Every finding on record at Willowbrook Manor

This citation pertains to intake Number 3050939. Based on observation, interview and record review, the facility failed to provide the necessary treatment consistent with professional standards of practice to prevent the development of and/or promote the healing of pressure ulcers for four residents (Resident #1, Resident #112, Resident #114, Resident #115) of six residents reviewed for pressure ulcers, resulting in the development of facility-acquired pressure ulcers. Findings include: Resident #1 (R1): R1 is [AGE] years old and initially admitted to the facility on [DATE] with diagnoses that include nontraumatic intracerebral hemorrhage, compression of the brain, Glasgow coma scale score of 3-8 (indicating a severe traumatic brain injury) and tracheostomy status. R1 has a BIMS score of 0, indicating severe cognitive impairment. On 08/12/2026 at 11:30AM, record review of an assessment titled, SW-Skin Check dated 5/04/2026 at 18:00pm, revealed question 13. was checked to indicate that no new skin issues found on this evaluation. On 08/12/2026 at 11:33AM, record review of an assessment titled, SW-Skin Issues dated 05/07/2026 at 13:13pm, revealed that R1 had new pressure injuries to the following areas: Rear Left Trochanter: In-house acquired, Stage 2 on 5/7/26. 2.4cmx1.24cm. This is classified as a medical device related pressure ulcer according to the assessment. Posterior Neck: In-house acquired, Stage 3 on 5/7/26. 0.63cmx1.92cm. This is classified as a medical device related pressure ulcer according to the assessment. On 08/12/2026 at 11:35AM, record review revealed a care plan titled, R1 has actual impairment to skin integrity r/t an open wound to his sacrum and right heel. Created date 3/13/26, last revision date of 8/5/26. Record review of the changes prior to completion of last review for that care plan revealed no mention of two pressure injuries, one on the back of the neck and one on the left hip. On 08/12/2026 at 11:56AM, an interview was conducted with WN I. WN I was asked how did R1 develop the wounds on his posterior neck and left trochanter from medical devices. WN I stated a combination of the trach ties and R1 had a neck pillow his wife brought in. She was adamant that he wore it. It put extra pressure on the trach ties and caused the wound. She finally took the pillow home and we keep an ABD pad on there if it looks like it is going to break down. WN I was asked when did the wife bring in the pillow. WN I stated that it was close to the time he admitted . WN I was asked if staff were monitoring under the trach ties when they did care. WN I stated, they should have been. Part of the weekly skin assessment is to assess head to toe. I can't say if they were or not. WN I was asked if someone has a medical device would there be an order to monitor under the device and a care plan intervention to monitor under the device. WN I stated yes that there should be and I believe there was an order to monitor under the ties. WN I was asked how the left hip wound developed. WN I stated the wife brought in one of those hemorrhoid donut pillows to float his sacrum, we didn't necessarily put it under him, but the wife did. We would put it under him at the request of the wife, but when we tried to give him a break from it the wife would put it back under him because she thought it was helping the sacral wound. WN I was asked if there should have been an order and care plan intervention for this device and to monitor under it. WN I stated that there wasn't an order, but there should have been, as soon as I discovered the wounds she took the devices home. WN I was asked if the devices should be care planned and monitored. WN I stated they probably should be. On 08/12/2026 at 11:55AM, record review revealed there were no care plans present to monitor skin and no physician orders to monitor the skin under the devices that caused the wounds. On 08/12/2026 at 2:19PM, an interview was conducted with the Director of Nursing (DON) The DON was asked if there are orders to change the trach ties. The DON stated yes that it is changed weekly on Thursdays for him. The DON was asked if when the staff change the inner cannula every shift, do they loosen up the trach ties and should they monitor the skin under the ties. The DON stated yes that they should be. Any time someone is in there they should be monitoring the whole process, including the skin. Review of the policy titled, Tracheostomy Ties Change, revealed: Implementation: -Adjust the right and left Velcro tabs as needed. Make sure you can slide only one finger under the tie at the back of the neck. Fastening the ties too tightly can lead to skin breakdown and vascular obstruction; fastening too loosely can lead to decannulation. Special Considerations: -Check the ties or tube holder frequently for moisture, tightness or friction. Inspect the skin under the medical device at least twice daily. Use padding under the ties or holder as needed. Review of the policy titled, Skin Management, revealed: Overview Residents with wounds and/or pressure injury and those at risk for skin compromise are identified, evaluated and provided appropriate treatment to promote prevention and healing. Ongoing monitoring and evaluation are provided to ensure optimal resident outcomes. Practice Guidelines 7. An initial care plan is developed upon admission/readmission if the resident is at risk or has a pressure injury and the comprehensive care plan may address: -Preventative Devices, including recumbent and seated support surfaces. 8. The licensed nurse will document preventative measure on the care plan/kardex. 9. The licensed nurse will monitor, evaluate and document changes regarding skin condition to include dressing, surrounding skin, possible complications and pain in the medical record. Resident #114 (R114): R114 is [AGE] years old and admitted to the facility on [DATE] with diagnoses that include dementia, aphasia and other symptoms and signs involving the musculoskeletal system. R114 has a BIMS score of 0, indicating severe cognitive impairment. On 08/10/2026 at 2:12PM, an interview was conducted with the sister of R114. The sister stated the wound on her leg is new since she got to the facility. A dressing is observed on the left foot, dated 8/9/26. Bilateral heel boots were not in place at this time. On 08/12/2026 at 9:41AM, record review of the Nursing Comprehensive Evaluation in the electronic medical record (EMR) revealed that R114 did not have any pressure ulcers on admission. On 08/12/2026 at 9:43AM, record review of an evaluation titled SW-Skin Issues in the EMR revealed that on 7/30/26, R114 was noted to have pressure injuries on her lateral right and left feet, both were classified as unstageable pressure injuries presenting as deep tissue injury. On 08/12/2026 at 10:23AM, record review of the Braden Scales in the EMR revealed they were completed on 6/7/26, 6/20/26, 6/27/26 and 7/4/26 and R114 is at risk for pressure ulcer development. On 08/12/2026 at 10:29AM, record review of the care plan focus: R114 has actual impairment to skin integrity r/t right lateral foot and left lateral food. Date initiated 06/06/2026. Last revision: 08/05/2026. Interventions: Bilateral puffy boots on as tolerated. Date Initiated: 08/11/2026. On 08/12/2026 at 11:03AM, an interview was conducted with Wound Nurse (WN) I. WN I was asked if R114 was admitted with pressure injuries or did she develop them in the facility. WN I stated that R114 developed them in the facility. WN I was asked what interventions were put in place at the time of admission to prevent pressure injuries from occurring. WN I stated that initially R114 was a on a pressure reduction mattress and once these wounds developed, we put her on a LTC 105 (pressure reducing mattress). WN I stated that prior to the development of the foot wounds R114 was not one to wear the heel protector boots, we made an agreement that she doesn't like to wear them in her wheelchair, so I really want her to wear them in bed. WN I was asked what they thought led to these wounds developing. WN I said I think that R114 does not like to be repositioned and she likes to remain sedentary. She will swing at us at times during repositioning. WN I was asked if they thought anything else could have been done to prevent these wounds. WN I stated, I truly don't, I think these were unavoidable and nothing we did could have prevented them. WN I was asked if R114 had the heel boots on admission for pressure reduction. WN I stated, no, she did not. WN I was asked if the staff were staff floating the heels of R114 instead of the heel boots. WN I stated that it is hard for R114 to float her heels with her contractures, we try not to cause too much pain for her. WN I was asked why the facility wouldn't put the pressure relieving boots in place as a measure of prevention prior to the development of the foot wounds. WN I stated that R114 doesn't like wearing them, she will swing at you if you try to put them on. WN I was asked if they thought the pressure relieving boots should have been put in place on admission considering the pressure injury risk for R114. WN I stated, yes, they should have been in place on admission. Review of the policy titled, Skin Management, revealed: 3. Appropriate preventative measures will be implemented on residents identified at risk and the interventions are documented in the care plan. Resident #112 (R112); On 8/10/26 at 12:20 PM, an interview was conducted with Confidential Person S regarding Resident 112's care at the facility. The Confidential Person (CP) reported the Resident had a wound to her buttock area that started while at the facility. The CP reported the resident was having a lot of pain because of the wound. The CP reported she looked at the wound, and it was opened. The Resident was observed in the rehab room in a geri chair. The Resident was interviewed, answered simple questions and reported having pain in her buttock area. An observation was made of the Resident sitting on a mechanical lift sling. The CP was asked to see if there was a pressure relieving cushion underneath the Resident. An observation was made with the CP of no pressure reduction cushion under the Resident who was seated in an upright position. A review of R112's medical record revealed an admission into the facility on [DATE] and readmission on [DATE] with diagnoses that included end stage renal disease, dependence on renal dialysis, muscle wasting and atrophy, dementia, anxiety disorder, restlessness and agitation, and morbid (severe) obesity. A review of the MDS dated [DATE] for significant change in status, revealed a Brief Interview of Mental Status score of 09/15 that indicated moderately impaired cognition and the Resident was dependent on a helper for oral hygiene, toileting hygiene, bathing self, upper body dressing, lower body dressing, personal hygiene, roll left and right, sit to lying, lying to sitting on side of bed and transfers. A review of R112's progress notes revealed the following: -Dated 7/10/26 at 7:34 AM, Skin Issues: Location: Sacrum, New: new wound. Pressure ulcer staging: Stage 2, Pressure ulcer/injury-partial thickness skin loss with exposed dermis. Wound acquired in-house. Length (cm (centimeters): 1.29; Width: 2.36 cm, Depth: 0; Area (cm2): 2.24 cm2. -Dated 7/23/26 at 12:02 PM, Skin Issues: Location: Sacrum; Partial thickness skin loss with exposed dermis; Length 1.42 cm; Width: 1.83 cm; Depth: 0; Area 2.27 cm2. -Dated 7/30/26 at 12:02 PM, Skin Issues: Location: Sacrum; Partial thickness skin loss with exposed dermis; Length 0.9 cm; Width: 1.9 cm; Depth: 0; Area 1.56 cm2. A review of R112's care plan revealed a Focus for Actual impairment to skin integrity r/t (related to) sacrum with an intervention Pressure reduction cushion to chair, initiated and created on 7/22/26. On 8/12/26 at 10:14 AM, an interview was conducted with Wound Care Nurse Manager (WCN) I regarding R112's pressure ulcer. The WCN reported the origination of the sacral wound was July 10th, 2026, when it was brought to her attention with a skin assessment done 3 days prior and it was not charted on at that time but had indicated no new skin issues. The WCN reported that a nightshift CNA was doing care and informed her that morning. The WCN reported the wound was a facility acquired pressure wound to the sacral area. When queried, the WCN reported that wound measurements were done weekly and they round with the Nurse Practitioner. A review of the measurements revealed measurements done on 7/10/26 and not again until 7/23/26 and was asked about the missed measurements. The WCN reported that the Resident was out for dialysis when rounds were made and then went on vacation after that. When asked why not go back to her when she returned, the WCN indicated she did not know when the Resident had completed dialysis and stated, I don't remember what happened that particular day, and reported no one else had completed the wound measurements for that week. On 8/12/26 at 2:12 PM, an interview was conducted with the Assistant Director of Nursing (ADON) E regarding R112's pressure ulcer. The ADON was informed of the observation of no cushion under the resident on 8/10/26. The ADON reported the Resident gets therapy and stated, They are to put the cushion into the chair and then place the resident in the chair. I will talk with the CNAs about that. An observation was made of Resident 112's room. The Resident had switched rooms to accommodate the bari bed that was placed. The Resident was not in the facility at that time. There was no pressure reducing cushion in the Resident's new room and a search of the Resident's former room was conducted without finding the pressure reducing cushion. The ADON reported she will continue to search for it. There was confusion about which chair the Resident used. There was one in the hallway that did not have the Resident's name on it and multiple geri chairs in the common area, but they did not have R112's identifying information. The ADON was unsure which chair the Resident used. On 8/12/26 at 3:00 PM, an interview was conducted with CNA O and CNA P who had taken care of R112. When queried regarding a pressure reduction cushion in the Resident's chair, CNA O stated, I do not remember putting a cushion under the resident, and reported they did not think the Resident had one. CNA O indicated they do not use a cushion for R112. CNA P stated, Usually we get her back to bed. I had her the other day; she did not have a cushion under her. On 8/12/26 at 3:12 PM, the ADON reported that the cushion had been located down in laundry. Resident 115 (R115): On 8/10/26 at 10:53 AM, an interview was conducted with Resident 115 (R115) who answered questions and engaged in conversation. The Resident was observed to be lying in bed who indicated he was waiting for the mechanical lift to get up into their wheelchair. When asked about any issues with his care, the Resident reported his dressing on his heel had come off and no one was in to put it back on. The Resident lifted his right foot up and an open wound was observed with some blackened area and dried drainage. The Resident was asked about the wounds, and he reported he had them before he came to the facility. The Resident lifted his left leg with amputation of the lower portion of the leg and foot and stated, I am diabetic and I had a wound on this foot too, but they had to take the leg. When asked how long the dressing had been off of the right foot, the Resident stated, It's been almost three days now, and reported he had told the nurse and they had told him they were going to put another one on, but no one has been in to put one on. A review of R115's medical record revealed an admission into the facility on 3/23/26 with diagnoses that included acute osteomyelitis of left ankle and foot, diabetes with diabetic peripheral angiopathy with gangrene, diabetes with foot ulcer and acquired absence of left leg below the knee. A review of the Resident's MDS revealed a BIMS score of 14/15 that indicated intact cognition and the Resident was dependent on helper with putting on/taking off footwear. On 8/10/26, a review of the Resident's progress notes revealed the following: -Dated 8/6/26 at 1:39 PM, Skin Issues, .Skin Issue: #002: . Location Right heel. Issue type: Pressure ulcer/injury. Wound was present on admission. Length (cm): 0.8 Width (cm); 1.36. Area (cm2): 0.86.Surrounding tissue: Fragile. Primary dressing: Hydrogel. Secondary dressing: Composite dressing.frequency of treatment: every 3 days and PRN (as needed). On 8/10/26 at 3:45 PM, a review of R115's Treatment Administration Record revealed an order for, Right Plantar Heel: Cleanse the area with wound cleanser and allow to dry. Apply hydrogel to the wound bed and cover with a border gauze. Daily and PRN every day shift every 3 days(s) for Wound Care, with a start date on 8/7/26. The date changed was documented on day shift on 8/7/26 and had not been documented as completed as of this date and time. There were no documented PRN dressings administered for the right plantar heel. On 8/10/26 at 3:50 PM, an observation was made of Resident 115 sitting up in his wheelchair. The right foot was covered in a yellow gripper sock, and the resident had his foot on the floor, there was not a foot pedal on the right side of the wheelchair. When asked if there was a dressing, the Resident lifted his foot and reported no dressing. On 8/10/26 at 4:33 PM, an interview was conducted with Nurse T who was assigned care of R115. The Nurse was asked if R115 was to have a dressing to the right foot. The Nurse reviewed the wound care treatment for the right heel to apply hydrogel to the wound bed and cover with a border gauze, every 3 days and PRN (as needed). The Nurse stated, It (a dressing) should be on there, indicating the wound to the right foot. The Nurse indicated she was not aware there was not a dressing on the foot, reported she had recently started her shift and did not get in report that the dressing needed to be completed. An observation was made with the Nurse of Resident 115 in his room in his wheelchair. The nurse removed the sock and there was no dressing to the right foot. R115 reported to the nurse that the dressing had come off about 2 and a half days now and no one has replaced it. The Nurse reported that she will check with the Wound Care Nurse to find out if they were to replace it with the same dressing or something else. On 8/11/26 at 10:01 AM, an observation was made of Resident 115 lying in bed. The right foot was wrapped with a dressing intact. The Resident reported that they had put the dressing on yesterday and wrapped it this time, it should stay on now, indicating the gauze wrap around the heel dressing and reported it would be changed every three days or if it falls off again. On 8/11/26 at 10:05 AM, an interview was conducted with Wound Care Nurse (WCN) I regarding R115's wound to the right foot. The WCN reported the Resident had a diabetic ulcer to the back heel and a pressure wound to the bottom of the right foot. The WCN reported that the Resident had a pressure wound when he was admitted into the facility and that he went to the wound clinic for treatment of his wounds. The WCN reported that the dressing was applied to the foot yesterday and that they changed it to have kerlex wrapped around to secure the dressing. The WCN reported the order for the dressing to the pressure wound on the bottom of the foot was to cleanse the area with wound cleanser, allow to dry, apply hydrogel followed by adaptic and foam and lightly wrap with kerlix, to be changed every three days and PRN. The WCN reported that the Resident had a recent amputation on the left leg, came to the facility after that, had gone to the wound clinic on August 5th where they changed the order for the dressing to be completed every three days. The WCN was asked if the foot wound should have a dressing and the WCN stated, Yes, and there are PRN orders in. When queried if the Nurse could have replaced the dressing after it had fallen off the WCN stated, yes.

This citation pertains to Intake Number 3054482. Based on observation, interview and record review, the facility failed to ensure that resident safety was provided during care for one resident (Resident #112) of three residents reviewed for falls and safety. Findings Include: Resident 112 (R112): On 8/10/26 at 12:20 PM, an interview was conducted with Confidential Person S regarding Resident 112's care at the facility. The Confidential Person (CP) reported the Resident fell out of bed when care was being provided and stated, They turned her too far and she fell out of bed, and reported bruising to the Resident's face. An observation was made of the Resident with bruising on the right side of the face around the eye area and forehead. The CP indicated she had two falls, the first one while sitting on the side of the bed, fell forward onto her face and the second time she was getting care done, they turned her too far but said she turned herself, she can't do that on her own. The CP stated, I've been asking for a bigger bed, and explained she asked at the care conference and stated, They said they would get her one, they still haven't gotten it for her. The CP reported asking for the bariatric bed prior to the fall that occurred during care.An observation was made that Resident 112's bed that was not a bariatric bed and had one assist bar on the left side of the bed. A review of R112's medical record revealed an admission into the facility on [DATE] and readmission on [DATE] with diagnoses that included end stage renal disease, dependence on renal dialysis, muscle wasting and atrophy, dementia, anxiety disorder, restlessness and agitation, and morbid (severe) obesity. A review of the MDS dated [DATE] for significant change in status, revealed a Brief Interview of Mental Status score of 09/15 that indicated moderately impaired cognition and the Resident was dependent on a helper for oral hygiene, toileting hygiene, bathing self, upper body dressing, lower body dressing, personal hygiene, roll left and right, sit to lying, lying to sitting on side of bed and transfers. R112's progress notes revealed the following:-Dated 7/13/26 at 4:06 AM, This writer was notified by the CNA (certified nursing assistant) that resident was on the floor. This writer went to assess resident. Resident was lying on the floor next to bed on right side. This writer asked resident what happened resident was unable to state. CNA stated she was being performed care and resident proceeded forward and rolled out of bed. Resident alert and oriented at baseline. Resident stated she hit her head. Assed prior to moving skin, ROM (range of motion) and neurological assessment. This writer observed swelling on right side of head no bleeding noted. No open areas. Resident was able to move upper and lower extremities. PERRLA (pupils equal, round, reactive to light and accommodate), hand grip equal bilaterally. NP (Nurse Practitioner Name) orders were to send resident out for further observation. Resident was safely transferred out of building via ems.-Dated 6/22/26 at 11:00 AM, The IDT meeting scheduled for 6/23/26 was held on 6/22/26 and was attended by the healthcare providers listed in the IDT evaluation. Medications, diet, and weight were discussed in the plan of care, along with a new notification to call the sister at anytime when the resident is upset to redirect her. Speech and Occupational Therapy will be revisited per NP. A review of R112's care plan with a focus for at risk for fall related injury and falls, revealed an intervention evaluate for bari bed, date initiated: 2/2/26. On 8/11/26 at 4:05 PM, an interview was conducted with the Unit Manager (UM), Nurse N regarding R112's fall on 7/13/26. The UM indicated that the Resident rolled out of bed while care was being provided. The UM reported that the Resident was a one person assist when rolling side to side prior to the fall on 7/13/26 but needed 2 person assist to boost up in bed. After the fall, the Resident was made a two person assist. The UM was asked, why wait for a fall to occur prior to putting in an intervention to prevent the fall. The UM reported that the Resident has had a gradual decline in ability and that they do quarterly nursing assessments or if out to the hospital for more than 24 hours an assessment is completed. A review of the fall prior on 5/23/26, the UM indicated the Resident had been observed on the floor laying on her stomach and had an injury to her face but indicated the Resident had not been transferred to the hospital at that time. When asked if the decline came from the fall on 5/23/26, the UM stated, No, the fall happened because of the gradual decline. On 8/12/26 at 11:03 AM, an interview was conducted with the Director of Nursing (DON) regarding R112's falls. The DON reported that the CNA had education provided for any peri care and it had been investigated by the Assistant Director of Nursing (ADON) E. When asked about the Bari bed intervention, the DON reported that the CP had talked to her on Monday, and room changes had to be made to accommodate the size of the bed in the room. When queried regarding the intervention in the care plan on 2/2/26, the DON reported the resident did not need one at that time, it was just an intervention, not put in as an order. When asked about the evaluation results for the bari bed, the DON reported she did not see any progress note on that. It was reviewed with the DON that the chart review did not show a risk versus benefit of not using the bari bed and that the resident was a larger lady. The DON reported that the bari beds were rated for a large weight, it would be patient preference and indicated that was why they made her a two person to turn in bed. When asked if a bari bed would allow more space to prevent rolling off the bed with care given the DON reported we can't speculate on that. On 8/12/26 at 12:04 PM, an interview was conducted with CNA Q regarding R112's fall during care being provided on 7/13/26. The CNA reported that the bed was positioned at waist height, she had to pull the Resident towards her first then turned her towards the other side of the bed away from her. The CNA reported the Resident had reached out but nothing was there just the divider curtain. The CNA reported an assist bar on the right side of the bed but not on the left side of the bed and stated, nothing to grab onto on the left side of the bed. The CNA reported that R112 was top heavy and you could not just roll her over without moving her towards you since she was on a small bed and stated, You can't just turn her where she lays in the bed, or she would be on the floor all the time. You have to scoot her over towards you then turn her. When asked if a bari bed would have made a difference, the CNA stated, yes. On 8/12/26 at 2:12 PM, an interview was conducted with the Assistant Director of Nursing (ADON) E regarding R112's fall on 7/13/26. The ADON reported that the CNA that had provided care had an education regarding obtaining extra assistance if needed when providing care for safety. The ADON was asked if the Resident needed to be a two person assist prior to the fall. The ADON reported it's hard to say if she should have had been a 2 person and stated, She uses a bar to assist with turning. The ADON was asked why not put two bars on if she uses the bars to turn? The ADON reviewed the chart and stated, Right sided assist bar padded with lambs' wool, and reported it was therapy departments recommendation and the Unit Managers. When asked about the intervention put in for a bari bed, the ADON reported that the Resident did not want to move rooms, that the bari bed had to go on the window side of the room so the other Resident in the room could get around it. The ADON was asked if it had been addressed again or if family was able to be involved and the ADON indicated it had not and the resident was her own person at that time and stated, I didn't realize there was not documentation for it. A review of facility policy titled, Fall Management, revealed, Policy: The facility will identify hazards and resident risk factors and implement interventions to minimize falls and risk of injury related to falls. Overview: Each resident is assisted in attaining/maintaining his or her highest practical level of function by providing the resident adequate supervision, assistive devices, and/or functional programs as appropriate to minimize the risk for falls. Residents will be evaluated by the interdisciplinary team for their risk for falls. A plan of care is developed and implemented based on this evaluation with ongoing review.

This Citation Pertains to Intake Number 2786215. Based on interview and record review, the facility failed to provide medications as ordered for one resident (Resident #1) of three residents reviewed for medication administration. Findings Include: Resident #1: A record review of the Face sheet and Minimum Data Set/MDS assessment indicated Resident #1 was admitted to the facility on [DATE] with diagnoses: Diabetes, hypothyroidism, arthritis, Dementia, history of falls, low back pain, hypertension, history of a stroke and urinary tract infection/UTI. The resident discharged to home on 2/27/2026. A review of the progress notes for Resident #1 indicated she was admitted to the facility on [DATE] at approximately 2:45 PM and a provider note by Nurse Practitioner E dated 1/8/2026 listed her medications including: Nitrofurantoin microcrystal, oral capsule 100 mg: Give 1 capsule by mouth two times a day for UTI for 2 administrations until finished, active 1/7/2026-1/8/2026. A review of the Hospital discharge instructions, dated [DATE], identified the following order: Nitrofurantoin (Macrocrystal monohydrate) 100 mg capsule, commonly known as: Macrobid- Take 1 capsule by mouth every 12 (twelve) hours for 2 doses, last time this was given: 100 mg on January 7, 2026, at 9:15 AM. The instructions indicated the resident received a dose of Nitrofurantoin Macrocrystal on 1/7/2026 at 9:15 AM and the dose would be due again on 1/7/2026 at approximately 9:00 PM (every 12 hours); it would be the 1st of 2 doses, as the resident was also treated in the hospital for a UTI and needed to finish the 2 doses of antibiotic therapy after admission to the facility. A review of the physician orders for Resident #1 revealed the following: Nitrofurantoin Macrocrystal oral capsule 100 mg, Give 1 capsule by mouth two times a day for UTI for 2 Administrations until finished, start date 1/7/2026. Nitrofurantoin Macrocrystal Oral capsule 100 mg, Give 1 capsule by mouth two times a day for UTI for 2 administrations until finished, start date 1/12/2026. A review of the Medication Administration Record for January 2026 for Resident #1 revealed the resident received 7 doses of Nitrofurantoin Macrocrystal 100 mg from 1/7/2026-1/11/2026. A dose was not administered at 9:00 AM on 1/9/2026 and 9:00 PM on 1/11/2026. On 1/12/2026 a new order for Nitrofurantoin Macrocrystal oral capsule 100 mg by mouth two times a day for UTI for 2 administrations, start date 1/12/2026 was initiated and the resident received 3 more doses from 1/12/2026-1/13/2026: a total of 10 doses was administered.Further review of the progress notes identified a provider Encounter note dated 1/13/2026 by Physician F for Resident #1, . she was watching television and informed me that she has a yeast infection right now and would like something for it. No other concerns. Candidiasis, unspecified: Dose of Diflucan (an antifungal medication used to treat yeast infections). The provider gave the resident a diagnosis of Candidiasis (per the CDC/Centers for Disease Control and Prevention, dated April 24, 2024 Candidiasis is a fungal infection caused by an overgrowth of the yeast Candida. A provider Encounter note, dated 1/15/2026 by Nurse Practitioner/NP G provided, . Today pt (patient) states she has symptoms of vaginal yeast infection including vaginal, itching, burning, and white discharge. She complains of intense vaginal itching with white discharge. Diagnoses: Vaginal yeast infection: Diflucan 100 mg daily times 3 days, Miconazole vaginal suppository times 3 days. Further review of the Medication Administration Records for January 2026 indicated Miconazole vaginal suppository and Diflucan oral tablet (both antifungal medications) were both started on 1/16/2026. A review of the progress notes identified an eMAR-Medication Administration Record note dated 1/16/2026 at 12:01 PM, NP notified of hold on. miconazole- pharmacy to send. During an interview with the Assistant Director of Nursing/ADON D on 3/16/2026 at 2:15 PM about Resident #1's medications, she said she had written the order in the computer (electronic medical record/emr) on 1/7/2026 for the Nitrofurantoin Macrocrystal for Resident #1. Nurse D reviewed the order in the emr and said the resident should have received 2 doses of the antibiotic medication and she said she did not know why the resident was given so many doses. Reviewed with the ADON D that after the resident received extra doses of antibiotic, she developed a yeast infection and was very uncomfortable. The ADON reviewed the EMR and said she could see the notes and orders related to the yeast infections that occurred after the antibiotics. A review of the Care Plans for Resident #1 revealed the following: (Resident #1) is at risk for complications r/t (related to) has infection of the: UTI, created on 1/8/2026 and revised 1/14/2026 with Interventions including: Administer medications as ordered. Observe for side effects and effectiveness, report abnormal findings to the physician, created on 1/8/2026 and revised 1/14/2026. (Resident #1) is at risk for complications r/t has infection of the: vaginal yeast infection, date initiated 1/16/2026 and revised 2/11/2026 with Interventions including: Administer medications as ordered. Observe for side effects and effectiveness, report abnormal findings to the physician. During an interview with the Director of Nursing/DON on 3/16/2026 at 4:30 PM, she said there was no additional information why Resident #1 received more doses of the antibiotic Nitrofurantoin Macrocrystal/Macrodantin than was ordered. A review of the facility policy titled, Medication Administration dated effective 10/17/2023 provided, Resident medications are administered in an accurate, safe, timely, and sanitary manner. Physician's Orders- Medications are administered in accordance with written orders of the attending physician.

This Citation pertains to Intakes 2713005 and 2717874.Based on observation, interview and record review, the facility failed to fulfill residents' rights with timely responses to call lights for five Residents (#1, #3, #4, #5, and #6) of six residents reviewed for residents' rights and call light response times. Findings include:Resident 1 (R1):A review of Resident 1's (R1) medical record revealed an admission into the facility on [DATE] with diagnosis that included heart failure, atrial fibrillation, chronic obstructive pulmonary disease and dependence on supplemental oxygen. Review of intake documentation revealed the Resident had been put on an oxygen tank when the concentrator malfunctioned. The oxygen tank had run out of oxygen, the Resident experienced a developing headache, dizziness, and lightheadedness. The Resident activated his call light and waited approximately 25 minutes before staff responded and then left the room to locate a full tank of oxygen. The incident placed (R1) at serious risk of harm and represents a failure to ensure basic medical safety and timely response. Resident 3 (R3):A review of Resident 3's (R3) medical record revealed an admission into the facility on [DATE] and discharged home on [DATE], with diagnoses that included femur fracture, disorders of muscle and history of falling. A review of the Minimum Data Set assessment revealed a Brief Interview of Mental Status (BIMS) score of 9/15 that indicated moderately impaired cognition, and the Resident was dependent on helper for toileting hygiene and lower body dressing and needed partial/moderate assistance with toilet transfers. On 2/4/26 at 2:07 PM, an interview was conducted with Confidential Person (CP) L and Confidential Person (CP) M regarding concerns of the care Resident 3 received when at the facility. CP M reported that R3 had had falls and had a fracture in her hip. The CP reported that R1 would need to use the bathroom and she had fallen, they said she walked out of the room to another resident's room and was found in middle of the floor with her pants down below her knees. The CP reported that they did not attend to her as they should and didn't help her to the bathroom. CP L reported being at the facility to visit, putting the call light on so R3 could get to the bathroom, waited more than 30 minutes with no staff response and had taken her to the bathroom by themselves. The CP reported that staff got mad and said we could not do that, we had to wait for them to get her to the bathroom, but she could not hold it that long and would try to get up on her own, she could not wait that long for them to come. The CP reported R3 would be incontinent waiting for staff to come and stated, response times are terrible for call lights! The CP stated, (R1) would be sitting in the wheelchair, we pulled that button (call light), no one came, I would take her. She had accidents multiple times. The CP reported that when I came in, she had (incontinence of bowel movement), and I had changed her myself. It took too long for someone to come. Resident 4 (R4):A review of Resident 4's (R4) medical record revealed an admission into the facility on 4/24/19 and readmission on [DATE] with diagnoses that included cerebral infarction (stroke), diabetes, adjustment disorder with mixed anxiety and depressed mood, hemiplegia and hemiparesis. A review of the R4's MDS revealed a BIMS score of 14/15 that indicated intact cognition and the Resident was dependent on a helper for oral hygiene, toileting hygiene, bathing, dressing and personal hygiene, mobility and transfers. On 2/3/26 at 2:45 PM, an observation was made of the light on above the door in room [ROOM NUMBER]. When questioned, R4 reported she had the call light on for about a half an hour now and reported no one had come in to check on the Resident. An observation of the wall where the call lights were plugged in revealed the call light was on for R4's roommate who indicated she had not put the call light on. R4 pressed her call light again and the call light did not go on. The Resident pushed the call light multiple times in a row and the call light on the wall did not activate. R4's roommate was unsure why their call light was on and did not know that it had been activated. R4 reported no staff have been into the room.The Maintenance S came into check the call light after being requested to R4's room. Maintenance S had the resident push the call light and it did not work until after adjustment to where the call light plugged into the wall. On 2/4/26 at 12:40 PM, R4 was observed lying in bed, was interviewed, answered questions and engaged in conversation. The Resident reported long call light wait times of more than 30 minutes sometimes and at different times during the day. The Resident stated, Can take an hour, for the call light to be answered. The Resident reported calling for assistance to get changed after incontinence and to get ice water. Resident 5 (R5):A review of R5's medical record revealed an admission into the facility on 5/10/23 and readmission on [DATE] with diagnoses that included peripheral vascular diseases, depression, diabetes, and left above the knee amputation. A review of R5's MDS assessment revealed a BIMS score of 15/15 that indicated intact cognition and the Resident was dependent on helper for toileting hygiene, bathing, lower body dressing and transfers. On 2/4/26 at 12:50 PM, an observation was made of the call light above R5's door. An interview was conducted with R5 who answered questions and engaged in conversation. The Resident reported she had put the call light on. When asked how long she had been waiting, the Resident stated, It's been on for a little while, and indicated she needed to be changed and wanted a drink. The Resident was asked if she had any issues with her call light response by staff. The Resident reported that sometimes it works and sometimes it doesn't, and stated, They will shut it off and say they will be back, and they don't come back. When asked if they waited more than 30 minutes, the Resident stated, sometimes when they don't come back. At 1:02 PM, an observation was made at the nurse's station that was positioned in the middle with the halls extending out. There were staff at the nurses' station behind the desks, staff in and around the area. The call light above R5's door can be seen from the nurse's station, and another call light was on a couple of doors down from R5's room.At 1:04 PM, an observation was made of no staff at the nurses' station, but staff remain in and around the area. A staff breakroom was in the same hall as R5. An observation was made by staff going into the breakroom. R5's light remains activated above the door and no staff were observed entering the room.At 1:08 PM, an observation was made of Housekeeping staff entering the room with the activated call light down from R5's room.At 1:11 PM, an observation was made of Staff going into R5's room, the light was turned off, and the Staff goes into the breakroom.At 1:16 PM, an observation was made of R5 with a diet coke. The Resident reported she had gotten her drink. The Resident had not been changed. Resident 6 (R6):A review of R6's medical record revealed an admission into the facility on 4/7/21 and readmission on [DATE] with diagnoses that included anxiety disorder, heart failure, need for assistance with personal care, respiratory failure, and dependence on supplemental oxygen. A review of R6's MDS revealed a BIMS score of 15/15 that indicated intact cognition and the Resident was dependent on a helper for toileting hygiene, lower body dressing, mobility and transfers. On 2/3/26 at 3:38 PM, an observation was made of Resident 6 lying in bed. The Resident was interviewed, answered questions and engaged in conversation. An observation was made of R6's call light on. When queried about when she had activated the call light, the Resident stated, It hasn't been too long. The Resident was asked if she had any concerns with call light response times and the Resident stated, It can be an hour, but they do a good job when they get here, and they are too thin on staff. Resident Council Concern/Recommendations notes taken during Resident Council Meetings for October, November, December, and January were reviewed. -Dated 11/24/25 revealed, .Nursing Call light response times are longer than normal. Resident Council Follow Up: . Nursing: Remind all staff about answering call lights (with Department Manager Signature and Date 11/24/25) .-Dated 1/2/26 revealed, .Nursing Call light response times are taking longer. Resident Council Follow Up: . Nursing: Remind all staff during monthly educations to answer call lights timely, (with Department Manager Signature and Date 1/8/26) .-Dated 1/30/26 revealed, .Old Business. 2. Concern: Call light response times are taking longer (not indicated as resolved or unresolved) Actions Taken: Remind all staff to answer call lights timely. New Business: .Nursing: Call lights not being answered timely. On 2/4/26 at 3:10 PM, an interview was conducted with Assistant Director of Nursing (ADON) N. When asked about call light response times, the ADON indicated that the call light should be answered as soon as possible, about 5 minutes, 10 minutes max. The ADON reported that if the need was not met when staff answer the call light, the call light needs to stay on. On 2/5/26 at 9:45 AM, an interview was conducted with the Director of Nursing and the Administrator (NHA) of concern from residents and intake complaints regarding long call light response times, observations during survey and concerns from residents of the call light being turned off, their needs not met and staff not returning timely. The NHA reported they have been working on the concern, but when staff ask about call light concerns when asked daily, the Residents were not giving the concern to the staff member. The concern of the call lights functioning properly was reviewed with the DON and NHA. A review of facility policy titled, Call Lights, with a effective date of 3/12/25, revealed, Policy: Call lights will be placed within the resident's reach and answered in a timely manner. Responding to a Call light: 1. Identify the location and answer the resident promptly. 3. Go to the location of the call light, and turn off the light if you are able to meet the resident request.

This Citation pertains to Intake Number 2717874.Based on observation, interview and record review, the facility failed to ensure that physicians' orders for oxygen use were followed for 1 resident (Resident #6),; oxygen was provided to 1 resident (Resident #5); and nebulizer equipment was stored properly for 1supplemental (Resident #7), of three residents reviewed for oxygen administration and one supplemental resident.Findings include:Resident #7:On 2/3/25 at 2:44 PM, an observation was made during the initial tour of the facility of Supplemental Resident #7's room. The Resident was not in the room at the time. The Resident had oxygen equipment set up in the room that included a nebulizer machine. The nebulizer mask and tubing were stored inside a clear bag. The nebulizer medicine chamber was observed to be stored inside the bag wet with drops of liquid inside the chamber.A review of Supplemental Resident #7's Medication Administration Record revealed the Resident had Ipratropium-Albuterol Inhalation solution, four times a day for COPD (chronic obstructive pulmonary disease), scheduled at 0900 (9:00 AM) and documented as last as administered and the 1300 dose (1:00 PM) was documented as not given. Resident #5:On 2/3/25 at 3:30 PM, an observation was made with Resident #5 (R5) lying in bed, awake with head of bed elevated. An observation was made of the Residents oxygen tubing and nasal cannula positioned by the wall and not within reach of the Resident. The Resident was interviewed, answered questions and engaged in conversation. The Resident was asked about her oxygen. The Resident reported that she was to use it all the time and stated, The aide forgot to give me my oxygen back. The Resident reported she had the CNA (certified nursing assistant) help in getting her shirt off and new one put on and had taken the oxygen off. When asked how long it had been since she was left without her oxygen in place, the Resident stated, It's been about an hour. Staff were alerted to the Resident needing her oxygen and a CNA came in with the vital sign machine, obtained an oxygen saturation of 87% to 88% and a Nurse came in and put the oxygen onto the Resident.A review of R5's medical record revealed admission into the facility on 5/10/23 and readmission on [DATE] with diagnoses that included peripheral vascular diseases, depression, diabetes, and left above the knee amputation. A review of R5's MDS assessment revealed a BIMS score of 15/15 that indicated intact cognition and the Resident was dependent on helper for toileting hygiene, bathing, lower body dressing and transfers.A review of R5's orders for oxygen dated 8/22/25, revealed and order 0.5-5L of supplementary oxygen to maintain SpO2>90% . Resident #6:On 2/3/25 at 3:38 PM, an observation was made of Resident #6 (R6) lying in bed, awake with head of bed elevated. The Resident was interviewed, answered questions and engaged in conversation. An observation was made of R6 with oxygen on, supplied by a nasal cannula on the nose and connected to an oxygen concentrator. The Oxygen (O2) was set at 4 L (liters of oxygen per minute). When asked if the Resident knew what her O2 was to be set at the Resident reported it should be at 4.A review of R6's medical record revealed an admission into the facility on 4/7/21 and readmission on [DATE] with diagnoses that included anxiety disorder, heart failure, need for assistance with personal care, respiratory failure, and dependence on supplemental oxygen. A review of R6's MDS revealed a BIMS score of 15/15 that indicated intact cognition and the Resident was dependent on a helper for toileting hygiene, lower body dressing, mobility and transfers. On 2/4/25 at 3:10 PM, an interview was conducted with Assistant Director of Nursing (ADON) N. A review of R6's medical record with the ADON revealed an order for Oxygen for 2 L/min (liters per minute). An observation was made of R6's oxygen concentrator set at 4L/min. The oxygen the resident was receiving did not match the physician order for oxygen. The ADON reported she would look into it and find out how many liters of oxygen the Resident should be on. A review of the facility policy titled, Use of Oxygen, did not give directive of following provider orders for oxygen use or monitoring liters of oxygen to be used. A review of the facility policy titled, Nebulizer therapy, small volume, revealed, Implementation. Rinse the nebulizer with water and allow it to air-dry.

This Citation pertains to intake Number 2659743.Based on interview and record review, the facility failed to transfer to the hospital in a timely manner one resident (Resident #1) of 1 resident reviewed for a delay in transfer to the hospital, upon an acute change of condition. Findings Include:On [DATE] at 9:15 AM, EMT (Emergency Medical Technician)/ LPN (Licensed Practical Nurse) C shared they were dispatched to the facility around 1:30 AM on [DATE] for a male resident with difficulty breathing, pulse of 150 and unresponsiveness. Upon arrival the nurse informed them she had recently arrived for her shift and per Resident #1's brother he had been in this condition prior to the beginning of her shift. The CNA (Certified Nurse Assistant) was sitting at the edge of the resident's bed and shared this was not his baseline and the night prior this was not how Resident #1 presented.EMT/LPN C stated the Resident #1 was unresponsive, diaphoretic and would awaken only to painful stimuli. He was hot to touch with a temperature of 104.1, his catheter was noted to be dark in color with sediment, and his lung sounds were wet bilaterally. Resident #1 would open his eyes for about 10-15 seconds, and he looked scared. They could hear him trying to breath and how wet it sounded. Resident #1 was intubated within 10 minutes of his arrival to the Emergency Room.On [DATE] at 10:10 AM, an interview was conducted with Resident #1's Brother/Guardian D. He reported the resident was still admitted at the hospital and was initially in the ICU (Intensive Care Unit) but stepped down. When he visited his brother on [DATE] at the nursing care facility, he raised some concerns to them regarding his brother's decrease in mobility, posture and slower than usual response times. Brother/Guardian D, stated Resident #1 was unable to raise his right arm and the facility said they would order some bloodwork. At about 1:30 AM he received a phone call that Resident #1 was unresponsive and would be transported to the Emergency Room. Upon his arrival at the hospital his brother had been placed on a ventilator. On [DATE] at approximately 10:30 AM, a review was conducted of Resident #1's medical records and it indicated he was admitted to the facility on [DATE] with diagnoses that included, Gram- Negative Sepsis, Anxiety, Myocardial Infarction, Heart Failure, Dependence on Supplemental oxygen, Bipolar and Schizoaffective Disorder. Further review yielded the following:Care Plan: .(Resident #1) has a potential for difficulty breathing and risk for respiratory complications R/T (related to): CHF.Supplemental oxygen use.observe for difficulty breathing (dyspnea) or exertion.observe for acute respiratory insufficiency .observe residents respiratory status at a minimum of daily and as needed ie. Auscultate lung sounds; observed respiratory rate; symmetry of chest expansion and any changed in color or level or consciousness.Resident is dependent on staff for toileting.There were no care-planned interventions listed for Resident #1's Foley catheter.Kardex: .Bed Mobility: Resident is dependent on staff for bed mobility. This is including rolling side to side. Lying to sitting on side of bed and sitting to lying.There was nothing mentioned in the Kardex related to Resident #1's Foley catheter. On [DATE] at 1:20 PM, Nurse E stated she did work on the night shift that Resident #1 was sent to the Emergency Room. She observed Nurse F moving back and forth quickly during medication pass and when asked if she was OK? she stated, No, and that Resident #1 needed to be sent out as he looked off.On [DATE] at 4:30 PM, CNA G stated nothing was passed on in report regarding Resident #1 that would have alerted her to check in on the resident more frequently. Upon arrival she completed her initial set of vitals and water pass around 11 PM and she recalls Resident #1 appearing that he was asleep and leaning to the side. She completed vitals and he did not stir while completing them. Sometime after midnight Resident #1's roommate needed something and she heard Resident #1 breathing loudly as if he was snoring, CNA G had never heard this from him before. CNA G called out the resident's name, and he did not respond or open his eyes. The CNA lifted his head off the bed, and his eyes were open, but he was not speaking. CNA G alerted Nurse F who asked for another set of vitals and his pulse was around 130 and steadily increasing. Resident #1's eyes were open, but he was just staring and not responding to any of their verbal commands. She reported, from what she could recall, they only completed a set of vitals when she heard him breathing oddly. Nurse G had her remain in the room with him as she went to contact the provider and prepare to send him to the emergency room for evaluation.CNA G was queried if she recalled the color of Resident #1's urine and she stated she did not but offered he did not have a lot of urine output and was unable to recall the color of his urine.It can be noted during review of the chart there was only one set of vitals entered between 10 PM -2 AM on the night shift of [DATE]/[DATE]- which were the entered by Nurse F. It is unknown what Resident #1's vitals were upon arrival of the night shift. On [DATE] at 4:40 PM, CNA H shared Resident #1 was total care, but he was able to express his needs to staff and had movement in one of his arms. They would set him up for meals and he was able to eat independently. The resident enjoyed his coffee throughout the day and was good with drinking water as well.On [DATE] at approximately 4:56 PM, an interview was conducted with Nurse I regarding Resident #1. He reported he worked on [DATE] from 3:00 PM-11:30 PM and did not receive anything in report regarding Resident #1 that would have alerted him to monitor more closely. Nurse I stated he administered his medications, and he was able to take them with no issue. Further review was conducted of Resident #1's records and it revealed the following:Mobile Medical Response Run Report:[DATE]: .Unit dispatched on [DATE] at 1:29 AM and arrived on scene at 1:36 AM and arrived to the patient at 1:40 AM.Altered mental status for 2 days.Vitals Table: BP (Blood Pressure): 123/80; HR (Heart Rate):150; SPO2: 94 (nasal cannula); Resp (respirations): 26, labored; ECG: Sinus Tachycardia. 2:00 AM: BP: 120/78; HR: 145; SPO2: 97; Resp: 26, labored; ECG: Sinus Tachycardia.1:40 AM- 6 liters per minutes, nasal cannula; improved.was dispatched to the above address with lights and sirens for AMS (altered mental status). Upon EMS arrival the male was responding to painful stimuli with his eyes only. Staff stated he is usually AOX3, but his son states that he had increased AMS x2 days. They stated that he has been altered with labored breathing, a fever, chunky urine, diaphoresis and tachycardia since 22:00 yesterday. He was lifted to the stretcher and continued on oxygen with NC (nasal cannula). He was placed on continuous cardiac monitoring and tachycardia was noted. His lungs were assessed and very wet throughout. Progress Notes:[DATE] at 08:00: .I recommend patient have a Foley catheter placed to promote wound healing and keep wound bed dry. [DATE] at 13:03: Pt brother in to visit and spoke with assigned CNA in hallway, pt brother concerned r/t (related to) pt deceased appetite, slower to respond and decreased overall interaction and participation in daily tasks. Pt responds appropriately to questions and pt does drinks when offered fluids however, pt is not independently picking up cups to take drinks independently, additional review may be necessary and information forward to unit manager.[DATE] at 01:22: .At the time of this evaluation resident/patient vital signs. Blood Pressure: 142/92 Pulse: 147; RR: 22; Temp: 97.9 Pulse oximetry: 93%.Mental status evaluation for this change in condition were: Mental Status Evaluation: Unresponsiveness; functional Status Evaluation: General Weakness decreased mobility.Send to ER.[DATE] at 02:43: CNA notified writer that resident's pulse was elevated, and he presented with labored breathing. Upon assessment by writer, resident appeared to be in respiratory distress due to labored breathing with accessory muscles. Resident was also verbally unresponsive, not did not respond to sternum rub, and did not respond to sternum rub and did not respond to painful stimuli. Vitals assessed as 142/92, 147, 97.9, 22, 93% on 2.5L O2. Writer notified on call NP (nurse practitioner) and she recommended sending resident to the ER. 911 was called and arrived at the facility to transport resident to (Hospital) at 0140. Writer notified ADON (Assistant Director of Nursing) and resident's guardian. No belongings were taken with resident. SBAR Communication Form: Unresponsiveness.weakness.decreased mobility.Respiratory Evaluation: Not clinically applicable to the change in condition being reported.Transfer Form:[DATE]: .Unresponsive.Vital Signs: Blood Pressure -142/92; Pulse-147; Respirations-22.0; Temperature- 97.9; 02 stats- 93.0%: Blood Glucose- 107.There was no further assessment documented, or nursing care provided to Resident #1 during this acute episode by his assigned nurse until EMS arrived.Review was completed of records related to Resident #1's Foley catheter and fluid intake.Treatment Administration Record:[DATE]:Foley Catheter Care Q (every) shift -- Documented as completed on day, evening and night shift on [DATE]st- [DATE]rd, 2025. There were no subsequent progress notes detailing any observed concerns with Resident #1's Foley catheter until EMS observed it when he was being transported to the Emergency Room. Toilet Continence: Review was conducted of the past 30 days of documentation and facility staff documented Toilet Continence Not Rated due to Indwelling Catheter. approximately 95% of the look back period.Indwelling Catheter Care: Review conducted of the last 14 days of CNA documentation and it indicated catheter care to include care, privacy bag, securement device, empty urine drainage bag every shift was being completed.Review was conducted of Resident #1's fluid intake over the last 30 days and it indicated within the day he drank approximately 20 oz- 45 oz. Per the task documentation, facility staff were not assessing Resident #1's continence as he had a catheter. There was no indication from the charting otherwise of any concerns related to his Foley catheter. On [DATE] at 11:45 AM, an interview was conducted with Unit Manager A regarding Resident #1. The progress note completed on [DATE] at 13:03 by Nurse J was reviewed. Unit Manager A was asked when she was made aware of information contained in the progress note and she expressed Nurse J printed the note and placed it in her mailbox that is affixed to her office door, but she did not see it until [DATE] and Resident #1 had already been transferred to the hospital. Manager A stated she believed she was still in the facility when the note was placed in her mailbox. Based on the documentation, it appeared it was a newly developed concern for the resident as he was table to hold his cup to drink independently.In reviewing the documentation, Unit Manager A stated the nurse could have informed her in person, reached out to therapy for an evaluation, ensured that he was offered extra assistance during meals and would have expected the information to be passed off in report. Manager A stated she was uncertain what questions were asked or where there was a thorough assessment of the concerns Resident #1 brother identified, was at. On [DATE] at approximately 9:00 AM, an interview was conducted with Infection Control Nurse B, regarding Foley catheters. She explained the CNAs complete the perineal care that is documented under tasks and facility nurses complete Foley care that is documented in the TAR. Nurse B was on leave in [DATE] and upon returning in [DATE] there was an uptick of UTIs (Urinary Tract Infections) in [DATE] leading into [DATE].Infection Control Nurse B stated Resident #1's Foley catheter was placed on [DATE] to promote wound healing. She stated the nurses should be observing residents' Foleys at least three times a day. Prior to marking it off in the TAR they should be cleaning the catheter from the insertion site down, checking to make sure the bag is below gravity and covered. If they notice any abnormalities (patient specific) such as unusual urine color or sediment they would document in a progress note and alert her.Nurse B clarified there is no other documentation/assessment completed by nursing staff related to residents' Foley catheters unless there is a concern identified. Review was completed of Resident #1 Kardex and care plan and there was nothing listed in regarding ongoing assessment/monitoring of his Foley catheter. Nurse B was queried how she is aware if Resident #1 is voiding or not. It was explained the CNA's document under toilet continence which is where she would review to see if there were issues with the voiding pattern. We reviewed the task for toilet continence and the documentation indicated continence not rated due to indwelling catheter. Nurse B was questioned on how she would know if the resident was producing urine or not if staff were not monitoring if. The nurse reported she would be unsure if Resident #1 was producing urine. A review was then completed of the daily fluid intake and Nurse B reported that with his intake of fluids he (Resident #1) should have had urine output. On [DATE] at 12:55 PM, an interview was conducted with the Administrator and the Director of Nursing (DON) regarding Resident #1's acute change in condition. A review was conducted of his care plan and Kardex with the absence of interventions to address ongoing monitoring and assessment of his Foley catheter. They expressed they were unsure why it was not on the Kardex as there are certain items that automatically pull over.The DON reported that CNA's complete perineal care on every shift and document under tasks and the nurses complete their care and document in the TAR every shift. They reiterated that the nurses only documentation, related to a resident's Foley catheter, would be the mark off in the TAR, unless there was a concern identified. The DON and Administrator were asked how they monitor if residents with catheters are voiding. They explained CNA's document under toilet continence under Tasks. Resident #1 tasks were reviewed, and his toilet continence was rated as continence not rated due to indwelling catheter. They continued if the resident was not producing urine they would mark not voiding and then notify the nurse. They were asked if they were aware that Resident #1 did have a lot of urine output per staff. They stated they were not aware of this.The DON stated they spoke to Nurse F yesterday evening and she shared she completed her initial rounds within the first hour of her shift and he was sleep with a normal chest rise and fall. The CNA alerted her to his labored breathing, and the nurse completed vitals, called his name and he only opened his eyes but was not responding verbally. His pulse was elevated and the nurse stated he was cool to the touch. The DON was asked if Nurse F completed any other assessment or delivered any other care (outside of the vitals taken) given that her note stated the resident was in respiratory distress and not responding to sternum rub or painful stimuli. The DON stated that, based on the progress note, the nurse only completed vitals on the resident as she awaited EMS.It can be noted upon EMS arrival, Resident #1 was unresponsive and only awakened to painful stimuli. His temperature was 104.1, he was hot to the touch, diaphoretic, his lung sounds were wet bilaterally, and his catheter was noted to have sediment and be dark in color. Resident #1 was in acute distress and there were no further nursing interventions that nursing staff rendered to the resident during this episode. Per the hospital records Resident #1 was still being treated at the time of the Abbreviated Survey. The records revealed the following:Hospital Records: .Patient presenting with altered mental status from nursing home normally ANOx4 was notably febrile per EMS with a temperature of 104 degrees axillary tachycardiac in the 150s was placed on 6 L (liters) nasal cannula.Upon transfer over the EMS from EMS to ER bed, patient O2 sats in the 84 to 87% on nasal cannula was placed on nonrebreather with developing significant amount of fatigue. Urine appeared to have significant sedimentation per information gathered from EMS.T: 39.5 C; HR: 147 (monitored).on examination patient appeared to be very fatigued, lethargic, slightly diaphoretic as well has some notable pitting edema in his left upper extremity abdomen is soft nontender nondistended.Foley catheter in place shows significant sedimentation and appears to be cloudy as well.Patient is notably warm to touch.Endotracheal intubation was performed at bedside. The reason was secondary to acute hypoxic respiratory failure with inability to protect airway. he appeared to be quite altered and inability to maintain Sp02 sufficiently with 15 L nonrebreather.Assessment/Plan: Septic Shock.initial impression was septic shock likely secondary to UTI.with acute hypoxic respiratory failure.XR Chest 1 view Portable: Impression: Suspected right lower lobe pneumonia.Sepsis related to UTI +/-pneumonia.urine culture showing gram-negative rods. Blood culture from 11/4 reporting MRSE in 2/2 sets. Sputum culture grew Staph aureus.XXX[DATE]: Assessment/Plan; 1. MRSA pneumonia; 2. Septic Shock.presented for fevers, hypoxia and decreased responsiveness. Sepsis criteria met with neutrophilic leukocytosis, tachycardia, tachypnea and fevers. Urine culture grew ES:, Klebsiella, patient has been on IV meropenem. Multiple attempts were made throughout the course of the investigation to contact Nurse F, to no avail. The facility attested they spoke with Nurse F on [DATE] regarding the incident.The facility provided a document entitled, How to care for a urinary catheter, The documented stated, .Call for advice if: the urine.is dark or coffee colored, has solid bits in it. The document provided did not address the ongoing monitoring/assessment related to urinary catheters. According to the National Library of Medicine: Respiratory Assessment, .Inspection during a focused respiratory assessment includes observation of level of consciousness, breathing rate, pattern and effort, skin color, chest configuration, and symmetry of expansion.Using the diaphragm of the stethoscope, listen to the movement of air through the airways during inspiration and expiration.

Based on interview and record review, the facility failed to provide prompt efforts to resolve complaints pertaining to prolonged call light response times, food palatability, bedtime (HS) snack distribution, group activities, and staff availability and attitude to assist and to ensure the process to address grievances was understood for nine (9) confidential group of residents resulting in unresolved grievances and potential for further frustration. Findings include: Resident Council: FACILITY On June 25, 2025, at 11:00 AM, a Resident Council Meeting was held. According to nine (9) members of a group of confidential residents, on June 25, 2025, at 11:00 AM, the Resident Council meets on the last Friday of every month. They requested to remain anonymous and to keep their identities confidential. One confidential resident stated that the issues brought up by the council do not get resolved and said, It does not go anywhere. It seemed that the concerns were not followed up on. No one gets back at us. A confidential group of residents expressed a lack of awareness about the grievance process and were unaware of a grievance form that could be filled out. Any complaint or issue raised by a group or individual must be filed using the designated form. Depending on the type of concern or issue, it is handled, followed up on, and addressed during the next group meeting or individually. The group of confidential residents stated that this was the first time they had heard about the process and wondered where the forms could be obtained and to whom they should report their grievances. They were unaware of the process for putting concerns in writing using a grievance form. When the Grievance form was presented and read to the council, some residents indicated that they had never seen the grievance form or had any idea it existed. The following were grievances brought up by the confidential group of residents during the meeting held on 6/25/25, from 11:00 AM to 12:05 PM: 1. Regarding activities, they have not had a field trip since the COVID-19 pandemic. The council went into specific details about the facility, sold the bus, and since they don't have transportation for group activities. Activities have been redundant, and choices were limited and not individual-centered. This was asked for in previous council meetings. 2. Prolonged wait times for Call Light response averaging from 30 minutes (at least). 9 out of 9 groups of confidential residents agreed; occasionally, during call light response, staff may turn off the call light and claim they are coming back with the request, but they don't. Some staff members are helpful, while others are not. They talk to other staff very loudly or on their cell phone while residents needing assistance have to wait. Staff ignore the lights because we see them at the nurse's station gathering, talking, or on their phones. 3. Palatability of the Food Menu. Residents complained that the food does not taste good, is repetitive, and lacks variety. One resident stated: They repeat the same menu more often. It seems like every 2 weeks. It used to be every four to six weeks. A lot of cold sandwiches, whatever the alternative, can be the leftovers from previous meals that they did not like to begin with. 4. No HS (Bedtime) Snacks are provided or are not distributed appropriately to residents. Residents revealed that they don't receive them unless they walk or wheel themselves to the nurse's station. The Resident Council expressed concern for other residents who were unable to reach the nurse's station or could not speak on their behalf. One resident with a diagnosis of diabetes never received an HS snack and was unaware that one was available. 5. Staff often make up reasons, such as equipment being unavailable or not being found, as the reason why they don't return immediately, but the equipment is available. We have seen where the equipment is kept, and we know its location. An example was the sit-to-stand lift. Staff would say it took them a long time to find them. Meanwhile, they've been soaking wet from waiting for prolonged periods. The Resident Council Meeting ended on 06/25/25 at 12:03 PM. The Activities Director and the Assistant Activities staff member were present during the meeting. The Activities Director, on June 25, 2025, at 12:05 PM was interviewed. She indicated that there had been no field trip activities because the group lacked a means of transportation. They only have a van that could fit only two wheelchairs. They don't go on field trips for that reason. A review of the RC Minutes from December to May 2025 was conducted on June 25, 2025, at 10:30 AM. It was revealed that the March 2025 RC Meeting Minutes were missing. There were no notes and no follow-up on previous issues discussed in the old business notes. There were no noted resolutions to some of the residents' concerns listed in the minutes from December to May. The monthly Resident Council Meeting Minutes revealed: > The December 2024 RC Meeting Minutes, dated January 24, 2025, at 11:00 AM, were reviewed and did not discuss any old or new business. Old Business, according to their minutes, refers to the list of follow-up items from last month's minutes, and Issues not resolved are moved to New Business. The Old Business section was left empty, and the New Business section was noted. See the attached form. The council discussed Nursing, Dietary, and activities concerns. The council suggested some ideas for future activities, and events were noted. > The January 2025 RC Meeting Minutes, dated January 24, 2025, at 11:00 AM, were reviewed and did not discuss any old or new business. Old Business, according to their minutes, refers to the list of follow-up items from last month's minutes, and Issues not resolved are moved to New Business. The Old Business section and the New Business were left empty. The Activities Director noted that the Council approved the Administrator's attendance at the February meeting. > The February 2025 RC Meeting Minutes, held on February 28, 2025, at 11:00 AM, revealed discussions about concerns regarding requesting a meeting with the Dietary Manager, including the menu, snacks sitting out and never being passed, and the call light response on the 3rd shift being too long. The old business section was left empty, and the new business is indicated to see the attached form. > March 2025 RC Meeting Minutes were unavailable. When queried, the Administrator stated that the council did not meet due to the COVID-19 outbreak. When asked if the concerns and issues were resolved or followed up? The Administrator stated there was no documentation. > The April 2025 RC Meeting Minutes, dated April 25, 2025, at 11:00 AM, were reviewed. Issues not resolved from the February meeting were noted. Additional concerns include staff being too loud, dissatisfaction with the food quality, and repetitive meals. Various activities are suggested by the residents to be included in the activities calendar. > The May 2025 RC Meeting Minutes, dated May 30, 2025, at 11:00 AM, were reviewed. The minutes revealed that old business, such as staff being too loud and disruptive to residents who are resting during shift changes or at the breakroom, Food Quality, Nursing staff assignments, and group activities, continued to be unresolved. Residents requested outings requiring transport to and from. On June 25, 2025, at 4:15 PM, the Administrator was interviewed. When queried about whether she was aware of the concerns and how to address them, she indicated that she was unaware that she was allowed to attend the council meeting or that she had invited herself to discuss and find appropriate solutions to some of the council's concerns. The Administrator asked the surveyor if that was something new or if the regulation had changed. When asked about the lack of Resident Council Meeting Minutes in March 2025, the Administrator explained that a COVID-19 outbreak had occurred in March, and therefore, they were unable to hold the meeting. When asked if they met one-on-one with the RC President or if the meeting was documented as being postponed. The Administrator stated, No, it was not documented. Was there an attempt to resolve some of the issues brought up by the council? The Administrator did not reply. The Administrator indicated that the Activities Director is new in her position, so there is still much need for improvement.

Based on observation, interview, and record review, the facility failed to ensure residents are treated in a dignified manner by timely call light response by staff and accessible to residents, maintain food palatability for two (2) Residents #58, #21, and a confidential group of residents resulting in residents needs not met, frustration, embarrassment and potential for skin impairment from being left soiled and wet for prolonged periods. Findings include: FACILITY Resident Council FACILITY On June 25, 2025, at 11:00 AM, a Resident Council Meeting was held. According to nine (9) members of a group of confidential residents, on June 25, 2025, at 11:05 AM, the Resident Council meets on the last Friday of every month. They requested to remain anonymous and to keep their identities confidential. One confidential resident stated that the issues brought up by the council do not get resolved and said, It does not go anywhere. It seemed that the concerns were not followed up on. No one gets back at us. The following grievances were brought up by the confidential group of residents during the meeting held on June 25, 2025, from 11:00 AM to 12:05 PM. 1. Prolonged wait times for Call Light response averaging from 30 minutes (at least). 9 out of 9 groups of confidential residents agreed; occasionally, during call light response, staff may turn off the call light and claim they are coming back with the request, but they don't. Some staff members are helpful, while others are not. They talk to other staff very loudly or on their cell phone while residents needing assistance have to wait. Staff ignore the lights because we see them at the nurse's station gathering, talking, or on their phones. 2. Palatability of the Food Menu. Residents complained that the food does not taste good, is repetitive, and lacks variety. One resident stated: They repeat the same menu more often. It seems like every 2 weeks. It used to be every four to six weeks. A lot of cold sandwiches, whatever the alternative, can be the leftovers from previous meals that they did not like to begin with. 3. No HS (Bedtime) Snacks are provided or are not distributed appropriately to residents. Residents revealed that they don't receive them unless they walk or wheel themselves to the nurse's station. 4. Staff often make up reasons, such as equipment being unavailable or not being found, as the reason why they don't return immediately, but the equipment is available. We have identified the location of the equipment, and we know where it was stored. An example was the sit-to-stand lift. Staff would say it took them a long time to find them. Meanwhile, they've been soaking wet from waiting for prolonged periods. The Resident Council (RC) Meeting ended on 06/25/25 at 12:03 PM. The Activities Director and an Assistant Activities staff member were present during the meeting. A review of the RC Meeting Minutes from December to May 2025 was conducted on June 25, 2025, at 10:30 AM. The Resident Council Minutes revealed that the March 2025 meeting minutes were missing. There were no notes and no follow-up on previous issues discussed in the old business notes. There were no noted resolutions to some of the residents' concerns listed in the minutes from December to May. The monthly Resident Council Meeting Minutes revealed: > December 2024 RC Meeting Minutes, dated January 24, 2025, at 11:00 AM, were reviewed and did not discuss any old or new business. Old Business, according to their minutes, refers to the list of follow-up items from last month's minutes, and Issues not resolved are moved to New Business. The Old Business section was left empty, and the New Business section was noted. See the attached form. The council discussed Nursing, Dietary, and activities concerns. The council suggested some ideas for future activities, and events were noted. > January 2025 RC Meeting Minutes, dated January 24, 2025, at 11:00 AM, were reviewed and did not discuss any old or new business, and the sections were left blank. > February 2025 RC Meeting Minutes, held on February 28, 2025, at 11:00 AM, revealed discussions about concerns regarding requesting a meeting with the Dietary Manager, including the menu, snacks sitting out and never being distributed, and the call light response on the 3rd shift being too long. The old business section was left empty. > March 2025- The facility did not have a March 2025 RC Meeting Minutes. When queried, the Administrator stated that the council did not meet due to the COVID-19 outbreak. When asked if the concerns and issues were resolved or followed up? The Administrator revealed there was no documentation. > April 2025 RC Meeting Minutes, dated April 25, 2025, at 11:00 AM, were reviewed. Issues not resolved from the February meeting were noted. Additional concerns include staff being too loud, dissatisfaction with the food quality, and repetitive meals. > May 2025 RC Meeting Minutes, dated May 30, 2025, at 11:00 AM, were reviewed. The minutes revealed that unresolved issues, such as staff being too loud and disruptive to residents who are resting during shift changes or in the break room, as well as concerns about food quality, nursing staffing assignments, and group activities, continued to persist. On June 25, 2025, at 4:15 PM, the Administrator was interviewed. When queried about whether she was aware of the concerns and how to address them, she indicated that she was unaware that she was allowed to attend the council meeting. The Administrator asked the surveyor if the regulation had changed. When asked about the lack of Resident Council Meeting Minutes in March 2025, the Administrator explained that a COVID-19 outbreak had occurred in March, and therefore, they were unable to hold the meeting. When asked if they met with the RC President or if the meeting was documented as being postponed. The Administrator stated, No, it was not documented. Was there an attempt to resolve some of the issues brought up by the council? The Administrator did not reply. The Administrator indicated that the Activities Director is new in her position, so there is still much need for improvement. Resident #58 (R58) Dignity An interview with R58 was conducted on June 25, 2025, at 1:44 PM. R58 complained of delayed staff response to call light, and there was always a long wait for assistance in Activities of Daily Living (ADLs). When asked about how long the wait time usually was? R58 stated, On average, over 30 minutes. At times, more so, due to staff attitude. There are times staff don't come back after shutting the call light off. R58's clinical record was reviewed on 6/25/25 at 2:30 PM and revealed R58 was admitted to the facility on [DATE] with the diagnosis of Chronic Embolism and Thrombosis Generalized Muscle Weakness and spastic Hemiplegia affecting the right dominant side and pharyngoesophageal phase dysphagia in addition to other diagnoses. R58 Brief Interview for Mental Status BIMS Score assessed on 5/15/25 was 15/15. A score of 15 means R58 was cognitively intact. Further review of R58's care plans indicated: R58's Careplan: Dysphagia Obtain and honor food preferences with dietary parameters. Assist with meals as needed, including setting up trays. Observe and report to physician PRN for s/sx of dysphagia: Pocketing, Choking, coughing-Drooling, Holding food in the mouth, Several attempts at swallowing, and pain in swallowing. R58's Careplan: Alteration in Musculoskeletal status r/t history rib fracture, spinal stenosis Attempt to anticipate and meet needs. Call Light is within reach and respond promptly to all request for assistance. Observe and document to identify the risk of falls. Educate resident, family/caregivers on safety measures that needs to be taken in order to reduce risk of fals. R58's Careplan: Risk for fall related injury and falls r/t decreased mobility, spinal stenosis, medication side effects. Put resident's call light within reach and encourage him/her to use it for assistance as needed. Resident #21( R21) Dignity On June 24, 2025 at 2:46 PM, R21 was observed in his room talking alone, saying, it's not right! I can't get anything done here. No one helps me around here. R21 was asked if he tried pressing his call light for help. He replied, I don't know where it is. When the surveyor searched around R21's room, it was noted that R21's call light button was on the floor, between R21's bed and the roommate's bed, and not within R21's reach from his seated position. Meanwhile, the housekeeping staff went in and out of the room but did not notice that the call light was on the floor. CNA K. On 6/24/25 at 3:00 PM, Nurse Aide K entered the room and acknowledged that R21's call light was on the floor and clipped the call light on his pillow.

Based on interviews and record review, the facility failed to ensure that a substantial HS (evening) snack was consistently offered and appropriately distributed to a group of confidential residents that attended the Resident Council Meeting, potentially affecting all residents who receive meals in the facility with 14 or more hours between last evening meal and breakfast the following day, resulting in resident dissatisfaction, frustration and potential for uncontrolled blood sugars, signs and symptoms of hypoglycemia, feeling of hunger, and weight loss. Findings include: FACILITY Resident Council: On June 25, 2025, at 11:00 AM, a Resident Council Meeting was held. According to nine (9) members of a group of confidential residents, on June 25, 2025, at 11:00 AM, the Resident Council meets on the last Friday of every month. They requested to remain anonymous and to keep their identities confidential. There were numerous grievances brought up by the confidential group of residents during the meeting held on 6/25/25, from 11:00 AM to 12:05 PM. One of the issues brought up was pertaining to HS (Bedtime) Snacks were not provided or are not distributed appropriately to residents. Residents at the meeting revealed that they don't receive them unless they walk or wheel themselves to the nurse's station. The Resident Council expressed concern for other residents who were unable to reach the nurse's station or could not speak on their behalf. One resident with a diagnosis of diabetes never received an HS snack and was unaware that one was available. The Resident Council Meeting ended on 06/25/25 at 12:03 PM. The Activities Director and the Assistant Activities staff member were present during the meeting. A review of the RC Minutes from December to May 2025 was conducted on June 25, 2025, at 10:30 AM. It was revealed that the March 2025 RC Meeting Minutes were missing. Upon review, there were no notes and no follow-up on previous issues discussed in the old business notes. There were no noted resolutions to some of the residents' concerns listed in the minutes from December to May. The Resident Council Meeting Minutes held on February 28, 2025, at 11:00 AM, revealed discussions about concerns regarding requesting a meeting with the Dietary Manager, including the menu, snacks sitting out and never being passed, and the call light response on the 3rd shift being too long. There was no follow-up noted the following month in March 2025 because there was no meeting held in March 2025. No notes or documentationfrom the facility that the February 2025 concerns and issues were addressed followed up or any efforts of resolutions were implemented. On June 25, 2025, at 4:15 PM, the Administrator was interviewed. When queried about whether she was aware of the concerns and how to address them, she indicated that she was unaware that she was allowed to attend the council meeting or that she had invited herself to discuss and find appropriate solutions to some of the council's concerns. The Administrator asked the surveyor if that was something new or if the regulation had changed. When asked about the lack of Resident Council Meeting Minutes in March 2025, the Administrator explained that a COVID-19 outbreak had occurred in March, and therefore, they were unable to hold the meeting. When asked if they met one-on-one with the RC President or if the meeting was documented as being postponed. The Administrator stated, No, it was not documented. The Administrator was asked if there was an attempt to resolve some of the issues brought up by the council last February meeting? The Administrator did not reply. The Administrator however, indicated that the Activities Director is new in her position, so there is still much need for improvement.

Based on observation, interview and record review, the facility failed to maintain a clean and sanitary kitchen that included: 1.) outdated food in the refrigerator; 2.) maintaining proper temperature of refrigerators and freezers; 3.) proper labelling of food items with a use by date; 4.) ensure dented cans were removed from supply; 5.) ice scooper not placed appropriately at the ice machine; and 6.) ensure the temperature log for refrigerator and freezer were not documented in advance. This deficient practice has the potential to affect all residents who consume food prepared by the facility of a census of 108. Findings include: Kitchen: On 06/24/25 10:05 AM, during Initial tour with the Dietary Manager (CDM) I. The following observations were validated with the Dietary Manager: 1. The walk-in refrigerator temperature was at 40 degrees farenheit as shown in the digital screen. Inside the refrigerator there was a bin containing pre-made sandwiches labeled with used by date and some did not have a label at all. Seven sandwiches were found with use by date that varied from 6/19/25- 6/23 and were removed from the sandwich bins. The CDM removed and discarded the sandwiches that were over the discard date and the ones with no label. The CDM revealed that the staff should be checking on the dates everyday. 2. In the walk-in freezer an observation was made of several cooked foods that were expired: a. Dish #1: A metal baking tray with frozen dish (unidentified) labeled with a use by date of 5/20/25 noted. The CDM reported he could not tell what dish it was. The unidentified dish #1 was observed in a metal baking pan without a tight seal cover/lid. Although it had a plastic clear cling wrap that was not entirely covering the top of the baking metal dish all the way. b. Dish 2: The second dish observed was also in a metal pan, also an unidentified cooked dish (#2) with a use by date 6/20/25 on the sticker. c. Polish/sausage links were in a plastic container with a used by date of 6/3/25. d. A labeled tray Mac & Cheese was dated 6/19/25 and use by date of 6/22/25. All these frozen food items were gathered by the CDM as they were found and verified by the CDM that he will discard them immediately because they were all out of date. 3. The Walk-in Freezer Temperature screen (outside thermostat) was 10 degrees Farenheit and inside Freezer thermometer was between 6-7 degrees Farenheit. The CDM revealed he was unaware it was not reading below 0 degrees Farenheit. When asked for the June Freezer Temp. Log, the CDM gave the surveyor the log hanging on the posted board in the kitchen. The June Freezer Temperature Log posted on the board was examined and the log was not filled completely. The Facility Name, Uni/ Location and Month/Year were left blank. Findings were: all days in June were noted zero (0) degrees or less EXCEPT: 6//7/25 AM shift 10 degrees 6/8/25 AM shift 6 degrees 6/12/25 AM shift 18 degrees *comment: Tells (a system to inform the maintenance department of an issue). 6/15/25 PM shift 10 degrees * comment: Tells 6/17/25 PM shift 6 degrees The Freezer Log instruction was noted that Freezer should be less or equal to zero (0) degrees Farenheit. Report Abnormal temperatures to the dietary manager or dietitian immediately. 4. Dented cans observed. There were 3 dented cans found: one of corn beef hash 10 ounces can was mixed with the other cans that were not dented. 2 were on the counter and were put away by the CDM immediately to be discarded. 5. Two ( 2) scoopers, one was in a case on top of the ice machine and the second one (blue) was placed on top of the ice machine bare (no cover) set on top of the machine. 6. Temperatures in the temperature log for the Refrigerator and the Freezers wer filled in before the shift started. At 10:15 am, 6/24/25 the evening shift temperature were already filled. The CDM did not have an explanation. 7. A spider on a web was found on the top of the grill during hot tray observation at 11:48 AM on 6/24/25. During tray line, the cook was shocked when she saw the spider and called the CDM attention. All concerns had been discussed with the CDM during the observation on 6/24/25 between 10:00-12:00 noon. Policies were requested and reviewed for Temperature monitoring for both freezer and refrigerator, leftover food, Kitchen sanitation. On 6/24/25 at12:15 PM. The surveyor discussed the kitchen findings to the Administrator regarding all the findings noted above.

Resident #81: Nutrition A record review of the Face sheet and Minimum Data Set/MDS assessment indicated Resident #81 was admitted to the facility on [DATE] with diagnoses: Heart failure, COPD, mild protein-calorie malnutrition, anxiety, and difficulty walking. On 6/24/2025 at 11:20 AM, Resident #81 was observed sitting in his room in bed. When asked about his meals at the facility, he said he was supposed to receive double portions of meat, but did not always receive them. He said he had talked to the Nurse Practitioner/NP and Unit Manager about it, but it didn't change anything. During the interview with Resident #81 on 6/24/2025 at 11:20 AM, he said the previous night, there were no hotdogs or hamburgers as an alternative to the regular menu. He said he was told by the staff they were out of them. The resident said he had to eat very greasy, grilled cheese. He said they gave him 2 grilled cheese, but he could only eat 1, because of the grease. The resident read the menu for 6/24/2025 and stated, Tonight they are having noodle casserole. How am I supposed to get double meat with that? The resident said he did not need double noodles, because he had low albumin levels and needed more protein. A review of the physician orders for Resident #81 identified a diet order dated 6/5/2025: Regular diet, regular texture, Thin Consistency, Large Protein portions, cranberry juice x 2. On further review the order was modified on 6/6/2025 to include Double protein portions then again modified on 6/6/2025 to indicate Large protein portions and on 6/9/2025 cranberry juice x2 was added. A review of the document scanned into the Documents tab in the electronic medical record titled Baseline Care Plan did not mention additional protein in the resident's diet, Dietary-Diet: Type: Regular; Texture: Regular; Consistency: Thin. A review of the Comprehensive Care Plan for Resident #81 identified the following: (Resident #81) has alteration in nutritional and/or hydration status r/t (related to) dx (diagnoses): heart disease, CHF (congestive heart failure), GERD, COPD, blind right eye, date initiated and created 6/6/2025 and revised 6/11/2025. A goal included, (Resident 381) will maintain adequate nutritional status as evidenced by maintaining weight within 2% of 220 (lbs.) and Albumin levels to be WNL (within normal limits), through review date, date created and initiated 6/6/2025 and revised 6/18/2025. Care Plan Interventions included: Provide diet as ordered: Regular diet, regular texture, thin liquids, Large portion protein, dated created and initiated 6/6/2025; Obtain weekly weights x 4 weeks, then monthly, if stable, date created and initiated 6/6/2025; Obtain lab/diagnostic work as ordered. Report abnormal results to MD and follow up as indicated, dated created and initiated 6/6/2025; Offer an alternate when 50% or less of meal is consumed, date initiated and created 6/6/2025; Obtain and honor food preferences within dietary parameters, dated created and initiated 6/6/2025. A review of the weights for Resident #81 indicated 3 weights in the electronic medical record Weights and Vitals tab. The weights were dated 6/5/2025 at 6:30 PM: 218.8 lbs., 6/6/2025 at 9:24 PM: 218.8 lbs., and 6/6/2025 at 11:50 PM: 218.8 lbs. Each weight was exactly the same. There were no additional weights. A review of the lab results for Resident #81 identified 2 results for Albumin levels: 6/9/2025- 3.2 low (normal 3.50-5.70) and 6/18/2025- 2.9 low. The residents Albumin levels were declining while in the facility. A review of a Nutritional Evaluation dated 6/11/2025 for Resident #81 identified the following: Summary/Recommendations: Resident admitted with dx: heart disease, CHF, GERD, COPD, blind right eye. Receives a regular diet with large portions. Eating 75-100% of meals. Skin is intact. Labs reviewed. RD (Registered Dietitian) to follow. The evaluation did not mention extra portions of protein. A review of the progress notes indicated one progress note addressing Resident #81's concern about not receiving double portions of protein: a nurses note, dated 6/25/2025 at 11:13 AM provided, . (the resident's significant other) also expressed concern that the resident was not receiving double portions of protein, as requested. Dietary was notified to ensure the resident is receiving double portions of protein servings per his preference . On 6/25/2025 at 4:27 PM interviewed Registered Dietitian/RD A about Resident #81's diet, she said he was supposed to receive double portions of food, reviewed resident said his albumin was low and he was concerned it would be lower without extra protein. RD said she was not aware of his recent albumin levels, reviewed most recent was 2.9 (6/18/2025) and prior 3.2 (6/9/2025)- both obtained at the facility. She said she would further review his chart. On 6/25/2025 at 5:05 PM, the RD was interviewed about Resident #81's diet. She provided information that protein does not help low Albumin levels, asked if this had been explained to the resident. She said she didn't know. Reviewed the resident was very focused on his albumin levels and asked if his physician could have encouraged him to increase his protein intake. She said she didn't know. Reviewed the progress notes and assessments. There was no dietary note and one Nutritional Eval dated 6/11/2025. The RD provided a copy of the Diet order used for meal preparation in the kitchen; it indicated Give double meat, Large portion entrée. On 6/27/2025 at 8:55 AM, Resident #81 was observed lying in bed, awake. His Breakfast tray was on the bedside table. He said he received eggs, a cinnamon roll, oatmeal, carton of milk, cranberry juice. He said there was no meat. It's the first day they didn't give me any meat for breakfast. He said someone from dietary came to talk to him about his diet orders to explain about the extra protein, but he said he prefers the meat. Asked the resident about his albumin levels and he said his albumin had been low for years and he was told he was supposed to eat more protein. On 6/27/2025 at 9:10 AM, Unit Manager B was interviewed about the resident's diet and his belief that he is to receive double portions of protein vs. the diet that said large portions of protein. Reviewed that the resident is upset and worried about this, as he feels it could prevent him from getting better if he does not receive the extra protein. Unit Manager B said she had spoken to the resident on 6/25/2025, during the survey, about this and documented a note. Reviewed the resident was concerned about his breakfast and wanted to talk to someone about it. A review of the facility policy titled, Resident Rights, dated origination 9/1/2013 and revised 5/14/2024 provided, Policy: The facility protects and promotes the rights of each resident. The resident has a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility . Based on interview and record review the facility failed to ensure that dietary care plans were revised for weight loss and failed to follow dietary orders for two residents (R36, R81) of seven residents reviewed for nutrition, resulting in the potential for continued weight loss. Findings include: Resident #36: R36 is [AGE] years old and admitted to the facility on [DATE] with diagnoses that include major depressive disorder, hyperlipidemia, congestive heart failure and anxiety. On 06/24/25 at 11:07AM, an interview was conducted with R36. R36 was asked if she has lost weight while at the facility. R36 stated she has lost weight and is concerned with as fast as she is losing it. On 06/26/25 at 09:43AM, record review of weights revealed that R36 weighed 224lbs on 12/17/24 and weighed 203.4lbs on 6/11/25. This represents a 10.1% weight loss in six months. On 06/26/25 at 9:45AM, review of dietary progress notes revealed that significant weight loss triggered on 3/19/25. On 06/26/25 at 09:48AM, record review revealed there was no care plan present that addresses actual weight loss. A care plan was present with a focus of, R36 has potential for alterations in nutritional/hydration status, it was last revised on 04/11/2024. On 06/26/25 at 01:43PM, an interview was conducted with Registered Dietitian (RD) A. RD A was asked if there should be a care plan for actual weight loss? RD A stated, yes there should be. Typically, I would add it to my weight loss care plan. I see it says potential for and doesn't say anything about actual weight loss. RD A was asked what interventions were put in place to help slow down the weight loss. RD A stated, I would update preferences when I speak with her and during the at-risk meeting. I don't believe I put anything additional in place for her. I updated her preferences and added her to weekly weights and the weight loss has slowed a bit. Review of the policy titled, Weight Management, revealed: 6. An initial care plan is developed upon admission and a comprehensive care plan should include: -Identified causes of impaired nutritional status -Reflects the resident's goals and choices -Identifies resident-specific interventions and a time frame -Parameters for monitoring 11. A Resident at Risk meeting will be conducted at least monthly by the Interdisciplinary Team and any changes documented in the care plan at the meeting. Residents that will be reviewed during the meeting are as follows (the following criteria is also up to the discretion of the clinician, supported by clinical documentation as to why a resident is not being reviewed in IDT meeting and a care plan with current interventions): -Residents identified with significant weight changes as determined by the CDM, RD, and/or diet tech -Residents with slow steady weight changes as determined by the CDM, RD, and/or diet tech -Residents receiving TPN or a tube feeding that do not have a stable weight -Any other resident identified by the IDT

This Citation pretains to Intake Number MI00153408. Based on observation, interview and record review, the facility failed to obtain dental services timely for a Resident who received a partial denture for the bottom teeth that were ill-fitting, and unable to be used by the resident who had problems with chewing some foods for one resident (#84) of two residents reviewed for dental services. Findings include: Resident #84: On 6/24/25 at 12:27 PM, an interview was conducted with Resident #84 who was in his room, seated in a wheelchair. The Resident was asked about food services and reported he had issues with eating some of the foods that included chicken and hamburgers. The Resident was asked about issues with eating and the resident reported he had dentures that were made for the bottom teeth that when he received them, they did not fit properly. The Resident reported he can not wear the dentures at all because They don't fit. An observation was made of the resident's mouth with two teeth observed and the Resident explained that the denture was to fit around the remaining teeth, but they never fit from the time he first got them. When asked how long ago he had the dentures, the Resident was unsure but thought it was around December or before that and it had been a problem since last year. When asked if they modified his diet to adjust for not having teeth on the bottom, the Resident reported he was on a regular diet, but there were foods he could not eat that was served to him. The Resident reported that staff knew he did not wear the bottom denture. The Resident reported that the dentist was supposed to make adjustments, but they never came back to do that. A review of Resident #84's medical record revealed an admission into the facility on 2/13/23 with diagnoses that included dementia, contracture and hemiplegia and hemiparesis following a stroke affecting left non-dominant side. A review of the Minimum Data Set assessment revealed a Brief Interview of Mental Status score of 13/15 that indicated intact cognition, and the Resident needed setup or clean-up assistance with eating, and substantial/maximal assistance with toileting hygiene, shower/bathe self, upper body dressing, mobility and transfers. A review of Resident #84's dental group visit documents revealed the following: -Exam date 8/5/24, Treatment notes, .does not wear his lower partial denture due to discomfort . lower partial denture is painful to wear, he does not wear it at all -Exam Date 2/18/25, Treatment notes, .He states I can't eat. I've been waiting 20 years for dentures. He told me at the last prophy that his lower partial denture was too painful to wear . patent is requesting dentures. -Exam Date 3/13/25, Reason for visit: RTBS by Hygienist; Initial Exam; lower partial is too tight. Treatment notes, . Requesting PA's (xray)to determine if teeth are restorable. Decay appears to be superficial. Patient's lower partial does not fit and needs relief around both teeth he has not worn it in so long and the teeth have shifted since then. Before adjustment, waiting on xrays, because perhaps the teeth are not restorable and need to come out and be replaced with an LCD. Patient is fine with that treatment plan, should it be needed. S-ray was scheduled for 3/14/25. -Exam Date 4/7/25, Reason for visit: XRAY. Treatment notes, .2 PA's taken of tooth #22 and #27 . On 6/26/25 at 1:14 PM, an observation was made of Resident #84 in his room with the lunch meal tray on the table. The Resident complained that he did not get enough protein that he could eat. The Resident reported he had chicken that he could not chew that was still on his plate. The Resident reported not always having soft foods that he could chew. The Resident reported that he wanted the dentures on the bottom fixed and that it had been an issue for a long time. On 6/26/25 at 2:49 PM, an interview was conducted with the Registered Dietitian (RD) G regarding Resident #84's dental concerns of the lower partial denture not fitting and difficulty eating some foods. When asked if she was aware that the Resident was not wearing his dentures and had difficulty eating, the RD stated, I don't have that he told me that. If he told me he was having issues, then I would have offered a soft diet. The RD reported that she might have been told that he was not wearing them (dentures) in the care conference, but she would have asked him if he wanted a diet change. When asked if she would get the dental visit notes, the RD stated, I don't get them straight to me, but I do have access to them. On 6/26/25 at 3:21 PM, the Registered Dietitian G reported that she had spoken to Resident #84 and stated, He is good with changing his diet to ground meats. On 6/26/25 at 3:23 PM, an interview was conducted with Unit Manager, Nurse H (UM) regarding dental services for Resident #84. A review of the August 2024 dental notes was reviewed of the issues with the dentures not fitting and the Resident not wearing the dentures. When asked what the facility should have done, the UM stated, He should have been added to see the dentist at that point and seen by dietary. The Unit Manager was asked if the XRAYs were completed and she reported they had been done on April 7th. When asked about feedback on the x-rays or a plan set up, the UM stated, just that they were completed. When asked if the dentist has seen the resident since the March dental visit, the UM reviewed Resident #84's medical record and stated, I don't see a consult from him. When asked if the dentist had been in since the x-rays were taken, the UM was unsure. It was reviewed with the UM of the time from August 2024 with the identification of issues with the partial denture for Resident #84, and the dentures had not been adjusted or fixed to meet the Resident's needs in the span of 10 months. On 6/27/25 at 10:47 AM, a list of dental visits made to the facility was received by the facility. The document listed Dentist with the dates of 8/13/24, 9/6/24, 10/30/24, 11/11/24, 12/19/24, 2/4/25, 2/28/25, 3/13/25, 3/17/25, 4/18/25, 5/13/25 and 6/4/25. A review of facility policy titled, Dental Services, effective 11/4/2024, revealed, Policy: The facility will provide or obtain from an outside resource, routine and twenty-four (24) hour emergency dental services to meet the needs of the resident and also when requested by the resident . 7. Within three (3) days of lost or damaged dentures/partials, the social worker/designee will make a referral for dental services. 8. If a consult is not completed within three (3) days following the report of lost/damaged dentures, the CDM/RD/therapy will document in the medical record to ensure that the resident is able to eat and drink in an adequate and safe manner while awaiting dental services, and what circumstances led to the delay. The residents diet will be adjusted as necessary . 10. The social worker/designee will maintain contact with dental services, the resident, and/or the resident representative until the problem is resolved and the dentures are replaced. Documentation must reflect this communication and the verification that the resident is able to eat and drink adequately in the interim . F. The residents' physician, family, and/or resident representative should be informed of the results of the service and any recommendations should be reviewed with the physician. A physician's order is obtained for changes in the plan of care . H. Follow up visits will be scheduled as needed.

Resident #43: Advance Directives A record review was conducted on [DATE] at 10:15 AM. According to the Electronic Medical Record (EMR), R43 was [AGE] years old, admitted to the facility on [DATE], with the primary diagnosis of Cerebral Infarction, dysphagia Type 2 Diabetes Mellitus, Hemiplegia, and Hemiparesis affecting Right dominant side and vascular dementia in addition to another diagnosis. R43 was enrolled in hospice services and has an appointed guardian. R43's Minimum Data Set (MDS) assessed on [DATE] revealed that her Brief Interview for Mental Status score is 00/15. A score of zero generally indicates severe cognitive impairment. MDS section GG indicated that R43 was dependent on all Activities of Daily Living (ADLs), especially personal hygiene tasks and mobility. A care plan related to dementia revealed that the guardian was in place for all medical and treatment decisions, as R43 is no longer able to follow directions and does not communicate with others. A Care Plan for DNR and Hospice services was initiated on [DATE]. On [DATE] at 10:15 AM, during a review of R43 Advanced Directives status, R43 was a Do-Not-Resiscitate status., R43 has a legal guardian-signed DNR (Do Not Resuscitate) Order form that expired on [DATE]. The currently uploaded DNR Order Form, dated [DATE], in R43's medical record, was also reviewed. The DNR Order Form dated [DATE] was found to lacked a physician's signature which was required. The physician's signature line was blank and undated. An interview with the assigned social worker was conducted on [DATE], at 2:00 PM. The social worker agreed that R43's DNR order was not signed by the physician as of [DATE]. After reviewing R43's records, the social worker indicated that the last DNR order form was signed on [DATE], had expired, and according to the facility policy, it must be done annually. The MD did not sign the form; therefore, there was no current DNR order. The social worker explained that it is their responsibility to ensure that all DNR Order forms are accurately filled out and signed. The facility policy dated [DATE] entitled Advanced Directives was reviewed on [DATE] at 2:15 PM. The policy revealed: . B. Obtain Documents. Copies of all advance directives will be obtained from the Resident and/or family and placed in the medical record. If applicable, a DNR Order will be signed and placed in the medical record.D. Code Status Form. If the initial facility cognitive evaluation (Nursing Comprehensive Evaluation and/or BIMS) indicates cognition to be intact, a Code Status Form will be completed by the resident and a DNR order signed by the resident, 2 witnesses and the physician, if a DNR is requested. Additionally, the same facility policy for Advanced Directives specified: Cognitively Impaired Resident Unable to make Medical Decisions with Duly Executed Advance Directives and/or DNR. > Code Status Form completed with the legal decision-maker > Complete a DNR form if necessary. > Place copies of all paperwork in the Resident's chart. > Review the Resident's advance directives quarterly and capacity at least annually and with any significant mental status changes. >If a DNR was requested it is re-signed annually, if still requested. Based on interview and record review, the facility failed to ensure Code Status was assessed, documented and accessible in the medical record for one resident (#209)) and signed by the physician for one resident (#43) of 4 residents reviewed for Advance Directives, resulting in the potential for the resident's lack of informed knowledge related to options for code status and miscommunication of code status which could lead to a lack of appropriate interventions for care. Findings Include: Resident #209: Advance Directives A record review of the Face sheet t indicated Resident #209 was admitted to the facility on [DATE] with diagnoses: History of a stroke, right sided weakness, hypertension, weakness, anxiety, aphasia (difficulty with speech), and dysphagia (difficulty swallowing). The Minimum Data Set assessment was not yet completed. On [DATE] at 12:07 PM, Resident #209 was observed sitting in a chair in her room. She was alert and talkative. A review of Resident #209's electronic medical record revealed the following: Full Code on the Face sheet. Full Code on the Medication Administration Record/MAR and Treatment Administration Recor/TAR for [DATE]. A review of the Care Plans for Resident #209 identified there was no Care Plan for Code Status. It did not indicate the resident wanted to be a Full Code (if the resident were to stop breathing and/or their heart stopped beating, CPR/ Cardiopulmonary resuscitation would be provided). A review of the Documents tab in the electronic medical record/emr did not include a document/assessment for Code Status preferences. On [DATE] at 1:47 PM, Social Worker C was interviewed related to lack of an assessment for Code Status for Resident #209. The Social Worker identified she had placed a Code Status assessment in the Documents tab of the emr that day [DATE] The form said Full Code but was not signed by the resident; the Social Worker had signed it and dated it [DATE]. The Social Worker was asked who was responsible to complete the Code status assessment form and she said either nursing or Social Work. When asked when the Code status assessment should be completed, she stated, Within 5-7 days of admission. It was missed. On [DATE] at 2:30 PM, Unit Manager B was interviewed about the Code status assessment forms, and she said the nurse would look at the admission documents from the hospital and copy the code status into the nurses admission assessment. Then the Social Worker talked to the resident, reviewed the code status with the resident and had them choose their option, Full code or DNR/Do Not Resuscitate and then signed the assessment form. On [DATE] at 12:11 PM, during an interview with the Director of Nursing/DON related to resident Code status, she said nurses would ask the resident on admission. The DON said many of the admissions were in the evening and the resident would often be full code by default until the form was reviewed with them. She said the Social Worker would do that. A review of the facility policy titled, Advance Directives- Michigan origination date [DATE] provided, . On admission, the Facility will determine whether the Resident has executed advance directives and if not, whether the Resident would like to execute advance directives. The Facility will also determine whether there was a DNR Order signed in another setting and whether the Resident would like a DNR Order issued while in the facility. A Code Status Form will be signed to reflect the decision regarding CPR/DNR .

Based on observation, interview and record review, the facility failed to ensure that blood pressure medications were administered as ordered for one resident (#209) of 6 residents reviewed for medications and a wound treatment was administered per physician's recommendation for one resident (#42) with a facility acquired wound of 2 residents reviewed for skin conditions. Findings Include: Resident #42: Pressure Ulcer/Injury A record review of the Face sheet and Minimum Data Set/MDS assessment indicated Resident #42 was admitted to the facility on [DATE] with diagnoses: Osteomyelitis (bone infection) of the right foot and ankle, Pressure ulcer sacrum unstageable, history of lung cancer, COPD, Morbid obesity, weakness, Chronic pancreatitis, and Gout. The MDS assessment dated [DATE] revealed the resident had a Brief Interview for Mental Status/BIMS score of 12/15 indicating mild cognitive loss and the resident needed assistance with care. On 6/24/2025 at 10:25 AM, Resident #42 was observed lying in bed, awake and readily answered questions. He said he had sores on his ankles, heels, legs, and on his sacrum. The resident said he had some when he was admitted to the facility, but the ones on his left foot were new since admission. Resident #42 said he had been receiving IV antibiotics for infected wounds on admission. On 6/25/2025 at 1:55 PM, Unit Manager B was interviewed about Resident #42's wounds. She said the nurses on the floor performed the routine wound care, but Wound Nurse D saw the resident's weekly with the Wound Care Practitioner. On 6/25/2025 at 1:57 PM, Wound Nurse D was interviewed about Resident #42's wounds. She said the resident had several wounds present on admission, including the Sacral wound Stage 3 pressure ulcer and the right foot wound/ right heel Stage 3 pressure ulcer. The Wound Nurse said the resident had a facility acquired wound on the left lateral malleolus/ankle. Th Wound Nurse D said Resident #42 had been going to a Wound Clinic weekly since admission for the right foot and sacral wounds. She said the Wound Clinic would assess, debride (remove dead tissue from) the wounds, and make treatment recommendations for the wounds. On 6/25/2025 at 2:00 PM, wound care for Resident #42 was observed with Wound Nurse D. She said she had recently changed the dressings on the resident's feet and sacrum. His feet were observed in heel boots while the resident was in bed. Both feet were wrapped with kerlix that was dated 6/25/2025. She said the treatment recommended by the Wound clinic was a collagen silver combination, but the facility was not able to consistently complete the dressing as ordered because they had only received a small supply of the collagen/silver dressing. The Wound Nurse said the supplier had said there was a shortage of the product. The Wound Nurse was asked if the Wound Clinic placed a collagen/silver treatment on the resident when they changed his dressing and she said they did. Wound Nurse D said the Wound clinic had said if they were unable to obtain the combination product then a collagen product without silver could be used. Resident #42 said he was worried about this because he was worried his wounds would not heal. On 6/25/2025 at 2:25 PM, Wound Nurse D was further interviewed about the collagen/silver treatment for Resident #42's facility acquired pressure ulcer on the left lateral malleolus. She was asked if the facility had attempted to obtain the treatment from a different supplier and she said she didn't know. A review of the progress notes identified the following: 5/28/2025 at 10:13 AM, a Nurses Note, Spoke with . Wound Clinic and ok to use collagen sheets until collagen and silver are delivered. Orders updated per consultation sheet after getting clarification on specific orders. 6/5/2025, a Wound Care Note, . being seen today for follow-up on wound care assessment and evaluation . Wounds are being managed by Wound Clinic Continue orders as prescribed from wound care clinic . Left lateral malleolus; Treatment: Prism according to wound care clinic . Location: Left Lateral malleolus; Stage: unstageable; Type: pressure . Length: 1.85 cm; Width: 0.94 cm; Drainage Type: sanguineous bloody Drainage; Amount: light; Granulation: Slough, 50 . 6/12/2025, a Wound Care Note, . seen and examined at the bedside for wound care evaluation and treatment. Continue wound care orders as prescribed by Wound Clinic . Location: Left Lateral Malleolus; Stage: unstageable; Type: pressure . Length: 1.92 cm; Width 0.92 cm; Drainage type: serosanguineous; Drainage amount: light . 6/18/2025, a Progress Note, Patient is a [AGE] year old male being seen today for pain . Pt (patient) reports shooting sharp pain in LLE (left lower extremity). He states it started a couple days ago after wound clinic assessed and dressed his wounds to left foot. Pt states pain is intermittent . 6/19/2025, a Wound Care Note, . Location: left Lateral Malleolus . Length: 2.31 cm; Width: 1.40 cm . 6/26/2025, a Wound Care Note, . . Location: left Lateral Malleolus . Length: 1.69 cm; Width: 0.84 cm . A review of the June 2025 Medication Administration Record/MAR and Treatment Administration Record/TAR for Resident #42 identified the following: Left lateral Malleolus: Cleanse the area with wound cleanser and allow to dry. Apply calcium alginate with silver to the wound bed. Cover with gauze and wrap with Kerlix. Daily and PRN (as needed) every day shift for Wound Care, start date 5/29/2025. This was not a collagen treatment. A review of the Wound Clinic consultation reports revealed the following: 5/27/2025 at 9:30 AM, (Resident #42); Note: Findings and Recommended Treatment- . left ankle (malleolus)- Calcium alginate w/silver, gauze and Kling daily . 6/2/2025 at 9:00 AM, (Resident #42); Note: Findings and Recommended Treatment- . Left ankle (malleolus) Prisma (collagen/silver) gauze, ABD and wrap daily . Silver Collagen: Cut to the size of wound and apply directly to wound base . Change dressing every day: dressing supplies for 30 days . 6/16/2025 at 8:30 AM, (Resident #42) Continue with Prisma (collagen/silver) . Wound #2 Left Ankle: Silver Collagen . Change Dressing Every Day; dressing supplies for 30 days . On 6/2/2025 and 6/16/2025, both Wound Consultations indicated the treatment for the resident's left Lateral ankle/malleolus was to be Prisma a collagen/silver combination dressing. Both consultations also said, dressing supplies for 30 days. The facility continued with the orders for Calcium Alginate with silver (a seaweed-based dressing) vs. a Collagen/silver dressing per the Wound Clinics recommendations. It was unclear if the Wound Clinic had provided a 30-day supply of the recommended dressings. A review of the Care Plans for Resident #42 identified the following: (Resident #42) has actual impairment r/t (related to) Right foot osteomyelitis, sacral decub (pressure ulcer), left heel, left lateral malleolus, left lateral lower leg, left second toe, left thigh, right second toe, right lateral fourth toe, right third toe, created and initiated 5/9/2025 and revised 6/25/2025 with Interventions including: Treatment to skin impairment per order, date initiated 5/26/2025. On 6/27/2025 at 12:45 PM, during an interview with the Director of Nursing/DON, she was asked about Resident #42's facility acquired pressure ulcer and the facilities inability to obtain the recommended wound treatment. She said she wasn't sure if the facility had tried different vendors. The DON was asked if the facility contacted other corporate facilities to see if they had the collagen/silver treatment and she said she didn't know. Resident #209 A record review of the Face sheet indicated Resident #209 was admitted to the facility on [DATE] with diagnoses: History of a stroke, right sided weakness, hypertension, weakness, anxiety, aphasia (difficulty with speech), and dysphagia (difficulty swallowing). The Minimum Data Set assessment dated [DATE] revealed the resident needed some assistance with care. On 6/24/2025 at 12:07 PM, Resident #209 was observed sitting in a chair in her room. She was alert and talkative. She said one of her medications ran out. She said she was told by the nurse that they did not have it. Resident #209 said she was receiving the medication 4 times a day and then it stopped, and stated I'm worried about that. It is for my blood pressure. I've been waiting 2 days for that. The resident started to cry, A record review of the June 2025 Medication Administration Record/MAR identified a medication Nifedipine oral Capsule 100 mg; Give 3 capsule by mouth four times a day for HTN (hypertension/high blood pressure). Hold if SBP (systolic blood pressure/top number) less than 110 or HR/heart rate below 60, start date 6/10/2025. The blood pressure medication for Resident #42 was documented by the nurses as not given on 6/10/2025, 6/11/2025, 6/12/2025, 6/13/2025, 6/23/2025, 6/24/2025, 6/25/2025. A record review of the progress notes identified the following: 6/10/2025, a Nurses Note from pharmacy related to the dosing of the Nifedipine. notes, 6/10/2025 at 6:32 PM, an eMAR Note, Waiting on pharmacy not in backup notified NP (Nurse Practitioner) and family. 6/10/2025 at 9:43 PM, an eMAR Note, Nifedipine . medication is not available, and not in back up. 6/11/2025, an Advance Care Planning Note, . Essential (Primary) Hypertension: Continue BP medications; monitor blood pressure . 6/11/2025, a Progress Note, General: Patient is a [AGE] year old female with past medical history of Intracranial hemorrhage (bleeding) CVA (stroke) with hemiplegia and hemiparesis right side, HTN (hypertension) . Patient was recently hospitalized and treated for intracranial hemorrhage . Patient was transferred to (the facility) for continuation of care and rehab services . Essential Hypertension: Monitor BP. Continue . Nifedipine . 6/11/2025, Encounter note, Telehealth . Situation: Nifedipine Oral Capsule 10 mg (Nifedipine) not available. BP 155/91, HR 64. Treatment: hold until pharmacy delivers. Clonidine 0.1 mg PO (by mouth) x1 dose., by Nurse Practitioner/NP E The resident had nine additional notes from 6/11/2025-6/25/2025 related to Nifedipine being unavailable and waiting for pharmacy to deliver it. On 6/25/2025 at 10:03 AM, a Nurses Note, Elevated BP- pharmacy did not send nifedipine (10 mg). The pharmacy stated it has already been requested to be sent to the facility stat. On 6/25/2025 at 3:40 PM Nurse F and Unit Manager B were interviewed about the Nifedipine for Resident #209. Unit Manager B stated, The pharmacy said it would be here tonight about 9pm. Nurse F said she had made several notes and contacted the pharmacy. Unit Manager B said the medication had to be ordered by the pharmacy because the capsule was not in a common dose that the pharmacy had on stock. Reviewed that this had been ongoing since admission and the resident was upset about it. Nurse F said if the medication did not arrive that night, it would arrive early in the morning. A record review of the Care Plans for Resident #209 identified the following: (Resident #209) is at risk for complications r/t (related to) recent intracranial hemorrhage, date created and initiated 6/18/2025 with Interventions including: Observe/document/report to nurse/physician s/sx (signs and symptoms) of CVA (stroke) such as: . elevated blood pressure . (Resident #209) is at risk for cardiac complications r/t HTN (high blood pressure) . date created and initiated 6/10/2025 and revised 6/11/2025 with Interventions including: Administer medications per order . date created and initiated 6/10/2025. On 6/27/2025 at 9:10 AM, Unit Manager B was interviewed about Resident #209's blood pressure medication Nifedipine; she said the resident's medication was delivered to the facility the night of 6/25/2025. She said the resident received the first dose on 6/26/2025 in the morning; reviewed the June 2025 MAR with the Unit Manager B. On 6/27/2025 at 9:15 AM, Resident #209 was interviewed. She said she received her medication. When asked if she knew why she did not receive it, she said no one told her, just that it was ordered. On 6/27/2025 at 12:35 PM, during an interview with the Director of Nursing, she was asked about Resident #209 not receiving her blood pressure medication Nifedipine. She said she had just become aware of it and the resident should have received her medication.

This Citation pertains to Intake Number MI00150954. Based on interview and record review the facility failed to timely obtain new prescription to reorder pain medication for one resident (#801) of two residents reviewed for pain management and pharmacy procedures, resulting in, Resident #801 going without her patch for three days and increased pain. Findings include: Resident #801: On 3/18/2025 at approximately 11:15 AM, a review was conducted of Resident #801's clinical record and it indicated she admitted to the facility on [DATE] with diagnoses that included, Acute Respiratory Failure, Depression, Hypertension and Amyloidosis. Resident #801 is cognitively intact and able to make her needs known to staff. On 3/18/2025 at 12:50 PM, Resident #801 reported her Fentanyl patch is supposed to be changed every three days but at the beginning of March she went without it for a few days, and no one could explain to her why. The resident shared the patch had fallen off and typically they would apply a new patch and change the application/removal schedule. During this time period her pain was increased as she did not have the patch, and she expressed frustration with the facility given the lack of communication regarding this matter. On 3/18/2025 at 4:05 PM, the DON (Director of Nursing) reported Resident #801's pain patch was applied on 3/2/2025 and was due to be replaced on 3/5/2025. On 3/4/2025 the patch had fallen off and there was not another patch to put on her as it was on order. On 3/7/25 it was found there were no more refills on Resident #801's patches and a new prescription was needed. The nurse reached out to on call who completed a onetime order, and the patch was pulled from back up and applied on 3/7/2025. The DON was unable to ascertain why a new script was not requested and refilled prior to 3/7/2025. Review was conducted of the Controlled Substance Proof of Use Log for Resident #801. It indicated on 2/10/2025 the facility received five Fentanyl 12 MCG (microgram)/HR (hour) patches for the resident. The first patch was applied on 2/18/2025 and the last patch (from the batch) applied on 3/2/2025. After application of the patch on 3/2/2025, Resident #801 would have been due for a new one on 3/5/2025. Physician Orders: Fentanyl Transdermal Patch 72 hours 12 MCG/HR - apply 1 patch every 3 days for pain and remove per schedule. March 2025 MAR (Medication Administration Record) -Patch applied on 3/2/2025 at 9:00 AM and 3/7/2025 at 7:00 PM. Resident #801's Fentanyl patch fell off on 3/4/2025 and was not reapplied for three days. Progress Notes: 3/4/2025 at 00:00: nurse reports residents Fentanyl patch came off and patient requested could tomorrows' dose be applied tonight. Nurse reports patient has PRN (as needed) pain medication to get through the night and new Fentanyl patch can be applied at 9 AM . 3/4/2025 at 23:02: Resident reported Fentanyl patch came off and was not able to locate it and resident requested a new one. Notified on call .who advised waiting until next dose in the morning. Resident informed no acute distress noted . 3/5/2025 at 09:49: unable to remove, patch fell off on 3/4/2025, noted by prior nurse. 3/7/2025 at 18:55: Resident daughter spoke with ADON regarding Fentanyl patch. Stating mother needs this and is concerned that she might go into withdraw. ADON spoke with writer via telephone asking for writer to contact on call for a new RX so resident will have patch over the weekend. Writer contacted oncall .who agreed to send RX over. Writer received auth to pull for patch and administered. 3/8/2025 at 18:55: Patch reapplied 3/7/25 at 1900. New order from NP. There was no other documentation located regarding contact with the pharmacy or provider regarding Resident #801's Fentanyl and the inherent delay. On 3/7/2025 at 6:35 PM, Nurse A was provided authorization from the pharmacy to pull the Fentanyl patch out of backup for Resident #801. The patch was pulled at 6:47 PM. Review was completed of the facility medications that are accessible in the back up box. The list had the following available: -Fentanyl 12 MCG/HR PAT (patch)-1 in back up. On 3/19/2025 at the DON explained, the pharmacy process is for them to either send a re-order form to the facility or contact the physician directly for a new script. The nurse re-ordered the Fentanyl patches on 3/5/25 through pharmacy, but there was not a valid script to process the refill. The pharmacy attempted to contact the provider directly multiple times for the script and was unsuccessful and a from was not sent to the facility.

This Citation pertains to Intake Number MI00147318. Based on observation, interview and record review the facility failed to assess and monitor intravenous medication therapy per professional healthcare standards and a provider's order for two residents (Resident #702 and Resident # 703) of two residents reviewed for intravenous antibiotic therapy, resulting in Resident #703 being administered two doses of Vancomycin after elevated levels were received and a lack of monitoring and dosing of Resident #702's Vancomycin. Findings Include: Resident #702: On 10/15/2024 at approximately 4:00 PM, a review was conducted of Resident #702's medical records and it revealed the resident admitted to the facility on [DATE] with diagnoses that included, Necrotizing Fasciitis, Hypertension, Peripheral Vascular Disease, Stage 3 Kidney Disease and Supraventricular Tachycardia. Resident #702 was alert and able to make his needs known to staff. Further review was completed and yielded the following results: Physician Orders: Vancomycin HCI Intravenous Solution 1500 MG (milligram)/15ML (milliliter)- use 1500 mg intravenously in the morning for necrotizing fasciitis & osteomyelitis BLE (bilateral lower extremities) for 32 days until finished. Initiated on 9/12/2024 and first dose administered on 9/13/2204. Pharmacy to dose Vancomycin - initiated on 9/12/2024 Practitioner Notes: 9/16/2024 at 00:00: .nursing to notify pharmacy for dosing purposes. 9/23/2024 at 00:00: .Continue with IV Ertapenem and IV Vancomycin- pharmacy to dose Vancomycin (nursing to notify pharmacy of Vancomycin level 14.7) . 9/26/2024 at 00:00: .Continue with IV Ertapenem and IV Vancomycin - pharmacy to dose Vancomycin (Nursing to notify pharmacy of Vancomycin level 14.7) . 10/9/2024 at 00:00: .He is being seen today to follow-up on recent lab results from 10/4 . Vancomycin level continues to be subtherapeutic at 13.7 (down from 15) without change in dosing. Order in PCC for pharmacy to dose. Provider called Omnicare infectious disease pharmacy and spoke with pharmacist. No order for pharmacy to dose has been received via fax; order faxed again today . Progress Notes: 9/13/2024 at 03:46: Resident was bring in by EMS (Emergency Medical Service) resident alert x 4, able to make needs known, resident has life vest .Numerous ulcer. The left heel is completely open all the way to the bone it had to be packed due to debridement after surgery to remove infection it's the entire left foot heel. The right heel is closed but also compromised, discoloration, Wound team is needed for numerous necrotizing fasciitis. Resident is on IV (intravenous) vanco, Invanz Also there is an moderate size open area left buttocks, open area. The PICC line in right arm upper . Vancomycin Laboratory Results: Normal Vancomycin levels per the facility's laboratory is 20.00-40.00. 9/13/2024: 17.1- indicated on report as low 9/20/2024: 14.7- indicated on report as low 9/27/2024: 15.5- indicated on report as low 10/4/2024: 13.7- indicated on report as low It can be noted there was no documentation located that the facility contacted the pharmacy when Resident #702's Vancomycin levels resulted, until the practitioner followed up on 10/9/2024. On 10/26/2024 at 10:10 AM, discussion was held with Pharmacist F from the IV Department at the facility's contracted pharmacy. Pharmacist F explained when facility residents are prescribed Vancomycin, they have it set up in their system to call the facility to check on laboratory results if they have not been received. Their systems for laboratory results are not interfaced with the facility and they rely on the facility to provide the results. Pharmacist F was queried regarding Resident #702 Vancomycin order and dosing. It was explained they had communication with the facility regarding it, but they did not receive the order to dose his Vancomycin until 10/9/2024. When asked what prompted the change Pharmacist F stated its possible when his laboratory values were 13.7 the facility practitioners thought it was low and wanted pharmacy to dose going forward. It was explained to Pharmacist F that in the facility documentation prior to 10/9/2024 it stated pharmacy was dosing. Pharmacist F stated they did not have the orders to dose Resident #702's Vancomycin so until their orders were received the facility practitioners were responsible dosing. On 10/16/2024 at 3:10, the DON stated they were not aware the pharmacy was not dosing Resident #703's Vancomycin as there was an order that was in his medical chart. The facility was under the impression that the pharmacy was dosing Resident #702's Vancomycin, while the pharmacy asserted, they never received an order to dose until approximately 4 weeks after initiation of the antibiotic. Resident #703: On 10/15/2024 at approximately 3:30 PM, a review was completed of Resident #703's medical records and it indicated the resident was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included Acute Kidney Failure, Cerebral Infarction, Heart Failure, Diverticloisis, Vascular Dementia and Hypertension. Further review of her chart yielded the following: Physician's Orders: Vancomycin 1000 MG/10 ML- use 1 gram intravenously two times a day for osteomyelitis R (right) heel. Cefepime HCI Intravenous Solution- use 2 grams intravenously every 8 hours for Osteomyelitis. Laboratory Values: Reference range values for Vancomycin, creatinine and BUN (blood urea nitrogen) are as follows: BUN Reference: 7.00-25.00 Creatinine Reference: 0.60-1.30 Vancomycin Reference: 20.00-40.00 7/10/2024: BUN: 22 Vancomycin: 19 Creatinine: 0.78 no changes made 7/15/2024: BUN: 22 Creatinine: 0.71 Vancomycin: 30.3 7/23/2024: BUN :26- indicated at high Creatinine: 0.75 Vancomycin: 34.1 No facility documentation located that levels were communicated to the pharmacy 7/24/2024: BUN: 27- indicated at high Creatinine: 0.76 Vancomycin: 33.7 No facility documentation that levels were communicated to the pharmacy 7/29/2024: Bun: 39- indicated as high Creatinine: 1.18 Vancomycin: 44.4 -indicated as high The laboratory results were reported to the facility on [DATE] at 13:49. Facility staff contacted the pharmacy 24 hours labs related to results. 7/31/2024: BUN: 54- indicated as high Creatinine: 1.86- indicated as high Vancomycin: 64.2- indicated as high No facility documentation that levels were communicated to the pharmacy July 2024 MAR (Medication Administration Record): Review was conducted of the MAR, and it showed Resident #703 was administered Vancomycin the evening of 7/29/24 and morning of 7/30/24, without prior communication to their pharmacy regarding the elevated Vancomycin levels. Contact was made with the pharmacy on 7/30/2924 at 14:24 (24 hours after results were received) after the levels resulted. Once pharmacy was alerted to her levels, an order was received to hold further administration of the antibiotic. On 10/15/2024 at 4:40 PM, an interview was conducted with the DON (Director of Nursing) regarding Resident #703. She reported when labs result, they show on the home board and if they are critical the laboratory would call them. Pharmacy doses their resident's Vancomycin and once the results were received the staff would fax them to pharmacy. She stated for them to receive Vancomycin they have to fax the physical copy of the order to the pharmacy. On 10/15/2024 at 5:08 PM, an interview was conducted with Nurse G regarding procedures when residents are prescribed Vancomycin. Nurse G explained they do not a plethora of residents that are prescribed Vancomycin. If the lab is critical, they will receive a phone call from the laboratory, otherwise they have to check the chart for the results. Upon receiving the results, they would contact the pharmacy with the results. Nurse G reviewed Resident #703's Vancomycin laboratory results from 7/29/2024 and her documentation of administrating the Vancomycin on the morning of 7/30/2024. Nurse G was asked if she called pharmacy with the laboratory results prior to administration of the Vancomycin or if it was received in report that pharmacy had been contacted. The nurse stated she did not receive any information in report that she can recall and was not sure why she did not contact pharmacy with the results prior to administration. On 10/16/2024 at 10:50 AM, an interview was conducted with the DON, she stated the nursing staff receive education regarding Vancomycin upon hire and additional education is provided if needed. The DON was asked when their last Vancomycin training was and it was reported she did not believe their had been one. She stated they complete spot education for specialty concerns. The DON further shared their phlebotomist is responsible for multiple buildings but is there daily for lab draws. Upon completing the draws a courier will pick up the specimens and deliver them to the laboratory. The DON further expressed they do not believe the times listed on the laboratory results are accurate, and they are working to see where the problem is. A discussion was held that the facility was unaware of the timing issue prior to survey and those times are documented in his chart. On 10/16/2024 at approximately 11:20 AM, Resident #703 was observed sleeping in her room, she was well groomed and did not appear to be in any distress. On 10/16/2024 at 2:20 PM, ADON (Assistant Director of Nursing)/Infection Preventionist explained when a resident is admitted on Vancomycin the admitting nurse will input the initial orders and she will review them for accuracy and add any other additional orders required. For the facility to receive the Vancomycin they have to print the order and then fax it to the pharmacy. The pharmacy to dose order has to be faxed as well. Upon the Vancomycin labs resulting the nurse could either fax to the pharmacy or call to alert them to the values and receive dosing orders, if applicable. For Resident #702, the ADON stated she inputted the order for pharmacy to dose but could not recall if she was the one that faxed it to pharmacy or if it handed to the nurse to do so. It is not standard practice to upload fax confirmations pages or complete a progress note once these tasks are completed. The ADON stated at their facility the pharmacy always doses their Vancomycin and was uncertain how this incident occurred. On 10/16/2024 at 10:10 AM, Pharmacist F was queried regarding Resident #703 Vancomycin dosing. They reported on 7/30/24 is when the facility reported her 44.4 levels, and this was when the antibiotic was placed on hold due to her elevated levels. The Administrator and DON stated there was no facility policy for Intravenous medications or a policy/procedure when residents are prescribed Vancomycin.

This Citation pertains to Intake Numbers MI00145623 and MI00145776. Based on observation, interview and record review, the facility failed to ensure that wounds were assessed, monitored, and appropriate interventions were in place for one resident (Resident #3) of 3 residents reviewed for wounds, resulting in Resident #3 developing a wound on the left foot great toe, left foot third toe and right foot third toe. Findings Include: Resident #3: On 9/16/2024 at 4:00 PM, Resident #3 was observed lying in bed in her room. She was awake, alert and very talkative. The resident was observed to have thick socks on. A review of the Face sheet and Electronic Medical Record (EMR) indicated that Resident #3 was admitted to the facility with the following diagnoses: Chronic kidney disease Stage 4, anemia, history of falls, fracture left ankle, diabetes, depression, history of seizures, anxiety, hypothyroidism, Dementia, and hypertension. A record review of an Orthopedic consult for Resident #3, dated 8/29/2024 at 10:00 AM, identified the following: Continue wound care for pressure sore on Left 1st digit . A review of the physician orders for Resident #3 indicated there was no mention of a wound on the resident's left foot 1st digit. A review of Resident #3's Medication Administration Record/Treatment Administration Record for September 2024, revealed there was no mention of a wound on the resident's left great toe. On 6/18/2024 at 9:45 AM, during an interview with Wound Nurse B, Resident #3 was observed in her room lying in bed awake. Wound Nurse B removed the resident's socks and showed a blackened necrotic (dead tissue) wound approximately 1.5 cm x 1.5 cm underneath and beside the resident's left great toe. The Wound Nurse said the resident was diabetic and it appeared to be a diabetic ulcer. There was also a small, red, abraded area on top of the resident's left foot 3rd toe. The toe was raised at the joint directly below the wound. The Wound Nurse said it was blanchable. On the resident's right foot 3rd toe, was another small area, dark with a scab. The 3rd toe was also raised at the joint. The resident commented that everyone wanted to look at her toes today. On 6/18/2024 at 10:05 AM, after observing Resident #3's feet and toes, with Wound Nurse B, the nurse was asked why there was no assessment of the wounds or interventions for prevention of the wounds occurring or worsening, as the Ortho provider mentioned the wound on 8/29/2024 during the resident's appointment. She said the consult was missed, and an assessment was started 9/16/2024. The Wound Nurse was asked if the resident's skin was routinely assessed and she said the nurses performed a weekly skin assessment but did not identify the wounds. On 9/18/2024 at 11:00 AM, a review of a Skin & Wound Evaluation, dated In progress: 9/16/2024 at 5:14 PM, ( it was incomplete), identified a Diabetic wound on Resident #3's Left Plantar- 1st Digit and was In-House Acquired. The wound was dated as occurring on 9/16/2024, but the Orthopedic provider had already identified it on 8/29/2024. The area was measured as 1.3 cm length x 1.5 cm width and depth of <0.1 cm. The rest of the Skin and Wound Evaluation, was blank. There was no description of the blackened area or surrounding area of the toe. There was no mention of the other wounds on the residents left foot 3rd toe and right foot 3rd toe. A review of the Care Plans for Resident #3 identified the following: (Resident #3) is at risk for fluctuation in blood sugar levels (related to) r/t: diabetes . date initiated and revised 10/13/2019 with Interventions: Check body for breaks in skin during care/showers and treat promptly as ordered by physician. Inspect feet during care/showers for open areas, sores, pressure areas, blister, edema, or redness; Provide proper foot care as needed. Observe for changes in circulation. Observe for changes in skin integrity to the feet. Document findings and report any abnormal findings to the physician . date initiated 8/9/2023. (Resident #3) is at risk for impaired skin integrity/pressure injury . created on 10/11/2029 and revised and initiated 2/19/2022 with Interventions: Conduct weekly head to toe skin assessments, document and report abnormal finding to the physician, date initiated 10/11/2019. On 9/18/2024 at 11:15 AM, during an interview with the Director of Nursing/DON the blackened area on Resident #3's left great toe, and the scabbed areas on the resident's left and right 3rd toes was discussed. Reviewed the Orthopedic consultant physician identified the left great toe wound, but it was not mentioned in Resident #3's medical record. The DON said the wound should have been identified and documented. She said the wounds on the left and right foot 3rd toes would be further assessed, but also had not been identified. A review of the facility policy titled, Skin Management, origination date 5/1/2010 and revised 8/14/2014 provided, . Residents with wounds and/or pressure injury and those at risk for skin compromise are identified, evaluated and provided appropriate treatment to promote prevention and healing. Ongoing monitoring and evaluation are provided to ensure optimal guest/resident outcomes . appropriate preventative measures will be implemented on residents identified at risk and the interventions are documented on the care plan . skin impairment location, measurements and characteristics documented . The licensed nurse will initiate documentation . document weekly until the area is resolved . A review of the facility policy/protocol titled Change in status, identifying and communicating, long-term care, revised: August 19, 2024 provided the following, . Communicate the change in the resident's status to the appropriate practitioner .

This Citation pertains to Intake Number MI00145623. Based on observation, interview and record review, the facility failed to provide necessary management of an indwelling urinary catheter for one resident (Resident #4) of 3 residents reviewed for urinary catheters, resulting in staff being unaware if Resident #4 had a urinary catheter. Findings Include: Resident #4: A record review of the Face sheet and Minimum Data Set (MDS) assessment, indicated Resident #4 was admitted to the facility on [DATE] and readmitted [DATE] with diagnoses: Heart disease, Bipolar disorder, diabetes, left leg below the knee amputation, peripheral vascular disease, COPD, asthma, history of seizures, hypertension, neuromuscular dysfunction of the bladder, chronic pain, depression and anxiety. The MDS assessment dated [DATE] indicated the resident had full cognitive abilities and needed some assistance with care. The MDS section H identified the resident had an indwelling urinary catheter. A review of the physician orders for Resident #4 revealed the following: Pt. (patient) has a 14 fr. Catheter and unit to be changed every 30 day or as needed, date initiated 3/20/2024. Change foley catheter as needed, date initiated 5/25/2024. D/C (discontinue) Indwelling foley, order date 8/27/2024. A review of the August 2024 Medication Administration Record and Treatment Administration Record- MAR/TAR revealed the following: Foley catheter care q (every) shift, start date 3/22/2024 and D/C date 8/29/2024. The nurses documented that Foley (urinary indwelling catheter) care was completed each shift (3 times a day) and was stopped on 8/29/2024. A review of the September 2024 MAR/TAR identified the following: Change foley catheter as needed, start date 5/25/2024. Pt. has a 14 fr. Catheter and unit to be changed every 30 days or as needed for change if patient is not voiding, start date 3/20/2024. The orders for an indwelling urinary catheter had not been discontinued after the catheter was removed on 8/27/2024. A review of the progress notes provided the following: 8/27/2024 at 10:58 AM, a nurses note Resident indwelling foley removed per order . 8/29/2024 a provider note, . Pt had catheter discontinued a couple days ago . 9/12/2024 an encounter note, . recently was able to have indwelling catheter removed. Pt is noted with some episodes of incontinence . A review of the Tasks documentation by the nurse aides for 8/19/2024 to 9/17/2024 identified the following: Indwelling catheter: the options were Yes or No. After the indwelling catheter was removed on 8/27/2024 there were 12 entries for Yes the resident had an indwelling catheter. Was indwelling catheter care performed per the resident's plan of care? After the catheter was removed on 8/27/2024, the staff documented 34 times that they had performed catheter care. The orders for a urinary catheter were still in the resident's orders and the staff continued to document the resident had the urinary catheter after it was removed. A review of the Care Plans for Resident #4 revealed: (Resident #3) is at risk for urinary tract infection and catheter-related trauma: has Indwelling Catheter (related to) neurogenic bladder, 14 Fr., date initiated 2/20/2023 and revised 6/14/2023. There was no mention the indwelling urinary catheter had been removed on 8/27/2024. On 9/17/2024 at 1:05 PM, Infection Preventionist/IP A was interviewed about Resident #4 having a urinary catheter; she said the resident no longer had a catheter. Reviewed with the Nurse that the orders still said she did and the staff were documenting that she had a urinary catheter. Entered the resident's room with IP A and viewed Resident #4 did not have a urinary catheter. On 9/17/2024 at 4:00 PM, reviewed with the Director of Nursing/DON that Resident #4 no longer had an indwelling urinary catheter, but there were still orders for the catheter and the staff continued to document there was a urinary catheter. The DON said the resident did not have a urinary catheter and she was looking into why the staff were documenting that she did. A review of the facility policy titled, Indwelling urinary catheter (Foley) care and management, dated 12/19/2023 revealed there was no mention of discontinuation/removal of the urinary catheter.

Based on observation, interview, and record review, the facility failed to maintain a sanitary kitchen, and maintain equipment and plumbing in good repair, resulting in an increased risk of food borne illness, affecting all residents that consume food from the kitchen. Findings include: On 5/29/24 at 1:43 PM, two wire racks, located in the walk-in cooler, were observed to have white mold-like accumulation. According to the 2017 FDA Food Code Section 4-601.11 Equipment, Food-Contact Surfaces, Nonfood Contact Surfaces, and Utensils. (A) EQUIPMENT FOOD-CONTACT SURFACES and UTENSILS shall be clean to sight and touch. Pf (B) The FOOD-CONTACT SURFACES of cooking EQUIPMENT and pans shall be kept free of encrusted grease deposits and other soil accumulations. (C) NonFOOD-CONTACT SURFACES of EQUIPMENT shall be kept free of an accumulation of dust, dirt, FOOD residue, and other debris. On 5/29/24 at 1:54 PM, the steamer, located on the cookline, was observed to be leaking water out of the front door on to multiple clean pitchers stored below. At this time, Chef EE confirmed the finding and stored the pitchers in another location. Chef EE continued to say they were unaware the steamer shouldn't be leaking water from the door. According to the 2017 FDA Food Code Section 4-501.11 Good Repair and Proper Adjustment. (A) EQUIPMENT shall be maintained in a state of repair and condition that meets the requirements specified under Parts 4-1 and 4-2. (B) EQUIPMENT components such as doors, seals, hinges, fasteners, and kick plates shall be kept intact, tight, and adjusted in accordance with manufacturer's specifications. (C) Cutting or piercing parts of can openers shall be kept sharp to minimize the creation of metal fragments that can contaminate FOOD when the container is opened. On 5/29/24 at 2:07 PM, the atmospheric vacuum breaker (AVB) (a backflow device commonly used in plumbing arrangements to prevent backflow/backsiphonage of contaminated water into the potable water supply), located at the dish machine, was observed to be covered with a cloth. Chef EE was queried on the cloth and was unaware of the reason for the cloth placement, then proceeded to remove it. The AVB was then observed to leak water out of the air inlet port when the dish machine was running a cycle. The AVB was observed to have scale build-up from hard water. According to the 2017 FDA Food Code Section 5-202.14 Backflow Prevention Device, Design Standard. A backflow or backsiphonage prevention device installed on a water supply system shall meet American Society of Sanitary Engineering (A.S.S.E.) standards for construction, installation, maintenance, inspection, and testing for that specific application and type of device. On 5/29/24 at 2:12 PM, an opened jug of soy sauce was observed on the shelf in the dry storage room. The manufacturer's label on the soy sauce jug states, Refrigerate after opening. Chef EE stated that they were unaware the soy sauce required refrigeration after opening. According to the 2017 FDA Food Code Section 3-501.16 Time/Temperature Control for Safety Food, Hot and Cold Holding. (A) Except during preparation, cooking, or cooling, or when time is used as the public health control as specified under S3-501.19, and except as specified under (B) and in (C ) of this section, TIME/TEMPERATURE CONTROL FOR SAFETY FOOD shall be maintained: (1) At 57oC (135oF) or above, except that roasts cooked to a temperature and for a time specified in 3-401.11(B) or reheated as specified in 3-403.11(E) may be held at a temperature of 54oC (130oF) or above; P or (2) At 5 C (41 F) or less. P . On 5/29/24 at 2:15 PM, the walk-in freezer door gasket was observed to be damaged with excessive ice build-up around the door opening. At this time, Chef EE stated that staff attempt to remove the ice by tapping it off the door, in turn, damaging the gasket. On 5/29/24 at 2:17 PM, a working spray bottle, located near the entrance of the kitchen, was observed to not be labeled to identify the contents. At this time, Chef EE instructed staff to label the [NAME] bottle. According to the 2017 FDA Food Code Section 7-102.11 Common Name. Working containers used for storing POISONOUS OR TOXIC MATERIALS such as cleaners and SANITIZERS taken from bulk supplies shall be clearly and individually identified with the common name of the material. Pf

Based on observation, interview, and record review the facility failed to ensure that accurate advance directive information was in place for two residents (Resident #88, Resident #182) of two residents reviewed for advance directives (legal documents that allow a person to identify decisions about end-of-life care ahead of time) from a total sample of 24 residents, resulting in potential for a resident's preferences for medical care not to be followed by the facility. Findings Include: Resident #182 (R182): Review of the medical record revealed R182 was admitted to the facility on [DATE] with diagnoses that included adult failure to thrive, repeated falls, dementia, pain in right leg, peripheral vascular disease (PVD), heart failure, hyperlipidemia (high fat content in blood), hypothyroidism (low activity of thyroid gland), muscle weakness, and anemia (low red blood cells). The most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of [DATE], revealed R182 had a Brief Interview for Mental Status (BIMS) of 00 (severe cognitive impairment) out of 15. During observation and interview on [DATE] at 10: 20 a.m. R182 was observed lying down in bed. Resident appeared to be well groomed. R182 did not answer questions during attempted interview. In an interview on [DATE] at 10:25 a.m. R182's family member J explained that her father was recently admitted to the facility and that she was his legal representative. During record review it was revealed that R182 had a physician order, dated [DATE], No CPR/DNR (no cardiopulmonary resuscitation/Do not resuscitate). Review of the R182's medical record demonstrated a document entitled Designation of Patient Advocate Form (Durable Power of Attorney for Health Care) which demonstrated R182's family member J was appointed his Patient Advocate and was signed [DATE]. R182's medical record did not demonstrate that he had been declared incompetent to make medical decisions. In an interview on [DATE] at 10:21 a.m. Social Worker (SW) Supervisor E explained that it was necessary for a Resident to be declared incompetent before a Durable Power of Attorney (DPOA) could be activated. She explained that incompetence had to be determined by two physicians or one physician and a psychologist. She explained that the facility typically uses the attending physician for one declaration of incompetence and a psychologist for the other declaration. SW Supervisor E also explained that a Residents Code Status (wishes for life saving measures) would then be determined once the DPOA was activated. She explained that the residents Code Status would then be entered into the medical record. SW Supervisor E confirmed that R182 had physicians order, dated [DATE], No CPR/DNR (no cardiopulmonary resuscitation/Do not resuscitate). She also confirmed that R182's medical record did not have any declaration of incompetence in the medical record. SW Supervisor E explained that R182's order for Code Status of Do not resuscitate was not correct because incompetence had not been determined and that R182 should have an order for Full Code (Cardiopulmonary resuscitation required). SW Supervisor E could not explain why an order No CPR/DNR (no cardiopulmonary resuscitation/Do not resuscitate) had been entered into R182's medical record without the proper declaration of incompetence. In an interview on [DATE] at 10:50 Social Worker (SW) K explained that prior to this interview she had already reviewed R182's Advance Directives, because she was told by her supervisor that the appropriate documentation was not present to determine his competency. She explained that she had been the person responsible to determine that the appropriate documentation should have been present and requested the appropriate orders for No CPR/DNR (no cardiopulmonary resuscitation/Do not resuscitate). SW K could not explain why she had not followed the appropriate process. Review of facility policy entitled Advance Directives-Michigan, with an effective date of [DATE], demonstrated Procedures Generally C-Determination Resident's Level of Cognition. All individuals are presumed to have the level of cognition to make informed health care decisions unless the Resident has been adjudicated as incompetent in a court of law or unless a determination is made by two physicians or a physician and licensed psychologist, that the individual is unable to participate in medical treatment decision. Further, if the initial facility cognitive evaluation (Nursing Comprehensive Evaluation and/or BIMS) indicate a level of cognition that questions the Resident's ability to participate in medical treatment decisions, the facility will initiate a capacity evaluation form. Two physicians or a physician and licensed psychologist will determine if the individual is able or unable to participate in medical treatment decisions. This determination is made on the Statement of Capacity. 45135 Resident #88 (R88): Review of the medical record revealed Resident #88 (R88) was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included Syncope (fainting) and Collapse, Adjustment Disorder with mixed Anxiety and Depressed Mood, Dysphagia (difficulty swallowing), Muscle Wasting and Atrophy, Difficulty with walking, and Unsteady on Feet. According to Resident #88 (R88)'s Minimum Data Set (MDS) dated [DATE], revealed R88 scored 15 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS- a cognitive screening tool) and had behaviors. R88 needs minimal to no assist with toileting, showering/bathing, getting dressed and personal hygiene. Record review revealed Advanced Directive where R88 was listed as a Do Not Resuscitate (DNR), was not witnessed by two people and dated ,d+[DATE]. A new Advanced Directive had not been completed for ,d+[DATE] yet as required by Michigan. During an interview on [DATE] at 09:01 AM, Social Worker (SW) K stated R88 Advanced Directives must not have been scanned in his medical records yet. Writer asked whose responsibility it was to see that this was done, she stated SW. Writer asked why ,d+[DATE] Advanced Directives for DNR did not have 2 witness signatures as required. SW K stated she would go look for it. During an interview on [DATE] at 10:50 AM, SW K stated the Advanced Directives were scanned in the medical record when she looked. Writer asked what date they were scanned in, and SW K stated she did not know, it was in the medical record when she looked in it. Record review revealed that the Advanced Directives for DNR was filled out on [DATE] during the survey and scanned into R88's medical record.

This Citation pertains to intake MI00138800. Based on observation, interview and record review, the facility failed to implement and operationalize policies and procedures for pressure ulcer (wounds caused by pressure) prevention and management for two residents (Resident #704 and Resident #710) of two residents reviewed, resulting in a lack of implementation and documentation of meaningful, resident-centered interventions for pressure ulcer prevention, the development and worsening of facility-acquired pressure ulcers, unnecessary pain, and the likelihood for a decline in overall heath status. Findings include: Resident #704: Review of intake documentation dated as received on 8/3/23 revealed concerns related to Resident #704 developing pressure ulcers while at the facility and staff failing to appropriately treat the Resident. Record Review revealed Resident #704 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included diabetes mellitus, heart disease, weakness and cerebral infarction (stroke) with resulting left sided hemiplegia and hemiparesis (one sided paralysis), left shoulder and lower leg contractures (tightening of the muscle, tendons, ligaments, and/or skin that prevents normal movement) and dysphagia (difficulty swallowing). Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the Resident was cognitively intact and required extensive to total assistance to complete all Activities of Daily Living (ADL) with the exception of eating. The MDS further detailed the Resident was at risk for pressure ulcer development and had one Stage III (full thickness tissue loss) facility-acquired pressure ulcer. Resident #704 was discharged to the hospital on 6/29/24 and did not return to the facility. On 5/21/24 at 12:23 PM, an interview was completed with Confidential Witness A. When queried regarding Resident #704's care at the facility, Witness A verbalized concerns related to staff not being attentive to the Resident and not responding to their needs while they were in the facility. Review of Resident #704's Electronic Medical Record (EMR) revealed documentation indicating the Resident developed a facility-acquired Stage II (partial thickness tissue loss presenting as an open ulcer) pressure ulcer on their left buttocks/gluteus on 1/14/23. The pressure ulcer worsened from a stage two to a stage three pressure ulcer. Additional review of the Resident's EMR revealed they had a history of pressure ulcers including a prior stage two pressure ulcer on their left buttocks which had healed. Documentation in Resident #704's EMR detailed the following: - 1/16/23 at 9:39 AM: Skin & Wound Evaluation . Pressure . Stage 2 . Left Buttocks . In-House Acquired . How long has the wound been present? Exact Date: 1/14/23 . Measurements . Length: 1.4 cm (centimeters) . Width: 1.4 cm . Depth: 0.2 cm . Exudate . Light . Serosanguineous . Pain . Controlled . Healable . Treatment . 1. Dressing appearance . None . Notes: Notified about open area to Left Buttock. Cleansed with wound cleanser & assessed. Treatment completed: Swabbed peri-wound with skin protectant. Applied Collagen Particles to wound bed & covered with a bordered gauze. Daily & PRN (as needed). Hall Nurse to continue treatment as ordered . - 6/14/23 at 4:06 PM: Skin & Wound Evaluation . Pressure . Stage 3 . Left Gluteus . In-House Acquired . How long has the wound been present? Exact Date: 1/14/23 . Length: 3.8 cm . Width: 2.4 cm . Depth: 0.1 cm . Wound Bed . Slough . 50% . Exudate . Light . Serosanguineous . Healable . Deteriorating . Notes: Evaluated during weekly wound care rounds. This wound is to be cleansed with wound cleanser and Medihoney applied to the wound bed. Dress with border gauze. Education: Educated staff and resident on new treatment orders, and the importance of turning and repositioning resident to aid in wound healing . Resident #704 was in the hospital from 6/21/23 to 6/26/23. - 6/28/23 at 10:37 AM: Skin & Wound Evaluation . Pressure . Stage 3 . Left Gluteus . In-House Acquired . How long has the wound been present? Exact Date: 1/14/23 . Length: 1.3 cm (centimeters) . Width: 2.4 cm . Depth: 0.1 cm . Wound Bed . Slough . 20% . Exudate . Light . Serosanguineous . Healable . Notes: Evaluated during weekly wound care rounds. This wound is to be cleansed with wound cleanser, Apply Medihoney to the wound bed, and cover with Bordered Gauze . Education: Educated staff and resident on new treatment orders, and the importance of turning and repositioning resident to aid in wound healing . Review of progress note documentation in Resident #704's EMR revealed no documentation of refusal to turn and reposition. Review of Resident #704's EMR revealed a care plan entitled, (Resident #704) has Actual impairment to skin integrity AEB (As Evidenced By) pressure ulcer to left gluteus (Initiated: 11/8/22; Revised: 6/5/23). The care plan included the interventions: - Encourage frequent repositioning as tolerated (Initiated and Revised: 6/28/23) - Encourage good nutrition and hydration in order to promote healthier skin. Provide dietary supplements as ordered (Initiated: 2/16/19; Revised: 7/22/22) - Apply pressure relieving/reducing mattress to protect the skin while in bed (Initiated: 9/1/21; Revised: 7/22/22) - Refer to at risk for skin break down for further interventions (Created and Initiated: 6/5/23) Another care plan entitled, (Resident #704) is at risk for impaired skin integrity/pressure injury R/T (related to) Decreased mobility . hemiplegia/paresis after CI (Cerebral Infarct- stroke) affecting L (left) side . prefers to lie on back while in bed. Hx (history): fungal infection. History of reopening wounds over scar tissue (Initiated: 4/13/20; Revised: 6/28/23). Care plan interventions included: - Encourage frequent repositioning as tolerated (Initiated: 6/28/23) - Pressure reduction cushion to w/c (wheelchair) or chair (Created and Initiated: 6/5/23) - Dietary consult and/or physician review as needed to make recommendations, for supplemental protein, amino acids, vitamins, minerals as ordered to promote wound healing (Created and Initiated: 6/28/23) - Follow facility policies/protocols for the prevention/treatment of impaired skin integrity (Created and Initiated: 6/28/23) A care plan entitled, (Resident #704) has an ADL Self Care Performance Deficit and requires assistance with ADL's and mobility r/t: skin impairment . contractures of left leg and left shoulder, hemiplegia/hemiparesis left side . decreased mobility (Initiated: 4/13/20; Revised: 6/28/23) was present in the EMR. This care plan included the interventions: - Bed Mobility . requires extensive assistance with 2-person assist to reposition and turn in bed (Created: 2/18/19; Initiated and Revised: 6/28/23) - Transfer . requires total two-person assistance with Hoyer (mechanical lift for dependent individuals using a sling) lift for transfers (Initiated: 4/13/20; Revised: 4/27/20) Review of Resident #704's Treatment Administration Record (TAR) for June 2023 revealed there was no treatment in place on the TAR for the Resident's left buttocks/gluteal. The treatments in place on the TAR, which matched the Skin and Wound Evaluation documentation specified the wound location as being the Coccyx. The ordered treatment for the coccyx was blank, indicating the treatment was not completed, on 6/10/24. Further review of documentation in Resident #704's EMR revealed the Resident did not have a specialty mattress implemented beyond the pressure reduction mattress utilized for all facility residents, did not have a pressure reduction cushion implemented on their wheelchair until 6/5/23 and there was not documentation of turning and repositioning every two hours at a minimum. Resident #710: Review of facility-provided CMS-802 form revealed Resident #710 had a Stage Three facility-acquired pressure ulcer. Review of Resident #710's EMR revealed the Resident was admitted to the facility on [DATE] with diagnoses which included heart failure, weakness, and falls. Review of the MDS assessment dated [DATE] revealed the Resident was cognitively intact and required partial to moderate assistance from staff to complete ADL's including rolling, repositioning, and transferring. The MDS further detailed the Resident was at risk for pressure ulcer development but did not have any pressure ulcers. Review of Resident #710's EMR revealed a care plan entitled, (Resident #710) is at risk for impaired skin integrity/pressure injury R/T (related to): decreased mobility (Initiated: 4/30/24; Revised: 5/1/24). The care plan included the interventions: - Cue to reposition self as needed (Initiated: 4/30/24) - Follow facility policies/protocols for the prevention/treatment of impaired skin integrity (Initiated: 4/30/24) Another care plan entitled, (Resident #710) has Actual impairment to skin integrity r/t left jaw, left elbow, left shin (Initiated: 4/30/24; Revised: 5/13/24). The care plan included the interventions: - Encourage frequent repositioning as tolerated (Initiated: 4/30/24; Revised: 5/1/24) - Encourage good nutrition and hydration in order to promote healthier skin. Provide dietary supplements as ordered (Initiated: 4/30/24) - Apply pressure relieving/reducing mattress, pillows to protect the skin while in bed (Initiated: 4/30/24; Revised: 5/1/24) Review of Resident #710's EMR revealed the following documentation: - 5/17/24 at 2:13 PM: Skin & Wound Evaluation . Pressure . Stage 3 . Left Heel . In-House Acquired . How long has the wound been present? . Exact Date: 5/17/24 . Length: 1.0 cm . Width: 1.5 cm . Depth: < (less than) 0.1 cm . Wound Bed . Slough . Exudate . Light . Serosanguineous . Healable . Progress . New . Notes: Cleanse the area with wound cleanser and allow to dry. Apply honey to the wound bed and cover with a border gauze. Daily and PRN . Education: Continue with supportive care. Elevate the extremities and float the heels. Reposition frequently . On 5/23/24 at 9:27 AM, an interview was completed with Certified Nursing Assistant (CNA) B. When queried if Resident #710 had a pressure ulcer, CNA B stated, No. With further inquiry, CNA B revealed the Resident had areas on the front of their legs that were weeping from fluid and edema but did not have a pressure ulcer. When queried what interventions the Resident had in place for pressure prevention, CNA B revealed the Resident did not have any specific interventions in place. CNA B was then asked how the Resident transferred and replied, With assist. At 9:30 AM on 5/23/24, Resident #710 was observed in their room. The Resident was sitting in a wheelchair with bilateral footrests in place. The Resident was wearing non-slip socks, and their feet/heels were directly against the footrest rests. Both of the Resident's legs were visibly edematous. An interview was completed at this time. When queried if they had any wounds, Resident #710 stated, I wasn't getting my water pill. The skin busted open, and the water was leaking all over my left front leg. When asked, Resident #710 revealed a lady from (insurance company) came. They called my heart doctor and indicated they were now receiving their diuretic (water pill) medications. Resident #710 was asked if they had any other wounds since coming to the facility and stated, One on my heel, I'm not sure what it's from. When queried regarding treatment for their heel, Resident #710 stated, They (facility staff) put a dressing on it this morning. When queried if their heel hurt where the wound was, Resident #710 replied, Sometimes. I can tell it is there when I put pressure on it. When queried if they had heel boots to reduce the pressure on their heels, Resident #710 stated, Not here (at facility). Resident #710 revealed they knew what heel boots were because they had them when they were in the hospital. When asked if facility staff floated their heels when they were in bed by putting a pillow or wedge under their legs with nothing under their heels, Resident #710 replied, No. The Resident revealed staff will sometimes put a pillow under their legs to elevate them but indicated their heels press into the pillow. An interview was conducted with Wound Care Registered Nurse (RN) E on 5/23/24 at 11:00 AM. When queried regarding Resident #710's left heel pressure ulcer, RN E confirmed it was facility-acquired. RN E was asked how they were notified of the pressure ulcer and stated, I was informed by one of the nurses that when they took (Resident #710's) sock off that there was something. When queried if Resident #710 was at risk for pressure ulcer development prior to developing the facility acquired pressure ulcer, RN E reviewed the EMR and verified they were. When asked what interventions were in place to prevent pressure ulcer development, RN E replied, We started treating it right away and indicated the pressure ulcer was improving but did not provide a response to the question asked. RN E was then asked what the facility did to prevent the pressure ulcer from developing, with the Resident's known risk, RN E reviewed the Resident's care plan and indicated the Resident was encouraged to reposition. When asked if Resident #710 was able to reposition independently or if they required staff assistance, RN E revealed they were unsure and indicated the Resident is working with therapy and improving. A review of Resident #710's Visual/Bedside Kardex (CNA tasks) was completed with RN E at this time. The Visual/Bedside Kardex revealed Resident #710 was only able to ambulate with therapy and required substantial/maximum assistance of one staff member for dressing, bathing, transferring, and bed mobility. The Skin section on the Visual/Bedside Kardex included the task, Cue to reposition self as needed. When asked how Resident #710 was able to reposition themselves when they required one assist from staff, RN E was unable to provide an explanation. Another section entitled, Resident Care on the Visual/Bedside Kardex specified, Apply pressure relieving/reducing mattress, pillows to protect the skin while in bed. Encourage frequent repositioning as tolerated. When queried what the pressure relieving/reducing mattress was, as a specialty mattress was not observed on Resident #710's bed, RN E revealed the standard mattress for all resident beds is pressure relieving/reducing. When asked what pillows to protect the skin in bed meant, RN E revealed that mean pillows for positioning as needed. Resident #710's care plan was then reviewed with RN E. When queried why the Resident's actual skin impairment care plan had not been updated to include the pressure ulcer on their left heel, RN E indicated care plans are updated weekly. When asked about the lack of specific interventions related to the Resident's heel such as floating heels and/or heel boots, RN E confirmed there were no specific intervention in place but reiterated the Kardex included pillows to protect the skin when in bed. When asked if CNA staff were the primary staff who assisted and positioned residents, RN E agreed they were. When queried how CNA staff assigned to Resident #710 knew to float the Resident's heels and/or specific positioning recommendations when they are not aware of positioning needs and/or current pressure ulcers, RN E did not provide an explanation. When informed that CNA B was unaware Resident #710 had a pressure ulcer on the left heel, RN E indicated direct care staff should be aware, but no further explanation was provided. When queried regarding Resident #704's pressure ulcer, RN E revealed they were not working at the facility during Resident #704's admission. RN E was queried regarding Resident #704 having pressure ulcers prior to the one identified as developing on 1/14/23 and interventions in place to prevent development and reviewed the Resident's EMR. RN E verbalized Resident #704 had the standard facility pressure reduction mattress in place. When asked why a specialty mattress was not implemented, due to the Resident's risk and history, RN E was unable to provide an explanation. When queried if Resident #704's pressure ulcer documented as both left buttock and left gluteus with the identification date of 1/14/23 was the same pressure ulcer, RN E reviewed the Resident's EMR and confirmed it was. When asked if the pressure ulcer was facility acquired, RN E indicated that was what was documented. When queried if the pressure ulcer worsened from a Stage Two to a Stage Three, RN E confirmed it had. RN E was then asked what frequent meant when included in the care plan care intervention, encourage frequent turning and repositioning RN E did not provide a response. RN E was then asked where documentation of turning and/or repositioning was completed in Residents EMR's and revealed staff do not document how often and/or when residents are turned and/or repositioned. No further explanation was provided. Review of facility policy/procedure entitled, Skin Management (Revised: 5/14/24) revealed, It is the policy that the facility should identify and implement interventions to prevent development of clinically unavoidable pressure injuries . Residents with wounds and/or pressure injury and those at risk for skin compromise are identified, evaluated and provided appropriate treatment to promote prevention and healing. Ongoing monitoring and evaluation are provided to ensure optimal guest/resident outcomes . Practice Guidelines . 3. Appropriate preventative measures will be implemented on residents identified at risk and the interventions are documented on the care plan. 4. Residents admitted with any skin impairment will have: Appropriate interventions implemented to promote healing .

This Citation pertains to Intake Number MI00141163. Based on observation, interview and record review the facility failed to 1) Monitor blood glucose levels and signs/symptoms of diabetic complications; 2) Recognize a change of condition in a timely manner; 3) Document clinical assessment of a resident during a change in condition and the subsequent measures taken; and 4) Provide documented clinical interventions, care plans and coordination for consistent refusal of all medications since readmission for one resident (Resident #902). This deficient practice resulted in Resident #902 being admitted to the Intensive Care Unit (ICU) for Diabetic Ketoacidosis (increased ketone levels in the blood) and Acute Kidney Injury (inability of kidneys to filter waste products), inadequate facility documentation related to the resident's change in condition and current refusal of medications that could lead to a diabetic or psychiatric episode. Findings include: Resident #902: On 12/19/2023 at 2:15 PM, an interview was conducted with Physician M regarding their assessment of Resident #902 during her hospital admission. Physician M stated they were consulted for psychiatric medication management to determine if her medications were a contributing factor to Resident #902's high blood sugars. Physician M shared her sugars were in the 1200's and the facility was not managing her diabetic needs. The resident became unresponsive, and they (the facility) transferred her to the emergency room but were unaware her blood sugar were as elevated as they were. The physician continued Resident #902 was extremely disoriented and not able to be assessed by their team. They attempted to contact the facility on 11/15/2023 but were informed facility nurses were busy and to callback. Upon calling back they received no answer, and thus were not able to ascertain any historic information on the resident to assist them in continuum of care. Physician M stated they were concerned regarding the diabetic sheer mismanagement by the facility of Resident #902. On 12/19/2023 at 2:30 PM, a review was conducted of Resident #902's medical record and it indicated the resident was admitted to the facility on [DATE] with diagnoses that included, Dementia, Schizoaffective, Type 2 Diabetes, Mood Disorder and Adjustment Disorder. Resident #902 was admitted to the hospital on 11/11/2023 and at the time of admission was not prescribed any diabetic management medications. Further review was completed and yielded the following results: Progress Notes: - There are no progress notes on 11/11/2023 that indicated why Resident #902 was transferred to the emergency room , nor were there any notes leading up to her transfer. Transfer Form: - The transfer form did not provide the receiving facility with any quality information. The most recent glucose listed on the document was from 6/26/2023 and was 33. There was no narrative as to the reasoning behind the facility sending her to the emergency room for further treatment and evaluation. On 12/19/2023 at 3:35 PM, the DON (Director of Nursing) was queried on facility expectations for transfers. The DON stated there should be a Transfer form, Change in Condition form and progress note completed by the nurse sending the resident out. The DON was asked if the facility could provide any further documentation related to assessment and monitoring of Resident #902 prior to her transfer to the emergency room , any laboratory results for diabetic monitoring, physician notes etc. The DON stated she would look for the requested information. On 12/19/2023 at 3:45 PM. Resident #902 was observed in her room with the flat sheet covering her entire body. She was speaking nonsensically and not able to be interviewed. Her roommates reported her behaviors have been escalated lately and its been difficult for them to sleep. On 12/19/2023 at 4:00 PM, an interview was conducted with Social Worker H regarding Resident #902. Social Worker H shared since the residents return from the hospital, she has not been the same person and they have been working closely with their contracted psychiatric group to re-stabilize her on medications. Since returning she refuses the majority of her medications including the insulin. Her last blood sugar check she allowed was on 12/15/2023. Further review was completed of Resident #902 MAR (Medication Administration Record) from October 2023 to December 2023. It should be noted Resident #902 regularly accepted her medication in October 2023 until she was admitted to the hospital on 11/11/2023. Upon the resident return on 11/18/23 it was a very few times when Resident #902 was administered any of her medications due to refusals. The last time she allowed her blood sugar to be checked was on 12/15/2023. December 2023: Glipizide 5 MG (Milligrams) give 1 tablet by mouth two times a day - Of the 38 opportunities Resident #902 was administered the medications 7 times Insulin Detemir Solution 100 Unit/ML (milliliters) inject 10 unit subcutaneously every morning and at bedtime - Of the 38 opportunities, Resident #902 never receive the medication Novolog Injection Solution 100 Unit/ML inject pas per sliding scale subcutaneously before meals - Of the 57 possible opportunities (if blood sugar was within sliding scale parameters) Resident #902 received the Novolog injection three times. It can be noted Resident #902 does not have a medication refusal care plan and it is unknown what methods/interventions the facility utilized to [NAME] her acceptance of her medication. Hospital Discharge Records: June 27, 2023 .She had severe hypoglycemia and treated with IV dextrose .Severe hypoglycemia due to glipizide blood sugar now in good range however patient still on D10 .If her blood sugars are rising then she should be controlled with Januvia only which does not cause hypoglycemia . Upon return to the facility there was no monitoring of her blood glucose levels by the facility or their practitioners. November 17, 2023 .Presented to ER .with complaints of altered mental status and hyperglycemia .On presentation patient was slightly hypotensive., UA negative except large glucose and ketones, leukocytosis WBC 12,000, hypernatremia 147, hyperkalemia 5.8, creatinine 2.4, glucose 1257 A1c 14.9, lactic acid 2.3 .showing respiratory acidosis .admitted to ICU for DKA, aki, metabolic disturbances and places on IV insulin drip . Laboratory Results: Collected 8/21/2023: -Glucose: 189 (flagged on report as high) o Reference range: 74-106 Blood Sugars: 4/1/2023: 136 mg/dL 4/29/2023: 152 mg/dL 6/26/2023: 33 mg/dL 11/18/2023: 361 mg/dL 11/18/2023: 464 mg/dL 11/19/2023: 441 mg/dL 11/21/2023:274 mg/dL Although Resident #902 had a diagnosis of Diabetes the facility was not consistent in monitoring her blood sugar levels. In June 2023 Resident #902 was hypoglycemic and admitted to hospital and upon readmission there were no orders inputted for blood glucose monitoring. In August 2023 laboratory results flagged Resident #902's glucose levels as abnormal but this did not alert facility management or practitioners. From June 2023 until November 2023 the facility did not check Resident #902's blood sugar. Practitioner Documentation: 7/3/23 at 00:00: .Pt returned from hospital with a change in her psych medications. Ativan has been effective in the past .Will add .Vitals signs: Blood Sugar: 33 mg/dL . 7/6/2023 at 00:00: .Patient admitted to the hospital and fully worked up and treated for hypoglycemia .Vitals Signs: Blood Sugar: 33mg/mL It can be noted the last Blood Sugar documented by facility staff propagated into all the practitioner's note (July 2023 - November 2023) and they did not catch that her blood sugar was not being monitored by facility staff. On 12/19/2023 at 4:05 PM, Nurse I was queried if Resident #902's current presentation was her baseline. The nurse reported prior to her hospitalization in November 2023, Resident #902 required minimal assistance from facility staff. She walked, toileted herself, spoke to staff and was out of her room and took most of her medications. Since her return she does not leave her room, refuses medications, speaks nonsensically, and had told the aides she cannot walk. Nurse I shared a few days prior to her hospital admission Resident #902 told staff she could not walk, and the aides were assisting her to the restroom. Nurse I clarified that Resident #902 could walk but she truly believed she was unable too. The nurse reported the change in Resident #902 began a few days prior to her being transferred to the emergency room . On 12/19/2023 at 4:30 PM, an interview was held with Nurse A regarding Resident #902's transfer to the emergency room . Nurse A stated prior to her hospitalization she always took her medications, was independent with cares, talked and was not secluded to her room. Nurse A stated they did notice there were no orders for blood glucose monitoring when she is Type II Diabetic. Nurse A stated she was uncertain as to why there were no orders to monitor her blood sugar levels. Nurse A shared she assisted Nurse L with transferring Resident #902 to the emergency room as Nurse L asked her to complete a secondary assessment as she was familiar with the resident. Upon assessment of Resident #902 she observed her, her eyes were fixed and glazed over, she was not talking (as she normally did), was drooling and her face/eyes/jaws appeared to be sunken in. Nurse A was informed the resident had been like this for a few days. Upon calling on-call provider they were given orders to send her to the emergency room for evaluation and treatment. On 12/20/2023 at 10:54 AM, an interview was conducted with CNA (Certified Nursing Assistant) J regarding Resident #902. The CNA stated the week leading up to her hospitalization she was lethargic, not toileting herself as she typically did and having frequent incontinent episodes. CNA J continued the resident appeared dazed and although her eyes were open it was as if she was not fully there. The CNA stated this was not typical behavior of Resident #902. CNA J stated the nurse was informed and ensured the oncoming aides that week were aware as well. On 12/20/2023 at 12:30 PM, an interview was conducted with Nurse Practitioner K regarding the facility's absence of diabetic management of Resident #902. Practitioner K reported she never received any report of a decline in the resident. The last time she assessed the resident she was a little more incontinent, but it was not concerning at that time. We discussed the residents admission for hypoglycemia in June 2023 and upon admission the absence of orders for any type of diabetic monitoring. Practitioner K understood the concerns of this writer. We further discussed Resident #902's vitals signs within their progress notes. Practitioner K was informed the blood glucose levels in her notes all showed as 33 and was not addressed in the assessment. Practitioner K explained the vital signs are pulled from the chart and she does not typically look at them when inputting her notes. But going forward she will be more vigilant in reviewing the propagated vital signs. Practitioner K reported she is aware Resident #902 had not been administered medications since 12/15/2023. She reported during her hospitalization many of her psychiatric medications were changed and she returned to them in a completely different state. They are monitoring her based off physical assessment as she is refusing all of her medications. On 12/20/2023 at 3:05 PM, an interview was conducted with Nurse L regarding Resident #902's emergent transfer on 11/11/2023. Nurse L reported Resident #902 was ill-appearing and when asked to further explain she stated the resident was lethargic, mumbling nonsensically, glazed eyes and her cheeks were sunken in. Nurse L reported she called their provider and was instructed to draw labs and complete a UA. She asked Nurse A for a 2nd opinion as she was more familiar with Resident #902. Nurse A completed her assessment and contacted their on call provider back and received orders to send the resident to the emergency room . Nurse L was queried as to what Nurse A reported to the on- call provider to receive orders when she was instructed to draws labs. Nurse L stated she did not know. Nurse L stated she did not recall completing a progress note detailing her assessment of the resident, initial contact with provider, requesting Nurse A assisting and then gaining orders to send Resident #902 to the emergency room . Nurse L did not provide an explanation as to why a progress note or change in condition document was not completed. On 12/20/2023 at approximately 4:55 PM, the DON (Director of Nursing) was queried about facility expectation for documentation. The DON stated they recently had a skills fair and the importance of documentation was reviewed in detail. They completed continuous education with facility nurses instructing them to take credit for the work they do. The DON was queried as to why when Resident #902 returned from the hospital in June 2023 after a hypoglycemic episode and orders were not implemented for diabetic monitoring. The DON reported it was error on their part that it was missed upon her readmission. She did not trigger as her diabetic medications had been discontinued. Resident #902 had labs in August 2023 (lab results indicated abnormal glucose result for Resident #902) that were reviewed by their practitioner on 8/22/2023 per the DON. The DON was asked regarding standing orders for residents with diabetes and she explained the facility does not have standing laboratory orders. The DON stated currently she is refusing all medications and blood sugar checks and the facility is trying all they can to get her to take the medications to no avail. The DON was further queried if Resident #902's DPOA was aware of the refusals and the last time she was contacted. She reported they last spoke to the DPOA regarding her medication refusals on 11/21/2023. The DON was informed there was no refusal care plan, detailed documentation on facility efforts for medications administration and coordination with DPOA. The DON expressed understanding of this writer's concern. Review was completed of the facility policy entitled, Diabetic Management, revised 9/22/2023. The policy stated, Diabetic Management involves both preventive measures and treatment of complications. Upon admission, the interdisciplinary team works together to implement a plan of care to minimize complications. Upon admission the interdisciplinary team evaluates the diabetic resident and implements a plan of care to ensure: Orders are received and accurate related to blood glucose monitoring and anti-diabetic agency .Blood glucose measurements are taken per the physician order .Anti- diabetic agents are administered per physician order .Residents are monitored for signs/symptoms of complications .Signs of Hyperglycemia .Incontinence, Change in behavior or ability or ability to think, Lethargy, signs of dehydration, Weakness. 1. If a resident is observed with, or complains of any symptoms of hyperglycemia, report to to the nurse immediately. 2. Test the resident's blood glucose . Review was completed of the facility policy entitled, Refusal of Medications and Treatments, revised 2/24/2022. The policy stated, .Should a guest/resident refuse his or her medications and/or treatments, documentation must be recorded concerning the situation. Documentation pertaining to a guest's/residents refusal of treatment shall include, as a minimum: a. The date and time the medications/treatment was attempted; b. The medications/treatment attempted; c. The guest's/residents response and reason (s) for refusal: d. The name of the person attempting to administer the treatment; e. Documentation the guest/resident was informed of the purpose of the treatment and the consequences of not receiving the care; f. Documentation each time the guest/resident refused his or her treatment, the guest/resident's condition and any adverse effects due to such refusal; g. The date and time of the physician and Guardian/Responsible Party was notified as well as the physician response . Review was completed of the facility policy entitled, Transfer and Discharge, effective 2/28/2023. The policy stated, The transfer and discharge process must provide sufficient orientation of guests/residents to ensure a safe and orderly transfer or discharge from the facility When a guest/resident is transferred on an emergency basis to an acute care facility, notice of the transfer is provided to the guest/resident and the guest/resident representative as soon as practicable .A transfer form is completed, a list of medications and copy of care plan goals is sent to the receiving hospital. Nursing documents the hospital transfer in the medical record. Review was completed of the facility policy entitled, Change in status, identifying and communicating, long term care, reviewed 8/19/2022. The policy stated, .Identify a suspected acute change in the resident .perform a complete physical assessment, focusing on the identified change in status .communicate change in residents condition to the appropriate practitioner if the resident requires a transfer to an acute care facility, make sure that documentation accompanies the resident. Call the department accepting the resident to provide handoff communication about the residents condition and care . Review was completed of the facility policy entitled, Skilled Care Documentation, Revised 9/2/2021. The policy stated, Daily documentation in the chart of the residents care and status is required as a condition of participation under the Medicare program as well as other insurance requirements .Complete a skilled care note no less than one time per day .

Based on observation, interview and record review, the facility failed to prevent facility-acquired pressure ulcers for 2 residents (Resident #42 and Resident #72) and ensure that residents were assessed, monitored, wound care was provided as ordered and appropriate interventions were in place for 3 residents (Resident #42, Resident #72 and Resident #262) of 5 residents reviewed for pressure ulcers, resulting in Resident #42 developing a Stage 2 sacral pressure ulcer, Resident #72 developing multiple Stage 2 pressure ulcers to the sacrum and right trochante,; and Resident #262 developing a sacral pressure ulcer that worsened to a Stage 4. Findings Include: Resident #262: Pressure Ulcer/Injury: On 6/14/23 at 10:36 AM during a tour of the facility, Confidential Person M said the resident had a large pressure ulcer on her bottom. He said it was smaller and then became much larger; he said she now had a wound vac. The Confidential Person pointed to the Wound Vacuum canister in a bag on the bedside table. He said the wound dressing was changed on Monday, Wednesday and Friday. Resident #262 was observed lying in bed on her back sleeping. The resident was receiving an IV antibiotic. The Confidential Person said she received it every day. A record review of the Face Sheet and Minimum Data Set (MDS) assessment indicated the resident was admitted to the facility on [DATE] and readmitted on [DATE] and 6/10/2023 with diagnoses: Colostomy, gastrostomy, urinary tract infection, kidney failure, dysphagia, asthma, anxiety, depression, arthritis, GERD, Gout, hypertension and neuropathy. The MDS readmission assessment dated [DATE] revealed the resident had a Brief Interview for Mental Status score of 13/15 indicating full cognitive abilities. The MDS also indicated the resident needed assistance with all care. The MDS section M revealed the resident had an Unstageable: due to slough or eschar pressure ulcer on this Admission assessment that was completed after a readmission. There was not another assessment completed between admissions on 3/22/2023 and 5/4/2023. A record review of the Nursing Comprehensive Evaluation: Section K. Skin, dated 5/5/2023 at 1:47 AM and lock date 5/6/2023 at 12:41 PM provided, Does the resident have any skin conditions? 'Yes'; . Coccyx pressure ulcer, left buttock skin tear, right iliac crest rear bruising . at risk for impaired skin integrity/pressure injury .Turn/reposition resident every---- hours and PRN (as needed). The timeframe for repositioning was not filled in. It was blank. A record review of the Skin & Wound Evaluation, dated 5/5/2023 at 3:18 PM and locked on 5/5/2023 at 3:30 PM revealed the following, Type: Pressure ulcer . Stage: Unstageable Obscured full-thickness skin and tissue loss; Due to: slough and /or eschar; Location Sacrum; Acquired Present on Admission . Wound Measurements: Length 3.0 cm x Width 2.8 cm; Depth: not applicable; Undermining: 2.5 cm; Tunneling: not applicable; Wound Bed: Granulation, 10%; Slough: 90%; Eschar: none . Exudate: moderate; Type serosanguineous; Odor: none; Peri wound: rolled edge . Surrounding tissue: fragile: skin that is at risk for breakdown, macerated: wet, white, waterlogged tissue . Goal of Care: Healable . Additional care: . Turning/repositioning program . A record review of a progress note by Wound Nurse Practitioner/NP Z dated 5/10/2023 untimed provided, Wound Care: . Skin: . Pressure Unstageable Sacrum- This wound measures 2.8 x 3.1 cm with a depth of 3 cm, undermining of 3 cm from 207 o ' clock. Wound bed consists of 50% slough and 50% pink moist tissue . serosanguinous discharge. Edges are attached . This wound is to be cleaned daily with wound cleanser and Santyl applied to the wound bed, pack with NS (normal saline)- moistened kerlix. Wound should be dressed with a dry dressing . Patient should be turned frequently. Patient should be supported with pillows or wedges to prevent pressure on wound . A record review of the Medication Administration Records and Treatment Administration Records for May 2023 identified the following: Sacrum: Cleanse with wound cleanser, skin prep to peri wound, allow to dry, apply Medihoney to wound bed, cover with bordered foam. Daily and PRN every day shift for wound care, start date 5/6/2023 and d/c (discontinue) 5/10/2023. The wound treatment was not provided as ordered on 5/9/2023 or 5/10/2023. Sacrum: Cleanse with wound cleanser, swab peri wound with skin prep wipe, allow to dry, apply Santyl to wound bed, pack wound with saline or sterile water soaked kerlix, cover with bordered foam daily and PRN every day shift for wound care, start date 5/11/2023 and d/c date 5/17/2023. The wound treatment was not documented as completed on 5/11/2023. The resident discharged back to the hospital on 5/17/2023 and returned to the facility on [DATE] with a wound vac applied to the sacral wound. Apply Triad cream to buttocks, (every) shift and PRN every shift for protection, start date 5/5/2023 and d/c date 5/21/2023. The buttocks treatment was not completed as ordered on 5/9/2023 and 5/11/2023. Upon readmission to the facility on [DATE], Resident #262 came back with a wound vac applied to her bottom, per the Nursing Comprehensive Evaluation, dated 6/10/2023 at 8:12 PM. There were no wound measurements on the readmission assessment. On 6/14/2023 a Skin & Wound Evaluation, dated 6/14/2023 at 12:16 PM and locked on 6/15/2023 at 11:18 AM, indicated the sacral pressure ulcer was now 6.4 cm length x 10.9 cm width x 3.2 cm depth x 2.5 cm undermining and no tunneling; . Evaluated during weekly wound care rounds. Wound bed consists of 30% of exposed bone, 705 granulation tissue. Cleanse wound with wound cleanser and apply Wound vac at 150 mmHg every Monday, Wednesday, and Friday. A record review of the physician orders identified a new wound care order for Resident #262, Sacral Wound Vac Site: remove vac foam & cleanse wound with wound cleanser. Apply skin protectant to peri-wound edges. Re-apply Wound Vac black foam (cut to fit) to wound bed. Cover with provided tap/drape. Wound Vac to be connected to continuous suction at -125mmhg. Change every M, W, F and PRN, date revised and started 6/14/2023. A review of the Care Plans for Resident #262 identified the following: (Resident #262 is at risk for impaired skin integrity/pressure injury r/t (related to): arthritis, neuropathy, decreased mobility, current stage 4 wound, created on 3/22/2023 and revised 6/12/2023 with Interventions: Follow facility policies/protocols for the prevention/treatment of impaired skin integrity, date created and initiated 3/29/2023; Encourage frequent repositioning as tolerated, dated created and revised 3/29/2023; If resident chooses not to follow recommended treatment, confer with resident, IDT and family to determine why and try alternative methods to gain compliance. (Specify alternative methods and preferences, 6/12/2023. There was no specified alternative methods; Pressure reduction mattress to bed, date created and initiated 6/12/2023; Turn/reposition resident every 2 hrs and PRN encouraging resident to avoid extended periods of time laying on sacrum/coccyx wound, created and revised on 6/12/2023. (Resident #262) has actual impairment to skin integrity r/t surgical site right abdomen, unstageable sacral wound, diverting colostomy, date initiated and created on 3/22/2023 with interventions: Observe for side effects of the antibiotics and over-the- counter pain medications . date created 6/12/2023. (Resident #262) is at risk for complications r/t has osteomyelitis (infection in the bone) of the sacral/coccyx wound, date initiated and created 6/12/2023 and revised 6/13/2023 with interventions: Observe for new or worsening signs and symptoms . date created 6/12/2023. On 6/15/23 at 3:59 PM, Resident #262 was observed lying on her back sleeping in bed. The mattress on the bed was not a specialty mattress. On 6/16/2023 at 11:00 AM, wound care was observed for Resident #262 with Nurses A, B, and C. An air mattress was observed on the bed, with a pump with controls hanging on the footboard of the bed. The setting was on Normal Pressure: Firm. The nurses were asked if that was the appropriate setting for Resident #262, as the Resident had a large Stage 4 pressure ulcer on the sacrum. Nurse A stated, I don't know. Nurse C stated, We would have to look at the manual for the bed. I haven't seen one like that before. Maintenance found it and brought it out. The nurses were not sure what setting was the most appropriate to aid in preventing worsening and promote healing of the sacral wound. Nurse C was asked about the previous mattress, that was on the bed the day before and said that was the mattress they used on all of the residents. The nurses were asked if a different mattress had previously been considered as the resident's wound continued to worsen until it was a Stage 4 with exposed bone. They said they normally used the mattress the resident was previously on. During the wound observation on 6/16/2023 at 11:00 AM, bloody/serosanguinous drainage was observed in the tubing from the wound to the Wound vac canister. The canister was about 30% full with drainage. The nurses said that was less than what it had been previously. When Nurse B removed the old dressing from the sacral wound, a very large and deep wound with pink granulation tissue and exposed bone was observed it was irregularly shaped approximately 6-7 cm in length and 10 cm width and several centimeters in depth. The resident was moaning and uncomfortable when the old dressing was removed, and Nurse A said she had received pain medication prior to the dressing change. Resident #262 was readmitted to the facility on [DATE] with an unstageable pressure ulcer on the sacrum. The wound continued to worsen and enlarge. The resident was transferred to the hospital several times and on 6/10/2023 was readmitted with a Stage 4 pressure ulcer with visible bone and a Wound vac for treatment. The resident had osteomyelitis in the sacral wound and was receiving IV antibiotics for 42 days. The resident had several different wound treatment orders including Medihoney and Santyl, but other interventions were not reassessed for effectiveness. Two hour repositioning was documented on the Care Plan on 6/12/2023. An air mattress was initiated on 6/16/2023, but the nurses did not know what setting it should be on. A record review of the facility policy titled, Skin Management, origin 5/1/2010, revised 7/14/2021 and effective 12/15/2022 revealed, It is the policy that the facility should identify and implement interventions to prevent development of clinically unavoidable pressure injuries. Guests/residents with wounds and or pressure injury and those at risk for skin compromise are identified, evaluated, and provided appropriate treatment to promote prevention and healing. Ongoing monitoring and evaluation are provided . Appropriate preventive measures will be implemented . Appropriate interventions implemented to promote healing . 22927 Resident #42: Pressure Ulcer/Injury: In an observation and interview on 06/14/23 at 09:22 AM, Resident #42 was asked about pressure ulcers. Resident #42 stated that it irritates his bottom when they clean him up, its sore down there. Resident #42 stated that yes, he does have sore on his bottom and that he did not know where he got those. Resident #42 was observed on a large bariatric bed with foam mattress. In an interview and observation on 06/15/23 at 02:12 PM, Certified Nurse Assistant (CNA) noted Resident #42 was sitting up in wide bariatric bed noted with no air mattress. Observed a Soft foam mattress. Resident #42 stated it has a hard hole right where he sits in the bed. Observation of Resident #42 having noon meal still. Resident #42 stated he can only eat with one hand because his other one doesn't work. Resident #42 stated that the aide has an attitude, she has light dark skin, she just brought it to me. There are some really rude aides that work here, but we don't want to get on their wrong side, or they don't come. Nasty attitudes here. Call lights take a while also. In an interview and record review on 06/16/23 at 09:56 AM, Licensed Practical Nurse (LPN) Unit Manager C stated that Resident #42 developed new pressure ulcer areas to the right gluteal and were facility-acquired and started on 6/7/2023. Record review of Resident #42's skin evaluation dated 6/7/2023 revealed a new right gluteus Stage II in-house acquired. Exact date 6/7/2023 length 3.1cm X width 1cm X depth 0.1cm, with a dressing. An interview on 06/16/23 at 12:06 PM with Licensed Practical Nurse (LPN) Wound Care Nurse B of surveyor's observation on Resident #42 showed the development of new Stage II wounds to the right gluteal which started on 6/7/2023. Resident #42 was observed on a soft foam bariatric mattress with no air mattress. LPN B stated that the facility use's Medline advantage select not an air mattress or a specialty mattress. LPN B was notified that Resident #42 says it's too hard. Resident #71: Observation and interview was conducted on 06/14/23 at 12:49 PM with Resident #71, who had returned back from Dialysis, in his room with the head of his bed slightly elevated. The lunch meal tray was in front of him, with a puree diet with thick liquids noted. Resident #71 acknowledged that he had sores on his bottom and that they developed while he was at the facility. The state surveyor noted that there was no air mattress on the bed. Resident #71 was noted to cough while speaking and that there was food in his mouth. In an interview on 06/15/23 at 02:08 PM, Resident #71 stated that he got the bed sores here (at the facility). Observed a soft foam boarder mattress in place and there was no alternating air mattress noted to the bed. Record review on 06/15/23 at 03:07 PM of Resident #71's care plans, pages 1-160, revealed last Pressure ulcer intervention update was in done in 2022. In an interview and record review on 06/16/23 at 09:30 AM, Licensed Practical Nurse (LPN) Unit Manager C stated Resident #71's wound is a Stage II facility-acquired to the Sacrum that started on 5/5/2023. Record review of Skin & Wound evaluation assessment, dated 5/5/2023, pressure ulcer Stage II to the sacrum, exact date of development 5/5/2023. Pressure ulcer measurements were 0.7cm length X 0.8cm width X 0.1cm depth, exudate light serosanguineous drainage with a dressing applied. Record review of Resident #71's Skin & Wound evaluation assessment dated [DATE] revealed a pressure ulcer Stage II to rear right trochanter (hip) that was in-house acquired with an exact date of 6/14/2023. Wound measurements of length 1.5cm X width 0.9cm X depth 0.1cm with light serosanguineous drainage were noted. Observation and interview on 06/16/23 at 11:59 AM with Licensed Practical Nurse (LPN) Wound Care Nurse B of Resident #71's wounds in his room revealed that the nurse on 6/14/23 found a Stage II to the right heel, observed dressing in place. LPN B and state surveyor observed open wound with serosanguinous drainage on dressing, LPN B stated that yes, it's a new wound that was in-house acquired. Observation of Resident #71's bilateral buttocks revealed three (3) open areas noted, the large one with eschar in the middle with pink surrounding. Record review of Kardex and care plans noted positioning wedge for safety. There was no positioning wedge found in resident's room for safety. Resident does have a soft perimeter mattress, not an air mattress.

This Citation pertains to Intake Number MI 094 Based on observation, interview and record review, the facility failed to properly identify, assess, manage, document, prevent development of, and treat skin conditions for two residents (Resident #30 and Resident #32) of three residents reviewed for pressure injuries resulting in residents developing two Stage 3 facility- acquired pressure injuries (Resident #32), a worsening of Stage 3 and 4 pressure injuries with developing of wound infection (Resident #30), lack of assessment, monitoring, and interventions for wound infection prevention, the likelihood of changes in condition, subsequent deterioration in health status, unnecessary hospitalization for [CONDITION(S)] shock, and preventable decline. Findings include: Resident #30: According to the admission face sheet, Resident #30 was a [AGE] year-old male, admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . According to Minimum Data Set (MDS) dated [DATE], Resident #30 was not scored on the Cognition Assessment, indicating severe Cognition Impairment. Resident #30 required two staff assistance with bed mobility, transfers, and toilet use. During facility tour on [DATE] at 3:45 PM Resident#30 was observed in his room. Upon entrance to the room television was noted to be on and loud. Resident #30 was lying in bed with eyes partially open, and mouth open, positioned slightly to his right side. A Foley catheter was hanging on the left side of the bed. Folded towel was noted positioned on resident's neck covering tracheotomy. When addressed resident did not respond. Upon further observation resident was found to be deceased . At 3:50 PM on [DATE] nurse in care, LPN A, was interviewed. She confirmed that Resident #30 passed away at 12:48 PM that day. Resident #30's electronic medical records (EMR) Skin and Wound Evaluation dated [DATE] at 10:05 AM had a following assessment recorded: Pressure wound stage 4 to sacrum, present on admission, measurements 4.1 x 4.7 cm, wound bed had 70% granulation, 20% slough and 10% eschar tissue. No evidence of infection, moderate serosanguineous exudate, no odor noted. Assessment of sacral wound #2 dated [DATE] at 10:05 AM had following: Pressure wound Stage 3 to sacrum, present on admission, measurements 2.6 x 1.6 x 1.2 cm, undermining 2.8 cm. No evidence of infection, moderate serosanguineous exudate, no odor noted. Wound Nurse Practitioner note dated [DATE] had additional wound assessments: Left trochanter unstageable (previously deep tissue injury) had a moderate amount of serosanguineous drainage and has no necrosis, 20% slough, 10% necrosis, no maceration, a depth of 4.2 cm, and undermining from ,d+[DATE] o'clock measuring 4.3 cm. The remaining wound bed appearing pink and granular. Peri wound is dry and intact. There is palpable and visible bone today. Right trochanter unstageable wound (previously stage 2) has a moderate amount of serosanguineous drainage. The site is covered with 30% slough, and has no necrosis, no maceration, a depth of 1.6 cm, and circumferential undermining measuring 1.4 cm. On [DATE] at 10:15 AM during an interview Wound Care Nurse Practitioner B reported working in the facility for about 10 months now. She said she remembers the Resident #30. On [DATE] she completed his wounds assessments and does not remember noting any signs of infection, or odor. When questioned about wound staging, she said that she follows facility policy, though some wounds that she sees can be harder to stage due to their appearance. On [DATE] at 10:30 AM during an interview the DON was asked how frequently nurses or aids assess residents' skin. She stated a complete assessment is done on admission. Also, nurses assess wounds when providing prescribed wound treatments per order. Review of Resident #30's Care Plan had following documentation: Focus: Resident is at risk for impaired skin integrity/pressure injury r/t: History of [CONDITION(S)] (stroke), [CONDITION(S)], chronic [CONDITION(S)] with tracheotomy, Seizures, PEG, weakness, Foley catheter, bowel incontinence, decreased mobility, wounds on left ankle, sacrum, bilateral trochanter (created on [DATE], initiated on [DATE], revision on [DATE]) Goal: -Minimize the risk in an effort to reduce likelihood of pressure injury development through next review date (created/initiated on [DATE], revision on [DATE]) -Pressure injury to coccyx will show signs of healing by the review date (created/initiated on [DATE], revision on [DATE]) -Pressure injury to bilateral trochanters will show signs of healing by the review (created/initiated on [DATE], revision on [DATE]) Interventions: - Braden scale per protocol (initiated on [DATE], revision on [DATE]) - Conduct weekly head to toe skin assessments, document, and report abnormal findings to the physician (initiated on [DATE], revision on [DATE]) -Follow facility policies/protocols for the prevention/treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] -Observe dressings to bilateral trochanters and coccyx frequently to ensure it is intact and adhering. Report loose dressing to nurse (initiated in [DATE]) -Obtain labs as ordered and report abnormal findings to the physician (initiated on [DATE]) -Provide diet as ordered, observe, and document food acceptance and offer substitutes as needed (initiated on [DATE], revision on [DATE]), [Resident #30 was a PEG tube feed] - Provide incontinent care with each incontinent episode and as needed and apply moisture barrier cream/ointment per facility policy/orders (initiated on [DATE]). - Turn/ reposition resident frequently and as needed (initiated on [DATE], revision on [DATE]) Next skin Care Plan note: Focus: Resident has actual impairment to skin integrity as evidence by wounds to sacrum, bilateral trochanter (initiated on [DATE], revision on [DATE]) Goal: Resident will have no complications r/t skin injuries through the review date (initiated on [DATE], revision on [DATE]) Interventions: -Apply pressure relieving/reducing mattress to protect the skin while in bed (initiated on [DATE], revision on [DATE]) -Observe for s/sx (signs and symptoms) of infection of area (i.e. temperature increases, increased drainage, odor or redness etc.) at all wound sites and report to physician as needed (initiated on [DATE], revision [DATE]) - Observe location, size and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . to physician (initiated on [DATE], revision on [DATE]) -Provide dietary supplements as ordered (initiated on [DATE], revision on [DATE]) - Treatment to skin impairment per order (initiated on [DATE]) -Turn and reposition frequently and as needed (initiated on [DATE], revision on [DATE]) There was nursing note dated [DATE] at 1:00 AM: Blood pressure (BP) ,d+[DATE], Heart rate (HR) 120, Temp 99.8, respirations 40, O2 97%. Right leg twitching, diaphoretic. Suctioned x 2 with return. Coughing on and off, not clearing secretions, HOB (head of the bed) elevated. Nurse Practitioner followed up with Resident #30 on [DATE]: Physical examination- BP ,d+[DATE], Temp 97.4 F, HR 103, Respiration 16, O2 98%, Blood sugar 97 (value from [DATE] at 4:45 PM) General: Patient is a [AGE] year-old male being seen today to follow up on Chest X-ray results. Nursing reported to on call provider that patient had right leg twitching and was diaphoretic. Chest X-ray, [MEDICATION(S)] level, CBC (complete blood count) and BMP (basic metabolic panel) ordered. Chest X-ray was negative for acute process, labs pending. This morning aid notified blood in his brief and by anus. On exam patient is note with hemorrhoids, no active bleeding at this time. Right leg twitching has resolved. Patient appears comfortable. Exhibits no signs or symptoms of acute distress. Reviewed Chest X-ray with patient (Resident #30 unable to communicate and has severe cognitive impairment) and nursing. Ordered Preparation H as needed for hemorrhoids. VSS (vital signs stable) HR RRR (regular rate and rhythm), afebrile. Respirations are regular and non-labored, bilateral lungs are CTA (clear to auscultation). Case discussed with nursing; no acute concerns reported. On [DATE] there was a Change in condition note: Patient was breathing fast, pulse rate in the ,d+[DATE], along with abnormal labs from [DATE]. Record review revealed laboratory values from [DATE] indicating elevated White blood cell count, critically low Hemoglobin, elevated BUN and BUN/creatinine ratio (results indicative of infection, [CONDITION(S)] and compromised kidney function). Resident #30 was hospitalized on [DATE] per family request. Emergency department note dated [DATE] at 8:46 AM had following documentation: Patient came from long term care facility due to decline in health, low BP, [CONDITION(S)] (fast heartbeat), and tachypnea (fast breathing), white (blood) count elevated. VS: HR 109, Respiration rate 37, BP ,d+[DATE], O2 100%. Hospital physician note dated [DATE] Resident presented to the hospital from SNF for fever, [CONDITION(S)], [CONDITION(S)], and overall decline in health. In ER patient received IV (intravenous) [MEDICATION(S)] IV crystalloid fluid per [CONDITION(S)] protocol. He continued to be [CONDITION(S)] and hypotensive afterwards. The patient was admitted to ICU (intensive care unit) for management of septic shock secondary to infected pressure ulcers and [CONDITION(S)] evident on urine analysis. T 37.2, 39.3 C, HR 121, RR 46, BP ,d+[DATE]. Patient pale, clammy, tachypneic; tracheotomy tube in situ with thick secretions. HR fast, regular rhythm, normal S1 S2. Two Sacral decubitus ulcers and bilateral pressure ulcers over ischial tuberosities, all are stage 4 with pustulous base (pus filled blisters), largest measuring 15 x 10 cm and smallest 3.3 cm, surrounding skin dark hairless. Assessment/Plan: 1. Septic shock 2. Pressure ulcer of hips 3. Sacral decubitus ulcers, all stage 4 4. [CONDITION(S)] 5. Chronic Foley 6. Acute kidney injury (Creatinine on arrival 3.6 with [CONDITION(S)] and acidosis, creatinine worsened today [DATE] to 4.2) 7. [CONDITION(S)] (without EKG changes) 8. High anion gap metabolic acidosis 9. [CONDITION(S)] Hgb 6.8, got blood transfusion On [DATE] Critical Care progress note by physician revealed: Patient is admitted to ICU (intensive care unit) for management of septic shock secondary to infected pressure ulcers and [CONDITION(S)] evident on urine analysis. Resident #30 was discharged from acute care to facility on Hospice care on [DATE]. Resident #30 experienced rapid decline and died at facility on [DATE]. Resident #32: According to admission face sheet, Resident #32 was an [AGE] year-old female, admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . According to Minimum Data Set (MDS) dated [DATE], Resident #32 was scored 15 on the Cognition Assessment, indicating no Cognition Impairment. Resident #32 required one staff assistance with bed mobility and toilet use, and 2 staff assistance with transfers. During facility observations on [DATE] at 9:45 AM Resident #32 was lying in her bed watching television. Wound care team had exited the room a minute prior. Resident #32 was asked about her skin. She stated she has a pressure sore on her bottom, and it hurts. When questioned how long ago she developed her sore, Resident #32 stated that it was about couple months ago. She shared that staff does not position her with a pillow to her side, and she cannot stay on her left or right side completely due to hip and shoulder pain. Resident #32 shared that the last time she slept on her side was several nights ago. She usually sleeps on her back. Resident #32's Care Plan revealed the following: Focus: Resident is at risk for impaired skin integrity/pressure injury r/t: [CONDITION(S)], PVD, [CONDITION(S)], [CONDITION(S)], DM, CAD (Coronary artery disease), MASD (Moisture associated skin damage),History of left buttocks ulcer, left second digit opened, left heel ulcer, venous stasis ulcers left lower extremity, left second toe, blister right calf, dry skin to bilateral lower extremities, left heel ad buttock wound, chooses to not reposition or offload bilateral lower extremities (created on [DATE], revision on [DATE]) Goal: - Resident's risk will be minimized in an effort to reduce likelihood of pressure injury development through next review date (created/initiated on [DATE], revision on [DATE]) -Pressure injury to left heel will show signs of healing by the review date (created/initiated on [DATE], revision on [DATE]) -Venous ulcers to lower extremities will show signs of healing by the review date (created/initiated on [DATE], revision on [DATE]) Interventions: - Administer medications as ordered. Observe for ineffectiveness and side effects, report abnormal findings to the physician (initiated on [DATE]) -Avoid positioning resident on flat on back for extended periods of time. Avoid unnecessary pressure to Left heel up in wheelchair (created/initiated/revision on [DATE]) -Braden scale per protocol (initiated on [DATE], revision on [DATE]) - Conduct weekly head to toe skin assessments, document, and report abnormal findings to the physician (initiated on [DATE]) -Cue to reposition self as needed (initiated on [DATE]) -Encourage resident not to wear brief while in bed, she may refuse to leave one off but educate that it causes her to sweat which leads to MASD (initiated on [DATE]) -Encourage to float heels while in bed and assist as needed (initiated on [DATE]) -Follow facility policies/protocols for the prevention/treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] -Observe dressings to be sure they are intact. Notify nurse if change is required if dressing is loose (initiated in [DATE], revision on [DATE]) -Observe skin with showers/care. Notify nurse immediately of any new areas of skin breakdown: redness, blisters, discoloration noted during bath or daily care (initiated on [DATE]) -Pressure reduction cushion to wheelchair (initiated on [DATE]) -Provide diet as ordered; observe and document food acceptance and offer substitutes as needed (initiated on [DATE]) - Provide incontinent care with each incontinent episode and as needed and apply moisture barrier cream/ointment per facility policy/orders (initiated on [DATE]) -Resident will refuse to wear offloading heal protectors at times (puffy boots). Encourage resident to wear puffy boots. If she declines to do so encourage the use of pillows (initiated on [DATE], revision on [DATE]) - Treatments per orders (initiated on [DATE]). - Turn/reposition resident frequently and as needed (initiated on [DATE], revision on [DATE]). Next skin Care Plan note: Focus: Resident has actual impairment to skin integrity as evidence by History of pressure injuries to left heel, MASD right gluteus and venous ulcer to left foot second digit r/t CHF, [CONDITION(S)], PVD, DM, CKD (chronic kidney disease), [CONDITION(S)] and decreased mobility and bowel incontinence, dry skin (initiated on [DATE], revision on [DATE]) Goal: Resident will have no complications r/t skin alterations through the review date (initiated on [DATE], revision on [DATE]) Interventions: -Apply pressure relieving/reducing mattress to protect the skin while in bed (initiated on [DATE], revision on [DATE]) - Encourage good nutrition and hydration in order to promote healthier skin. Provide dietary supplements as ordered (initiated on [DATE], revision on [DATE]) -Encourage to elevate heels in bed and educate on benefits of promoting healing and decrease risk of further breakdown (initiated on [DATE]) -Observe for s/sx (signs and symptoms) of infection of area (i.e. temperature increases, increased drainage, odor or redness etc.) and report to physician as needed (initiated on [DATE], revision [DATE]) - Observe location, size and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . to physician (initiated on [DATE], revision on [DATE]) - Provide incontinent care and use moisture barrier treatment as needed after incontinent episodes (initiated on [DATE], revision on [DATE]) -Turn and reposition frequently and as needed (initiated on [DATE], revision on [DATE]) Electronic medical record review of Resident #32 revealed: Skin and Wound Evaluation note dated [DATE] at 10:14 AM and signed by a wound care provider- pressure wound to left buttock, unstageable: obscured full-thickness skin and tissue loss, identified on [DATE], in-house acquired, measurements 1.3 x 1.2 cm. Skin and Wound Evaluation note dated [DATE] at 11:15 AM- pressure wound to left buttock, unstageable: obscured full-thickness skin and tissue loss, identified on [DATE], in-house acquired, measurements 3.2 x 2.7 cm, wound bed with 90% granulation and 10% eschar tissue, light serosanguineous drainage, no odor. Chamosyn (wound treatment) daily and open to air. Skin and Wound Evaluation note dated [DATE] at 10:30 AM- pressure wound to left buttock, Stage 2: Partial sickness skin loss with exposed dermis, identified on [DATE], in-house acquired, measurements 3.2 x 0.9 cm, wound bed with 100% granulation, light serosanguineous drainage, no odor. Chamosyn daily and open to air. Skin and Wound Evaluation note dated [DATE] at 10:53 AM- pressure wound to left buttock, Stage 2: Partial sickness skin loss with exposed dermis, identified on [DATE], in-house acquired, no measurements. Note- the site is completely closed and without drainage, this issue may resolve today, Chamasyn to continue d/t (due to) fragile tissue. Skin and Wound Evaluation note dated [DATE] at 10:35 AM- deep tissue injury to sacrum, identified on [DATE], in-house acquired, measurements 6.8 x 4.1 cm. Chamosyn daily and open to air. Skin and Wound Evaluation note dated [DATE] at 10:04 AM- pressure wound to sacrum, Stage 3: full thickness skin loss, identified on [DATE], in-house acquired, measurements 3.5 x 2.2 x 0.1 cm, wound bed with 100% granulation. Treatment: Chamosyn daily and open to air. Skin and Wound Evaluation note dated [DATE] at 10:46 AM- pressure wound to sacrum, Stage 3: full thickness skin loss, identified on [DATE], in-house acquired, measurements 2.1 x 5.4 cm, wound bed with 100% granulation. Treatment: Chamosyn daily and open to air. Skin and Wound Evaluation note dated [DATE] at 9:23 AM- pressure wound to sacrum, Stage 3: full thickness skin loss, identified on [DATE], in-house acquired, measurements 2.3 x 1.8 cm, wound bed with 100% granulation, light serosanguineous drainage, no odor, stable. Treatment: Chamosyn daily and open to air. On [DATE] at 10:15 AM during an interview, Wound Care Nurse Practitioner B stated that she has been taking care of Resident #32's skin issues since she started working with the facility, and it has been a challenge to manage her venous ulcers. When questioned about Resident #32's tendency for development of pressure injuries to her bottom she said that resident was prone to it. Regarding wound staging, she said that she follows facility policy, though some wounds that she sees can be harder to stage due to their appearance. On [DATE] at 10:30 AM during an interview, the DON was asked how frequently nurses or aids assess residents' skin. She stated a complete assessment is done on admission. Also, nurses assess wounds when providing prescribed wound treatments per order. When queried how Resident #32 acquired an unstageable pressure wound to left buttock on [DATE] without staff noticing skin changes prior to development of the wound and how her new deep tissue injury to sacrum identified on [DATE] progressed in 8 days to a Stage 3: full thickness skin loss to sacrum, identified on [DATE], she stated she was unsure. Further review of the Resident #32's Care Plan revealed no revisions in care/goals/interventions after resident developed new sacral/ gluteal pressure injuries (Stage 3). Policy for Skin Management revised on [DATE] was provided by the facility and was reviewed. Policy indicated: It is a policy that the facility should identify and implement interventions to prevent development of clinically unavoidable pressure injuries. Guests/residents with wounds and/or pressure injury and those at risk for skin compromise are identified, evaluated, and provided appropriate treatment to promote prevention and healing. Ongoing monitoring and evaluation are provided to ensure optimal guest/resident outcomes. Under section Practice guidelines of the Policy the following statement was found: 3. Appropriate preventive measures will be implemented on guests/residents identified at risk and the interventions are documented on the care plan. 13. Guest's/resident's with pressure injury and lower extremity ulcers will be evaluated, measured, and staged weekly (pressure injury and vascular ulcers only) in accordance with the practice guidelines until resolved. National Pressure Injury Advisory Panel, [DATE], Unstageable Pressure Injury: Obscured full-thickness skin and tissue loss. Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough (yellow, brown, wet stringy dead skin) or eschar (brown or blackened dead skin tissue). If slough or eschar is removed, a Stage 3 or Stage 4 pressure injury will be revealed . According to International NPUAP/EPUAP (National Pressure Ulcer Advisory Panel/ European Pressure Ulcer Advisory Panel; a group of experts who serve as the authoritative voice in pressure injuries) defined pressure injury stages. (A) Stage I-nonblanchable [CONDITION(S)]. (B) Stage II-partial thickness skin loss with exposed dermis. (C) Stage III-full-thickness skin loss. (D) Stage IV-full-thickness skin and tissue loss. (E) Unstageable pressure injury-obscured full thickness skin and tissue loss. (F) Deep tissue pressure injury-persistent non-blanchable deep red, maroon, or purple discoloration. (2016 NPUAP Pressure Injury Staging Illustrations from http://www.npuap.org/resources/educational-and-clinical-resources/pressure-injurystagingillustrations/. Used with permission of the National Pressure Ulcer Advisory Panel [DATE]. © NPUAP.) Nursing and Patient Care Considerations: Prevent Pressure Ulcer Development- 1. Provide meticulous care and positioning for immobile patients. (a.) Inspect skin several times daily. (b.) Wash skin with mild soap, rinse, and pat dry with a soft towel. (c.) Lubricate skin with a bland lotion to keep skin soft and pliable. (d.) Avoid poorly ventilated mattress that is covered with plastic or impermeable material. (e.) Employ bowel and bladder programs to prevent incontinence. (f.) Encourage ambulation and exercise. (g.) Promote nutritious diet with optimal protein, vitamins, and iron.

This Citation pertains to Intake Number MI 094 Based on interview and record review, the facility failed to assess, monitor, prevent and timely treat Urinary Tract Infections ([CONDITION(S)]) for three residents (Resident #30, Resident #32 and Resident #34) of three residents reviewed for catheter care, resulting in a lack of assessment and monitoring for development of infections, multiple hospitalization s, deterioration in health status, pain, suffering and preventable decline. Findings include: Resident #30: According to admission face sheet, Resident #30 was a [AGE] year-old male, admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . According to Minimum Data Set (MDS) dated [DATE], Resident #30 was not scored on the Cognition Assessment, indicating severe Cognition Impairment. Resident #30 required two staff assistance with bed mobility, transfers, and toilet use. During facility tour on [DATE] at 3:45 PM Resident#30 was observed in his room. Upon entrance to the room television was noted to be on and loud. Resident #30 was lying in bed with eyes partially open, and mouth open, positioned slightly to his right side. A Foley catheter was hanging on a left side of the bed, had dark amber color urine in it. A folded towel was noted positioned on resident's neck covering tracheotomy. When addressed resident did not respond. Upon further observation resident was found to be deceased . At 3:50 PM on [DATE] nurse in care, LPN A, was interviewed. She confirmed that Resident #30 passed away at 12:48 PM that day. Resident #32: During facility observations on [DATE] at 9:45 AM Resident #32 was lying in her bed watching television. Wound care team exited the room a minute prior. Resident #32's Foley catheter was observed on the floor on resident's right side of the bed. When asked about her catheter care Resident#32 stated that it bothers her when she is wearing briefs. Resident #32 pulled her bed sheet down and showed her inner thighs area. Visible redness was observed on both sides with white flaky skin. Catheter tube was secured to resident's right mid-thigh. Resident #34: On [DATE] at 10:05 AM Resident #34 was observed sitting in a wheelchair in his room solving a word puzzle. When asked if he has some time to talk resident stated he will be available later. Foley catheter was observed hanging on resident's left side of the wheelchair with catheter's bottom resting on the floor. During an interview on [DATE] at 10:30 AM, the DON stated those nurses are expected to hang Foley catheter bags after completing care. Foley bags should not be placed on the floor or touching it. Resident #30: Review of Resident #30's Care Plan revealed the following: Focus: Resident is at risk for urinary tract infection and catheter -related trauma: indwelling catheter 16 Fr (created on [DATE], initiated on [DATE], revision on [DATE]) Goal: -Will show no s/s of Urinary infection through review date (initiated on [DATE], revision on [DATE]) -Catheter will remain patent and without complications through the review date (initiated on [DATE], revision on [DATE]) Interventions: -Change catheter and tubing per facility policy (initiated on [DATE], revision on [DATE]) -Ensure catheter tube is secure (initiated on [DATE], revision on [DATE]) -Ensure dignity bag covering drainage bag (initiated on [DATE]) -Observe for/document/report s/sx of discomfort on urination and frequency (initiated on [DATE]) -Observe/document for pain/discomfort due to catheter (initiated on [DATE], revision on [DATE]) -Observe/record/report to physician foe s/sx [CONDITION(S)]: pain, burning, frequency, blood-tinged urine, cloudiness, no output, deepening of urine color, increased pulse (HR), increased temp, foul smelling urine, fever, chills, altered mental status, change in behavior, change in eating patterns (initiated on [DATE], revision on [DATE]) -Position catheter bag and tubing below the level of the bladder. Check tubing for kinks each shift (initiated on [DATE], revision on [DATE]) -Provide catheter care per policy (initiated on [DATE], revision on [DATE]) Physician's History and Physical note dated [DATE] had following Resident #30's history: He (Resident #30) was admitted to the hospital from [DATE] to [DATE] after presenting to ER (emergency room ) from [facility] because he was found to be Covid-19 positive and septic. He was treated at the hospital for severe [CONDITION(S)] (likely source: urine, treated with [MEDICATION(S)], [MEDICATION(S)]). Provider's note dated [DATE] revealed: Patient being seen today for follow up on hematuria (blood in urine) noted in Foley bag. Recent trauma to penis head from Foley earlier this week with bleeding immediately after. Hematuria noted again by staff last night. On exam patient appears comfortable. No signs of acute distress. Assessments and Plans- Acute [MEDICATION(S)] with hematuria, positive suprapubic tenderness. Obtain UA (urine analysis), with culture and sensitivity, CBC, BMP. Upon further review of Resident #30's record there was the following laboratory documentation: On [DATE] urine sample was collected per order. Results were reported on [DATE] as Rejected specimen, specimen not suitable for analysis. No follow up laboratory results for urine analysis were found in records. On [DATE] Urine analysis specimen was sent to laboratory. Results were reported on [DATE] as Rejected specimens, specimen not suitable for analysis. No follow up laboratory results for urine analysis were found in records. From [DATE] till [DATE] Resident #30 did not have a urine analysis test result for providers to assess and evaluate for presence of infection/bacteria in urine for a resident with a history of [CONDITION(S)]'s, chronic urinary catheter, and a history of urine bacteria induced [CONDITION(S)] (In [DATE]). There was nursing note dated [DATE] at 1:00 AM: Blood pressure (BP) ,d+[DATE], Heart rate (HR) 120, Temp 99.8, respirations 40, O2 97%. Right leg twitching, diaphoretic. Suctioned x 2 with return. Coughing on and off, not clearing secretions, HOB (head of the bed) elevated. Nurse Practitioner followed up with Resident #30 on [DATE]: Physical examination- BP ,d+[DATE], Temp 97.4 F, HR 103, Respiration 16, O2 98%, Blood sugar 97 (value from [DATE] at 4:45 PM) General: Patient is a [AGE] year-old male being seen today to follow up on Chest X-ray results. Nursing reported to on call provider that patient had right leg twitching and was diaphoretic. Chest X-ray, [MEDICATION(S)] level, CBC (complete blood count) and BMP (basic metabolic panel) ordered. Chest X-ray was negative for acute process, labs pending. This morning aid notified blood in his brief and by anus. On exam patient is note with hemorrhoids, no active bleeding at this time. Right leg twitching has resolved. Patient appears comfortable. Exhibits no signs or symptoms of acute distress. Reviewed Chest X-ray with patient (Resident #30 unable to communicate and has severe cognitive impairment) and nursing. Ordered Preparation H as needed for hemorrhoids. VSS (vital signs stable) HR RRR (regular rate and rhythm), afebrile. Respirations are regular and non-labored, bilateral lungs are CTA (clear to auscultation). Case discussed with nursing; no acute concerns reported. Record review revealed laboratory values from [DATE] indicating elevated White blood cell count, critically low Hemoglobin, elevated BUN and BUN/creatinine ratio (results indicative of infection, [CONDITION(S)] and compromised kidney function). No urine analysis was found within lab results. On [DATE] there was a Change in condition note: Patient was breathing fast, pulse rate in the ,d+[DATE], along with abnormal labs from [DATE]. Resident #30 was hospitalized on [DATE] per family request. Hospital physician note dated [DATE] revealed: Resident presented to the hospital from SNF for fever, [CONDITION(S)], [CONDITION(S)], and overall decline in health. In ER patient received IV (intravenous) [MEDICATION(S)] IV crystalloid fluid per [CONDITION(S)] protocol. He continued to be [CONDITION(S)] and hypotensive afterwards. The patient was admitted to ICU (intensive care unit) for management of septic shock secondary to infected pressure ulcers and [CONDITION(S)] evident on urine analysis. T 37.2, 39.3 C, HR 121, RR 46, BP ,d+[DATE]. Patient pale, clammy, tachypneic; tracheotomy tube in situ with thick secretions. HR fast, regular rhythm, normal S1 S2. Two Sacral decubitus ulcers and bilateral pressure ulcers over ischial tuberosities, all are stage 4 with pustulous base (pus filled blisters), largest measuring 15 x 10 cm and smallest 3.3 cm, surrounding skin dark hairless. Assessment/Plan: 1. Septic shock 2. Pressure ulcer of hips 3. Sacral decubitus ulcers, all stage 4 4. [CONDITION(S)] 5. Chronic Foley 6. Acute kidney injury (Creatinine on arrival 3.6 with [CONDITION(S)] and acidosis, creatinine worsened today [DATE] to 4.2) 7. [CONDITION(S)] (without EKG changes) 8. High anion gap metabolic acidosis 9. [CONDITION(S)] Hgb 6.8, got blood transfusion On [DATE] Critical Care progress note by physician revealed: Patient is admitted to ICU (intensive care unit) for management of septic shock secondary to infected pressure ulcers and [CONDITION(S)] evident on urine analysis. Resident #30 was discharged from acute care to the facility on Hospice care on [DATE]. Resident #30 suffered significant decline in condition and died at the facility on [DATE]. Review of facility provided Indwelling urinary catheter (Foley) care and management Policy revealed: Catheter-associated urinary tract infection (CAUTI) is the most common type of health care-associated infection in adult patients. Complications associated with indwelling urinary catheter use, besides CAUTI, include [CONDITION(S)] trauma, epididymitis (inflammation at the back of the testicle in men), retained balloon fragments, bladder fistula (with prolonged use), bladder stone formation, and incontinence. Resident #32: A review of Resident #32's medical records revealed an admission into the facility on [DATE] with a readmission on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the Minimum Data Set (MDS) assessment revealed intact cognition with a Brief Interview of Mental Status (BIMS) score of ,d+[DATE] and needed extensive assistance with bed mobility, transfer, dressing, toilet use and personal hygiene. Further review of the medical record revealed the Resident had a urinary Foley catheter. A review of the orders for Resident #32 revealed the following: -Order date [DATE], Change Foley and collect UA w/C&S (with culture and sensitivity) one time only for Dysuria, SPT (suprapubic tenderness), chronic Foley for 2 Days. -Order date [DATE], Change Foley and collect UA w/C&S one time only for Dysuria, SPT, chronic Foley for 1 Day. -Order date [DATE], Change Foley Catheter and obtain UA/C&S Lab Requisition in book one time only until [DATE]. -Order date [DATE], Change Foley and obtain UA w/C&S, CBC (blood count) BMP (basic metabolic panel) one time only for Flank pain for 7 Days. Review of the medical record for Resident #32 revealed the following progress notes: -Date [DATE], Nurse Practitioner, .Retention of urine, unspecified: Chronic indwelling Foley catheter. Suprapubic tenderness, dysuria. Nephrology recommendations reviewed. Change Foley and obtain UA with culture and sensitivity . -Date [DATE], 5:59 AM, Foley catheter [20 French] changed and UA obtained, urine noted clear yellow with no sediments noted, resident tolerated well. Lab techs in building for pick up. Further review of the medical record revealed a lack of urine culture and sensitivity results. On [DATE] at 4:02 PM, the Director of Nursing (DON) was asked about the lab results for the UA on Resident #32 for the ordered UA with C&S for [DATE] and [DATE]. The DON indicated that the labs were in the lab portal and looked up the results. The DON indicated the UA was obtained on [DATE] and received by lab on [DATE] but was rejected. When asked why the UA specimen was rejected, the DON was unsure and unable to find documentation in the medical record of why the specimen was rejected, that the Provider was notified, or if another specimen had been collected. The DON was asked when a urine specimen should be collected after being ordered. The DON stated, Within 24 hours. A concern was discussed with the DON of the lack of follow through with the ordered laboratory testing to detect a potential urinary tract infection and lack of identification and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #34: A review of Resident #34's medical record, revealed an admission into the facility on [DATE] with a re-admission on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the MDS assessment revealed a BIMS score of ,d+[DATE], that indicated intact cognition, and needed limited assistance with bed mobility and transfers and needed extensive assistance with dressing, toilet use and personal hygiene. Further review of the medical record revealed the Resident had an aerobic wound culture obtained on [DATE] from skin surrounding existing suprapubic catheter insertion site. Review of the progress notes for Resident #34 revealed the following: -Dated [DATE], progress note from Nurse Practitioner (NP), .Patient is being seen today to follow-up on drainage around suprapubic catheter. Maleodorous green drainage around suprapubic catheter site reported by staff, unclear exact duration .Suprapubic catheter draining cloudy yellow urine. Malodorous black-green drainage noted on gauze. Mild [CONDITION(S)] around site . -Dated [DATE], Aerobic wound culture obtained from skin surrounding existing suprapubic catheter insertion site per NP order . -Dated [DATE], progress note from NP, .Patient is being seen today to follow-up lab results. Recent drainage around suprapubic catheter reported by staff. UA and C&S and site culture obtained. Culture results pending . Given drainage around site will start [MEDICATION(S)] to coverage possible pseudomonas; will adjust PRN (as needed) based on C&S . -Dated [DATE], Progress note from NP, .C&S report from wound surrounding PEG site reviewed. Will d/c [MEDICATION(S)] and start [MEDICATION(S)] x 7 days for appropriate antimicrobial coverage . -Dated [DATE], (Name) NP notified regarding moderate green drainage present to resident's suprapubic catheter dressing. Resident reports increased discomfort to insertion site. Awaiting orders for possible wound culture. Review of the orders revealed no wound culture ordered or obtained. No further documentation or follow-up documented on the green drainage and discomfort at the suprapubic catheter site. -Dated [DATE], Progress note from NP, .seen today to follow-up on drainage around suprapubic catheter. On exam this morning patient is sitting up in wheelchair at bedside . Patient's suprapubic catheter site has dressing with small amount serous drainage noted on dressing . -Dated [DATE], progress note from NP, .There is maceration in multiple areas around suprapubic cath site with small amount of yellow/clear drainage on dressing; order for [MEDICATION(S)] was placed by oncall d/t reports of thick yellow drainage . [MEDICATION(S)] Ointment 500 unit/gm: Apply to per additional directions topically every day shift for Around suprapubic catheter for discharge for 5 days around suprapubic catheter .Apr (April) 28, 2022 to [DATE] . -Dated [DATE], Writer observed yellowish thick discharge with a odor from Resident suprapubic catheter site. On call (name) NP notified. New order for [MEDICATION(S)] Ointment, daily, for x 7 days. Will continue to monitor. -Dated [DATE] at 3:26 PM, Nurses Notes, Residents surrounding skin to his suprapubic catheter is very red and inflamed, tender to the touch and had a large amount of drainage. -Dated [DATE] at 11:10 AM, Nurses Notes, Appointment with urological services scheduled for today at 1:15 PM . -Dated [DATE] at 5:36 PM, Nurses Notes, Pt returned from urology appointment, no new orders or paperwork. Suprapubic catheter intact, flowing clear yellow urine, no drainage noted. Pt denies pain or discomfort. -Dated [DATE] at 6:11 PM, Nurses Notes, Pt was recently. Urology office called and faxed over script for [MEDICATION(S)] ,d+[DATE] mg BID x 10 days. Order entered. On [DATE] at 4:23 PM, an interview was conducted with the DON regarding Resident #34's suprapubic catheter. A document in the Resident's medical record from the Urology appointment was reviewed with the DON. The document dated [DATE] was an email communication and revealed the Resident was started on [MEDICATION(S)] and to stop the [MEDICATION(S)] and that only one of the bacteria will be taken care of by the [MEDICATION(S)]. The DON was asked if the Resident had been on [MEDICATION(S)]. The DON reported there had not been an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . When queried regarding the bacteria causing the infection, tracking for infection control purposes and if precautions were initiated, the DON indicated that the Resident did not come back with any paperwork on [DATE], had returned later in the day and that the office was probably closed after the Resident returned from the appointment. The DON indicated that the office had not been called and that the Resident was to return to the urologist on the 21st of June and stated, We would not look at that till Monday and he was going out on Tuesday again. When asked what is usually done when the Resident comes back from appointments with a specialist, the DON stated, We would call the office, but indicated the office was probably closed when the Resident returned. When asked if the Physician had an answering service to call, the DON was unsure if the office had that service. When asked if any communication was provided regarding the bacteria involved, the DON indicated they did not receive documentation and that they would call the Urologist to inquire. The DON was asked regarding identification and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . The DON reviewed the medical record and reported a culture and sensitivity was not ordered or obtained for the area around the suprapubic catheter for those dates. When asked about treatment to the suprapubic catheter site prior to awaiting to see the urologist, the DON reviewed the medical record and indicated there was no treatment prior to the urology appointment until started on the [MEDICATION(S)] on [DATE]. On [DATE] at 2:55 PM, an interview was conducted with the DON regarding Resident #34's culture and sensitivity results. The DON indicated they had called the Urologist office for the test results and that one of the bacteria was mirabilis but was unable to remember the other bacteria and reported the Infection Control Preventionist was notified, and isolation precautions were not indicated. A review of the Microbiology report for Resident #34, with a date on [DATE] of a urine culture and sensitivity with organism: Enterobacter cloacae complex and Proteus mirabilis with Enterobacter cloacae complex susceptible and Proteus mirabilis resistant to [MEDICATION(S)]/[MEDICATION(S)] ([MEDICATION(S)]). A culture and sensitivity for the area around the suprapubic site was not received from the facility. On [DATE] at 4:30 PM, an observation was made with Unit Manager C of Resident #34. The Resident was laying in bed. The dressing over the suprapubic site was clean, dry, and dated [DATE]. The dressing did not have any drainage. When questioned, the Resident indicated the nurse had just changed the dressing and denied pain at the site of the catheter.

This Citation Pertains to Intake Number MI 073. Based on interview and record review, the facility failed to ensure that Foley catheter care was provided according to standards of practice for one resident (Resident #1) of four residents reviewed for catheter care, resulting in a hospitalization for Resident #1 with mold present in the Foley catheter, a urinary tract infection ([CONDITION(S)]) and [CONDITION(S)]. Findings include: Resident #1: A review of Resident #1's medical record, revealed an admission into the facility on [DATE] and readmission on 11/15/21 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the Minimum Data Set assessment revealed the Resident had severely impaired cognition and was total dependent with transfers, dressing, eating, and bathing. Further review revealed the Resident had a PEG tube, [CONDITION(S)], and a Foley catheter. Further review of the medical record revealed the Resident was discharged to the hospital on 9/17/21 for dislodgement of a [CONDITION(S)] tube. A review of Resident #1's medical records revealed the following: -Date of Service 9/17/2021 at 11:54 AM, .History of present illness: .Patient lives in a nursing home he is nonverbal, he has contractures he is bed bound. He came to the hospital due to having dislodgment of his inner cannula on his trachea unable to be replaced by nursing staff. He was seen urgently in the emergency room by his surgery team it was replaced he has been stabilized. He also met [CONDITION(S)] criteria diagnosed with [CONDITION(S)] started on broad-spectrum antibiotic. He is more stable now he is now afebrile he seen and examined emergency room there is no family present, again he is nonverbal he opens his eyes to painful stimuli. I discussed with the emergency room nurse I reviewed the record and paperwork form the nursing home. Patient looks disheveled he is clammy he has bilateral purulent drainage in both eyes. Foley catheter tube is cloudy with significant amount of sediment. Patient is covered in foul-smelling urine. - .Interval History/Progress (Subjective) Comments: 9/18/2021 RN (Registered Nurse) states they attempted to exchange foley but met a lot of resistance and there is significant mold and foul smell coming from the tube, awaiting urology. Having low grade fevers but has been opening his eyes and more responsive this morning. 9/19/2021 I was called by RN 9/18/2021 and informed that the PEG was clogged and unable to flush or give medications after multiple attempts. Spoke with RN this am, PEG now working well. Urology did come and exchange the foley . -Urine Culture, collected on 9/17/21 with Last Updated on 9/19/21, . Isolate 1, >100,000 CFU/mL [CONDITION(S)]. A review of the medical record for Resident #1 revealed a lack of documentation for the changing of the Foley catheter. The Resident had an order to change the Foley catheter as needed. A review of the care plan revealed a Focus for (Resident #1) is at risk for urinary tract infection and catheter-related trauma: indwelling catheter 16 Fr (French), with a revision date on 7/28/21, with a Goal of Catheter will remain patent and without complications through the review date, and Will show no s/sx (signs and symptoms) of Urinary infection through review date, with revision on 6/18/21. The Care Plan had interventions to Change catheter and tubing per facility policy, revised on 6/18/21, Observe/record/report to physician for s/sx [CONDITION(S)]: pain, burning, frequency, blood tinged urine, cloudiness, no output, deepening of urine color, increased pulse, increased temp, foul smelling urine, fever, chills, altered mental status, change in behavior, change in eating patterns, and Provide catheter care per policy, revised on 6/18/21. On 11/17/21 at 1:45 PM, an observation was made of Resident #1 lying in bed. The Resident was awake with eyes open but did not respond to conversation. The [CONDITION(S)] tube appeared to be in place and the dressing was clean and intact. An observation was made of the Foley catheter hanging on the side of the bed, the tubing was clean and there was dark yellow urine that appeared to be slightly cloudy. The room and Resident did not smell of urine or have a foul odor. On 11/19/21 at 12:59 PM, an interview was conducted with the Director of Nursing (DON) and Unit Manager, Assistant Director of Nursing (ADON) A regarding Resident #1's catheter care. The DON was asked about the facility policy for changing Foley catheters. The DON reported that they change them as needed, the nurse would assess the need, if there is any heavy sediment they would notify the Doctor, and have it changed out and that the catheters should be monitored every shift even if not doing the care for them. The DON indicated that the CNA (Certified Nursing Assistant) would be responsible for emptying the bag and clean them daily and report any abnormal's to the nurse. The hospital records were reviewed with the documentation that the Resident had mold in the catheter. The ADON stated, That was not reported by anyone (nursing staff). I don't know how they would have missed something like that. When asked when the Resident had the Foley catheter last changed, the DON reviewed the medical record and stated, I did not see that he had his catheter changed in September at all. The DON indicated that changing the catheter was usually documented on the Treatment Administration Record (TAR). After review of the medical record the DON stated, Does not look like they changed it in August either. June was the order to change the catheter, it's ordered as needed. July, he didn't have it changed then either. He could have had it changed when he was out at the hospital as well. The DON and ADON were unable to verify if the catheter had been changed after looking back through the documentation to June 2021. A review of facility policy titled, Catheter Associated Urinary Tract Infection (CAUTI) Prevention,, revised 8/2021, revealed, Policy: To ensure appropriate technique in the care and maintenance of indwelling catheters . 14. Do not routinely change indwelling catheters or drainage bags except when clinically indicated .

This Citation pertains to Intake Number MI 228. Based on observation, interview and record review, the facility is placed in Immediate Jeopardy for 1) Its failure to assess, monitor and change a dressing, that was saturated with drainage from a surgical wound, on the upper left chest and a surgical wound on the left lower leg and 2) Its failure to apply a wound vac to the surgical wound on the left lower leg as ordered for one resident (Resident #1) of six residents reviewed for wound care. This deficient practice increased the likelihood of infection causing serious harm (sepsis, shock, organ failure), serious injury (loss of a limb) and/or death. Immediate Jeopardy: Resident #1 was readmitted from the hospital on 07/14/21 with physician's orders for the placement of a wound vac to the surgical site on the left lower leg. The wound vac was not applied until 07/16/21 and wound dressings to the left lower leg and anterior chest wall, which were saturated with drainage, were not changed until 07/16/21. Resident #1 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #1 also had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . The Immediate Jeopardy (IJ) begun on 07/14/21. The Immediate Jeopardy was identified on 07/16/21 at 4:30 PM. The Administrator was notified of the Immediate Jeopardy on 07/16/21 at 8:35 PM and was asked for a plan to remove the immediacy. The IJ was removed on 07/16/21 based on the approval and implementation of the facility's Removal Plan as verified onsite on 07/16/21. Findings include: Resident #1: A review of Resident #1's medical record, revealed an admission into the facility on [DATE] with a re-admission on 7/14/21 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the Minimum Data Set (MDS) assessment revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated that the Resident was cognitively intact. Further review of the MDS revealed the Resident needed extensive assistance with bed mobility, transfers, dressing and toilet use. According to [NAME] Hopkins Medicine, copyright 2021, Vacuum-Assisted Closure of a Wound .A type of therapy to help wounds heal. It's also known as wound VAC. During the treatment, a device decreases air pressure on the wound. This can help the wound heal more quickly .A wound vacuum device removes this pressure over the area of the wound. This can help a wound heal in several ways. It can gently pull fluid from the wound over time. This can reduce swelling, and may help clean the wound and remove bacteria . On 7/16/21 at 3:00 PM, an observation was made of Doctor E entering Resident #1's room and then exiting the room shortly after entering. The Resident was in an isolation room that required PPE (personal protective equipment) of an isolation gown, gloves, N95 mask, and face shield/goggles. After the Physician had exited the Resident's room, an observation was made of the Resident sitting up on the side of the bed. The Resident had dried and wet areas on the front of his gown of bloody drainage that encompassed the top left chest and upper abdomen area of the gown. The neck of the gown came down low over the front and the Resident's dressing on his left upper chest was exposed. The edges of the taped area of the ABD dressing were curled and exposing the packing at the incision area. The dressing was soiled and appeared to be saturated with bloody drainage. When asked when the dressing was last changed, the Resident reported it was changed during the night. An observation was made of the Resident positioned with his left leg up with his ankle/side of his calf resting on his right leg. His right leg had on a prosthesis for a below the knee amputation and there was a folded towel positioned underneath the dressing of the right lower leg. The towel was observed to have a wet soiled area with drainage from the wound that seeped through the dressing on the Resident's left lower leg wound. The soiled area on the towel encompassed a large area and when the Resident showed the towel, the drainage from the dressing had soaked through multiple layers of the folded towel. The underside of the dressing was wet and saturated with drainage that discolored the dressing and towel. The drainage was a tan color. An observation was made of the fitted sheet on the Resident's bed that had the same colored soiled area where the Resident's left leg would rest in bed when lying down. The Resident was asked when the dressings had soaked through with drainage and the Resident reported sometime during the night the dressings on his chest and leg had drainage that came through the dressing and indicated it had been wet since he woke up in the morning. The Resident explained that when he was sleeping, he had his leg up in the bed and the drainage had come through to the fitted sheet. The Resident reported that two staff had been in to put on the wound vac earlier, sometime after breakfast, but had realized parts were missing from the wound vac and the wound vac dressing had not been done. When queried if the dressings to the left lower leg and upper left chest area had been changed at that time, the Resident stated, No. When queried if the dressings were soiled when staff was in, the Resident reported both dressings had been visibly soiled since this morning. The Resident was asked if the Physician had looked at the dressings and the Resident reported she had not taken a look at the dressings but indicated that he had been sitting up on the side of the bed as he was during this interview, when the Physician had been in. When queried if the Physician indicated his dressings needed to be changed, the Resident reported she had not. When asked about the wound vac, the Resident reported he had a wound vac on and they took it off at the hospital prior to discharge from the hospital on 07/14/21 and it was to be placed back on when he got to the facility. The Resident reported admitting to the facility later in the afternoon on 07/14/21. The Resident reported that the wound vac had not been placed back onto the left lower leg wound since arrival to the facility on [DATE]. The Resident reported that he had [CONDITION(S)] and had multiple surgeries to both areas. He originally came to the facility after being in the hospital and had a wound vac to the leg wound prior to going out to the hospital. The interview with the Resident had lasted approximately 45 minutes and during that time, no staff arrived to change the dressing on the Resident's chest or left lower leg or change the soiled linen. On 7/16/21 at 5:30 PM, an observation was made of Resident #1 sitting up on the side of the bed. The front of the Resident's gown had more bloody drainage than what was observed at 3:00 PM. The dressing to the left lower leg had more drainage noted on the dressing and the Resident had the same towel with more drainage noted on the towel. The Resident had a gripper sock on and when queried, the Resident indicated the sock was wet with drainage from the wound. The soiled bed linen had not been changed. The top of the left anterior chest dressing was not secured and the wound packing was visible. The Resident lifted his gown and the Resident's chest and abdomen were observed to have bloody drainage dripping down from the saturated dressing. On 7/16/21 at 5:40 PM, the Assistant Director of Nursing (ADON) K was asked why Resident #1 did not have a wound vac for the wound on the left lower leg. The ADON indicated that the plug for the wound vac was missing. When queried regarding the dressing change for Resident #1, the ADON indicated they were going to be in to apply the wound vac. The ADON reported they had been in earlier, before lunch, to put on the wound vac, then realized the cord was missing. When queried if the dressings had been changed at that time, the ADON reported they had not changed the dressing. On 7/16/21 at 5:45 PM, ADON K was observed changing the dressing to Resident #1's left lower leg with Nurse J assisting. The wet sock was removed and the saturated dressing was removed. The Resident had a large open area on the outer calf with muscle exposed and the tendon exposed. A Xeroform dressing was over the tendon. The Xeroform dressing fell to the floor, ADON K picked up the dressing and threw it away then applied the new Xeroform dressing onto the exposed tendon. The Nurse did not change her gloves or perform hand hygiene after taking off the old dressing and picking up the Xeroform dressing that had fallen on the floor before applying the wound vac dressing. The ADON secured the dressing and wound vac. After confirming the wound vac was working properly, the ADON reached underneath the isolation gown with her gloved hands and removed a pen from her pocket to date the tag with the date of the wound change. The ADON then replaced the pen back into her pocket. The ADON removed the dressing to the left chest area and cleaned the bloody drainage on the chest/abdominal area of the drainage from the saturated dressing. The ADON did not change her gloves after removal of old dressing and cleaning the drainage off of the chest/abdomen prior to applying packing into the open area of the surgical wound and applying the new dressing. After completion of the dressing change, the Resident's left leg was positioned on the bed linen that was soiled. After cleaning the area of debris from the dressing change, Nurse J positioned a pad underneath the Resident's left leg and over the top of the soiled fitted sheet. The Nurses left the room. The Resident was asked if drainage from the wounds usually seep through the dressings. The Resident reported that drainage does come through sometimes but that staff only change the dressing once a day and does not recall having them change the dressing more often. When queried what time he had arrived at the facility on 7/14/21 the Resident stated, In the afternoon about 5 or 6. The Resident was asked if the facility knew he was returning and stated, yup. When asked if they knew he was to have the wound vac when he returned, the Resident stated, Yes, and indicated the hospital took it off prior to him leaving and that the facility was to put it back on when he got here. On 7/16/21 at 6:35 PM, an interview was conducted with Nurse L who was assigned care of Resident #1. When queried regarding when the dressing was last changed, the Nurse reported the date on the dressing was today's date and that the nightshift had changed it. The Nurse reported that the nightshift was there from 7:00 PM to 7:00 AM but did not know what time the dressing had been changed. When queried about the dressing being saturated, the Nurse stated, It was not draining earlier that much. I asked if it was draining that much at the hospital. I have not seen it that saturated before. A review of the Residents medical record did not reveal an order to do a dressing change after the physician had seen the Resident earlier at 3:00 PM. On 7/16/21 at 4:30 PM, a record review revealed an order dated 7/15/21 for L (left) Lower Extremity: Cut Xeroform gauze to fit the wound bed, and place inside wound bed. Cut foam to fit inside bed and place overtop of the Xeroform. Place [MEDICATION(S)] transparent dressing over the foam. Cut small slit in the [MEDICATION(S)] to attach wound vac suction tubing. Set for 125 mmHg, every night shift every Mon (Monday), Wed (Wednesday), Fri (Friday) for wound care, with a start date on 7/15/21. A review of hospital discharge instruction document titled, After Visit Summary, with a printed date on 7/14/21 at 10:12 AM, revealed, . Active Lines/Drains/Airways/Wounds at Discharge . Negative Pressure Wound Therapy (wound vac.) Leg Left; Lower; Outer . There was no other order for a dressing to the left lower leg, except for the order for the wound vac, in Resident #1's medical record or on the After Visit Summary from when the Resident readmitted from the hospital. A review of Resident #1's progress notes revealed the following: -7/1/21 Date of Service, Progress Notes, Visit Type: Wound Care . history of [CONDITION(S)], hypertension, [CONDITION(S)], on [CONDITION(S)], type 2 diabetes mellitus, below-knee amputation right leg 2018, GERD, obesity, left great toe amputation. Patient's recent admission to the hospital from 5/8/21-6/1/21 for management of left anterior chest [CONDITION(S)] and chronic wound of left lower extremity. Patient underwent multiple operations during his hospitalization s for his wounds. Wounds have been managed with wound vac's. Patient was discharged to inpatient rehab on 6/1/2021. Patient then transferred from inpatient rehab for concern of poor wound healing and need for further debridement of chest wall. Patient has been on multiple courses of IV (intravenous) antibiotics . 1. Left lower extremity lateral calf diabetic ulcer: Measures 12.4 x (by) 6.5 x 1.0 cm (centimeters). Full thickness wound. Tendon exposed. Wound bed is majority pale red granular tissue. Wound edges with epiboly. Heavy serous drainage. 2. Left anterior chest surgical wound: measures 13.9 x 2.4 x 1.1 cm. Tunneling at 12:00 measuring 1.4 cm. Wound bed is red moist tissue. No necrosis. Evidence of sutures intact. Heavy serosanguinous drainage. Surrounding tissue hyperpigmented . Plan: Left leg: Wound VAC to be placed left calf wound. Cut black sponge to fit wound, occlusive dressing, set wound VAC to continuous pressure -125 mmHg. Change 3 times per week. Until wound VAC is applied, placed Xeroform gauze in the wound bed, pack open wound with saline moistened gauze. Cover with dry gauze and ED pad. Secure with tape. Change dressing twice daily . -7/6/21 at 12:38 AM, an eINTERACT SBAR Summary for Providers note revealed the Resident had Shortness of breath . Blood pressure: BP 221/122 . Pulse oximetry: O2 88% and Recommendations: Send to ER (emergency room ). -7/14/21 at 6:32 PM, Nursing Summary, Note Text: Patient arrive Via EMS (emergency medical service) . The Resident was readmitted to the facility from the hospital. -7/15/21 Date of Service, Progress Notes, Visit Type: Wound Care . Left anterior chest surgical wound has a moderate amount of sanguineous drainage. The wound has a moderate amount of sanguineous drainage. The wound bed itself is red and moist has no necrosis, no slough, no maceration, and sutures in place. There is a depth of 1.4 cm and a tunnel at 12:00 measuring 6.6 cm. Surrounding tissue hyperpigmented. Left lateral calf diabetic wound has a large of serous drainage. The wound bed is red granulation tissue. There are multiple exposed tendons to the site. Wound edges with epiboly . Left calf: Wound VAC every 3 days and as needed as recommended by surgeon: set to -125 mmHg . Encounter for change or removal of surgical wound dressing: Left chest : Pack with [MEDICATION(S)] daily and cover with ABD . A review of the Referral Information for Resident #1, dated 6/29/2021, revealed, .Referral Comments: Patient will be discharged with a wound vac and is a [CONDITION(S)] patient . Response: Yes, willing to accept patient . Comment: We can accommodate this patient . A review of Resident #1's orders in the medical record revealed the following: -admitted on 6/30/21: -Left leg wound care: wound vac to be placed to the left calf wound black sponge with occlusive dressing with vac set to 120-125 one time a day every Tue, Thu, Sat for changed 3x weekly with a start date 7/1/2021. -chest wound care: Pack the wound with one continuous piece of saline moistened gauze/[MEDICATION(S)], cover with dry gauze secure with tape two times a day for wound care, with a start date 7/1/2021. -Re-admission on 7/14/21: -Ordered 7/15/21, start date 7/15/21, L Lower Extremity: Cut Xeroform gauze to fit the wound bed, and place inside wound bed. Cut foam to fit inside bed and place overtop of the xeroform. Place [MEDICATION(S)] transparent dressing over the foam. Cut small slit in [MEDICATION(S)] to attach wound vac suction tubing. Set Wound Vac for 125 mmHg. Every night shift every Mon, Wed, Fri for wound care . -Ordered 7/15/21, start date 7/15/21, Monitor wound vac for proper function. Pressure to be set at 125 mmHg. Change canister if full. Every shift . -Ordered 7/15/21, start date 7/15/21, Left Chest: Cleanse with wound cleanser and allow to dry. Gently pack wound with [MEDICATION(S)] packing gauze. Cover with ABD Pad and secure with tape. Every night shift for wound care AND as needed for wound care . On 7/20/21 at 3:08 PM, an observation was made of Resident #1 sitting on his bed in his room. The Resident showed the left leg dressing and wound vac was in place. The date on the dressing was 7/20/21. When queried regarding why the dressing was dated today when it had been ordered to be changed on Monday, the Resident was unsure and reported the dressing had not been changed since Friday, 7/16/21. When queried why the dressing was not changed on Monday, the Resident reported the Nurse never came back to do it and indicated he thought the Nurse was going to come back later in the shift to do it. The Resident reported the chest dressing had been done and when asked why the leg dressing had not been done at the same time, the Resident indicated he was unsure. On 7/20/21 at 4:33 PM, an interview was conducted with the Administrator (NHA), Director of Nursing (DON) and Assistant Director of Nursing (ADON) regarding Resident #1's wounds. The observation of the saturated dressings to the chest and leg wounds were reviewed and the indication that the wound vac had not been applied upon admission on 6/30/21 and had not been applied on re-admission into the facility on [DATE]. The DON indicated that the facility was aware the Resident was to have a wound vac to the left lower leg on admission and re-admission. When queried regarding the dressing being saturated and when should the dressing be changed, the DON indicated that the dressing should be changed as ordered and if the dressing was ordered for daily, then the Nurse would call the Doctor for a PRN (as needed) dressing change. When asked at what point when drainage appears on the dressing should it be changed, the DON indicated when there was shadowing that appeared and when the wound vac was not applied to the wound, the provider should have ordered a dressing until the wound vac was able to be put on. The Resident's diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . When asked why the wound vac was not placed on re-admission on 7/14/21, the ADON reported that the cord was missing. When asked why the cord was missing, the ADON reported the Resident had come back from the hospital and did not have the right cords. The ADON reported that the Wound Care Provider had seen the Resident but was unable to place the wound vac and stated, There was no cord so she could not have put it on. The Resident's need for a wound vac was reviewed and it was determined that the facility was aware the Resident needed a wound vac prior to admission on 6/30/21 and upon admission, the charger was missing and needed to be ordered, wound care team was unable to place the wound vac when seen on 7/1/21 but the charger came in on 7/2/21 and then the wound vac was placed at that time. When queried why the wound vac was documented as applied on the Treatment Administration Record (TAR) on 7/1/21, Nurse A was asked to come in the room. The Nurse reported that the wound team came in and did the dressing on 7/1/21 and stated, I assumed they put it (wound vac) on, and indicated she did not see the wound vac but had documented that it was done. The NHA and DON reported that on 7/1/21, they realized the cord was the wrong one and one was ordered that day and the wound vac was put on 7/2/21 after the cord arrived. The Resident had gone out to the hospital on 7/6/21 and returned on 7/14/21. The DON indicated the facility was aware that the Resident needed a wound vac for both the admission and re-admission. On re-admission the cord was not available, and the wound vac was not applied until 7/16/21 at 5:45 PM when the observation was made of the dressing change. When queried why the dressing was changed today, Nurse M came in the room at 5:25 PM and stated, We were going to change his dressing changes to Tuesday, Thursday and Saturday so the wound team can see the wound and change the dressing on wound rounds on Thursday. When queried what date was on the old dressing, the Nurse stated, I took it off and threw it away, didn't look at the date. The Nurse indicated she had gotten a verbal order from the Nurse Practitioner, but the order had not been put into the medical record yet. When queried when a dressing was to be changed when drainage was present, the Nurse stated, Change if visibly soiled or not secured. Nurse C, who had the Resident on 7/19/21 and documented the dressing was changed on 7/19/21 and the Resident reported the dressing had not been changed, was called, but there was no answer. When queried if Doctor E had ordered a dressing change after seeing the Resident on 7/16/21, a review of the medical record revealed no order for a dressing change. The Resident had an admission on 6/30/21 and the wound vac was not applied until 7/2/21 and had a re-admission on 7/14/21 and the wound vac was not applied until 7/16/21. When queried if the Resident should have an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The DON was queried that the expectation was that the Resident was to have the wound vac upon admission and re-admission and the DON stated, Correct. On 7/21/21 at 12:15 PM, an interview was conducted with the DON regarding Resident #1's dressing change that was documented as completed on 7/19/21, but the Resident reported that the dressing to the left leg with the wound vac, that was scheduled to be changed on 7/19/21, had not been completed. The DON reported she had talked with Nurse C and she said she was going to change the dressing, but the resident refused but let her change the chest wound. She did not go back and change her charting until last night after I talked with her. On 7/21/21 at 12:17 PM, a phone call was made to Nurse C, with the DON present, regarding Resident #1's wound vac dressing change to the left leg. Nurse C stated, The Resident refused the dressing change, said it was all good. I took it as refusing. A review of the documented entry in Resident #1's progress notes revealed, Resident refused wounds care to lower extremity stating that it was good. However allowed writer to complete chest wound. Writer will continue to monitor. On 7/21/21 at 12:25 PM, the DON was asked about documenting treatments when not completed. The DON indicated the Nurse should not have signed out the treatment and stated, I educated her on signing out her meds or treatments until it is administered. On 7/21/21 at 1:26 PM, an interview with Physician E was conducted regarding Resident #1's wound care. When queried regarding the drainage, the Physician stated, His gown was really red, and had asked the Resident if he was doing ok and he said he was fine, I didn't think they were actively oozing though. The Physician reported that the nurses were taking care of the wounds and there was an order to have it done as needed and stated, They should take care of it as appropriate. I knew the nurses would be taking care of it, I have every confidence they would be changing the dressing. When queried regarding the wound vac not placed on the left leg wound, the Physician reported the wound was oozing as well and stated, I knew the wound vac needed to be placed and that was taken care of. The Physician indicated she had not been notified of the wound vac not being placed or that the Resident had refused his dressing change and reported the Unit Manager would be taking care of it and letting the Nurse Practitioner know. The Physician was asked about wound vac orders on admission and re-admission and the physician indicated that medications and special needs can be requested prior to the Resident coming to the facility so the quality of care is not compromised when they arrive, and indicated that if the Resident needed a wound vac then it should be placed. On 7/29/21 at 10:30 AM, an interview was conducted with Nurse Q regarding wound care. The Nurse reported that he had education as part of the plan of correction for the IJ. The Nurse indicated that saturated dressings and soiled linen was a cause for infection to develop. On 7/29/21 at 2:57 PM, an interview was conducted with Nurse Practitioner S regarding Resident #1's order for wound vac. When queried when a wound vac should be placed once ordered, the NP stated, Ideally, it would be applied right away. When queried regarding changing a dressing that is saturated, the NP reported that their standard order for dressing changes was once to twice daily and prn (as needed) depending on the drainage and reported possibly a change in type of dressing for wounds that drain a lot. A facility policy for wound vac treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the facility policy titled, Skin Management, last revised 7/2021, revealed, .Guests/residents with wounds and/or pressure injury and those at risk for skin compromise are identified, evaluated and provided appropriate treatment to promote prevention and healing . 4. Guests/residents admitted with any skin impairment will have: Appropriate interventions implemented to promote healing, A physician's order for treatment . A review of the facility policy titled, Physician's Order, revised 6/2021, revealed, Purpose: Physician orders are obtained to provide a clear direction in the care of the guest/resident . Treatment rendered to a guest/resident must be in accordance with the specific standing, written, verbal, or telephone order of a physician or other licensed health professional ordering within their scope of practice and clinical privileges . Facility Removal/Abatement Plan for IJ for F-600 received and approved on 7/16/21. A tour of the facility and review of the facility training and audits was completed on 7/16/21 to confirm enactment of the Abatement Plan that included the following: 1. Resident identified to be affected by the alleged deficient practice. Identified resident currently resides within the facility. The resident has had a (Provider) visit and wound care was provided on 7/16/21. A wound vac was applied per physician order on 7/16/21. 2. Residents with the potential to be affected by the alleged deficient practice. On 7/16/2021, the administrative nurses reviewed and validated in house residents with wound care orders. The residents that were observed with skin impairment were noted to have appropriate treatment orders in place. Wound care dressing were noted to have been completed timely per physician order. 3. Systemic Measures a) The facility policy on Skin Management, Physician Orders, and Change in status, identifying and communication, Long Term Care policy was reviewed and deemed appropriate on 7/16/2021. Reeducation to the licensed nursing staff began on 7/16/2021 at 9:00 PM. The licensed nursing staff was reeducated on the skin Management Policy, Physician Orders Policy, and Change in status, identifying and communication, Long Term Care policy, with emphasis on following physician orders and conduction dressing changes timely. Licensed nurses will be reeducated prior to the start of each shift. 4. Quality Assurance The administrative nurses will review 10% the residents that were admitted to ensure dressings are changed timely and per physician orders weekly for 4 weeks, monthly times 2 months. All concerns will be addressed immediately Findings will be reported to QA monthly for 3 months for recommendations. 5. The Administrator is responsible for sustained compliance. While the Immediate Jeopardy was removed on 7/16/21, the facility remained out of compliance at a Scope of No actual harm with potential for more than minimal harm that is not immediate jeopardy and a Severity of Isolated until compliance can be verified by the State Agency (SA).

Based on observation, interview and record review, the facility failed to operationalize policies and procedures to proactively identify prospective causes of pressure, implement timely interventions to prevent pressure ulcer development, employ appropriate infection control principles during wound care treatment, and complete wound care treatments as ordered for two resident (Resident #30 and Resident #68) of five residents reviewed for pressure ulcers (wounds caused by pressure) resulting in Resident #30 developing multiple Stage III pressure ulcers (wound with full thickness tissue loss) and Resident #68 developing an open Stage II pressure ulcer on their sacrum, verbalization of discontentment with care, unnecessary pain, and the likelihood for additional pressure ulcer development, infection, pain, and decline in overall health. Findings include: Resident #30: On 7/29/21 at 9:56 AM, Resident #30 was observed in their room in the facility in bed. The Resident was noticeably tall, and their feet were at the very end of the bed. A wound dressing was present on the Resident's left foot and the heel of their left foot was positioned directly on the mattress. The dressing was noted to have a significant amount of visible drainage and the kerlix gauze wrap was not completely covering the wound bed. An interview was completed at this time. When asked how tall they were, Resident #30 replied, 6' 6 (six feet, six inches). When queried regarding the wound on their foot, Resident #30 stated, It started here because the bed was too short. The Resident continued, I was constantly asking them (staff) to remove the bottom (footboard). With further inquiry, Resident #30 revealed their foot had been constantly pressed against the footboard causing pressure and pain. When asked, Resident #30 indicated the footboard was not removed until after they developed pressure injuries. When queried how frequently the dressing is changed, Resident #30 stated, They miss dressing changes on the weekends. When queried if they were having pain in their left foot, Resident #30 replied, Hurts, not gonna lie. A specialty mattress and/or pressure reduction devices for the Resident's heels were not observed in the room. Record review revealed Resident #30 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the Resident was cognitively intact and required extensive assistance to complete all Activities of Daily Living (ADLs) with the exception of supervision for eating. An observation of wound care treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . Prior to wound care treatment completion, NP D was queried regarding their familiarity with the Resident's wounds and replied, This is my third week here. Upon entering the room, Resident #30 was observed sitting their wheelchair. Unit Manager LPN L removed the kerlix gauze wrap and three dressings covering open wounds on the Resident's left foot. LPN L then removed the dressing covering the wound located on the lateral side of plantar (bottom) of the Resident's foot. The wound was distal to their toes, on the pad area of the foot. The removed dressing was noted to have a significant amount of copious, thick brown/green drainage with a distinct foul odor present. The wound bed was irregularly shaped with white tissue noted in center aspect of the wound bed and visible depth. The area surrounding the open wound was noted to be red in color. LPN L did not change gloves or perform hand hygiene before removing the dressing in place over the second open wound on Resident #30's foot. The second wound was on the lateral aspect of bottom of their left foot, distal to the first wound, approximately where the heel begins. The dressing removed from this wound was noted to have a moderate amount of Serosanguineous drainage. The wound bed was red in color and irregularly shaped. LPN L proceeded to remove the dressing in place over the Resident's left heel without changing their gloves or performing hand hygiene. The wound bed on the Resident's heel was open, red in color with visible white colored tissue present. The wound edges were white in color. After removing the dressings LPN L doffed their gloves and washed their hands while NP D visualized the wounds and then exited the room. NP D did not complete wound measurements. Wound measurements were completed electronically via camera image taken by LPN L. When queried regarding measurements, LPN L revealed the camera obtains length and width measurements and NP D only measures depth if needed. LPN L washed all the wounds with wound cleanser. The Resident's heel wound began bleeding after LPN L cleansed the wound bed. LPN L did not change gloves nor wash their hands between each individual, separate wound area. During the wound care treatment, Resident #30 was observed displaying facial grimacing. When queried regarding their pain level on a scale of zero to 10 (zero being no pain and 10 being the worst pain), Resident #30 stated, It's a seven. Resident #30 was then asked about pain medication and stated, Last had it at 6:00 (AM), can't have it again until noon. After performing hand hygiene and applying new gloves, LPN L wiped each open wound bed with a separate [MEDICATION(S)] cleanser pad. LPN L wore the same gloves for each separate area. LPN L then doffed their gloves and washed their hands. After washing their hands, LPN L entered the drawn privacy curtain in the room to assist Resident #30's roommate. After reemerging from the roommate's side of the room, LPN L proceeded to don new gloves and complete the dressing application for all wound areas without performing hand hygiene again. LPN L did not perform hand hygiene between application of [MEDICATION(S)] gel (wound treatment) and maxsorb (wound dressing) to each open wound. Two ABD (absorbent wound dressing) pads were placed over the plantar aspect of the Resident's left foot and their entire foot was wrapped in kerlix dressing. An interview was completed with NP D following the wound care treatment. NP D was asked when the wounds were first observed and indicated they would need to review the Resident's medical record. Review of Resident #30's medical record with NP D revealed all the wounds were facility acquired. The wounds and onset dates included: - Left Heel: 3/11/21 - Left Foot Sole (Distal to toes): 3/4/21 - Left foot Sole (Near heel): 2/25/21 Review further revealed Resident #30 also had a wound on the lateral aspect of the right plantar foot which had resolved as of 7/9/21. When queried regarding the etiology of Resident #30's wounds, NP D revealed the wounds had been classified as Diabetic Mellitus Ulcers. When asked how they determined the etiology of the wounds were from diabetes and not pressure, NP D reiterated they were not working at the facility when the wounds developed and stated, I do not change the wound (type) classification when I start somewhere. Resident #30's statements regarding the footboard of the bed creating pressure, requesting the foot board be removed and wound development were discussed with NP D at this time. With further inquiry regarding the distinction and determination of whether or not a wound is caused by pressure or diabetes mellitus, NP D indicated an individual's Hemoglobin (hbg) A1C (laboratory test which monitors blood glucose levels over a three-month timeframe) also play a role in the diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . When asked about the Resident's hbg A1C level and the wound classification, NP D stated, I wished they would have done another one (hbg A1C) level, I would have. NP D revealed the level did not reflect uncontrolled diabetes mellitus and did not correlate with the development of diabetic ulcers. Review of individual wound detail documentation images for Resident #30 was completed with NP D. During review of the images, the footboard was observed to be present in the picture on 3/25/21. When asked about the footboard being present in the image, NP D stated, Oh, that changes things. When queried if the etiology of the wound may have been pressure, NP D indicated they felt bad and stated, Yes. Review of Resident #30's health care provider orders and Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #30's Treatment Administration Record (TAR) for July 2021 revealed the following treatments: - Left Heel .cleanse with wound cleanser. apply Santyl moist gauze, place AG Pad over gauze, cover with an ABD Pad and wrap with kerlix every day shift . (Start 6/18/21; Discontinued: 7/9/21). There was no documentation of treatment completion on 7/7/21. - Left Heel: cleanse with wound cleanser. Apply AG Pad, cover with an ABD Pad and wrap with kerlix every day shift for wound care (Start 7/9/21; Discontinued 7/15/21). No documentation of wound care completion on 7/15/21. - Left plantar foot: cleanse with wound cleanser. Apply Santyl and moist gauze to wound beds, place AG Pad over gauze, cover with ABD Pad and wrap with kerlix . (Start 6/18/21; Discontinued: 7/9/21). There was no documentation of treatment completion on 7/7/21. - Cleanse Right lateral plantar foot with wound cleanser. Apply thin layer of hydrogel, cover with ABD Pad and wrap with kerlix every day shift for wound (Start 6/11/21; Discontinued: 7/9/21). There was no documentation of treatment completion on 7/7/21. - Right Lateral Plantar Foot: Apply A&D ointment to foot and keep open to air every day shift for skin protectant (Start 7/9/21). No documentation of completion on 7/15/21. Review of Resident #30's care plans revealed a care plan entitled, (Resident) is at risk for impaired skin integrity/pressure injury R/T (related to) . (diagnoses) . Left foot diabetic ulcers, Lt foot sole blister, hx (history) lateral right foot diabetic ulcer, dry skin to bilateral feet . (Initiated: 11/2/20; Revised: 7/30/21- during survey). The care plan included the interventions: - Administer medications as ordered. Observe for ineffectiveness and side effects, report abnormal finding . (Initiated: 2/23/21) - Braden scale per protocol (Initiated: 11/2/20) - Conduct weekly head to toe skin assessments, document and report abnormal findings . Initiated: 11/2/20) - Cue to reposition self as needed (Initiated: 11/2/20) - Follow facility policies/protocols for the prevention/treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] - (Resident #30) will at times decline the use of pressure offloading boots. Reapproach as needed to educate and encourage the use of (Initiated: 12/3/20; Revised: 7/18/21). - Observe left and right foot dressings frequently to ensure it is intact and adhering. Report loose dressing to nurse (Initiated: 12/21/20; Revised: 4/12/21) - Provide diet as ordered, Observe and document food acceptance and offer substitutes as needed (Initiated: 11/2/20) - Turn/reposition resident frequently and PRN (as needed) (Initiated: 11/2/20; Revised: 11/4/20). Review of Resident #30's medical record revealed the Resident did not have any wounds upon admission to the facility. Progress note documentation in the Electronic Medical Record (EMR) was only able to be visualized from 5/17/21 to present. Review of Skin & Wound Evaluation and available progress note documentation in the EMR revealed the following: - 2/25/21: Skin & Wound Evaluation . Sole Left Foot . In-House Acquired . Date: 2/25/21 . Measurements . Length: 1.2 cm (centimeters) . Width: 2.0 cm . Depth: 0.1 cm . Exudate: Light . - 3/4/21: Skin & Wound Evaluation . Location (Blank) . Measurements . Length: 3.0 cm . Width: 2.1 cm . Depth: Not Applicable . Healable . Stable . Note: Handwritten sticky note on top of the paper evaluations provided indicated, Blister Sole Left Foot. - 3/12/21: Skin & Wound Evaluation . Left Heel . In-House Acquired . Date: 3/11/21 . Measurements . Length: 0.6 cm . Width: 1.6 cm . Depth: 0.1 cm . Exudate: Light . Serous . Pain Frequency: Intermittent . - 3/12/21: Skin & Wound Evaluation . Blister . Sole Left Foot . In-House Acquired . Date: (Blank) . Measurements . Length: 5.9 cm . Width: 5.8 cm . Depth: Not Applicable . Healable . Stable . - 4/8/21: Skin & Wound Evaluation . Left Heel . Measurements . Length: 2.7 cm . Width: 2.1 cm . Depth: Not Applicable . Exudate: Light . Serosanguinous . Pain Frequency: None . Healable . Improving . Additional Care: Heel Suspension/Protection Device . - 4/22/21: Skin & Wound Evaluation . Sole Left Foot . In-House Acquired . Date: 2/25/21 . Measurements . Length: 2.8 cm . Width: 3.6 cm . Depth: Not Applicable . Eschar . Exudate: Light . Sanguineous/Bloody . Pain Frequency: None . - 4/29/21: Skin & Wound Evaluation . Blister . Sole Left Foot . In-House Acquired . Date: (Blank) . Measurements . Length: 2.6 cm . Width: 3.0 cm . Depth: Not Applicable . Granulation . Slough . Exudate: Moderate . Serosanguineous . Healable . Stable . Note: Depth visible in wound picture. -5/6/21: Skin & Wound Evaluation . Left Heel . Measurements . Length: 3.6 cm . Width: 5.3 cm . Depth: Not Applicable . Granulation . Slough . Eschar . Exudate: Light . Serosanguinous . Surrounding Tissue: Maceration . Pain Frequency: None . Healable . Stable . Additional Care: Heel Suspension/Protection Device . Turning/Repositioning program . - 5/19/21: Encounter . Skin: Multiple wounds on bilateral feet see wound care notes for measurements and details. Warm and dry otherwise . Patient instructed to ensure adequate fluid intake . - 5/20/21: Encounter . Wound . noncompliant with position changes and has been resting feet on head of bed often despite staff recommendations. Foot board has been removed. Data skin . Dry flaky skin at BLE (Bilateral Lower Extremities) . 1. Left foot plantar aspect: Resolved . 2. Right foot lateral and plantar . Measures 2.3 x 1.0 cm (centimeters). Wound bed is dry skin and scabbed tissue. Scant serosanguinous drainage . 3. Sole of left foot . Measures 3.3 x 4.3 cm. 80 % dark eschar and yellow slough and 20% red granular tissue. Unable to determine depth . Moderate serosanguinous drainage. debrided loose slough. (Mid foot) . 4. Left sole of foot blister: Measures 3.5 x 2.9 x 0.6 cm. Wound bed is 30% soft yellow and brown slough. Periphery of the wound bed with red budding granular moist tissue 70% . Moderate serosanguinous drainage. (Plantar aspect under 4/5th digit) . 5. Left heel . Measures 3.4 x 3.5 cm. Unable to determine depth. Wound bed with 70% yellow slough and 30 % red granular moist tissue at periphery. Mild maceration. Moderate serosanguineous drainage . -5/27/21: Encounter . Wound . Left foot . Wound is resolved. Continue preventative measures. Surgical shoes when ambulating. Cover with dry dressing ABD and Kerlix along with left foot sole wounds. 2. Right foot . discontinue and Kerlix daily. 3. Sole of left foot . procedure . Sharp debridement of nonvital tissue was done with #10 scalpel. Area debrided approximately 8 cm . Treatment Santyl. moist gauze, apply dry dressing with ABD and Kerlix every day. 4. Left foot sole blister: Santyl moist gauze dry dressing with ABD and Kerlix every day. 5. Left heel: Santyl and moist gauze to necrotic tissue . - 5/27/21: Skin & Wound Evaluation . Blister . Sole Left Foot . In-House Acquired . Date: (Blank) . Measurements . Length: 2.2 cm . Width: 2.8 cm . Depth: 0.9 cm . Granulation . Slough . Exudate: Moderate . Serosanguineous . Wound Pain: At dressing . Healable . Stable . Note: Depth visible in wound picture. - 6/3/21: Visit Type: Wound Care . 2. Right foot lateral and plantar aspect . measures 1.4 x 1.0 cm . Scant serosanguinous drainage . 3. Sole of left foot . Measures 2.7 x 2.6 x 2.0 cm. 50 % dark eschar and yellow slough and 50% red granular tissue. Unable to determine depth . Moderate serosanguinous drainage. (Mid foot). 4. Left sole of foot blister: Measures 2.1 x 2.6 x 0.5 cm. Tunneling noted at 2:00 measuring 1.1 cm. Wound bed is 30% soft yellow and brown slough. Periphery of the wound bed with red budding granular moist tissue 70% . Moderate serosanguinous drainage. (plantar aspect under 4/5th digit). 5. Left heel .Measures 4.0 x 2.3 x 0.2 cm. Wound bed with 40% yellow slough and 70 % red granular moist tissue at periphery . Moderate serosanguineous drainage . - 6/17/21: Visit Type: Wound Care . Foot board has been removed. Skin: positive for wounds . Santyl Ointment (prescription [MEDICATION(S)] wound treatment) . Apply to R (right) lat (lateral) foot topically every day shift . Skin . Dry flaky skin at BLE (Bilateral Lower Extremities) . 2. Right foot lateral and plantar aspect . measures 1.0 x 0.8 cm . Scant serosanguinous drainage . 3. Sole of left foot . measures 2.0 x 1.7 x 0.6 cm. 20 % yellow slough and 80% red granular tissue . Heavy serosanguinous drainage. Wound edges with epibole (rolled under closed wound edges) (Mid foot) 4. Left sole of foot blister: Measures 2.1 x 2.7 x 0.5 cm. Dimple in wound bed noted at 2:00 (o'clock) measuring 0.8 cm. Wound bed is 30% soft yellow and brown slough . Heavy serosanguinous drainage. (plantar aspect under 4/5th digit). 5. Left heel . measures 5.0 x 3.6 x 0.6 cm. Wound bed with 20% yellow slough and 80 % red granular and hyper granular moist tissue . Heavy serosanguineous drainage . - 7/1/21: Visit Type: Wound Care . 2. Right foot lateral and plantar aspect . measures 1.0 x 0.7 cm . Scant serosanguinous drainage . 3. Sole of left foot . Measures 1.8 x 2.4 x 0.9 cm. Dimple in wound 9:00 (o'clock) is 1.5 cm in depth. 10 % yellow slough and 90% red granular tissue . Heavy serosanguinous drainage. Wound edges with epibole (Mid foot). Debrided loose yellow slough . 4. Left sole of foot blister . measures 1.9 x 2.2 x 0.4 cm. Dimple in wound bed noted at 2:00 (o'clock) measuring 0.9 cm . Heavy serosanguinous drainage. (plantar aspect under 4/5th digit). Debrided small amount of yellow slough in the center . 5. Left heel diabetic ulcer: Measures 2.6 x 2.2 x 0.2 cm. Dimple in center 0.5 cm . Heavy serosanguineous drainage . Debrided loose yellow slough . - 7/15/21: Visit Type: Wound Care . Left foot sole . large amount of serosanguineous drainage. There is 20% slough . mild maceration, and a depth of 0.3 cm. Left sole blister (located closer to toes) has a moderate amount of serosanguineous drainage. The site itself has 50% necrosis, 10% slough, extensive maceration, and a total depth of 1.4 cm . Left heel . moderate amount of serosanguineous drainage. The wound itself has 10% slough . extensive maceration, and no depth due to hyper granulation . - 7/15/21: Skin & Wound Evaluation . Sole Left Foot . In-House Acquired . Date: 2/25/21 . Measurements . Length: 1.7 cm . Width: 1.7 cm . Depth: Not Applicable . Wound Bed: Slough . Exudate: Moderate . Serosanguineous . Healable . Stable . - 7/22/21: Skin & Wound Evaluation . Blister . Sole Left Foot . In-House Acquired . Date: (Blank) . Measurements . Length: 1.5 cm . Width: 2.2 cm . Depth: Not Applicable . Granulation . Eschar . Exudate: Moderate . Serosanguineous . Healable . Improving . Note: Depth visible in wound picture. - 7/29/21: Visit Type: Wound Care . Left foot, sole . mildly malodorous serosanguineous drainage . depth of 0.3 cm. Left sole blister (located closer to toes) has a moderate amount of mildly malodorous serosanguineous drainage. The site itself has 60% necrosis, no slough, excessive maceration, and no depth due to slough . Left heel . moderate amount of serosanguineous drainage 10% necrosis, moderate maceration . -7/29/21: Skin & Wound Evaluation . Left Heel . Measurements . Length: 2.6 cm . Width: 2.3 cm . Depth: Not Applicable . Wound Bed: Slough . Exudate: Moderate . Serosanguinous . Surrounding Tissue: Maceration . Pain Frequency: None . Healable . Stable . Additional Care: Heel Suspension/Protection Device . Turning/Repositioning program . On 8/4/21 at 10:36 AM, Resident #30 was observed in their room in bed. Both of the Resident's legs were hanging off of the end of the bed. A dressing was present on their left foot. When queried if they were comfortable with their legs hanging off of the bed Resident #30 replied, If my left leg hands off to long, it starts hurting. Resident #30 then stated, Yesterday I pressed my light at 6:00 (PM) and no one came until 8:00 (PM). I wanted to get pulled up because my leg was hurting me. Resident #68 On 7/28/21 at 2:16 PM, Resident #68 was observed in their room. The Resident was in bed, positioned on their back with their legs and feet positioned directly on the mattress. A Hoyer (mechanical lift) sling was observed sitting on a chair in the Resident's room. When queried regarding the level of assistance they require to get out of bed, Resident #68 stated, I used to do for myself but then I got that virus and now I'm dependent on others. Resident #68 revealed staff use the Hoyer to transfer them out of bed. When queried if they use the toilet in the room, Resident #68 stated, They let me use the bedpan. It's hard for them (staff) to get me in the bathroom. Resident #68 was asked if they knew when they needed to use the restroom and replied, Yeah. Resident #68 then stated, Have to wait a long time because they shorthanded. When I be up, I have to wait a long time to get back to bed. Resident #68 revealed they do not like to get out of bed anymore because they do not like it when they are up and cannot get back to bed. When asked if that is the reason they use the bedpan, Resident #68 stated, Yes. When queried if they had any sores on their body, Resident #68 replied, On my bottom. Resident #68 was then asked if they are able to move themselves in bed and replied, No. When queried if staff assisted to turn or reposition them in bed every couple of hours, Resident #68 replied, No. A specialty mattress and/or any other pressure reduction devices were not observed in the room. Record review revealed Resident #68 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of MDS assessment dated [DATE] revealed the Resident was cognitively intact and required extensive assistance to perform all ADLs with the exception of eating. The MDS further revealed the Resident was at risk for pressure ulcer development but did not have any skin alterations. Review of Resident #68's care plans revealed a care plan entitled, (Resident #68) is at risk for impaired skin integrity/pressure injury R/T (Related To): Decreased mobility, DM2 (diabetes mellitus), OA (Osteoarthritis), [CONDITION(S)]/paresis after (stroke) affecting left side . does not like to take rests in bed during the day and spends most of time in wheel chair . (Initiated: 4/13/20; Revised: 4/14/20). The care plan included the interventions: - Complete weekly head to toe skin assessments, document, and report abnormal findings to the physician (Initiated: 2/28/19) - Observe dressing frequently to ensure it is intact and adhering. Report loose dressing to nurse. (Initiated: 6/28/21) - Provide incontinence care with each incontinent episode and as needed and apply moisture barrier cream/ointment per facility policy/orders (Initiated: 2/16/19) - Treatments per orders (Initiated: 8/19/20) - Turn/reposition resident frequently (Initiated: 2/16/19) Review of Resident #68's Treatment Administration Record for July 2021 revealed a treatment, Barrier cream to buttocks q (every) shift and PRN (as needed) every shift for skin care (Start Date: 5/11/21). There was no documentation of treatment completion on 7/11/21 night shift, 7/13/21 night shift, and 7/14/21 evening shift. Review of Resident #68's progress note documentation on 7/30/21 revealed the Resident did not have any open wounds. On 8/4/21 at 10:18 AM, Certified Nursing Assistant (CNA) O entered Resident #68's room without knocking or announcing themselves. CNA O walked past the Resident's bed without acknowledging them and entering their roommate's area of the room. Resident #68 was observed laying in their bed, positioned on their back. Their legs and feet were positioned directly on the mattress. An interview was completed at this time. When asked if staff frequently enter their room without knocking or requesting permission to enter, Resident #68 indicated it depended upon the staff member. When queried how they were doing, Resident #68 stated, Supposed to get me back up today. The last time they got me up, they didn't put me back to bed until 7:00 (PM). Resident #68 indicated they were hesitant to get out of bed for that reason. Review of Resident #68's progress note documentation on 8/4/21 revealed the following: - 8/4/21 at 4:27 AM: Nurses' Notes . Resident has a open wound Coccyx . wound consult order was put in. On 8/4/21 at 4:00 PM, an interview was completed with the Director of Nursing (DON). When queried which Resident had developed an open wound on the 500-hall and the etiology of the wound, the DON replied, Not sure. An interview was completed with Licensed Practical Nurse (LPN) A on 8/4/21 at 4:10 PM. When queried regarding Resident #68's progress note documentation indicating the Resident had developed a new open area on their coccyx, LPN A stated, What? I'm the nurse and no one told me. An observation of the Resident #68's open wound was completed with LPN A at this time. Upon entering the room, Resident #68 was observed in bed. The Resident was positioned on their back with their legs and feet directly on the mattress. A foam dressing was in place over the Resident's sacral/coccyx area. When LPN A peeled back the dressing. A moderate amount of yellow/brown colored drainage was noted on the dressing. The wound was open, irregularly shaped, and slightly larger than a pencil eraser in size. When queried if the wound was a pressure ulcer, LPN A indicated that is what they would call it. LPN A reapplied the dressing and the Resident was repositioned on their back with their legs and feet directly on the mattress. When queried why the Resident's heels were not elevated and/or why the Resident did not have pressure reduction boots, LPN A was unable to provide an explanation. An interview was completed with the Director of Nursing (DON) on 8/5/21 at 1:09 PM. When queried if a blister is caused by pressure, the DON replied Yes. When asked why Resident #30's blister wounds were not classified and documented as pressure when blisters are caused by pressure, the DON replied, I didn't follow wounds before. I don't know. When queried regarding the Resident's recent hemoglobulin (hbg) A1C (laboratory test which measures blood glucose levels over previous three months) indicating the Residents blood glucose levels had been controlled and the rationale for the wound etiology being classified as diabetic, rather than pressure, the DON replied, I agree, not high enough for uncontrolled diabetes mellitus. When queried regarding Resident #30's statements regarding their foot pressing against the footboard of the bed causing pain and pressure, the DON reiterated they were not in the DON role at the time of the Resident's ulcer development. The DON was then asked about the pictures of the footboard being present in the initial facility wound picture documentation including the wound documentation on 3/25/21 as well as Wound Care NP D's statements pertaining to the wound etiology and pressure, the DON did not provide a response but specified they would review the documentation and, if found, would provide any information demonstrating the wounds were not caused by pressure. Progress note documentation from the Resident #30's date of admission to 5/17/21 was also requested at this time. When queried regarding Resident #68 developing an open area on their sacral/coccyx area, observations of the Resident always being on their back with their legs and feet directly on the mattress, and the Resident's statements regarding lack of repositioning, the DON revealed they were frustrated but did not provide an explanation. An interview was completed with the facility Administrator on 8/5/21 at 2:48 PM. When queried regarding Resident #30's wounds, including documentation, etiology, and statements during interviews with the Resident and staff, the Administrator did not provide further explanation. When queried regarding Resident #68 developing a pressure ulcer during the survey including observations and statement of the Resident always being positioned on their back, the Administrator did not provide further explanation. The requested progress notes and/or no further documentation related to wounds for Resident #30 was received prior to the conclusion of the survey. Review of facility policy/procedure entitled, Skin Management (Revised: 7/21) revealed, It is the policy that the facility should identify and implement interventions to prevent development of . pressure ulcers . 3. Appropriate preventative measures will be implemented . and the interventions are documented on the care plan .

This citation pertains to Intake Number MI 399. Based on interview and record review, the facility failed to maintain professional standards by 1) not ensuring a complete and accurate nursing assessment (documentation of complete assessments of respiratory, cardiac, urinary and cognitive systems) was done and in a timely manner prior to transfer to the hospital on [DATE] for 1 resident (Resident #4), who developed Septic shock (infection through the body) and pneumonia, and by 2) not informing 1 resident's (Resident #4) primary physician of a change in condition (hypotensive blood pressure-low blood pressure) in a timely manner, resulting in transfer to the Emergency Department (ED), pneumonia, septic shock, decreased urinary output and admission to the Intensive Care Unit (ICU). Findings Include: Review of the Face Sheet, Minimum Data Set (MDS), resident assessment tool) dated ,[DATE], Physician, Nurses and Social Services note's dated [DATE] through [DATE], History and Physical dated [DATE] and hospital records dated [DATE] through [DATE], revealed Resident #4 was 72-years-old, confused with a BIMS of 5 (cognitive assessment tool, 0 to 15 score, 10 to 15=alert 1 to 9=not able to be interviewed-confused), was originally admitted to the facility on [DATE] and readmitted after transfer from the facility to the hospital with the [DIAGNOSES REDACTED]. The resident's [DIAGNOSES REDACTED]. mental status, dementia, [MEDICAL CONDITION], anxiety, [MEDICAL CONDITION] and chronic heart and lung disease. Resident #4 was transferred from the facility to the Emergency Department on [DATE], due to [MEDICAL CONDITION]. The resident was transferred and [DIAGNOSES REDACTED]. Review of the Resident Code Status dated [DATE], revealed Resident #4 was, Full Resuscitation. Review of the residents facility Cognition care plan dated [DATE], revealed staff were to observe and report to physician any changes in cognitive function including but not limited to decision making ability, memory, changes in baseline. Review of the residents facility Respiratory care plan dated [DATE], revealed staff were to report abnormal findings to the physician, specify oxygen. Review of the residents facility [MEDICAL CONDITION]/Kidney Disease care plan dated [DATE], revealed staff were to observe and report to physician PRN (as needed) for s/sx (signs and symptoms) of acute failure: Oliguria (urine output less 400 ml per 24 hr.). Review of the residents facility Cardiac care plan dated [DATE], revealed staff were to notify physician of abnormal readings as needed. Review of Resident #4's facility nursing notes dated [DATE] through [DATE], are as follows: -On [DATE] at 6:30 p.m., stated Resident is frequently restless and calling out for HELP, disrupting fell ow residents on the hall. Writer spoke with (Physician #1 J) re: previous [MEDICATION NAME] (given for anxiety, panic and depression) order that has been discontinued since ,[DATE]. Per MD, okay to order [MEDICATION NAME]. Increased anxiety is common when experiencing decrease oxygenation levels, low SPO2's. -On [DATE] at 10:32 p.m., stated Continues on [MEDICATION NAME] antibiotic therapy for UTI, yelling out at times. Medicated with PRN (as needed) pain meds and scheduled [MEDICATION NAME], encouraged fluids throughout the shift. No other facility nursing notes dated [DATE], were found. No complete facility nursing assessment dated [DATE], was documented. -On [DATE] at 11:48 p.m., stated Resident remains [MEDICATION NAME] a UTI no s/s (signs/symptoms) of adverse effects (of the antibiotic) noted. No other facility nursing notes dated [DATE], were found. No facility documentation of a complete nursing assessment was found dated [DATE]. Review of the residents nursing notes dated [DATE] through [DATE], revealed the only documentation found in Resident #4's closed EMAR regarding oxygen being put on the resident was on the facility Hospital Transfer Form dated [DATE] (the day the resident was transferred to the hospital), it stated, O2 at 7%9 L/min, new. Review of the facility Hospital Transfer and SBAR Communication dated [DATE] done at 8:06 a.m. (nursing assessment for a change in condition that was done prior to the residents transfer to the hospital), revealed Resident #4 had altered mental status, blood pressure was ,[DATE], had shortness of breath, and was a full code. The SBAR stated, Nursing observations, evaluation, and recommendations are: change in L[NAME] (level of consciousness), sig (Significant) [MEDICAL CONDITION], sob (SOB-shortness of breath), low bp (B/P-blood pressure), low SPO2 (low oxygen level). Primary care Provider Feedback: Paged twice and no return received. Review of the facility Hospital Transfer and SBAR Communication dated [DATE], were both completed on [DATE] by the Assistant Director of Nursing (ADON), RN G. Review of Resident #4's EMR (Electronic Medical Record) done by this surveyor accompanied by ADON G, revealed no physician order to transfer to the hospital. No documentation was found in the residents' EMR of notifying a physician one-on-one or per phone of the residents change of condition or of an order given to transfer to the hospital by the primary physician or the facility Medical Director. Review of the facility SBAR Communication Form dated [DATE], revealed the situation (resident condition) had started on [DATE], had shortness of breath, [MEDICAL CONDITION], and other respiratory changes. No nursing complete assessment including a respiratory assessment was done until ADON G did it on [DATE], for the transfer of the resident to the hospital. During an interview done on [DATE] at 11:00 a.m., ADON G stated, there should be a transfer to ED (emergency room ) order, if an emergency you can get it after. The ADON G was unable to locate any physician order to transfer Resident #4 to the hospital on [DATE]. During an interview done on [DATE] at 11:00 a.m., ADON G stated, I was the DON (Director of Nursing) at the time (on [DATE]), I did help the nurse with his transfer (the residents transfer to the hospital on [DATE]). The ADON said she filled out the facility Hospital Transfer Form (dated [DATE]), the SBAR Communication Form (dated [DATE]) and the SBAR Summary for Providers sheet (dated [DATE]), and did the resident assessment on these forms prior to transferring the resident to the hospital. These forms were filled out and the resident was assessed by ADON G after the decision had been made to transfer to the hospital due to condition change. Review of the electronic Weights and Vitals Summary dated [DATE] through [DATE], revealed two blood pressure were done on [DATE], at 6:50 a.m. ,[DATE], and at 7:10 a.m., ,[DATE]. No documentation was found on [DATE], regarding Resident #4's blood pressures. On [DATE], the residents blood pressure was ,[DATE], on [DATE], the residents blood pressure was ,[DATE]. No documentation was found on [DATE], [DATE] and [DATE], regarding Resident #4's oxygen saturation levels. Review of the hospital History and Physical dated [DATE], stated The patient (Resident #4) is a [AGE] year-old with known history of dementia and cognitive impairment was sent from (the facility) to ER (emergency room ) because of [MEDICAL CONDITION]. Workup did show pneumonia and septic shock. Also, the patient is having [MEDICAL CONDITION]. Blood pressure: ,[DATE] (low blood pressure), Lungs: Decreased breathing sounds with bilateral rhonchi (abnormal breath sounds, likely of pneumonia). Impression: Septic shock, Acute pneumonia right lung, possible aspiration (foods/fluids going into the lungs causing pneumonia), Acute kidney insufficiency, [MEDICAL CONDITION]. Review of the hospital records dated [DATE], revealed Resident #4's blood pressures were as follows: -At 8:00 p.m., ,[DATE] -At 8:30 p.m., ,[DATE] (an IV of normal saline for hydration was started in the ED) -At 9:00 p.m., ,[DATE] -At 9:30 p.m., ,[DATE] Review of the ED clinical workup dated [DATE], revealed Resident #4 had an oxygen saturation on room air of 79% (abnormal low), he was lethargic (sign/symptom of low oxygen), respirations were shallow, using and the resident was using accessory muscles (chest wall muscles) to breath with inspiratory and expiratory diffuse wheezing found (respiratory distress). The hospital ED put the resident on 15 liters of oxygen per minute using an oxygen mask. Review of the hospital nursing notes dated [DATE] at 8:02 p.m., stated Pt. admitted to hospital w (with) C/O (complaints) SOB (shortness of breath) and unable to get SPO2 (oxygen level) sats above 80% (normal 90% to 100%), pt. had [MEDICAL CONDITION] as well, pt. cool to touch, unable to obtain temperature of pt. by mouth or armpit upon arrival, pt. will open eyes when talked to however cannot answer any questions. Review of hospital nursing notes dated [DATE] at 8:53 p.m., stated Placed bear hugger (heated blanket) on pt. to increase temp. Review of hospital nursing notes dated [DATE] at 9:00 p.m. and 9:50 p.m., stated Pt has had 2 L (2 liters) of fluids and BP (blood pressure) still low, (hospital physician) aware, received order for additional 1 L bolus (additional liter of fluids due to low blood pressure). Pt's BP still remains low even after fluid resuscitation, (hospital physician) aware, received orders to begin vasopressors (medications to maintain blood pressure). Review of the physician consultation dated [DATE], stated unable to insert Foley, no urine output. [MEDICAL CONDITION], severe [MEDICAL CONDITION] structure (unable to urinate due to constrictor). Review of hospital physician notes dated [DATE], stated Septic shock, admit to ICU (Intensive Care Unit admitted on [DATE]), Acute [MEDICAL CONDITION], [DIAGNOSES REDACTED] (low calcium), severe [MEDICAL CONDITION] (very low iron). Review of the hospital Hematology Report dated [DATE], revealed Resident #4's WBC's (white blood cells, indicating infection) were 15.27 (normal WBC's are 4.50 to 11.00). Review of the hospital blood cultures dated [DATE], revealed Resident #4 had Staphylococcus Aureus, Group D [MEDICATION NAME] in his blood (septic shock). Review of the hospital chest X-ray dated [DATE] at 8:00 p.m., stated Large air-space opacity in the right lung with small pleural effusion worrisome pneumonia. Review of the hospital X-ray dated [DATE] at 7:00 p.m., stated Progression of bilateral [MEDICAL CONDITIONS] and pleural effusions. Review of the X-ray dated [DATE] at 6:09 p.m., revealed the resident had been intubated (put on a ventilatory for respiratory assist). Review of the hospital record dated [DATE], stated Code blue (CPR was initiated) due to acute [MEDICAL CONDITIONS], likely [MEDICAL CONDITION] (low oxygen level). Review of the hospital physician progress notes [REDACTED].#4) didn't have spontaneous movements, there was no spontaneous breathing. Resident #4 was pronounced deceased on [DATE]. During a phone interview accompanied by the ADON G done on [DATE] at 9:45 a.m., Nurse LPN I stated Maybe I just did not see anything (any changes in the resident's condition), I don't remember if I reviewed (the residents) vitals. I don't remember anyone reporting it (low blood pressures and condition change), I did not come in everyday (to work on the resident's unit) and look at everybody's blood pressure history. I didn't really know (the resident) was having blood pressure issues (lack of assessment). I should have charted better. During a phone interview done accompanied by the ADON G done on [DATE] at 10:15 a.m., Nurse RN H stated I finished the med pass (medication pass for residents on [DATE]) while (ADON G) did the hospital paperwork (the Hospital Transfer Form dated [DATE], the SBAR Communication Form dated [DATE], and the SBAR Summary for Providers sheet dated [DATE]). I went to give (the resident) his meds (medications) in the morning and (the resident) was extremely lethargic and I had (the ADON G) look at him. I should of put a note in, I should of documented. I guess the documentation was supposed to be there, it was crazy. During an interview done on [DATE] at 8:25 a.m., Nurse RN F stated I would have documented the outcome with primary care (the primary care physician), it should have been documented. During an interview done on [DATE] at 9:35 a.m., the ADON G stated They (nursing staff) should of charted better, they should be writing (the residents) change of condition. The ADON G said the nursing staff should have assessed and monitored Resident #4 prior to [DATE], and transferred him to the hospital sooner as his condition changed. During a phone interview accompanied by the ADON G done on [DATE] at 11:30 a.m., Physician #1 J said he was not in the country until ,[DATE], and stated no one talked to me him (about the resident), he was that bad. During an interview done on [DATE] at 2:50 p.m., the Director of Nursing (DON) stated There was a lack of intervention due to lack of assessment. Now there is a vital and weight tab in PCC (Point Click Care, the facility electronic charting program), and now it requires a progress note and doctor order. The DON said she had reviewed the nursing charting and due to a lack of assessments and monitoring in a timely manner, the facility had implemented a new tab in their electronic charting system that prompted nursing to write a note and inform the physician of a change in the residents condition in a timely manner. A nursing assessment is the gathering of information for the nursing plan of care. A delay in the process can lead to decreased awareness of an acute medical problem and delayed treatment, even death. The nursing process provides of methodical approach to examine patient's problems and looks at ways of resolving these problems. It consists of four clinical stages, assessment, planning, implementing and evaluating. Assessment is the first stage of the nursing process and enables the nurse to undertake a holistic assessment of the patient considering all the individuals needs in order to identify their problems. Defining Assessment and The Importance of Assessment Nursing Essay, [DATE], Manual of Clinical Nursing, 5th edition A nursing assessment or examining the respiratory system consists of several components, inspection, auscultation, percussion, and palpation. Given the importance of the respiratory system, at least a basic exam should be conducted and documented on nearly all patients. Inspect the external chest, shape, respiratory rate, signs of respiratory distress, how the patient is breathing (labored, mouth, etc ), any use of muscles between the ribs for breathing, skin color, lung sounds with abnormalities noted. Cognition is also important for assessment of non-baseline cognition and low oxygen levels. Lung sounds should be listened to front and back and percussion of all lobes. An oxygen level is also important for assessment of the patient's oxygenation and any discomfort or pain with breathing. Documenting a Respiratory Exam, Just the Basics (MONTH) 11, (YEAR), The Rounds: Clinical considerations, Manual of Clinical Nursing, 5th edition. A nursing assessment for urine retention consists of the character of the urine, color, odor and specific gravity (how concentrated urine is). Voiding frequency and amount are important; the patient should be within their normal baseline. Pain upon urination may indicate a UTI. Check for signs of [MEDICAL CONDITION], mental changes, abnormal urine and monitor blood pressures. [MEDICAL CONDITION] Gil Wayne, BSN, R.N., (MONTH) 7, (YEAR), NursesLabs, Manual of Clinical Nursing, 5th edition. A nursing assessment consists of reviewing labs, heart sounds, pulse sounds, blood pressure, [MEDICAL CONDITION] and chest heart sounds. Vital signs are indicators of cardiac problems, along with increased anxiety with possible pain and shortness of breath. The nurse needs to know the patient's baseline and assess for signs and symptoms of cardiac problems on a regular basis with higher risk patients. Mosby's Medical Dictionary, (YEAR) 10th edition St. Louis, MO Elsevier, Manual of Clinical Nursing, 5th edition

Based on observation, interview and record review the facility failed to follow their policy for the prevention, identification, assessment, and monitoring of pressure ulcers for 3 residents (Resident #13, Resident #32, Resident #90) out of 4 residents reviewed, resulting in the development of a pressure ulcer for Resident #32, the worsening of Resident #13's Stage III pressure ulcer, and the worsening of a Stage III pressure ulcer to a Stage IV pressure ulcer for Resident #90. Findings include: The facility policy Skin Management, revised date 8/2016, revealed It is the policy of the facility that a resident does not develop pressure injury unless clinically unavoidable. Residents with wounds and /or pressure injury and those at risk for skin compromise are identified, assessed and provided appropriate treatment to promote healing. Ongoing monitoring and evaluation are provided to ensure optimal resident outcomes. Practice guidelines: 1. Upon admission/re-admission all residents are assessed for skin integrity by completing a baseline head-to-toe skin assessment and documented in the electronic medical record. 2. The Braden Scale will be completed upon admission . 3. Appropriate preventative measure will be implemented on residents identified at risk . 4. Residents admitted with skin impairments will have: > Appropriate interventions to promote healing, > A physician order for [REDACTED]. The licensed nurse will initiate documentation the electronic health record, which includes a description of the pressure and non-pressure injury as follows; * In Electronic Health Record (EHR) facilities, the licensed nurse will document on the Wound/Skin Healing Record. * Document weekly until the area is healed. 6. The IDT team considers whether the resident exhibits conditions or is receiving treatments that may place the resident at higher risk of developing pressure injury or complicate their treatment . 7. An initial care plan is developed up on admission if the resident is at risk or has a pressure injury and the comprehensive care plan should address . *. The licensed nurse will document preventative measures on the care plan/Kardex. (. The licensed nurse will monitor evaluate and document changes regarding skin condition (to include: dressing, surrounding skin, possible complications and pain) in the medical record. 10. A Nutritional Assessment: 11. Place each resident on a weekly head-to-toe skin assessment that is completed by the licensed nurse 12. If a new area of skin impairment is identified, notify the resident, responsible party, attending physician, DON and treatment team, if applicable. 13. Resident's with pressure injury will be assessed, measured and staged weekly in accordance with the practice guidelines until healed. It is best to choose the same day and a consistent person to measure wounds on a weekly basis, if possible. 14. The licensed nurse will notify the attending physician with any changes as needed . Resident #32: Review of Resident #32's electronic medical records, including physician's orders-dated (MONTH) 2019, physician/nurse practitioner progress notes, progress notes, care plans, and the admission Minimum Data Set assessment-dated 4/24/19 revealed that the resident was admitted on [DATE] with diagnoses that included major [MEDICAL CONDITION], recurrent, anxiety disorder, acute kidney failure, gastro-[MEDICAL CONDITION] reflux disease without esophagitis, [MEDICAL CONDITION], hypertension, diabetes type 2, repeated falls, arthritis, retention of urine, chronic pain, [MEDICAL CONDITIONS], dementia without behavioral disturbance. The resident was on hospice. On 06/26/19 at 8:30 AM, during an interview, Director of Nursing (DON) and Unit Manager H were requested to observe Resident #32's pressure ulcer and dressing change. On 06/27/19 at 8:35 AM, during an interview, DON and Unit Manager H were requested to observe Resident #32's pressure ulcer and dressing change. Review of Resident #32's admission records revealed that the resident was admitted on [DATE] and the comprehensive admission assessment, dated 4/18/19, revealed no documentation of an open area on the sacrum. Review of Resident #32's physician progress notes [REDACTED]. Review of Resident #32's physician progress notes [REDACTED]. I discussed with the wound care nurse and unit manager to include her on her wound rounds and start offloading and using topical treatment for [REDACTED]. Review of Resident #32's physician orders, dated 4/22/19, revealed treatment of [REDACTED]. Review of Resident #32's treatment record revealed that the resident had received a treatment Cleanse w/wound cleanser and apply Allevyn dressing every evening shift Tuesday and Friday and as needed starting 4/23/19 through 5/17/19. Order was restarted 5/17/19 On 06/26/19 10:34 AM, a review was made of the facility's first identified documented nursing assessment of Resident #32's Pressure Ulcer and was dated 5/17/19, (25 days after identified by physician). The skin & wound evaluation revealed an in-house acquired Stage 2 Pressure ulcer located on the sacrum and measured 0.5 cm x 1.0 cm x 0.7 cm x 0.1 cm. with light serosanguineous exudate. On 6/25/19 a Stage 2 sacrum pressure ulcer was measured 0.3 x 0.7 x 0.5 x 0.1 cm with light serosanguineous exudate documented as present on admission unknown date. On 6/17/19 a Stage 2 sacrum pressure ulcer measured 0.4 x 0.8 x 0.5 x 0.1 cm with light serosanguineous exudate documented as present on admission unknown date. On 6/4/19 a Stage 2 sacrum pressure ulcer measured 0.4 x 0.8 x .5 x 0.1 cm with light serosanguineous exudate documented as present on admission unknown date. On 5/31/19 a Stage 2 sacrum pressure ulcer measured 0.5 x 1.2 x 0 x 5 x 0.1 cm with light serosanguineous exudate documented as present on admission unknown date. On 5/21/19 a Stage 2 sacrum pressure ulcer measured 0.4 x 0.9 x 0.6 x 0.2 cm with light serosanguineous exudate present on admission unknown date. Resident #32's care plan, initiated on 4/18/19, included a cushion on the wheel chair, incontinence care, turning and positioning frequently. A specialty bed was not implemented until date of pressure ulcer-5/17/19. Review of Resident #32's Nurse progress note, dated 5/12/19, revealed in wheel chair through out shift . Review of Resident #32's Nurse progress note, dated 6/14/19, revealed, at risk for increased decline in wound r/t hospice status, does like to sit in chair all time with no rest. 06/27/19 10:25 AM , during an interview and review of Resident #32's electronic medical record, DON reviewed admission assessment dated [DATE] and agreed there was no open area on the sacrum at the time of admission, and stated that there was a cushion on the wheel chair, incontinence care, turning and positioning frequently, initiated low loss mattress mattress on date of pressure ulcer on 5/17/19, and avoid coccyx for extended periods of time on 5/17/19. DON stated do not know if resident was asked about air mattress at the time of admission. DON reported that the resident had been wheeling herself around the facility from the time of admission until just recently. On 06/27/19 02:04 PM, not previously noted in the miscellaneous section of the EMR, was a document that revealed unavoidable Pressure Ulcer Assessment, dated 5/18/19, with diagnoses that indicated one risk factor of diabetes, and residents to receive two or more of the following treatments; and resident was marked for one that included head of the bed up due to GERD. Resident's status was marked on the side of the form as [MEDICAL CONDITION], hypertension, HX MI, acute kidney failure, LLE (left lower leg) [MEDICAL CONDITION] and hospice. During review of the EMR and miscellaneous medical records, the DON had not mentioned or provided any information related to the unavoidable pressure ulcer assessment at the time of the interview or during the review of the EMR. Review of weight log and admission assessment, dated 4/8/19, revealed that weight was documented as the following on: 4/18/19 admission weight of 126 # with [MEDICAL CONDITION] present in lower extremities; 5/1/19 at 127 #; 6/5/19 at 110 # and 6/6/19 at 111.4 #. On 06/27/19 at 02:27 PM, during an observation of a dressing change of a pressure ulcer for Resident #32 with LPN S, and Hospice CNA T, LPN S was observed to have washed hands, put gloves on prepared supplies, touched her hair, and removed dressing from resident. LPN S reported CNA reported the dressing had not been present this morning so it had been replaced. Resident had fecal matter present and on the brief. LPN S washed hands, cleansed area, washed hands. and applied treatment. Following the treatment LPN S and Hospice CNA T removed the old brief and replaced it with a new one. Hospice CNA T was unable to fine any wipes in the room so the resident was not cleaned of fecal matter at that time. Hospice CNA T removed gloves. Staff entered with fresh water, CNA T placed the new water on the dresser with soiled hands. Hospice CNA T reported that she planned to wait for pain med to take effect and then take the resident for a shower. LPN S agreed there was concern with handling the brief and not washing hands. Resident #90: Review of Resident # 90 electronic medical records physician orders dated (MONTH) 2019, physician/nurse practitioner progress notes, progress notes, care plans, and admission minimum data set assessment dated [DATE] revealed that the resident was admitted on [DATE] with diagnoses that included pressure ulcer of sacral region, stage 3, diarrhea, muscle wasting and atrophy, [MEDICAL CONDITION], hypertension, heart failure, [MEDICAL CONDITIONS], and [MEDICAL CONDITION]. Review of Resident #90's hospital discharge summary, dated 6/3/19, revealed that the resident was admitted to the hospital on [DATE], with an infected sacral decubitus ulcer, underwent debridement by general surgery with cultures positive for beta-[DIAGNOSES REDACTED] strep and was recommended to have IV [MEDICATION NAME] and [MEDICATION NAME]. Resident also received a rectal tube due to diarrhea. On 06/25/19 at 01:47 PM, during an interview, Resident #90 reported she had developed a pressure ulcer at home prior to going in to the hospital. Resident complained of discomfort and it was noted resident's fecal tubing was tangled up in her wheelchair wheel. CNA AA answered the call light and assisted in untangling the tubing, cleaning the apparatus and repositioning the resident. On 06/26/19 at 8:30 AM, during an interview, Director of Nursing (DON) and Unit Manager H were requested to observe Resident #90's pressure ulcer and dressing change. On 06/27/19 at 8:35 AM, DON and Unit Manager H were requested to observe Resident #90's pressure ulcer and dressing change. Review of Resident #90's admission assessment, dated 6/5/19 (2 days after admission), revealed a pressure ulcer on the coccyx. No measurements were documented on the admission assessment. Review of Resident #90's facility total body skin assessment,, dated 6/12/19, revealed no new areas and no documentation of the sacral area. There were no measurements documented for the pressure ulcer. Review of Resident #90's facility total body skin assessment, dated 6/19/19, revealed no new areas and no documentation of the sacral area. There were no measurements documented for the pressure ulcer. Review of Resident #90's wound clinic note, dated 6/10/17, revealed that the wound was documented as a Stage III sacral wound, 11.0 cm with skin bridge by x 4.2 x 0.6 cm minimal amount of serosanguineous drainage no clinical evidence of infection surrounding tissue is intact bases granular with scattered biofilm. Review of Resident #90's wound clinic note dated 6/17/19 revealed that the wound was documented as a Stage III sacral wound 5.8 x 3.1 x 1.0 cm minimal amount of drainage no clinical evidence of infection surrounding tissue is intact bases granular with scattered biofilm. Review of Resident #90's facility skin wound evaluation, dated 6/24/19, revealed that the wound was documented as a decline to a stage IV on the coccyx measuring 4.4 cm x 3.7 x 1.5 cm x 1.4 cm with light serosanguineous exudate. There was no documentation that the physician was notified the pressure ulcer had declined to a Stage IV. On 06/27/19 at 02:58 PM, during an interview LPN S reported she was not going to do the dressing change at this time because she had to proceed with 3:00 PM medication pass. LPN S reported she works full time. The treatment was scheduled for bedtime and she had not seen Resident 90's pressure ulcer. On 06/27/19 at 03:45 PM, LPN U, was observed for doing the dressing change for the pressure ulcer with CNA V. LPN U washed hands, gloves applied, set up treatment on tray, washed hands, removed old dressing, washed hands, cleaned wound, washed hands and applied the treatment as ordered. Wound was noted to be a deep Stage IV wound with dark base, light serosanguineous exudate, and edges surrounding the wound were slightly uneven. LPN U reported that on an admission of any resident, the nurse on duty was responsible for the resident's admission assessment which included the comprehensive skin assessment and measurements of any pressure ulcers. 06/27/19 10:25 AM , during an interview and review of Resident #90's electronic medical record, the DON reported that the resident was admitted with a Stage 3 pressure ulcer and did not state that she was aware of the decline to a Stage 4 pressure ulcer. Resident #13: A record review of the Face Sheet and Minimum Data Set (MDS) assessment for Resident #13 indicated initial admission to the facility on [DATE] and multiple discharges to the hospital and readmission with the most recent readmission on 4/25/19 with Diagnoses: [REDACTED]. The MDS dated [DATE] revealed the resident had severe cognitive decline and needed assistance with all care including bed mobility, transfers, toileting, bathing and eating and had no pressure ulcers. The MDS dated [DATE] indicated there were no Pressure Ulcers. The MDS dated [DATE] indicated 1 unstageable pressure ulcer. A record review indicated Resident #13 had developed a Stage 3 pressure ulcer (A pressure injury with full thickness skin loss exposing adipose (fat) tissue: National Pressure Ulcer Advisory Panel 2019) on the coccyx after admission to the facility 3/22/19. A review of the Nursing Admission Assessment indicated a sore on the coccyx but did not include measurements. There was no [DIAGNOSES REDACTED]. A review of the Wound Care Consult notes for Resident #13 revealed the following, 3/25/19 .On her coccygeal region there is some central open areas surrounded by darkened non-blanchable tissue . 6.7 cm (length) x 5.0 cm width (no depth) scant drainage. A 6/24/19 Skin and Wound Evaluation, measured the wound at 3.6 cm length x 2.9 cm width x 0.2 cm depth . 10% slough (dead, stringy tissue) and light serosanguinous drainage. A review of the physician orders indicated the same treatment had been administered since 4/25/19, Coccyx: cleanse with generic wound cleanser, apply Santyl (enzymatic ointment), moist gauze and cover with large [MEDICATION NAME], every evening shift for wound care. A review of the Skin, care plan titled Actual impairment to skin integrity related to recent surgery, dated 3/22/19 and updated on 5/17/19 as Actual impairment to skin integrity related to unstageable pressure injury to coccyx . with added interventions Provide treatment as ordered, provide incontinent care and LTC 105 mattress, all dated 5/17/19; two months after the wound was identified and had developed an increased depth and slough. On 6/25/19 at 4:05 PM Nurse W was asked to observe wound care. On 6/27/19 at 8:30 AM, Nurse W was contacted about observing wound care and said, Ok, I will let you know. At 12:00 PM Nurse W said she didn't know it was a night dressing change. Nurse W said this was her regular assignment but didn't know when the resident's dressing was changed. On 6/27/19 at 3:36 PM, the Director of Nursing was interviewed about the lack of updated interventions on the Care Plan and staff knowledge of the resident's wound care and said the facility was working on hiring a Wound Care Nurse. A review of the facility policy titled, Skin Management, revised 8/2016 provided . Residents admitted with skin impairments will have: appropriate interventions implemented to promote healing . wound location, measurements and characteristics documented .the licensed nurse will initiate documentation in the electronic health record . the licensed nurse will document preventative measures on the care plan/kardex .

Based on observation, interview and record review the facility failed to implement the plan of care to prevent falls and provide appropriate assessment after falls with injury for 2 residents (Resident #29 and Resident #32) of 11 residents reviewed for falls, resulting in Resident #29 falling from the side of the bed onto her head and face leading to her eye swelling shut and Resident #32 falling resulting in swelling, discomfort and soft tissue bleeding to the left lower extremity and a left femur fracture. Findings Include: Resident #29: 0n 6/25/19 at 10:05 AM Resident #29 was observed lying in bed talking with a visitor. She said she had a fall from bed the night before, while sitting on the side of the bed, after being assisted into a semi-sitting/leaning position unsupervised when the nurse left the room. She said she hit her forehead and it hurt. Her left cheek was visibly swollen, and the left eye was swollen shut. A record review of the Face Sheet and Minimum Data Set (MDS) assessment indicated that the resident was admitted to the facility on [DATE] with Diagnoses: [REDACTED]. The MDS assessment, dated 5/1/19, revealed Resident #29 had full cognitive abilities and needed assistance with all care, including bed mobility and transfers and had poor balance, left-sided weakness and was only able to stabilize with staff assistance. A record review indicated a nursing progress note on 6/24/19, after the incident, which stated small puffy area noted to left eyebrow, ice applied . On 6/25/19 at 10:50 AM, after this Surveyor interviewed the resident, Nurse W assessed the resident and noted, Right side of face slight [MEDICAL CONDITION] noted at this time. Ice Pack offered . There was no documentation of physician notification in the medical record until a nurse's note on 6/25/19 at 12:28 said x-rays were ordered. On 6/25/19 at 12:01 PM, a progress note written by the Director of Nursing (DON) said there was a conversation with the resident's son and the facility would order an x-ray. The son was upset because this was not done sooner. An x-ray was completed at 2:35 PM on 6/25/19 with results reported on 6/25/19 at 6:33 PM, which indicated No fracture- facial bones. A review of the Incident and Accident report I&A dated 6/24/19 at 5:30 PM, revealed Pt (patient) states she was trying to sit up at bedside and lost her balance. Swelling noted to left eyebrow. The report said the resident was found Face down on floor. The Interventions Implemented section of the I&A report indicated, Reinforced pt (patient) needs assistance in bed. On 6/26/19 at 5:45 PM, Nurse X was interviewed related to Resident #29's fall on 6/24/19 and he stated, I was in with her right before the fall. I had just left the room and was right outside the door when it happened. I heard it then went right back in there. She was lying on the floor. Nurse X was asked if he assisted the resident to sit on the edge of the bed and he stated, I helped her to sit on her side with her right elbow bent and the right arm raised off the bed. She was kind of sitting sideways on the bed. During the interview, Nurse X was asked if he left the room with Resident #29 sitting in that position and he said, I just left for a minute. A review of the Fall Care Plan for Resident #29 indicated the care plan was initiated 4/24/19 and the last Intervention was dated 4/25/19. There were no updated interventions after the resident fell on [DATE] and injured the left side of her face and eye. On 6/27/19 at 4:30 PM, the Director of Nursing (DON) was interviewed about Resident #29's fall and injury on 6/24/19 and the lack of documentation of the injury (her left eye was swollen shut, left cheek was swollen and both were painful), the lack of updated interventions to prevent future falls and the resident's poor sitting balance. The DON stated, We had an x-ray done the next day and it was negative (for fractures). They are working on the care plan. On 6/27/19 at 5:30 PM, the Administrator was interviewed about Resident #29's fall with injury and said the facility was meeting with the resident and family the next day to discuss their concerns. A review of the facility policy titled, Fall Management, dated revised 8/2016 revealed, . Each resident is assisted in attaining/maintaining his/her highest level of practical function by providing the resident adequate supervision . to minimize the risk of falls . Residents identified at risk for falls will have a care plan developed and implement appropriate fall prevention interventions . the IDT (Interdisciplinary team) will review/modify the plan of care . Resident #32: Review of Resident #32's electronic medical records that included physician orders dated (MONTH) 2019, physician/nurse practitioner progress notes, progress notes, care plans, and admission minimum data set assessment dated [DATE] revealed that the resident was admitted on [DATE] with [DIAGNOSES REDACTED]. The resident was on hospice. Review of Resident #32's electronic record revealed radiology report of left knee x-ray, dated 6/13/19, revealed fracture deformity distal femur, some evidence of healing. Knee joint replacement. Osteopenia with [MEDICAL CONDITION] changes. conclusion subacute fracture with residual deformity distal femur. Review of Resident #32's nurse's progress note, dated 6/13/19, revealed resident's hospice aide was here today. While bathing the resident, the hospice aide observed a protrusion near the resident's knee. The aide informed the writer and the unit manager. (Agency) Hospice was notified and they will be contacting Mobile X for an in house X-Ray. Review of physician's progress note, dated 6/13/19, revealed .She still has considerable swelling in the left lower extremity from the previous trauma which caused significant soft tissue bleeding. Her pain however is controlled with use of [MEDICATION NAME]. Review of physician progress notes [REDACTED]. There was no actual witnessed fall and she apparently had no injuries and she was alert and coherent and was subsequently monitored with no evidence of injuries and did not require any further action Review of Resident # 32's incident report, dated 5/12/19 at 6:55 AM, revealed, 2nd incident resident observed on the floor sitting with her back against the bathroom doorway facing her bed. Resident stated she sat down after she attempting to toilet self. type of injury: n/a, location of injury n/a, witnessed no. Interventions offer early toileting in AM. There was no documentation that an assessment was actually completed. Review of Resident # 32's incident report, dated 5/12/19 at 2:28 am, revealed, 1st incident Resident observed sitting on floor. resident sustained [REDACTED]. Resident stated that she was attempting to toilet self and slid down on to her knees. When questioned she admitted no injuries. Interventions Reinforce use of call light, educate r/t complications from falls should others occur and hazard of falls. type of injury: n/a, location of injury; n/a, witnessed no. There was no documentation that an assessment was actually completed. Review of Resident #32's nurse's progress note revealed on 5/12/19 at 6:55 am, Resident had two change in elevations whereby she attempted to self transfer to toilet. Incident 1 at 02:30 and incident 2 at 6:30 am resident is alert x 4 but CNA that works with her regular and is more attuned to residents normal behaviors, stated that she (resident) seemed a little off of her normal self. Will have 1st shift regular nurse assess for possible change in orientation for need of UA lab draw. Review of Resident #32's EMR revealed there was no documentation of a pain assessment following the falls on 5/12/19 until 5/14/19. There was no documentation of a full body assessment was completed after the fall incident at 6:55 AM on 5/12/19. Review of Resident # 32's incident report, dated 5/12/19 at 2:28 am, revealed, 1st incident Resident observed sitting on floor. resident sustained [REDACTED]. Resident stated that she was attempting to toilet self and slid down on to her knees. When questioned she admitted no injuries. Interventions Reinforce use of call light, educate r/t complications from falls should others occur and hazard of falls. type of injury: n/a, location of injury; n/a, witnessed no. Review of Resident #32's nurse's progress note revealed on 5/12/19 at 2:47 am, attempted to self-transfer and toilet, resident stated that she slid to the floor and sat down because she could not support her self. Resident was examined and no obvious signs or symptoms of injury were expressed or observed. Resident was cleaned and the wound dressing changed (on her gluteal cleft) . Resident's son was notified and a message left for Dr. (name). Review of clinical record revealed no documentation of neurological checks initiated on 5/12/19 related to the unwitnessed falls. On 06/26/19 at 03:02 PM during an interview, Attending Physician F reported that the resident was previously a patient in private practice prior to admission, had falls prior to admission and problems with gait, refusing any x rays, and had significant swelling, to the leg and thigh. [MEDICATION NAME] was controlling the pain, so x rays were not done at the time. The femur was sticking up and, due to the swelling, did not see anything at the time. Attending Physician F reported the [MEDICAL CONDITION] had decreased and the femur sticking up was more noticeable on 6/13/19, the X-ray was done and fracture noted. Resident was easily transferred at that time and was mobile in w/c. Son was notified and was ok with mother's choice. The facility now has a policy to document the falls and follow up. Attending Physician F reported it is expected that the nurse will send a text with information to the physician for follow up, when a resident falls. Attending Physician F reported if the fall was not a witnessed fall, nursing is expected to complete neuro checks and further stated, It a standard with a fall to require neuro checks. It is no excuse for why documentation is not there. 06/27/19 09:12 AM, during an interview, Unit Manager H and DON, reported that they only do an investigation if there was a deficiency related to falls. DON reported she expected nursing staff to document for 72 hours following a fall, residents to have call light in reach for safety and any pain assessments to be completed. DON reviewed documentation for pain assessment and reported it was completed on 5/14/19. DON thought a 48 hour lapse was appropriate for a pain assessment with a fall. DON reviewed document and agreed the documentation was not consistent for 72 hours, reported resident received scheduled [MEDICATION NAME] and was assessed for pain according to the Medication Administration Record [REDACTED]. DON reported that it was an unwitnessed fall. They should have done report of neuro checks in (misc) and that should be in the EMR. On 6/27/19 DON provided a copy of a Resident #32's neuro checks that were initiated on 5/12/19 and was noted as incomplete for the last 2 entries on 5/14/19 at 5:15 PM and 5/15/19 at 1:15 AM.

This citation pertains to Intake Number MI 687. Based on interview and record review, the facility failed to transcribe physician orders for wound care, follow orders for wound care and monitor [MEDICAL CONDITION] in the right foot for one resident (#11) out of two residents reviewed for wounds resulting in Immediate Jeopardy on 4/18/19 as a result of the development of dry gangrene in the toes of R11's right foot and the resulting surgical amputation of the four toes in his right foot. Findings include: Resident #11 (R11) was admitted to the facility on [DATE] with a primary [DIAGNOSES REDACTED]. Additional [DIAGNOSES REDACTED]. At the time of the survey, R11 was not in the facility. On 4/18/18, a record review of the discharge instructions sent from the local hospital to the nursing home indicated R11's discharge diagnosis (from the hospital) included [MEDICAL CONDITION] of the right foot. Under the heading Notify Physician and under the topic Wound Care Signs/Symptoms of Infection the following physician order was noted Dress wound daily with [MEDICATION NAME] soak 4 x 4, secure with tape or kerlix. On 4/18/19 at 9:10 AM, an interview was done with Social Worker (SW) N at the local hospital. SW N stated R11 was admitted from the wound care clinic on 4/12/19 with a [DIAGNOSES REDACTED]. SW N stated the wound to the right foot had worsened and looked black and gangrenous. R11 stated to the hospital physicians that he did not get dressings changed daily. On 4/18/19, a record review of R11's electronic medical record (EMR) was done. A review of physician's orders did not reveal orders for a dressing change to the right foot. A review of progress notes did not indicate any assessments, dressing changes or wound care to the right foot. One progress note entry, dated 4/11/19, indicated the wound care team looked at R11's left foot but there was no mention of R11's right foot. On 4/18/19 at 11:30 AM, Director of Nursing (DON) B was interviewed. DON B was asked about a progress note that DON B had written when R11 was sent to the wound care clinic on 4/13/19 indicating that a dressing change was done prior to R11 leaving the facility but with no indication which extremity had a dressing. DON B stated she was unsure which foot had a dressing but the nurse who cared for R11 stated she changed his dressing before R11 left for the clinic. On 4/18/19 at 1:35 PM, Licensed Practical Nurse (LPN) K was interviewed by phone. LPN K was the nurse identified by DON B as providing wound care prior to R11's appointment at the local wound care clinic. LPN K recalled R11 and stated that she was preparing R11 to go to his wound care appointment. R11 stated the dressing on his left foot had fallen off and R11 requested a new dressing. LPN K stated she put a fresh dressing to R11's left foot. When queried about a dressing or any wound care to the right foot, LPN K stated R11 did not have any dressings to the right foot and she did not assess his right foot when she applied a new dressing to the left foot. LPN K stated she recalled the toes on his right foot were very dark. On 4/18/19, a record review of the Medication Administration Record [REDACTED]. A record review of the Policy and Procedure titled Physician's Orders, release date of 2/2015, did not address how physicians' orders from a hospital transfer are addressed and implemented. On 4/18/19, a record review of the emergency room (ER) documentation, dated 4/12/19, from a local hospital revealed the following information: Chief Complaint: rt (right) foot toes black suspected gangrene. Additional Information: (R11) presented to the ER after being sent over by wound care. Pt (patient) reports over the past two weeks he has had increasing right foot pain and inability to bear weight on that right foot. Over the last couple days, patient reports that he has lost feeling in the right first four toes and has not been able to move his toes well. Under the topic of Physical Exam, the following was documented under Musculoskeletal has evidence of dry gangrene of the first through fourth toes on the right foot. Patient unable to flex or extend his toes. Necrotic discoloration extends up to the level of the metatarsal heads, with [DIAGNOSES REDACTED] extending to about the level of the mid to proximal metatarsals. Toes look supportive (suppurative - pus forming), evidence of necrosis. On 4/18/19. a record review of the podiatry progress note, dated 4/17/19, revealed the following information: Patient (R11) reports possible neglect with daily checks and wound care. Under Clinical Course, the following documentation was noted I called the podiatry resident on call and discussed the case with him. (name of message service) message was sent to him with pictures of the foot today. He states this looks completely different and was not previously appearing black on exam. Under Exam: Right foot Sores on dorsum of foot and toes. No hx (history) of diabetes. The dorsum of the foot is the top of the foot. Nursing Home Administrator was presented with Immediate Jeopardy notification on 4/18/19 due to the facility's failure to transcribe and follow a physician's order from the transferring hospital for wound care, resulting in the amputation of R11's four toes on the right foot due to dry gangrene of the right foot. The facility initiated the following action plan to address the Immediate Jeopardy: (Facility Name) submits the following Credible Allegation of Compliance outlining the measures it has completed to remove the findings of immediate jeopardy regarding the facility's alleged failure to closely review incoming orders from the local hospital when admitting residents to the facility. 1. Resident identified to be affected by the alleged deficient practice. Identified resident no longer resides at the facility. The resident was transferred to the hospital on (MONTH) 12, 2019 for further evaluation from an outside physician visit. 2. Residents with the potential to be affected by the alleged deficient practice. On 4/18/2019, the administrative nurses reviewed and validated order transcription on 33 of 92 residents from current residents within the facility, admitted after 3/23/19 and forward. The 33 residents that were admitted after 3/23/2019 had no transcription errors noted. On 4/18/2019 92 of 92 current residents within the facility has had a skin assessment completed using PCC Skin & Wound- Total Body Skin Assessment. The residents that were observed with skin impairment were noted to have appropriate treatment orders in place. 3. Systemic Measures - a) The facility policy on Medication Administration, Physician Order Policy, Skin Management Policy, and Change in status, identifying and communication, Long Term Care policy was reviewed and deemed appropriate on 4/18/2019. There is currently 42 licensed nursing staff and reeducation began on 4/18/2019 at 6:00 PM. The licensed nursing staff was reeducated on the Medication Administration Policy, Physician Order Policy, Skin Management Policy, and Change in status, identifying and communication, Long Term Care policy, with emphasis on transcribing and following physician orders. There is 32 licensed nursing staff out of 42 that have been reeducated as of 4/18/2019 at 11:00 PM. The remaining facility staff will be reeducated on Medication Administration Policy, Physician Order Policy, Skin Management Policy, and Change in status, identifying and communication, Long Term Care policy, with emphasis on transcribing and following physician orders prior to the start of their next shift beginning 4/19/2019. All newly hired staff will be educated on Medication Administration Policy, Physician Order Policy, Skin Management Policy, and Change in status, identifying and communication, Long Term Care policy, with emphasis on transcribing and following physician orders upon hire. 4. Quality Assurance The administrative nurses will review 10% the residents that were admitted to ensure orders are transcribed and verified weekly for 4 weeks, monthly times 2 months. All concerns will be addressed immediately Findings will be reported to QA monthly for 3 months for recommendations. 5. The Administrator is responsible for sustained compliance. Although the Immediate Jeopardy was removed on 4/18/19 when it was verified that the facility implemented the action plan, the facility remained out of compliance at the scope of isolated and a severity of no actual harm with potential for more than minimal harm that is not Immediate Jeopardy, due to the fact that sustained compliance could not be verified by the State Agency. The Immediate Jeopardy began on 3/23/19, when Resident #11 was admitted to the facility from the hospital. The Immediate Jeopardy was identified on 4/18/19. The facility Administrator was notified of the Immediate Jeopardy on 4/18/19. The Immediate Jeopardy was removed on 4/18/19, when facility started to implement all aspects of their Removal Plan.

This regulation have 3 Deficient Practice Statements ( DPS) DPS #1 This citation pertains to intake # MI 411 Based on interview and record review, the facility failed to monitor and assess the skin integrity of one resident (#716) that wore a leg immobilizer brace out of two residents sampled for assessment from a total of 18 sampled residents, resulting in an infection of a surgical incision, prolonged healing, unnecessary pain, surgical debridement (the process of cutting out dead tissue with a scalpel) of the wound, extra physician visits, and the need for antibiotics. Findings include: On [DATE] at 1:20 p.m., record review revealed that Resident #716 was admitted into the facility for rehabilitation following a [MEDICAL CONDITION] on [DATE]. Other [DIAGNOSES REDACTED]. According to the Minimum Data Set (MDS) assessment dated [DATE], Resident #716 had a Brief Interview of Mental Status (BIMS) of 02 (severe cognitive impairment) and needed extensive assist with transfers, eating, bathing and hygiene. On [DATE] at 8:50 a.m., a review of the progress notes and assessments revealed the following: [DATE]: initial Nursing Comprehensive Evaluation revealed that Resident #716 had a surgical incision on her left hip/outer left thigh that was closed with staples. There was a small amount of pink drainage and a dark bruise to the area. [DATE]: physician History and Physical revealed a surgical wound on the posterior lateral aspect of the left thigh with staples in place . [DATE]: Weekly Head-To-Toe assessment noted a brace and old hip repair. There was no further Weekly Head-To-Toe assessments between [DATE] and [DATE]. [DATE]: Weekly Head-To-Toe assessment noted a small red abrasion .probably from leg brace. [DATE]: Wound care consult stated, they removed her (Resident #716) leg brace and noted drainage and an open area on her thigh .daughter states she (Resident #716) was seen by the orthopedic surgeon .and said there was a scab on this area. The consult described the wound as 5.8 centimeters (cm) long and, at the distal end (far end of the wound) there is a little pinpoint area that is dehiscing (wound has split open). Then centrally, there is an open dehiscence and then proximally it is also beginning to open and soften. There is minimal amount of serosanguineous (thin yellow) drainage. There is surrounding [MEDICAL CONDITION] (infection of the skin/wound). Periwound borders are granular (wound tissue). The base is granular with necrotic slough biofilm (nonviable, dead tissue). According to the note, the wound nurse practitioner ordered an oral antibiotic (Keflex) and an antibiotic ointment to the area to be completed daily. [DATE]: Resident #716 was transported to her orthopedic doctor for a consult. An order was written for a [MEDICATION NAME] ointment (Santyl) to the wound. [DATE]: Weekly Head-To-Toe assessment noted a left lateral thigh open area with sero- sanguineous drainage. On [DATE] at 9:05 a.m., a review of the care plan titled, Risk for skin breakdown, created [DATE] addressed the brace for Resident #716 with the following intervention: .should wear pajama pants under her knee brace while in bed for the evening. Brace should not come in contact with skin at any time. On [DATE] at 9:55 a.m., an interview was completed with the wound care registered nurse (RN A). According to RN A, she was notified by a nurses aide of the wound. RN A stated that she ordered for a wound consult and that they quickly got Resident #716 an appointment to see her orthopedic surgeon who then debrided the wound and ordered Santyl. On [DATE] at 11:35 a.m., an interview with the Director of Nursing (DON) was completed. During the interview, a review of the Treatment Administration Record (TAR) for November and [DATE] for Resident #716 was done. According to the TAR, there was no order or treatment in place to regularly monitor the skin underneath the leg brace or monitor the surgical incision for signs and symptoms of infection for Resident #716. The order that was put into place dated [DATE]-[DATE] stated, ABD pad (large 5 x 9 cm thick gauze) for padding in brace PRN (as needed) for comfort. According to the TAR, this was completed once on [DATE]. The DON did not provide an explanation as to why there was not a daily treatment in place to monitor the wound and brace. On [DATE] at 5:00 p.m., a confidential family member E interview was completed. Family member E stated, That wound looked horrible! There was no way that they were looking at that wound everyday! There was yellow crust on the inside of her (Resident #716) brace where the wound was. She (Resident #716) had Dementia, so she could not tell you if she was in pain but I could tell she was in pain from that wound! It (the wound) never healed after she was discharged , we had to continue to put bandages on it everyday. On [DATE] at 5:10 p.m., a review of the facility policy titled, Brace and Splint Program released ,[DATE] revealed the following: 4. If the resident enters the facility with a brace .The order will define the following information: a. Where the splint/brace is to be worn. b. When the splint/brace is to be worn. c. Why the splint/brace is to be worn. d. Who will apply the splint/brace . 5. A care plan will be developed that has measurable objectives and interventions and that include the following: a. Applying the brace/splint .b. Staff has a scheduled program of applying and removing the appliance that includes: Scheduled hours to be worn and when skin will be inspected for signs and symptoms of pressure areas, irritations .c. Communicate individualized interventions to the direct care providers. Provide specific directions and training as needed (e.g., correct splint application, range of motion tech, skin integrity). Update Care plan and Resident Care Guide. On [DATE] at 5:15 p.m., a record review of the policy titled Skin Management revised ,[DATE] revealed the following: 4. Residents admitted with skin impairments will have: A appropriate interventions to promote healing; A physician's order for treatment, and; Wound location, measurements and characteristics documented. DPS #2 Based on observation, interview and record review, the facility failed to properly assess and treat for pain prior to wound care for two residents (#701 and #705) observed during wound care out of a total of 18 sampled residents, resulting in unnecessary pain experienced by these residents during a medical procedure. Findings include: Resident #701 On [DATE] at 11:00 a.m., record review revealed that Resident #701 was originally admitted into the facility on [DATE] and then readmitted on [DATE] with the following Diagnoses: [REDACTED]. The MDS dated [DATE] revealed that Resident #701 had a BIMS score of 05 indicating cognitive impairment and was dependent for transfers and needed extensive two person assist for bed mobility. On [DATE] at 2:45 p.m., wound care was observed with RN A and the wound nurse practitioner (NP J). Resident #701 was lying flat on her back in bed. NP J was on the right side of the resident standing beside her bed. NP J reached across Resident #701 and gently grabbed her from the left side to assist the resident on to her right side. While rolling Resident #701, she (the resident) was grimacing in pain. NP J stated, Is that shoulder bothering you again? Resident #701 replied, Yes. On [DATE] at 8:20 a.m., an interview was completed with Resident #701 regarding her pain in the left shoulder. Resident #701 had stated that she has pain from her head to her toes and had not received any medication to help alleviate the pain. When asked why she had not received any medication, Resident #701 stated, I am not a big pill pusher you know .the pills constipate me. When asked if she would be willing to take medication that was not constipating, Resident #701 stated, Well sure, I was not aware that there were pills that would not constipate me that could help my pain. On [DATE] at 8:30 a.m., a Licensed Practical Nurse (LPN B) was queried in regards to pain assessment and medication. LPN B stated, We assess them (residents) for pain when they get PRN medication. On [DATE] at 8:45 a.m., a record review of the pain care plan created on [DATE] for Resident #701 revealed that she has a potential for pain related to a [MEDICAL CONDITION] humerus. Interventions include: Monitor/record/report to Nurse any s/sx (signs and symptoms) of nonverbal pain .grimacing . Anticipate resident's need for pain relief PRN and respond immediately to any complaint of pain. On [DATE] at 8:50 a.m., a record review of the Medication Administration Record [REDACTED]. Resident #705 On [DATE] at 10:25 a.m., record review revealed that Resident #705 was admitted into the facility on [DATE] with the following Diagnoses: [REDACTED]. The MDS dated [DATE] revealed that Resident #705 needed extensive assist with toileting and transfers and had a BIMS score of 04, indicating cognitive impairment. On [DATE] at 2:15 p.m., wound care was observed with RN A and NP J. Resident #705 had a chronic wound on her left heel. RN A removed the old dressing, causing Resident #705 to grimace in pain. The wound bed had black and yellow soft, slough tissue (dead tissue). NP J cleansed the wound with a damp 4 x 4 gauze to assess the wound. During the cleanse, Resident #705 had facial grimacing each time the wound was touched. RN A then proceeded to wipe the wound to remove some of the dead tissue. As she was doing that, Resident #705 continued to frown and have facial grimacing. On [DATE] at 10:00 a.m., an interview was completed with RN A. During the interview, RN A stated, They (the nurses) know when I am coming to do the treatments. It's hard to tell if she (Resident #705) is having chronic pain or episodic pain. When she grimaces we ask her if she wants something for pain but she won't answer you. On [DATE] at 11:45 a.m., the DON was queried in regards to pain management, especially those that may not be able to consistently communicate their pain. The DON replied, It's a standard of care to assess for pain. It's done as a quarterly assessment too, I am not sure what they (the nurses) do with that information once they collect it. On [DATE] at 10:05 a.m., a record review of the MAR indicated [REDACTED]. On [DATE] at 2:25 p.m., a record review of the pain care plan created [DATE] for Resident #705 revealed the following: at risk for pain and/or has chronic pain r/t (related to) Arthritis, Chronic Physical Disability, Wounds. The care plan interventions included the following: Observe and report to Nurse PRN any s/sx of non-verbal pain .grimacing . On [DATE] at 2:35 p.m., a record review of the facility policy titled, Pain Management revised ,[DATE] revealed the following: 3. Observed for indicators of pain .Indicators include: Wincing or frowning and other facial expressions. 4. In residents who have dementia and cannot verbalize that they are feeling pain, symptoms of pain can be manifested by particular behaviors such as: Pained facial expressions . DPS #3. This Citation pertains to Intake # Based on interview and record review, the facility failed to respond quickly and thoroughly document a significant change in condition for one (#715) of three Residents reviewed for assessment and monitoring of a total sample of 18, resulting in the potential delay in medical treatment and deterioration in medical status. Findings include: Record review on [DATE] at 7:45 AM revealed Resident #715 was originally admitted into the facility on [DATE] and readmitted on [DATE]. The Resident was discharged from the facility on [DATE] and had [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the Resident was cognitively intact and required extensive assistance to complete Activities of Daily Living (ADL's). The Resident was a full code (wanted resuscitation efforts completed). Record review of Resident #715's Electronic Medical Record (EMR) on [DATE] at 8:00 AM revealed the Resident was being treated with oral antibiotics for a Urinary Tract Infection when the Resident was discharged from the facility. The following documentation by Nurse M dated [DATE] at 7:56 PM pertaining to the Resident's change in condition and subsequent discharge was noted within the Residents EMR: Approximately 1830 nurse walked into room to check on another resident. Family was at residents bed side, they had been feeding (Resident # 715) dinner they brought. Nurse heard resident coughing and asked if everything was ok? Residents daughter said no (Resident) is vomiting. Nurse pulled back curtain and saw resident red in the face and coughing very hard, (Resident) had vomit on their gown and family unfolded the blanket that was on (Resident) chest, it too was full of vomit. Nurse checked 02 sat 67%. 02 tank and suction machine brought to room. Placed (Resident) on 5 lpm (liters per minute), checked remaining vital signs, ,[DATE] , 150, 97.8, 86% on 5 lpm, Nurse suctioned (Resident) only small pieces of food and mucus. Gave (Resident) breathing treatment. 02 sat at 90% during breathing treatment, coughing continued. Family were at bedside and wanted (Resident) sent to ER . 911 contacted. Vitals checked when EMS arrived ,[DATE], 155, 86 via n/c (nasal cannula) at 5 lpm, resp 30. Dr. Unit manager and POA contacted and informed of situation. Family told Nurse that (Resident) had been congested when they arrived and the sister (who is a nurse) had visited earlier in the day and also stated (Resident) was congested. This nurse talked with this resident for about 5 mins at approximately 1700 and she was not congested or coughing. Nurse asked CNA assigned to resident if any coughing or congestion was heard they too did not hear anything. On [DATE] at 12:00 PM, an interview was completed with the Director of Nursing (DON). EMR documentation was reviewed with the DON at this time. When queried regarding the timeframe from when Nurse M observed the Resident #715 in respiratory distress and the Resident was transferred to a higher level of care. The DON stated, Let me get back to you. When queried if the DON was able to get a clear picture of the Resident's condition from this note, the DON replied, No but I'm sure the nurse was busy. When asked if the Resident's medical condition worsened during the situation from the information documented by Nurse M, the DON declined to answer. When queried if an incident and accident report had been completed, the DON replied, No, we wouldn't do one for this. On [DATE] at 2:00 PM, another interview was completed with the Director of Nursing (DON). The DON stated, I found the 'e-INTERACT Transfer Form' in the computer, it has the time the Resident left the building. The DON stated, Nurse M first noticed the situation at 6:30 PM, Resident #715 was transported to the emergency room by Ambulance at 7:20 PM, and the Doctor and Family were notified at 7:30 PM. When queried why there was a 50 minute timeframe between when the nurse first observed the Resident in respiratory distress and leaving the facility by ambulance, the DON was unable to provide an answer. When queried why type of suctioning was performed by Nurse M, the DON stated, Oral, I'm sure. When asked how that could be determined from Nurse Ms documentation, the DON replied, You can't, that is what I assume it means. When inquired further if the Resident had an order for [REDACTED]. When asked if the Resident had an order to receive breathing treatments, the DON replied, Not that I am aware of. When asked if the facility had standing orders for emergency situations, the DON did not provide a response. Facility policies/procedures pertaining to emergency treatment including standing orders, and/or change in Resident condition were requested at this time. On [DATE] at 3:10 PM, an interview was completed with Nurse N. When queried regarding staff requirements related to emergency response training in the facility, Nurse N replied, All nurses have to have CPR (Cardio-pulmonary Resuscitation). When queried if nursing staff at the facility were required to have Basic Life Support (BLS) CPR or Advanced Cardiac Life Support (ACLS) training, Nurse N stated, BLS. When queried if suctioning a Resident in respiratory distress is covered in BLS training, Nurse N stated, No. Record review on [DATE] at 3:30 PM of facility provided documentation, upon request for facility policy, entitled Lippincott Procedures - Oropharyngeal Suctioning (Dated: 2017) revealed Verify the Practitioners order for oropharyngeal suctioning if your facility requires one. The document further revealed Documentation: Record the date, time, reasons for suctioning, and technique used; the amount, color, consistency, and odor (if any) of the secretions; the patient's respiratory status before and after the procedure; any complications and nursing actions taken; and the patient's tolerance for the procedure. On [DATE] at 3:40 PM, an interview was conducted with the DON. When queried if the facility had a policy pertaining to suctioning and treatment of [REDACTED]. No further explanation was provided. Record review on [DATE] at 3:50 PM of facility provided documentation, upon request for facility policy, entitled Lippincott Procedures: Change in Status, Identifying, and Communicating, Long-Term Care (Only pages 1, 2, and 5 of document were provided) (Dated 2017) was reviewed. Review of the received pages of the document did not reveal pertinent information. Phone number for Nurse M was requested but not received by the conclusion of the survey.

THIS CITATION PERTAINS TO INTAKE NUMBER MI 295 BASED ON OBSERVATION, INTERVIEW, AND RECORD REVIEW, THE FACILITY FAILED TO APPROPRIATELY ASSESS, MONITOR, AND TREAT A PREEXISTING HEAD WOUND FOR ONE (#501) OF FOUR SAMPLED RESIDENTS REVIEWED FOR QUALITY OF CARE, FROM A TOTAL OF FOUR SAMPLED RESIDENTS, RESULTING IN A LARGE UNTREATED, ABSCESSED, INFECTED, AND NECROTIC HEAD WOUND. A COMPLAINT ON FILE ALLEGED, "...THE DOCTORS CUT OFF DEAD BLACK TISSUE FROM (RESIDENT #501'S) HEAD; THERE WAS A BED OF PUS (THICK FLUID PRODUCED BY THE BODY AS IT FIGHTS AN INFECTION) UNDERNEATH....MEDICAL AUTHORITIES FEEL THAT (RESIDENT #501) IS NOT BEING PROPERLY SUPERVISED..." ON 8/28/13 AT 9:00 A.M., A TOUR OF THE FACILITY REVEALED RESIDENT #501 NO LONGER RESIDED AT THE FACILITY . DURING AN INTERVIEW WITH THE DON, IT WAS REVEALED RESIDENT #501 WAS TRANSFERRED TO THE hospital on [DATE]. ON 8/28/13 AT 2:10 P.M., RESIDENT #501, THE SUBJECT OF THE COMPLAINT, WAS VISITED AT A NEARBY HOSPITAL. RESIDENT #501 WAS OBSERVED IN BED LYING DOWN AND HAD MULTIPLE FACIAL BRUISES. BILATERAL SOFT WRIST RESTRAINTS WERE OBSERVED AROUND THE RESIDENT'S WRISTS AND THE RESTRAINTS WERE TIED TO THE BED FRAME. THE HOSPITAL NURSE WAS OBSERVED PERFORMING A DRESSING CHANGE TO #501'S HEAD AND AN OBSERVATION OF RESIDENT #501'S LEFT PARIETAL (LEFT SIDE) HEAD WOUND REVEALED A LARGE OPEN WOUND WITH VISIBLE SKULL. THE NURSE CLEANED RESIDENT #501'S HEAD WOUND WITH NORMAL SALINE AND APPLIED [MEDICATION NAME] CREAM (ANTIBACTERIAL) AND A DRY DRESSING. RESIDENT #501'S HOSPITAL PHYSICIAN WAS PRESENT DURING THIS OBSERVATION AND STATED, "...THE ER (emergency room ) REMOVED DEAD TISSUE AND SCABBING FROM HER SCALP-- IT WAS INFECTED. THERE WAS PURULENT (PUS) DRAINAGE UNDERNEATH THE SCAB. RIGHT NOW WE'RE CLASSIFYING IT AS A NECROTIC SCALP WOUND. WE DEBRIDED (SURGICAL PROCEDURE TO REMOVE DEAD TISSUE) IT AND WOUND CARE WILL BE FOLLOWING UP..." ( ) HOSPITAL RECORDS FOR RESIDENT #501 WERE REVIEWED ON 8/28/13 AT 3:00 P.M. THE "ED (EMERGENCY DEPARTMENT) PROVIDER NOTE DATED 8/25/13 AT 7:15 P.M. DOCUMENTED, "...A LARGE, IRREGULAR 5 IN (INCH) BY 4 IN AREA OF DRY NECROTIC (DEAD) TISSUE PEELED OFF THE SCALP. UNDERNEATH IS A NON-ODOROUS THICK, YELLOW EXUDATE (FLUID THAT DRAINS FROM AN OPEN WOUND)." THE ED PROVIDER NOTE FURTHER STATED THAT THE SCALP INJURY WAS DEBRIDED (A SURGICAL PROCEDURE TO REMOVE DEAD TISSUE FROM A WOUND), THE WOUND WAS IRRIGATED, AND RESIDENT #501 WAS STARTED ON ANTIBIOTICS ([MEDICATION NAME] AND [MEDICATION NAME]). "IMPRESSION...SCALP LESION WITH NECROSIS AND SCALP ABSCESS (COLLECTION OF PUS)." A "WOUND CARE" PROGRESS NOTE DATED 8/26/13 AT 11:15 A.M. DOCUMENTED, "THICK BLACK ESCHAR (DEAD TISSUE) WAS NOTED AT THE SITE OF THE SCALP LACERATION AND THE WOUND WAS DEBRIDED AND CULTURED IN THEER on [DATE]." THE HISTORY AND PHYSICAL COMPLETED BY THE HOSPITAL PHYSICIAN ON 8/27/13 AT 8:05 P.M. DOCUMENTED, "...NECROTIC HEAD WOUND..." UPON RETURN TO THE NURSING FACILITY ON 8/29/13 AT 10:25 A.M., THE DON WAS INTERVIEWED ABOUT THE WOUND LOCATED ON RESIDENT #501'S HEAD AND REPORTED THE RESIDENT HAD THE WOUND AT THE TIME OF HER ADMISSION INTO THE FACILITY. THE DON REVIEWED THE CLINICAL RECORD AND PROVIDED A "PATIENT TRANSFER ASSESSMENT FORM", DATED 7/29/13 WHICH DOCUMENTED THE RESIDENT WAS admitted TO THE FACILITY WITH A SCAB LOCATED ON THE LEFT UPPER SCALP. THE DON REPORTED THE PHYSICIAN ORDERED "WOUND CARE PROTOCOL". THE DON EXPLAINED "WOUND CARE PROTOCOL" MEANT RESIDENT #501 WAS TO BE ASSESSED BY WOUND CARE AND THE FACILITY'S TREATMENT NURSE. THE DON WAS UNABLE TO FIND EVIDENCE THE WOUND CARE TEAM AND THE TREATMENT NURSE WERE CONTACTED TO ASSESS THE SCABBED HEAD WOUND. REVIEW OF SECTION K (SKIN) OF THE INITIAL NURSING ADMISSION ASSESSMENT ENTITLED, "NURSING COMPREHENSIVE EVALUATION", DATED 7/29/13, REVEALED THE NURSE IDENTIFIED "HEMATOMA" BY CIRCLING THE TOP PORTION OF THE RIGHT SIDE OF THE HEAD ON A "BODY DIAGRAM" (THE WOUND WAS ON THE LEFT SIDE OF THE HEAD). NO OTHER INFORMATION REGARDING THE HEAD HEMATOMA WAS DOCUMENTED. THE INITIAL NURSING PROGRESS NOTES AND SUBSEQUENT NURSING PROGRESS NOTES DID NOT ADDRESS THE HEAD HEMATOMA OR HEAD WOUND. REVIEW OF THE JULY 2013 MONTHLY PHYSICIAN ORDER [REDACTED]. A NURSING CARE PLAN DATED 7/29/13 DOCUMENTED, "(RESIDENT #501) WILL BE FREE OF SKIN BREAKDOWN WITH GOOD SKIN INTEGRITY." THE CARE PLAN DID NOT ADDRESS RESIDENT #501'S SCALP HEMATOMA/SCAB. ON 8/29/13 AT 10:25 A.M., THE DON STATED THE WOUND LOCATED ON RESIDENT #501'S HEAD "APPEARED DARK--MORE LIKE ESCHAR (DEAD TISSUE COVERING THE SURFACE)--ALMOST LEATHERY LOOKING." WHEN ASKED WHERE THAT INFORMATION WOULD BE DOCUMENTED, THE DON STATED, " I DID NOT DOCUMENT IT--I ASSUMED MY NURSES WOULD. " IN A PREVIOUS INTERVIEW, ON 8/28/13 AT 12:10 PM, THE DON REPORTED THAT RESIDENT #501 WAS "...ALWAYS PICKING AT THINGS...I THINK SHE IS THE ONE WITH THE BIG SCAB ON HER HEAD AND SHE WAS ALWAYS PICKING AT IT..." WHEN QUERIED ABOUT INTERVENTIONS TO ADDRESS RESIDENT #501'S HISTORY OF PICKING AT THINGS, THE DON STATED, "WE JUST WATCH HER REAL CLOSE." THE DON WAS QUESTIONED SPECIFICALLY ABOUT HOW THE AREA ON RESIDENT #501'S HEAD WAS MONITORED AND STATED, "IT WAS OUT THERE (VISIBLE). YOU COULD SEE IT." THERE WAS NO DOCUMENTATION OF THE ABOVE MENTIONED BEHAVIORS, MONITORING, OR INTERVENTIONS TO ADDRESS THE HEAD WOUND. THE MEDICAL RECORDS DIRECTOR PROVIDED THE NURSING WEEKLY (HEAD TO TOE) SKIN ASSESSMENT SHEET FOR RESIDENT #501. THE SHEET WAS DESIGNED TO DOCUMENT, ON A WEEKLY BASIS, THE CONDITION OF RESIDENT #501'S SKIN-- FOR A DURATION OF SIX WEEKS. THE THREE ASSESSMENT DATES DOCUMENTED ON THE FRONT OF THE SKIN SHEET WERE DIFFICULT TO READ; HOWEVER, THE SKIN ASSESSMENT FOR THE FOURTH WEEK, LOCATED ON THE BACK OF THE SHEET WAS DATED 5/28/13. RESIDENT #501 WAS admitted [DATE]. THE HANDWRITTEN NARRATIVE OBSERVED ON EACH OF THE FOUR WEEKLY SKIN ASSESSMENT NOTES DID NOT DESCRIBE ABNORMALITY IDENTIFIED ON THE RESIDENT'S HEAD. A REVIEW OF THE FACILITY'S ADMISSION FACE SHEET REVEALED THAT RESIDENT #501 WAS admitted INto the facility on [DATE] WITH [DIAGNOSES REDACTED]. A "NURSING COMPREHENSIVE EVALUATION" DATED 7/29/13 DOCUMENTED THAT RESIDENT #501 WAS BLIND IN THE RIGHT EYE AND SAW "SHADOWS ONLY" WITH THE LEFT EYE. A HISTORY AND PHYSICAL DATED 7/31/13 REVEALED AN ADDITIONAL [DIAGNOSES REDACTED]. THE INITIAL MINIMUM DATA SET (MDS) assessment dated [DATE] DOCUMENTED THAT RESIDENT #501 HAD SEVERELY IMPAIRED COGNITION WITH NO BEHAVIORS AND REQUIRED EXTENSIVE TO TOTAL ASSISTANCE WITH MOST ACTIVITIES OF DAILY LIVING (ADLS) INCLUDING TRANSFERS, LOCOMOTION ON UNIT, DRESSING, TOILETING, HYGIENE, AND BATHING. THE FACILITY'S POLICY AND PROCEDURE FOR ASSESSING SKIN, ENTITLED, "SKIN MANAGEMENT", DATED 5/2010 WAS REVIEWED AND DOCUMENTED THE FOLLOWING: "...THE LICENSED NURSE WILL MONITOR, EVALUATE AND DOCUMENT CHANGES REGARDING SKIN CONDITION IN THE MEDICAL RECORD...". "...PLACE EACH RESIDENT ON A WEEKLY HEAD-TO-TOE SKIN ASSESSMENT THAT IS COMPLETED BY THE LICENSED NURSE...THE CNA'S WILL REPORT ANY NEW SKIN IMPAIRMENT TO THE LICENSED NURSE THAT IS IDENTIFIED DURING DAILY CARE..." "...IF A NEW AREA OF SKIN IMPAIRMENT IS IDENTIFIED, NOTIFY THE RESIDENT, RESPONSIBLE PARTY, ATTENDING PHYSICIAN, DON, AND TREATMENT TEAM..." "...THE IDT (INTERDISCIPLINARY TEAM) WILL EVALUATE RESIDENT SKIN CHANGES, REVIEW TREATMENT MODALITIES, INTERVENTIONS AND WILL MAKE RECOMMENDATIONS AS NEEDED. CARE PLANS...WILL BE UPDATED ACCORDINGLY. RESIDENTS REVIEWED FOR SKIN ALTERATIONS ARE AS FOLLOWS:...ANY PRESSURE OR NON-PRESSURE AREA THAT HAS SHOWN NO SIGNS OF HEALING IN A 2 WEEK TIME FRAME...NEW ADMISSIONS AND READMISSIONS WITH SKIN CONDITIONS (...NON-PRESSURE RELATED...)..." "...THE DON/DESIGNEE WILL DOCUMENT ANY CHANGES INT HE CARE PLAN..." THE FACILITY'S POLICY FOR GENERAL ASSESSMENT AND MONITORING OF RESIDENTS WAS REQUESTED, HOWEVER, THE DON REPORTED THAT THEY DO NOT HAVE ONE. ( )

THIS CITATION PERTAINS TO MI 191. BASED ON OBSERVATION, INTERVIEW AND RECORD REVIEW, THE FACILITY FAILED TO ASSESS AND MONITOR 1 OF 6 SAMPLED RESIDENTS (RESIDENT #500) REVIEWED FOR SIGNS OF DEHYDRATION AND URINARY TRACT INFECTION [MEDICAL CONDITION], AND FAILED TO PROVIDE NUTRITIONAL SUPPLEMENTS PER PHYSICIAN ORDERS, RESULTING IN hospitalization , UTI AND WEIGHT LOSS. FINDINGS INCLUDE: REVIEW OF THE FACE SHEET, MINIMUM DATA SET (RESIDENT ASSESSMENT TOOL) DATED 2/22/12, HISTORY AND PHYSICAL DATED 1/26/12, PHYSICIAN ORDERS [REDACTED].#500 WAS admitted to the facility on [DATE], FOR REHABILITATION SERVICES, WAS CONFUSED WITH MEMORY LOSS, WAS AT RISK FOR FALLS AND DEPENDENT ON STAFF FOR ALL ACTIVITIES OF DAILY LIVING (ADL'S) AND TRANSFERS. RESIDENT #500'S [DIAGNOSES REDACTED]. UPON ADMISSION RESIDENT #500 had a history of [REDACTED]. REVIEW OF THE HOSPITAL RECORDS DATED 3/26/12 THROUGH 3/28/12, REVEALED RESIDENT #500 WAS TRANSFERRED FROM THE FACILITY DUE TO A FALL AND admitted TO THE hospital on [DATE]. RESIDENT #500 DID NOT RETURN TO THE FACILITY AND WAS discharged on [DATE], UNDER HOSPICE SERVICES. REVIEW OF THE HOSPITAL EMERGENCY DEPARTMENT RECORDS DATED 3/26/12, REVEALED RESIDENT #500 HAD FALLEN AT THE FACILITY AND RECEIVED INJURIES. DEHYDRATION: OBSERVATION MADE ON 4/17/12 AT 2:00 P.M., REVEALED AN UN-SAMPLED ALERT RESIDENT HAD AN EMPTY WATER CUP AT HER BEDSIDE DATED 4/16/12. THE RESIDENT SAID SHE "HAD NOT GOTTEN WATER AT ALL" THAT DAY (ON 4/17/12). OBSERVATIONS WERE MADE ON 4/17/12 (AT 3:20 P.M., 3:22 P.M., 3:23 P.M. AND 3:25 P.M.), OF 4 UN-SAMPLED RESIDENTS ON HALL 300. 4 OUT OF 4 RESIDENTS HAD WATER CUPS DATED "4/16/12" AND HAD NOT RECEIVED ANY WATER ON 4/17/12. INTERVIEWS WERE DONE ON 4/17/12 AT 2:25 P.M., WITH NURSING ASSISTANT (CNA) #2 AND #3. CNA'S #2 AND #3 STATED "WE JUST GOT ON (THE START OF THEIR SHIFT), WE PASS THE WATER". CNA #2 AND #3 REVEALED FRESH WATER WAS TO BE PASSED TO RESIDENTS ON EACH SHIFT (THREE SHIFTS PER DAY). AN INTERVIEW WAS DONE ON 4/16/12 AT 12:45 P.M., WITH THE REGISTERED DIETICIAN (RD) #1. RD #1 STATED "THE CNA'S PASS WATER EACH SHIFT". AN INTERVIEW WAS DONE ON 4/16/12 AT 1:26 P.M., WITH THE INFECTION CONTROL NURSE (IC NURSE) #2. IC #2 NURSE SAID THE FACILITY DID NOT HAVE A POLICY ON WHEN THE WATERS WERE TO BE PASSED TO THE RESIDENTS DAILY, HOWEVER STAFF WERE AWARE TO PASS FRESH WATER ON EACH SHIFT. AN INTERVIEW WAS DONE ON 4/17/12 AT 12:20 P.M., WITH THE DIRECTOR OF NURSING (DON) #3. DON #3 CONFIRMED STAFF PASSED FRESH WATER TO RESIDENTS (WITH NO FLUID RESTRICTIONS) ON EACH SHIFT. REVIEW OF THE NUTRITIONAL EVALUATION DATED 1/25/12, REVEALED RESIDENT #500 WAS CONFUSED, REQUIRED ASSISTANCE WITH MEALS AND FLUIDS AND WAS TO RECEIVE "1140" ML'S OF FLUID DAILY. AN INTERVIEW WAS DONE ON 4/16/12 AT 12:45 P.M., WITH RD #1. RD #1 AGREED RESIDENT #500 REQUIRED 1140 ML'S OF FLUID DAILY. RD #1 STATED "I REVIEWED THE HYDRATION, NUTRITION, NURSES AND DOCTOR NOTES, WEIGHTS, LABS, I AND O'S". REVIEW OF RESIDENT #500'S FACILITY DEHYDRATION/FLUID IMBALANCE CARE PLAN DATED 1/25/12,STATED STAFF WERE TO "MONITOR URINE OUTPUT, COLOR AND SEDIMENT, [MEDICAL CONDITION], SKIN TURGOR, MUCOUS MEMBRANES AND ENCOURAGE FLUIDS AS CALCULATED BY THE RD". REVIEW OF THE POTENTIAL FLUID DEFICIT R/T (RELATED TO) DECREASED PO (ORAL) INTAKE CARE PLAN DATED 2/1/12, STATED "MONITOR AND DOCUMENT INTAKE AND OUTPUT". REVIEW OF THE BLADDER INCONTINENCE CARE PLAN DATED 2/1/12, STATED "MONITOR AND DOCUMENT INTAKE AND OUTPUT. IF THE PATIENT IS NOT EATING/DRINKING ADEQUATELY, THE NURSE [MEDICATION NAME] THEM FOR DEHYDRATION. SIGNS AND SYMPTOMS OF DEHYDRATION ARE, POOR SKIN TURGOR, FLUSHED DRY SKIN, DECREASED TEARING OR SALIVATION, COATED TONGUE, DECREASED URINE OUTPUT, INCREASED CONFUSION, IRRITABILITY AND DRY ORAL CAVITY (FUNDAMENTALS OF NURSING, PATRICIA A. POTTER, MOBSY COMPANY 1985). REVIEW OF THE INTAKE/OUTPUT RECORD REVEALED ON 1/25/12, 1/26/12, 1/27/12, 1/28/12, 1/29/12, 1/30/12, 2/3/12, 2/4/12, 2/5/12, 2/6/12, 2/10/12, 2/11/12, 2/12/12, 2/13/12, 2/14/12, 2/18/12, 2/19/12, 2/21/12 AND 2/22/12, REVEALED RESIDENT #500 RECEIVED INADEQUATE FLUID INTAKE ACCORDING TO THE NUTRITIONAL EVALUATION DATED 1/25/12. REVIEW OF THE INTAKE/OUTPUT RECORD DATED 1/25/12 THROUGH 2/22/12, REVEALED THE FACILITY HAD STOPPED ASSESSING THE RESIDENTS INTAKE ON 2/22/12 AND THE WORD "DONE" WAS HAND WRITTEN ACROSS THE DATES 2/24/12 AND 2/25/12. DURING AN INTERVIEW WITH THE DON ON 4/17/12 AT 12:20 P.M., THE DON WAS UNABLE TO EXPLAIN WHY THE FACILITY DISCONTINUED INTAKES ON THE RESIDENT WHEN SHE HAD 19 DOCUMENTED DAYS OF INADEQUATE FLUID INTAKE. URINARY TRACT INFECTION : REVIEW OF THE EMERGENCY DEPARTMENT REPORT DATED 3/26/12, REVEALED A URINARY CATHETER WAS PLACED AND THE RETURN WAS "150 ML CLOUDY URINE". REVIEW OF THE HOSPITAL PHYSICIAN NOTE DATED 3/27/12, STATED "ACUTE UTI: IV CIPRO". REVIEW OF THE HOSPITAL MEDICATION RECORDS DATED 3/27/12, REVEALED RESIDENT #500 WAS PUT ON "CIPRO", AN ANTIBIOTIC. REVIEW OF THE HOSPITAL PHYSICIAN ORDER [REDACTED]. REVIEW OF THE HOSPITAL LABS DATED 3/26/12, REVEALED RESIDENT #500'S URINE WAS "CLOUDY" (SIGN OF DEHYDRATION OR UTI, NORMAL=CLEAR), THE URINE SPECIFIC GRAVITY (AIDS IN EVALUATING HYDRATION STATUS) WAS "1.057" (NORMAL=1.001-1/030) AND THE URINE WBC'S (WHITE BLOOD CELLS) WAS "TOO NUMEROUS TO COUNT", NORMAL URINE WBC'S=NONE. REVIEW OF THE POTENTIAL FLUID DEFICIT R/T (RELATED TO) DECREASED PO INTAKE CARE PLAN DATED 2/1/12, REVEALED THE FACILITY WAS TO "MONITOR/DOCUMENT FOR S/SX (SIGNS AND SYMPTOMS) OF UTI: PAIN, BURNING, BLOOD TINGED URINE, FEVER, CHILLS, ALTERED MENTAL STATUS, CHANGE IN BEHAVIOR, CHANGE IN EATING PATTERNS". IF THE PATIENT IS NOT EATING/DRINKING ADEQUATELY, THE NURSE [MEDICATION NAME] THEM FOR DEHYDRATION, SIGNS AND SYMPTOMS ARE, POOR SKIN TURGOR, FLUSHED DRY SKIN, DECREASED TEARING OR SALIVATION, COATED TONGUE, DECREASED URINE OUTPUT, CONFUSION, IRRITABILITY AND DRY ORAL CAVITY. (FUNDAMENTALS OF NURSING, PATRICIA A. POTTER, MOBSY COMPANY 1985) AN INTERVIEW WAS DONE ON 4/16/12 AT 1:26 P.M., WITH THE INFECTION CONTROL NURSE (IC NURSE) #2. IC #2 NURSE SAID SHE DID NOT HAVE THE RESIDENT ON HER INFECTION TRACKING SHEET (LINE LISTING OF SIGNS/SYMPTOMS OF INFECTION) BECAUSE THE NURSING STAFF HAD NO DOCUMENTATION OF ASSESSMENT'S OR SIGNS/SYMPTOMS OF A UTI. IC #2 NURSE STATED "I HAVE NOT DONE AN IN SERVICE ON UTI'S (ASSESSMENT AND PREVENTIVE MEASURES), I DON'T RECALL WHEN, OR IF ONE WAS DONE". REVIEW OF A YEAR OF FACILITY IN SERVICES, REVEALED NO DOCUMENTATION OF AN IN SERVICE ON UTI'S FOR NURSES OR NURSING ASSISTANTS. REVIEW OF THE INFECTION CONTROL LINE LISTING (RESIDENT INFECTION TRACKING SHEET) DATED 3/9/12 THROUGH 4/12/12, REVEALED NO DOCUMENTATION OF RESIDENT #500. REVIEW OF THE FACILITY HYDRATION POLICY DATED 8/11, STATED "IT IS THE POLICY OF THIS FACILITY TO ASSIST RESIDENTS TO MAINTAIN ADEQUATE HYDRATION WHENEVER POSSIBLE. PROCEDURE: -THE RD WILL CALCULATE THE RESIDENTS MINIMAL FLUID NEEDS. THE RD WILL REVIEW THE TOTAL FLUIDS PROVIDED AND INCREASE FLUIDS IF NEEDED TO ASSURE THE FLUID REQUIREMENTS ARE MET. -THE NURSING STAFF WILL ENCOURAGE ALL OF THE RESIDENTS TO CONSUME ALL THEIR FLUIDS. EACH RESIDENT WILL BE PROVIDED BEDSIDE WATER UNLESS CONTRAINDICATED. -THE CARE PLAN SHOULD INDICATE RISK FACTORS FOR DEHYDRATION AND APPROACHES SHOULD BE INDIVIDUALIZED TO MEET FLUID REQUIREMENTS. SUPPLEMENTS: REVIEW OF THE HOSPITAL discharge date D 1/25/12, STATED "[DIAGNOSES REDACTED]. REVIEW OF THE PHYSICIAN ORDER [REDACTED].O. (NEW ORDER), SUGAR FREE HOUSE SUPPLEMENTS TID (THREE TIMES A DAY), R/T DECREASED PO INTAKE". REVIEW OF THE PHYSICIAN ORDER [REDACTED]. REVIEW OF THE NUTRITIONAL PROGRESS NOTES DATED 2/2/12, 2/6/12 AND 2/20/12 REVEALED DOCUMENTATION THE RESIDENT WAS PUT ON NUTRITIONAL SUPPLEMENTS 3 TIMES A DAY. REVIEW OF THE NUTRITIONAL PROGRESS NOTES DATED 3/16/12, REVEALED THE RESIDENTS SUPPLEMENTS HAD BEEN INCREASED TO "6X" PER DAY. REVIEW OF THE PHYSICIAN ORDERS [REDACTED]. REVIEW OF THE RESIDENTS Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]"SUGAR FREE HOUSE SUPPLEMENT TID". REVIEW OF THE MAR indicated [REDACTED]. REVIEW OF THE RESIDENTS FACILITY POTENTIAL FOR ALTERATION IN NUTRITIONAL STATUS CARE PLAN DATED 2/1/12, STATED "PROVIDE AND SERVE SUPPLEMENTS AS ORDERED: SF (SUGAR FREE) HOUSE SUPPLEMENTS TID (2/2/12), 6 X/DAY (3/16/12)". AN INTERVIEW WAS DONE ON 4/16/12 AT 12:45 P.M., WITH THE RD. THE RD AGREED SHE HAD WRITTEN THE ORDER ON 2/2/12, FOR RESIDENT #500 TO RECEIVE SUGAR FREE HOUSE SUPPLEMENTS THREE TIMES PER DAY FOR DECREASED ORAL INTAKE AND THE ORDER DATED 3/16/12, FOR SUGAR FREE SUPPLEMENTS TO BE INCREASED TO 6 TIMES PER DAY. REVIEW OF RESIDENT #500'S FACILITY DEHYDRATION/FLUID IMBALANCE CARE PLAN DATED 1/25/12, STATED STAFF WERE TO GIVE SUPPLEMENTS AS ORDERED. REVIEW OF THE CLOSED CLINICAL RECORD REVEALED NO DOCUMENTATION WAS FOUND THAT RESIDENT #500 HAD RECEIVED THE SUGAR FREE HOUSE SUPPLEMENT PER PHYSICIAN ORDERS. REVIEW OF THE RESIDENTS DOCUMENTED WEIGHT ON 1/26/12 WAS "84.2" LBS., ON 2/21/12, "85.5" LBS., ON 2/27/12 "81" LBS., AND ON 3/13/12 WAS "80.5-78.5" LBS. THE NURSE IS OBLIGATED TO FOLLOW ALL PHYSICIAN ORDERS [REDACTED]. (FUNDAMENTALS OF NURSING, PATRICIA A. POTTER, ANNE G. PERRY, MOBSY COMPANY 1985). AN INTERVIEW WAS DONE ON 4/17/12 AT 12:20 P.M., WITH THE DON AND THE I/C NURSE. AFTER A COMPLETE REVIEW OF RESIDENT #500'S CLOSED CLINICAL RECORD, THE DON AND I/C NURSE WERE UNABLE TO LOCATE DOCUMENTATION OF ANY NURSING ASSESSMENTS OR MONITORING FOR UTI, NO ASSESSMENTS OR MONITORING FOR DEHYDRATION (FROM 2/22/12 TO 3/26/12), OR DOCUMENTATION THE RESIDENT RECEIVED ANY SUGAR FREE HOUSE SUPPLEMENTS PER PHYSICIAN ORDERS. ( )