**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to Intake Number 2574995.Based on observation, interview, and record review, the facility failed to provide the appropriate skin care interventions to prevent the development of pressure ulcers and promote healing consistent with professional standards for one resident (R103) of four sampled residents reviewed for pressure ulcers, resulting in a delay in treatment and healing, worsening of newly developed wounds, infection and further complications. Findings Include:Resident #103 (R103) A review of R103 Electronic Medical Record (EMR) was conducted on August 22, 2025, at 3:30 PM. According to the clinical record, R103 was [AGE] years old, admitted to the facility on [DATE], with the diagnosis of laceration of the scalp, Cerebral Palsy, Obstructive Hydrocephalus, and Epilepsy in addition to other diagnoses. R103's Brief Interview for Mental Status (BIMS) Score, assessed on June 27, 2025, was left as zero or 99, indicating that the patient was unable to complete the interview for the assessment. Minimum Data Set (MDS) section GG dated July 1.2025, indicated that R103 is dependent on staff with all Activities of Daily Living (ADLs), including but not limited to eating, toileting, showers, and personal hygiene. R103 relied on one to two staff members for transferring to and from the chair and bed, as well as rolling in bed from side to side, and using the toilet.General Progress Notes dated 8/8/25, at 9:26 AM, was reviewed, Noted text: Resident's wound has foul odor, and had a temp of 99.1 last evening. Dr K (Last name mentioned) informed and new order received to start Bactrim DS BID (Twice a day) for 7 days. Orders Noted.A review of R103's Care Plan indicated:ADLs Care plan initiated on 6/24/25, revealing the need for assistance with incontinence care, mobility, showers, personal hygiene, toilet use, and transfers. R103 also required one-on-one assistance with feeding. R103 was assessed as a two-person assist using a Hoyer lift.A care plan for Risk of skin breakdown r/t (related to) impaired mobility, contractures, and incontinence indicated that R103 had scarring from previous pressure ulcers to the coccyx and left outer ankle. There was no active open skin breakdown noted upon admission skin assessment on 6/24/25.R103 has impaired skin integrity: Pressure ulcer to coccyx, and wounds to ischium and left heel related to mobility, contractures to lower extremity, incontinence of bowel and bladder. Initiated on 6/24/25, revision date: 8/8/25.Goal: 1.) Tissue injury will improve and be free from complications with a revised date of 8/8/2025.Note: A wound treatment intervention was initiated in R103's care plan on July 16, 2025.The following were R103's recorded Skin Assessment and Condition from admission to discharge (June 23, 2025, to discharge date on August 8, 2025: According to the Skin assessment dated [DATE], upon admission). Staff assessed by: UnknownStaples on top of R103's head from a previous history of scalp lacerationLeft trochanter hip (closed wound)Left outer ankle (closed wound)Coccyx-Scar tissue with surrounding dark soft tissue DTI (Deep Tissue Injury)Treatment applied: No. A review of the admission Skin Evaluation revealed that it was dated on 6/23/25, but was locked and signed until July 6, 2025. It was unknown who the nurse who did the assessments on June 23rd and who the staff member who locked the assessment in July 6th. The Director of Nursing and the wound Nurse was asked subsequently but no staff member could verify the accuracy of the findings during the surveyor's review on August 22, 2025, at 4:30 PM. The Weekly Skin Evaluation Forms were reviewed on 8/22/2025 at 4:30 PM. It indicated:06/30/25 A. Skin Evaluation: 1. After completing a head-to-toe skin assessment, are there any new skin areas? NO07/07/25 A. Skin Evaluation: 1. After completing a head-to-toe skin assessment, are there any new skin areas? NO07/14/25 A. Skin Evaluation: 1. After completing a head-to-toe skin assessment, are there any new skin areas? NO07/21/25 A. Skin Evaluation: 1. After completing a head-to-toe skin assessment, are there any new skin areas? NO07/28/2025 A. Skin Evaluation: 1. After completing a head-to-toe skin assessment, are there any new skin areas? NO08/04/2025 A. Skin Evaluation: 1. After completing a head-to-toe skin assessment, are there any new skin areas? NO A review of R103's Skin assessment dated [DATE], (noted: this is R103 discharged date from the facility) revealed:Coccyx (UTD)- UTD means unstageable or unknown depth.Measurement size: 7.5 X 7.0 X depth UTD with eschar 1 00 % wound filled, heavy exudate, purulent drainage. Noted erythema described as intense bright red, dark red, or purple. 2. Left Heel-(acquired in house on 7/16/25)Measurement size: 3.5 X3.5 X depth (UTD) unstageable or unknown depth100% wound filled slough with a light amount of exudate described as purulent discharge 3. Left Ischium (acquired at the facility, first observed on 7/31/25, described as shearing and UTD (Unstageable Full Thickness or Tissue Loss)Measurement size: 3.0 cm (centimeters) X 3.2 cm x depth UTD, Slough 100% wound filled slough with a light amount of purulent drainage. A review of R103's skin record and treatment orders revealed:Physician's orders: From 6/23/25 (admission date) through 8/8/25 (discharge date ):Coccyx: Order Start Date: 7/6/26: Cleanse with cleanser, pat dry, apply calcium alginate to the wound bed, and cover with a wound dressing as needed, daily. Order Discontinued Date: 8/8/25Left Heel: Left heel wound was first discovered on 7/15/25. Physician's Order Start Date 7/29/25: Cleanse with wound cleanser, pat dry, apply calcium Alginate to wound bed, cover with foam dressing daily and as needed (PRN). Order Discontinued Date: 08/08/2025Left Ischium: Order Start Date: 8/8/25: Cleanse left Ischium with NS, cover with comfort foam, change qd and PRN every day shift for wound A review of R103's Treatment orders revealed:Date ordered: 6/23/25, Started on 6/24/25: Apply House Barrier cream to (B) Buttocks, coccyx, and peri-area every shift with incontinent episodes. Frequency: every shift and PRN (as needed)Date ordered: 8/8/25. Start Date: 8/8/25. Cleanse coccyx with NS (Normal Saline). Apply moistened gauze with Dakins Solution 1/4 strength pack to the wound. Cover with sacral dressing, changing BID and PRN (as needed) twice a day for wound care.Order Date: 8/8/25, and Start Date: 8/8/25: Cleanse Left Heel with NS, apply Medihoney topically, and cover with comfort foam, changing qd (daily) and PRN (as needed).Order Date 8/8/25 and started 8/8/25: Cleanse Left Ischium with NS, apply medihoney, cover with comfort foam, change qd and PRN. Every day shift for the wound. No treatment to the Left Ischium was ordered, despite being observed and assessed on 7/31/25, with an open area 2.8 cm (length) X 2.6 cm (width) X 0 depth with a light serous drainage.Order started on 7/22/25, Enhance Barrier Precautions when engaging in high-contact resident care activities for chronic wounds every shift.Order started on 8/8/25 - Bactrim DS oral Tablet 800-160 mg (Sulfamethoxazole-Trimethoprim). Give one (1) tablet by mouth two times a day for wound infection until 8/14/25 Treatment Administration Record (TAR) for R103 was reviewed, and it was found that missed treatments and assessments were as follows: Missed Treatment in July 2025 was noted below:- Weekly Skin Assessment (every Tuesday)= missing on 7/15/25- House Barrier cream to (B) Buttocks, coccyx, and Peri-Area every shift with an incontinence episode. There were no record of 7/13/25 (Days), 7/20/25 (Days), and 7/21/25 (Days)- Left Heel= 7/18/25 & 7/28/25 Coded 2 (Refused)-Coccyx= 7/13/25, 7/15/25, 7/20/25, and 7/21/25 did not indicate that the treatment was done. 7/18/25 and 7/28/25 were coded as 2 (Refuse)- No treatment to the Left Ischium was ordered despite the 7/31/25 assessment with an open area 2.8 cm (length) X 2.6 cm (width) X 0 depth with a light serous drainage Missed Treatment in August 2025, were noted below: Sunday, August 3, 2025: No treatment was administered to the Coccyx, Left Heel, and House barrier cream was not applied as ordered.An interview with the previous wound care Nurse, H, was conducted on August 21, 2025, at 1:15 PM. Nurse H admitted that she was the Wound nurse during 6/19/25 through 7/31/25. She was assigned the evening shift as a Unit Manager (Nights). She recalled that R103 did not have any open area when she was admitted . R103 had some noticeable scars from a previous injury at the coccyx area that had healed. She explained that, We noticed the same area developed discoloration and later opened up as described on the 7/10/25 assessment as a deep tissue injury (DTI). Stage 3 pressure sore on the coccyx measurement: 6.2 cm (Length) X 7.9 cm (Width) X zero (Depth). It had moderate serosanguineous drainage. Nurse H was an LPN and was a certified wound nurse. She stated that she was unaware of a newly developed open area on the left heel, which was first noted on July 15, 2025. The Director of Nursing conducted the initial assessment, but no one had informed me about the newly opened area. I was unaware of the left heel, so during the 7/17/25 evaluation, I was unable to reassess the wound on the left heel. So, on the 7/17/25 assessment I did, it did not include the left heel, because I did not get a report from a nurse aid or nurses. When asked about the Left Ischium open area, she confirmed she assessed a newly developed open area located at the left ischium described as another site that measured 2.8 cm (Length), 2.6 cm (width) X zero depth, denuded (loss of epidermis caused by exposure to urine, feces, body fluids, wound exudate, or friction. Not sure what happened, but we were putting treatment on the wound, but it was not recorded. We applied the same treatment as the coccyx, considering the wound as extending from the coccyx; however, this was not documented in the doctor's order or recorded. There was no treatment order from the doctor obtained for the Left ischium. Nurses don't do wound rounds with the doctors. No one was assigned to rounds with the doctor. Doctors do their own assessment and evaluation.An interview with the current Wound Nurse M was conducted on 8/20/25 at 4:20 PM. Nurse M indicated she started working as a wound nurse at the facility on 8/4/25. Nurse M revealed that she is an LPN with wound certification. She admitted that she vaguely remembers R103. But reviewing the assessment done on 8/8/25, before R103's discharge, Nurse M mentioned that the wound in the coccyx was infected with a purulent heavy drainage and foul odor. The physician was called, and oral antibiotics were ordered immediately. An interview with the Director of Nursing (DON) was conducted on August 20, 2025, at 4:30 PM. She revealed that R103 was discharged on 8/8/25 to a new foster care home. He stayed with us from 6/23/25 to 8/8/25 for short-term rehab and for new home placement. There was a question about previous foster care, and because of physical violence, he needed a new placement. R103 had mental incapacity- he was struck on the head. On 7/15/25, during therapy, they stated they found shearing on the Left outer heel. The Therapist (PTA) found it during the therapy session. The DON admitted that the left heel wound developed and was acquired at the facility. She further stated: The hospital records did not mention any open area or DTI in R103's hospital Discharge summary dated [DATE]. On August 8, the physician prescribed oral antibiotics because his wounds were infected. On the same day, R103 was discharged because a bed opened up, and was immediately discharged to the community. He started with only one dose. An interview with the PTA staff B was conducted on 8/21/25 at 10:30 AM. PTA staff B stated, R103 was at the rehab gym on his [NAME] chair, doing R103's stretches when I noticed the sock was damp. I immediately removed the sock on his left foot. I found an open area that looked like the skin had come off. It appeared that a blister had ruptured, and the fluid had been absorbed into the sock. I did not see blood. The sock was damp where the wound (Left Heel) was wet to the touch. It was rounded in shape, a bit bigger, and superficial. The wound was located on the inner side of the heel of the left foot. I immediately notified my Rehab Department Director and got the Director of Nursing. I don't remember what day it was, as it was not found in the notes. I don't know how the wound developed. I have no idea, to be honest! R103 doesn't move very much. I did not observe any repetitive or jerky movements in his feet during the therapy session. He did not express any discomfort or pain.An interview with Dr. K was conducted by phone on 8/27/25 at 4:45 PM. She indicated that she does rounds to see residents and see them, but did not remember rounding with the wound nurse on a weekly or monthly basis. She further specified: We see patients individually. Dr. K reviewed R103's medical record during the interview and stated that she saw the resident a few days after admission. On 6/25/25, Dr. K noted during examination that R103 was non-verbal with no open wound ongoing during her assessment. Although R103 was bedbound, Dr. K recalled examining his back in bed, and there were no other skin impairments noted on the legs, ankles, and feet during the examination on June 25, 2025. The subsequent encounter I had with R103 was pointed out in the Progress Notes dated August 7, 1925, which stated that at 5:15 PM, I received a text regarding a necrotic coccyx with foul drainage. I ordered an antibiotic of Bactrim to give immediately after a wound culture. Dr. K was not sure what happened, but the following day on 8/8/25, R103 started on Clindamycin and not the Bactrim she had ordered. The resident was discharged on August 8, 2025, so she did not follow up.Late Entries progress notes entered Dr. L was unavailable for interview due to a scheduled vacation internationally, but according to both Dr. J and Dr. K, the dictated notes should not take more than 48 hours. The two physicians were unaware of the delay of all seven (7) Late Entries of progress notes in the EMR for R103.POLICIESOn August 22, 2025, at 3:30 PM, the Wound Management Policy was reviewed.Wound Management Policy (Original date-1/2/2024) Policy: To promote wound healing of various types of wounds. It is the policy of the facility to provide evidence-based treatments in accordance with current standards of practice and physician orders.Procedure:Wound treatments will be provided in accordance with physician orders, including cleansing method, type of dressing, and frequency of dressing change.In the absence of treatment orders, the licensed nurse will notify the physician to obtain treatment orders. This may be the treatment nurse or the assigned licensed nurse in the absence of the treatment nurse .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This Citation Pertains to Intake Numbers MI00152877 and MI00152910. Based on observation, interview and record review, the facility failed to ensure wounds were assessed, monitored, and that appropriate interventions were in place for 3 Residents (#1, #2, #3) of 3 residents reviewed for wounds, including Resident #1 who had a above the right knee amputation after a lack of assessment and monitoring, infection and a dehisced/opened right below the knee amputation surgical site. 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: recent right below the knee amputation, diabetes, COPD, heart disease, atrial fibrillation, peripheral vascular disease, history of a stroke, depression and arthritis. The MDS assessment dated [DATE] revealed the resident needed assistance with care. The resident was transferred to the hospital on 5/1/2025 for additional surgery. Further review of the MDS assessment dated [DATE] for Resident #1 identified in Section M that the resident had a surgical wound and there was no treatment. A review of the admission Skin assessment for Resident #1 titled, Skin Evaluation, dated 3/31/2025 did not mention Resident #1 was admitted with a surgical wound related to a recent right below the knee amputation. On 4/3/2025 a Skin Condition Evaluation, revealed the resident had a RBKA (right below the knee amputation) surgical incision with no measurements. It did not identify if staples or sutures were present. It indicated a non-removable pressure dressing intact. There was no assessment of the surrounding skin (peri-wound). The assessment also provided, unable to see with this assessment due to dressing that stays in place until next appt. (appointment). On 4/10/2025 a Skin condition Evaluation, identified a RBKA, surgical incision, with no measurements. There was no mention of sutures or staples or what the peri-wound looked like. A review of the Hospital discharge instructions dated 3/31/2025 for Resident #1 identified the following: Leg Amputation, Care After . Check your residual limb, especially your incision, every day. Check for: Blisters, Scrapes, Signs of infection, such as: More redness, swelling, or pain. More fluid or blood; warmth, Pus or a bad smell. Follow instructions from your health care provider about how to take care of your incision . Change your dressing as told by your health care provider . Leave stitches (sutures), staples, skin glue, or adhesive strip in place. These skin closures may need to stay in place for 2 weeks or longer . A review of the progress notes for Resident #1 identified there was no mention of the resident's surgical incision, assessment or monitoring from 3/31/2025 the day of admission through 4/14/2025. A review of the March and April 2025 Medication Administration Records/MAR and Treatment Administration Records/TAR for Resident #1 identified there was no mention of assessment or monitoring of the Right below the knee amputation surgical site from the day of admission 3/31/2025 through 4/14/2025. A review of the Interdisciplinary Team document titled, IDT Care Plan Conference Summary, dated 4/3/2025 and locked 4/10/2025 revealed there was no mention of Resident #1's right below the knee amputation surgical site. The Nursing Goals and Summary section of the document was blank. A review of the physician orders indicated there was no mention of assessment or monitoring of the resident's RBKA surgical site until 4/15/2025: two weeks after the resident was admitted with the RBKA surgical site. A review of the Care Plans for Resident #1 revealed the following: (Resident #1) has impaired skin integrity: admitted with a R BKA surgical incision, date initiated 3/31/2025 and revised 4/18/2025 with interventions including: Assess and document skin condition, notify MD of signs of infection (redness, drainage, pain, fever), date initiated 3/31/2025; Wound treatment as ordered, date initiated 3/31/2025. Further review of the progress notes identified a Late Entry note dated 4/15/2025 at 12:30 PM, The resident returned from his appoint (ment) with a dehisced (surgical incision opened on its own) wound, to the R. BKA. Cleanse with wound cleanser, pat dry, apply iodoform packing into wound bed, apply skin prep to peri wound and allow to dry, cover with bordered dressing. Change daily and prn (as needed). The physician orders the resident to be on 1 tablet by mouth two times a day for skin infection to surgical wound until 4/25/2025. A Vascular Surgical consult note dated 4/15/2025 revealed, S/P (status post) right BKA 3/26/25 Surgical wound with dehiscence @ mid-incision. Staple removed here and there is tunneling about 1 ½ inch deep. Bloody/purulent drainage. This will need to be packed daily with packing strips. Rec. (recommend) Bactrim DS 800 mg/160 mg po BID (twice a day) x 10 days; Schedule surgical washout and debridement . Further review of the April 2025 MAR/TAR's for Resident #1 revealed a new entry dated 4/16/2025, RBKA surgical wound. Cleanse with wound cleanser, pat dry, apply iodoform packing into wound bed, apply skin prep to peri wound and allow to dry, cover with bordered dressing. Change daily and prn (as needed, every day shift for surgical wound care. A progress note dated 4/24/2025 at 1:28 PM revealed, Patient had pressure dressing to RBKA from admission until follow up with ortho. At that follow up appointment, incision was noted with open wound and infection. RBKA surgical incision with wound is currently treated with antibiotic therapy. Around the incision is not healing with the intention of surgeon's treatment order. Wound has slough (dead stringy tissue), copious serosanguinous drainage. Redness, swelling and warmth remains to suture line . A review of a Vascular Surgical consult dated 4/25/2025 for Resident #1 provided, Wound check of Right Below Knee amputation stump- non- healing . Debridement in hospital- please hold Apaxiban appropriately . On 5/13/2025 at 1:49 PM , Confidential Person E was interviewed about Resident #1's RBKA and said the resident was admitted to the facility on [DATE] from the hospital after having surgery: a right below the knee amputation/RBKA. She said the resident had a history of circulation issues, poor blood flow and prior wounds to his right lower leg. She said that is why he had an RBKA and needed to be monitored closely. She said the hospital discharge instructions said the surgical wound was to be inspected daily. Confidential Person E said the resident had a follow-up appointment with the Vascular Surgeon on 4/15/2025 and at that appointment the surgical wound opened up because it was infected and was not being monitored. She said the wound needed to be surgically cleaned (debrided, with removal of the dead tissue). At the resident's next appointment with the Vascular Surgeon on 4/25/2025 he was scheduled to have the debridement, but could not have it because the facility did not appropriately hold the resident's blood thinners prior to the procedure, so it could not be done. She said she was told if the wound did not heal, the resident would need another surgery: a right above the knee amputation. She said the resident went back to the hospital on 5/1/2025 to have the right above the knee amputation. During an interview with Wound Care Nurse A on 5/14/2025 at 8:50 AM, she was asked about Resident #1's RBKA and whether the surgical wound was being monitored. She said she was told by one of the medical providers that some surgeons do not want the surgical dressing to be removed prior to the scheduled post-surgical follow-up appointment, so the facility did not remove it. Nurse A was asked if the Surgeon's office was contacted to obtain information on how to care for the surgical site and she said the office was not contacted until after the first appointment on 4/15/2025. She was asked if there was documentation that the nurses were routinely assessing and monitoring the wound and she said there was a weekly skin assessment. Reviewed with Nurse A that the assessments did not describe the condition of the wound, how many staples, sutures or the surrounding skin. Nurse A was asked if it had been reviewed with the resident's physician at the facility, as there was no order not to monitor the surgical site or how to care for the wound. She said after the 4/15/2025 appointment, the nurses performed wound care daily, as the wound was infected and had opened. There was no routine documentation of assessment or monitoring to aid in identifying a change in the condition of the wound. Resident #2: A record review of the Face sheet and MDS assessment indicated Resident #2 was admitted to the facility on [DATE] with diagnoses: recent right above the knee amputation 5/2/2025, diabetes, chronic kidney disease, heart disease, and anxiety. On 5/14/2025 at 9:00 AM, Resident #2 was observed awake, alert, and sitting up in bed. Wound Nurse A was present and rolled up the resident's right pant leg to visualize his surgical site. Nurse A said there were 20 staples and 10 sutures; all were intact without redness or drainage. The resident said he had a dressing on the wound, but it was new, and he took it off because it was bulky. He said the nurses checked the incision every other day. A record review of the admission Skin assessment for Resident #2 titled, Skin Evaluation, dated 5/9/2025 and locked 5/10/2025 revealed the resident had a wound on the Right lower leg (rear) and Treatment was applied. There was no mention of the right above the knee amputation site. A review of a progress note dated 5/12/2025 at 6:19 PM revealed, Resident's right AKA (above the knee amputation) surgical site was assessed this a.m. Incision line is well approximated with staple intact. No redness. Swelling, or drainage noted. Orders to leave incision open to air for healing. Will continue to monitor . The resident had been in the facility for 3 days and this was the first note describing his right AKA surgical site. A record review of the physician orders for Resident #2 identified the following: Wound care: monitor right AKA site and sutures every shift. Notify Dr. If changes or signs and symptoms of infection (drainage, redness, swelling) may cover with dry dressing if needed, dated ordered 5/12/2025. This was the first order to monitor the resident's right AKA surgical wound. The assessment started 4 days after admission. A review of the May 2025 MAR/TAR's for Resident #2 revealed, Monitor right aka for signs/symptoms of infection q (every) shift, start date 5/12/2025 and Wound care: monitor right AKA site and sutures every shift. Notify Dr. If changes or signs and symptoms of infection (drainage, redness, swelling) may cover with dry dressing if needed, every day and night shift for wound care, start date 5/13/2025. A review of the Interdisciplinary Team (IDT) note titled, IDT Care Plan Conference Summary, dated 5/12/2025 and locked 5/13/2025 had a section titled Nursing goals and summary; this was blank. A review of the Hospital discharge instructions dated 5/9/2025 for Resident #2 included, Instructions: Wound care for right AKA: Ace wrap and elevate the R AKA to compress the stump and reduce edema until 5/9; Start wearing stump shrinker on 5/9; Sutures and staples to remain in place for 3 weeks, will be removed at outpatient follow up with (surgeon); You may shower but do not soak the wound in water or scrub at the incision line. Further review of the physician orders for Resident #2 identified an order written on 5/13/2025, Apply stump shrinker, one time a day for wound care, start date 5/14/2025. This was 5 days after admission. A review of the Care Plans for Resident #2 identified the following: (Resident #2) has impaired skin integrity: Right AKA surgical site, date initiated 5/10/2025 and revised 5/12/2025 with Interventions including: Wound treatment as ordered, dated 5/10/2025. There was no mention of the Hospital discharge recommendations including an assessment of the staples/sutures, how to shower or that the resident was to wear a stump shrinker beginning on the day of admission. Resident #3: A record review of the Face sheet and MDS assessment indicated Resident #3 was admitted to the facility on [DATE] with diagnoses: acquired absence of left great toe, heart failure, diabetes, peripheral vascular disease, visual loss both eyes, anxiety, depression and history of falls. The MDS assessment dated [DATE] revealed the resident had full cognitive abilities with a Brief Interview for Mental Status score of 13/15 and the resident needed assistance with some care. On 5/14/2025 at 9:15 AM, Resident #3 was observed sitting in a chair in her room. She had two wound dressings: one on her right mid- shin and one on her left great toe amputation site. Both dressings were dated 5/13/2025. Wound Nurse A was also present and said she changed the dressings on 5/13/2025. Resident #3 said she worries about her left great toe site because the toe was already amputated and she is worried if it doesn't heal, she will lose more of her foot. She said the nurses were not always changing the dressing. Wound Nurse A removed the dressing on the left great toe area to observe the wound. The area was open approximately 1.2 cm x 1.2 cm in circumference with yellow stringy slough. The Wound Nurse said she was using Therahoney and calcium alginate over the area. The surrounding area was very red and inflamed. A review of the Nursing admission Skin Assessment titled, Skin Condition Evaluation, dated 4/28/2025 and completed 4/30/2025 (4 days after admission), identified two wounds present on admission: Right lower leg (front); laceration; length 4 cm, width 0.5 cm Left toe; surgical incision There was no measurement. Scabbed over; 100% wound covered over, surface intact Calloused-Fibrotic or Hyper-keratotic; Fragile: Skin that is at risk for breakdown; Intact: Unbroken skin No swelling or edema. A Skin Condition Evaluation, dated 5/1/2025 and locked on 5/5/2025 identified the following: Left toe; surgical incision; 1.8 cm length, 1.2 cm width and 0.1 cm depth; No closure measure present; Granulation, Slough (dead stringy tissue); 90% of wound bed filled Amount of exudate (drainage): moderate; Type of exudate: serosanguinous (fluid with blood); Peri-wound edges: Non-Attached: Edge appears as a cliff; Fragile skin that is at risk for breakdown; No swelling or edema. A Skin Condition Evaluation, dated and locked 5/8/2025 identified the following: Left toe; surgical incision; 1 cm length, 1.1 cm width, 0.1 cm depth; No closure method; Slough; 100% of wound filled; Amount of exudate: Moderate; Type of Exudate: serosanguinous; Periwound edges: Attached: Edge appears flush with wound bed or as a sloping edge; Periwound surrounding tissue: Intact: Unbroken skin; Normal in color; No swelling or edema. A review of the physician orders for Resident #3, on 5/14/2025 at 9:30 AM, identified the following: There was no order for a wound dressing/treatment for Resident #3's left great toe open wound. A review of the April and May 2025 Medication Administration Record/Treatment Administration Record (MAR/TAR) for Resident #3 revealed there was no documented treatment to the resident's left great toe open area. A review of an Infection screening Evaluation, dated 4/30/2025 and locked 5/6/2025 provided, Infection Analysis: . Suspected skin and soft tissue infection; McGeer's Criteria Met: Cellulitis, Soft tissue or wound infection. There was no identification of the infection location. On 5/14/2025 at 9:30 AM, Wound Nurse A was interviewed about the lack of a wound order for Resident #3's left great toe amputation site. She said she thought it was included in the order for the resident's right lower leg treatment. A review of the order revealed the left great toe was not mentioned. A review of the progress notes, MAR/TAR and nursing assessments did not identify routine assessment and monitoring of Resident #3's left great toe except for a weekly measurement by the Wound Nurse A. The wound had developed yellow stringy slough, and the peri-wound was reddened and inflamed. There was no order for the wound dressing that was observed on the left great toe area on 5/14/2025. Resident #3 had verbalized that the nurses were not consistently providing wound care to the left great toe area, but wound care was not ordered. A review of the Care Plans for Resident #3 identified the following: (Resident #3) has Skin Trauma upon admission due to post amputation to Left toe and Laceration to right lower extremity- tibial with history of Skin Infection to left toe amputation, date initiated 4/30/2025 and revised 5/7/2025 with Interventions including: Assess and document skin condition weekly and as needed, date initiated 4/30/2025; Document abnormal findings and notify MD, dated 4/30/2025; Observe for symptoms of infections (redness, drainage, warmth, increased pain), date initiated 4/30/2025; Treatment as ordered, 4/30/2025. On 5/14/2025 at 11:00 AM, Nurse C was interviewed about surgical wounds and she said assessment started on admission of the resident. She said the nurse assigned to the resident would complete the assessment and look for skin redness, breakdown, wounds, and if there were dressings. She said the nurse would document in the chart. Unit Manager B was interviewed on 5/14/2025 at 11:10 AM and asked about wound assessment of Surgical wounds. She said the wound should be assessed at least daily and documented and if there were any questions about the surgical wound, the surgeon should be called. The Director of Nursing/DON and Wound Nurse A were interviewed on 5/15/2025 at 9:30 AM, they were asked about assessment and monitoring of surgical wounds and specifically surgical amputations, as Resident's #1, #2 and #3 were not routinely monitored. Resident #1's RBKA was not monitored for 14 days after admission. There was no assessment documentation or routine monitoring to aid in identifying the wound was infected and not healing. Resident #2 did not receive a wound assessment until 3 days after admission and on the 4th day wound monitoring was initiated. Resident #3 did not have an order for treatment to her left great toe amputation site, although a treatment was being applied. The DON said the facility was reviewing their processes to ensure the resident's wounds were appropriately cared for. Physician F was interviewed on 5/15/2025 at 9:46 AM about Residents #1, #2 and #3, as each had a surgical wound from an amputation and were lacking assessment, monitoring and a written order for wound care for Resident #3. He said the residents' skin should be looked at starting on admission and should be assessed and documented at least daily. He said he wasn't sure why the nurses were not assessing or documenting that this was done. Physician F was also asked about holding a blood thinner when a resident was to have a surgical procedure, and he said sometimes the surgeon would specify how long in advance to hold it. He said it would depend on what blood thinners the resident was taking and what the procedure was. Physician F said if the surgeon did not specify how long to hold the blood thinner, then the provider at the facility would do that. If any questions, the surgeon would be contacted. A review of the facility policy titled, Wound Management Policy, dated effective 5/30/2024 provided, It is the policy of this facility to ensure residents who do not have skin integrity impairments do not develop a new condition affecting the skin. It is also the policy of this facility that those resident with impaired skin integrity are recognized by our care team, treated timely, and interventions to heal are not exhausted until the skin is healed . Resident of this facility have their skin assessed at the time of admission/re-admission and evaluated routinely . A review of the facility policy titled, Anticoagulants, dated original 1/2/2024 did not mention management of the anticoagulant medication/blood thinner prior to a surgical procedure.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This Citation pertains to Intake Number MI00145161 Based on interview and record review the facility failed to maintain the safety of one resident (Resident #701) of one resident reviewed for mental health procedures, resulting in Resident #701 attempting twice to commit suicide via strangulation at the facility without appropriate facility interventions. The facility is being cited at Past-Non-Compliance with a Compliance Date of 06/15/2024. Findings Include: Redsident #701: On 8/13/2024 at approximately 3:30 PM, a review was conducted of Resident #701's record and it revealed he admitted to the facility on [DATE] with diagnoses that included Alcoholic Cirrhosis of Liver, Paranoid Personality Disorder and Alcohol induced persisting Dementia. Further review of Resident #701's record revealed the following: Care Plan: .resident attempting to wrap call light chord around neck .1:1 sitter . (Resident #701) has two blanching red areas on neck . initiated on 6/13/2024. Physician Orders: -Resident to have 1:1 sitter upon return from hospital for personal safety - inputted on 6/12/2024. Hospital Records: Pt (patient) from (long term care unit), pt was found with a phone cord wrapped around his neck. Pt arrives with bruising and bleeding around his neck. Pt gasping. Was found unresponsive for EMS .presented as Class I trauma after being found with phone cord around neck. This is a presumed suicide attempt .problems addressed: strangulation or suffocation . On 8/14/2024 at approximately 12:45 PM, Scheduler M was asked why there was no specified 1:1 for Resident #701 on 2nd and 3rd shift on 6/14/2024. The scheduler explained CNA N was supposed to stay over on 2nd shift but was directed by CNA A to go home. On 8/14/2024 at 1:15 PM, an interview was conducted with CNA A regarding Resident #701's 1:1. The CNA explained their scheduler will denote on their assignment sheet if there is a 1:1. CNA M was Resident #701's sitter on 1st shift from 6:00 AM - 2:00 PM and they did not know who CNA M's relief was. CNA A directed the aide to speak to their scheduler regarding her relief and never directed her to go home. On 8/14/2024 at 4:00 PM, Nurse D shared the morning after Resident #701's first suicide attempt she and housekeeping completed a sweep of his room for any items he could utilize to harm himself. Nurse D reported they found multiple pill bottles in his house shoes and the sleeves of his shirts. The bottles found in the sleeves were rubber banned so they would not fall out. Nurse D stated they also found scissors and some other miscellaneous items but she did not see the cell phone charging cord or tape in the room during the sweep. On 8/14/2024 at 4:25 PM, an interview was conducted with CNA B regarding Resident #701 2nd suicide attempt at the facility on 6/14/2024. The CNA explained she and Nurse O took turns completing 10-20 minutes checks on Resident #701 during 3rd shift, as there was no staff designated for 1:1. CNA B stated Resident #701 was intelligent so they staggered the checks so he would not know exactly when they were coming. CNA B was unsure who was completing the checks on him prior to her arrival at 10:00 PM. During her visual checks of the resident, she did not observe a phone cord or tape in his room. Around 3:05 AM, Nurse O checked on him before going on break and he was fine. CNA B went to check on him at 3:20 AM and found him supine in the bed with the sheet covering his body, she noticed what looked like a dressing by his neck and that is what prompted her to pull the flat sheet back. CNA B Resident #701 had wrapped a phone charger around his neck, then wrapped toilet paper or Kleenex around the charger and secured it with tape. Resident #701 was breathing but would not respond verbally to CNA B. CNA B yelled for help and another aide responded and they had to cut the items around his neck in three or four places to release it. Further review was completed of Resident #701's record's and yielded the following: Progress Notes: 6/12/2024 at 01:00: .He was referred to (contracted psychiatric group) for cognitive assessment and mania.6/12/24: Resident was seen in his room around lunchtime with a sitter 1:1. No acute distress noted today. He elaborated on how he was feeling by stating all of the medical issues he has including his paracentesis. He seemed to be highly manic, going from one subject to another without any flow. He started with his medical issues, and then went on how he is very particular about his medications, which according to staff, he has not been taking. He also seemed to be aloof and tangeltial with a mixed of flight of ideas, which sometimes alluded to SI/HI, but made vague comments on any particular plan. His flight of ideas included his hx of being a real estate agent, which how he met his ex-girlfriend, then how his real estate partner wilson had made millions by having the real estate gain 64% of the profit and the duo gained the reset of the profit in AZ. He was then asked about not taking his medication and he endorsed I just want to know what they are, but I am not refusing, just catious. Staff has indicated that he does not take his meds every day. He is not sutable to be outpatient services right now, since he has had a hx of SI, recently, and him going over with vague plans needed to be either stay on 1:1 or recommended to be petitioned . 6/12/2024 at 01:44: .Neurological Status Evaluation:I answered his call light and found him with 2 strings tied very tightly around his neck and knotted. There were paper towels between the knotted strings and his neck. I cut the strings off .He appears of his usual cognition and is alert. He refuses to discuss why or how this happened, stating that his room mate put the call light on, not him. He has a very small reddened area in the front of his neck where strings were knotted . 6/12/2024 at 02:49: I answered the call light for (Resident #701) room around 12:45 am. When I entered I noted his roommate was sleeping, so I pulled (Resident #701's) curtain open to see if I could assist him and I found him with 2 strings tied very tightly in knots around his neck. His bed gown tie as well as what appeared to be an overhead light pull string. There were paper towels between the strings and his neck skin. I couldn't get the strings untied so I cut them off. His eyes were moving left to right. He was not speaking, he was breathing rapidly but not gasping. He was not discolored, his facial skin and lips were of normal color. When I attempted to speak with him, his eyes moved from left to right, non-rythmically and he did not answer. I immediately took his vitals .I shook him stating, I know you are ok, why would you do this? and his eyes flinched and he opened his eyes, his breathing was normal. He refused to answer when I asked him if he is ok and began moving his eyes from left right not rythmically, but everytime I said something his movement would stop as if to listen to me then his eye movement would begin again as would his increase of respirations. When I asked him if he put the call light on he said, no, it must've been my roommate. His eyes then moved from left to right in such a way that appeared to be focused effort to do so. His roommate was sleeping. I asked him if his visitors previously in the day had anything to do with this and he said, no, I don't want to live. I asked him if I can do anything to help him and he said, no.Staff passed water and assisted this room a few minutes after 11:30pm and both residents in this room appeared to be of their usual . 6/12/2024 at 03:43: : I received a call from (the hospital). (Resident #701) has been evaluated and appears to be of normal status, they expect to send him back to us soon. ADON and Administrator notified; orders given to assign him a 1:1 sitter upon arrival . 6/12/2024 at 15:53: Resident room was cleaned today during the cleaning approximately 5 pill bottles were found in his room inside of his house shoes. Inside of his shirts pills not in bottles were found in his shirt sleeve with a rubber band keeping them from falling out along with 2 pairs of scissors and a tile scrapper. Resident also two heated blankets on his bed. All items was turned into the administer. 6/12/2024 at 22:56: .Patient was assessed in his room, resting in bed. He had a sitter at bedside, as he attempted suicide last night with a string and paper towel around his neck. He was sent to the ER for evaluation and sent back. He requires 24/7 staff at this time . 6/14/2024 at 06:35: Resident observed in bed with a charger cord that that was reinforced with toilet paper and tape around his neck. He was unresponsive but breathing. Cord was so tight is was unable to be untangled so it had to be cut with scissors. Vitals immediately taken; all appropriate persons notified. Order to send patient out given. Spoke with Social Worker at (Hospital) and she stated she will initiate a Petition. Thorough report given. On 8/14/2024 at approximately 2:00 PM, an interview was conducted with the Administrator and DON (Director of Nursing) regarding Resident #701's two suicide attempts at the facility via strangulation. They explained after his first attempt they thought he would have been admitted to an inpatient psychiatric unit, but he was at the hospital for a short amount of time and returned back to the facility. Upon his return he was placed on 1:1 for continued safety and monitoring. They had a nurse complete a sweep of his room and found many items such as pill bottles and scissors that were removed to maintain his safety. The Administrator and DON were asked if he was petitioned by facility staff after his first or second attempt and they stated he was not. After further discussion it was found there were no other interventions implemented to maintain Resident #701 safety, no facility policy to address suicidality and subsequent procedures. Additionally, the facility discovered there was no specified 1:1 on the assignment sheet for 2nd and 3rd shift on 6/14/2024. The Administrator and DON reported the facility took steps after the incident to correct self-found deficiencies. They presented this writer with Past Non-Compliance. Facility Investigation of Suicide Attempts: Staff was in the room on 6/12/24 passing water and had checked on (Resident #701) and he was in bed. The nurse went down to residents' room at approximately 12:45 am on 6/12/24 to answer call light and observed resident with 2 strings tied around his neck. Nurse unable to loosen ties so cut with scissors . (Resident #701) told the nurse that he did not want to live so one on one was placed and nurse called the physician and received orders to send to ER for psychiatric evaluation . (Resident #701) returned from (Emergency Room) on 6/12/24 at approximately 3:40 am with no new orders and that he was fine it was just Anxiety. One to one provided to resident upon return as an immediate intervention for all day on 12th . On 6/14/24 at approximately 3 am staff completed room check and observed (Resident #701) with phone cord around his neck, the cord was cut off with scissors he was alert .The physician was called at 3:30 am and received orders to send to (Emergency Room) for inpatient. Social worker at hospital completed petition, and physician completed cert for involuntary placement. Facility tracked progress of resident during psychiatric placement, because of residents' acuity he was not placed at a psychiatric facility .From facility investigation we revealed that facility failed to appropriately denote 1 to 1 of staffing and maintaining safety of resident with recent active suicidal attempt as well as suicide precautions. Facility implemented suicide policy, as well as how to complete room sweeps, and how to petition residents out for active suicidal ideations . On 8/15/2024 at 1:25 PM, an interview was conducted with Nurse C regarding Resident #701's first suicide attempt. Nurse C explained there was never any indication that he was suicidal. She recalled charting at the nurses' station and the call light sounding, Resident #701's roommate was blind and a fall risk so Nurse C immediately responded to the alarm and saw Resident #701's roommate was sleeping. She then pulled back the privacy curtain to check on Resident #701 and found the pull sting from the light above his bed and string for his gown tied tightly around his neck and knotted. Nurse C stated this was toilet paper in between the two stings. The Nurse was able to cut the strings from around his neck. Resident #701 was breathing, was not gasping for air, no skin discoloration and his vitals were stable. Past Non-Compliance (PNC): During the onsite survey, Past Non-Compliance (PNC) was cited after the facility implemented actions to correct the noncompliance which included: 1.Systemic Changes to Prevent Recurrence: - DON/designees started education on 6/14/24, with Licensed Nurses on the process when the schedule does not appear to be correct who to call. Suicide precautions with emphasis on making sure we sweep and remove all items including trash liners, sheets, belts phone cords, call lights, shoestrings, belts anything that resident may use to harm themselves. Education completed with scheduler on making sure sitters are identified on schedule and it is accurate. Staff members are not permitted to work a shift until education has been completed -The administrator/Designee will interview 4 staff members weekly times 4 weeks, then monthly times 1 to verify understanding of who to call when they have concerns with the schedule or schedule is not accurate with a summary of findings to QAPI for review and recommendations. -Identified residents at risk for suicidal ideations or harmful behavior will be reviewed in Behavior Management weekly time four weeks then bi-weekly times 2 weeks, and then monthly times one, with findings submitted to QAPI for review and recommendations. -The DNS/Designee will review new admissions for suicidal ideations risk and assure interventions are put in place, three times a week for 4 weeks, and then weekly times 2 weeks, and then monthly with findings submitted to QAPI for review and recommendations. The facility was able to demonstrate monitoring of the corrective actions and maintained compliance. Compliance Date: 06/15/2024.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This Citation pertains to Intake Number MI00143579. Based on observation, interview, and record review the facility failed to provide pressure ulcer care per health care provider order and prevent the deterioration of Resident #74's unstageable coccyx wound and Resident #290 and #292's wound dressings not being completed per standards of clinical practice, resulting in Resident #74's wound care treatment not being completed as ordered, wound worsening, infection, and sepsis and Resident #290's and #292's foot wounds not being dated and labeled per nursing standards of practice. Findings Include: Resident #74: During initial tour on 5/20/2024, Resident #74 was observed resting in bed and did not appear to be in any distress. On 5/21/2024 at approximately 2:00 PM, a review was conducted of Resident #74's medical record and it revealed the resident initially admitted to the facility on [DATE] with diagnoses that included, Sepsis, Chronic Kidney Disease, Anemia, Myocardial Infarction and Hypertension. Resident #74 was dependent on facility staff to meet all her care needs. Further review of the resident record yielded the following: Discharge Hospital Records: .Pressure Ulcer 2/12/24 Coccyx (buttocks) .cleanse/irrigate with NS (normal saline). Apply skin prep periwound. Apply Mepilex silicone border dressing to wound bed. Date, initial, and designate T for treatment or P for prevention on Mepilex. Roll back edges every shift to assess and cleanse wound bed. Re-secure with skin prep. Change Mepilex Q3 days & prn . Treatment Administration Record (TAR): - Allevyn Sacrum External Pad- Apply to sacrum topically every day shift every 3 day(s) for wound cleanse with ns, pat dry and cover. Ordered on 2/22/24 and discontinued on 2/29/2024. - Wound Treatment- Coccyx- Cleanse site with saline or wound wash. Gently pat dry. Apply dime size amount of triad cream and spread thin layer. May leave in place and reapply in thin layers for 3 days. Remove with A&D ointment on day 4 and reapply triad as per previous instructions. Ordered on 2/23/2024. Review was completed of the TAR and indicated Resident #74's Allevyn treatment was not completed on 2/22/24, 2/25/24 and 2/28/24. The TAR had numerical indicators for the three dates listed that coded for other/see progress note. The progress notes for each date the dressing was due to be completed stated: 2/22/2024: No subsequent progress note related to the treatment. 2/25/2024: No Allevyn dressing. 2/28/2024: There was no explanation listed in the progress note as to why this treatment was not completed. It is unclear as to why Resident #74 had two different wound care treatment orders from 2/22/2024 to 2/29/2024 (when Allevyn was discontinued) when the wound care practitioner ordered Triad on 2/22/2024. On 5/21/2024 at 10:56 AM, an interview was conducted with the complainant regarding wounds at the facility. It was shared community acquired wounds at the facility were worsening as wound care was not being completed as ordered. They reported Resident #74's wound was supposed to be packed and it was only being completed when the Wound Nurse Practitioner rounded. They stated Resident #74's wound worsened and became infected due to facility neglect. Further review was completed of Resident #74's wound progressing from admission to transfer to the emergency room on 3/14/2024. Nursing admission Assessment 2/20/2024: The assessment indicated Resident #74 admitted to the facility with the following skin conditions .Sacrum- Full thickness wound 4.5cm x 6.3cm. moist . She has wounds 3. Sacrum-unusual shaped full thickness wound across coccyx 4.5cm x 5.3cm. Regions cleaned with NS (normal saline) pat dry and cover with foam gentle Allevyn as were found upon admission . She is also totally dependent for all ADL as she is totally paralyzed . Care Plan: (Resident #74) was admitted with pressure ulcer to sacrococcygeal area and L (left) heel closed .Assess and document skin condition, notify MD of signs and infection (redness, drainage, pain, fever) .Notify MD of worsening or not improvement in wound .wound treatment as ordered . Nursing Progress Notes: 2/22/2024 at 11:56: Coccyx - unstageable. 2.5 x 1.6 x 0 (measurements)First Observation, no reference. Serous (Drainage). Small. (Drainage Amount). No (Odor). fragile with deep purple discoloration. Attached. triad as per order in TAR. pressure reducing mattress low air loss mattress. NP first rounding observation . 2/29/25024 at 11:03: Coccyx - unstageable 4.0x1.4x 0 (measurements) .Unstageable. Worsening. Serosanguineous (Drainage). Small (Drainage Amount). Yes (Odor)strong malodorous . 3/7/2024 at 13:53: Coccyx - St (stage) 4.4. x 5.01.1. admitted . Stage 4. Worsening. Serosanguineous (Drainage). Moderate (Drainage Amount). Yes (Odor)slight malodorous smell. Fragile. Macerated .deterioration . 3/14/2024 at 12:40: Coccyx - unstageable 4.7 x 5.5 x 0 (measurements) .Unstageable .Worsening .Moderate (Drainage Amount) .Yes .(Odor)slight malodorous smell .fragile .not attached .poor 3/14/2024 at 13:18: Resident with probable sepsis VS (vital signs): bp:94/60 HR 111 WBC over 20 HGB 7.8, okay to sent out per DON (Director of Nursing ) ADON on call notified of transfer . 3/15/2024 at 00:00: WBC 20, on abx for wound infection. Pressure Ulcer Weekly Observation Assessment: 2/22/2024: Unstageable coccyx wound with 100% yellow adherent slough and small serous drainage. The peri wound tissue was fragile wit deep purple discoloration and wound edges attached. Current treatment was Traid This was the first observation of the wound completed by the wound NP. 2/29/2024: Worsening unstageable coccyx wound with 100% yellow adherent slough and small serosanguineous drainage. The wound had eschar forming and a strong malodorous odor. The peri-wound tissue was fragile with wound edges attached. Continue treatment of triad. 3/7/2024: Worsening stage 4 pressure ulcer with slough and neurotic tissue present. Moderate amount of pale yellow seropurulent drainage with slight malodorous smell with macerated wound edges. Treatment orders were changed. 3/14/2024: Worsening unstageable coccyx wound with 20% slough and 80% necrotic tissue. Moderate seropurulent drainage with slight malodorous smell. 12-12 undermining 2.4 cm at 11 and depth was unknown. The wound edges were attached, and infections was suspected. Wound progress was evaluated at poor. Nurse Practitioner Wound Care notes: 2/22/2024 at 00:00: .Will initiate a treatment plan to coccyx to be that of triad cream to promote autolytic debridement and to protect area from further moisture related breakdown . Coccyx, unstageable- This wound measures 2.5 x 1.6 centimeters with unknown depth. This wound is an assumed full thickness. There is a light amount of serous drainage from this area. Wound bed consists of 100% pale yellow adherent slough. Edges are attached and there is no eschar, tunneling, undermining, or odor. The surrounding tissue is fragile with a deep purple discoloration but without redness, warmth, swelling, pain, induration, or sign of infection. Treatment: Cleanse site with saline or wound wash. Gently pat dry. Apply dime size amount of triad cream and spread in thin layer. May leave in place and reapply in thin layers for 3 days. Remove with A & D ointment on day 4 and reapply triad as per previous instructions . 2/29/2024 at 00:00: .Will continue treatment plan for sacral unstageable to be that of triad cream to promote autolytic debridement and to protect area from further moisture related breakdown . Sacrum, unstageable- This wound measures 4.0 x 1.4 centimeters with unknown depth. This wound is an assumed full thickness. There is a light amount of serous drainage from this area. Wound bed consists of 100% pale yellow adherent slough with eschar formation. Slight malodorous smell. Edges are attached and there is no eschar, tunneling, or undermining. The surrounding tissue is fragile with a deep purple discoloration but without redness, warmth, swelling, pain, induration, or sign of infection. Treatment: Cleanse site with saline or wound wash. Gently pat dry. Apply dime size amount of triad cream and spread in thin layer. May leave in place and reapply in thin layers for 3 days. Remove with A & D ointment on day 4 and reapply triad as per previous instructions . 3/7/2024 at 00:00: Sacral site now stageable as there is noted granulation tissue. Bone is palpable with noted facia making this a stage IV. Will adjust treatment plan for sacral to be that hydrogel impregnated gauze to promote autolytic debridement . declining sacral wound . Sacrum, stage 4- This wound measures 4.5 x 5.0 centimeters with a depth of 1.1 centimeters. This wound is full thickness. There is a moderate amount of serosanguanious and yellow seropurlent drainage from this area. Wound bed consists of 40% pale yellow adherent slough, 30% necrotic tissue, and 30% intermittent granulation tissue. Slight malodorous smell. Edges are not attached as there is noted undermining from 9 to 11 o'clock with max depth of 1.1 centimeters and again from 12 to 2 o'clock with a max depth of 0.6 centimeters .surrounding tissue is fragile with a deep purple discoloration but without redness, warmth, swelling, pain, induration, or sign of infection. Treatment: Cleanse site with normal saline or wound wash. Pat dry. Apply hydrogel impregnated gauze (autolytic debridement) to site and gently pack with undermining areas. Apply barrier cream to periwound. Cover with gently bordered gauze. Perform daily and as needed if soiled or dislodged . 3/14/2024 at 00:00: .Sacral site unstageable as there is noted 80% necrotic tissue with a malodorous smell. Will adjust treatment plan for sacrum to be that of 1/2 percent dakins soaked gauze (wet-to-dry) dressing. This is to be performed BID and as needed if soiled or dislodged x 7 days. Will start patient on antibiotics, keflex 500 mg BID x 7 days for wound infection . declining sacral wound .Sacrum, stage 4- This wound measures 4.7 x 5.5 centimeters with an unknown depth. This wound is full thickness. There is a moderate amount of light brown seropurlent drainage from this area. Wound bed consists of 20% yellow-brown adherent slough, and 80% necrotic tissue. Noted malodorous smell. Edges are not attached as there is noted 360% undermining with a max depth at 11 o?clock of 2.4 cm. The surrounding tissue is fragile with a deep purple discoloration but without redness, warmth, swelling, pain, induration, or sign of infection . IDT (interdisciplinary Team) Risk Review Notes: IDT met .Wound note 3/7 reviewed. Wound care orders reviewed . The IDT reviewed Resident #74's wound care notes and orders from 3/7/2024 and overlooked the change in the wound care treatment order. It can be noted that after Resident #74 was assessed by the practitioner on 3/7/2024 the wound care treatment order was not changed from Triad to hydrogel impregnated gauze until 3/14/2024 at 6:00 AM. Resident #74 did not receive the appropriate wound care treatment for seven days. On 3/14/2024, Resident #74 was assessed by the practitioner and found with 80% necrotic tissue, malodorous smell, and signs of infections. Resident #74 was sent to the emergency room for probable sepsis. The hospital admission record stated the following, XXX[AGE] year old female with history of CVA and left sided hemiparesis who is bed-bound and PEG tube dependent for feeding with chronic kidney disease and hypertension .patient with infected sacral decubitus ulcer as well as foul smelling urine .CBC with WBC of 22.9, hgb 8.4 .placed on IV antibiotics .Principal problem: Sepsis Leukocytosis/Sepsis/ Infected Sacral Decubitus . Resident #74 admitted with a wound but during her course of stay at the facility it worsened and became infected. The facility did not implement the wound treatment timely nor were there any physician notes that indicated the wound worsening was unavoidable. On 5/22/2024 at 10:00 AM, a discussion was held with DON (Director of Nursing), ADON (Assistant Director of Nursing) and Corporate Consultant P, regarding the deterioration and infection of Resident #74's coccyx wound. They reported the wound began to worsen when she completed her course of antibiotics that she was admitted on . They explained they were packing her wound with hydrogel as the wound was deep and full of slough. This writer, Consultant P and DON reviewed Resident #74's wound treatment orders against the wound practitioner notes and found on 3/7/24 the practitioner changed the wound care order from Triad to Hydrogel Impregnated gauze, but this order was never inputted into the resident's chart. Resident #74 was not receiving the appropriate wound care treatment for seven days; her wound worsened and became infected. The DON and Consultant P were not able to provide rationale as to why the appropriate treatment intervention was not implemented timely. Resident #290: During initial tour on 5/20/2024, Resident #290 was observed resting in bed and was in good spirits. The resident was observed to have a dressing on her right foot that was not dated nor initialed. On 5/21/2024 at approximately 8:45 AM, Resident #290's right foot was dressing was observed to still not dated nor initialed. The ADON (Assistant Director of Nursing) was shown the dressing and reported it should be dated and initialed by the nurses who completed wound care. On 5/21/2024 at 9:39 AM, Resident #290's right foot wound dressing change was completed by the ADON. The dressing was not dated nor initialed. The dressing was dried onto the wound and wound wash had to be utilized to remove the stuck-on dressing. On 5/21/2024 at approximately 10:30 AM, a review was completed of Resident #290's medical records and it indicated the resident admitted to facility on 5/10/2024 with diagnoses that included, Sepsis, Bacteremia, Urinary Tract Infection, Anxiety, Depression, Paroxysmal Atrial Fibrillation and Heart Disease. Resident #292: During initial tour on 5/20/2024, Resident #292 was resting in bed watching television. She was in good spirits and spoke about her reasoning for entering the facility. Resident #292 had bilateral dressings to her feet that were not dated or initialed. The residents' feet were not floated nor were heel protector boots on. On 5/21/2024 at approximately 9:00 AM, this writer and the ADON observed Resident #292's bilateral dressings to her feet and they again were not dated nor initialed. The dressings were observed to have drainage seeping through that was yellow in color. The ADON was asked regarding the blank dressing and stated upon dressing changes being completed nurses should initial and date the dressings. On 5/21/2024 at approximately 10:45 AM, a review was completed of Resident #292's medical record and it indicated the resident admitted to the facility on [DATE] with diagnosis that included, Chronic Osteomyelitis with draining, Methicillin Resistant Staphylococcus Aureus (MRSA), Diabetes, Peripheral Vascular Disease (PVD) and Chronic Kidney Disease. Further review of Resident #292's medical records revealed the following: Physician Orders: - Resident to wear heel protectant boots while in bed every shift. Care Plan: (Resident #292) was admitted with right heel ischemia area d/t (due to) PVD . (Resident #292) was admitted with left heel ischemia area d/t (due to) PVD .elevate heels when in bed as allows .wound treatment as ordered . While the care plan indicated to elevate heels the resident had an order for heel protectant boots that did not carry over to care plan and [NAME]. On 5/21/2024 at approximately 4:20 PM, this writer and Nurse B observed Resident #292 lying in bed and did not have on her heel protectant boots. Nurse B searched for the boots and were not able to locate them in the resident's room. We reviewed the orders and saw the resident was ordered to wear heel protectant boots while in bed. Review was completed of the facility policy entitled, Pressure Injury Prevention and Management. The policy stated, This facility is committed to .provide treatment and services to heal the pressure ulcer/injury, prevent infection and the development of additional pressure ulcers/injuries .Any changed to the facility's pressure injury prevention and management processes will be communicated to relevant staff in a timely manner . The policy was not dated with a reviewed or revised by date.

Resident #17 (R17): Review of R17's Electronic Medical Record (EMR) revealed admission to the facility on 8/24/23 with diagnoses including dementia with other behavioral disturbances. According to the 3/1/24 Quarterly Minimum Data Set (MDS) assessment, R17 received a 4/15 on the Brief Interview for Mental Status (BIMS) score indicating severely impaired cognition. Review of R17's Progress Notes read, in part, 5/5/24 Resident was assisted to Central unit by another nurse who said resident was visiting another resident and fell. Resident was sitting in his wheelchair with his right hand wrapped in ice. Resident tip of right finger was ben upward .resident to be transferred to ER (Emergency Room) .5/6/24 patient transferred back to facility via w/c (wheelchair) .X-ray results to right hand indicating has fractures to the third and fourth metacarpals. Cast noted to right hand up to arm is intact . On 5/20/24 at 11:52 a.m. R17 was observed in the hallway with his right arm noted to be in a cast wrapped with an ACE bandage. An interview with the Director of Nursing (DON on 5/21/24 at approximately 4:30 p.m. confirmed R17's injury of unknown source did not include witness statements from staff. The DON stated that R17 and the other resident involved were able to tell you what happened despite being cognitively impaired, and that staff were able to see R17 exit the room. The DON stated that R17 was asked to visit this specific resident in more public areas instead of her private room, and that was not followed and the time of the incident. During this interview with the DON, R17 was observed to be wheeling by the office. R17 was asked if he could recall the incident that took place on 5/5/24. R17 stated, Fall down, go boom! and pointed to the sidewalk outside. The DON stated that R17 knows that he should not have been visiting the female resident (later identified as R66) and is changing his story. On 5/22/24 at 9:05 a.m. an interview was attempted with R66. R66 recalled that R17 was in her room. When asked what happened, R66 stated, Well he (R66) likes to cuddle on the bed and likes to hum-hum with his hands. R66 could not recall when or how R17 fractured his hand and continued to attempt to fold towels on her bed. On 5/22/24 at 9:19 a.m. a follow up interview was conducted with the DON. When told what R66 had stated earlier, the DON confirmed that R66's cognition changes from day to day. The DON stated that they saw R17 come out of R66's room and did not suspect abuse. Review of R17's care plan read, in part, (R17) is at risk for falls or fall related injury r/t (related to), poor safety awareness, confusion, incontinence, gait/balance problems .he has a hx (history) of falls including recent fall with metacarpal fractures . It was noted that the interventions listed for R17 did not include increase in supervision or to attempt to keep R17 out of other resident rooms. This Citation pertains Intake Number MI00143956 Based on observation, interview and record review, the facility failed to provide supervision to prevent injuries for 2 residents (Resident #17, Resident #84) of 4 residents reviewed, resulting in Resident #17 sustaining a fracture of the 3rd and 4th metacarpal on the right hand, and no complete comprehensive post fall assessments for Resident #84, who sustained a fall with head injury, laceration, and required emergency medical treatment. Findings include: Record review of facility 'Fall management' policy dated 6/2023 revealed the purpose to prevent injuries related to falls. Post-Fall: (1.) Any resident experiencing a fall will be assessed immediately by the charge nurse for possible injuries and necessary treatment will be provided. A neurological assessment will be initiated on all residents with a suspected head injury based upon the fall; every 15 minutes for 1 hour then every 30 minutes for 1 hour then every 1 hour for four hours, then every 4 hours for 24 hours, then every 8 hours until 72 hours. (4.) The family will be notified immediately by the charge nurse of falls with injury. Record review of facility 'Documentation in Medical Record' policy undated with reference date of February 2023 Appendix PP guidance material, revealed each resident's medical record shall contain an accurate representation of the actual experiences of the resident and include enough information to provide a picture of the resident's progress through complete, accurate, and timely documentation. (4.) Principles of Documentation: (b.) Documentation shall be accurate, relevant, and complete, containing sufficient details about the residents' care and/or responses to care. Resident #84: Record review of Resident #84's electronic medical record revealed an admission date of 4/12/2024. Record review of Resident #84's progress notes dated 4/12/2024 at 6:15 PM noted resident arrival to facility via EMS from hospital. Resident noted as alert and oriented to self only. Head to toe assessment completed. Record review of Resident #84's fall/accident report, dated 4/14/2024, revealed the resident was trying to leave the building unauthorized and when he pushed through the door a staff was standing there and startled him and he tripped and fell and hit his head on the floor. Resident #84 was noted to be unable to give a description of what he was doing. The nurse helped the resident back to his room and gave first aid, called another nurse to help facilitate the paperwork to send resident to the emergency room for the big knot that formed on the right side of his forehead and the bleeding from the abrasion on the side of the face. Resident's mental status was noted to be oriented to self and there were alarms sounding at the time. Resident #84 was noted to be an active exit seeker. Resident #84 was resistive with redirection. Record review of resident #84's progress note, dated 4/14/2024 at 00:12 AM, revealed the resident was trying to leave the building unauthorized and when he pushed through the door a staff (member) was standing there and startled resident and he tripped and fell and hit his head on the door. Record review of progress note dated 4/14/2024 at 00:13 AM noted resident sent to the emergency room for further evaluation. Record review of the Resident #84's progress note, dated 4/14/2024 3:12 AM, the resident returned from the hospital at 3:30 AM. Resident received 2 stitches on forehead and basic first aid treatments to other abrasions. EMT reported that he fell at hospital and was in restraints upon pick up. Cannot assess pain at time due to resident not being able to verbalize. Record review of the Resident #84's progress note, dated 4/14/2024 4:18 AM, revealed follow up and care instructions are on the discharge papers. Resident needs to be seen to get stitches out in 5 days. Record review of Resident #84's progress notes, dated 4/13/2024 through 4/15/2024, revealed there was no neurological evaluations documented post-fall with head injury that required emergency room treatment and sutures to the head. An interview on 05/20/24 at 11:20 AM with Resident #84, while he was lying in bed, revealed that he did try to go home, and that he got hit in the face with the door. Resident #84 stated he was going. When asked where Resident #84 was going to, the resident did not respond to the question. An interview and record review was conducted on 05/21/24 at 12:19 PM with the Director of Nursing (DON) regarding Resident #84's falls, dated: 4/14/2024, 5/15/2024, and 5/19/24. The state surveyor had the DON review the electronic medical record of Resident #84 who sustained a fall with head injury, went to the emergency room for evaluation and stitches to the head and the surveyor was requesting 'Neurological Evaluation Flow Sheet' dated 4/14/2024 once the Resident #84 returned to the facility. The DON stated that the North Hall Unit manager would have the fall packet. The DON reviewed the yellow folder post fall packets note to a shelf on the bookcase in his office. No post fall packet was found for Resident #84 in the DON's office. The DON stated that on April 14, 2024, the facility placed Resident #84 on 1 to 1 supervision while awake. An interview and observation was conducted on 05/21/24 at 12:29 PM with Licensed Practical Nurse (LPN) North Hall Unit Manager E regarding Resident #84's fall packets and a check off list that is part of the post-fall investigation. LPN E stated that the post-fall packet has everything that needs to be done post fall. Observation of a blank post fall packet revealed a 'Neurological Evaluation Flow Sheet', Incident/Fall Checklist, Incident & Accident Investigation Form, Resident #84 has had three falls since being admitted . LPN E stated that she did not do or have any post-fall packets for Resident #84. Record review of Resident #84's fall report, dated 4/14/2024, noted resident received a head injury. LPN E stated that the fall packets are filled out by the nurse at the time incident, then it goes to the Director of Nursing (DON), with the previous DON, the fall packet and neurological checks were to be scanned into electronic medical record system. LPN E stated that she had not seen or received a post-fall packet for the falls of Resident #84. LPN E stated that the facility had process that was working, and the facility got new management and the process stopped, if The DON does not have them then the there is none.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to intake MI00138477. Based on interview and record review, the facility failed to prevent an injury during activities of daily living (ADL) care for one (Resident #7) of three reviewed for accidents, resulting in Resident #7 sustaining a fractured hip during a shower. Findings include: Review of the medical record reflected Resident #7 (R7) admitted to the facility on [DATE] and readmitted [DATE], with diagnoses that included unspecified intracapsular fracture of right femur, aftercare following joint replacement surgery and presence of right artificial hip joint. The significant change in status Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 8/14/23, reflected R7 scored 12 out of 15 (moderate cognitive impairment) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool), did not walk and required total assistance (a decline from extensive assistance on the 7/1/23 quarterly MDS) of two or more people for bed mobility and transfers. A discharge return anticipated MDS, with an ARD of 7/24/23, reflected R7 was coded for one fall with major injury since admission or the prior assessment, whichever was more recent. R7 discharged from the facility on 9/11/23. An SBAR (Situation, Background, Assessment, Recommendation) Summary for Providers Progress Note for 7/24/23 at 9:02 PM reflected, .Functional Status Evaluation: Fall .Resident has moderate severe pain in R [right] hip. Recommendation stat exray [sic] and pain medication or transfer to hospital . The Primary Care Provider Feedback reflected a recommendation for an x-ray. A Progress Note for 7/24/23 at 9:25 PM reflected, .Resident and [significant other] want to have resident taken to the ER .Resident is claiming he fell out of shower bed today [sic] shower aid states this did not happen. Resident complains of r [right] hip pain and r [right] toe pain. Resident given stat pain medicine and a stat r hip exray [sic] ordered. Resident still wants to go to hospital . A facility investigation included a typed interview with former Director of Nursing (DON) S for 8/1/23, which revealed that the first shift nurse notified her around 4:30 PM that R7 reported falling in the shower. The facility investigation included a typed statement from Certified Nurse Aide (CNA) L for 7/25/23, which revealed that while bathing R7, he was rolled with his left side going towards the wall. The bed rail gave, and R7 rolled further, with his left leg going off the rail and hitting the wall. R7's hip and body went towards the wall. She did not remember R7's body hitting the wall but stated it could have. CNA L reached to grab R7 and to keep him from falling off the shower bed. From her strength, she was able to pull him back up on the shower bed. R7 was bleeding from his arm and toe. She rinsed off the blood and took R7 back to his room for care. In the room, R7 was complaining of pain. The nurse dressed the wound on R7's buttocks and his arm. CNA L covered R7's toe with a towel and blanket. CNA L put on R7's T-shirt, finished care and left the room. Additionally, the facility's investigation reflected the shower bed had since been removed from the facility until it could be repaired or replaced. The investigation did not include why the shower bed needed to be repaired or replaced. An attempt was made to contact CNA L via phone on 2/21/24 at 1:13 PM. A voicemail was left, but a return call was not received prior to the survey exit on 2/22/24. CNA L was no longer employed by the facility at the time of the survey. Review of CNA L's personnel file included a Care Team Member Corrective Action Form, dated 7/25/23, which reflected CNA L was suspended pending investigation, at 11:06 PM, once the investigation revealed the care team member may have been involved. The document reflected the incident was not discovered until 7/25/23 at 8:00 PM. The description of the violation reflected Abuse/neglect allegation. A Care Team Member Corrective Action Form, dated 7/28/23, reflected the refusal to cooperate in investigation of an allegation and that CNA L was not truthful or forthcoming with information during the investigation. The corrective action reflected CNA L's employment was terminated. During a phone interview on 2/22/24 at 9:11 AM, LPN K reported recalling that R7 claimed he had fallen in the bathroom, while being showered. She reported to her boss, former DON S. LPN K stated she assisted the CNA to transfer R7 from the shower bed to bed. R7 said his right leg hurt, and she asked if he wanted something for pain. LPN K reported administering medication for pain. She noticed an abrasion on R7's elbow. LPN K asked the CNA about it, who reported R7 got scraped when she turned the shower bed around. When going back to reassess pain, R7 said he thought his hip hurt and that he broke his hip. When LPN K asked how he would have broken his hip, R7 said he fell. The facility's investigation included a typed statement from RN M for 8/1/23, which revealed she received in report that R7 was claiming he fell out of the shower bed and wanted to go to the hospital. When answering R7's call light after report, R7 complained of right hip pain. R7 told RN M that he had fallen and that was why his hip was hurting. A few minutes after R7 was given pain medication and notified of a STAT x-ray order, R7's significant other informed RN M that R7's right big toe was bleeding. According to RN M's statement, R7's toenail was almost completely ripped off and it was bleeding rather heavily. There was gauze inside R7's sock to absorb the blood and prevent bleeding through the sock. R7 stated he wanted to go to the hospital. An attempt was made to contact RN M via phone on 2/22/24 at 10:29 AM. A voicemail was left, but a return call was not received prior to the survey exit on 2/22/24. RN M was not longer employed by the facility at the time of the survey. R7's July 2023 Medication Administration Record (MAR) reflected 650 milligrams (mg) of Tylenol was administered for level four out of ten pain at 4:00 PM on 7/24/23 and was noted to be ineffective. R7 received 50 mg of tramadol for level four out of ten pain at 4:27 PM on 7/24/23, which was documented to be effective. R7 received 50 mg of tramadol for level five out of ten pain at 7:46 PM on 7/24/23, which was documented to be ineffective. A hospital Orthopedic History and Physical for 7/25/23 at 3:23 AM reflected, .Chief Complaint: pt [patient] states he fell from bed, per ECF [extended care facility] he did not fall. Pt c/o [complains of] right hip pain .presents today with right hip fracture status a [sic] fall while being carried out of the shower .Patient was at the extended care facility where he was taking shower when he was dropped while getting out of the shower .Right lower extremity is externally rotated and slightly shortened in comparison to contralateral left .Tenderness to palpation was elicited with direct palpation about the level of the lateral aspect of the thigh .Unable to examine range of motion due to pain referred from the hip .X-ray of the pelvis, right hip does reveal a subcapital femoral neck fracture .Given the patient's right subcapital femoral neck fracture, recommendation is for operative intervention in the form of right hemiarthroplasty . A Surgical Documentation Operative Report for 7/27/23 at 5:41 PM reflected R7 underwent surgery for a right displaced femoral neck fracture. During an interview on 2/22/24 at 1:36 PM, DON B stated he was not employed by the facility at the time of R7's fracture.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to implement and operationalize policies and procedures for pressure ulcer (wounds caused by pressure) care for five residents (Resident #10, Resident #21, Resident 37, Resident #245, and Resident #250) of seven residents, resulting in a lack of implementation of resident-centered and/or planned interventions, timely assessment, inaccurate documentation/staging of wounds/pressure ulcers, care per professional standards of practice, Resident #245 developing a Deep Tissue Injury (DTI-unstageable pressure injury with unknown depth due to damage to underlying tissues) and Stage II (partial thickness loss of tissue presenting as a shallow open ulcer with a red pink wound bed, without slough) pressure ulcers, unnecessary pain, and the likelihood for decline in overall health status. Resident #245: An observation of Resident #245 occurred on 4/25/23 at 12:45 PM in their room. The Resident was laying in bed, positioned on their back with their heels directly on the mattress. An interview was completed at this time. Resident #245 appeared uncomfortable during the interview with noted facial grimacing. When asked if they were in pain, Resident #245 revealed they were and stated, I have a sore on my butt. Resident #245 was asked if they had any other pain, Resident #245 indicated they did but the wound on their buttocks was bothering them the most. When queried if they received interventions for pain relief, including medications, Resident #245 indicated they did not receive scheduled medication but were able to receive a pain pill when they ask nursing staff. Resident #245 was then asked how frequently staff reposition them in bed and revealed they are only repositioned when staff check their brief and/or provide incontinence care. When queried how frequently that occurs, Resident #245 revealed it is usually once or twice during a shift. Resident #245 was then asked how often they get out of bed and/or leave their room and replied, Don't leave (their room) to do anything. When asked if they are able to move their legs and feet, Resident #245 revealed they had limited mobility on their own and depended on staff to assist them. When queried regarding their heels being positioned directly against the mattress and if staff elevate their feet and heels off of the bed, Resident #245 revealed they do not and stated they used to have boots that they would wear in bed but did not know what happened to them. With permission from the Resident, an observation of their room was completed, and no heel/positioning boots were present in the room. At 2:20 PM on 4/24/23, Resident #245 was observed laying on their back in bed with their heels positioned directly on the mattress. An interview was completed with Certified Nursing Assistant (CNA) KK on 4/25/23 at 2:24 PM. When queried regarding Resident #245, CNA KK revealed the Resident required staff assistance to turn and reposition in bed and for Activity of Daily Living (ADL) care. When asked if staff work eight or 12-hour shifts, CNA KK specified shifts are scheduled for eight hours. CNA KK then stated, I'm staying over until 6:00 PM because of low staffing. With further inquiry, CNA KK revealed there would only be one aide working on the North and Medbridge units if they did not stay over (24 Residents reside on the units). When asked, CNA KK revealed the facility was frequently short staffed. On 4/26/23 at 10:04 AM, Resident #245 was observed in their room. The Resident was in bed, positioned on their back with their heels directly against the mattress. An interview was completed with LPN MM on 4/26/23 at 8:24 AM. When asked if any Residents they were assigned to care for had wounds and/or wound treatments, LPN MM stated, Resident #245 has an open wound on their coccyx. Record review revealed Resident #245 was admitted to the facility on [DATE] with diagnoses which included Congestive Heart Failure (CHF), Chronic Obstructive Pulmonary Disease (COPD), Parkinson's disease, and diabetes mellitus. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the Resident was cognitively intact and was totally dependent upon staff for all ADL's with the exception of eating. The MDS further revealed the Resident was at risk for pressure ulcer development, did not have any pressure ulcers, but did have Moisture Associated Skin Damage (MASD- skin damage caused by prolonged exposure to excessive moisture). Review of Resident #245's Electronic Medical Record (EMR) revealed the Resident did not have a resident centered care plan pertaining to their wounds with personalized interventions. A care plan entitled, Resident is at Risk for skin breakdown (Initiated: 4/7/23) was present in the EMR. The care plan included the interventions: - Assist with bed mobility to turn and reposition routinely (Initiated: 4/7/23) - Assist with routine toileting (Initiated: 4/7/23) - Preventative skin care as ordered/indicated (Initiated: 4/7/23) - Skin inspection weekly and as needed, document and notify MD of abnormal findings (Initiated: 4/7/23) Additional review of Resident #245's Electronic Medical Record (EMR) revealed the following documentation: - 4/6/23: Nursing Admission/readmission Evaluation . Skin Conditions . Groin MASD . Right buttock MASD . Right thigh (front) inner MASD . Right toe(s) lateral great toe red blanchable area tx (treatment) in place . Left toe(s) tip of great toe old, discolored area . - 4/7/23: History and Physical (Physician) . came to this facility after a recent hospitalization . here for rehab and medical care . Positive: Fatigue, Low energy . Skin . Negative . Changes in skin color . Bruises, Rash . Open lesions . Skin: No rash or bruises noted . Negative: Changes in hair or nails, Changes in skin color, Swelling, Itching, Bruises, Rash, Mass, Open lesions . - 4/10/23: Progress Notes (Nurse Practitioner) . Skin: No acute changes . - 4/12/23 at 7:56 AM: Non-Pressure Ulcer - Weekly Observation . (Lock Date: 4/21/23) . Coccyx . MASD . Unchanged . Dry . Drainage: None . Length: 8.5 (centimeters [cm]) . Width: 5.5 (cm) . Current treatment plan: Apply barrier cream Q (every) shift . Wound Progress: Unchanged . - 4/12/23: Progress Notes (Nurse Practitioner) . Skin: No acute changes . - 4/14/23 at 3:26 PM: Weekly Nursing Summary . Weekly Skin Assessment . 1. Resident skin condition: Warm and dry . 2. Skin turgor . a. Normal turgor . 4. Indicate any current tissue injury . No Current Issues . - 4/17/23: Progress Notes (Nurse Practitioner) . Skin: No acute changes . - 4/19/23 at 7:51 AM: Non Pressure Ulcer - Weekly Observation . (Lock Date: 4/21/23) . Coccyx . MASD . Unchanged . Dry . Drainage: None . Length: 5.5 (cm) . Width: 5.5 (cm) . Describe any changes to treatment plan in the last week: Treatment changed to Hydrogel (wound dressing used for partial and full thickness loss wounds and wounds with slough [moist white/yellow colored wound exudate wound exudate] or eschar [necrotic tissue]) . 2. Current treatment plan: Cleanse coccyx with wound cleanser apply hydrogel cover with border gauze daily and PRN (as needed) . Wound Progress: Unchanged . - 4/20/23 at 1:49 PM: IDT . Risk Review . Reason for review: Weekly Follow-up . IDT Recommendation: IDT team met to discuss resident's plan of care for wound care treatments. Resident presents with 2 wounds: one on buttocks and one on right inner thigh. Coccyx wound unchanged new treatment started, inner right thigh resolved. There are no changes to diet order at this time, new treatment order . for buttocks. Resident is currently not on any additional supplements. Will continue to monitor. - 4/20/23: Progress Notes (Nurse Practitioner) . Skin: No acute changes . - 4/21/23 at 7:28 PM: Weekly Nursing Summary . Weekly Skin Assessment . 1. Resident skin condition: Warm and dry . 2. Skin turgor . a. Normal turgor . 4. Indicate any current tissue injury . No Current Issues . - 4/24/23: Progress Notes (Nurse Practitioner) . Skin: No acute changes . Review of Resident #245's Health Care Provider orders, Medication Administration Record (MAR), and Treatment Administration Record (TAR) revealed the following wound care treatments: - Apply house barrier cream to (B [bilateral]) buttocks, coccyx, right inner thigh, and peri-area every shift with incontinent episodes. May keep at bedside to be reapplied as needed every shift (Ordered: 4/6/23; Start Date: 4/7/23) - Cleanse coccyx with wound cleanser pat dry apply hydrogel cover with border gauze daily and PRN (as needed) for wound care (Ordered: 4/21/23; Start Date: 4/21/23). The treatment was not completed on 4/21/23. - Cleanse coccyx with wound cleanser pat dry apply hydrogel cover with border gauze daily and PRN every day shift for wound care (Ordered: 4/21/23; Start Date: 4/22/23) - Cleanse right lateral great toe with wound cleanser pat dry apply skin prep to right great toe daily every day shift for wound care (Ordered: 4/7/23; Start Date: 4/8/23) On 4/27/23 at 11:16 AM, Resident #245 could be heard from the hallway of the facility yelling Help me, help me repeatedly. Upon entering the Resident's room, Resident #245 was observed laying in bed, positioned on their back with their heels directly against the mattress. The Resident's call light was hung over the dresser next to their bed and not within their reach. When queried what was wrong, Resident #245 replied, The pain in my buttocks. Resident #245 was visibly uncomfortable, unsuccessfully attempting to move in the bed and non-verbal signs/symptoms of pain including facial grimacing. When asked if they had informed staff of their pain, Resident #245 revealed they had. Resident #245 stated, It been hurting since they changed me around 8:00 (AM). Resident #245 continued, I be hollering, and they get on me about that. When asked what that meant, Resident #245 revealed that facility staff told them to stop that hollering. When queried how that made them feel, Resident #245 revealed they did not like it and asserted, I can't (stop) because of the pain. Resident #245 was asked when they were last repositioned in bed and revealed it was when they were last changed around 8:00 AM. When asked to rate their pain on a scale from zero to 10, with 10 being the worst pain imaginable, Resident #245 stated their pain was a 10. While speaking to Resident #245, Unit Manager Licensed Practical Nurse (LPN) TT entered the Resident's room at 11:18 AM and administered Tylenol to the Resident. LPN TT did not assess the Resident's pain level/location nor provide any non-pharmacologic interventions including repositioning prior to exiting the room. Resident #245 revealed they were going to be discharged home today. When queried if their wound care treatments had been completed, Resident #245 answered they did not recall their wound care dressing being changed. Review of Resident #245's MAR and TAR revealed the Resident's wound care treatments had not been documented as completed on 4/27/23. An interview was completed with LPN TT on 4/27/23 at 11:26 AM. LPN TT was queried regarding Resident #245's pain level and stated, Five (out of 10). When asked what time they had assessed the Resident's pain level at five out of ten, LPN TT did not provide a response. When LPN TT was informed the Resident had stated their pain was at a 10/10, they did not provide further explanation. LPN TT was then queried if Tylenol was the only medication Resident #245 had ordered for pain and indicated they were only able to receive Tylenol at this time. A request to observe Resident #245's skin and wound care treatment prior to their discharge was requested with LPN TT at this time. LPN TT indicated the Resident's nurse had informed them they had already completed the treatment. When asked why Resident #245 did not recall the treatment being completed and the treatment was not documented as completed on the Resident's MAR/TAR, LPN TT revealed that was the first time they had seen the Resident that day and would let the Resident's nurse know. Further review of Resident #245's MAR and TAR revealed the following medication orders for pain management: - Hydrocodone-Acetaminophen (Norco- narcotic medication to treat moderate to severe pain) Oral Tablet 5-325 mg (milligram) . Give 1 tablet by mouth every 6 hours as needed for pain (Start Date: 4/6/23). Per the MAR, Resident #245 reviewed the medication multiple times during the month of April 2023 for pain levels ranging from zero to seven. The Resident had last received the medication on 4/6/23 at 7:31 AM. - Acetaminophen (Tylenol) Oral Tablet . Give 500 mg by mouth every 6 hours as needed for pain (Start Date: 4/7/23). Per the MAR, Resident #245 had received Tylenol once during their admission on [DATE] at 11:18 AM when administered by LPN TT. At 11:40 AM on 4/27/23, Resident #245 was observed laying in bed, positioned on their back with their heels directly on the mattress. On 4/27/23 at 11:42 AM, an observation of Resident #245's wound care treatment was completed with LPN MM and CNA CC. Upon entering the room, Resident #245 was observed in the same position in bed with their heels positioned directly against the mattress. When the facility staff were preparing the turn the Resident to complete the wound care treatment, discolored skin was observed on the medial aspect of the Resident's left heel. Upon request, an observation of the Resident's skin on their bilateral feet was completed. The area of Resident #245's left heel which had been positioned directly against the mattress was noted to be deep/dark red and black in color. When queried if the tissue was blanchable, LPN MM pressed the deep/dark red colored area of the skin, and the tissue was observed to be non-blanchable (lack of blood perfusion). When LPN MM pressed the skin on the Resident's heel, Resident #245 yelled, Ouch! and their facial grimacing was observed. When asked, Resident #245 revealed their heel hurt when touched. LPN MM was asked if the tissue was blanchable and replied, No. With further inquiry regarding the wound, LPN MM indicated they do not stage wounds. When asked if the area was caused by pressure and if it was a pressure ulcer, LPN MM confirmed it was and reiterated they did not stage pressure ulcers. On Resident #245's right foot an open area, approximately the size of a dime, was present on the Resident's right great toe. The wound bed was shallow with visible tissue loss and was shiny and pink in color. There was no dressing in place over the wound and noting in place to prevent the blankets from rubbing on the wound. When asked, Resident #245 revealed their pain level was a nine or 10 out of 10. LPN MM indicated they were going to wait to complete the wound care treatment. Following the observation, Resident #245 remained positioned on their back in bed. An interview was completed with Unit Manager LPN TT on 4/27/23 at 12:05 PM. LPN TT was asked when Resident #245 developed a pressure ulcer on their heel and stated, (Resident #285) doesn't have one. LPN TT was informed of skin observation completed with LPN MM and revealed they were unaware of the Resident having any new skin concerns. An observation of Resident #245's left heel was completed with Unit Manager LPN TT at this time. When queried regarding the skin alteration, LPN TT stated, It's a DTI. Definitely a DTI pressure injury. When asked if Resident #245 was at risk for pressure ulcer development, LPN TT confirmed they were. When queried regarding observations of the Resident's heels being directly on the mattress, lack of repositioning, and lack of planned interventions to prevent pressure ulcers, LPN TT was unable to provide an explanation. When queried regarding the frequency in which skin assessments are completed by nursing staff, LPN TT revealed skin assessments are completed weekly and documented in the EMR. When asked if skin observations are also completed when Resident's received showers, LPN TT revealed CNA's observe the skin and report any abnormalities to nursing staff. When asked about documentation of showers, LPN TT revealed showers are documented in the EMR and CNA's also fill out paper shower sheet forms. Resident #245's paper shower sheets were requested at this time. Review of Resident #245's shower documentation revealed the Resident had not received a shower in the past 30 days at the facility. An interview was completed with the Director of Nursing (DON) on 4/27/23 at 12:16 PM. When queried if they were aware Resident #245 had a new, facility acquired DTI pressure ulcer identified today during the requested skin observation by this Surveyor, the DON confirmed they had been made aware by facility staff. The DON then stated, It has been almost a week since the last skin assessment was completed. When queried if they were saying that Resident skin is only observed during the weekly skin assessment, the DON did not respond. When asked if Residents skin should be observed when daily care and showers are completed, the DON replied, They should. The DON was then asked if it was acceptable that the area had not been identified by staff, the DON stated, No. The DON was asked how often dependent Residents, such as Resident #245 should be repositioned per standards of care, the DON revealed Residents should be repositioned every two hours. The DON was then asked about observations of Resident #245's heels being directly against the mattress and not being repositioned in bed and was unable to provide an explanation. When queried if they were aware and agreed that it was a concern Resident #245 had developed a facility acquired pressure ulcer and the lack of interventions to prevent pressure ulcers, the DON stated, I know. At 12:44 PM on 4/27/23, an observation of Resident #245's coccyx wound care treatment was completed with LPN MM and CNA KK. Upon entering the room, Resident #245 remained positioned on their back in bed. The facility staff repositioned Resident #245 on their side to complete the dressing change and wound care treatment. The dressing in place on the Resident's coccyx was undated. LPN MM proceeded to remove the dressing and a moderate amount of off-gray colored; foul smelling drainage was noted on the removed dressing. The exposed wound bed had two distinct wound areas. The skin on Resident #285's sacrum/buttocks was red/maroon in color. The area was approximately two and a half inches long and two inches across. A separate, open wound was present directly over the Resident's coccyx. The wound bed was irregularly shaped and approximately the size of a dime. The wound bed had visible tissue loss and depth. The wound bed was pink and white and coated with white/yellow slough with attached edges. Following wound care observation, the following documentation was added in Resident #245's EMR: - 4/27/23 at 12:19 PM: Pressure Ulcer- Weekly Observation . Left heel . Length: 4.5 (cm) . Width 4 (cm) . 2a. Indicate whether this site was acquired during the residents stay or whether it was present on admission: Acquired . 2b. Date acquired: 4/27/23 . What stage does ulcer currently present as? a. DTI (Suspected Deep Tissue Injury -pressure injury with unknown depth often seen as a localized area of discolored, intact skin due to damage of underlying tissue) . middle of left heel non-blanchable and firm . Describe any changes to treatment plan in the last week: Skin prep to be applied to left heel and profo boots to be worn while in bed . - 4/27/23 at 1:22 PM: Pressure Ulcer- Weekly Observation . Coccyx . Length: 5.3 (cm) . Width 5 (cm) . What stage does ulcer currently present as? c. Stage 2 . 5a. Overall Impression: d. Worsening . Drainage . None . Peri- Wound Tissue . intact . Describe wound edges and shape: well-defined . Wound Progress: Progressed . On 4/28/23 at 8:36 AM, an interview was conducted with the DON. When queried regarding Resident #245's coccyx pressure ulcer, the DON confirmed the wound was a pressure ulcer not MASD. The DON then stated, Nurses assess (skin) weekly and indicated the Resident's skin assessment had not been completed for the week yet. The DON continued, The nurse would have caught it when the assessment was completed. When asked why the change in the wound was not identified and documented by the floor nursing staff who completed daily dressing changes, the DON replied, The nurse noticed the change (in the wound) but didn't change the classification. When asked if they were referring to the wound care treatment being changed from barrier cream to hydrogel on 4/21/23, the DON verified they were. When asked why the treatment order was not changed until 4/21/23 and not implemented until 4/22/23 when the wound (Non-Pressure Ulcer - Weekly Observation) assessment completed on 4/19/23 specified the wound treatment was changed to Hydrogel, the DON did not provide an explanation. When queried why the wound was documented as MASD and not a facility acquired pressure ulcer following the change in the wound, the DON reiterated the nurse did not change the wound classification after identification of the change. When queried if the pressure ulcer was a facility acquired pressure ulcer, the DON confirmed it was. The DON was then asked if stage two pressure ulcers have slough in the wound bed and indicated they did not. When asked why Resident #245's pressure ulcer was documented as a stage two pressure ulcer when the wound bed had visible slough, the DON was unable to provide an explanation. (Note: Stage three pressure ulcers have full thickness tissue loss and slough may be present). Resident #10: On 4/26/23 at 11:30 AM, Resident #10 was observed in their room in bed with their eyes closed. The Resident was positioned on their back with their heels directly on the mattress. An alternating air mattress was in place on the Resident's bed. The alternating air mattress was not making any noise and there were no lights on. Closer inspection of the air mattress controller revealed the power switch was in the off position and the alternating air mattress was turned off. Record review revealed Resident #10 was admitted to the facility on [DATE] with diagnoses which included hemiplegia and hemiparesis (one sided paralysis) following cerebral infarction (stroke), bipolar disorder, epilepsy, dysphagia (difficulty swallowing), and gastrostomy (tube inserted into the stomach through a surgically created opening in the abdominal wall for the insertion of food). Review of the MDS assessment dated [DATE] revealed the Resident was moderately cognitively impaired and required extensive to total assistance to complete all ADL's with the exception of eating. The MDS further revealed the Resident was at risk for pressure ulcer development and had one stage two pressure ulcer. Review of Resident #10's care plans revealed a care plan entitled, Resident has impaired skin integrity right buttocks small, scabbed area left buttocks MASD (Initiated: 3/22/23; Revised: 3/23/23). The care plan included the interventions: - Assess and document skin condition, notify MD of signs of infection (redness, drainage, pain, fever) (Initiated: 3/22/23) - Assess for pain and treat as indicated (Initiated: 3/23/23) - Assist with bed mobility to turn and reposition routinely (Initiated: 3/23/23) - Assist with toileting (Initiated: 3/23/23) - Check for incontinence and provide incontinent care as needed. Notify nurse of any redness or irritation (Initiated: 3/23/23) - Notify MD of worsening or not improvement in wound (Initiated: 3/23/23) - Pressure reducing/redistributing cushion in chair (Initiated: 3/23/23) - Pressure reducing/redistributing mattress on bed (Initiated: 3/23/23) - Wound treatment as ordered (Initiated: 3/23/23) Review of Resident #10's Health Care Provider orders revealed the Resident did not have an active wound care treatment order. The following active orders related to pressure ulcer prevention were in place: - Pressure reduction mattress every shift . (Ordered: 3/22/23) - Pressure reduction cushion to wheelchair every shift . (Ordered: 3/22/23) - Apply house barrier cream to (B [bilateral]) buttocks, coccyx, and peri-area every shift with incontinent episodes. May keep at bedside to be re-applied as needed (Ordered: 3/22/23) There were no orders in the EMR specifying the settings for the Resident's alternating air mattress. Review of documentation in Resident #10's EMR detailed the following: - 3/23/23: Progress Notes . Acute . new admit . seen today to establish care . recently admitted to the hospital for altered mental status, slurred speech, diarrhea, cough and weakness. Pt (patient) treated for aspiration pneumonia . R (Right) buttock wound - wound care to follow . - 4/5/23 at 12:16 PM: Non-Pressure Ulcer Note . Left Buttock . Acquired . 3/22/23 . MASD on left buttock, unable to measure . Apply barrier cream Q (every) shift . pressure reducing mattress . pressure reducing chair cushion . - 4/5/23 at 1:06 PM: Pressure Ulcer Note . Right buttock - stage 2, 2 x 1 x 0 (cm) . Stage 2 (pressure ulcer) . Worsening . - 4/6/23 at 1:08 PM: IDT . Weekly Follow-up . Met with IDT team to discuss progress of resident's wound treatment. Resident currently presents with MASD on left buttock which resident was admitted with. Due to the nature of the wound, measurements were not able to be obtained. Overall, the wound looks unchanged. In addition, also has a stage 2 wound on right buttocks that appears to be worsening, compared to last week's measurements. This week measurements read 2 x 1 x 0 (cm) compared to last week 1.5 x 1 x 0 (cm) . - 4/12/23 at 11:10 AM: Non-Pressure Ulcer Note . left buttock . admitted . resolved . - 4/12/23 at 11:14 AM: Pressure Ulcer - Weekly Observation . Right buttock . Resolved . Stage 2 . Healed . Preventative measures/special equipment . Pressure reducing mattress . On 4/27/23 at 3:02 PM, Resident #10 was observed laying in bed, positioned on their back with their heels directly against the mattress. Upon saying the Resident's name, they opened their eyes. When asked questions, Resident #10 made eye contact but did not provide meaningful responses to questions when asked. The alternating air mattress controller was in the same position at the end of the bed with the power off. At 3:07 PM on 4/27/23, LPN MM was asked to enter Resident #245's room to check the alternating air mattress. When asked what was wrong with the alternating air mattress, LPN MM did not immediately identify that the mattress power was off. When asked if the mattress was on, LPN MM did not respond. After pointing out where the power switch was on the alternating air mattress, LPN MM flipped the switch, the alternating air mattress motor was heard, and the mattress began to inflate. LPN MM then confirmed the mattress had been off. When queried who was responsible to ensure the mattresses were turned on and functioning, LPN MM did not provide a direct answer. On 4/27/23 at 3:10 PM, an interview was completed with Unit Manager LPN TT. When queried regarding facility policy/procedure related to monitoring of alternating air mattress function and staff responsibility, LPN TT replied, Nurses should check. LPN TT was informed of observation of Resident #10's alternating air mattress being off on 4/26/23 and 4/27/23, LPN TT was unable to provide an explanation. When queried what the settings were supposed to be on Resident #10's alternating air mattress, LPN TT revealed they did not know and there was no order/documentation of what the settings are supposed to be set at. An interview was conducted with the DON on 4/28/23 at 8:44 AM. When queried regarding the facility policy/procedure related to monitoring and use of alternating air mattresses, the DON replied, Nurses and CNA's. The DON revealed they were aware of the concerns related to air mattress not being on and lack of orders/staff awareness of settings. The DON then stated, (Air mattress monitoring/settings) are on the TAR task now. When asked if they were saying the task was added, the DON revealed they added the orders/tasks the previous day. The DON stated, We did an order and put it on the TAR and care plans that includes the settings. When queried if the mattress had to be turned on and at appropriate settings in order to provide optimal pressure reduction and relief, the DON confirmed it did. When queried regarding Resident #10's air mattress being observed off on 4/26/23 and 4/27/23 and staff not identifying the mattress being off, the DON stated, There is no excuse. On 5/3/23 at 9:57 AM, Resident #10 was observed in their room in bed. The Resident was positioned on their back with their heels directly against the mattress. Resident #10 smiled and made eye contact when spoke to but did not verbally respond to questions. Resident #21: On 4/25/23 at 3:14 PM, Resident #21 was observed in their room. The Resident was sitting in a wheelchair with their feet on the floor. Non-slip socks were present on the Resident's feet and their left foot was notably larger than their right and both lower extremities appeared edematous. A family visitor was present in the room. An interview was conducted with Resident #21 and their family member at this time. An alternating air mattress was present on the Resident's bed. The mattress was set to 1000 pounds. When queried if they had any wounds, Resident #21 stated, My butt hurts. With further inquiry, Resident #21's family member revealed they assisted with the Resident's care and stated, Not sure what the sore is. When asked if they had any other wounds, Resident #21 revealed they had a dressing in place on their left foot. Resident #21's wheelchair did not have a pressure reduction pad in place on the wheelchair seat. Resident #21 was asked if they were able to reposition themselves in the wheelchair and revealed they needed staff assistance to move and transfer. When asked how long they had been sitting in their wheelchair, Resident #21 and their family member both revealed the Resident had been in the same position since 12:30 PM. When queried if facility staff had assisted them to reposition in the chair since they had been sitting up, Resident #21 and their family member stated that staff had not repositioned them in their chair. Record review revealed Resident #21

Based on observation, interview and record review, the facility failed to prevent and monitor weight loss for one resident (Resident #70), resulting in the likelihood for continued weight loss and prolonged illness. Findings include: Record review of the facility 'Weight Monitoring' policy dated 3/2023, revealed weight can be a useful indicator of nutritional status. Significant unintended changes in weight (loss or gain) or insidious weight loss (gradual unintended loss over a period of time) may indicate a nutritional problem. 1. The facility will utilize a systemic approach to optimize a resident's nutritional status. This process includes: (a.) Identifying and assessing each resident's nutritional status and risk factors (b.) Evaluating/analyzing the assessment information (c.) Developing and consistently implementing pertinent approaches (d.) Monitoring the effectiveness of interventions and revising them, as necessary. Resident #79: In an interview and observation 04/25/23 1 at 2:56 PM with Resident #79's family member revealed that the resident had lost weight since admission to the facility. The family member revealed that Resident #79 use to be around two hundred pounds and now is below 150 pounds. Resident #79 does have a tube feed tube in his abdomen. Resident #79 walked over to show the surveyor his PEG tube with no dressing in place and crusty material around the opening. The family member stated that Resident #79 is takes food by mouth and that the tube has not been used for a while. Record review on 5/4/2023 of Resident #79's electronic weight log from admission in October 2022 revealed a weight of 176.4 pounds. The Resident #79 was stable through March 3, 2023, weight of 170 pounds. April 5, 2023, weight was documented as 139. That was a 31-pound weight loss within a 34-day time period. The Electronic Medical Record (EMR) documented a 19.4% weight loss in 30 days. Record review of the facility 'Weight Monitoring' policy dated 3/2023, revealed (#5.) A weight monitoring schedule will be developed upon admission for all residents: (a.) Weights should be recorded at the time obtained. Mathematical rounding should be utilized (i.e., if weight is X 0.5 pounds [lbs] or more, round weight upward to the nearest whole pound. If weight is X 0.1 to X 0.4 [lbs] round down to the nearest whole pound). (b.) Newly admitted residents - monitor weight weekly for 4 weeks (c.) Residents with weight loss - monitor weight weekly (d.) If clinically indicated - monitor weight daily (e.) All others - monitor weight monthly (#6.) Weight Analysis: The newly recorded resident weight should be compared to the previous recorded weight. A significant change in weight is defined as: (a.) 5% change in weight in 1 month (30 days) (b.) 7.5% change in weight in 3 months (90 days) (c.) 10% change in weight in 6 months (180 days). In an interview and record review on 05/04/23 at 08:27 AM with Registered Dietician (RD) BB of Resident #79's electronic medical record review of the resident's weight log of 3/3/2023 weight of 170.0 pounds was noted. On record weight of 139.0 that was a 31-pound weight loss in 30 days, and a 35-pound weight loss since admission. RD BB stated that Resident #79 was NPO (nothing by mouth) at the time due to the tube feedings resident was getting. The tube feedings were increased, and he was stable in his weight. On 2/27/2023 he had a video laryngeal test that noted reduced swallow with aspiration risk. The RD BB was getting agitated and seeking out food. He was restless, getting up and down, seeking out food, hanging out at nurse station near food carts. Resident #79 was wanting to eat food items. Weights are once a month when stable. We met in April with the guardian (Father or brother), and he wanted the resident to have regular diet with food items and to hold the tube feedings. The Resident #79's care plan was updated. Record review of Resident #79's care plans pages 1-21, revealed that tube feeding care plan intervention dated initiated 3/3/2023 weigh as ordered and as needed. Record review of nutrition care planned initial date of 10/5/2022 and revision date of 3/3/2023 revealed only one intervention: Diet as ordered; resident is NPO (nothing by mouth) receives nutrition via his G-tube. Record review on 05/04/23 at 11:32 AM of the facility weight loss policy revealed that the resident with the 31-pound weight loss should be weighed weekly, the last documented weight was on 4/13/2023, was 141 pounds, which was 3 weeks ago.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to implement and operationalize processes and procedures to ensure monitoring, accountability, and pharmacological oversight of controlled medications in the Med-bridge and North Hall of the facility per professional standards of practice. This deficient practice resulting in lack of appropriate storage, securement, reconciliation, administration, and disposal and/or return of controlled medications including lack of accurate comprehensive documentation and reconciliation of Methadone (prescription opioid medication frequently used to treat individuals with opioid dependence) brought into the facility, and the likelihood for inappropriate medication use and administration, accidental exposure, and diversion which has the potential to effect all 92 residents residing in the facility. Findings include: A tour of the North Hall Medication Cart with Licensed Practical Nurse (LPN) MM on 4/26/23 at 8:33 AM. Within the medication cart, an unlabeled medication cup filled with pills was observed in the locked narcotic drawer. When queried what the medications in the cup were, LPN MM replied that the medications were for Resident #247. When asked why the medications were in the drawer, LPN MM revealed they had pulled the meds to administer to the Resident but they were not in their room, so they put them in the drawer. When queried what medications were in the cup, LPN MM indicated the medication cup contained the Resident's morning medications. When asked if there were any narcotic/controlled medications, LPN MM revealed the medication up contained a Norco (controlled, narcotic medication for pain) and Gabapentin (controlled medication used to treat nerve pain). When queried if they had documented the medications as administered on Resident #247's Medication Administration Record (MAR), LPN MM indicated they had. Resident #247's Controlled Medication Administration Count Documentation Record was reviewed and reconciled with LPN MM at this time. The paper Controlled Medication Count Documentation Record form for Resident #247's for Norco 7.5/325 milligram (mg) and Gabapentin 300 mg did not match the number of pills in the Resident's bubble pill package. For both medications, there was one less pill in the blister pack than on the Controlled Medication Administration Count Documentation Record. When queried why the number of pills did not match (reconcile) with the number on the Controlled Medication form, LPN MM revealed they had not documented the medication on the Controlled Medication form. All Resident's narcotic medications within the cart were counted and reconciled with LPN MM at this time. The following discrepancies were identified: - Norco 5/325 mg blister pack for Resident #250. Controlled Medication Administration Count Documentation Record specified there should be 22 pills in the Resident's medication blister pack. The medication blister pack only contained 21 pills. - Norco 7.5/325 mg blister pack for Resident #251. Controlled Medication Administration Count Documentation Record specified there should be 3 pills in the Resident's medication blister pack. The medication blister pack only contained 2 pills. - Norco 5/325 mg blister pack for Resident #245. Controlled Medication Administration Count Documentation Record specified there should be 22 pills in the Resident's medication blister pack. The medication blister pack only contained 21 pills. - Clonazepam (controlled medication used treat/prevent seizures and anxiety) Disintegrating Tablets 0.25 mg for Resident #248. Documentation Record specified the Resident should have 30 tablets. There were 29 individually wrapped tablets in the medication cart. - Norco 7.5/325 mg blister pack for Resident #248. Controlled Medication Administration Count Documentation Record specified there should be 52 pills in the Resident's medication blister pack. The medication blister pack only contained 51 pills. - Norco 5/325 mg blister pack for Resident #246. Controlled Medication Administration Count Documentation Record specified there should be 3 pills in the Resident's medication blister pack. The medication blister pack only contained 2 pills. When queried regarding the discrepancies on the Controlled Substance Shift Inventory forms and the narcotic/controlled medications present in the medication cart, LPN MM stated, Gave the meds but didn't sign them out (on form). When asked why they did not sign out the medications, LPN MM revealed they were going to sign the medications out later. When queried regarding the facility policy/procedure pertaining to administration of controlled substances and documentation, LPN MM revealed they were supposed to sign out the medications on the form. When queried how another nurse would know the medication had been administered when it was not signed out, an explanation was not provided. A review and reconciliation of the North Hall Controlled Substance Shift Inventory form for April 2023 was completed with LPN MM at this time. When asked about the form, LPN MM revealed the form is utilized to count the total number of controlled medication blister packs in the cart. The form included documentation sections for Date, Time, Total # of RX (prescription) at start of shift . (+) Received from Pharmacy, (-) Emptied by Nurse, Total at End of Shift, Initial Signed: Means no discrepancies on blister packs, Outgoing Nurse, Incoming Nurse, # Turned into DNS (Director of Nursing Services). The following inaccuracies and discrepancies were identified upon review of the Controlled Substance Shift Inventory form for April 2023: - 4/6/23 at 6:00 PM: Total # of RX (prescription) at start of shift = 34; Received from Pharmacy = (+) 0; Emptied by Nurse: (-) 3; Total at End of Shift: 34 . The date was initialed as having no discrepancies. - 4/7/23 at 6:00 AM: Total # . at start of shift = 35; Received from Pharmacy = (+) 0; Emptied by Nurse: (-) 1; Total at End of Shift: 34 . The date was initialed as having no discrepancies. - 4/8/23 at 6:00 PM: Total # . at start of shift = 36; Received from Pharmacy = (+) 0; Emptied by Nurse: (-) 5; Total at End of Shift: 36 . The date was initialed as having no discrepancies. - 4/8/23 at 10:00 PM: Total # . at start of shift = 36; Received from Pharmacy = (+) 0; Emptied by Nurse: (-) 0; Total at End of Shift: 31 . The date was initialed as having no discrepancies. - 4/9/23 at 6:00 AM: Total # . at start of shift = 31; Received from Pharmacy = (+) 0; Emptied by Nurse: (-) 0; Total at End of Shift: 30 . The date was initialed as having no discrepancies. - 4/11/23 at 6:00 PM: Total # . at start of shift = 35; Received from Pharmacy = (+) 0; Emptied by Nurse: (-) 0; Total at End of Shift: 32 . The date was initialed as having no discrepancies. - 4/12/23 at 6:00 AM: Total # . at start of shift = 31; Received from Pharmacy = (+) 0; Emptied by Nurse: (-) 14; Total at End of Shift: 18 . - 4/12/23 at 6:00 PM: Total # . at start of shift = Blank; Received from Pharmacy = Blank; Emptied by Nurse: Blank; Total at End of Shift: Blank . The date was initialed as having no discrepancies. - 4/16/23 at 6:00 AM: Total # . at start of shift = 21; Received from Pharmacy = (+) 2; Emptied by Nurse: (-) Blank; Total at End of Shift: 22 . The date was initialed as having no discrepancies. - 4/21/23 at 6:00 PM: Total # . at start of shift = 38; Received from Pharmacy = (+) 6; Emptied by Nurse: (-) 1; Total at End of Shift: 27 . The date was initialed as having no discrepancies. The following incomplete/missing documentation was noted on the Controlled Substance Shift Inventory Form: - No documentation of Total # of RX (prescription) at start of shift on: 4/10/23 at 6:00 PM and 4/12/23 at 6:00 PM. - No documentation under section of form titled: Initial Signed: Means no discrepancies on blister packs on: 4/6/23 at 6:00 AM, 4/9/23 at 6:00 PM, 4/11/23 at 6:00 AM, 4/1/23 at 6:00 AM, 4/13/23 at 10:00 PM, 4/14/23 at 6:00 AM, 4/14/23 at 6:00 PM, 4/25/23 at 6:00 AM, 4/15/23 at 6:00 PM, and 4/26/23 at 6:00 AM. - No documentation of Total at end of shift on 4/12/23 at 6:00 PM and 4/13/23 at 6:00 PM. - No signature and/or initials of Outgoing Nurse and/or Incoming Nurse on 4/24/23 at 10:00 PM. - No signature and/or initials of Incoming Nurse on 4/26/23 at 6:00 AM. An interview and review of the North Hall Controlled Substance Shift Inventory form for April 2023 was completed with the Director of Nursing (DON) at 9:30 AM on 4/26/23. When queried regarding the facility policy/procedure related to controlled/narcotic medication administration and documentation, the DON stated, Should be signed out on the form. The DON revealed they were aware LPN MM had not documented administration of controlled medications. When queried regarding the medication cup filled with pills, including narcotic/controlled medications, in the cart drawer, the DON stated, They (meds) should have been wasted. The Controlled Substance Shift Inventory form was reviewed with the DON including identified inaccuracies. The DON verified the inaccuracies and incomplete documentation. When asked who is responsible for monitoring the form and ensuring periodic reconciliation of controlled medication inventory, the DON replied, My unit managers are supposed to be doing it. With further inquiry, the DON revealed the current process was not working and would need to be changed. When asked how they were able to identify and prevent loss and/or diversion of medications with the current documentation, the DON was unable to provide an explanation. A tour of the North Hall Medication room was conducted with Unit Manager LPN TT on 4/28/23 at 9:09 AM. During the tour, a black box was observed towards the back left side in a cabinet above the sink. The box was sitting on an open plastic bag with the front of the box facing the cabinet door. There was no identification present on the top of the bag/open box. Upon removal of the box from the cabinet, it was noted to be an opened and unlocked black metal lockbox. The lockbox appeared worn and had a key lock. The locking mechanism on lockbox was engaged causing the box to be opened with the key lock remaining in the locked position. The locking mechanism had visible wear and appeared damaged. The box contained two packages of very old appearing Tic Tacs, a Bridge benefit card for Witness AAA, and 15 bottles. LPN TT was asked what the bottles were and indicated they did not know. Upon touching the bottles to identify the contents, the bottles were noted to be sticky, and the contents were identified as liquid methadone. There were eight empty bottles and seven bottles of liquid methadone (prescription opioid drug) labeled for administration to Resident #253 in the lockbox. The label on each bottle specified, (Resident #253) . Methadone . Dosage: 200 mgs (milligrams) . Detailed inspection of the medication bottles revealed each of the seven bottles of liquid methadone specified the same dosage was in the container; however, there was a different amount of liquid in each bottle. LPN TT was queried regarding Resident #253, and they revealed the Resident no longer resided in the facility but was unsure of their discharge date . There was no documentation and/or reconciliation of how much methadone was originally brought into facility. LPN TT was asked when and how much medication was brought into the facility. LPN TT revealed they did not know. LPN TT was asked to have the DON come to the medication room. When queried who audits and monitors the medication storage room, LPN TT did not provide a response. LPN MM entered the medication room at this time and were asked if they knew anything about the Methadone. LPN MM did not respond. Resident #253's face sheet including their admission/discharge date s was requested. A paper was noted on the bottom of the outside of the open bag which had been positioned under the lock box. Review of the paper detailed, Security Bag . Instructions . 4 . Remove adhesive backing and fold at line indicated to create tamper evident seal . Other: Lockbox with methadone. Box is locked. No Key . The form was undated and contained illegible signatures of staff members. When asked whose signatures were on the form, LPN TT revealed they did not know. After arriving at the medication room, the DON was queried regarding the Methadone including the reason the medication was in the medication room. The DON examined the unlocked black metal lock box and was unable to provide an explanation. When queried regarding the facility policy/procedure for securement of controlled substances, the DON revealed narcotic/controlled medications are supposed to be accessible only to licensed nurses. When asked if narcotic/controlled substances should be double locked, the DON replied, Yes. When asked if all controlled medications which enter the facility should be accounted for, the DON responded that they should be. The DON was then asked why the Security Bag . Instructions . form indicated bag was sealed and the box was locked with no key when the bag was not sealed, and the box was clearly unlocked. The DON was unable to provide an explanation. A review of Resident #253's face sheet was completed at the time. Per the face sheet, Resident #253 was admitted to the facility on [DATE] and discharged on 11/3/22. When queried if the lockbox had been in the facility since 9/14/22 when the Resident was admitted , LPN TT indicated they believed it came with the Resident when they were admitted . When asked why it was not sent home with the Resident when they were discharged , neither the DON nor LPN TT were able to provide an explanation. When queried how they knew the total amount of Methadone that was present in the box when the Resident was admitted , the DON stated, I don't know and indicated they would look for documentation. When asked what should have happened with the Methadone when it was brought into the facility, the DON revealed the medication should have been counted and documented by two nurses and returned to the Resident upon discharge and/or sent home with family if available/appropriate. No explanation was provided when asked why that did not occur. When queried why each bottle with liquid Methadone had a different amount of liquid but the label indicated it contained the same dosage, the DON was unable to provide an explanation. Review of Resident #253's medical record revealed the Resident was originally admitted to the facility on [DATE] with diagnoses which included depression, alcohol use, abdominal hernia, hepatitis C, and drug abuse surveillance. 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 (ADL's) with the exception of eating. Review of Resident #253's Michigan admission Agreement . EXHIBIT G . Inventory of Resident's Belongings . Date: 9/30/22 . Name of Facility Staff Performing Inventory: (admission Staff YY) . List of Resident's Personal Belongings . In patients' chart . A list of Resident #253's personal belongings was not noted in their medical record. A Controlled Medication Administration Count Documentation Record for Methadone 200 mg was also not present in the medical record. Review of documentation in Resident #253's medical record revealed the following: - 9/14/22 at 11:31 PM: General Progress Note .Writer was given report from (Hospital). Resident was brought in alone about 17:15 via ambulance. Ambulance gave writer residents property lock box that had medications and other property such as Tic Tacs, which was witnessed by second nurse being locked in med room . (Authored by LPN BBB) - 11/3/22 at 2:05 PM: General Progress Note . Resident was discharge . leave with two EMT driver. Resident took all belong with (them) . (Authored by LPN MM) Review of staff list provided by the facility revealed LPN BBB was not listed as an employee. On 4/28/23 at 2:30 PM, Resident #253 was attempted to be contacted at the phone number listed on the facility provided face sheet. The phone number did not belong to Resident #253. A detailed review of Resident #253's face sheet revealed Witness AAA was listed as an emergency contact. Witness AAA was contacted on 4/28/23 at 2:40 PM. When queried if they had Resident #253's current contact information, Witness AAA revealed they were with the Resident and gave them the phone. An interview was completed at this time. When queried if they recalled their stay at the facility, Resident #253 verbalized they did. When asked if they had taken their home methadone with them when they were admitted to the facility, Resident #253's voice raised and began speaking in an upset tone. The Resident stated, They stole it at (Hospital). I never got it back. It was in my lock box. Resident #253 continued, I filed a complaint with the hospital. I can get in trouble at the Meth clinic. When asked what they meant regarding the Meth Clinic, Resident #253 revealed they were going to a Methadone clinic as part of their recovery from intravenous (IV) drug use and that the Methadone had very specific rules and regulations related to Methadone. Resident #253 then stated, Have to keep it (Methadone) in a lock box. I had to buy a new one (lock box). Resident #253 was asked if they were aware the Methadone and lockbox were at facility and stated, No. I thought they stole it at the hospital. Resident #253 questioned, You mean it's at the facility? When queried if they recalled what was in the lockbox when they went to the facility, Resident #253 stated, Been a long time but six or seven bottles (of Methadone). Resident #253 then stated, They (Methadone bottles) are 200 milligrams (each). I take 100 mg in the morning and 100 mg at night. When queried if all the bottles have the same amount of liquid in them when they receive them from the Methadone clinic and replied, Yes, why. Resident #253 was then asked if there was a reason all the bottles with Methadone in them had different amounts of liquid in the bottles and stated, They all have the same amount in them when I get them. They must have taken some out off the top. With further inquiry, Resident #253 stated, My nurse there goes to the Methadone Clinic with me. Resident #253 was asked if they were saying a nurse who worked at the facility and cared for them went to Methadone clinic with them, Resident #253 replied, I don't want to get them in trouble. When queried if the box was locked when they last had it, Resident #253 stated, Yes. I still have the key. I want it back. Resident #253 reiterated they can get in trouble at the Methadone clinic. Resident #253 stated, I have to keep track of it all. I didn't know they had it (at the facility). I want it back. When asked if there were any empty bottles in lock box, Resident #253 replied, Yes, I have to take the empty bottles back to the (Methadone) clinic. With further inquiry, Resident #253 revealed they are supposed to keep the empty bottles locked up in the lock box and take the entire lock box with them when they go to Methadone Clinic. Resident #253 verbalized they were upset their lockbox was at the facility, they did not know, and had filled a complaint against the hospital. The Resident expressed how difficult it was for them to stop doing drugs, how the Methadone Clinic had helped them, and the difficulties they experienced when they did not have their lockbox and Methadone to return to the clinic. When queried why they thought the hospital had taken their lockbox and Methadone, Resident #253 revealed they asked a nurse at the facility about it and were told it was not there. When asked the name of the nurse who had told them that, Resident #253 provided a physical description but was unable to recall the nurse's name. Resident #253 verbalized they were very upset that the facility did not return their property to them. On 5/1/23 at 10:34 AM and 5/4/23 at 2:10 PM, the Methadone Clinic listed on Resident #253's prescription bottles were contacted and a message with return number was left for Supervisor CCC. A return phone call was not received. LPN BBB's contact information was requested from Human Resources Staff DD on 5/3/23 at 12:22 PM but not received by the conclusion of the survey. No further documentation related to reconciliation of Resident #253's Methadone was provided prior to the conclusion of survey. Review of facility provided policy/procedure entitled, Medication Administration (Revised 3/23) revealed, Policy: Medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection . 17. Sign MAR after administered. For those medications requiring vital signs, record the vital signs onto the MAR. 18. If medication is a controlled substance, sign narcotic book . Review of facility provided policy/procedure entitled, Controlled Substance Administration & Accountability (No Date) detailed, Policy: It is the policy of this facility to promote safe, high quality patient care, compliant with state and federal regulations regarding monitoring the use of controlled substances. The facility will have safeguards in place in order to prevent loss, diversion or accidental exposure . 1. General Protocols: a. Controlled substances are stored in a separate compartment of an automated dispensing system or other locked storage unit with access limited to approved personnel . All controlled substances (Schedule II, III, IV, V) are accounted for in one of the following ways . ii. All controlled substances obtained from a non-automated medication cart or cabinet are recorded on the designated usage form. Written documentation must be clearly legible with all applicable information provided. iii. All specially compounded or non-stock Schedule II controlled substances dispensed from the pharmacy for a specific patient are recorded on the Controlled Drug Record supplied with the medication or other designated form as per facility policy . h. The Controlled Drug Record (or other specified form) serves the dual purpose of recording both narcotic disposition and patient administration. i. The Controlled Drug Record is a permanent medical record document and in conjunction with the MAR is the source for documenting any patient-specific narcotic dispensed from the pharmacy . j. The charge nurse or other designee conducts a daily visual audit of the required documentation of controlled substances. Spot checks are performed to verify . i. Controlled substances that are destroyed are appropriately documented; and ii. Medications removed from either the automated dispensing system or medication cart/cabinet have a documented physician order . 2. Storage and Security . b. Areas without automated dispensing systems utilize a substantially constructed storage unit with two locks and a paper system for 24-hour recording of controlled substance use . Obtaining/Removing/Destroying Medications . d. Two licensed staff must witness any disposal or destruction of a controlled substance and document same on the Drug Disposition Record, Controlled Drug Record, or via the automated dispensing system . 9. Inventory Verification . b. For areas without automated dispensing systems, two licensed nurses account for all controlled substances and access keys at the end of each shift . e. Any discrepancies which cannot be resolved must be reported immediately as follows: i. Notify the DON, charge nurse, or designee and the pharmacy; ii. Complete an incident report detailing the discrepancy, steps taken to resolve it, and the names of all licensed staff working when the discrepancy was noted; iii. The DON, charge nurse, or designee must also report any loss of controlled substances where theft is suspected to the appropriate authorities such as local law enforcement, Drug Enforcement Agency, State Board of Nursing, State Board of Pharmacy and possibly the State Licensure Board for Nursing Home Administrators. f. Staff may not leave the area until discrepancies are resolved or reported as unresolved discrepancies .