Every finding on record at WellBridge of Clarkston

Based on interview and record review, the facility failed to provide in writing, upon transfer to the hospital, the notification of transfer and bed hold policy for two residents (R13 and R97) two residents reviewed for hospitalizations. Findings include: R97 On 08/04/2026 The medical record for R97 was reviewed and revealed the following: R97 was initially admitted to the facility on [DATE] and had diagnoses that included Cellulitis of left lower limb and Sepsis. A review of R97's census record (documentation of R97's admissions/transfers/discharges) revealed R97 was sent out of the facility on 6/7/26. A review of R97's MDS (minimum data set) with an ARD (assessment reference date) of 6/7/26 indicated R97 was discharged and anticipated to return. Further review of R97's medical record did not reveal any documentation that R97 was provided a written notification of transfer, or a copy of the bed hold policy upon transfer to the hospital. A summary dated 6/7/2026 revealed the following: eINTERACT SBAR (Situation, Background, Assessment, Recommendation) Summary for Providers-Situation: The Change In Condition/s (CIC) reported on this CIC Evaluation are/were: Change in skin color or condition-Nursing observations, evaluation, and recommendations are: during wound care writer observed redness due to cellulitis increasing less than an inch of initial sited location, daughter present during wound care, requested transport to hospital, for further evaluation and treatment. NP (Nurse Practitioner) advised send out per family request. wound care provided. A. Recommendations: send out per family request . On 8/4/2026 at approximately 1:20 p.m., the Administrator was asked for documentation that R97 was issued a copy of the bed hold policy upon transfer to the hospital. On 8/4/2026 at approximately 1:37 p.m., the Administrator was queried for documentation of the written bed hold notification provided to R97 upon transfer to the hospital. The Administrator reported the facility practice was to call the resident/resident representative and discuss the bed hold, but they did not provide a written copy of the bed hold policy upon transfer. On 8/5/26 a review of the list of residents that were sent to the ombudsman office for transfer/discharge notification that was provided by the facility was completed. R97's name was not on the list. On 8/5/2026 at approximately 10:50 a.m., during a conversation with the Business Office Manager A (BOM A), BOM A was asked if the facility sent written notices of bed hold policies to residents when they were transferred to the hospital from the facility and they reported they did not. The BOM indicated they only called the representative and discussed bed holds but did not send a written copy of the notification. The BOM A was queried regarding sending the written notice of transfer that included the local ombudsman information and appeal rights if not permitted to return to the facility, and they reported it was not a practice their facility did. R13 Review of the clinical record revealed R13 was initially admitted into the facility on 8/13/24 and recently readmitted on [DATE] with diagnoses that included: cerebral palsy, type 2 diabetes mellitus, neuromuscular dysfunction of bladder, acute respiratory failure with hypoxia, metabolic encephalopathy, and acute kidney failure. According to the census information in the electronic health record (EHR), R13 had 22 transfers to the hospital between 7/1/25 – 7/31/26 on: 7/27/26, 7/10/26, 7/5/26, 7/1/26, 6/21/26, 5/22/26, 5/11/26, 5/3/26, 4/30/26, 4/4/26, 3/31/26, 3/21/26, 3/4/26, 2/14/26, 2/5/26, 1/30/26, 1/18/26, 1/6/26, 11/11/25, 9/13/25, 8/24/25, and 7/13/25. According to the profile information, R13 had a legal guardian in place at the time of each transfer to the hospital. Further review of R13's EHR revealed there was no documentation that R13's legal guardian was provided a written notification of transfer, or a copy of the bed hold policy upon each transfer to the hospital. On 8/4/26 at 1:53 PM, the facility was requested via email to provide all notice of transfers and bed hold notifications from July 2025 – July 2026, as well as the facility policy for notice of transfers and bed hold notifications. On 8/4/26 at 3:15 PM, review of the facility documentation provided for the above request included only R13's eINTERACT Transfer forms utilized by the facility at the time of transfer. This documentation did not include/address the required written documentation which included: .483.15(c)(5) Contents of the notice. The written notice specified in paragraph (c)(3) of this section must include the following: (i) The reason for transfer or discharge; (ii) The effective date of transfer of discharge; (iii) The location to which the resident is transferred or discharged ; (iv) A statement of the resident's appeal rights, including the name, address (mailing and email), and telephone number of the entity which receives such requests; and information on how to obtain an appeal form and assistance in completing the form and submitting the appeal hearing request; (v) The name, address (mailing and email) and telephone number of the Office of the State Long-Term Care Ombudsman; (vi) For nursing facility residents with intellectual and developmental disabilities or related disabilities, the mailing and email address and telephone number of the agency responsible for the protection and advocacy of individuals with developmental disabilities established under Part C of the Developmental Disabilities Assistance and [NAME] of Rights Act of 2000 (Pub. L. 106-402, codified at 42 U.S.C. 15001 et sequ.) . Review of the documentation provided for a facility policy for notice of transfers and bed hold notifications included an untitled and undated document that read, .admission Transfer & Discharge Policy .If the facility in conjunction with your physician determines that it is necessary for you to be discharged or transferred, we will give you advance notice of the discharge or transfer and will let you and your responsible party know as required by law .Bed Hold Policy-Medicaid Michigan's bed hold policy is the bed may be held up to 10 days per leave and there is no limit per year if you are hospitalized . The facility will hold your bed for a Leave of Absence (LOA) to home up to 18 days per year and that is calculated based on a rolling calendar year. If you hospitalization or LOA exceeds the number of days allowed, you will be readmitted immediately upon the first availability of a vacant bed in a semi-private room if you require the services provided at WellBridge and you are eligible for Medicaid nursing center services. Bed Hold Policy - Private Pay and Medicare Medicare does not pay to hold a bed. If Medicaid is your secondary payor, see the Medicaid section. Private pay-we will hold your bed up to 30 days while you are in the hospital or on a therapeutic leave, unless you notify us that you do not want the bed to be held. Upon transfer to the hospital or other place for a therapeutic leave, our Director of Business Office will contact you regarding a bed hold to determine if you desire to pay to have your bed held . On 8/5/26 at 10:45 AM, an interview was conducted with the Business Office Manager (Staff 'A') who reported they had been in their role for five years. When asked about the facility's process of notification of bed hold policies and appeal rights for residents with developmental disabilities (R13's diagnosis of Cerebral Palsy), Staff 'A' reported they were not aware of the requirements for written notices or for any additional notification requirements but confirmed there was nothing provided to residents and/or their families in the form of a written notification.

Based on observation, interview and record review, the facility failed to maintain a clean, comfortable and homelike environment, affecting multiple areas throughout the facility. Findings include: On 8/3/26 at 9:30 AM, an observation of the units for the high number rooms included: the appearance of the foyer/common area was clean but there was a strong [NAME] like odor that permeated the area. A further observation of the 500 and 600 units was made and upon walking onto each unit, the [NAME]-like odor became stronger and stronger and lingered on into several rooms on these units. On 8/3/26 at 10:50 AM, an interview was conducted with Family Member (FM L). When asked about the cleanliness of the facility and if there had been any uncomfortable odors they had noticed, FM L reported that the facility is not being cleaned like it used to be. FM L further reported that the staff does not clean their loved one's room like they used to several months ago. FM L also reported their own observations of staff leaving (soiled) brief pieces on the floor from when they would remove the resident's briefs, and would not pick them up and at times remained on the ground for a few days until they asked someone from the facility to pick it up. FM L also reported that the flooring in the room was not being kept clean and believed that housekeeping did not have a cleaning schedule for the rooms anymore. FM L reported that when something spilled or dropped on the carpet, the facility does not clean it so it sort of soaks into the carpet. On 8/3/26 at 9:45 AM, 11:00 AM, 11:40 AM, and 12:20 PM, upon walking throughout the 100, 200, 300, and 400 hallways, including the common area and dining room, there were significant lingering urine and musty odors. Some of these odors were observed both with and without any residents in these areas. On 8/4/26 at 8:50 AM, observations of the same areas from 8/3/26 revealed continued lingering urine and musty odors. Although the odors were slightly less, they remained. On 8/5/26 at 9:00 AM, observation of the dining area near the 100, 200, 300, and 400 hallways revealed a strong musty, urine odor which extended down to the center common area and resident hallways. On 8/5/26 at 9:10 AM, the [NAME] President of Clinical Services (Staff 'M') was asked about the strong odors and they confirmed the same and reported they had identified and asked about that this morning as well. Staff 'M' was informed of the observations from 8/3 – 8/5/26 and they reported it may be an issue with the air handler. On 8/5/26 at 10:00 AM, the Staff 'M' reported their maintenance staff confirmed there was an issue with the air handler and would have someone out today to look into it. On 8/3/2026 at 1:15 PM, interviewed the Director of Housekeeping (HK) F regarding housekeeping staffing. HK F indicated that housekeeping had been short staffed but recently hired two additional staff and each housekeeping staff member provides housekeeping services to two halls/units; an additional housekeeping staff member works a daily shift (9AM-3PM) to clean the common areas/bathrooms. When asked about floor care staffing, HK F indicated there is one staff member for floor care and they are off all week this week and they last worked this past Friday. On 8/3/2026 at 1:20 PM observed the 100 Hall with HK F and an odor of urine was present. HK F concurred and indicated she would use the carpet cleaner in this area today. On 8/3/2026 at 1:25 PM observed the 300 Hall with HK F and a musty odor was present. HK F concurred and indicated she would use the carpet cleaner in this area today. On 8/3/2026 at 9:00 AM – observed while walking through the dining area to the 100 hallway were stains observed on the hallway carpet. Identified on the 100 hallway was a strong odor of urine. At 9:23 AM, a walk through the 400 hallway revealed a strong odor of urine throughout the unit. On 8/3/26 at 11:20 AM, a telephone interview was conducted with Family Member (FM) I (family to one of the residents residing in the facility at the time of the survey) who reported their only concern was with the facility housekeeping. FM I stated they observed food on the floor in their loved ones room that stayed on the floor for weeks. FM I reported their loved one's room and bathroom to be dirty and unkept most of the time. According to the facility's policy titled, Quality of Life – Homelike Environment dated Revised October 2009: .The facility staff and management shall maximize, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. These characteristics include: a. Cleanliness and order.Pleasant, neutral scents.

Based on interview and record review, the facility failed to ensure Medicare liability notices were provided to the resident's appointed legal representative responsible for finances for one (R6) of three residents reviewed for liability notices. Findings include:Review of R6's documentation of the Medicare liability notices which included the Notice of Medicare Non-Coverage (NOMNC) and the Skilled Nursing Facility Advance Beneficiary Notice (SNFABN) forms revealed R6 was discontinued from their Medicare A benefits on 5/12/26 and remained in the facility. These documents further identified the facility's Business Office Manager (Staff 'A') notified Family Member (FM 'K') of the financial changes and potential liability who was not the resident's authorized representative.According to the profile section in R6's electronic health record, the resident's medical and financial power of attorney documentation dated 7/21/2012 designated FM 'J' as their successor patient advocate and appointed attorney in fact.On 8/4/26 at 12:56 PM, an interview was conducted with Staff 'A'. When asked about the facility's process for providing NOMNC and SNFABN notices, Staff 'A' reported they were responsible for issuing those notices and when they were not available, the facility's social services staff backed them up. When asked about why FM 'J' was not notified and instead FM 'K' had been notified, Staff 'A' reported difficulty in reaching FM 'J' due to their occupation and so they contacted FM 'K' instead. When asked why that would occur when they were not the legally authorized representative, Staff 'A' reported they thought that was ok to do. Staff 'A' was requested to provide a facility policy regarding provision of NOMNC and SNFABN notices.On 8/4/26 at 1:15 PM, the Administrator responded via email, .we don't have a specific policy for NOMNC we follow federal regulations.

This citation pertains to intake 2988970. Based on interview and record review, the facility failed to ensure accurate medication transcription and administer medications according to the manufactures guidelines for one resident (R902) of one resident reviewed for medication administration. Findings include: On 7/7/26 a complaint submitted to the State Agency (SA) was reviewed which alleged R902 was administered an excessive amount of Acetaminophen causing nausea and vomiting. On 7/7/26 at approximately 12:24 p.m., R902 was interviewed via phone and reported the facility had administered excessive amounts of acetaminophen to them for multiple days that had caused them nausea. R902 was asked how they were made aware of the medication error and they reported they were informed by a Nurse Manager after their medications were reviewed. On 7/7/26 the medical record for R902 was reviewed and revealed the following: R902 was initially admitted on admitted on [DATE] and discharged on 4/14/26 with diagnoses including Type 2 Diabetes Mellitus and Aftercare following joint replacement surgery. A review of R902's initial admission medication orders revealed the following: Acetaminophen Oral Tablet (Acetaminophen) Give 500 mg by mouth three times a day for Pain (0800, 1400, 2000) -Start Date- 04/02/2026Tylenol Extra Strength Oral Tablet 500 MG (Acetaminophen) Give 2 tablet by mouth three times a day for pain (0400, 1200, 2000) -Start Date- 04/01/2026Acetaminophen Tablet 325 MG Give 2 tablet by mouth every 4 hours as needed for Pain -Start Date- 04/01/2026 A review of R902's April 2026 Medication Administration Record (MAR) revealed the following dosages that were documented as being administered: Acetaminophen Oral Tablet (Acetaminophen) Give 500 mg by mouth three times a day for Pain (0800, 1400, 2000) -Start Date- 04/02/2026-4/3-(all three doses), 4/4-(All three doses), 4/5-(All three doses), 4/6 (All three doses), 4/7-(All three doses)Tylenol Extra Strength Oral Tablet 500 MG (Acetaminophen) Give 2 tablet by mouth three times a day for pain (0400, 1200, 2000) -Start Date- 04/01/2026 4/3-(1200 and 2000 doses), 4/4/-(All three doses), 4/5-(All three doses), 4/6-(All three doses) and 4/7-(All three doses) On 7/7/26 at 7/7/26 at approximately 9:40 a.m., a request for investigations/concerns pertaining to R902's stay at the facility was requested from the Administrator and the investigation that was provided revealed the following: Medication Error Investigation / Soft File Narrative-Event Summary: .On 4/8/2026, during a routine medication regimen review, it was identified that the guest had been receiving a total of 4,500 mg of acetaminophen (Tylenol) daily for six consecutive days, exceeding the recommended maximum daily dosage. The medication administration record (MAR) and physician orders were immediately reviewed to verify the discrepancy and determine the duration of the error. Upon identification of the medication error, the attending physician, Director of Nursing (DON), consulting pharmacy, and the guest were promptly notified. The physician provided orders for laboratory evaluation to assess for potential hepatic injury, including liver function testing. The guest was placed under increased clinical observation for any signs or symptoms of acetaminophen toxicity or other adverse effects, including nausea, vomiting, abdominal pain, jaundice, altered mental status, or changes in vital signs. As part of the investigation, the facility conducted a review of admission medication reconciliations completed during the seven days preceding identification of the error. No additional medication discrepancies, transcription errors, or medication administration concerns were identified during this review. The investigation determined the event to be an isolated occurrence related to the acetaminophen dosing error identified above. Throughout the monitoring period, the guest remained alert and oriented and denied experiencing any adverse symptoms related to the medication error. Nursing assessments remained within the guest's baseline with no clinical evidence of acetaminophen toxicity observed. Laboratory studies were obtained as ordered and reviewed by the attending provider for any indication of hepatic dysfunction. Appropriate adjustments were made to the medication regimen to ensure acetaminophen dosing remained within recommended therapeutic limits. A review of the medication reconciliation, physician orders, pharmacy dispensing records, and medication administration process was completed to determine the contributing factors leading to the dosing discrepancy. Findings were reviewed with nursing leadership, and education was provided to the licensed nursing staff regarding verification of cumulative daily acetaminophen dosing, accurate order transcription, medication reconciliation, and adherence to the facility's medication administration policies. Ongoing monitoring of medication orders and pharmacy recommendations was reinforced to reduce the risk of recurrence Conclusion: The investigation determined that the guest received a cumulative daily dose of 4,500 mg of acetaminophen for six consecutive days due to a medication administration/process error. Upon discovery, the facility responded promptly by notifying the attending physician, consulting pharmacy, Director of Nursing (DON), and the guest; obtaining appropriate laboratory testing; and implementing increased clinical monitoring. The facility also completed a review of admission medication reconciliations from the previous seven days and identified no additional medication-related concerns, supporting that this was an isolated event. The guest remained asymptomatic throughout the observation period and denied any adverse effects, with no evidence of clinically significant harm identified during the investigation. Corrective actions included immediate adjustment of the medication regimen, review of medication reconciliation and medication administration processes, reinforcement of pharmacy verification procedures, and staff education regarding cumulative acetaminophen dosing limits and medication verification practices. The facility will continue to monitor medication administration practices through routine audits and ongoing staff education to promote medication safety and reduce the risk of similar occurrences . On 7/7/26 at approximately 2:50 p.m., the Regional Clinical Director A (RCD A) was queried regarding the acetaminophen error for R902. They reported they had assisted with the investigation, and the error was found during a medication review. RCD A reported the Nurse who admitted the resident initially did not transcribe the acetaminophen correctly and it was not caught by the Nurse Manager either who does the look behind to ensure duplicate orders are not entered into the medication profile. RCD A reported they did an investigation that did not reveal any other medication errors had been made, and the Nurse Manger was provided additional education on best practices for identifying duplicate orders. On 7/7/26 at approximately 2:58 p.m., Nurse Manager E (NM E) was queried regarding the medication transcription error for R902's acetaminophen. NM E indicated they were a new manager and were just learning how to review medication profiles for duplicate errors. NM E was asked how the error was made and they reported that the admitting Nurse had implemented an order when one was already in the medication profile which ended up having R902 being administered more acetaminophen than they should have received. NM E reported they had been educated on the best practice of identifying duplicate orders and were confident in moving forward with medication reviews. During the onsite survey, past noncompliance (PNC) was cited after the facility implemented actions to correct the noncompliance which included.education to NM E on best practices for identifying duplicae orders, a medication lookup investigation of all newly admitted residents in the last seven days and ongoing reivew of newly admitted residents by the Nurse Managers for transcription/duplicate order errors. The facility was able to demonstrate monitoring of the corrective action and maintained compliance.

This citation pertains to intake 2790121.Based on observation, interview and record review, the facility failed to ensure care was provided in a safe manner to prevent accidents for one (R802) of two residents reviewed for accidents, resulting in unnecessary pain and a fall with subsequent fractured manubrium and multiple rib fractures and transfer to the emergency department for further evaluation. Findings include:Review of a complaint filed with the State Agency included allegations that care was not provided in a safe manner to prevent a fall with injury.Review of the documentation provided by the facility identified R802 as a resident that had a fall with major injury.On 3/10/26 at 9:58 AM, R802 was observed lying in bed. When asked about with television on. When asked about their general health and what they could recall from a recent fall during care, R802 began crying and stated they were upset they didn't think they were continuing therapy and they felt they really needed it. The resident was too upset to continue talking and requested someone come see them about their therapy. At 10:10 AM, the Administrator was notified and reported they would follow up.Review of the clinical record revealed R802 was initially admitted into the facility on 9/17/25, and recently readmitted on [DATE] with diagnoses that included: fracture of manubrium (2/7/26), multiple fractures of ribs, right side (2/7/26), displaced intertrochanteric fracture of right femur (1/16/26), trigeminal neuralgia, Meniere's disease, and unspecified psychosis not due to a substance or known physiological condition.According to the significant change Minimum Data Set (MDS) assessment dated [DATE], R802 had no communication concerns, had intact cognition (scored 15/15 on the brief mental status exam), was independent with self-care, used a walker and wheelchair for mobility, had no upper extremity functional limitation in range of motion, had impairment on one side of lower extremity functional limitation in range of motion, was dependent for toileting hygiene, required supervision or touching assistance for lower body dressing, required substantial/maximal assistance to roll left and right and for lying to sitting on side of bed; has an indwelling urinary catheter, was occasionally incontinent of urinary and bowel, and had not had a fall since admission or prior assessment.Review of the care plans included: Risk for falls r/t (related to) Sternal Fx (fracture), Multi Rib Fx, R Femur Fx, Fall, urinary tract infection, other asthma, type 2 diabetes mellitus without complications, headache, unspecified, essential (primary) hypertension, chronic kidney disease, stage 3 unspecified, hypothyroidism, atherosclerotic heart disease of native coronary artery without angina pectoris, encephalopathy, acute kidney failure, anemia, trigeminal neuralgia, meniere's disease, unspecified ear, gastrointestinal hemorrhage, hypo-osmolality and hyponatremia, hyperkalemia, dysphagia, unspecified presence of automatic (implantable) cardiac defibrillator, personal history of transient ischemic attack (tia), and cerebral infarction without residual deficits, heart failure. Date initiated 9/18/25, revision on 2/10/26.Interventions included: Encourage and assist guest to be positioned in the middle of the bed prior to rolling. Date initiated 2/2/26. Transfer: 1 PA w/ 2WW, non ambulatory. Init. 9/18/25, revision on 2/10/26On 3/10/26 at 10:10 AM, the Administrator and Corporate Clinical Nurse were informed of R802's request and reported they would follow-up - the Administrator further reported the resident was currently under Medicare A skilled care and their baseline was they were easily upset and tearful and was not a new onset.R802's diagnoses included:Fracture of manubrium (upper sternum) (2/7/26), multiple fractures of ribs right side (2/7/26), displaced intertrochanteric fracture of right femur (1/16/26), trigeminal neuralgia, Meniere's disease, and unspecified psychosis not due to a substance or known physiological condition.Review of the interdisciplinary progress notes included:An entry on 2/2/26 at 1:26 AM by Nurse 'C' read: .NA (Nurse Aide) notified me that resident rolled out of bed in the middle of her ADL (Activities of Daily Living) care, resident was observed on the floor on her left side. writer assessed resident and took vitals, upon assessment writer observed blood on residents left pinky, resident pinky nails is broken and half way detected. resident was assisted back into bed by staff.An entry on 2/2/26 at 4:13 AM by Nurse 'C' read: resident is experiencing left shoulder pain, pain medication administered as prescribed , physician confirmed order for x-ray to left shoulder due to fall. continue to monitor remainder of shift.An entry on 2/2/26 at 11:01 PM read: .[02/02/2026 09:04 AM].resident fell last night ordered stat xray for left shoulder guest complained of pain, right arm and shoulder, arm to shoulder is swollen, verbalized pain during ROM (Range of Motion), bilateral ribs and hip ordered, guest complained of hip pain and rib pain on both sides.resident results were clear. no fractures np (Nurse Practitioner) notified no additional orders.An entry on 2/3/26 at 3:30 PM by Nurse Practitioner (NP 'A') read: .Pt (patient) seen and examined, pt observed in bed, in mild distress.S/p (status post) fall out of bed. XRs (x-rays) reiewed, negative for acute process. Continues to c/o (complain of) right rib pain with deep breathing. Reports that right arm pain persists. RUE (Right Upper Extremity) with +1 non pitting edema.RUE weakness noted. Right hand grip weak and only able to lift arm approximately 20 degrees off of bed which is not baseline. Patient reports that she hit her head during fall event and has not felt the same since. Purple bruising noted to right temple - unclear if bruise is from fall event as patient states she hit the left side of her head. Patient has headaches at baseline r/t (related to) trigeminal neuralgia, stating that she has a headache differing from her baseline. States that she feels dizzy and she is having new onset visual changes she describes as dark shadows in her peripheral vision.continues on Heparin (blood thinnger) subq (subqutaneously) for DVT (Deep Vein Thrombosis) prophylaxis. D/W (discussed with) nursing - send to hospital for CT (Cat Scan) head due to complaints s/p fall with head injury.surgical incisions right rear, right lateral thigh, and right rear above knee - well approximated, staples in place (from a previous fall with injury on 1/11/26 which resulted in a displaced intertrochanteric fracture of right femur).An entry on 2/7/26 at 4:47 PM by Nurse 'B' read: resident has returned from hospital, a/ox2 (alert and oriented to person and place) - new signs of confusion only knew her name and that she fell and broke her ribs.c/o pain - gave prn (as needed) oxycodone.Review of the hospital documentation available in R802's clinical record included:CT (computed tomography) Imaging results dated 2/3/26 read, .Impression.Minimally displaced fracture in the right anterior superior manubrium.Mildly displaced fracture in the anterior right 2nd rib. Nondisplaced fracture in the anterior right 1st rib.Patient is a 78 y.o. female prsents to the hospital after a fall from bed at her rehab facility resulting in new minimally displaced right anterior superior manubrium and right 1-2 rib fractures. Given her injuries and RIG score (a clinical triage tool used in trauma centers to assess the severity of traumatic rib fractures and determine the appropriate level of care for a patient), patient was sent to the ICU (Intensive Care Unit). She was also found to have the flu and was given tamiflu.Review of the hospital History & Physical (H&P) documented, .H&P TRAUMA.recently admitted to the trauma service last month for R (Right) hip fracture presenting after falling from the bed at her rehab facility resulting in new minimally displaced R anterior superior manubrium and R 1-2 rib fractures. Patient states she rolled out of bed as she was being turned by staff at her facility.On 3/10/26 at 9:55 AM, the facility was requested to provide any concerns/grievances, incident/accident reports and facility investigations since 2/1/26.Review of the documentation provided by the facility included an undated, unsigned soft file that documented, in part: Soft File Investigation - (R802) Fall with Subsequent Fracture.At the time of the event the resident's BIMS score was 14, indicating she was cognitively intact with mild impairment. Her functional status included independent transfers and ambulation with assistance of one person and a two-wheeled walker.On 02/02/2026 at approximately 0050, the nurse was notified by the CNA (Certified Nursing Assistant) that the resident had rolled out of bed during ADL care. The CNA reported that while providing care, the resident rolled over and went too far toward the edge of the bed, resulting in her sliding onto the floor. The CNA remained present in the room at the time of the event. Upon entering the room, the nurse observed the resident lying on the floor on her left side. The resident was noted to be continent and wearing non-skid socks at the time. The nurse immediately asked the resident what had occurred. The resident stated that she did not know what happened but reported pain in her left shoulder. The CNA reported she did not observe whether the resident struck her head during the event.The resident expressed pain with movement of the left shoulder, but no other injuries were identified at that time. Neurological checks were initiated immediately following the fall and remained within the resident's baseline. Vital signs.were stable.The on-call physician was notified, and new orders were received for an x-ray of the left shoulder and continued monitoring with neurological checks.The x-ray of the left shoulder returned negative for fracture.The resident was subsequently sent to the emergency department the following day for further revaluation and treatment per nurse practitioner assessment.The investigation determined that the resident rolled too far while repositioning during ADL care, resulting in her sliding from the bed onto the floor. A the time of the incident, staff were present in the room providing care (it should be noted that there was only one staff member who was providing care - this makes is seem as if there were multiple).The root cause analysis concluded that the fall occurred due to the resident rolling beyond the edge of the bed during repositioning.Additional intervention was implemented to encourage and assist the resident to remain positioned in the middle of the bed prior to rolling during care to reduce the risk of rolling beyond the bed edge.Review of the included QA (Quality Assurance) Tool: Fall with fracture included a check list of report details, which included, .Environment & Equipment.Bed height appropriate (check mark) Yes.Root Cause & Preventability.Was the fall preventable? .(check mark) No.Explanation: isolated event - 1:1 given to CNA.New interventions implemented: encourage and assist to be in middle of bed with care.Staff education provided: (left blank). The bottom of this document identified a date of when this incident was reviewed with QA committee, DON, Administrator and Medical Director signatures however all of these sections were left blank (incomplete).Review of the Witness statement from CNA 'D' dated 2/1/26 documented: I entered the resident's room to provide care bed was already elevated to an appropriate working height and did not require adjustment. I explained what I was there for to the resident and asked which side she preferred to turn to the resident indicated her preference and I unsnapped the brief prior to turning when the resident turned she started exhibiting unusual movements including sudden jerking and jolting I asked the resident what was wrong and during the next movement the resident fell onto the floor.Included with this was a One on One Education with CNA 'D' which read, .Employee will position residents in the center of the bed and roll the residents towards her body to provide personal care.Employee provided personal care with resident and resident was not rolled towards the employee during care.Method of Education: Discussion.At the conclusion of this One on One Education session the participant will be able to verbalize/demonstrate the objective of the education.via phone education 2/2/26. This form was signed by the DON and another Nurse on 2/2/26.On 3/10/26 at 1:07 PM, a phone interview was conducted with CNA 'D'. When asked to recall the events from 2/1/26 during ADL care, CNA 'D' reported they were coming in to provide care and had gathered their supplies and was rolling R802 over and she began jerking or something and she wasn't herself and by the time I knew it she had went on the floor. CNA 'D' further reported R802 was having weird behavior.When asked if they could recall the position/placement of the bed in the room, CNA 'D' reported they were changing the resident who was incontinent and the bed was pulled up higher. CNA 'D' further reported they had told R802 to roll to the side a little bit so they could do the rest but she began jerking herself.When asked if they could recall if they rolled R802 away or towards them during the repositioning, CNA 'D' reported I rolled her away from me. When asked if they typically rolled residents away during incontinence care and they reported they would normally roll from side to side (both away and towards) to pull the brief around and tuck in.When asked how long they had worked as a CNA, they reported about five years. When asked if they had received any education or write-up after the incident with R802, CNA 'D' reported they wrote up a statement. When asked again if they received anything such as a one to one education following this incident, CNA 'D' reported, Um, yes let me see what I can remember. No can't recall it's been too long.When asked to why they didn't stop providing care and ask for help when R802 began jerking around, CNA 'D' reported I think people were doing someone at the time. I let the nurse know her behavior after.When asked to recall where they were in the room, CNA 'D' reported they were on the side by the window and reported R802's bad hip was on that side (right) so that's why it was easier to roll her onto the other side (left). When asked if they considered moving themselves to the other side, CNA 'D' reported that's what they normally do but that side was better to put the brief under the resident.It should be noted that R802's soft file documentation revealed several discrepancies within the documentation available in the clinical record and documentation provided of the facility's investigation documents.The soft file documented staff were present which suggested multiple, but there was one CNA providing ADL care; the facility's QA tool also identified the bed height as appropriate but failed to identify it was in an elevated position during ADL care as included in CNA 'D's statement; and the investigation identified R802 as being continent at the time of the incident, but they had just received incontinence care in which they rolled out of the bed.Additionally, this investigation did not identify or address the CNA's statement of R802's sudden jerking and jolting movement, nor was this included in any of the progress notes, communications with the provider per the text statements reviewed, QA tool, or the facility's investigation. The facility identified the cause of the fall was due to the resident rolling beyond the edge of the bed during repositioning with ADL care and did not identify concerns with the positioning of the resident by CNA 'D', or whether R802 had limitations to repositioning due to their recent fall on 1/11/16 with subsequent intertrochanteric fracture of right femur which required surgical intervention.On 3/10/26 at 2:00 PM, an interview was conducted with the DON and Administrator. When asked what the process should be when a resident has a sudden change of condition during care if care is provided, the DON reported the expectation would be the CNA stops what they are doing and notifies the Nurse. They were informed that when CNA 'D' was asked if they stopped care to get help, or notify the nurse and they reported they didn't because they knew there wasn't anyone else to help, the DON reported even if there is one person, they should've stopped to get help.When asked about the general process for positioning and whether staff would position a resident away from them, or towards them, the DON reported the expectation is to roll towards you, or get help.When informed of the discussion with CNA 'D' about not being able to recall what they were educated on, the DON expressed their frustration and reaffirmed the expectation is to roll towars you or get help.On 3/10/26 at approximately 2:30 PM, the Administrator, and DON were asked about the policies requested. At that time the corporate clinical staff (Nurse 'F') reported they didn't have a policy specific to positioning. Nurse 'F' reported that was a part of basis skills that staff should know to ensure proper positioning in the bed.On 3/10/26 at 2:40 PM, during the exit conference with the Administrator, DON, and Corporate Nurse 'E' and Corporate Nurse 'F'. All present were informed of the concerns and when asked if there were any additional questions, all present reported they did not.On 3/10/26 at 3:19 PM and 3:21 PM, Corporate Nurse 'F' attempted to contact this surveyor by phone and a message was left that stated they had a few more questions and requested a return call.On 3/10/26 at 3:35 PM, Corporate Nurse 'F' was contacted by phone and they acknowledged they reported they didn't have any questions at the exit but they did have further questions now. Corporate Nurse 'F' proceeded to say they were not able to find anything that specifies how a residents should be positioned and then multiple other people began talking. They were informed that the concerns were discussed with the Administrator and DON during the survey and as a courtesy, the phone call was returned but this was not open for further discussion.

Based on observation, interview and record review, the facility failed to ensure proper medication storage in one of six controlled medication wall storage units. Findings include:On 3/10/26 at 10:03 AM, observation of the 800 hall narcotic storage wall unit revealed the outer door was not properly secured. Upon further observation, the outer door was able to be opened completely and there was a second inner door that also had a locking mechanism and this was also unlocked. The inner door was observed to have several rubber bands around the locking mechanism and a rubber band secured around the lock and top of the inner door. There were multiple resident narcotic medications observed stored inside. There was no staff present in the hallway.On 3/10/26 at 10:04 AM, the Administrator came onto the hallway and was asked about the unlocked controlled substance wall unit. The Administrator sent a text message via their cell phone and reported they were going to look for the Nurse.On 3/10/26 at 10:06 AM, Nurse 'B' exited a room from further down the hallway and approached the wall unit. At this time, both the Administrator and Director of Nursing (DON) were present. Nurse 'B' was asked about the unlocked controlled substance wall unit and they reported they thought it was locked and proceeded to attempt to engage the lock on the outer door which was already in the locked position and unable to close. Nurse 'B' proceeded to insert the key and locked the outer door. When asked about the inner door, Nurse 'B' attempted to use the key but reported it didn't work and further reported they thought the lock had recently been changed or fixed. The DON then opened the outer door and attempted to secure the inner door with the same keys Nurse 'B' used and confirmed there was no working key for that door. When asked when the last time they had accessed the narcotic wall unit, Nurse 'B' reported they thought probably around 9:00 AM.On 3/10/26 at 2:40 PM, during the exit conference with the Administrator, DON, and two Corporate Nurses (Nurse 'E' and Nurse 'F'), the DON confirmed the facility had six controlled medication wall units and further reported nurses had been educated and they didn't find an issue with any other wall units. Corporate Nurse 'E' reported they had been aware of the need for repair to that controlled medication wall unit prior to today and were working on having the lock fixed and reported the nurse might not have put the key in correctly. They were informed of the observation in the presence of the Administrator and DON. Corporate Nurse 'E' was further asked if the facility had known the wall unit was not locking properly, why weren't the controlled medications removed from that storage area prior to today and they offered no further explanation. All were asked if there were any additional questions and all reported they did not.According to the facility's policy titled, Medication Storage Controlled Medication Storage dated 11/2017: Medications included in the Drug Enforcement Administration (DEA) classification as controlled substances are subject to special handling, storage, disposal and record keeping in the nursing care center n accordance with federal, state and other applicable laws and regulations.Only authorized licensed nursing and pharmacy personnel have access to controlled medications. The medication nurse on duty maintains possession of the key to controlled medication storage areas.

Based on observation, interviews, and record reviews, the facility failed to effectively clean and maintain the physical plant potentially affecting all 88 residents residing in he facility, resulting in the increased likelihood for cross-contamination and bacterial harborage and accidents. Findings include: On [DATE] at approximately 8:47 a.m., an environmental tour of the kitchen was conduced with Regional Kitchen Manager Q (RKM Q). At approximately 8:51 a.m., a review of the facility ice machine was conducted which revealed an expired filter with a change by date of [DATE]. RKM Q was queried why the filter had not been changed in [DATE] as indicated and they reported they did not know, but that they they would get it changed out that day. On [DATE] during at approximately 11:13 a.m., a tour of the facility environment was conducted with the facility Administrator. At that time, the laundry room was observed for sanitary conditions and cleanliness. The area behind the multiple dryers was observed to have a floor surface covered with dried liquid spillage from the cleaning chemicals. The top of the dryer was observed to have a thick layer of lint encompassing the entirety of the top of the dryers. The Administrator was queried regarding the layer of dryer lint and the dried chemicals on the floor and acknowledged they would have to get some help to have the area cleaned.

Based on observation, interview, and record review, the facility failed to ensure one Resident (R64) of one resident reviewed for standards of practice, had complete and accurate vital monitoring per physician orders and professional standards of practice. Findings include: Review of R64's Minimum Data Set (MDS) assessment, dated 4/23/25, revealed R64 was admitted to the facility on [DATE], with diagnoses including Alzheimer's disease, diabetes, and high blood pressure. The assessment revealed R64 required supervision for transfers, walking, and toileting and showed R64 had two falls, and was on an anti-coagulant medication (blood thinner), an anti-platelet medication (second different type of blood thinner), and insulin. The Brief Interview for Mental Status (BIMS) assessment revealed a score of 9/15, which showed R64 had moderate cognitive impairment. On 5/13/25 at 1:11 p.m., R64 was observed dressed in their room, seated in a chair, with a front wheeled walker next to her. R64 was wearing white slippers with an open-back, which appeared worn. On 5/13/25 at 1:13 p.m., R64 reported they had a fall last week, and said, I went to the bathroom fine, and fell flat on the floor and hit my head . I move too fast . R64 pointed to the right side of the back of their head, and told this surveyor there was a bump which was gone now. R64 could not describe the bump further. Their right arm was observed with a bandage, with steri-strips closing a wound with some dried blood. Review of R64's progress note, dated 5/07/25 at 23:08 (11:08 p.m.), showed, On 5/07/25 at approximately 0810 (8:10 a.m.), the nurse was notified the guest (R64) was on the floor in (their) bathroom The nurse observed (R64) on the bathroom floor sitting upright. (R64) was continent and (their) slippers were next to (R64) . (R64) stated that after (they) used the toilet (they) tried to wear their slippers and lost (their) balance and slipped to the floor. (R64) stated that (they) hit (their) head and pointed to the right side of (their) head .The nurse noted a bump to the right side of the head, with no open areas. The nurse also noted a skin tear to the right arm . The note further revealed neuro checks (assessment of an individual's neurological functions, motor and sensory response, and level of consciousness) were initiated. The nurse contacted the on-call provider, who did not send R64 out emergently, and noted they were taking Plavix (anti-platelet blood thinner) and Eliquis (anti-coagulant blood thinner) medications. There was no further description of R64's head wound (measurements or size), and no skin assessment or documents in the Electronic Medical Record (EMR) describing R64's head bump further. Review of the electronic medical record (EMR) on 5/15/25 at 9:45 a.m. by the survey team revealed no neuro checks were found in the EMR. On 5/15/25 at approximately 10:00 a.m., the Survey team verbally requested R64's neuro checks from their fall on 5/07/25 from the Director of Nursing (DON) and nursing management, with none received or able to be located at that time. On 5/15/25 at approximately 10:20 a.m., the survey team requested R64's neuro checks via email from the Nursing Home Administrator (NHA) and the Director of Nursing (DON). On 5/15/25 at 11:18 a.m., during a phone interview, Registered Nurse (RN) P confirmed they were working as R64's nurse when R64 was found on the floor in their bathroom, sitting up. RN P described a protruding bump on R64's head as about 5 cm in length and 3 cm wide and was closed. When asked why this description was not in the medical record, RN P explained they did not believe this was necessary since it was a smaller closed bump. RN P reported they monitored R64 with completing vitals and neuro checks, and saw no change in R64's mental status. R64 conveyed there was no medical or functional decline since the fall, as they were their nurse regularly. RN P reported they called R64's Nurse Practitioner, (NP) H, who recommended they continue to monitor R64, and keep them in house for monitoring. RN P reported there was no change in R64's pupils during the neuro checks. RN P explained when asked a patient on blood thinner medication who hits their head was typically sent out emergently, but they did not see a concern, given there was no status change, and NP H was made aware. RN P was asked why R64's neuro checks were not found in the medical record, or their vitals at the time of their fall at 8:10 a.m., and had no explanation. Further review of R64's May (2025) Medication Administration Record (MAR), accessed 5/15/25, confirmed R64 was on Plavix and Eliquis medications. The MAR also showed R64 was on Metoprolol Tartrate (blood pressure mediation which lowers blood pressure and heart rate), 50 mg. The dose showed, Give 1 tablet by mouth two times a day for htn (hypertension - high blood pressure). Hold if SBP (systolic blood pressure) (below) 110 or HR (heart rate below) 60. Start Date - 01/15/2025 1800 (5:00 p.m.) . The medication was documented as administered twice a day, 5/01/25 through 5/14/25, with one dose given on 5/15/25. The MAR was absent of any blood pressure readings. Further review of R64's MAR and TAR (Treatment Administration Record) revealed no documentation of R64's blood pressure readings being monitored prior to the administration of their Metoprolol Tartrate medication doses, per physician orders. Review of R64's blood pressure readings, in the vitals section of the EMR, revealed R64's blood pressure was monitored five times during the month of May (2025), only once a day, as follows: 5/14/25 07:26 (7:26 a.m): 136/76. 5/10/25 21:29 (9:29 p.m.): 187/88. 5/04/25 09:04 (9:04 a.m.): 156/76. 5/02/25 15:24 (3:24 p.m.): 120/73. 5/01/25 21:15 (8:15 p.m.): 144/61. The vitals blood pressure logs for May (2025) showed there were five blood pressure readings of 29 opportunities (given Metoprolol was initialed as given twice a day from 5/01/25 through 5/14/25, with one dose administered on 5/15/24). This showed no record of consistent blood pressure monitoring in the EMR. Without consistent blood pressure readings per physician orders, it was unable to be determined if low blood pressure may have contributed to R64's fall with injury on 5/07/25. On 5/15/25 at 11:38 a.m., R64's one page neuro checks were received at 11:38 a.m Review of R64's neuro check document revealed this one-page document had no neuro checks when R64's injury occurred at 8:10 a.m The documentation of R64's neuro checks began at 8:25 a.m., 15 minutes after R64's fall. This document was not found in the EMR earlier in the survey. Review of R64's change of condition nursing assessment, dated 5/07/25, showed R64's vitals were dated 5/04/25, showing inaccurate vitals reflected in the EMR, with none available at 8:10 a.m. on 5/07/25, when their fall occurred. On 5/15/25 at 12:02 p.m., NP H reported they oversaw R64's care, and saw R64 on 5/07/25, after their fall. NP H described R64 was alert and oriented times three (identity, location, and time) after their fall, and had appropriate conversation. NP H confirmed they knew R64 was taking Plavix and Eliquis at the time of their fall, when they hit their head. NP H described the bump on R64's head as about the size of a quarter, with a bruise and no bleeding, as well as a skin tear on their right arm. NP H was asked why R64 was not sent out of the facility emergently, given a bump on their head while on blood thinning medications, per typical standards of practice. NP H reported they were in the building monitoring R64, and ensured R64 had no change in status, cognition or vital signs. NP H was asked about R64's vitals not being consistently taken for their blood pressure medication, Metoprolol, as there was no way to ascertain if low blood pressure may have contributed to R64's fall. NP H reported they understood this concern. NP H reported they saw no reason to send R64 out emergently, as they monitored them closely in house with nursing monitoring input, and there was no change in R64's functional or neurological status. NP H conveyed they had not seen a neuro check record but understood R64 was being monitored. On 5/15/25 at 12:44 p.m., the DON (Director of Nursing) was interviewed with the NHA (Nursing Home Administrator) present. The DON shared their standard of practice was to do vital monitoring for falls, not skin assessments, and this was why there was no assessment describing the wound to R64's head. The DON reported they pushed a wrong button when inputting data on the change of condition form, which was locked on 5/08/25, which showed the set of older vitals. The DON conveyed they understood the concern related to R64's blood pressures not being taken consistently when their blood pressure medication was administered. The DON reported they concurred with NP H R64 did not need to be sent out emergently with a bump on their head on blood thinner medications, given no change in neuro or functional status. The DON produced the original neuro check monitoring one page document, which was not found in the EMR, which showed R64's vitals and neurological status was monitored beginning 15 minutes after their fall, beginning at 8:25 a.m. on 5/07/25. The DON reported they understood the concern with R64's vitals not being monitored at 8:10 a.m., when the fall occurred, with no vital signs found taken at 8:10 a.m. The DON asked if they could call RN H and see if they had vitals documented elsewhere. The Survey team related the expectation would be vital signs would be found in the medical record. The DON reported they understood the concern related to vital monitoring, accurate documentation, and potential outcome for R64, given R64's vitals were not monitored with each dose of their blood pressure medication, and the incorrect vitals in the SBAR (situation,background, assessment, recommendation) document. The DON stated no outcome was found related to the missing vitals when R64's blood pressure medications were administered. On 5/15/25 at 2:46 p.m., the DON brought a paper to the conference room to the survey team, with hand printed vitals on the back of the neuro check paper, showing vital monitoring at 8:10 a.m., the time of R64's fall. The DON reported that the NHA had forgotten to scan the backside of the neuro check sheet, which showed vitals dated 5/07/25 at 8:10 am., which were within normal range. This was not earlier provided when the one-page neuro check page was reviewed with the survey team. A policy was requested related to professional standards of practice, and none received by survey exit on 5/15/25. Review of the policy, Medication Administration, dated 1/21, revealed on Page 3, Medications are administered in accordance with written orders of the prescriber .2. Obtain and record any vital signs as necessary prior to medication administration . Review of the policy, Falls Reduction Program, revised 4/14/25, revealed, To provide a safe environment for residents, modify risk factors, and reduce risk of fall-related injury. All residents who are admitted are at risk for falls .3. If fall occurs, Charge Nurse to complete the following: .Neurological Assessment, as applicable with any known or suspected head trauma .

Based on observation, interview and record review facility failed to complete a thorough investigation and root cause analysis of a skin tear and timely follow-up with implementation of plan for one (R61) of one Resident (with fragile skin and multiple comorbidities) reviewed for accident hazards. This deficient practice has the potential for further accidents. Findings include: R61 Record review revealed R61 was recently admitted to the facility on [DATE] after hospitalization for skilled nursing and rehabilitation services. R61's admitting diagnoses included compression of lumbar vertebra, sick sinus syndrome (a problem with the heart's natural pacemaker, the sinus node, which controls the heartbeat), postural dizziness, cirrhosis of the liver and kidney failure. Based on Minimum Data Set (MDS) assessment dated [DATE], R61 had a Brief Interview of Mental Status (BIMS) score of 12/15, indicative of moderate cognitive impairment. However, a recent practitioner evaluation (dated 5/13/25) read that R61 had no cognitive deficits; had good insight and judgment. R61's had signed their admission agreement with the facility. An initial observation was completed on 5/13/25 at approximately 11:55 AM. R61 was observed in their room sitting in a wheelchair. R61 had a dressing on their right forearm. When queried what happened, R61 reported that they had a skin tear from their wheelchair two days ago. They added that they were in the bathroom when it happened and stated that something scrapped their arm when their forearm hit on the armrest of their wheelchair, and pointed to the right arm rest. When the surveyor observed under the right armrest pad, the plastic cap for the metal frame for the armrest was missing and the sharp area from the metal pipe (which was part of the armrest frame) was exposed. The plastic cap was intact on the left side of the wheelchair. This sharp area is not visible for the resident while sitting in the wheelchair, as the missing cap was under the padding; it was visible from the front of the wheelchair for an observer at a chair/barstool height. When queried if anyone had come into inspect the wheelchair, R61 reported that no one had checked their wheelchair. A follow-up observation was completed on 5/14/25 at approximately 9:30 AM. R61 was observed in their bed and had dressing on their right forearm. When queried how they were doing, R61 stated I feel ok. When asked if they remembered the surveyor, they reported yes, I remember you from yesterday. R61's walker was at bedside and the wheelchair was parked in the bathroom. When the surveyor checked under the right armrest padding the cap was still missing, exposing the sharp edges. Later that day at approximately 10:30 AM, R61 was observed in their room in their bed. R61 reported that the staff had just moved them and they were resting. When queried if they had therapy, R61 reported no and that they were going in the afternoon. During this observation the wheelchair was parked in the bathroom. When the surveyor checked the wheelchair's right arm rest frame, the cap was still missing. On 5/14/25, at approximately 1:20 PM, when the surveyor was in the hallway speaking to the nurse, a staff member from therapy was taking R61 in the same wheelchair (with missing armrest cap). At approximately 2:20 PM, R61 was walking in the hallway (between salon and training room) with a therapy staff member and staff member was pulling the wheelchair behind. At approximately 3:45 PM, R61 was sitting up in wheelchair in their room, with their feet up on their bed and arms on the wheelchair arm rests. R61 was sitting in the same wheelchair and the right arm rest frame cap was missing. A final observation was completed on 5/15/25 at approximately 10:05 AM. R61 was observed standing in front of the sink and the wheelchair was behind. R61 had a different wheelchair, when queried R61 reported the staff had brought a different wheelchair for yesterday evening. Review of R61's order summary revealed a treatment dated 5/11/25 that read, Cleanse Right outer forearm with NS, Pat dry, apply foam lite patch two times a day every 3 day(s) for skin tear. A request for incident/accident reports and investigation for R61 (from date of admission to current date) was sent via e-mail to the facility administrator and Director of Nursing (DON) on 5/14/25 at 9:41 AM. The Administrator replied on 5/14/25 at 11:50 AM that they did not have any incident/accident reports for R61. Review of R61's Electronic Medical Record (EMR) revealed a nursing progress note dated 5/11/25 at 19:27, that read, guest reports hitting their arm on wheelchair. Skin tear noted on right outer forearm, minimal bleeding noted controlled by pressure, no signs of infection present treatment applied. Another nursing note dated 5/11/25 at 19:30 read, guest states that he wants kerlix wrapped around the patch for additional security. Review of R61's care plan revealed that R61 has potential/actual impairment to skin due to fragile skin and interventions included use caution during transfers and bed mobility; educate resident/family/caregivers of causative factors and measures to prevent skin injury, dated 4/29/25. There were no other care plan updates after 5/11/25 event. Review of R61's EMR revealed progress note dated 5/14/25 at 20:07 that was completed by the Director of Nursing (DON), after concern was brought to the attention of the facility. The note read in part, Guest reported to the nurse he hit his arm on the wheelchair and obtained a skin tear to right outer forearm .DON also assessed the wheelchair and did not find any potential signs that could have caused the injury and guest has a fragile skin .PT did not observe any abnormalities with wheelchair. It was identified on 5/13/25 that that that the wheelchair arm rest had a missing cap that caused the skin tear. Wheelchair was replaced and cap placed on old chair. It must be noted that R61 had been using the wheelchair with the missing cap since the incident until 5/14/25 at approximately after 4 PM when the surveyor brought the concern to the facility's attention. An interview with the Licensed Practical Nurse (LPN) K was completed on 5/14/25 at approximately 3:45 PM. LPN K was assigned to care for R61 on 5/13/25 and 5/14/25 during the 7 AM - 7 PM shift. LPN K was also the nurse assigned to care for R61 on 5/11/25 (date of event). During the interview they were questioned about the skin tear incident. LPN K reported that they remembered the incident and reported that R61 hit their right arm on their wheelchair while attempting to self-transfer. R61 was not sure how it happened and added that they checked the wheelchair and did not see anything wrong with it. When queried further about the follow-up process on checking the equipment they added they had usually had maintenance or therapy check and follow up. At approximately 3:50 PM, this surveyor walked in with LPN K to R61's room. R61 was sitting up in their wheelchair. This surveyor asked LPN K if they see anything wrong with the wheelchair, LPN K reported that they did not see anything wrong the wheelchair. This surveyor showed them the missing cap on the right arm frame with exposed sharp edges, LPN K stated I see it now and agreed that it needed to be fixed and they would follow up. R61 witnessed the missing cap and reported they did know there was a missing cap exposing a sharp area. At approximately 4 PM, LPN K approached the surveyor and reported that they did not see anything wrong with the chair when they had checked after the incident. This surveyor asked why they did find anything wrong with the chair a few minutes ago, until it was brought to their attention by the surveyor, LPN K did not provide any further explanation. They were queried if any of their unit managers were involved, they reported that they had few unit managers and they were unsure. An initial interview with the DON was completed on 5/14/25 at approximately 4:15 PM. During the interview they were queried about the investigation process for skin tears. They reported that they completed investigations for skin tears and completed their root cause analysis. They added that the investigation involved their interdisciplinary team and they were documented in EMR. They were notified of the missing cap and exposed sharp edges in the right arm rest of R61's wheelchair. DON agreed on the concern and reported that they would follow up. Approximately 15 minutes later, at 4:30 PM, Regional Nurse Consultant RNC RNC1 and RNC2, with the DON approached the surveyor and asked for clarification on the concern. The surveyor explained the multiple observations, and the missing wheelchair part on the right-side where R61 had acquired a skin tear, and the incident was on 5/11/25 why there were no further investigation and why the risk was not addressed timely by the interdisciplinary team (IDT). They reported that they understood the concern. During the conversation the DON and RNC1 had left and RNC2 stayed back and they agreed on the concern. At approximately 4:45 PM, the DON, accompanied by another leader from a different facility (RNX) approached the surveyor. The DON reported that they were still investigating the incident and they were in the 72-hr. window. No rationale on why R61 was still sitting in the wheelchair with an exposed sharp area till 5/14/25 until the concern was brought to the attention of the facility by the surveyor. The DON confirmed that R61 was provided with a different wheelchair. On 5/15/25 at approximately 11:25 AM, the DON brought a folder and reported that it was the investigation folder for R61's skin tear. It had statements from LPN K, maintenance staff, and occupational therapist (OT) O. The statement from OT O was dated for 5/14/25. An interview with OT O was completed on 5/15/25 at approximately 11:40 AM. They were queried if they had worked with R61 on 5/14/25 and what time. They reported that they worked with R61 after lunch and they had signed their note at 2:54 PM. They were queried about the statement written for the investigation and how did they check R61's wheelchair. OT O reported they just checked overall. They were queried further if they had performed a thorough inspection of the wheelchair related to R61's skin tear on their right forearm, they reported that they did not do an inspection. They added if they saw anything obvious they would address it. Review of the facility provided document titled Accidents and Incidents - Investigating and Reporting with a revision date of 2011 read in part, All accidents or incidents involving residents, employees, visitors, vendors, etc., occurring in our premises shall be investigated and reported to the administrator. Policy Interpretation and Implementation: 1. The nurse supervisor/charge nurse/ or the department director or supervisor shall promptly initiate and document investigation of the incident or accident. 2. The following data, as applicable, shall be included on the report of accident form: a. the date and time of accident or incident took place b. the nature of injury/illness example bruise, fall, nausea etcetera next bullet the circumstances surrounding the accident or incident next bullet where the accident or incident took place next bullet the names of witnesses and their accounts of the incident are accident next bullet the injured person's account of the incident or accident next bullet the time the injured persons attending physician was notified, as well as the time the physician responded and his or her instructions . c. the date slash time the injured person's family was notified and by whom . 6. The director of Nursing shall ensure that administrator receives a copy of the Report of Incident/Accident for each occurrence .

Based on observation, interview and record review, the facility failed to assess, monitor and document on skin wounds or growths for two (R57 and R66) of two residents reviewed for non-pressure skin conditions. Findings include: R57 On 5/13/25 at 10:32 AM, R57 was observed lying in bed. R57 was observed to have male pattern baldness and on the top of his head there was what appeared to be a cutaneous horn (conical-shaped skin protrusions) that was observed protruding approximately 3/4-1 inch in height from the top of R57's head. R57 was asked what was on the top of his head. R57 explained he knew about the stand up thing on his head, at which time R57 grabbed it and wiggled it from side to side, and said he had not pulled it out because he knew it would bleed a lot, and that he had other similar things on his hand. Observation of R57's left hand and forearm revealed two other smaller protrusions of similar color. Review of the clinical record revealed R57 was admitted into the facility on 8/16/24 and readmitted [DATE] with diagnoses that included: heart failure, emphysema and dementia. According to the Minimum Data Set (MDS) assessment dated [DATE], R57 had severely impaired cognition. Review of R57's admission Total Body Skin Assessment dated 8/16/25 documented R57 had Dry skin and 0 New Wounds. No mention of any skin protrusions were documented. Review of R57's progress notes revealed an admission summary dated [DATE] at 4:03 PM by Licensed Practical Nurse (LPN) F that contained no mention of any skin protrusions. Further review of R57's progress notes revealed no documentation of a skin protrusion by nursing, physician or nurse practitioner. On 5/14/25 at 10:44 AM, LPN E, R57's assigned nurse, was interviewed and asked about R57's skin protrusion. LPN E explained she usually did not have that unit, but she knew R57 had one on the top of his head. LPN E was asked if it was there when R57 had admitted into the facility, or had occurred after admission. LPN E explained she thought it had been there since he admitted . On 5/14/25 at 12:02 PM, LPN F was interviewed by phone and asked about R57's admission. LPN F explained she had been working contingent at the facility at the time and only slightly remembered R57, but did not remember any skin protrusion on the top of his head. On 5/14/25 at 1:07 PM, the Director of Nursing (DON) was interviewed and asked if R57 had admitted into the facility with the skin protrusion on the top of his head, or did it develop after admission. The DON explained she thought it was present on admission. When informed there was no documentation of any skin protrusion in R57's clinical record, the DON explained she would look into it. On 5/14/25 at 2:39 PM, Dr. G, R57's Attending Physician, was interviewed by phone and asked about R57's skin protrusion that resembled a cutaneous horn. Dr. G agreed it was a cutaneous horn, but that was not something he would normally document anything about. On 5/14/25 at 2:42 PM, the DON provided hospital discharge paperwork dated 4/23/24 that read in part, .Exophytic lesion (cutaneous horn) on scalp, superior at midline . The DON was asked if it was present on admission, should it have been documented. The DON agreed there it should have been documented on admission. On 5/15/25 at 11:56 AM, Nurse Practitioner (NP) H was interviewed and asked about there being no documentation on R57's cutaneous horn. NP H explained there was not much that could be done about it. NP H was asked if it should be monitored due to the fact it could be premalignant. NP H explained cutaneous horns were always benign. NP H was asked if there was no baseline assessment done, how would it be known if there was a change. NP H agreed there should be a baseline assessment done. According to an article from the National Library of Medicine titled, Cutaneous Horn updated 2/29/24, link at https://www.ncbi.nlm.nih.gov/books/NBK563820/ read in part, .cutaneous horns signify underlying conditions more significantly than the horns themselves . The etiology of cutaneous horns varies as it is a secondary manifestation of a benign, premalignant, or malignant primary disease . They are also more likely to be premalignant or malignant in geriatric populations . R66 On 5/13/25 at 11:21 AM, R66 was observed sitting in a wheelchair in a common area of the facility. R66 had an undated adhesive foam bandage on their right forearm. There was shadowing of drainage visible on the bandage approximately 1 inch in diameter. When asked questions, R66 did not answer. Review of the clinical record revealed R66 was admitted into the facility on 4/19/23 and readmitted [DATE] with diagnoses that included: Parkinson's disease, dementia and major depressive disorder. According to the MDS assessment dated [DATE], R66 had a staff assessment of moderately impaired cognition and required the assistance of staff for all activities of daily living (ADL's). Review of R66's progress notes revealed a Skilled Charting note dated 5/10/25 at 4:12 AM that read in part, At approx (approximately) 2140 (9:40 PM), guest was observed on the floor . assessed for immediate injury and a skin tear with blood was noted on R (right) forearm . Review of R66's physician orders revealed no order for a dressing to R66's right forearm. On 5/14/25 at 1:15 PM, R66 was observed sitting in a wheelchair in a common area. The adhesive foam dressing on R66's right forearm appeared to have been changed as the drainage shadowing was different that the previous day. The dressing was also undated. On 5/14/25 at 3:40 PM, R66 was observed sitting in a wheelchair in a common area. The bandage to R66's right forearm was dated with5/14/25, however the drainage shadowing appeared to be approximately the same as the undated bandage seen at 1:15 PM. On 5/14/25 at 3:43 PM, Registered Nurse (RN) C, R66's assigned nurse, was asked if he had changed R66's right forearm bandage that day. RN C explained he had not changed R66 bandage. When asked who did dressing changes at the facility, RN |C explained the assigned nurse changed dressings. On 5/14/25 at 3:51 PM, the DON was interviewed and asked about R66's right forearm dressing. At that time, Unit Manager (UM) D walked up and explained she had changed R66's bandage that day. UM D was asked about the bandage being undated when seen earlier and was now dated. UM D explained she had not had a sharpie marker when she changed the dressing. UM D was asked why there was a dressing on R66's right forearm. UM D explained they had figured out that it was from R66's fall on 5/9/24. UM D was asked if she knew how old the bandage she had removed from R66's right forearm was. UM D had no answer. UM D and the DON were informed there was no order for dressing changes. The DON was asked if a nurse thought a wound required a bandage, should the nurse call the doctor and get an order for treatment. The DON agreed there should be an order for wound treatments. When asked if all dressing should be dated, the DON agreed. On 5/14/25 at 4:24 PM, the facility was asked for a policy on wound/skin including assessment and treatment. The policy provided, Pressure Ulcer/Skin Breakdown revised 10/2010 did not address non-pressure skin conditions.

Based on observation, interview and record review, the facility failed to ensure Nursing standards of practice were utilized including transcribing/implmenting Phyiscan orders and notifying administration of new skin injuries for one resident (R902) of two resident's reviewed for non-pressure wound care. Findings include: On 4/15/25 at approximately 11:21 a.m., R902 was observed in their room, laying in their bed with CNA A (Certified Nursing Assistant A ). R902's left upper thigh area was observed to have a pink/healing burn on it without any blistering. CNA A reported that it was looking better and healing. On 4/14/25 the medical record for R902 was reviewed and revealed the following: R902 was initially admitted to the facility on [DATE] and had diagnoses including Presence of Urogenital Implants and Neuromuscular Dysfunction of Bladder. A review of R902's MDS (minimum data set) with an ARD (assessment reference date) of 4/2/25 revealed R902 needed assistance from staff with most of their activities of daily living. R902's BIMS score (brief interview for mental status) was 15 indicating intact cognition. A progress note dated 3/8/25 revealed the following: Skilled Charting Note Text: Resident complained of red abrasion sited on his left upper thigh. Wound assessment completed in . (Electronic medical record). A eINTERACT SBAR (Situation, Background, Assessment, Recommendation)Summary for Providers dated 3/8/25 revealed the following : .Situation: The Change In Condition/s reported on this CIC (change in condition) Evaluation are/were: Skin wound or ulcer . A Skin and Wound Evaluation dated 3/8/25 revealed the following: Describe: Burn .Degree: second degree .Location: Front Left Trochanter (Hip) .Acquired: In-house acquired .How long has the wound been present?: New .Wound Measurements: Area-4.9 CM2 (centimeters squared) .Length-3.6 CM .Width-1.8 CM .Depth-0.1 CM .Wound bed: Epithelial .% Epithelial: 40% of wound covered .Granulation: 40% of wound filled .Slough: 20% of wound filled .Eschar: 0% of wound filled .Exudate: Sanguineous/Bloody .Treatment: Generic wound clenanser .Primary Dressing-Other .Specify Other: Silver sulfadiazine Further review of the medical record did not reveal any physician orders transcribed into the EMR for the Silver Sulfadiazine order on 3/8/25. A review of R902's March 2025 TAR (treatment administration record) did not reveal any treatments applied to R902's identified burn on 3/8/25. An admission summary note dated 3/15/25 revealed the following: Note Text: .The patient reports pain in right thigh due to thermal burn Abdomen is soft, non-tender with bowel sounds present in all four quadrants. Skin is warm, dry, and intact with thermal burn noted on left thigh; burn is stable with no s/s (signs and symptoms) of infection at this time . On 4/15/25 at approximately 1:14 p.m., the Director of Nursing (DON) was queried regarding R902's burn and they reported that they go to the bistro to get coffee and lattes all the time. The DON reported that R902 went out to an eye appointment on and did not tell anyone about spilling coffee on themselves and then the next day they started complaining about it. The DON reported they did not know about the burn until R902 was readmitted from the facility from the hospital on 3/15/25. The DON reported they had a soft file on R902's burn investigation and would provide the report on it. On 4/15/25 a review of the investigation conducted by the facility pertaining to R902's burn revealed the following: 3/17-Upon completing manager skin assessment and admission, red abrasion was noted to guest thigh. Dressing was clean dry and intact upon assessing guest. During assessment dressing was removed and wound was assessed. Wound was red but did not have any other signs of infection. Writer asked guest what had happened as it was listed as a thermal burn in his chart. Guest stated that when he went to his eye appointment he had got coffee from the bistro and that he had spilled it on himself. Guest was asked if he notified anybody about this and he said no because he didn't want to bother anyone .Eye appointment was on 3/6. On 3/8 guest reported to Nurse that he had a red abrasion on left upper thigh at 0704 (military time). At 1530 on 3/8 guest was sent to the hospital after calling 911 with complaints of urethral pain. Guest was readmitted to facility on 3/15. Wound care orders were placed on 3/15 upon re-admission. On 4/15/25 a review of the investigation summary conducted by the facility and provided by the DON pertaining to R902's burn revealed the following: .DON educated [Nurse B] on the importance of notifying the DON and the Administrator of injuries of unknown origin and when there is a wound or open area that a treatment needs to be in place Administrator spoke with the guest regarding the situation and the guest told him he burned it with coffee from the bistro Spoke with guest on how it happened and guest stated he took the lid off of the coffee and it spilled and asked why he takes the lid off and he stated that he drinks it fast and the top doesn't allow for him to drink it quickly Guest made an agreement that he would leave the lid on if he is getting hot drinks until he decides if he wants the tumbler or not and the guest agreed Further review of the investigation file revealed the following one to one Education provided to Nurse B by the DON on 3/17/25 regarding the deficiency. 1:1 Education-Injury of Unknown Origin is an injury that as not observed and could not be easily explained by resident and the injury is suspicious do <sic> the severity, location, or the number of injuries at once or over time. Ensure that Abuse coordinator is notified immediately A treatment order needs to be (in)place for all new wounds that are observed . On 4/15/25 at approximately 2:37 p.m., the DON was queried regarding the investigation of R902's thermal burn on their left thigh and reported that they had to provide education to Nurse B due to them identifying the burn on 3/8/25 and not notifying them or the Administrator regarding it. The DON indicated that Nurse B should have implemented a Physician's order into the EMR and documented that it had been completed but they did not. The DON reported that when they interviewed Nurse B regarding the identification of the burn, Nurse B reported they place an abdominal pad on it but did not document that either or the completion of the identified treatment in the record. The DON reported that they have been reviewing Nurse B's documentation since they provided the education on 3/17/25 and have not had any further instances of them not documenting treatments or implementing Physician orders or notifying administration of new injuries of unknown origin. During the onsite survey, past noncompliance (PNC) was cited after the facility implemented actions to correct the noncompliance which included education to the identified Nurse (Nurse B) and ongoing monitoring of Nurse B's documentation of treatments. The facility was able to demonstrate monitoring of the corrective action and maintained compliance.

This citation pertains to MI00150120. Based on interview and record review, the facility failed to notify the Physician of a change in condition post fall for one (R901) of three residents reviewed for accidents. Findings include: An allegation was sent to the State Agency on 2/10/25 alleging the facility failed to assess, monitor, and delayed sending R901 to higher level of care for injuries that resulted from a fall. Clinical record review revealed R901 was admitted to the facility on [DATE] with significant cardiac disease which included hypertensive emergencies (severe elevated blood pressure systolic pressure >180) with convulsions (involuntary muscle contractions that occur during a seizure). The medical history included lung cancer and chronic obstructive pulmonary disease (COPD) and diabetes. R901 had a Brief Interview for Mental Status (BIMS) assessed on 2/11/25 and scored 9/15 indicating moderate cognitive impairment. Record review authored by Registered Nurse (RN) D documented at 6:47 that R901 was found on the floor in their bedroom and had an injury to their head (described as a skin tear to forehead) and right shoulder. RN D contacted the on-call physician of the findings .who gave orders (Xray to right shoulder. Writer notified the guest family (SON) awaiting call back . On 2/8/25 at 8:30 AM, A Nursing progress note authored by RN A (dated 02/08/2025) .Spoke with night shift Nurse .stated had a fall and sustained an abrasion to right forehead and right shoulder. Upon assessment, patient in fact had a gash to the right side of (their) forehead and an abrasion on the shoulder. I followed up the DON (Director of Nursing) and on-call and informed them of what I visualized myself and notified them of the discrepancy between the writer and night shift nurse assessment and categorization of the injuries .Vitals read as follows Blood Pressure (BP) 180/116 .and was A&Ox1 (A scale used to assess alertness and orientation. There are four levels of awareness Person, Place, Time, Situation. The higher the number indicates better orientation). Asked Night shift nurse if this was baseline and she stated, from what I've been told.Was told to cleanse, dress patients wound with gauze and continue neuro checks. Informed the on-call that I felt patient needed to be sent out and was informed to continue to monitor . On 3/4/25 at 11:36 AM, RN A was contacted and acknowledged they were not familiar with R901 as they work at the facility as a PRN Nurse (contingent status) and recalled when they started their shift on 2/8/25, there was a vague report of the fall. RN A was expecting to see R901 with an abrasion to their forehead and during their assessment revealed an open bloody gash above the right eyebrow, actively bleeding, swollen and bruised and was concerned about the extent of injury, RN A then sent a picture to the on-call Provider and recommended they be sent out (the resident). RN A remarked, I should have used my Nursing Judgement and just sent them out (to the hospital). Record review of the Post Fall checklist/Neuro Checklist (dated 02/08/2025) and vital sign documentation revealed two manual blood pressures from 10:38 AM sitting Left arm was 180/116. BP at 10:38 sitting Right arm was 180/116. Ordered blood Pressure medication was administered. Vital signs documented on the post fall neuro check at 12:30 PM revealed R901 had a blood pressure of 201/96. On 3/4/25 at 12:47 PM, an interview with Nurse Practitioner (NP) D. NP D acknowledged they were contacted by Nursing regarding R901's laceration to their forehead, reviewed the picture and instructed to cleanse the wound, cover with gauze, and continue with neuro checks. NP D confirmed they too were not familiar with the resident's medical history or mental status baselines, and commented they oversee 30 different facilities and provide Telemedicine only. All decisions are dependent on what Nursing communicates. When asked if they were later notified of mental status changes or increased blood pressure readings, and increased bleeding, NP D confirmed they were not notified. On 3/4/25 at 1:15 PM,the Director of Nursing (DON) indicated that Certified Nurse Assistant (CNA) B was very familiar with R901 and available for an interview. CNA B confirmed on 2/8/25 at the start of their shift they overheard R901 had fallen. When CNA B went into the room they remarked to Nursing if R901 was being sent out to get stitches. CNA B said the gash on their forehead was open and bleeding and their right eye was swollen shut and bruised badly. When questioned how R901 presented for the duration of the morning and afternoon CNA B remarked that they seemed more tired and informed RN A who then escorted R901 to their bed. When asked how the dressing (on R901's head) appeared, CNA B remarked that it kept bleeding through the dressing and had to be changed three to four times that they observed. CNA B said R901's son had arrived at the unit around dinner time (3:30-4:30PM) and commented to CNA B that they were left a message that morning that R901 had a fall. They contacted the facility by phone four times, but there never was an answer. The son was unable to receive information on the condition of their parent and decided to drive up to facility. CNA B said the son was very concerned about the forehead, saw blood on the floor, started taking pictures of R901, and the room. Nursing Progress note dated 2/8/25 at 5:00 AM documented R901's son arrived at the facility, and explained the extent of the fall, at which time the son requested R901 be transferred to the hospital. Record review of Emergency Department (ED) medical documentation (dated 02/08/2025) revealed R901 presented to the ED, was admitted under trauma surgery service given fall with confusion. Later in the day, R901 was noted to be more confused and had more bruising to their eye and is on aspirin. Primary consideration includes possible head injury given their confusion they are A&Ox1 (alert and oriented), typically more A&Ox2-3 and trauma had to repair the laceration. On 3/4/25 at 4:30 PM, during an interview with the Nursing Home Administer (NHA) and the DON, both remarked that the sutures placed by trauma at the hospital were necessary seeing how thin the skin as they would have just used steri strips. When asked if they physically assessed the laceration, both denied, but remarked based on the photograph, the facility could have treated the laceration accordingly. The high blood pressure readings and R901's history of Hypertensive Crisis were reviewed and both agreed Nursing should have notified the on-call provider. When asked if the facility had a charge nurse or nurse manager as resource for Nursing on weekends, both said they do not but the DON is on call and they should have been notified if Nursing was not satisfied with a Providers response.

This citation pertains to intake: MI00149594. Based on interview and record reviews the facility failed to follow the facility policy on oxygen administration, ensuring orders were timely implemented for one (R404) of four residents reviewed for a change in condition. Findings include: A review of a complaint submitted to the State Agency (SA) documented concerns regarding R404's oxygen administration while inpatient at the facility. Review of the medical record revealed R404 was admitted to the facility on [DATE]. R404's admitting diagnoses included: acute on chronic systolic congestive heart failure, atrial fibrillation, chronic kidney disease, cardiac murmur, cardiac pacemaker and dyspnea (difficulty breathing). Review of an admission nursing assessment dated [DATE] at 2:53 PM, documented in part, . Respiratory . Equipment - Oxygen . Rate 1 L (liter) . A review of the physician orders revealed no implementation of an initial physician order for the administration of oxygen. Review of a facility policy titled Oxygen Administration revised October 2010, documented in part . The purpose of this procedure is to provide guidelines for safe oxygen administration . Verify that there is a physician's order for this procedure. Review the physician's orders or facility protocol for oxygen administration . Review of the progress notes revealed the following: On 3/30/24 at 7:10 PM, a Nursing note documented in part . patient on oxygen 2 liters nasal cannula . On 3/31/24 at 5:46 PM, a Nursing note documented in part . On Oxygen concentrator 3 liters nasal cannula . Further review of the physician orders revealed the implementation of the following oxygen order on 4/1/24: Administer 1.5 L/NC (nasal cannula) if oxygen saturation is 90% or below . every 24 hours as needed and every shift. Review of the medical record revealed no documentation or clarification on why R404's oxygen orders were implemented three days after admission. On 1/30/25 at 1:12 PM, the Director of Nursing (DON) was asked the facility's protocol of a resident who admitted to the facility with oxygen administering via nasal cannula, who may or may not have oxygen orders documented on their hospital discharge documents. The DON replied that all orders are clarified with the doctor upon admission and if they arrived with oxygen and no orders for oxygen, the physician should have been notified for further directive. The DON was asked why orders were not implemented upon admission/timely for R404. The DON stated they were not employed with the facility at the time of R404's inpatient stay but would look into it and follow back up. At 1:55 PM, the DON returned with the facility's Nurse Consultant (NC) A, both acknowledged the concern. No further explanation or documentation was provided by the end of the survey.

This citation pertains to intake MI00148800 Based on observation, interviews and record review, the facility failed to implement timely resident specific interventions and provide adequate supervision to prevent falls, for one (R702) of two residents reviewed for falls. Findings include: A complaint received by the State Agency revealed that R702 had two falls after they were admitted to the facility, within nine days. The first fall was on 10/25/24 and R702 was transferred to the emergency room (ER) and returned to the facility. The second fall was on 10/31/24 and R702 was transferred to the ER and required surgery for a right hip fracture. On 10/31/24, R702 was sitting up in the wheelchair alone in their room. The compliant stated that facility was well aware that R702 was a high risk for falls and did not have appropriate interventions in place. R702 An observation of the unit where R702 was residing was completed on 12/17/24 at approximately 11:55 AM. R702 resided at the end of the hallway, second from the last room in the hallway. The common area was approximately 100 feet away from the room. A review of R702's Electronic Medical Record (EMR) revealed R702 was admitted into the facility for a short-term stay after hospitalization due to a fall at home that resulted in a left hip fracture. R702 had surgery to the left hip and they were admitted to the facility on [DATE]. R702's other diagnoses included dementia, osteoarthritis and age-related osteoporosis (brittle bones) without any pathologic fracture. Based on a MDS assessment dated [DATE], R702 had severe cognitive impairment. Prior to admission into the facility, R702 lived with their daughter who was their primary care giver. R702's daughter was the Durable Power of Attorney (DPOA) for R702 and made decisions on their behalf. Further review of R702's EMR revealed the following nursing progress notes. An admission progress note dated 10/23/24 at 7:16 PM read in part, Patient arrived via the ambulance with the daughter. Patient was alert and oriented X1- 2 .right hip has staples. Review of the fall risk assessment dated [DATE] revealed a score of 17, indicative of high risk for falls. Intervention /comment section of the fall assessment read PT (Physical Therapy) will evaluate. Review of R702's care plan revealed a fall care plan. The care plan read, Risk for falls related to left femur fracture, falls, dementia, osteoporosis etc and interventions initiated on 10/23/24 (day of admission) included: Administer medication as ordered by physician; transfer 1 person assist with 2 wheeled walker - non ambulatory; and weight bearing as tolerated. Review of 702's Kardex - information/plan of care for Certified Nursing Assistants (CNA) revealed care information that included: Section that read safety staff to assist patient with toileting and settle patient in bed after dinner initiated on 10/29/24 and Resident care encourage guest to stay in high traffic areas while awake initiated on 10/25/24. Prior to the initiation of the interventions on 10/25/24 and 10/29/24, R702 (who had severe cognitive impairment and was a high risk for falls) did not have resident specific fall prevention interventions and or supervision in place. A care transition progress note dated 10/24/24 read in part, Guest is alert and oriented to person only with confusion to place and time. She does have a diagnosis of dementia .guest has been given a BIMS score of 3/15, cognitively intact . A practitioner progress note dated 10/24/24 read in part, Discussed plan of care with daughter at bedside .melatonin ordered per request. Per daughter with some agitation and delirium at bedtime. A change in condition progress note dated 10/25/24 revealed that R702 was transferred to hospital for x-ray per family request. The progress notes and incident report revealed that CNA observed R702 on the floor next to their bed. An investigative summary dated 10/29/24 (4 days after the fall) revealed, Resident had unwitnessed fall around shift change .was unable to explain what happened .stated that she was trying to go to her apartment. Resident did not activate call light.Staff will implement toileting schedule and assist patient to settle in bed. A care transition note dated 10/31/24 at 10:21 AM revealed that R702 planned to return home with their daughter and with hospice services. The plan was to return home on 11/1/24 at 11 AM. Nursing progress note dated 10/31/24 at 18:42 read in part, Guest was observed laying on the floor on her buttocks .guest was visiting with her son and once he left she was trying to stand up and the wheelchair was not locked wheelchair rolled back . Review of an incident report dated 10/31/24 at 18:54 read in part under immediate intervention, .I transferred guest into bed position reiterated to please call staff for assistance press call light red button for assistance don't stand on her own and guest verbally acknowledged understanding . It must be noted that that R702 had significantly impaired cognition with diagnosis of dementia. The mental status section of the report revealed that R702 was oriented to person, place and situation. The incident report also revealed an investigative summary dated 11/9/24 (7 days after R702 was transferred to the hospital) and root cause section read in part, .BIMS of 3, severe cognitive impairment. Guest was trying to self-transfer without assistance and fell . Further review of R702's EMR revealed x-rays that two sets bilateral hip x-rays and pelvis were ordered and completed on 11/1/24 and 11/2/24. Results did not reveal any fracture or dislocation on both hips. The reports revealed old hardware on the right hip with no hardware complication. A progress note dated 11/3/24 revealed that R702 was transferred to hospital as daughter had concerns with ongoing hip pain after the fall and were not comfortable with x-ray findings. Review of pain assessment for 11/3/24 at 4:30 revealed a score of 8/10. An interview was completed with R702's representative on 12/16/24 at approximately 4 PM. R702's representative reported that they had been taking care of their mother for [AGE] years and they were admitted to the facility for healing and recovery. They added that when R702 was admitted to the facility they had communicated that they were a high fall risk, requested floor mats next to their bed, and asked them to check on R702 frequently due to their dementia. They added that confusion had gotten worse after the left hip surgery (prior to admission to the facility). R702's representative further added that they were notified by floor staff that facility did not use floor mats as they are a trip hazard. They stated that they did not understand why it was a trip hazard when their mom could not walk. They added that after the second fall on 10/31/24, they noticed their mother was in severe pain in the right groin area. The two sets of x-rays that were ordered did not show anything new. They went in to see her on 11/3/24 with their brother and their mother was in a lot of pain. They had requested R702 to be transferred to the hospital. When R702 arrived at the hospital they did x-rays and they were notified that the right hip was completely shattered. R702 had surgery on their right hip Monday morning. R702 was currently at home with their daughter and they were receiving hospice services. They added that they did not see appropriate fall precautions in place even after they had brought the concern to the attention of the facility staff. An interview was completed with CNA A on 12/17/24 at approximately 12:05 PM. They reported that thy usually were on a different hall and they covered the hall they were on due to a call off. They were queried how did they know what to do for their patients and they added they obtained the information from the Kardex (CNA car plan) from the EMR and that included their mobility level, fall precautions, diet, etc. An interview was completed with the unit manager (UM B) who covered the hallway that R702 resided on during their stay at the facility. They reported that they were new to their role. They were queried what was their expectation for their staff if a high fall risk resident with history of falls and recent fracture due to fall was newly admitted to the facility. They reported that based on their clinical assessment they would recommend frequent rounding, knowing their routines to meet their needs, floor mats, enabler bars, or positioning pillows. They were not able to provide why any resident specific interventions were not in place for R702 as they had just started working at the facility. An interview with Licensed Practical Nurse (LPN C) was completed on 12/17/24 at approximately 1:10 PM. They reported that they had been at the facility for a total of one year. They were queried on what they would do if a high fall risk resident with history of falls and recent fracture due to fall was admitted to the facility. LPN C reported that they would do frequent rounding, try to do every 15 minutes between the nurse and CNA, had the bed in the lowest position, floor mats on the sides of the bed, and to keep them in a room closer to a common area/station and tried to keep them in the front end of the hallway as soon as a bed became available. An interview with CNA D was completed on 12/17/24 at approximately 1:25 PM. CNA D reported that they had been at the facility for approximately 3 months. They were queried how did they get their information to care for their residents. They reported that they would get the care and safety related information from the Kardex. An interview with LPN E' was completed on 12/17.24 at approximately 1:35 PM. They reported that they had been at the facility for approximately 6 months. They were queried on what they would do if a high fall risk resident with history of falls and recent fracture due to fall gets admitted to the facility. LPN D' reported that they would add interventions based on their assessment and that might include low bed, floor mats, frequent t rounding, make sure personal items were within reach, change to a touch pad call light as they are more sensitive etc. and communicate with their CNA. An interview was completed with Director of Nursing (DON) on 12/17/24 at approximately 1:40 PM. DON reported that they were new to their role at this facility. They were asked about their expectations for their staff if a high fall risk resident with history of falls and recent fracture due to fall gets admitted to the facility. DON reported that they would expect them to put interventions in place and be proactive based on their assessment and that might include touch pad call light, positioning, frequent rounding, move them closer to the front end of the hallway. They were queried about R702 and what was in place when they were admitted . They reported after review of the EMR that R702 had standard of care every 2 hours rounding in place. The DON did not provide any further explanation. An interview with Regional Nurse Consultant (RNC) F was completed on 12/17/24 at approximately 2:05 PM. They were queried about their expectations for their staff if a high fall risk resident with history of falls and recent fracture due to fall was admitted to the facility and what was in place for R702 when they were admitted and after the falls. They reported that they would try and work with family to understand their needs and routines and tried to put interventions in place. They were queried further on interventions that were in place when R702 was admitted to facility and how educating a cognitively impaired resident with a BIMS of 3 would be an effective immediate intervention. RNC 'F' acknowledged the concern. An interview with the facility administrator was completed on 12/1724 at approximately 3:45 PM regarding the concerns with R702's fall interventions. The Administrator reported they understood the concern.

This citation pertains to intake #MI00141722, MI00142873, MI00140148, MI00140897 Based on observation, interview, and record review, the facility failed to ensure activity of daily living care including personal hygiene, bathing/showers, facial hair care, and dressing for eight residents, (R#'s 385, 391, 2, 39, 54, 238, 49, and 71) of 12 residents reviewed for activity of daily living (ADL) care, resulting in verbalized complaints, frustration, and embarrassment from poor personal hygiene. Findings include: A complaint was made with the State Agency that alleged residents were not receiving ADL care. R385 A review of the medical record and face sheet revealed that R385 was a former resident of the facility and they were originally admitted on [DATE]. R385's admitting diagnoses included Parkinson's, neuropathy, depressive disorder, anxiety disorder and muscle weakness. R385 was discharged home with their family with 24-hour care on 4/23/24. Based on the most recent Minimum Data Set (MDS) assessment, R385 had a Brief Interview for Mental Status score of 15/15, indicative of intact cognition. Review of a complaint received by the State Agency revealed that R385 did not receive their showers/baths for several days despite multiple requests from the Resident and the family members. The compliant read in part, (R385 - Pronoun omitted) had gone couple of weeks without being showered the concerns have already been reported .after several complaints, someone washed (R385's name omitted) . Review of R385's Electronic Medical Record (EMR) reveled that R385 was at risk for falls related to their diagnosis and they needed staff assistance with their activities of daily living such as dressing, baths/showers, toileting, and personal hygiene. Review of R385's care record revealed that R385 did not receive any showers or baths from 1/1/24 to 1/16/24 (for 16 days). Further review revealed that R385 received baths/showers on 4 days for the entire month. An interview with the Complainant was completed on 6/4/24 at approximately 4:25 PM. During the interview, the Complainant had confirmed that they had addressed their concerns with showers and other care issues to facility leadership. An interview with CNA Q was completed on 6/4/24 at approximately 11:45 AM. During this interview, CNA Q was queried on how they had documented showers/baths and other ADL care provided for their residents. CNA Q reported that they documented on their EMR system and they had showed the tablet they were documenting on. CNA Q was queried on their process if a resident refused their showers/baths. CNA Q reported that if a resident had refused any showers/baths they were documenting on the EMR and had notified their nurse. An interview with the Unit Manager P was completed on 6/4/24 at approximately 9:25 AM. During the interview Unit Manger P was queried how the showers/ADL care documentation was completed by the Certified Nursing Assistants (CNA) and they reported that the CNA's were documenting on their EMRs using the tablets that were mounted on a cart/stand. Unit Manager P had confirmed that they did not use any other forms of documentation. An interview with Director of Nursing (DON) was completed on 6/5/24 at approximately 9:10 AM. The DON was queried about the shower and bathing process. The DON reported that residents typically were scheduled to receive two showers/week and staff were able to provide additional showers as needed. They also reported that bed baths were provided on the days that residents were not scheduled for showers. Staff were documenting on their EMR using their tablets. Unit Managers were monitoring their residents to ensure that staff were meeting their needs. When notified of the concerns, they reported that they understood the concerns. R391 A review of the medical record and face sheet revealed R391 was admitted to the facility on [DATE] for a short-term stay to receive skilled nursing and rehabilitation after hospitalization due to a fall at home. R391 had injuries on both of their lower extremities from the fall. R391's admitting diagnoses included fracture of right ankle and left ankle sprain, pneumonia, and chronic pain syndrome. Based on the Minimum Data Set (MDS) assessment dated [DATE], R391 had a Brief Interview for Mental Status (BIMS) score 15/15, indicative of intact cognition. An initial observation was completed on 6/3/24, at approximately 1:05 PM. R391 was sitting in their wheelchair. R391 had a hard cast on their right leg that extended from below the knee to their foot and a Controlled Ankle Motion (CAM) boot on their left leg. An interview was completed during this observation. R391 reported that they had been in the facility for a little over two weeks. R391 reported that they were upset as they did not receive any staff assistance with their showers for several days. When queried further they reported that they had spoken with several staff members and the Unit Manager P. Unit Manager P reported that they were initially notified of one shower schedule when they had asked the staff on their scheduled day, the Resident was given a different schedule. R391 stated I kept getting different days when I asked for one and no one bothered to give me one. R391 added that they received assistance form their occupational therapist for their first shower and they had received a shower that AM (on 6/4/24). R391 was queried about the bed baths and R391 reported that they did not receive the help they needed from the staff timely when they had asked for one. When queried further they reported that they were not allowed to bear weight on their right leg and they needed help with the setup and assistance with baths. R391 reported that their plan was to return home with their daughter. A follow-up observation was completed on 6/4/24 at approximately 9:30 AM. R391 was observed in their bed. When the surveyor asked how they were doing, R391 stated You don't want to know. When queried further R391 reported that they had to wait for assistance to go to the bathroom for long time and they had transferred from bed to wheelchair and the toilet twice that night without any staff assistance. R391 reported that their legs are sore and they had their pain medications in the morning. When queried further they reported that it was later at night, after dinner between 11 PM and 4 AM. Review of R391's EMR revealed a shower/bathing report revealed that R391 received a shower/bath on 5/17/24 and one on 6/3/24. There were no showers/baths for approximately 16 days. Review of R391's Kardex (care plan for CNAs) revealed that R391 needed staff assistance with their transfers due to their weight bearing restrictions on their leg and they needed assistance with their baths/showers. Review of R391's most recent physical and occupational therapy progress notes revealed that R391 needed staff assistance with their transfers from bed to wheelchair and from wheelchair to toilet. The progress notes also revealed that R391 needed staff assistance with bathing and toileting. 34208 R2 On 6/3/24 at 11:45 AM, R2 was observed in their bed and appeared to have several days of unshaven facial hair. At that time, an interview was conducted with R2 regarding their preferences for facial hair. They indicated they normally had a clean shaven face. They were asked if anyone in the facility offered assistance to remove their facial hair and said, No. They went on to say their daughter usually took care of it, but hadn't in quite some time. On 6/4/24 at 8:47 AM, R2 was observed in their bed asleep. R2 remained with several days of unshaven neck and facial hair. On 6/5/24 at 8:51 AM, R2 was observed in their bed eating breakfast. R2 remained with several days of unshaven face and neck hair. A review of R2's clinical record revealed their most recent re-admission to the facility was on 4/3/24 with diagnoses that included: acute respiratory failure, pneumonia, falls, atrial fibrillation and dementia. R2's most recent completed Minimum Data Set assessment dated [DATE] indicated moderately impaired cognition and partial/moderate assist with personal hygiene. R2's care plans were reviewed and an intervention for Activities of Daily Living (ADL's) dated 3/27/24 read, .Assist with dressing, hygiene and toilet needs . R39 On 6/3/24 at 9:23 AM, R39 was observed in their bed dressed in a green dress, it appeared eggs had been spilled down the front of the garment. R39 was also observed to have several long hairs on their face/chin. At that time, R39 was asked about various aspects about their stay in the facility and said staff had not assisted them with changing their clothing in two days. They were asked how often they were not assisted to change their clothing and said it happened at least twice a week. R39 was asked if they had extra clothing and offered the observation of their closet and drawers that revealed numerous articles of clothing. R39 was also asked about the hair on their chin and said the were unaware of the hair and would want it removed. On 6/5/24 at 8:45 AM, R39 was observed in bed watching television, long facial hairs remained on R39's chin. A review of R39's clinical record revealed they admitted to he facility on 8/14/23 with diagnoses that included: heart attack, protein calorie malnutrition, and high blood pressure. R39's MDS assessment dated [DATE] indicated they had intact cognition, required substantial/maximal assist for shower/bathing, and set-up assist with hygiene. A review of R39' CNA task documentation for showers/bathing was conducted and revealed the following: March 2024-No documented shower/bathing given from 3/1/24 thru 3/26/24. April 2024-No documented shower/bathing given from 4/4/24 thru 4/30/24. There were no documented refusals and nursing progress notes did not indicate R39 refused any shower/bathing for the month of April. May 2024-One documented incidence of shower/bathing from 5/1/24 thru 5/18/24. There were no documented refusals and nursing progress notes did not indicate R39 refused any shower/bathing for the month of May. A review of R39's care plans was conducted and an interventions for ADL's dated 8/14/23 that read, .Assist pt (patient) with showers/bed baths .Assist with dressing, hygiene, and toilet needs . R54 On 6/3/24 at 9:56 AM, R54 was observed in their room. R54 appeared with several days/weeks of facial/neck hair growth. At that time an interview was conducted with R54. They were asked about various aspects of their life in the facility including whether they were provided regular showers. They said they were not. 6/3/24 at 3:58 PM, a follow-up interview was conducted with R54 regarding their facial hair. They were asked if they preferred a moustache/beard and said they would like to have their facial hair groomed soon. They were asked the last time they were assisted with shaving and said it was the last time they got their hair cut. They further said they didn't need a hair cut at this time, but would still like their facial hair groomed. On 6/4/24 at 8:44 AM, R54 was in bed, watching television. At that time, R54 remained with long, unshaven facial hair. A review of R54's clinical record revealed they admitted to the facility on [DATE] with diagnoses that included: stroke, hemiplegia, dysphagia, cellulitis falls, adjustment disorder and psychotic disorder with delusions. R52's most recently completed MDS assessment dated [DATE] indicated they had moderately impaired cognition, and required substantial/maximal assistance with showering, bathing, and hygiene. A review of R52's Certified Nursing Aide (CNA) task documentation for showers/bathing was conducted and revealed the following: March 2024-No documented showers/bathing provided from 3/2/24 thru 3/18/24, and no documented shower/bathing after 3/19/24. There were no documented refusals and nursing progress notes did not indicate R54 refused any shower/bathing in the month of March. April 2024-No documented shower/bathing given from 4/16/24 thru 4/30/24. There were no documented refusals and nursing progress notes did not indicate R54 refused and shower/bathing for the month of April. May 2024 thru June 2024-No documented shower/bathing given 5/4/24 thru 5/17/24, and no documented shower/bathing from 5/25/24 thru 6/3/24. There were no documented refusals and nursing progress notes did not indicate R54 refused any shower/bathing for the months of May or June. A review of R54's care plans was conducted and an interventions for ADL's dated 2/22/24 read, .Assist pt (patient) with showers/bed baths .Assist with dressing, hygiene, and toilet needs . R238 On 6/3/24 at 4:00 PM, R238 was observed in their room, seated in a chair visiting with their family. R238 was observed to be wearing red and blue, tiger stripe print, cotton lounge pants. At that time, an interview was conducted with R238's family about their family member's stay in the facility. They reported their only complaint was R238's was not having their clothing changed regularly. They said every time they visited R238 was wearing the same pants (the red/blue tiger striped lounge pants) and they had assisted their family to change their shirt three times. They said they were aware R238 had refused showers, but believed they would not refuse to have their clothing changed with some assistance. On 6/4/24 at 8:49 AM, R238 was observed receiving therapy in the gym. At that time, R238 was observed to be wearing the same red/blue tiger stripe printed lounge pants. 38271 R49 On 6/03/24 at approximately 9:58 am., R49 was observed in their room, laying in their bed. R49 was was queried if they had any concerns regarding their care and they reported the facility is short staffed. R49 was queried why they believed the facility was short of staff and they reported that the CNA's (Certified Nursing Assistants) come in and tell them they cannot give them any bed baths because there was not enough help. R49 reported they only get one bed bath a week due to short staffing. On 6/4/24 at approximately 11:06 a.m., R49 was observed in their room, laying in their bed. R49 was queried if anyone had offered to bathe them the previous night and they reported nobody had. R49 reported again estimated they have only been proved three bed baths in last month. R49 reported that nobody was around to help and they were supposed to get bathed twice a week. On 6/5/24 at approximately 9:00 a.m., R49 was observed in their room, laying in their bed. R49 was queried if anyone had offered to bath them on the previous day (6/4) and they reported nobody had. R49 was informed that documentation was in the medical record that they had a shower the previous day and they indicated that was not true and nobody had offered to bath them. The medical record for R49 was reviewed and revealed the following: R49 was initially admitted to the facility on [DATE] and had diagnoses including Morbid obesity and Muscle weakness. A review of R49's MDS (minimum data set) with an ARD (assessment reference date) of 4/14/24 revealed R49 needed assistance from facility staff with most of their activities of daily living. R49's BIMS score (brief interview for mental status) was 14 indicating intact cognition. A review of R49's comprehensive careplan revealed the following: Focus-Potential/Actual ADL/Mobility deficit R/T (related to) Wound infection, Chronic lymphedema, HX (history) PE (Pulmonary embolism) , restless Leg Syndrome, HTN (Hypertension), HLD (Hyperlipidemia), Osteoarthritis, Glaucoma, DM (Diabetes Mellitus) and Morbid Obesity, Rt (right) ankle fracture Date Initiated: 01/02/2024 .Interventions-Assist the pt (patient) with showers/bed baths Date Initiated: 01/02/2024 . A review of R49's CNA bathing documentation for the previous 30 days was reviewed and revealed R49 was documented as being bathed only on 5/21, 5/24 and 6/4. Further review of the record revealed no documented episodes of refusals. On 6/5/24 at approximately 11:23 a.m., during a conversation with the Director of Nursing (DON), the DON was queried regarding the lack of bathing documentation in the record for R49. The DON was then observed reviewing the record and indicated they agreed that R49 had only three instances of bathing in the previous 30 days. At that time, the DON was queried if they had identified problems getting residents bathed and they indicated that they had and that they had recently hired a new Nurse Manager who was going to assist in making sure bathing was being provided. 39592 R71 On 6/3/24 at 12:10 PM, R71 was observed sitting in a wheelchair in their room. R71's Legal Guardian was also sitting in R71's room. Both R71 and R71's Guardian were asked about the care in the facility. R71's Guardian explained that there were six hours a day, in two hour blocks of time, at breakfast, lunch and dinner, where there was no staff available for ADL care due to the CNA's having to carry trays one by one from the kitchen to the rooms, then having to pick up all the trays when the meal was over to take back to the kitchen. R71's Guardian also explained they had to make sure R71's brief was changed before mealtimes, or R71 would have to sit in soiled briefs until after all the trays were picked up after the meal service. On 6/3/24 at approximately 12:25 PM, observation of the kitchen/dining room revealed staff standing in a line. As a tray was assembled for a resident's lunch, a staff member would take the tray and walk with it to a resident's room, then walk back to stand in line until they received another tray. The only staff in the hallways were delivering trays. On 6/5/24 at 11:50 AM, R71's Guardian explained when they came to see R71 in the morning on 6/1/24, both R71 and the bed were completely wet, they were informed that several other residents on the same hall were in a similar condition. Review of a facility policy titled, Assisting the Nurse in Examining and Assessing the Resident revised 10/2010 read in part, .Activities of daily living (ADL) include the resident's physical, psychological, social and spiritual activities . As you provide the resident with personal care needs, you should note: a. The type of bath the resident likes (i.e., tub, shower, etc,); b. Assistance needed with bathing, hair and nail care, dressing and undressing, mouth care . As you provide the resident with personal toileting needs, you should note: a. Assistance needed with going to the bathroom; and b. Any changes in the resident's toileting habits .

This citation pertains to intake #s: MI00140148, MI00141564, MI00141722, and MI00143733. Based on observation, interview, and record review, the facility failed to ensure call lights were within reach and answered promptly for three residents (R14, R60, and R72) reviewed for accommodation of needs, and two of five residents that attended the confidential resident council meeting. Findings include: Review of multiple complaints reported to the State Agency included allegations that call lights were not placed within reach, and call lights were not answered timely (beyond half an hour and longer). On 6/3/24 at 10:25 AM, observation of the facility's call light monitor screen included a split screen in which the top portion showed the rooms that were activated and not yet responded to, and a lower portion that showed call lights that had been activated but were answered (turned off). The room occupied by R14 on the top portion of the screen identified it had been activated at 9:42 AM and was still active (not responded to). Review of the previous six months of resident council minutes identified a concern with call lights during the 2/7/24 meeting which read, .Nursing - call lights need improvement . Review of the Resident Council Departmental Response Form dated 2/7/24 further documented, .Nursing .Issue(s) Identified by Resident Council Per Resident Council call light times needs some improvement .Explanation and/or Response/Actions Taken by Department to Resolve Issue(s) Identified New staff coming in creating 2 hr schedule to monitor call lights. This form was signed by the Director of Nursing (DON) and Former Administrator (Staff 'J') on 2/7/24. On 6/4/24 at 8:20 AM, while reviewing the call light monitor screen between the 300 and 400 hallways, the [NAME] President of Clinical Services (Staff 'L') inquired if there were any questions about the observation of the call light monitor. Staff 'L' reported the facility's call light responses have been better and had reviewed the past resident council minutes and had not been aware of any concerns with call light responses. They reported their average response times were between 10-12 minutes and they were working on encouraging staff to make sure they have pagers on them and the nurses have their portable phones. Staff 'L' further reported the Director of Nursing and Administrator also has portable phones and they get notified if call lights are prolonged. When asked if they could print call light reports for a specific room and they reported they thought they could but would have to figure out how to access. On 6/4/24 at 10:00 AM, a confidential resident council meeting was conducted with five residents, most of whom attend meetings regularly. When asked about whether there were any current concerns with staff's response to call lights, two of the five residents expressed concern. Their responses included: Sometimes we've waited an hour or hour and half while they help with someone else. Sometimes it's a long time, but only when short on staff. Weekends they were short. On 6/4/23 at 12:36 PM and 6/5/24 at 10:23 AM, the Administrator was requested to provide the call light for several rooms on several dates, including the room occupied by R14 from 6/3/24. Review of the documentation provided revealed there was no documentation of R14's room of any call light activations on 6/3/24. On 6/5/23 at approximately 12:45 PM, the Administrator reported they were unable to print the call light report but would take a picture of the screen from their monitor and provide that for review. On 6/5/23 at 12:55 PM, Staff 'L' was asked about the call light report for R14's room and why the documentation provided revealed no call light activations despite actual observation of that on 6/3/24, they reported they were able to find that and put into the electronic system for review. Review of the documentation now revealed R14's the call light was activated on 6/3/24 at 9:42 AM, and was cleared at 10:26 AM. There were no other call-light activations documented or provided for the remainder of 6/3/24. 34208 R72 On 6/3/24 at 9:31 AM, R72 was observed lying in their bed. They verbalized they were uncomfortable and activated their call light for assistance. On 6/3/24 at 9:41 AM, an observation from the hallway was made. At that time Staff Member 'T' peeked into R72's room from the hallway but did not enter the room. Staff Member 'T' was then observed to proceed up the hallway and enter another room. Staff Member 'T' was not observed to address R72, the reason the call light was on, or deactivate the call light. Immediately after Staff Member 'T' entered the second room, an observation of the call light box in R72's room was made and displayed a red light indicating it was still activated. On 6/3/24 at 9:48 AM, Staff Member 'T' exited the room they were assisting in and an interview was conducted about them previously peeking their head in R72's room. They were asked if they were aware the call light was on when they looked in the room and said they did not know. They were asked how staff were aware of an activated call light and said they carried pagers. They were asked if they attended to R72's request and said they did not previously, but would go and check on them. 38271 R60 On 6/4/24 at approximately 8:37 a.m., and again at 12:57 p.m., R60 was observed in their room, laying in their bed. R60's call light button was observed on the floor, out of reach of the resident The call light button was observed in the same spot and position during both observations. On 6/5/24 at approximately 8:54 a.m., 10:08 a.m., 11:16 a.m., and at 11:30 a.m., R60 was observed in their room, laying in their bed. R60's call light was observed on the floor out of reach of the resident. R60's call light button was in the same spot and position during all the observations. The DON (Director of Nursing) was shown R60's call light button that was out of reach during the 11:30 a.m., observation and reported that it should have been within her reach and that R60 needed a clip for their call button to hold it in place. The DON reported they would look to find a clip and that staff should be looking for the call light to ensure it is within the residents reach. On 6/3/24 the medical record for R60 was reviewed and revealed the following: R60 was initially admitted to the facility on [DATE] and had diagnoses including Anxiety disorder and Chronic obstructive pulmonary disease. A review of R60's MDS (minimum data set) with an ARD (assessment reference date) of 5/5/24 revealed R60 needed assistance from facility staff with most of their activities of daily living. On 6/5/24 a facility document pertaining to answering the residents call light was reviewed and revealed the following: Purpose-The purpose of this procedure is to respond to the resident's requests and needs. 1. Explain the call light to the new resident. 2. Demonstrate the use of the call light. 3. Ask the resident to return the demonstration so that you ill be sure that the resident can operate the system) (Note: Explain to the resident that a call system is also located in his/her bathroom. Demonstrate how it works. ) 4. Be sure that the call light is plugged in at all times. 5. When the resident is in bed or confined to a chair be sure the call light is within easy reach of the resident. 6. Some residents may not be able to use their call light. Be sure you check these residents frequently. 7. Report all defective call lights to the nurse supervisor promptly. 8. Answer the resident's call as soon as possible. 9. Be courteous in answering the resident's call .

Based on observation, interview and record review, the facility failed to ensure a medication error rate less than five percent when six medication errors out of 27 opportunities for error were observed for three (R44, R43 and R68) out of five residents reviewed during the medication administration observation, resulting in a 22.22% error rate. Findings include: Review of a facility policy titled, Medication Administration dated 1/2021 read in part, .Medications are administered as prescribed in accordance with manufacturers' specifications . Prior to administration, review and confirm medication orders for each individual resident on the Medication Administration Record (MAR). Compare the medication and dosage schedule on the resident's MAR with the medication label. If the label and MAR are different, . the prescriber's orders are checked for the correct dosage schedule . On 6/4/24 at 8:01 AM, Licensed Practical Nurse (LPN) C was observed as part of the medication pass task. LPN C was observed to place a needle on a NovoLog FlexPen, turn the dial to 14 and inject the Insulin into R44's arm. LPN C was then observed to prepared seven oral medications, including Docusate Sodium 250 mg (milligrams). LPN C administered all seven medications to R44. After exiting R44's room, LPN C was asked about the lack of priming of the NovoLog FlexPen. LPN C explained she had been taught that priming was not needed for Insulin pens. On 6/4/24 at 8:52 AM, LPN E was observed to prepare seven medications, including one Super Omega-3 1200 mg, one Vitamin B Complex with B-12 and one Senna Plus 50mg/8.6mg. LPN E took a Vitamin D3 5000 IU (international units) or 125 mcg (micrograms) bottle out of R43's medication cabinet, and attempted to place a tablet into the medication cup however, the bottle was empty. LPN E then took a bottle of Magnesium out of the cabinet and explained it was not the correct dosage so she did not give the Magnesium into the medication cup. LPN E explained R43's family member brought the supplements for R43 as they did not want R43 to get the facility's stock medications. LPN E was then observed to administer the medications to R43. On 6/4/24 at 9:08 AM, LPN F was observed to prepare five medications, including a Multivitamin tablet. LPN F was then observed to administer all the medications to R68. On 6/4/24 at 9:46, R44's physician orders were compared to the medications observed to have been given. The reconciliation revealed R44 had an order for Docusate Sodium 100 mg. It should be noted R44 received Docusate Sodium 250 mg. On 6/4/24 at 9:51 AM, R43's physician orders were compared to the medications observed to have been given. The reconciliation revealed R43 had an order for Omega-3 1200 mg, two capsules, Vitamin B Complex two capsules and Senna 8.6 mg. R43 received only one capsule each of the Omega-3 1200 mg and Vitamin B Complex, and had received Senna Plus (also containing Docusate Sodium) 50mg/8.6mg. The physician order for Vitamin D3 was for 1000 IU or 25 mcg, the bottle in the cabinet was 5000 IU or 125 mcg. It was also noted that the order for Magnesium 400 mg two capsules was marked off as given on R43's Medication Administration Record (MAR) when it was observed LPN E did not administer any Magnesium. On 6/4/24 at 10:00 AM, R68's physician orders were compared to the medications observed to have been given. The reconciliation revealed R68 had an order for Multivitamins with minerals ordered. It should be noted R68 received a Multivitamin with no added minerals. On 6/5/24 at 9:00 AM, the Director of Nursing (DON) was interviewed and asked if Insulin pens should be primed before every use. The DON explained an airshot (priming) should be done before every use. When informed of the dosage errors observed, the DON had no explanation. The DON was asked if a medication should be marked off as given if it was not given. The DON explained nothing should be marked off as given or done until after it was given or done. Review of the Manufacture's Instruction For Use for the NovoLog FlexPen revised 4/2015 read in part, .Before each injection small amounts of air may collect in the cartridge during normal use. to avoid injecting air and to ensure proper dosing: E. Turn the dose selector to select 2 units. F. Hold your NovoLog FlexPen with the needle pointing up Tap the cartridge gently with your finger a few times to make any air bubbles collect at the top of the cartridge. G. Keep the needle pointing upwards, press the push-button all the way in. The dose selector returns to 0. A drop of insulin should appear at the needle tip .

This citation pertains to intake # MI00143489. Based on interview and record review, the facility failed to verify an employee (Staff 'M') who was employed at the facility as a Registered Nurse (RN) had the required education, experience and valid nursing license to provide nursing services. This deficient practice had the ability to affect multiple residents that resided in the facility. Findings include: A complaint was filed with the State Agency (SA) that alleged the facility allowed a staff member to work 12 shifts before it was found they did not have a valid RN license. Review of documentation provided by the facility which was identical to the documentation provided from Attorney General (AG) office included an initial complaint filed by the [NAME] President of Clinical Services (Staff 'L') which documented Staff 'L' had been checking licenses of staff and identified some discrepancies with Staff 'M's license and registry information. The interview statement provided to the Office of the Oakland County Sheriff by Staff 'L' conducted with Staff 'M' on 3/9/25 at 5:00 PM documented, in part: .Q: (Question) Please state your first middle and last name? A: (Answer) [Name of Registered Nurse/RN 'O']. Q: Help me understand why the RN license is under the name: [Name of RN 'O'] and your ID MI (Michigan) Driver's license is: [Name of Staff 'M']. A: States I feel like an alien there is no account of me. It's like I vanished <sic> the earth. Maybe someone stole my identity. Maybe it's because I got a divorce in 2007. Q: Help me understand why your employment application state no for a degree/certificate but you stated you graduated from Davenport? A: I wasn't thinking that was a degree since it was a RN license. I let my LPN (Licensed Practical Nurse) expire 1990. Q: Can you confirm your date of birth? X/XX/72 [full date redacted] How is it your RN licence <sic> was issued on X/X/1982 [full date redacted] and you were [AGE] years old? I am really struggling to follow your story. Is there something else you would like to tell me because none of this makes sense? A: I need to confess. I faked all of this. Q: What do you mean? Your not a nurse? A: No, I am not a nurse. Q: Were you ever a nurse? A: No, I have experience in phlebotomy. Q: Please confirm you were never a nurse? A: No, I was never a nurse . Q: .I will also report you to the professional licensing bureau for impersonating a RN. A: I understand and I am ready to pay for this. Q: This writer asked if there was anything else she wanted to disclose. A: She states No. Q: Asked how were you able to fake it without getting caught? A: I knew enough from phlebotomy conversation ended. On 6/3/24 at 12:30 PM, an interview was conducted with Staff 'L'. They recalled the same events as included in the above interview with Staff 'M' and further reported their former HR (Human Resource) Manager (Staff 'K') had not identified the discrepancies with Staff 'M's identification and license and had since resigned. When asked what had been done to ensure this would not occur again, Staff 'L' reported they had reviewed all employee files to verify their information was correct, and there were no further concerns identified. They further reported the new HR Manager verified all new employees closely upon hire. Review of the documentation provided of the facility's investigation included Staff 'M's time-punch reports which identified in addition to three days of orientation, they were assigned 25 shifts as an RN which included: 1/23/24 in 9:00 AM - out 4:30 PM - ORIENTATION 1/24/24 in 9:00 AM - out 6:00 PM - ORIENTATION 1/25/24 in 9:20 AM - out 1:00 PM - ORIENTATION 1/25/24 in 6:53 PM - out 7:45 AM 1/26/24 in 6:54 PM - out 3:04 AM 1/27/24 in 3:36 AM - out 7:30 AM 1/29/24 in 6:56 PM - out 2:44 AM 1/30/24 in 3:24 AM - out 7:14 AM 2/1/24 in 6:56 PM - out 3:03 AM 2/2/24 in 3:32 AM - out 7:40 AM 2/5/24 in 6:50 PM - out 7:30 AM 2/6/24 in 6:54 AM - out 8:17 AM 2/10/24 in 6:52 PM - out 3:31 AM 2/11/24 in 4:03 AM - out 8:39 AM 2/11/24 in 6:51 PM - out 8:39 AM 2/12/24 in 6:54 AM - out 7:21 AM 2/15/24 in 6:55 PM - out 8:21 AM 2/19/24 in 6:51 PM - out 7:20 AM 2/20/24 in 6:53 PM - out 8:23 AM 2/24/24 in 6:49 PM - out 7:08 AM 2/25/24 in 6:53 PM - out 7:30 AM 2/26/24 in 6:54 PM - out 7:07 AM 2/29/24 in 6:57 PM - out 7:16 AM 3/1/24 in 6:58 PM - out 7:16 AM 3/4/24 in 6:58 PM - out 4:38 PM 3/5/24 in 5:02 AM - out 7:42 AM 3/5/24 in 7:05 PM - out 4:21 AM 3/6/24 in 5:02 AM - out 7:41 AM On 6/4/24 at 8:58 AM and 6/5/24 at 2:00 PM, multiple attempts were made to contact the former HR Manager (Staff 'K') for an interview, however the phone number was no longer in service and there was no other contact information available. Review of the facility's investigation summarized, .The facility believes based on the interview & record review that [Staff 'M'] had utilized [RN 'O'] Registered Nursing License and she was never a RN herself. She did have a background in phlebotomy. She worked at the facility for approximately 1 month. No negative outcome was seen with any patients who were under her care during this time. This investigation was also submitted to the professional licensing bureau . Further review of the documentation provided of the facility's investigation and audits, revealed no further concerns. Discussion with the survey team acknowledged this deficient practice as an accepted Past Non-Compliance. Review of the facility's documentation provided for their process for hiring included a New Hire/Rehire Checklist that included, .Pre-Employment .License/Certification Verified .I-9 Document/Verify completed . Review of the Registered Staff Nurse Job Description dated 7/31/2015 documented, .Must be a graduate from an accredited school of nursing with an Associate's or Bachelor's Degree, or higher .Current license to practice as an RN in Michigan .

Based on observation, interview and record review, the facility failed to ensure a Resident's personal preferences for care was honored for one (R53) of one resident reviewed for self-determination/choices. Findings include: On 6/3/24 at 9:31 AM, R53 was observed lying in bed. R53 was asked about care at the facility. R53 explained they were scheduled to get showers on Tuesday and Friday afternoons. They had asked to have them in the mornings, but had been told they could not be moved to mornings because the day shift nurse aids were too busy. Review of the clinical record revealed R53 was admitted into the facility on [DATE] and readmitted [DATE] with diagnoses that included: chronic obstructive pulmonary disease, heart failure and paraplegia. According to the Minimum Data Set (MDS) assessment dated [DATE], R53 was cognitively intact and required the assistance of staff for activities of daily living (ADL's). On 6/4/24 at 11:01 AM, R53 was observed lying in bed. R53 was asked about their indwelling urinary catheter. R53 explained the indwelling catheter was changed once a month on the midnight shift, but did not want it done at night, they would prefer to have it done during the day. On 6/5/24 at 9:00 AM, the Director of Nursing (DON) was interviewed and asked about R53's shower and indwelling catheter preferences. The DON explained R53 wanted to be switched to have their showers on the day shift, but the day shift is full and the Certified Nursing Assistants (CNA's) can not take on another shower, so R53 has to stay on the afternoon shift. Review of a facility Resident Rights Handbook, undated, read in part, .Self-Determination and Participation: The resident has the right to- (1) choose activities, schedules, and health care consistent with his or her interests .

This citation pertains to intake #MI00141722 Based on observation, interview, and record review, the facility failed to ensure treatment in a dignified manner for three residents (R#'s 54, 72, and 235) of four residents reviewed for dignity, resulting in the potential for feelings of embarrassment. Findings include: A complaint was received by the State Agency that alleged residents were not being treated in a dignified manner. A review of a facility provided policy titled, Quality of Life-Accommodation of Needs was reviewed and read, Our facility's environment and staff behaviors are directed toward assisting the resident in maintaining and/or achieving independent functioning, dignity, and well-being . R54 On 6/3/24 at 9:56 AM, R54 was observed in their bed. At that time, they were asked about various aspects of their stay in the facility and said some staff, Are not respectful. R54 said staff argue and are rude to one another. R54 continued to say the facility was their home but, staff make them feel like, you are in their facility, not home. R72 On 6/3/24 at 1:24 PM, a review of R72's progress notes was conducted and revealed the following note entered into the record by Nurse 'B' on 4/23/24 that read, .resident was yelling and calling out at the beginning of shift. writer went to check on resident and found resident laying in bed c/o (complaints of) not being able to see still and that sh*t <sic> needed to used the restroom. writer attempted to remind resident that she uses a brief, resident became upset and stated how much she hated being incontinent, then starts crying about how she's ready to 'just pass' . On 6/4/24 at 2:55 PM R72 was observed in their bed. At that time, an interview was conducted with R72 and they were asked if staff ever directed them to urinate or have a bowel movement in their incontinence brief. R72 said I have been told that, I am not buying into it. R72 was asked if they can feel the sensation of when they need to use the bathroom and said, Occasionally. R235 On 6/3/24 at 10:23 AM, R235 was observed being transferred via wheelchair to their room by Certified Nursing Assistant (CNA) 'A'. When they arrived to their room, CNA 'A' did not close the room door and could very loudly be heard from the hallway giving R235 instructions saying, I need you to sit down on the toilet so I can change that brief. On 6/5/24 at 9:20 AM, an interview was conducted with the facility's Director of Nursing (DON) regarding resident dignity. They said it was inappropriate for staff to be overheard from the hallway giving instructions about bathroom use and staff should never tell a resident to use their incontinence brief.

This citation pertains to intake: MI00138676. Based on observation, interview and record review, the facility failed to ensure accurate/completed skin assessments, timely implement adequate interventions to prevent the development and/or worsening of wounds, and failed to monitor, timely identify and treat the worsening of wounds for two (R802 and R804) of two residents reviewed for pressure ulcers, resulting in R802 to have developed bilateral heel wounds, a stage 3 coccyx wound and the need to be transferred and admitted to the hospital for the infected bilateral heel wounds which required Intravenous (IV) antibiotics; and the potential for worsening pressure ulcers for R804. Findings include: Review of a complaint submitted to the State Agency (SA) documented concerns of the facility's failure to prevent and care for pressure ulcers. On [DATE] at 10:27 AM, the complainant was interviewed via telephone when asked, the complainant stated R802 developed multiple wounds at the facility. The complainant stated on [DATE] R802 wounds were observed with the facility nurse which revealed in part .bilateral full thickness pressure ulcers with foul smelling purulent drainage and necrotic edges . The complainant stated a coccyx wound was also identified as well as skin impairment to the scrotum. The complainant stated R802 was transferred to the hospital and admitted for Intravenous (IV) antibiotic treatment for bilateral infected heels. The complainant explained the course of treatment was intense and the family ultimately decided to place R802 in hospice care. R802 was discharged home on hospice care on [DATE] and died four days later on [DATE]. Review of the medical record revealed R802 was admitted to the facility on [DATE] with diagnoses that included: alzehimer's disease, unspecified displaced fracture of surgical neck of left humerus and a fall. A Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 2 (which indicated severely impaired cognition) and required the assistance from staff for all Activities of Daily Living (ADLs). Further review of the MDS Skin Condition section documented the resident was admitted to the facility with no pressure ulcers. Review of an admission summary dated [DATE] at 9:36 PM, documented in part .Guest arrived to facility via stretcher at 8pm from (hospital name), A&O x1 (alert and oriented times one), hospitalized for fall encountering a subdural hematoma and (L) humerus fx (fracture), sling in place to LUE (left upper extremity) .Skin assessment completed with discoloration noted to LUE and (L) (left) shoulder, scabbed area on (R) (right) hand and RFA (right forearm) . Review of the facility weekly Skin & Wound assessments dated: [DATE], [DATE], [DATE], and [DATE] documented no wounds or skin impairment were identified for R802. Review of an admission Braden assessment dated [DATE] documented a score of 17, which indicated the resident was at risk for pressure ulcers. Review of a progress note dated [DATE] at 12:37 PM, documented in part .Resident's daughter notified of areas to heels and potential friction cause by shoes. Daughter states she will bring different shoes. Review of a Nurse Practitioner (NP) note dated [DATE] at 3:07 PM, documented in part .Patient seen and examined. Patient observed ambulating in room .Pt has severe cognitive deficit .Patient observed standing at sink, bil (bilateral) heel wounds noted. Appear to be from patient's shoes which he wears daily .Nursing notified, will + treatments .+ heel wounds to bil. Heels .treatment orders for heel wounds, monitor sites .Follow up with ortho (orthopedics) - appt (appointment) [DATE] . Review of an Occupational Therapy treatment encounter note dated [DATE] at 3:32 PM, documented in part .Patient dressed and seated in w/c (wheelchair) upon therapist arrival. NP notifying this writer of bilateral heel wounds. Observed patient's feet to which both heels have open wounds, right one with blood present. Nurse on hall aware and to assess. Tx (Treatment) session focused on seated activities to prevent further shearing of shoes on heels . Prior to the NP identification of R802's heels and notification to the nursing staff on [DATE], there was no documentation of the staff to have identified the changes to R802's heels. Review of a Skin & Wound Evaluation dated [DATE] at 11:29 AM, documented in part .Friction from shoes .Left Heel .In-House Acquired .New .Area 2.8 cm2 (centimeters squared) .Length 2.3 cm (centimeters) .Width 1.5 cm .Depth Not Applicable .Ruptured blister .Exudate - None .Indication that current shoes may be causing friction . Review of a picture of the Left heel attached to the assessment revealed a ruptured blister with depth observed, although depth was not documented in the assessment. Review of a Skin & Wound Evaluation dated [DATE] at 11:38 AM, documented in part .Friction from shoes .Right Heel .In-House Acquired .New .Area 3.5 cm2 .Length 2.4 cm .Width 2.0 cm .Depth Not Applicable .Slough 60% of wound filled . Review of a Skin & Wound Evaluation dated [DATE] at 11:49 AM, documented in part .Open Lesion .Coccyx .Acquired (left blank) .Area 2.7 cm2 .Length 2.5 cm .Width 1.6 cm .Depth Not Applicable .Slough 100% of wound filled .New . Review of a picture of the coccyx wound attached to the assessment revealed a coccyx wound, not an open lesion as documented in the assessment. Review of the medical record revealed no prior identification of the coccyx wound or skin impairment identified by the facility staff. Review of a NP note dated [DATE] at 1:30 PM, documented in part .Patient seen and examined. Patient observed sitting in chair. Pt has severe cognitive deficit .Patient appears to be wincing and shaking in pain .Daughter at bedside, was going to take patient to ortho appointment today. NP was notified to see patient due to uncontrolled pain and b/l (bilateral) heel wounds. Heel wound undressed - dark wound beds to b/l heels with small amount of foul-smelling purulent blood-tinged drainage. Both heels with surrounding blanchable erythema. Patient wincing while heel wounds being assessed. Daughter agreeable to send patient to hospital via ambulance for evaluation of wounds, likely IV antibiotic therapy. Discussed with .(assigned nurse name, DON name and director) .Skin .rash (Excoriation to groin) and ulcer (DTI's - Deep Tissue Injury- to b/l heels with s/s (signs/symptoms) infection. Stage 3 (full-thickness loss of skin, in which subcutaneous fat may be visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. Slough and/or eschar may be visible) to left buttock.) .Pressure injury of heel - B/l DTIs with small amount of foul-smelling purulent blood-tinged drainage .Patient sent to hospital for wound evaluation .Pressure ulcer of unspecified heel, unspecified stage . Review of the medical record revealed no documentation of the facility staff to have identified the worsening of the resident wounds prior to the identification on [DATE] when the resident was transferred to the hospital. This indicated R802 who was admitted to the facility for rehabilitation after a fall at home developed two bilateral heel wounds and a stage 3 coccyx wound within 5 weeks after being admitted to the facility with no wounds and to have developed an infection of the heel wounds shortly after. Further review of the medical record documented that daily treatment for the heels- cleanse, triple antibiotic ointment and abdominal wrap daily for two weeks and coccyx- cleanse, apply skin barrier cover with aquacel pad daily for two weeks was implemented. Review of the care plans revealed the interventions implemented were not adequate to prevent the development or the worsening of the resident wounds. Further review of the care plans revealed the heels and coccyx was not added to the .potential impairment for skin integrity . care plan until [DATE], the day R802 was transferred to the hospital for their infected wounds. Review of the [DATE] Medication Administration Record (MAR) and Treatment Administration Record (TAR) documented the implementation of Float heels to be applied on [DATE], however the record did not document why the float heels were implemented. Review of the hospital medical records revealed the following: A ED (Emergency Department) Provider Notes dated [DATE] at 4:52 PM, documented in part .Patient presents to the Emergency Center today with a wound problem .patient has been in a subacute rehab facility .for a left proximal humerus fracture .Six days ago, ECF (Extended Care Facility) staff informed the patient's daughter of blisters he had developed on his bilateral heels. The patient has been having difficulty standing and ambulating due to the pain .wounds are foul-smelling with purulent drainage .ulcer on the patients coccyx .Ulcers to bilateral heels with surrounding erythema 2.5 cm with some necrosis and purulent drainage .WBC (White Blood Cell) 13.7 (H- high) .Patient with infected pressure ulcers of bilateral heels, concerned for possible osteomyelitis. Purulent drainage on exam .Antibiotics started .CRP (C-Reactive Protein levels- under 10 milligrams per liter is considered normal) 225 .Labs show leukocytosis, 13.5 .Escalation of care including admission/observation was considered. Patient will be admitted .Disposition: Admission .Final Impression: Infected pressure ulcers of bilateral heels . Review of a History and Physical dated [DATE] at 9:54 AM, documented in part .admitted to our facility on [DATE] with worsening of bilateral heel wounds .He has been in an extended care facility where they (family) felt like his wounds were not being properly cared for. Staff at the facility had told the family that patient developed blisters on his heels .he was complaining of severe leg pain at which time the family remove the bandages and found his wound had purulent drainage. For this he was brought into our facility .Given oral and IV analgesics, IV hydration and a dose of IV vancomycin and Zosyn (antibiotics) .Continue IV vancomycin and Zosyn . Review of a Discharge Summary dated [DATE] at 8:59 AM, documented in part .Date of Admission: [DATE], Date of Discharge: [DATE] . Diagnosis - Primary Problem: Wound drainage .presented to the hospital with bilateral heel wounds .At an outside facility he apparently developed these heels ulcers which were noted by family and found to be having purulent drainage which was brought to our facility. Initially had significantly elevated CRP/ESR (Erythrocyte Sedimentation Rate) and was started on oral/IV analgesics as well as IV antibiotics. Patient was evaluated by orthopedic surgery, infectious disease, podiatry, vascular surgery .He completed 1 week of IV antibiotics while admitted . Family elect home with hospice care .Plan for discharge home with hospice this afternoon. Discussed with family, new prescriptions for Augmentin to complete 1 week as well . Further review of the hospital medical record revealed photographs taken of both heels by the hospital staff that reflected the documented assessment findings by the hospital providers. On [DATE] at 2:22 PM, the Director of Nursing (DON) was interviewed. The DON was asked if they were familiar with R802's care at the facility and replied they remembered they received a call on the last day of the resident being in the facility because R802's daughter stated that R802's heels were necrotic, needed debridement and the resident needed to go out for IV antibiotics. The DON stated they went down to R802's room to assess their heels and they denied the heel wounds to be necrotic as stated by R802's daughter. The DON then stated they told R802's daughter that it is their choice to transfer R802 to the hospital and the facility staff then facilitated R802 to be transferred to the hospital. The DON was then read the NP note dated [DATE] that reflected R802's heel wounds were infected, a stage 3 coccyx wound and the need to be transferred to the hospital for IV antibiotics. The DON stated they did not talk to the NP and was unaware of the NP note dated [DATE]. The DON was then read the portion of the NP's note from [DATE] that documented that the NP communicated their findings with the DON and the DON stated they could not recall. The DON was asked why who and when the first identification of the coccyx wound was made by the facility staff and the DON stated they were unsure. The DON stated staff should have written a progress note of the identification of all of R802's wounds. The DON was then asked about the skin assessment completed on [DATE] which failed to identify any skin impairments, despite three days later two heel and a coccyx wound to have been identified, the DON replied they were unable to answer the question but if staff observed any skin impairments the protocol is to take a picture, notify themselves (DON) and the physician and implement treatment. The DON was asked if the facility staff applied socks to R802's feet to prevent the rubbing of the skin against their shoes and the DON stated they were unable to answer that. The DON was asked the facility's protocol on the identification of a wound worsening and stated staff should take a picture and notify the physician. The DON was then asked if additional interventions should had been implemented on the care plan for the heels and coccyx wounds to prevent worsening besides the treatment implemented and the DON stated additional interventions should have been implemented on the care plan and was unable to state why additional interventions were not implemented. The DON was asked why the float boats was ordered on [DATE] and the DON stated they were unsure. The DON was then asked if the facility followed up with the staff to see how this happened and how they could prevent this incident from happening again in the future considering that the facility staff applied treatments daily to the wounds, showered/bathed resident, changed the briefs of the resident daily and failed to identify the worsening of the wounds, the DON replied they did look into it but .we probably should have looked into the situation a little better to see what happened . At this time the DON was informed of the concerns of accurate skin assessments, the implementation of adequate interventions, the monitoring of the wounds and the timely identification and treatment of the worsening of R802's wounds. The DON stated they would look into the concerns and follow back up. No further explanation or documentation was provided by the end of the survey. 30675 R804 Review of the facility documentation provided for residents with pressure ulcers (PU) identified there were a total of 10 residents currently with PU's, and three of these residents had acquired PU's while in the facility. Further review of the documentation identified R804 had developed two unstageable PU's (full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because the wound bed is obscured by slough or eschar) since admission into the facility, one on the left heel and one on the right heel. These were identified by nursing staff on [DATE]. On [DATE] at 11:47 AM, R804 was observed seated in a wheelchair that was pushed up to a table in the dining/activity room. Both of R804's feet were observed resting directly on the leg rests (hard surface) and the resident wore light blue socks with grippy material on both feet. There were no visible pressure relieving materials in use such as a pillow, cushion or padded protective boots. Although R804 had significant cognitive impairment, they responded to simple questions asked. Review of the clinical record revealed R804 was admitted into the facility on [DATE] with diagnoses that included: anterior dislocation of left humerus, type 2 diabetes mellitus without complications, unspecified psychosis, adjustment disorder with mixed disturbance of emotions and conduct, meningitis, other encephalitis and encephalomyelitis, urinary tract infection (UTI), hypertension (HTN), and bacteremia. According to the MDS assessment dated [DATE], R804 had moderately impaired cognition, required extensive assistance of two or more people for bed mobility, was totally dependent upon two or more people for transfers, had no functional limitation in range of motion for upper and lower extremities, used a wheelchair for mobility, was not on a therapeutic diet, had no weight fluctuations, was at risk for developing pressure ulcer/injury upon admission but did not have any, and had a pressure reducing device for the bed. Review of the skin/wound care plan initiated on [DATE], revised on [DATE] documented, The resident has the potential impairment to skin integrity r/t (related to) UTI, Anemia, Anterior Dislocation of left Humerus, Arthritis, Hypothyroidism, Back pain, PUD (Peptic Ulcer Disease) and HTN. The following interventions were initiated on [DATE], with the exception of one added [DATE]: Educate resident/family/caregivers of causative factors and measures to prevent skin injury. Identify/document potential causative factors and eliminate/resolve where possible. Monitor/document location, size and treatment of skin injury. Report abnormalities, failure to heal, s/sx of infection, maceration etc. to MD. pressure reducing cushion to protect the skin while up in chair. Float Heels (initiated [DATE]). Review of two Braden Scale assessments (tool used to determine risk for PU development; a lower score indicates a higher level of risk for PU development) documented on [DATE] (score of 11 = high risk) and on [DATE] (score of 13 = moderate risk). Review of R804's Skin & Wound Evaluation V7.0 assessment dated [DATE] documented, .Pressure .Unstageable: Obscured full-thickness skin and tissue loss .Location Right Heel .In-House Acquired .How long has the wound been present? .New .Staged by .In-house nursing .Wound Measurements .Area 12.5 cm2 (centimeters squared) .Length 5.6 cm .Width 3.2 cm .Depth Not Applicable .Exudate .Light .Serous . The remaining sections of this assessment for wound pain, orders, treatment, and notifications including practitioner/resident/responsible party/dietician/therapy were left blank (incomplete). There was no documentation available for review that any of the above disciplines or emergency contact had been notified of the significant change in R804's skin condition with two unstageable PU's. Further review of the progress notes revealed there were no skin/wound documentation included in the progress notes for the change identified on [DATE]. Additionally, review of R804's physician orders for the treatments implemented once the PU's were identified on [DATE] revealed there was no treatment/interventions implemented until [DATE]. Review of the two treatment orders for R804's PU's included: The first started on [DATE], Cleanse Bil. Heels with NS, pat dry, apply foam dressing, wrap with kerlix and secure with tape. Change every 3 days and PRN (as needed) if soiled/dislodged. As needed for if soiled/dislodged. There were no PRN treatments documented. The second started on [DATE], Cleanse Bil. Heels with NS (Normal Saline), pat dry, apply foam dressing, wrap with kerlix and secure with tape. Change every 3 days and PRN (as needed) if soiled/dislodged. In the morning every 3 day(s). Treatments were documented as completed on [DATE] and [DATE]. Review of the physician/extender documentation included: An entry on [DATE] at 12:20 PM by Nurse Practitioner (NP 'D's) documented, .Patient seen and examined today for new bil (bilateral) Heel wounds. Patient observed in wheelchair .A&Ox2 on exam today .Pt (patient) has new bil heel wounds. + Drainage to R heel wound .Will + treatment and monitor .Discussed and agreed upon with [Name of Medical Director], Cont (Continue) wound care, monitor bil. Heel wounds . An entry on [DATE] at 3:00 PM by NP 'D' read, .Patient seen and examined today for f/u (follow-up) on bil. Heel wounds .Patient observed in wheelchair, in no acute distress. Awake and alert, Able to answer simple questions. A&Ox2 on exam today .Bil heels assessed. L (Left) heel with intact eschar cap, no s/sx (signs/symptoms) of infection at this time R (Right) heel with deep tissue injury; unable to visualize wound bed, not stageable at this time .Discussed and agreed upon with [Name of Medical Director] Cont wound care, monitor bil. Heel wounds . A phone interview was conducted with R804's first emergency contact. When asked about whether they had been notified of the resident's development of two unstageable PU's, they reported they were not, they found it out themselves when the went to ask the nurse why the resident had leaking on the bottom of their heels. They further reported they thought it was weird because weren't they supposed to change her stockings, and it wouldn't happen just like that. When asked if they could recall the specific date or name or nurse, they reported they were not sure but maybe a week or so ago. When asked if the resident had a history of skin breakdown, especially for those areas, the emergency contact reported there was no history of breakdown and they were worried about an infection now that the skin was broken. On [DATE] at 2:21 PM, an interview was conducted with the DON. When asked who was responsible for notifying the family/responsible party for changes in condition such as new skin breakdown, the DON reported it should be the nurse that identified the changes to the family and physician. When asked when would treatments be implemented upon identification of new PU's, the DON reported that should be done immediately as well as adding interventions to float heels and turn/reposition immediately. When asked why there were no treatment orders implemented until ,d+[DATE] and ,d+[DATE] when the wounds were identified on ,d+[DATE], the DON reported there should've been a treatment initiated on the day they were identified. The DON was asked to review the skin and wound evaluation from [DATE] with the missing documentation and confirmed the incomplete documentation. When asked what other disciplines should have been notified, the DON reported the Registered Dietician (RD) and would expect an evaluation within a day or so. The DON was informed there was no additional nutritional assessments or progress notes since an initial dietary assessment on [DATE]. When asked if there is a change in skin condition, such as a new or worsening wound, where would that documentation be maintained, the DON reported usually they would get a picture, put in a treatment, the nurse notifies myself and I notify my people, but the nurse should write a note. The DON was unable to explain why this had not occurred for R804. When asked about the intervention added to float heels and what that meant specifically, given the observation of R804 seated in the wheelchair with their heels directly on the hard leg rests, the DON reported R804 frequently stayed in the wheelchair but they were not sure as you can't float heels in a wheelchair. When asked if there was a wound physician that consulted with the facility, the DON reported there was not, but that NP 'D' evaluated weekly. The DON further reported they monitored the wounds weekly via the dashboard (not available to surveyors) and they would go through the wound pictures to make sure treatments were appropriate. When asked if they had identified any concerns with R804, or previously such as during their quality improvement reviews, the DON reported they did not. On [DATE] at 3:05 PM, an interview was conducted with RD 'A'. When asked if they had been notified of R804's two unstageable PU's since [DATE], they reported they did not. When asked how they would be notified, RD 'A' reported usually in meetings held in the morning. When asked had they been notified, what alternate interventions might they have implemented for R804, RD 'A' reported they would have reviewed the food acceptance record, they would've interviewed the resident, watched her eat, maybe implement a multi-vitamin with minerals and maybe more protein or a supplement like prostat, mighty shake, or ensure. On [DATE] at 3:46 PM, the Administrator reported NP 'D' was no longer at the facility and provided their phone number to call. On [DATE] at 3:46 PM, NP 'D' was attempted to be contacted by phone, there was no answer, and a message was left to return the call. On [DATE] at 4:01 PM, a phone interview was conducted with NP 'D'. When asked when they were first notified of R804's two unstageable PU's, they reported they were notified the same day they first saw R804's wounds ([DATE]). When asked what interventions would they recommend implementing when new PU's were identified, NP 'D' reported they would always recommend pressure reduction. When asked how the facility was to provide pressure reduction when R804 is in wheelchair, NP 'D' reported the heels should have added protection such as a pillow and the order for the foam dressing might also help add cushion to that area and to encourage R804 to raise their legs up (to take pressure off of heels). NP 'D' was asked if they would consider additional supplements, they reported that would typically be something the RD would order and there should've definitely been a notification to do that. NP 'D' was informed that did not occur and reported it was unfortunate those breakdowns happened, but their goal was to maintain the wound and prevent infection.

This citation pertains to Intake Number: MI 179 and MI 955. Based on interview and record review, the facility failed to clarify admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] . This deficient practice resulted in recurrent [CONDITION(S)] ([CONDITION(S)]) Bacteremia, [CONDITION(S)], and a hospital admission requiring continued antibiotic therapy. Findings include: The State Agency received a complaint that alleged R802's [MEDICATION(S)] (an antibiotic medication) was discontinued prematurely. Review of R802's clinical record revealed R802 was admitted into the facility on [DATE] from the hospital with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a Minimum Data Set (MDS) assessment dated [DATE] revealed R802 had intact cognition and required extensive physical assistance with transfers and bed mobility and was independent with set up only for eating. The MDS documented R802 received antibiotics two days during the assessment period, which began at admission on 4/2/22. Review of hospital records scanned into the R802's electronic medical record (EMR) at the facility (from R802's hospital stay prior to admission into the facility) revealed the following: An After Visit Summary, uploaded into the EMR on 4/4/22, documented, 3/21/2022-4/2/2022 .Diagnosis .Severe [CONDITION(S)] due to [CONDITION(S)] ([CONDITION(S)]) with acute organ dysfunction .History of [CONDITION(S)] .Resolved Hospital Problems .[CONDITION(S)] .Gram-positive bacteremia .Infected prosthetic knee joint .Patient Instructions .Discharge to: Extended Care Facility .[MEDICATION(S)] through at least 5/7/2022, weekly CBC (Complete Blood Count) and CMP (Comprehensive Metabolic Panel), [MEDICATION(S)] trough (the concentration reached by a drug immediately before the next dose is administered, used in therapeutic drug monitoring) on 4/5/2022 and if therapeutic (trough between 15-20), weekly trough afterwards . Review of R802's Medication List from the hospital revealed several pages of medications. However, there were missing pages from the medication list, and it ended at page nine of 15 and did not include [MEDICATION(S)]. An After Visit Summary, uploaded into the EMR on 4/2/22 and labeled with an effective date of 4/2/22 included pages 10 through 15. Review of the after-visit summary revealed the following on page 10: Start [MEDICATION(S)] HCl 1500 MG (milligrams)/300 ML (milliliters) into the vein once daily .Last time this was given: Ask your nurse or doctor . Review of R802's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] [MEDICATION(S)] HCl Solution 1500 MG/300ML use 1500 mg intravenously one time a day for ANTI-INFECTIVE AGENTS with a start date of 4/3/22, ordered (verbal) by Physician 'A' and entered by Nurse 'F' on 4/2/22. The end date for this order was 4/3/22. The order was signed by Physician 'A' on 4/4/22. [MEDICATION(S)] HCl Solution 1500 MG/300ML use 1500 mg intravenously in the morning for infection until 04/05/2022 . with a start date of 4/3/22, ordered by Physician 'A' and entered by Nurse 'F' on 4/2/22. The end date for this order was 4/3/22 and it was discontinued due to duplicate order. [MEDICATION(S)] HCl Solution 1500 MG/300ML use 1500 mg intravenously in the morning for ANTI-INFECTIVE AGENTS until 04/05/2022 . with a start date of 4/4/22, ordered by Physician 'A' and entered by Nurse 'G' on 4/3/22. The end date for this order was 4/5/22. Review of R802's progress notes revealed no documented clinical rationale by the physician that explained the reason [MEDICATION(S)] was stopped on 4/5/22 instead of through at least 5/7/22 as documented in the discharge instructions from the hospital. Review of a Pharmacy Recommendation progress note dated 4/3/22 at 5:05 PM revealed the following documentation, Pharmacist recommends: Chart reviewed; Please update her order for [MEDICATION(S)] with the stop date for therapy. The hospital MAR (Medication Administration Record) listed a planned stop date of 4/5/22 .Is follow up required? Yes . The note was signed by Consultant Pharmacist, PharmD 'H'. Review of a Pharmacy Recommendation progress note dated 4/3/22 at 6:45 PM revealed the following documentation: Pharmacist recommends: Chart reviewed; Please update her order for [MEDICATION(S)] with the stop date for therapy. The hospital MAR listed a planned stop date of 4/5/22. What is the response to the recommendation? Complete Is follow up required?: No. The note was signed by Nurse 'G'. Review of an assessment form titled (Facility Name) H/P (History/Physical) completed by Physician 'A' with an effective date of 4/4/22 revealed no documentation that R802 was prescribed [MEDICATION(S)] for [CONDITION(S)] and no documented rationale as to why a stop date of 4/5/22 was ordered. The assessment was signed by Physician 'A' on 4/5/22. Review of a SBAR (Situation, Background, Assessment, Recommendation - a communication tool used to provide information during a change in condition) Summary for Providers note dated 4/25/22 revealed the following: The Change in Condition/s reported on this CIC (Change in Condition) Evaluation are/were: Altered mental status. Food and/or fluid intake (decreased or unable to eat and/or drink adequate amounts) .Mental Status Evaluation: Altered level of consciousness .Abdominal/GI (gastrointestinal) Status Evaluation: Decreased appetite/fluid intake .Observed resident feeding self at lunch. Unable to cut food apart, took 3 bites and sat form down. I assisted her to complete meal. More fatigued, more confused .Recommendations: Followed up with therapy. We changed resident to 1:1 (one to one) with meals. Therapy will see her in the AM . Review of a physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] .Reason for visit: Medical management, altered mental status .Patient presenting today with altered mental status, more confused than usual. Patient SPO2 (pulse oximetry) also down to around 90 (percent) .Patient does have extensive hx (history) of [CONDITION(S)]/[CONDITION(S)] .Plan: Will order stat (performed immediately) labs, CXR (chest X-ray), D/W (discussed with) nursing to notify provider of any acute changes . Review of a SBAR Summary for Providers note dated 4/26/22 revealed the following: The Change In Condition/s reported on this CIC Evaluation are/were: Altered mental status .Fever .Blood Pressure 157/90 (high blood pressure) .Pulse 100 (beats per minute - BPM .Temp: .101.2 (degrees F) .Outcomes of Physical Assessment: .Altered level of consciousness .Needs more assistance with ADLs (activities of daily living) .General weakness .Resting pulse greater than 100 (BPM) .Resident is febrile with hallucinations. Labs show WBC (White Blood Count) 17,000. Resident just completed IV ABT (antibiotic) for knee infection/[CONDITION(S)]. [CONDITION(S)] (elevated heart rate). (Physician 'A') notified. Transfer to ER for possible SIRS (Systemic [CONDITION(S)] Response Syndrome - an [CONDITION(S)] state affecting the whole body as a result of an infection) . Note that the SBAR did not mention R802's antibiotic treatment being stopped approximately one month earlier than was documented on the hospital discharge instructions. On 8/10/22 at 3:06 PM, an interview was conducted with the Director of Nursing (DON). When queried about the facility's process when a resident was admitted into the facility, the DON reported the resident was greeted, vitals were taken, skin was assessed, physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The DON further explained that the assigned floor nurse was responsible to assess the newly admitted resident and review, reconcile, and obtain physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . According to the DON, the floor nurse and/or the Unit Manager entered the medications into the electronic health record (EHR). The DON further reported that the Unit manager did a second check on all medications to make sure they were accurate and updated, as well as the care plans. When queried about the steps taken to verify the medications from the hospital, the DON reported the nurse, and the Unit Manager reviewed the discharge instructions from the hospital and all medications were reviewed with the physician if the resident was admitted prior to 7:00 PM and with a Nurse Practitioner (NP) if it was after 7:00 PM. At that time, the DON was interviewed regarding R802. When queried about why [MEDICATION(S)] was stopped on 4/5/22 instead of through at least 5/7/22 as documented in the discharge instructions from the hospital, the DON reviewed the discharge instructions from the hospital and reported the medication list was missing pages 10 through 13. When queried about whether the missing pages were obtained from the hospital, the DON reported they could rarely get additional information from the hospital. The DON further reviewed the hospital records received by the facility when R802 was admitted on [DATE] and reported the medication list did not include an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . When queried about the [MEDICATION(S)] order entered on 4/2/22 with no stop date, the DON stated, It looks like they were going off the MAR (Medication Administration Record) from the hospital and it was approved by the physician. We can only go off what we have. At that time, the DON was asked about the After Visit Summary that documented, Discharge to: Extended Care Facility .[MEDICATION(S)] through at least 5/7/2022, weekly CBC (Complete Blood Count) and CMP (Comprehensive Metabolic Panel), [MEDICATION(S)] trough on 4/5/2022 and if therapeutic (trough between 15-20), weekly trough afterwards . and whether further clarification should have been obtained from the hospital if the facility was not provided with an order and only a MAR. The DON reported there was no order, so the nurse looked at the MAR. When queried about whether a MAR was the same as a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . When queried about whether labs (CBC and CMP) and troughs were completed as documented in the discharge instructions, the DON reported troughs were not drawn because R802 did not stay on the [MEDICATION(S)] long enough for a trough to be drawn. The DON further explained that the Consultant Pharmacist, PharmD 'H' recommended that R802's [MEDICATION(S)] order was updated with a stop date of 4/5/22 as documented on the hospital MAR and the physician agreed. On 8/10/22 at approximately 4:10 PM, the Administrator provided an email that was explained to be communication from a Continuum Care Network between the hospital and facility. The Administrator reported the Infectious Disease Physician at the hospital questioned why R802's [MEDICATION(S)] was discontinued on 4/5/22 rather than according to the hospital discharge instructions. On 8/10/22 at 4:20 PM, the Administrator and DON provided page 10 from the Medication List of the hospital discharge paperwork. The DON reported R802's order for [MEDICATION(S)] did not include a stop date for the nurse went off of the hospital MAR (which was used while resident was admitted in the hospital). When queried about whether the nurse should have obtained clarification for the [MEDICATION(S)] order if there was no stop date, the DON reported the physician approved it. On 8/11/22 at 8:59 AM, the Pharmacy Recommendation Summary from R802's 4/3/22 medication regimen review was requested. Review of a Weekly Pharmacy Recommendation Summary for R802 revealed, MRR Date: 4/3/22 Please update her order for [MEDICATION(S)] with the stop date for therapy. The hospital MAR listed a planned stop date of 4/5/22. The form was signed by PharmD 'H' but did not document the physician's response. Review of R802's progress notes revealed no documentation of the physician's response to the pharmacist's recommendation. On 8/11/22 at 8:46 AM, an interview was conducted with Nurse 'F' via the telephone. Nurse 'F' was the admitting nurse assigned to R802 when she was admitted into the facility on [DATE]. When queried about the process for residents admitted into the facility, Nurse 'F' reported discharge papers from the hospital were reviewed and entered into the EHR. When queried about what document the nurse reviewed the medications from, Nurse 'F' reported it was from the medication list that instructed to start these meds and continue these meds. Nurse 'F' reported she entered medications into the EHR first, then notified the on-call provider. Nurse 'F' further explained that the facility had a policy where the Unit Manager or DON reviewed all admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Nurse 'F' was further interviewed about R802's admission into the facility on [DATE]. When queried about how R802's [MEDICATION(S)] order was determined, Nurse 'F' reported the order from the hospital did not include a stop date, so it was entered how it was ordered and the Unit Manager, Nurse 'G', was notified. Nurse 'F' reported she was confused by the hospital order because she knew labs and troughs were required for [MEDICATION(S)]. When queried about whether the rest of the discharge instructions were reviewed or if the hospital was contacted for clarification of the [MEDICATION(S)] order, Nurse 'F' reported she told the Unit Manager and he said he would take care of it. On 8/11/22 at 9:08 AM, Physician 'A' was interviewed via the telephone. When queried about why R802's [MEDICATION(S)] was discontinued on 4/5/22 instead of through at least 5/7/2022, weekly CBC (Complete Blood Count) and CMP (Comprehensive Metabolic Panel), [MEDICATION(S)] trough on 4/5/2022 and if therapeutic (trough between 15-20), weekly trough afterwards . as documented on the hospital discharge instructions, Physician 'A' reported he first heard about the concern the previous day (8/10/22), four months after R802 was admitted into the facility on [DATE]. Physician 'A' reported he approved R802's [MEDICATION(S)] order based on what was documented on the hospital MAR because the discharge instructions did not have a stop date. When queried about whether he spoke with the Infectious Disease physician at the hospital, Physician 'A' reported he did not, but PharmD 'H' or one of the nurses confirmed with the hospital that the [MEDICATION(S)] was to be stopped on 4/5/22. When queried about the discharge instructions that included a stop date of 5/7/22, and instructions for troughs and lab draws, Physician 'A' reported they were not done because the [MEDICATION(S)] was stopped on 4/5/22. On 8/11/22 at 10:01 AM, Nurse 'G' was contacted via telephone for an interview and a message was left. Nurse 'G' was not available prior to the end of the survey. On 8/11/22 at 12:10 PM, an interview was conducted with PharmD 'H' via the telephone. PharmD 'H' reported she was a Consultant Pharmacist for the facility, reviewed residents' medications at least monthly, and if there were any irregularities that needed to be addressed, she would make a recommendation that was reviewed by the medical provider. When queried about [MEDICATION(S)] and whether a stop date was required, PharmD 'H' reported it would typically require a stop date or further instructions and if there was no stop date, she typically reviewed the hospital record to find more information and made a recommendation to add a stop date. When queried about the recommendation made for R802 on 4/3/22 that read: Please update her order for [MEDICATION(S)] with the stop date for therapy. The hospital MAR listed a planned stop date of 4/5/22, PharmD 'H' reported she could only find the hospital MAR in the EHR which had a stop date for [MEDICATION(S)] on 4/5/22. PharmD reported she stated that in her recommendation, but the physician ultimately followed through on any changes in orders. PharmD reported she was reporting on any irregularities that needed to be addressed. PharmD reported she obtained the information in her recommendation from the hospital MAR and did not contact the hospital. On 8/11/22 at approximately 10:30 AM, the Administrator was interviewed about the email provided on 8/10/22. When queried about the email that read: .Is there any way we can get the script with the end date or a discharge packet? My staff ended the IV ABT on 04/05/22 because the MAR from the hospital had that date listed. We never received anything to the contrary .The nurse states that the sending nurse during nurse report confirmed the 04/05/22 stop date . When queried about who the nurse was that spoke with the sending nurse, the Administrator reported it was Nurse 'F' (Note that Nurse 'F' reported she acknowledged the [MEDICATION(S)] order did not have a stop date and did not clarify with the hospital, but notified Unit Manage, Nurse 'G'). The Administrator did not have the name of the sending nurse at the hospital. When queried about the discharge instructions uploaded into the facility's EHR on 4/3/22 and 4/4/22 with effective dates of 1/26/22 (the documents in this filed were from the 4/2/22 discharge from the hospital and admission into the facility) and 4/2/22 that included the following instructions Discharge to: Extended Care Facility .[MEDICATION(S)] through at least 5/7/2022, weekly CBC (Complete Blood Count) and CMP (Comprehensive Metabolic Panel), [MEDICATION(S)] trough on 4/5/2022 and if therapeutic (trough between 15-20), weekly trough afterwards ., the Administrator reported they only had the MAR available. Review of R802's hospital records revealed the following: R802 was admitted to the hospital on 4/26/22 and discharged on [DATE] with a primary diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A scanned EMS (Emergency Medical Service) run sheet dated 4/26/22 documented R802 had a fever, pain to their left knee (10 out of 10), and was in a moderate level of distress ED (Emergency Department) Triage Notes on 4/26/22 at 9:42 AM documented, Pt presents to EC for abnormal labs. Pt has been at (facility name - incorrect facility name in hospital records) for SAR (subacute rehabilitation) after a L (left) knee replacement. Per (facility) staff, her labs this morning revealed pt (patient) may be septic . ED Provider Notes dated 4/26/22 at 9:30 AM documented, .presents .from nursing care with leukocytosis (high white blood cell count), fever, altered mental status .Lab work notable for leukocytosis and elevated [CONDITION(S)] markers. CT (Computerized Tomography) scan of lumbar spine showing evidence of [CONDITION(S)] (bone infection) and discitis (infection in the intravertebral disc space). Orthospine surgery consulted. Patient started on [MEDICATION(S)] and [MEDICATION(S)] (an antibiotic medication) .Ultimately recommending admission to medicine for further treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . A History and Physical Note dated 4/26/22 at 4:36 PM documented, .Chief Complaint: Fever, leukocytosis .Has had infectious issues, including infected left knee .lumbar discitis .and [CONDITION(S)] bacteremia .She was most recently admitted from 3-21 through 4-2-2022. She was found to have recurrent [CONDITION(S)] bacteremia . She was presumed to have discitis as source. She was discharged with PICC (Peripherally Inserted Central Catheter) to SAR. She was supposed to have IV Vanco ([MEDICATION(S)]) for 6 weeks from date of last negative blood culture (last day would have been 5-8-2022) .Patient has been at SAR since last discharge .However, she was sent back to the hospital for elevated temperature and leukocytosis .she complained that she wasn't receiving antibiotics. (Family member) also noted that when he visited patient last, he was told the PICC was removed. Reviewed limited SAR records. Vanco not on current med list with apparent order noted for DC (discontinue) PICC Line on 4-7-2022 .Labs notable for leukocytosis. Urinalysis is negative for [CONDITION(S)] (Urinary Tract Infection) .no pneumonia seen on CT. Lumbar CT was concerning for progression of lumbar discitis/[CONDITION(S)] findings. She was ordered for IV fluids and antibiotics. She was admitted .Assessment/Plan: 1. ID (Infectious Disease) .Acute [CONDITION(S)]. She had recent visit for [CONDITION(S)] bacteremia thought to be from discitis. She was supposed to be on IV Vanco for 6 weeks from date of last negative blood culture (last day 5-8-2022). However, it appears her antibiotics were stopped too soon at SAR. Limited records available and will need to verify her actual last dose of antibiotics. There is an order for [MEDICAL RECORD OR PHYSICIAN ORDER] .There is concern for ongoing discitis .Await new blood culture results . Lumbar CT noted progression of lumbar discitis findings .ID service consulted and await recommendations .Multiple episodes of [CONDITION(S)] bacteremia. Await repeat cultures. Had negative TEE and wbc scan during March visit. Last episode was presumed due to discitis .Acute metabolic [CONDITION(S)]. Considered due to [CONDITION(S)] .Disposition: No [CONDITION(S)] or pneumonia noted. There is concern for ongoing spine infection and suspect that she missed antibiotics at SAR. There is note of an apparent DC PICC line order there on 4-7, however, antibiotics were supposed to end on 5-8-2022 (6 weeks from last negative blood culture) . An Infectious Diseases consultation dated 4/27/22 documented, .History of Present illness .readmitted (3rd admission) 3/22 for [CONDITION(S)] bacteriemia for which source was unknown but suspected vertebral OM ([CONDITION(S)]) or discitis/[CONDITION(S)] (L1-L3 signal abnormality seen on MRI 3/13/22). A WBC scan did not show any significant changes. Was discharged on [MEDICATION(S)] till 5/8/22, however, due to unclear reasons why her [MEDICATION(S)] was stopped on 4/5/22 .Culture Data: 4/26 BCX (blood cultures) [CONDITION(S)] in 2/2 (secondary to) blood culture sets .4/26: (laboratory test): staph aureus, staph spp (saprophyticus) .Impressions: .Recurrent [CONDITION(S)] bacteremia: Significant workup on multiple admissions including a WBC scan (that was unrevealing) only significant for L1-L3 OM/discitis which subsequent imaging showing improvement (at previous hospital admission) .Plan was to treat with [MEDICATION(S)] through 5/8/22 .Recommendations: .Continue with [MEDICATION(S)] as recurrence of the [CONDITION(S)] bacteremia is likely from premature discontinuation and not resistance . A Discharge Summary Note dated 5/10/22 documented, .Hospital Course .Acute [CONDITION(S)] for [CONDITION(S)] Bacteremia, spine [CONDITION(S)] .She had recent visit for [CONDITION(S)] Bacteremia through to be from discitis. From her last admission, she was supposed to be on IV vanco for 6 weeks from date of last negative blood culture. Last dose was supposed to be 5-8-2022. However, her antibiotics were stopped too soon at SAR: last dose there was 4-5-2022. Ordered for DC PICC Line there on 4-7-2022 .Blood cultures this visit grew [CONDITION(S)] again. Lumbar CT discitis findings. IV vanco was ordered .On 4-29-22, underwent C5 (cervical - neck)-T4 (thoracic - upper back) laminectomy (surgical removal of some or all of vertebral bone) and fusion and T1-2 diskectomy (surgical repair of the spine). Surgical cultures from 4-29 grew [CONDITION(S)] as expected .DO NOT STOP IV ANTIBIOTICS EARLY. This led to severe recurrence of infection at other facility . Review of a facility undated policy titled, Admission Assessment and Follow Up: Role of the Nurse revealed the following: .Reconcile the list of medications from the medication history, admitting orders, the previous MAR (if available), and the discharge summary from the previous institution, according to established procedures .Contact the Attending Physician to communicate and review the findings of the initial assessment and any other pertinent information and obtain admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a facility policy titled, Reconciliation of Medications on Admission (only one page provided by the facility) revealed the following: The purpose of this procedure is to ensure medication safety by accurately accounting for the resident's medications, routes and dosages upon admission or readmission to the facility .Gather the information needed to reconcile the medication list: .Approved medication reconciliation form .Discharge summary from referring facility .Admission order sheet .Most recent medication administration record (MAR), if this is a readmission .Medication reconciliation reduces medication errors and enhances resident safety by ensuring that the medication the resident needs and has been taking continue to be administered without interruption, in the correct dosages and routes, during the admission/transfer process . Review of a facility policy titled, Medication Monitoring - Medication Regimen Review and Reporting, dated 9/2018, revealed the following: .A record of the consultant pharmacist's observations and recommendations is made available in an easily retrievable format to nurses, physicians and the care planning team within 48 hours of MRR completion .The nursing care center follows up on the recommendations to verify that appropriate action has been taken. Recommendations shall be acted upon within 30 calendar days .For those issues that require physician intervention, the attending physician either accepts and acts upon the report and recommendations or rejects all or some of the report and should document his or her rationale of why the recommendation is rejected in the resident's medical record .If there is potential for serious harm and the attending physician does not concur, or refuses to document an explanation, the director of nursing and the consultant pharmacist contact the medical director. If the attending physician is also the medical director, a meeting shall be arranged to discuss issues and come to an agreement in order to ensure that no actual harm occurs .

This citation pertains to intake #'s MI 4 and MI 6. Based on interview and record review, the facility failed to ensure communication and coordination of wound care consultations, accurate and timely skin assessments, wound care treatments were ordered and implemented, and turning and repositioning interventions were performed consistently for one resident (R599) of three residents reviewed for pressure ulcers, resulting in the development of a stage III pressure injury (full thickness loss of skin, in which fat is visible in the ulcer and granulation tissue and rolled edges are often present. Slough and/or eschar may be visible) and deterioration to an unstageable pressure injury (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). A review of R599's closed clinical record was conducted on 3/31/21 and revealed an admitted [DATE], a re-admitted [DATE], and a discharge date of [DATE]. R599's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R599's admission Minimum Data Set assessment dated [DATE] was conducted and Section M-Skin Conditions revealed R599 admitted with on stage 4 pressure injury (Full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer. Slough and/or eschar may be visible, rolled edges and undermining or tunneling often occur). A review of an admission summary note dated 2/18/20 was conducted and read, .Guest is here from hospital for wound infection to coccyx . Further notes in the record indicated R599 had admitted with a wound vac system in place to promote wound healing. A review of R599's Admission Total Body Skin assessment dated [DATE] was reviewed and indicated the resident had 2 new wounds. It was noted the assessment form did not indicate where R599's wounds were located. It was noted the resident's next Total Body Skin Assessment was dated 3/3/20 (2 weeks after admission) and documented no new wounds. The next skin assessment dated [DATE] also documented no new wounds. R599 had an order dated 3/20/20 that indicated a left hip dressing was to be applied to the left hip at bedtime for protection. The order was noted to be discontinued on 3/24/20. A progress note dated 3/24/20 was reviewed and read, .Left trochanter (hip) abrasion observed .leave area open to air . A review of a document titled Wound Evaluation dated 3/24/20 that contained a picture of R599's left trochanter wound (documented as an abrasion) was conducted. The wound in the picture revealed a documented measurement of 3.87 centimeters (cm) in length and 3.09 cm in width. No depth was recorded. The photograph showed an open skin with a dark pink center, lighter pink edges, and what appeared to be dark bruising around the open area. The wound was noted to be over a bony prominence (trochanter) and resembled a stage II pressure injury (partial-thickness loss of skin with exposed dermis. The wound bed is viable, pink, or red, and moist. This type of injury commonly result from adverse microclimate and shear in the skin.) It was further noted the sheets in the picture were stained with a yellow/pink stain near where R599's wound have had contact with the bed. It was further noted a urinary catheter with drainage tubing that contained a hard plastic port appeared in the picture draped over R599's left leg. It was observed the port appeared in close proximity to the wound. A progress note dated 3/24/20 was reviewed and read, .Left trochanter (hip) abrasion observed .leave area open to air . A review of the next Total Body Skin assessment dated [DATE] was reviewed and indicated R599 had no new wounds. A review of an outpatient wound care consultation dated 4/2/20 (scanned into the record) for R599 was conducted and revealed R599 had a left trochanter wound, however; it was noted the consultation documentation scanned into the record did not include details including the type of wound, description of the wound, or any measurements. The documentation dated 4/2/20 only included orders for wound care. Further outpatient wound care consultation documents dated 4/9/20, 4/17/20, 4/23/20 were reviewed, and indicated R599 had a left trochanter wound, however; it was noted the consultation documentation scanned into the record did not include any details including the type of wound, description of the wound, or any measurements. The scanned documents only contained orders for wound care treatments. On 3/31/21 at 3:00 PM, A request from the facility's Director of Nursing for complete wound care consultations from each of R599's outpatient appointments was requested; to include the outpatient consultant's assessments of the wounds. At approximately 4:00 PM, the DON reported the outpatient wound care consultant would not release the documents. At that time, the DON was asked why the full consultation reports were not collected and put into R599's record after each of their appointments, and they had no explanation. A wound care consultation scanned into the record dated 5/12/20 was conducted and revealed the following assessment: .Wound #4 Left Trochanter is an acute Stage 3 Pressure Injury Pressure Ulcer and has received a status of Not Healed .Adipose is exposed .There is a moderate amount of serosanguineous drainage noted .Yes slough, Yes pink, firm granulation . Continued review of the consultation documentation dated 5/12/20 was conducted and revealed a photograph of the trochanter wound obtained by the wound care consultant on 4/2/20 that indicated the wound type was Pressure Ulcer as well as documented measurements of the wound on that date. It was further noted another image in the document included a description and measurement of the wound obtained from R599's appointment on 4/23/20. The report did not reveal wither the wound care consultant ruled the pressure ulcer as either avoidable, or unavoidable. A review of the Certified Nursing Assistant (CNA) task documentation for the task of turning and repositioning for R599 was reviewed. The question read, Did you turn and reposition? Y-Yes N-No and revealed the following: February 2020 Day shift: 2/22/20, 2/23/20, and 2/25/20 thru 2/27/20, No documentation (yes or no) that R599 had been turned or repositioned. February 2020 Afternoon shift: 2/18/20, 2/22/20, and 2/25/20, N (No) had been documented for turning and repositioning R599. 2/19/20 thru 2/21/20, 2/23/20, 2/26/20, and 2/27/20, No documentation had been recorded that R599 had been turned or repositioned. February 2020 Night shift: No documentation for 2/22/20 and 2/21/20, and N documented for 2/25/20. March 2020 Day shift: No documentation for 3/2/20, 3/4/20, 3/9/20 thru 3/11/20, 3/13/20, 3/14/20, 3/117/20, 3/18/20, 3/20/20, 3/21/20, 3/23/20, 3/26/20 thru 3/29/20, and 3/31/20. March 2020 Afternoon shift: No documentation for 3/1/20, 3/3/20 thru 3/6/20, 3/9/20 thru 3/21/20 (13 days), and 3/24/20 thru 3/29/20. It was noted R599's left trochanter wound was identified on 3/24/20. March 2020 Night shift: 3/8/20, 3/16/20, 3/18/20 thru 3/22/20, 3/24/20 thru 3/27/20, 3/29/20, and 3/30/20. Review of R599's wound care treatment orders was conducted and revealed that on 4/17/20 treatment orders for R599's left trochanter wound were implemented. It was noted the order was discontinued on 5/27/20 and there were no new wound care orders for R599's left trochanter until 6/1/20. On 4/1/20 at approximately 2:30 PM, a follow-up interview was conducted with the facility's DON regarding the facility's assessment for wounds. The DON indicated the Wound Evaluation to include photographs and measurements were to be done on a weekly basis. A review of R599's last outpatient wound care consult contained in the clinical record was reviewed and revealed that on 7/31/20, R599's left trochanter wound was documented as, .Stage: Unstageable (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) Pressure Injury Obscured full-thickness skin and tissue loss . The documentation indicated the wound measured 3.5 cm x 3.5 cm. A review of the weekly Wound Evaluation documentation was conducted following R599's re-admission to the facility on [DATE] up until their discharge on 9/22/20. It was discovered no Wound Evaluations had been documented after 8/18/20. A review of R599's last documented Wound Evaluation dated 8/18/20 read, .#4-Pressure-Unstageable (slouch and/or eschar. Body Location: Left Trochanter .Acquired: In-House Acquired .Length 4.15 cm, Width 5.45 cm . It was noted no depth was recorded. A photograph contained with the Wound evaluation showed an irregular shaped ulceration of undeterminable depth with yellow/green/black slough in the center. The wound edges were reddened, and dark bruising appeared around the intact peri-wound skin. A review of a facility provided policy titled, WOUND MANAGEMENT PROGRAM revised 3/15/17, was conducted and read, .POLICY: To assure that residents who are admitted with, or acquire, wounds receive treatment and services to promote healing, prevent complications and prevent new skin conditions from developing .

This citation pertains to intake number: MI 283 This citation contains two deficient practices. Deficient practice #1 Based on interview and record review, the facility failed to properly assess, monitor and inform the surgical doctor of a change of condition of a post abdominal surgery for [REDACTED].#702) of three residents reviewed for quality of care, resulting in delayed treatment, worsening of a surgical site, documented worsening of pain, voiced complaints and ultimately causing the family to remove the resident from the facility and transfer to the hospital for a higher level of care. Findings include: A complaint was filed with the State Agency and included, in part, the following allegation documentation pertaining to R#702, (MONTH) 1st (2019)- noticed excessive swelling .Leakage from incision was increasing. Nurse agreed that a culture kit was needed. So sorry they did not have one (MONTH) 2nd (2019) .His confusion was very bad .The swelling was getting excessive .I had to add tape to his incision because it was leaking all over his clothes, again the nurse apologized for no culture kit .We also notice the smell from the incision and notify the nurse .(R#702) was complaining that the stomach pain was getting much worse. I asked the nurse about the culture kit. She was very apologetic. She thought that whoever drew blood overnight would have brought it .He was in an enormous amount of pain and clothes were soaked from the wound leaking, more than the bandage could hold .the stomach just kept increasing in size as well with increased seeping .He needs medical attention and we were going to take him . On 7/9/19 - 7/10/19, an onsite investigation into the complainant's allegation was conducted. R#702 was admitted into the facility on [DATE] with a primary [DIAGNOSES REDACTED]. R#702 required assistance from staff all activities of daily living. Review of the hospital discharge paperwork given to the facility for admission documented, Remember to weigh yourself at the same time everyday and call your doctor's office for the following symptoms: If you have weight gain more than 2 pounds since yesterday or 5 pounds this week. If you have increased swelling in your ankles, legs or stomach/abdomen If your pain medication is no longer working .If you develop a pressure ulcer or new skin sore If your incision becomes more swollen, tender or drainage increases. Review of the facility's history and physical (H&P) admission assessment for R#702, dated 5/31/19 documented, monitor abdominal wound. Review of R#702's (MONTH) and (MONTH) 2019 Treatment Administration Record (TAR) revealed no orders to monitor the abdominal surgical site/abdomen. Review of R#702's progress notes revealed the following: On 6/1/19 at 19:56 (7:56 PM), a nursing note documented, .He is A&O (alert and oriented) x2-3 with confusion noted at times . On 6/2/19 at 20:06 (8:096 PM), a nursing note documented, .Family is concerned that [MEDICATION NAME] is making guest confused . On 6/3/19 at 16:32 (4:32 PM), a nursing note documented, Abdominal incision checked right side of incision is hard and redness is present. small amount of sero sang drainage noted from right side of wound. (Dr name redacted) aware. Ordered STAT (As soon as possible) CBC with diff (lab) which was drawn, also ordered Wound culture. Will obtain once culturette is obtained from lab.ABD (abdomen) applied to abdomen for drainage . A physician order [REDACTED]. Culture of wound one time only for Infection of wound for 1 day. Review of R#702's clinical record revealed no documentation that the abdomen incision wound culture was ever completed, although signed off as completed on: 6/3, 6/5 and 6/6 (On R#702's (MONTH) 2019 TAR). On 6/4/19 at 4:25 PM, a physical therapy note documented, Pt (patient) is lethargic and c/o (complaints of) fatigue. nursing aware. On 6/4/19 at 20:28 (8:28 PM), a nursing note documented, Guest alert and oriented x 3. Family voiced concerns of wound drainage, BLE (bilateral lower extremity) [MEDICAL CONDITION], guest confusion. Notified doctor. Doctor assessed and spoke with family. Several new orders entered . On 6/5/19 at 12:05 PM, a physician's progress note documented, .examined to f/u (follow up) abdominal wound drainage. WBC (white blood cell) 6.3 on 6/3/19. Labs and wound culture pending today.Drainage is moderate serous and foul smelling. No [DIAGNOSES REDACTED] or increased warmth around incision. Call placed to surgeon .F/U (follow up) with surgeon ASAP (As soon as possible). [MEDICATION NAME] prn (as needed) for pain .Surgical wound infection: check wound cultures. Cont (Continue) wound care . Reviewal of R#702's clinical chart revealed this to be the only attempt made by the facility to contact the surgeon for R#702, with no documented medical directive from the surgeon. A Physical Therapy Progress Report with the dates of service documented as 5/31/19-6/6/19 revealed the following documented comments: .patient is experiencing an increase in fluid retention in abdominal region with d/c (discharge) from surgical incision resulting in increased pain. patient has reduced appetite as well resulting in reduced strength .Precautions: horizontal mid abdominal incision . On 6/6/19 at 12:40 PM, a nursing note documented, Met with guest, daughter, and other family regarding concerns of increased swelling in ABD (abdomen). Guest complained that his abd (abdomen) is more swollen and the [MEDICATION NAME] was not completely affective for his pain . On 6/6/10 at 14:07 (2:07 PM), a nursing note documented, Notified by floor nurse daughter of guest stated they were taking the guest to the hospital because he is really sick. Notified ED and physician . A Discharge Review dated 6/6/19 at 14:11 (2:11 PM), completed by the Director of Nursing (DON) documented, Guest admitted for surgical aftercare on the GI (Gastrointestinal) system, hx CA (history [MEDICAL CONDITION]). No s/s (signs/symptoms) of infection. Guest family c/o (complaints of) surgical incision concerns, wound culture obtained per request - NP into assess incision site on 6/5, no concerns noted. Family took guest AMA (against medical advice) 6/6. Family c/o (complaints of) abd (abdomen) swelling 6/6, notified (Doctor name redacted) of concern, physician on the way to see guest. Family stated they were not waiting and wished to take guest AMA (Against medical advice) to his PCP (Primary care physician) and then ER (emergency room ) for eval (evaluation) . Hospital reports from (hospital name redacted) were obtained, reviewed and revealed the following: An Emergency Physician Record dated 6/6/19 at 15:58 (3:58 PM) documented, increasing abd (abdomen) distension .+ (positive) discharge .abdominal distention and pain .WBC (white blood cell) 14.31. Is there a suspected source of infection by history of physical examination? Yes (is circled) .Antibiotics started (is checked off). R#702 was admitted into (hospital name redacted). Review of an inpatient physician consultation dated 6/7/19 documented .lateral running incision, intact except furthest right lateral area, open 2.5 cm, drainage noted . Review of an inpatient physician consultation dated 6/11/19 documented .Agree with present antibiotic regimen (defepime and [MEDICATION NAME]- antibiotics), for empiric treatment of [REDACTED]. On 7/9/19 at 3:54 PM, the DON was interviewed. When queried on how the staff would monitor and assess R#702's surgical site to report any abnormal changes, worsening of the site or change of condition to the physician, The DON stated, Based on the dressing change, we would monitor it and report to the physician any worsening of the wound. When queried on why R#702 didn't have a dressing change order, monitoring order or assessment order to his surgical site on his abdomen or abdomen (after having abdominal surgery) DON stated, I'm not sure why he didn't have any orders. I would have to review it. When queried on why R#702's abdomen incision site was never cultured as ordered by the physician on 6/3/19, The DON stated, I don't see a mention of it until 6/5. I don't know why it took so long to get it, but I know that it was done. When the DON was asked to find the abdomen wound culture results, The DON stated, Nope it's not there, you see it's not there. On 7/9/19 at 10:30 AM, the facilities physician was interviewed regarding R#702 and stated, This man was very sick. We all tried to contact the surgeon to get further directive. He had a very complicated surgery. We couldn't get in touch with him. I advised the family to have him seen by one of his associates in the office and the family didn't want to have to travel all the way down there. I remember the family, they left against medical advice. A care plan titled, The resident has impairment to skin integrity r/t (related to) fragile skin, abdominal incision, skin tears to BUE (both upper extremities), [MEDICAL CONDITION] to LE (lower extremity) with a start date of 5/31/19 and a revision date of 6/1/19, revealed no interventions to monitor or assess R#702's abdominal incision. One intervention documented follow facility protocols for treatment of [REDACTED]. Deficient practice #2 Based on observation, interview and record review the facility failed to order and complete a wound culture for one (R#704) of three residents reviewed for pressure ulcers, resulting in a physician ordered wound culture not being completed as ordered, and the increased likelihood for timely identification of changes and/or complications of the resident's surgical wound. Findings include: R#704's clinical record was reviewed and revealed the following: R#704 was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. Reviewal of a Skin and Wound Admission assessment dated [DATE] at 23:11 (11:11 PM), documented 3 wounds. Reviewal of Skin and Wound Evaluation (s) dated 7/7/19 revealed a right buttock wound, stage 2, left buttock wound, stage 2 and Coccyx wound, stage 2. Reviewal of a Physician Visit dated 6/28/19 at 14:24 (2:24 PM) documented, .Plan: wound culture ordered . A review of R#704's clinical record revealed that a wound culture was not ordered or completed. On 7/9/19 at 3:04 PM, the DON was asked where the wound culture test was kept and if the facility had any onsite, the DON stated, Yes. When asked to see the supply on hand the DON was followed to the supply room and medication room. The DON then asked Registered Nurse (RN) B to unlock the medication room and to show the supply of wound culture testing supplies. The DON and RN B reviewed the cabinets in the room and the DON stated, No, we don't have any. On 7/9/19 at 3:56 PM, the DON was queried on when the physician consults with a resident and orders cultures, labs, test etc how that is communicated with staff and implemented. The DON stated, The doctor will give verbal orders to the nurse and the nurse would put the orders in and if there is anything, he will follow up with me as well. When queried on why R#704 did not have a wound culture completed as documented as the plan by the physician on 6/28/19, The DON stated, I don't see any documentation that the nurse put in the order or that the doctor communicated with the nurse to put in the order. I'm texting him now to see what transpired there. At 4:25 PM the DON was informed that (Doctor name redacted) was on the phone and wanted to talk to the DON. The DON and Administrator left the room. The DON returned with no further explanation on why R#704's wound culture order was not ordered or completed. Review of the facility's policy titled Change in Condition and Status (revised (MONTH) 2011) documented, The Nurse Supervisor/Charge Nurse will notify the resident's Attending Physician or On-Call Physician when there has been .Instructions to notify the physician of changes in the resident's condition.