change it. CNA L was asked where they would look in the EMR (Electronic Medical Record) to see what the rate is supposed to be for a resident on oxygen in order to make sure it is set correctly. CNA L replied they would look In the Kardex (an area in the EMR that CNA's have access to and helps to guide their care) and the rate should be available, if not, CNA L stated they can check the physician orders and see what the rate should be. On 10/16/24 at 04:15PM, record review of the Kardex revealed that R117 was on continuous oxygen via NC at 2LPM. The care plan for altered respiratory status, last revised on 06/03/2024, revealed an intervention/task that stated R117 is on continuous oxygen via nasal cannula at 2LPM. Humidified as needed, last revised on 06/03/2024. On 10/16/24 at 04:20PM, record review of the physician's order for oxygen administration states, PRN(as needed) oxygen at 1-6LPM via nasal cannula for signs and symptoms of respiratory distress and/or to maintain oxygen saturation greater than/equal to 90%. May humidify PRN for resident comfort. On 10/17/24 at 09:22AM, an interview was conducted with RN (Registered Nurse) K. RN K was asked how they confirm the rate of oxygen administration for residents. RN K stated the nurses have a standing order for oxygen for 1-6LPM to titrate to the residents needs. RN K stated when a resident admits from the hospital they set the rate to the hospital order, monitor the oxygen saturation levels and confirm if that is a good rate for the resident. RN K stated the physician will be notified if the rate needs to change but the staff nurses can immediately titrate it according to the standing order. RN K was asked how would a CNA know what the rate should be, so they can confirm if it is correct or not. RN K stated the CNA's will come to the nurses and ask what the rate is and then confirm if it is correct on the oxygen concentrator or portable tank. Review of the policy titled, Oxygen Delivery Systems, revised 11/15/23, revealed: 5. Nursing Guidelines for Oxygen Therapy: a. Licensed staff using oxygen equipment will be trained in its operation, safety precautions, and manufacturer ' s instructions for using the equipment. Training will occur upon hire and periodically for review of safety guidelines and usage requirements. b. Oxygen therapy requires a Physician's Order, except in the case of an emergency. Standing orders for oxygen are found in policy # 701-222 Standing Order Protocols c. Follow the order from the physician for flow rate, device and specific parameters related to oxygen saturation levels. d. Humidification is appropriate for discomfort associated with mucous membranes and can be added prn. e. Using pulse oximetry, maintain Oxygen Saturation greater than or equal to 90% or per Physician ' s order. f. Oxygen saturation should be monitored every shift while resident is receiving continuous oxygen or has an order for PRN oxygen. g. If oxygen is not used for a period of 1 week, obtain an order to have oxygen therapy discontinued due to non-use. Review of the policy titled, Standing Order Protocols, last revised 5/30/24, revealed: POLICY: The Medical Director of TCMCC has outlined protocols to give Nurses the authority to initiate treatment to maintain the health and well-being of a resident until the physician can be notified. OXYGEN THERAPY: For signs of respiratory distress and/or oxygen saturation less than 90%: O2 1-6 L/min. per Nasal Cannula to maintain O2 sat greater than or equal to 90%. Humidify PRN for complaints of dry mucous membranes. Check oxygen saturation every shift and as needed For oxygen saturation less than 90% and/or continued signs of respiratory distress after implementing above standing order, contact the physician for further orders regarding oxygen flow rate and oxygen delivery device.

Based on interview and record review, the facility failed to implement a yearly Quality Assessment Process Improvement (QAPI) Plan specific to the facility's population and concerns to ensure correction of deficiencies necessary to ensure resident safety and quality of life for 127 residents of the facility, resulting in the potential for negative physical and psychosocial outcomes for all 127 residents of the facility. Findings Include: FACILITY QAPI and QAA On 10/17/24 at 2:23 PM, the Administrator was interviewed about the facilities QAA/QAPI program. The Administrator said he oversaw the QAPI program at the facility; he said the committee met monthly, except for December. He said they met the quarterly meeting requirements. When asked to review the committee attendance forms. The Administrator provided a document with 3 paragraphs; he said he had typed the names of those in attendance and those that were not present for the meetings and were excused. The entries he provided did not meet the attendee requirements as the Medical Director/Physician did not attend on one of the meetings provided. When asked again to review the attendance forms, the Administrator would not let the surveyor see the original documents. He provided another typed date that met the quarterly requirement. When asked about the processes for the QAPI program, the Administrator responded We meet that requirement. The Administrator was asked how areas of focus were identified for improvement and he said the committee focused on Quality measures. When asked for further specifics he said he was not sure if he could relay that information. During the review of the QAPI program with the Administrator, he was asked if the QAPI committee had completed a yearly performance improvement project (PIP) and he stated, No. The question was re-worded, and a performance improvement project definition was clarified with the Administrator and he said he knew what it was, and they had not completed one. The review of the QAPI program continued and the Administrator said he thought the committee might have completed a performance improvement project (PIP). He said he would have to check on it. No further information about a performance improvement was received prior to exit on 10/17/2024 at 4:40 PM.

Based on observation, interview and record review, the facility failed to prevent development and worsening of pressure ulcers for two residents (Resident #24, Resident #37), resulting in the worsening of a skin injury for Resident #24 and a facility-acquired Stage III pressure ulcer for Resident #37. Findings include: Record review of facility 'Skin Care' policy dated 11/8/2022 revealed a head-to-toe skin assessment is completed and documented on all residents upon admission by a licensed nurse and/or registered nurse, and weekly skin assessment thereafter by licensed or registered nurse that is documented in EMR. Skin Risk assessment to be completed on admission, weekly for 4 weeks then quarterly with MDS schedule and as needed. All residents will be reviewed for appropriate pressure relief interventions in place. Nursing will assess and plan additional interventions as needed. The focus of the skin assessment is to: (1.) Promote the health of the skin and identify residents at risk for skin breakdown. (2.) Prevent the development of pressure ulcers and other alterations of skin integrity. (3.) Provide healing when the skin integrity of the resident has been altered. Record review of Form CMS-802 Roster Matrix identified Resident #24 as having a Stage IV (4) Pressure ulcer and Resident #37 as having a Stage III (3) facility-acquired pressure ulcer. Resident #24: Record review of Resident #24's re-admission assessment dated [DATE] section C: Skin Integrity revealed normal color was normal, temperature was warm, equal, and dry. Skin turgor was noted as normal. Skin integrity noted multiple areas. The right buttocks noted 1 cm X 1 cm in size excoriated open area and allevyn foam applied. Left buttocks 1.5 cm X 1 cm in size excoriated open area and allevyn foam applied. Record review of Resident #24's Admission Minimum Data Set (MDS) dated [DATE] revealed an elderly male with Brief Interview of Mental Status (BIMS) score of 15 out of 15, cognitively intact. Medical diagnosis included: anemia, atrial fibrillation, heart failure, hypertension, orthostatic hypotension, benign prostatic hyperplasia, obstructive uropathy, pneumonia, diabetes, arthritis, other fracture, depression, and chronic obstructive pulmonary disease (COPD). Section G: Functional status assessment Resident #24 as: Extensive assist on one person with bed mobility, dressing, eating, toilet use and personal hygiene. Total dependence on staff of one person with transfers, locomotion, and bathing. An interview on 10/25/23 at 09:30 AM with Resident #24 revealed that his tail bone was cracked, the sore flared up every once in a while, and yes, the sore was painful. Resident #24 acknowledged that the sore on his bottom had gotten larger while he has been living at the facility. In an observation and interview on 10/25/23 at 09:40 AM with Certified Nurse Assistant (CNA) B of Resident #24's dressing to the coccyx, no date on the dressing was noted. Both CNA B and the state surveyor looked for a date to the dressing. CNA B stated that the wound care nurse was in here this morning. Record review of Resident #24's progress notes from 5/19/2023 through 10/26/2023 revealed: On 6/5/2023 at 8:43 AM skin care notes of pressure ulcer of unstageable with 100% yellow wound bed, measurements: length 4.5 cm X width 4 cm with no depth. Noted 10 cm X 10 cm of redness surrounding area. On 6/12/2023 at 7:38 AM skin care notes of pressure ulcer of unstageable with 100% yellow wound bed, measurements: length 4.5 cm X width 4 cm with no depth. Noted 10 cm X 8.5 cm of redness surrounding area. On 6/20/2023 at 6:35 AM skin care notes of pressure ulcer of unstageable with base visible with 100% yellow wound bed, no measurements noted. On 7/3/2023 at 12:53 PM skin care notes of pressure ulcer of unstageable with 100% yellow wound bed, measurements: length 4.2 cm X width 3.2 cm with no depth. On 7/10/2023 at 1:00 PM skin care notes of pressure ulcer of unstageable wound bed visible, 25% yellow/75% redness with scant drainage noted. Measurements: length 4.2 cm X width 3 cm X depth 1.4 cm with undermining at 12 to 6 O'clock measurement of 1.4 cm, and 7-11:00 O'clock measurements of 2.5 cm. On 7/17/2023 at 11:59 AM skin risk note of pressure ulcer is staged IV (4) with visible base of 10% yellow/90% redness. Measurements: length 4.7 cm X width 3 cm X depth 1.2 cm with undermining around the entire wound measurements of 2.5 cm. Area with blanchable redness. On 7/24/2023 at 2:17 PM skin care notes of pressure ulcer of unstageable wound bed visible, 25% yellow/75% redness with serosanguinous drainage noted. Measurements: length 4.7 cm X width 2.5 cm X depth 1.2 cm with 2.7 cm undermining around entire wound with bone palpable. On 7/31/2023 at 1:22 PM skin risk note of pressure ulcer is a stage IV (4) with visible base of 10% yellow/90% redness with serosanguinous drainage of moderate amount. Measurements: length 5 cm X width 2.5 cm X depth 1 cm with undermining around entire wound, deepest area at 2.5 cm at 11:00 O'clock. Surrounding skin area appearance is reddened. On 8/8/2023 at 10:07 AM skin care note of pressure ulcer is stage IV (4) with wound base of 10% yellow/90% redness with serosanguinous drainage of moderate amount. Measurements: length 5 cm X width 2.5 cm X depth 1 cm with undermining around entire wound, deepest area at 4.0 cm at 11:00 O'clock. Surrounding skin area appearance is reddened. On 8/13/2023 Resident #24 was sent to the emergency room for gastrointestinal issues. An interview on 10/26/23 at 02:02 PM with Licensed Practical Nurse (LPN) F revealed that she was made aware of the observation of the surveyor on 10/25/2023 and LPN F owned up to the fact that there was no date and initials/signing the coccyx dressing on that day. LPN F was made aware of the incident that the state surveyor observed the dressing and there was no date or initials of nursing found on the dressing, that was because LPN F stated she was using up the residents' old supplies in the wardrobe and LPN F did not date the dressing that was used. LPN F acknowledged that Resident #24 was admitted on [DATE] with a wound on admission. Over time the facility debrided the wound with Santyl, and it is now a Stage IV (4). The state surveyor inquired how the wound advanced to Stage 4 from slough. LPN F stated that the Santly with debridement. In an observation of Resident #24's coccyx wound on 10/27/23 at 09:42 AM, Licensed Practical Nurse (LPN) F prepared wound dressing items of: Promogran Prisma AGE, silver, and collagen, for new tissue growth. Observation of the Stage IV (4) dressing change observation, enhanced barrier precautions were used. The state surveyor observed suprapubic catheter dressing in place. LPN F stated the suprapubic catheter has come out, and resident was awaiting replacement, The state surveyor observed coccyx wound dressing was removed had been dated and initialed. LPN F proceeded to use Normal Saline to cleanse. LPN F acknowledged there was tunneling noted to deepest at 12:00 O'clock and 1-7:00 PM tunneling. LPN F applied outer skin barrier applied. Measurements performed: length of 6.0 cm X width 3.0 cm X depth 0.7 cm. Tunneling measurement increased since last measurement to 1.9 cm 12 o'clock. Edges of alginate dressing pushed under lip of the wound. LPN F stated that Resident #24 has not had a wound vac or wound clinic visits for this wound. LPN F place large absorb dressing covered with a clear outer dressing dated and initialed. Positioning pillows placed for comfort. Resident #37: Record review of Resident #37's Admission Minimum Data Set (MDS) dated [DATE] revealed an elderly female with Brief Interview of Mental Status (BIMS) score of 9 out of 15, cognitive impairment. Medical diagnosis included: anemia, coronary artery disease, heart failure, hypertension, renal insufficiency, neurogenic bladder, urinary tract infection, arthritis, osteoporosis, hemiplegia, post [NAME] syndrome, and weakness. Section G: Functional status assessment Resident #37 as: Extensive assist on one person with bed mobility, dressing, eating, toilet use and personal hygiene. Total dependence on staff of one person with transfers, locomotion, and bathing. There were no skin issues noted. Record review of Resident #37's weekly wound care assessment dated [DATE] noted left ischial tuberosity facility acquired pressure ulcer unstageable with wound base color 50% yellow/50% red with serosanguinous drainage. Measurements: length 1.5 cm X width 1.0 cm with peri wound tissue noted as reddened. Treatment of Medi honey/mepilex. Record review of Resident #37's progress notes from 1/1/2023 through 10/26/2023 revealed: On 4/18/2023 at 9:10 AM wound/skin note documented a left ischium abrasion measuring length 1.5 cm X 0.7 cm red wound base with no drainage noted. On 4/26/2023 at 11:54 AM progress note documented an abrasion to the left ischial measuring length 1.5 cm X width 1.0 cm with yellow/red wound base. On 5/2/2023 at 12:30 PM progress note left ischial tuberosity as pressure ulcer unstageable with 100% yellow wound base. Measurements: length 1.5 cm X width 1.0 cm with undermining related to slough. Observation on 10/25/23 at 11:08 AM of Resident #37 revealed the resident to be seated up in chair in bingo activity. Observation noted a urinary catheter in place. Record review of Resident #37's Progress notes, dated 9/22/2023 at 12:51 PM, revealed pressure ulcer to the left ischial tuberosity Stage III wound closed with redness remains. On 9/25/2023 at 1:07 PM noted the left ischial tuberosity area closed with 100% non-blanchable redness. On 10/3/2023 at 11:53 AM noted left ischial tuberosity Stage III wound base was closed, pink blanchable tissue remains. Record review of Resident #37's Progress notes, dated 10/23/2023 at 1:34 PM, documented the re-opening of the left ischial tuberosity Stage III with scant drainage. Measurements: length 1.3 cm X width 1.3 cm with depth less than 0.1 cm. In an interview on 10/26/23 at 02:50 PM, Licensed Practical Nurse (LPN) F revealed that Resident #37's left ischial wound started on 5/2/2023 and it did get bigger and then the wound closed in September 2023. LPN F stated that then on 10/23/2023 the left ischial tuberosity wound re-opened to a Stage III and was facility acquired. Resident #37 was re-started on a multi-vitamin, vitamin C, Zinc, and alginate. Observation of Resident #37's wound care on 10/27/23 at 10:06 AM with Licensed Practical Nurse (LPN) F revealed that enhanced barrier precautions were followed. LPN F gathered her supplies of exiderm, dermafilm, hydrocolloid dressing. bottom drawer of treatment cart retrieved 4 x 4 gauze out of package, sat them on to top of treatment cart, did not clean top of cart between residents or use a barrier. LPN F stacked all supplies on top of each other applied a gown and gloves. Observation of the Left ischial dressing was removed, and a stage III (3) wound was noted. LPN F used 44 gauzes wetted with normal saline and applied to the wound bed for cleansing, more 44 gauze was then used to dry area, skin prep applied to the skin around the wound. Measurements of length recent X width 0.5 cm with depth less than 0.1 cm. LPN F applied treatment of debridement hydrocolloid dressing applied. Record review of the 'National Pressure Ulcer Advisory Panel (NPUAP) Pressure Injury Stages' document dated 2017 revealed pressure injury staging definitions: Unstageable Pressure Injury- obscured full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar. Stage III (3) pressure injury- Full thickness skin loss, in which adipose (fat) is visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. Stage IV (4) pressure injury- Full thickness skin tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage, or bone in the ulcer.

Based on observation, interview, and record review the facility failed to follow professional standards of practice by ensuring four residents' (#11, #35, #79 and #83) comprehensive quarterly assessment progress notes were inputted timely, resulting in the four residents having 2-3 missed assessment progress notes due to lack of oversight and time management. Findings include: Resident #79: During initial tour on 10/25/2023, Resident #79 was observed resting in her room. Further review of Resident #79's medical records revealed she was admitted to the facility on [DATE] with diagnoses that included, Vascular Dementia, Hemiplegia and Hemiparesis, Schizophrenia, Bipolar Disorder, Epilepsy, and Insomnia. Further review was completed of Resident #79's record and yielded the following results: Social Work Quarterly Assessment Progress Notes: After April 2023 there was no quarterly assessments completed in the months of July 2023 and October 2023. Resident #35: On 10/26/2023, a review was completed of Resident #35's medical record and it revealed the resident was admitted to the facility on [DATE] with diagnoses that included Alzheimer's, Dementia, Post-traumatic stress disorder and Diabetes. Further review was conducted of Resident #35's records and yielded the following: Social Work Quarterly Assessment Progress Notes: After January 2023 there was no quarterly assessments documented in the months of April 2023 and July 2023 for Resident #35. Resident #83: On 10/26/2023, a review was completed of Resident #83's medical record and it revealed he was admitted to the facility on [DATE] with diagnoses that included, Parkinson's, Dementia, Diabetes, Heart Disease and Anxiety. Further review was conducted of Resident #35's records and yielded the following: Social Work Quarterly Assessment Progress Notes: After March 2023 there were no quarterly assessments documented in the months of March 2023 and September 2023 for Resident #83. Resident #11: On 10/26/2023, a review was completed of Resident #11's medical record and it revealed she was admitted to the facility on [DATE] with diagnoses that included, Multiple Sclerosis, Bipolar Disorder, Anxiety, Delusional Disorder ad Alzheimer's Disorder. Further review was conducted of Resident #11's records and yielded the following: Social Work Quarterly Assessment Progress Notes: After January 2023 there were no quarterly assessments documented in the months of April 2023, July 2023 and October 2023 for Resident #11. It can be noted the Social Worker quarterly progress notes are very detailed and provide extensive information related to the resident's needs, background, likes/dislikes etc. and is of greatly aide in the daily care provided to the resident. On 10/27/2023 at 12:40 PM, and interview was conducted with Social Work Director Y and Social Worker Z regarding documentation of social work quarterly assessments. Director Y stated it's the departments expectation the team completes a progress note after their annual or quarterly assessment and then input the information into the appropriate MDS section. Social Worker Z stated they are responsible for MDS sections C, D, E, Q for quarterly assessments and for annual assessments they complete sections C, D, E, Q and V. Director Y was queried if she was aware, four residents were missing two or more documented quarterly assessment progress notes. She stated she was not. This writer reviewed the missing assessments with the Director who shared the residents were all assigned to Social Worker AA. On 10/27/2023 at 12:50 PM, an interview was conducted with Social Worker AA regarding the missing quarterly assessment documentation for Resident's #11, #35, #79 and #83. Social Worker AA, stated typically she will input all the information into the appropriate MDS section after the assessment was completed but is not the best at inputting the subsequent progress notes. Social Worker AA shared they are trained to complete a detailed progress note of the assessment and input into the resident's medical record. Social Worker AA was asked if she was aware she had about two or more quarterly assessment progress notes missing for four different residents. She shared she is behind on inputting the progress notes for all her assigned residents as she struggles with time management. When asked how many residents she is assigned she stated, 30. Review was completed of the facility policy entitled, Social Services Assessments, reviewed 3/13/2023. The policy stated, Assessments will be completed by a Social Worker in order to determine a resident's level of cognition, mood, behavior and psychosocial status .A Social History and Assessment will be obtained as necessary to obtain pertinent background information and a better understanding of the resident . Review was completed of, Social Worker Job Description, it stated, . Perform administrative requirements, such as completing necessary forms, reports, etc., and submitting such to the Administrator as required .

Based on observation, interview and record review, the facility failed to ensure the provision and care of indwelling urinary catheter drainage bags per professional standards of practice for five residents (Resident #24, Resident #37, Resident #46, Resident #61, and Resident #235) of six residents reviewed, resulting in urinary catheter drainage bags and tubing being maintained in an unsanitary conditions and a lack of comprehensive assessment and monitoring of urinary catheters for residents. Findings include: Resident #46: On 10/25/23 at 2:13 PM, an observation of Resident #46 occurred in their room. One side of the Resident's bed was positioned against the wall. Resident #46 was in bed, positioned on their back, with their eyes closed. An indwelling urinary catheter drainage bag was positioned directly on the floor. Record review revealed Resident #46 was admitted to the facility on [DATE] with diagnoses which included urinary retention, Benign Prostatic Hyperplasia (BPH), skin cancer, and heart disease. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the Resident was moderately cognitively impaired and required supervision to moderate supervision to complete Activities of Daily Living (ADL). On 10/27/23 at 8:17 AM, Resident # 46 was observed sitting in their wheelchair at a table in the dining room of the unit. The Resident's urinary catheter drainage bag was in a dignity bag under the wheelchair. The urinary catheter drainage tubing was directly on the floor. The dignity bag, containing the urinary catheter drainage bag, was on the floor and dragged under the wheelchair when the Resident's wheelchair was moved. An interview was completed with Registered Nurse (RN) T on 10/27/23 at 8:35 AM. When asked if urinary catheter tubing should be directly on the floor, RN T replied, No. An observation of Resident #46's urinary catheter drainage bag was completed with RN T at this time. When queried regarding Resident #46's catheter and tubing, RN T stated, We are supposed to put it in the bag (dignity bag). When queried regarding the dignity bag dragging on the floor, RN T indicated the bag is able to be adjusted so it doesn't drag. RN T then stated, They just put a suprapubic (surgically created opening in the abdomen to the bladder to allow for the drainage of urine) in yesterday. RN T did not pick the tubing off the floor and/or adjust the dignity/drainage bag. Resident #235: On 10/25/23 at 12:11 PM, Resident #235 was observed in the dining room of the facility sitting in a wheelchair. The Resident was observed attempting to reposition themselves in the wheelchair. When queried, Resident #235 revealed their back was hurting them in the wheelchair. The Resident was noted to have an indwelling urinary catheter. The urinary catheter drainage bag was positioned under their chair with the tubing and bag positioned directly on the floor. Record review revealed Resident #235 was admitted to the facility on [DATE] with diagnoses which included respiratory failure, heart failure, kidney failure, and urinary retention. Review of admission documentation indicated the Resident was cognitively intact and required supervision to total assistance to complete ADL. Review of Resident #235's care plans revealed a care plan entitled, The resident has Indwelling Catheter in place R/T (related to): Urinary Retention (Initiated: 10/21/23). The care plan included the interventions: - Catheter care per policy & procedure (Initiated: 10/21/23) - Catheter: The resident has (SPECIFY Size) (SPECIFY Type of Catheter). Position catheter bag and tubing below the level of the bladder (Initiated: 10/21/23) - Keep in cloth bag for discreteness/cleanliness (Initiated: 10/21/23) - Maintain a closed system (Initiated: 10/21/23) - Change drainage bag per policy & procedure (Initiated: 10/21/23) At 2:47 PM on 10/25/23, Resident #235 was observed in their room in bed with Witness V. Resident #235's indwelling urinary catheter drainage bag and tubing were not contained and positioned directly on the floor. An interview was completed at this time. When queried regarding their indwelling urinary catheter, Resident #235 revealed the catheter was inserted in the hospital prior to coming to the facility. When asked additional questions, Resident #235 referred to Witness V to respond. With further inquiry, Witness V revealed the hospital nursing staff took out the catheter but had to put it back in before transferring to the facility because Resident #235 was unable to urinate. When asked what the plan was in relation to the catheter, Witness V indicated the Resident needed to see a urologist and stated the hospital said, We would need to have one (appointment) set up. When queried a urologist appointment had been set up/scheduled by the facility, both Resident #235 and Witness V disclosed an appointment had not been scheduled. An interview was completed with Unit Manager RN W on 10/27/23 10:57 AM. When if indwelling urinary catheter drainage bags and tubing should be directly on the floor, Unit Manager RN W confirmed that drainage bags and tubing should be contained and not directly on the floor. When queried regarding observations of Resident #46 and Resident #235's urinary catheter drainage tuning and drainage bags on the floor, Unit Manager RN W was unable to provide an explanation. On 10/27/23 at 11:50 AM, an interview was conducted with the Assistant Director of Nursing (ADON). When queried regarding urinary catheter tubing and drainage bags on the floor, the ADON indicated they would need to refer to facility policy/procedure. No further explanation was provided. 39059 Resident #61: On 10/26/23, at 8:39 AM, Resident #61 was resting in bed. Their urinary catheter tubing was pink in color with sediment noted to the tubing. On 10/26/23, at 1:44 PM, an observation along with Nurse Manager U of Resident #61's urinary catheter and tubing was conducted. Nurse Manager U was asked what they saw and Nurse Manager U stated, it looks like brown sediment. The catheter tubing along with the chamber in the drainage bag was brown in color and appeared to have had large amount of sediment built up. On 10/26,23, at 1:51 PM, a record review along with Nurse Manager U of Resident #61's progress notes revealed the most recent mention of the urinary catheter was on 10/6/2023 06:04 Residents Foley catheter collection bag with more than a pink tinge, color is now sanguine in color resident denies any flank or pelvic pain, denies any nausea, vomiting, fever or chills. Urine does have a pungent odor when emptying collection bag. Routine labs completed this AM . There was no mention of notifying the physician of the findings. A review of the Physician progress note on 10/16/2023 and 10/2/2023 along with Nurse Manager U revealed no mention of the urinary catheter with blood tinged urine, pungent odor or sediment. On 10/26,23, at 3:30 PM, a record review of Resident #61's electronic medical record revealed an admission on 8/15/2023 with diagnoses that included Kidney failure, Obstructive and Reflux Uropathy and Pressure ulcers. Resident #61 required extensive assistance with all Activities of Daily Living and had impaired cognition. A review of the The resident has indwelling Catheter in place R/T (related to) Other Obstructive and Reflux Uropathy Date Initiated: 08/14/2023 Revision on: 08/18/2023 Goal Device will function properly without complication through review date . Interventions/Tasks . Monitor/record/report to MD for s/sx (signs and symptoms) UTI: (urinary tract infection) pain, burning, blood tinged urine, cloudiness, no output, deepening of urine color, increased pulse, increased temp, Urinary frequency, foul smelling urine, fever, chills, altered mental status, change in behavior, change in eating patters. Date Initiated: 08/14/2023 Monitor/Report any sediment, blood, or mucous in tubing. Date Initiated: 08/14/2023 A review of the Weekly Nursing Assessment documents for the month of October, 2023 revealed no mention of sediment that was present in the urinary catheter tubing. On 10/27/23, at 8:45 AM, Nurse Manager U was asked if they had alerted the physician of the sediment in Resident #61's urinary catheter and Nurse Manager U stated, they sent them a text. The Text was unable to be reviewed and Nurse Manager U stated, they would put in a late progress note. A further review of the nurse progress notes revealed 10/26/2023 16:47 Late Entry: Note Text: Text sent to MD related to brownish sediment noted in catheter tubing fluids con't to be encouraged. Resident denies discomfort. 22927 Resident #24: Record review of Resident #24's Admission Minimum Data Set (MDS) dated [DATE] revealed an elderly male with Brief Interview of Mental status (BIMS) score of 15 out of 15, cognitively intact. Medical diagnosis included: anemia, atrial fibrillation, heart failure, hypertension, orthostatic hypotension, benign prostatic hyperplasia, obstructive uropathy, pneumonia, diabetes, arthritis, other fracture, depression, and chronic obstructive pulmonary disease (COPD). Section G: Functional status assessment Resident #24 as: Extensive assist on one person with bed mobility, dressing, eating, toilet use and personal hygiene. Total dependence on staff of one person with transfers, locomotion, and bathing. Observation and interview on 10/25/23 at 09:30 AM of Resident #24 was seated up in a high back wheelchair in the resident's room. Resident #24 stated that his tail bone was cracked and had a sore, the sore flares up every once in a while, and yes it was painful. The state surveyor observed catheter tubing to be on the floor under the wheelchair. Resident #24 stated that he was waiting Hoyer transfer back to bed. Observation and interview on 10/27/23 at 09:00 AM of Resident #24 while seated up in the first-floor main dining room the state surveyor observed urinary catheter tubing on the floor, while seated up in dining room for meal. The surveyor asked the Registered Nurse (RN) G to come into the dining room and have RN G get the catheter tubing off the floor. RN G had to sit on the floor and reach under the wheelchair to elevate the privacy bag off the floor and raise the tubing up off the floor. The surveyor asked about cross contamination and RN G stated that they did not want germs from the floor to get on the catheter due to infection. In an interview on 10/27/23 at 11:24 AM with Registered Nurse (RN)/In-Service staff education K was asked about when the last Peri care/catheter education was done for the nursing staff. RN K stated that peri care/catheter care education is given when in orientation, as new Certified Nursing Assists, and that there was a check off sheet. The state surveyor inquired about refresher peri care education for current staff and RN K stated that there was no peri care/catheter care education not this year in 2023. Not unless there was a reason. RN K stated that Urinary Tract Infections (UTI's) in-service/education was done by the Infection Control Preventionist (ICP) in June or July at the request of the dementia unit manager just on Gaberial's Garden. The Urinary Tract Infections (UTI) prevention Education Recap was only done on the Gaberial gardens because of increased frequency of UTI's with straight catheterizations of a resident residing on that unit. Resident #37: Record review of Resident #37's Admission Minimum Data Set (MDS) dated [DATE] revealed an elderly female with Brief Interview of Mental status (BIMS) score of 9 out of 15, cognitive impairment. Medical diagnosis included: anemia, coronary artery disease, heart failure, hypertension, renal insufficiency, neurogenic bladder, urinary tract infection, arthritis, osteoporosis, hemiplegia, post [NAME] syndrome, and weakness. Section G: Functional status assessment Resident #37 as: Extensive assist on one person with bed mobility, dressing, eating, toilet use and personal hygiene. Total dependence on staff of one person with transfers, locomotion, and bathing. There were no skin issues noted. Observation on 10/25/23 at 12:32 PM of Resident #37 was seated up in a wheelchair at a table all by herself. Resident #37 had a surgical mask under her chin. Geri sleeve on right arm and with a soft food/chopped consistency tray. Observation of the urinary catheter tubing was on the floor in dining room with the urinary catheter bag in privacy bag hung below the wheelchair. Record review on 10/25/23 at 02:24 PM of Resident #37's paper chart labs revealed that on 9/1/2023 a urinalysis result with greater than 100,000 Escherichia coli/10,000-49000 pseudomonas aeruginosa was noted. Record review of Resident #37's August 2023 Medication Administration Record revealed that on 8/29/2023 Resident #37 was started on antibiotic Rocephin 1-gram intramuscular (IM) injection until 8/31/2023. On 9/2/2023 Resident #37 was switched to antibiotic Macrobid 100 mg oral for 7 days and received the antibiotic on 9/1/23 and 9/2/23. On 9/2/2023 Resident #37 was switched to antibiotic ciprofloxacin 500 mg oral for 7 days due to creatin clearance.

Based on observation, interview and record review, the facility failed to implement policies and procedures to ensure the provision of Peripherally Inserted Center Catheter (PICC- intravenous [IV] catheter inserted in the body through the arm that extends to the heart utilized for long term administration of medications) care per professional standards of practice for one resident (Resident #50) of one resident reviewed, resulting in a lack of appropriate port cleaning prior to access, inappropriate flushing technique including Resident #50's PICC line being flushed unnecessarily with heparin 41 times during October 2023, and the potential for PICC complications and infection. Findings include: Resident #50: On 10/25/23 at 12:58 PM, signage outside of Resident #50's room indicated the Resident had Enhanced Barrier Precautions in place. The signage specified, Providers and Staff Must . Wear gloves and gowns for the following Device Care or Use: Central line . Wound Care . Upon entering the room, Resident #50 was observed sitting in a wheelchair in their room with their left lower extremity placed on a stationary chair in the room on top of two pillow. A PICC line was present in the Resident's Right Upper Extremity (RUE). When spoke to, Resident #50 indicated they were deaf, and communication was completed via writing. During the interview, at 1:14 PM, Licensed Practical Nurse (LPN) L entered the room. LPN L proceeded to flush Resident #50's PICC line and initiate IV antibiotic therapy. LPN L wiped Resident #50's PICC line port with an alcohol port for three seconds and immediately attached the Normal Saline (NS) flush without waiting for the port to dry. LPN L proceeded to flush the PICC line slowly without pulsating and/or aspirating for blood to check for placement. LPN L completed the flush and then removed the syringe but did not withdrawal the syringe as they were infusing the last 0.5 milliliters of the NS flush. LPN L disconnected the NS flush, prepared the IV antibiotic, cleaned the PICC line port in the same manner, and connected the IV tubing for antibiotic infusion via IV pump. The exposed connector of the IV tubing was observed contacting LPN L's hand while they were cleaning the PICC line port prior to connecting. LPN L exited the room. LPN L wore gloves but not a gown when accessing the PICC line. Examination of Resident #50's PICC line revealed it was a Power PICC Solo. The hub on the port specified, Check blood return and Flush. Record review revealed Resident #50 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included bilateral hearing loss, non-pressure lower extremity ulcer, and diabetes mellitus. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the Resident was cognitively intact and required limited to extensive assistance to complete Activities of Daily Living (ADL) with the exception of eating. Review of Resident #50's care plan revealed a care plan entitled, Resident has IV access: 4.0 Fr single lumen Power PICC placed 9/28/23 at (hospital) . (Initiated and Revised: 10/5/23). The care plan included the interventions: - Flushes per protocol (Initiated: 10/5/23) - Monitor site for patency and s/sx (signs/symptoms) of infection (Initiated: 10/5/23) - Site care and dressing change per protocol (Initiated: 10/5/23) Review of Resident #50's Orders in the Electronic Medical Record revealed the order, PICC site flush before and after medication administration or every 12 hours for maintenance every 12 hours for Treatment Flush with 10 mL (milliliters) Normal Saline followed by 5 mL Heparin EACH lumen Use 10 mL syringe or larger (Ordered: 10/5/23). Review of Resident #50's Medication Administration Record (MAR) and Treatment Administration Record (TAR) revealed documentation that the PICC line was flushed with Heparin 41 times from 10/5/23 at 8:00 PM to 10/26/23 at 8:00 AM. An interview was completed with LPN L on 10/26/23 at 4:26 PM. LPN L was asked what Resident #50 had enhanced precautions in place for and stated, Their wound. When queried if a PICC line was considered a Central line, LPN L indicated it was. LPN L was then asked if enhanced barrier precautions also included central/PICC lines, LPN L indicated they would need to review the policy. When queried regarding the verbiage on the Enhanced Barrier precaution sign, LPN L revealed they should have worn a gown and gloves when accessing Resident #50's PICC line and stated, I will now. When queried regarding assessment of placement and checking for blood return prior to initiating medication infusion through the PICC when flushing, LPN L replied, As an LPN, I am not sure I can (check for blood return). When asked if they had received training in the care and use of central/PICC lines, LPN L did not respond. When queried why they did not pulsate when flushing the PICC line, LPN L indicated they flushed the catheter slowing and had stopped while flushing. When asked if they knew the reason the pulsating method was utilized when flushing a PICC/Central line and evidence-based practice, LPN L revealed they did not. LPN L was then asked if heparin was always used to flush Resident #50's PICC line and stated, Yes. LPN L proceeded to show this surveyor a chart with different central lines and flushing protocols on it in Resident #50's paper medical record. Power PICC was highlighted on the chart which indicated to use saline and heparin when flushing the line. The chart also contained a column for Power PICC Solo which specified only normal saline was to be used for flushing. When queried if Resident #50 had a Power PICC or a Power PICC Solo line, LPN L revealed they assumed it was a Power PICC because that was what was highlighted. An observation of Resident #50's PICC line was completed with LPN L in the Resident's room at this time. After assessing the PICC line, LPN L stated, It's the Solo Power PICC. LPN L was asked what the port had written on it and confirmed the PICC line stated to check blood return and flush. After exiting Resident #50's room, LPN L returned to Resident #50's paper medical record and review the central line flushing chart. LPN L stated No heparin with Solo Power PICC. A review of Resident #50's hospital medical records was completed with LPN L. Review revealed the hospital had not used heparin when flushing the PICC line. Unit Manager Registered Nurse (RN) W entered the room at this time. RN W was queried regarding the reason Resident #50's PICC line was being flushed with heparin. RN W indicated they had entered the order based upon the Resident's PICC line type and the facility protocol. The flushing chart was reviewed with RN W. When queried why the flushing orders were for a Power PICC when the Resident had a Power PICC Solo line, RN W began reviewing the hospital documentation in the paper medical record and indicated they entered the orders based upon the hospital documentation of the PICC line. With further discussion, LPN L confirmed Resident #50's line specified it was a Power PICC Solo on the line itself. RN W then revealed they would need to change the order. RN W was asked if they assessed Resident #50's PICC line prior to entering the flush/care orders in the Electronic Medical Record but did not provide a response. On 10/27/23 at 11:35 AM, an interview was completed with the Assistant Director of Nursing (ADON). When queried regarding Resident #50's PICC line, the ADON indicated they were aware. With further inquiry regarding care, maintenance and flushing of PICC lines, the ADON specified they would defer to the facility policy. An interview was completed with Staff Education RN K on 10/26/23 at 5:12 PM. When queried regarding staff training related to PICC lines and aspiration of blood when flushing to ensure placement, RN K indicated that was not part of the facility procedure. When queried why it was not when it was written on the PICC line to complete, an explanation was not provided. RN K was then queried if staff were educated to pulsate when flushing and indicated they were. An interview was completed with Infection Control RN S on 10/27/23 at 1:06 PM. When queried regarding Resident #50's enhanced barrier precautions, RN S indicated the precautions were in place for the Resident's wound and PICC line. When asked about observations of staff not wearing a gown when accessing the PICC line, RN S did not provide an explanation. RN S was then queried regarding cleansing of the PICC line access port hub prior to accessing. When asked if the hub should be allowed to dry after wiping, RN S indicated it should. No further explanation was provided. Review of facility provided policy/procedure entitled, Vascular Access Device Care Maintenance with Grid (Reviewed: 11/21/22) revealed, In order to provide consistent, safe and quality infusion services to our residents . will implement the procedure on (facility) Vascular Access Device Care Protocol . Procedure: 1. Initiate the (facility) Vascular Access Device: Care and Maintenance Grid upon receiving an order for intravenous infusion therapy . 2. High-light the appropriate column . Line Type . Solo Power PICC . Routine Flush . 10ml Saline before & after medication. No Heparin Needed. Use 10cc (cubic centimeter) syringe or larger . Always remove syringes slowly while injecting saline. Leave 0.5ml saline in syringe rather than bottoming out syringe .

Based on observation, interview and record review, the facility failed to ensure appropriate interventions were in place and enacted to ensure resident safety for 3 residents (Resident #56, Resident #99 and Resident #150) of 5 residents reviewed for falls, resulting in Resident #56 falling out of bed during care creating a skin tear, Resident #99 developing a large bruised area to the left forehead and eye of unknown origin and Resident #150 falling and receiving staples to a laceration on her forehead after hitting her head and face. Findings Include: Resident #56: A record review of the Face Sheet and Minimum Data Set (MDS) assessment indicated Resident #56 was admitted to the facility on [DATE] with Diagnoses: [REDACTED]. The MDS, dated [DATE], revealed severe cognitive loss and a need for 1-2 person assistance with all care and 2-person assistance with bed mobility. The MDS, dated [DATE], identified the resident needing 2-person assistance with bed mobility On 7/09/19 at 2:41 PM, Resident #56 was observed in a very low bed. The resident was calling out from bed with confused speech. Upon approaching the resident, she calmed, but did not answer any questions. On 7/09/19 at 2:54 PM, the resident was observed bumping her toes onto metal bars hanging at the foot of the bed. The bars were hanging about 2 feet over the lower part of the bed (foot cradle to prevent rubbing toes on a blanket). There was no blanket on the cradle. Certified Nursing Assistant (CNA) U said, It is to prevent the blankets from lying on the resident's toes. CNA's U and V observed Resident #56 bumping her toes onto the metal bars. CNA U took the bars off. The CNA's were asked how many staff were needed to reposition the resident and both said 2. A review of the Incident and Accident Reports (I&A) for Resident #56 revealed the following on 4/11/19, Cena (X) was changing resident's brief and rolled the resident towards her. When Cena did this the resident's leg went over the edge of the bed, Cena attempted to put leg back on the bed, but couldn't get leg back on bed, Cena started lowering the bed and the resident's other leg fell off the bed also . Cena rolled resident off the bed during care . right elbow abrasion, right elbow skin tear . Cena overestimated her ability to roll resident by herself . written by Nurse W on 4/11/19 at 4:00 PM. A review of a statement, dated 4/11/19 at 4:30 PM and written by CNA X revealed I was changing the resident's (#99) brief in room . I was having a hard time rolling the resident to her side, so I pushed my staff assist. Another CENA came in to help me roll the resident over. After she left the room and I cleaned the resident up, I tried to roll the resident towards me. The resident's leg went over the edge. I tried to push it back up on the bed but was unable to . On 4/12/19 Quality Review Nurse CC wrote, . Fall Care Plan with appropriate interventions in place . A review of Resident #56's Care Plan titled, .at risk for falls related to incontinence, history of stroke, poor safety judgment and awareness, date initiated 11/2/16 with revision 5/15/19, indicated there was no mention of the number of staff needed for bed mobility (repositioning) for the resident. The care plan was not updated with any new interventions after the incident where CNA X tried to reposition the resident on her own while changing the resident's brief and rolled the resident off the bed. The 2/1/19 and 5/1/19 MDS assessments both said Resident #56 needed a 2-assist with bed mobility. CNA X was not able to be interviewed and no longer worked at the facility. On 7/11/19 at 11:31 AM, Quality Review Nurse W was interviewed related to the incident and said the resident was receiving care by CNA X at the time of the incident. Resident #99: A record review of the Face Sheet and MDS assessment for Resident #99 indicated the resident was admitted to the facility on [DATE] with Diagnoses: [REDACTED]. The MDS, dated [DATE], revealed the resident had severe cognitive decline and needed 1-person assist with all care, including walking and had an unsteady balance. During the initial tour of the facility on 7/09/19 at 2:15 PM, Resident #99 was observed walking in the hall with a discolored (dark blue/green/gray) left eye. A review of the resident' Care Plans revealed: .Elopement risk due to wandering with no rational purpose or safety awareness due to cognitive loss . date initiated 5/20/19 with revision on 5/23/19 with Interventions: Provide a protective and safe environment, use consistent caregivers and maintain accustomed environmental structure and If noted increase in restlessness/wandering: observe and address resident's comfort needs: cold/hot, hunger/thirst, bored/lonely, toilet need and pain, both initiated 5/20/19 and . at risk for Falls related to confusion, date initiated 5/16/19 with Interventions: Instruct resident on safety measures, Follow facility fall protocol, both dated 5/16/19. On 6/12/19 the resident's ambulatory status was changed to Transfers: Independent, Ambulation in room: Independent and Ambulation in Hall: 1 stand-by assist with gait belt . The resident's mobility status was changed to independent from 1 assist, after she was injured and unaccompanied in another resident's room. She was supposed to have 1 staff member with her at the time of the incident. A review of the Incident and Accident (I&A) reports for Resident #99 revealed the following: 6/11/19 at 6:42 PM, Resident found wandering in another resident's room. She was trying to go to the bathroom. The CNA noticed a large lump on the left side of her forehead and called for the nurse. Lump is measuring at 4 x 6 cm around while protruding 3 cm. Purple bruise starting to surround area. Resident complains of head hurting and wanting to lay down and go to sleep . Resident states I hit my head on the wall but will also state I don't know what happened . completed by Nurse Z. On 07/09/19 at 2:18 PM, Quality Review Nurse W was interviewed and said the resident (#99) had a history of [REDACTED]. She said the Resident had a BIMS (Brief Interview of Mental Status) score of 4 (severely impaired cognition) and was unable to identify what happened and the Resident was transferred to ER for evaluation and an MRI for the head injury at 7:00 PM on 6/11/19. Nurse W said the facility couldn't say exactly how the injury occurred and the resident was found in another resident's bathroom after the incident. Nurse W was asked if the injury of unknown origin was reported to the State and stated That is (the Administrator's) call. We reviewed it and tried to determine what happened. We don't think she could rise from the floor on her own and think maybe she tried to use another resident's commode chair and possible it scooted out from her. We didn't know what happened. The staff saw her in the hallway walking (wandering) before she was found in the other resident's room. The CNA could not find the resident in her room after the meal, went to look for her and found her in another residents room asking for help with an Injury on her face/head. A review of a statement dated 6/12/19 by CNA Y provided, When I found (Resident #99) she was confused but she was asking for help . was unaware of who's bathroom she was in and unaware she had hit her head but she was saying her head hurt . A review of a statement undated, by CNA AA, During dinner routes I was gathering up Residents, I approached Residents (#99) room and she wasn't in her room or bathroom. So I began to look for Resident. Found Resident in (another) resident's bathroom. I then noticed she had a wound to face (forehead). Pulled light to get assistance . A review of a progress note, dated 5/11/19 at 12:30 AM, revealed, Resident returned to room at 0020 (12:20 AM) via (ambulance). Report was called the CT was negative of the head and the x-ray of the left arm was also negative. Called to get results sent, unable to do it at this time but will send it in the AM. Resident was able to transfer one person off the stretcher and ambulate to bathroom. Resident had a unsteady gait resident is a one person at this time with transfers. No distress noted at this time complains of pain to her lower back and left shoulder PRN (as needed) Tylenol given. Skin has no new bruises noted just one to her head and left shoulder that was there before she was transferred . A review of the Facility policy titled, Falls and Fall Risk, dated revised 9/21/2018 provided, .Incorporating a treatment/management program related to the individual resident's needs . The resident and treatment interventions are monitored for effectiveness. If the initial intervention is ineffective, alternative approaches may be necessary to prevent and manage fall risk and falling . Resident #150: A review of Resident #150's medical record revealed an admission into the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the Minimum Data Set assessment revealed the Resident had moderately impaired cognition and needed extensive assistance with bed mobility, transfer, locomotion on and off unit, dressing, toilet use and personal hygiene. A review of the Morse Fall Scale, dated 7/9/19, revealed a score of 75, indicating a high risk for falling. A review of Resident #150's care plan revealed the following: -Focus, The Resident is @ (at) risk for falls R/T (related to) impaired safety awareness, right [MEDICAL CONDITION], impaired balance, with a date initiated on 6/7/19. -Goal, Resident will have reduced risk factors for falls through next review, with a date initiated on 6/7/19 -Interventions/Tasks that included: --Assess resident's footwear for proper fit with non-skid soles & (and) ensure is wearing appropriate footwear, with a date initiated on 6/13/19. --Gripper socks on when shoes off, with a date initiated on 7/9/19. Review of the documentation for Resident #150's falls at the facility revealed the following: -On 6/12/19 at 9:20 PM, Cena (Certified Nursing Assistant) notified nursing of resident sitting on bedroom floor. Resident sitting on floor with right leg out and left leg underneath her facing the doorway, back leaning against the bed. Resident was changed by cena 5 mins prior and was incontinent again after fall. Resident may have been getting out of bed to use the restroom . Predisposing Situation Factors, (checked) Improper Footwear . -On 6/16/19 at 9:05 AM, In room with resident changing battery and leads on event monitor, grabbed wrong battery, went back to med room to get a different battery. Resident was in wheelchair with feet propped up on bed . when returned resident was on her knees with her w/c (wheelchair) behind her locked, gripper socks on, kneeing in front of bed with arms and head resting on bed . -On 6/19/19 at 3:30 PM, Called to resident room where resident was observed laying on floor left side facing curtain/bedroom door with legs outstretched toward bed, both legs on beveled floor mat. Resident was last observed by cena staff a few minutes prior with ST (Speech Therapy) and resting in bed. Another therapy staff came to room after ST left and reported observing resident on floor. Resident is known to self-transfer and has history of falls r/t lack of impulse control. 1847 (6:47 PM) 1.5 x (by) 1 cm (centimeter) flesh colored soft raised area to back of right hand . -On 7/9/19 at 4:45 AM, 0445 (4:45 AM) res (resident) emergency call light in bathroom activated, cena observed res sitting on floor between toilet and sink. Bleeding noted from above right eye and area of swelling noted on right forehead . Predisposing Situation factors (checked) Ambulating without Assist, Improper Footwear . An interview was conducted on 7/11/19 at 9:15 AM, with Quality Review Nurse CC, who reviewed the fall of Resident #150 that occurred on 7/9/19. The Nurse indicated the Resident had fallen on 7/9/19, had hit her head, had a laceration above the right eye, a skin tear to her elbow and the Resident had gone to the hospital to receive sutures on the right eyebrow. The Nurse stated, Gripper socks was one of the last interventions we added for her. I think before, she was always wearing shoes with the first couple falls that happened. When queried why the need for gripper socks on when shoes off was not assessed as an intervention upon admission the Nurse indicated that not all residents like to wear the gripper socks and stated, We don't always add it right off the bat. An interview was conducted on 7/11/19 at 10:57 AM, with the Unit Manager NurseBB, regarding Resident #150's fall on 7/9/19. When queried regarding why the Resident wasn't assessed for gripper socks when shoes off upon admission with a history of falling and subsequent multiple falls at the facility. The Unit Manager stated, I suggested that this week. I don't know why they weren't started before that. They weren't started until this week when she had this fall on Tuesday (7/9/19). When queried when the gripper socks were started, the Unit Manager stated, The gripper socks activated on 7/9 by restorative post fall. On 7/11/19 at 4:02 PM, an interview was conducted, with the Director of Nursing (DON), regarding the intervention of gripper socks activated on 7/9/19 for Resident #150. The DON indicated that the intervention was put on the care plan and would carry over to the Kardex (a plan of care for staff to use that indicated specific care regarding the Resident) and stated, Yes, it would be on the Kardex for them to be more aware that it is an intervention.

Based on observation, interview and record review the facility failed to prevent pressure ulcers and promote and monitor the healing of pressure ulcers in 1 of 4 residents (Resident #5) in a total sample of 24 residents resulting in Resident #5 developing an unstageable pressure ulcer to the left heel and left great toe. Findings include: According to npuap.org, National Pressure Ulcer Advisory Panel (NPAUP, 2002), Deep Tissue Injury reflected, Deep tissue injury is a term proposed by NPUAP to describe a unique form of pressure ulcers. These ulcers have been described by clinicians for many years with terms such as purple pressure ulcers, ulcers that are likely to deteriorate and bruises on bony prominences (Ankrom, 2005). NPAUP's proposed definition, is a pressure-related injury to subcutaneous tissues under intact skin. Initially, these [MEDICAL CONDITION] have the appearance of a deep bruise. These [MEDICAL CONDITION] may herald the subsequent development of a Stage III-IV pressure ulcer even with optimal treatment. The facility provided a policy/procedure for Pressure Ulcers #701-219 that reflected, All residents will be placed on .Skin Management Program with the skin being assessed and the information recorded in Optimus under skin and wound. This is to assure that all necessary nursing measures are taken to assess and treat residents with actual or potential alterations of skin integrity. The focus of skin assessment is to: a. Promote the health of the skin and identify residents at risk for skin breakdown. b. Prevent the development of pressure ulcers and other alterations of skin integrity. c. Provide healing, when skin integrity of the resident has been altered .Deep Tissue Injury or suspected Deep Tissue Injury, 1. Notify Wound Care Nurse, 2. Initiate preventative measures, 3. Wound care as ordered by Wound Care Nurse and Physician. Review of the Face Sheet and Minimum Data Set (MDS), dated [DATE], reflected Resident #5 was a [AGE] year-old female who was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. According to the MDS dated [DATE], Resident #5 was cognitively intact and required staff assistance for all activities of daily living. During an observation and interview on 5/4/16 at approximately 9:00 AM, Resident #5 was laying on the bed as Certified Nurse Assistant (CNA) D removed Resident #5's sock. Resident #5 complained of pain to the heel. The wound to the left heel was dry and had a dark purple center. The wound to the tip of the left great toe was dry and had a dark purple center. Record review of the wound healing record dated 4/7/16 reflected that Resident #5 developed a new facility acquired pressure ulcer to the left heel that measured 4.0 cm x 5.0 cm. It reflected, Unable to accurately stage - Suspected Deep Tissue Injury in Evolution .Resident c/o (complained of pain to the left heel. Dark red center with red blanchable outer area .Spoke with staff and resident has refusing heel boots in bed . Record review of the wound healing record dated 4/18/16 reflected that Resident #5 developed a new facility acquired Stage II pressure ulcer to the coccyx that measured 0.3 x 0.3. Record review of the progress noted dated 4/18/16 reflected that Resident #5 developed a new blister to the left great toe that measured 0.5 x 0.5 that was dark red in color. According to the wound measurements dated 5/3/16 reflected that the heel wound measured 1.0 x 2.0, the left great toe measured 0.5 x 0.4 and the coccyx was healed. Review of the venous duplex of the left leg dated 4/25/16 reflected, Impression: normal venous duplex of the left leg. During an interview and record review on 5/2/16 at 3:45 PM with Licensed Piratical Nurse (LPN) C stated that Resident #5 developed a pressure ulcer to the left heel on 4/7/16. When asked about the causative factors and root cause of the pressure ulcer LPN C stated that facility discusses that every two weeks. When asked where the discussion is documented LPN C stated, It isn't. LPN C stated that after she spoke with the staff it was discovered that Resident #5 was refusing to wear the preventative boots but that was not documented nor was the intervention changed. LPN C provided a copy of the pressure ulcer care plan dated 4/18/16 (11 days after the heel ulcer was first noted and the same date the new coccyx and left great toe wound were discovered). When asked about the monitoring of the heel and toe wounds, LPN C stated that they document it on Treatment Administration Record (TAR). When the April 2016 and May 2016 were reviewed for monitoring there was no monitoring ordered nor documented. When asked if the pressure ulcers were avoidable or unavoidable the LPN C stated that the physician makes that decision and provided a copy of the physician assessments. Record review of the physician progress notes [REDACTED]. and circled. The assessment for the coccyx and toe blister was signed by the physician on 4/25/16 and both boxes were checked and the Avoidable blank and check was circled. After the interview on 5/2/16 with LPN C, LPN C provided a copy of the TAR for May 2016 that included a new order (dated 5/2/16) to monitor the left heel wound and left great toe wound 3 times daily. (# )

Based on interview and record review, the facility failed to provide the necessary level of supervision for a resident who had become restless and ensure that the care planned alarm devices were in place for 1 of 17 residents (#302) reviewed for falls, from a total sample of 24 residents, resulting in an avoidable fall with a painful fracture of the resident's left femoral neck (hip area), pain, hospitalization and surgery. Findings Include: Review of the Minimum Data Set (MDS) assessment dated [DATE], nurse's notes dated 5/1/14-5/31/14, physician progress notes [REDACTED].#302 was a [AGE] year old female admitted to the facility on [DATE], had advanced dementia, severe cognitive impairment, behaviors with inability to express her needs, a history of falls, and required staff to perform all Activities of Daily Living (ADL) care. The resident's [DIAGNOSES REDACTED]. Review of the nurse's notes and physician orders [REDACTED].#302 was transferred and admitted to the hospital on [DATE], after falling at the facility on 5/27/14 and sustaining a left hip fracture. Review of the Physical Function Interdisciplinary Resident Screen, dated 11/8/13 (prior to fall on 5/27/14), revealed the resident required assistance with bed mobility, transfers, dressing, toileting, hygiene and positioning. Review of the facility Abuse/Neglect Risk Assessment, dated 8/9/13 (prior to fall on 5/27/14), revealed Resident #302 was vision and speech impaired, had behaviors which included confusion, disorientation and inability to express needs, and had escalating anxiety and increased fearfulness. Review of the facility's Fall Risk Assessment, dated 1/1/14 (prior to fall on 5/27/14), revealed Resident #302 had periods of altered perception and awareness of surroundings, disorganized speech, restlessness, lethargy, was abusive, resisted care, had mental function that was varied over the course of a day, and a history of "3 or more falls." Review of the facility Incident Report Investigation Checklist, Incident Details and staffs' written statements, dated 5/27/14, revealed on 5/27/14 at 8:15 p.m., staff member "B" (Charge Nurse, LPN) was called to the dining room by a nursing assistant (staff member "A") and found Resident #302 had fallen on the floor. An x-ray was ordered of her left hip due to left leg and hip pain. Review of the nurse's notes, dated 5/27/14 at 21:14 (9:14 p.m.), stated "Called to dining room by CNA (staff member "A", Nursing Assistant/CNA). Resident noted laying (on the floor in the dining room) on her left side, head on carpet, face looking tward (toward) the windows. Assisted resident in bending her left leg in tward (toward) her chest, resident states oh my gosh that hurt. Resident noted to be grimacing, called (physician). New order made for left hip x-ray complete." Review of Resident #302's facility radiology report (x-ray report), dated 5/27/14 at 11:29 p.m., stated "There is a fracture involving the left femoral neck (left hip area) with mild displacement." Review of the facility physician order [REDACTED]." Review of the hospital notes dated 5/28/14 at 9:08 a.m. stated, "This [AGE] year-old female patient who lives at (the facility) who has advanced dementia and she was sent for a fall, was not witnessed at nursing home. X-ray showed left femoral neck fracture. She does not follow commands. Assessment: status [REDACTED]." Because urinary tract infections can be uncomfortable, residents may also experience increased anxiety and restlessness. This, in turn, may put them at increased risk for falls and potentially necessitate re-evaluation of their safety and supervision needs. Review of the hospital Operative Report dated 5/29/14 stated, "She (Resident #302) was having quite a bit of pain and in order to mobilize her and assist her with getting up out of bed with therapy, we recommended that we go ahead and treat her with surgery." Review of the hospital Transfer Summary dated 6/3/14 at 9:20 a.m. stated, "This is a [AGE] year-old female with past medical history of [REDACTED]. X-ray did show a left femoral neck fracture. Additionally, urine studies were positive for urinary tract infection." An interview was done on 2/10/14 at 12:35 p.m., with facility staff member "A" (Nursing Assistant/CNA). Staff member "A" (CNA) stated, "I was assigned to monitor all residents in the dining room (1st floor dining room, on 5/27/14). She (Resident #302) was very restless and she kept trying to climb out of her broda chair (therapeutic positioning chair). I pushed the chair (broda chair), the whole left side of her chair up against the emergency door so she couldn't climb out that side. I was feeding another resident about 4 to 5 feet away from (Resident #302). She climbed out of the right side of her chair. I turned around, because I heard a bump or like something had fallen, she had fell on the floor, then the alarm went off (the sensor pad alarm under the resident, which should have activated immediately when the resident moved). She would wiggle so much sometimes that her alarm would scoot up her back. It was a sensor alarm. It would wrinkle up from her moving so much, so we had a personal alarm (a magnetic alarm, attached directly to the resident). I told my nurse (staff member "B"/Charge Nurse, LPN) that she wasn't staying in her chair and she needed someone to stay with her until she settled down. The nurse (staff member "B" Charge Nurse, LPN) said there are not very many people in the dining room and (said) I should be able to stay with her until she settled down. There were approximately 5 residents in the dining room. I put her (Resident #302) at the window so she could look out and pushed her up against the window; previous times this worked. This could have been prevented. I should of stood next to her no matter what the nurse said. When the Focus Review Coordinator (the staff person who reviewed all of the facility incident/accidents) called me, she said I should of gone with my gut and stayed with her. The nurse was passing her meds (medications), not within sight of the resident." Review of a facility "Intervention & Documentation Ideas For Safety" (a general educational sheet, un-dated) reflected the following suggestions: - "Place resident at nursing station during times when supervision is needed." - "1:1 supervision during determined periods of high risk for only short-term emergent intervention." - "check alarm for proper functioning." An interview was done on 2/10/14 at 2:50 p.m., with staff member "E" (CNA). Staff member "E" (CNA) stated, "It was around 8:00 p.m. I was walking past the nursing station and the dining room doors; the doors were open. I was about 10 to 15 feet from the dining room door and I heard people running towards the dining room. I don't remember hearing any alarms going off. Sometimes I did see her (the resident's) sensor alarm scrunched up (under Resident #302). The sensor pad gets folded and use to being folded, and the extra pressure makes it not go off sometimes. It (the sensor pad alarm) goes under her back or her butt, (and) the alarms are of no use. At dinner, we (staff) unhook the magnetic clip alarm because she (Resident #302) leans forward and keeps setting the alarm off. She was probably, could have been in the dining room from dinner still (just prior to her fall on 5/27/14) because I have 6 to 7 residents to do (toilet and give P.M. care) and she is one of my lasts." Review of the physician orders [REDACTED]." Review of the physician orders [REDACTED]. Review of Resident #302's fall care plan dated 2/15/12 (prior to her fall on 5/27/14), revealed she was to have "bed/chair w/c (wheelchair) "magnetic" alarm which was to be directly connected onto the resident and a "sensor pad" an alarm pad the resident would sit on which would activate if the resident were to attempt to move. An interview was done on 2/10/14 at 2:20 p.m., with staff member "B" (Charge Nurse, LPN). Staff member "B" (Charge Nurse, LPN) stated, "No one saw her (Resident #302) fall. I was called into the dining room by (staff member "A", CNA), I seen her (the resident) laying on the floor. When in her room, she said her left leg hurt, I called the doctor and got an x-ray. We put her (the resident) by the exit door as a distractor, as an intervention. She was supposed to have a sensor alarm pad and a magnetic alarm on. The CNA did not ask me for help (regarding Resident #302's supervision) prior to the fall." An interview was done on 2/10/15 at 11:35 a.m., with staff member "C" (Risk Management Nurse at the time of the fall on 5/27/14). Staff member "C" (Risk Management Nurse) stated "(staff member "B"/Charge Nurse, LPN) had instructed (staff member "A"/CNA) to put the resident by the back window (in the dining room on 5/27/14). She (the resident) should have had both tab (magnetic) and sensor alarms on." Review of Interdisciplinary Physical and Occupational Therapy Screenings (dated 5/12/14, 4/14/14 and 2/4/14), revealed Resident #302 had repeated falls at the facility prior to her fall on 5/27/14, which were as follows: -Review of Resident #302's Interdisciplinary Physical Therapy Screening note dated "5/12/14", stated "Res. (Resident #302) rolled out of bed, found on floor with alarm off of base & not going off." Resident #302 had fallen from her bed on 5/10/14. A phone interview was done on 2/12/15 at 7:43 a.m., with staff member "I" (CNA). Staff member "I" (CNA) revealed on 5/10/14 she was working on Resident #302's unit when she had fallen from her bed in her room. Staff member "I" (CNA) stated "she had an integrated call light system alarm (when the alarm is activated, all staff on the unit received a signal through a pager system). The part it goes in was not plugged in at all. The alarm (bed alarm) was not plugged in when she (the resident) fell ." -Review of Resident #302's Interdisciplinary Occupational Therapy Screening note dated "4/14/14" stated, "Res. (resident) was on floor, her sheets were wrapped around motion sensor." -Review of Resident #302's Interdisciplinary Occupational Therapy Screen dated "2/4/14", stated "Resident in D/R (dining room) when fall took place. Per staff Pt. (patient) constantly attempts to scoot in her chair (broad chair) w/ (with) back on the bottom of the chair except on the day of the fall resident scooted up on the arm rests & fell over the side." Review of the facility Fall Risk policy dated 2/22/13 stated, "The goal of the (facility) is to improve the prevention and management of resident falls by assessing/identifying the resident's risk for falls. Then, incorporating a treatment/management program related to the individual resident's needs and finally, monitoring/evaluating the effectiveness of interventions that have been employed." ( )

Based on record review, interviews, and observations the facility failed to ensure that 1 of 5 residents (#201) reviewed for falls from a total sample of 5, had an operable alarm attached to her wheel chair as an assistance device to prevent accidents, resulting in a fall with injury. Findings include: A review of the facility's incident report and nurse's progress notes dated 6-9-11 at 7:45 A.M. identified that the resident was observed on the floor face down on hallway floor. The resident was dry, had on appropriate footwear and clip alarm was attached to clothing. The resident was confused and attempted to stand up. A laceration was noted to upper lip, bruise on tip of nose and abrasion to right knee with pain and discomfort. The resident was assessed for range of motion to all extremities and assisted up with Hoyer lift. Vital signs were checked: temperature 98.4, blood pressure 154/94, respiratory rate 20, and pulse 96. The physician and family were notified. The physician order [REDACTED]. Resident #201's clinical record was reviewed. The resident was admitted [DATE] and had [DIAGNOSES REDACTED]. The Minimum Data Set Resident Assessment and Care Screening with an Assessment Reference Date (ARD) of 6/9/11, noted cognitive skills that were severely impaired. The resident required extensive assistance with transfers and ambulation. A plan of care was in place to address fall risk related to weakness, cognitive impairment and lack of safety awareness. The care plan approaches included wheelchair magnetic alarm. The resident was assessed on readmission and plan of care was updated to address safety needs. The hospital medical records dated 6-9-2011 (time not indicated) was reviewed. On physical examination the resident had prominent contusions bilaterally and blackened and bruised eye socket, with a laceration repair above the upper lip. The CAT Scan showed a stable small left posterior parietal subdural hematoma. The resident was admitted for observation and neurological checks. The resident was discharged [DATE] and transferred back to the facility. On 6-29-2011 at 10:30 A.M., the Focus Review Coordinator was interviewed and the investigation report was reviewed. It was found that resident #201 had a clip alarm in place for safety to alert the nursing staff of unassisted attempts at standing. However, the clip alarm was in the off position and did not sound. On 6-29-11 at 1:25 P.M. Resident #201 was interviewed. The resident was observed sitting up in room, in reclining chair. The call light was in reach and code alarm clip attached. The alarm was checked and found to be working. The resident opened her eyes but was non-responsive to questions. No current marks, bruises or injury was noted. 0n 6-29-11 at 2:00 P.M. an attempt was made to contact the assigned Certified Nurse Aide, but there was no answer. A review of the personal file noted that she had been employed at the facility since 12-6-2010 and had a current nurse aide registration document with no findings of abuse or criminal history. On 6-9-2011 the aide obtained extensive reeducation related to alarms and alarm safety. The reeducation focused on the importance of checking both placement and the functioning of the alarms. On 6-29-11 at 2:30 P.M. and 3:38 P.M., two other Certified Nurse Aides were interviewed and verified reeducation and training on the importance of checking alarms for attachment and functioning. ( )