**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to intake MI00150279. Based on interview and record review, the facility failed to prevent a fall for one (Resident #150) of three reviewed for accidents, resulting in a fall with bilateral femur fractures when Resident #150 fell from her bed. Findings include: Resident #150 (R150) Review of the medical record reflected R150 was admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses that included dementia, senile degeneration of brain, right femur pathological fracture, and left femur pathological fracture. The Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 11/20/24, reflected R150 scored 7 out of 15 (cognitively impaired) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). R150 no longer resided in the facility. Review of R150's Care Plan revealed R150 was a two person assist with the use of a Hoyer for transfers and ambulated via wheelchair with staff assist. Review of a Nurses Note dated 7/22/2024 at 7:28 PM revealed Guest (R150) was observed on floor next to bed .with head towards foot of bed. Bed was noted to be in elevated position. Guest not able to state how incident occurred r/t (related to) cognitive impairment. Guest c/o (complained of) pain to LUE (left upper extremity), and left knee. Guest not able to provide pain details r/t (related to) cognitive impairment. Rounding provider at facility in to evaluate guest at time of incident, and unable to assess guest for injury r/t positioning and c/o pain .and potential injury r/t height of bed at time of fall. Review of an Incident Report dated 7/22/24 confirmed that R150's bed was in an elevated height position at the time of her fall out of bed. Review of R150's Fall Care Plan revealed an intervention added on 7/23/24 which stated Bed to be in lowest position at all times unless performing cares. Bed remote to be out of patient reach due to cognitive inability to safely position bed. Review of a Nurses Note dated 2/1/25 at 6:56 AM revealed Guest (R150) had had an unwitnessed fall upon shift change. She was found in the opposite side of her bed hollowed [sic] for help . Called 911 to send guest out due to fall generalized pain. Resident states that she has intense pain on Left knee and lower limb and back .transferred to [NAME] Hospital at 7 AM . Review of an Incident Report dated 2/1/25 stated guest (R150) observed on the floor with her head at the foot of her bed with head slightly under and her hands holding the side of the bed. The incident happened upon shift change. Both caregivers who happened to be close to the guest's room upon overhearing guest called for help. The fall was unwitnessed .guest voiced to be in severe pain .guest stated that she was trying to go to the bathroom . The immediate action taken section of the Incident report stated, resident transferred to hospital .Ct scan and x-rays of bilateral lower extremities showed pathological fractures to bilateral femurs .resident underwent surgical repair .discipline provided to CENA (certified nursing assistant) as bed was waist level after cares provided .physician documentation and orthopedic review indicated pathological fractures that likely [were] caused [by] the fall when resident attempted to stand out of bed. The same incident report revealed an investigation for the fall that occurred on 2/1/25. The investigation revealed R150 was interviewed prior to being transferred out to the hospital and R150 stated that she was attempting to stand up and walk to the bathroom. She reported that she stood up, immediately went down, and was in pain. R150's room was evaluated post fall, and her bed was noted at a waist level height and the bed controller was attached to the headboard. Director of Nursing (DON) B interviewed LPN E and CNA F on 2/3/25 who stated that they observed R150 on the floor calling for help. They reported that the call light was on the floor at the head of the bed and that R150's bed was waist high. The investigation report indicated that CNA H was interviewed and stated that she performed care on R150 at approximately 5:15 AM. CNA H reported that she left the bed at waist level position upon completion of care. CNA H was educated that the bed was to be in the lowest position possible, and at the time of the fall the bed was noted to be at waist level. Review of the After Visit Summary from R150's Hospitalization revealed the following (R150) female was admitted to the trauma service following a fall that resulted in bilateral (left and right) femur fractures. Upon evaluation, it was determined that she required surgical intervention. Orthopedic surgery was consulted, and the patient underwent an open reduction internal fixation (ORIF) procedure using a . rod for stabilization of the fractures .Although the decision was made to proceed with surgery initially, post-operative discussions led to the conclusion that the focus should shift to comfort measures only, in alignment with the family's wishes. Throughout her hospital stay, [R150'S] pain was well-managed, and efforts were made to ensure her comfort during recovery .Despite her surgical intervention, the overarching goal was to honor her and her family's preferences regarding end-of-life care. The medical team provided education and support for transitioning to hospice care, emphasizing the importance of quality of life during this time . Further review of the After Visit Notes from the hospital revealed R150 sustained bilateral supracondylar fractures of the femur. According to the National Library of Medicine, this classification of fracture is most commonly causes by a high impact trauma to the bone. In an interview on 2/20/25 at 10:38 AM, Certified Nursing Assistant (CNA) D reported having familiarity with R150 and the fall that occurred on 2/1/25. CNA D stated that she was walking down the hallway when she overheard R150 calling out for a doctor. When CNA D entered the room, she observed R150 on the floor of her room next to her bed. R150 had obvious deformity of both legs. CNA D stated that the height of the bed was waist level, confirming that the bed was not in the lowest position per the plan of care. In an interview on 2/20/25 at 11:30 AM, Licensed Practical Nurse (LPN) E stated that she was working the day of R150's fall on 2/1/25. LPN E indicated that she observed R150 on the floor next to her bed with obvious deformity to both legs. LPN E stated that R150's bed was up pretty high confirming that the height of the bed was not low, per the care plan. In an interview on 2/20/25 at12:47 PM, CNA H reported that she was working the night shift when R150 sustained the fall on 2/1/25. CNA H stated that she had completed care on R150 at 5:15 AM, and before exiting the room, did not ensure that R150's bed was in the low position like it should have been. CNA H confirmed that she had received education regarding the bed height after R150's fall. In an interview on 2/20/25 at 1:27 PM Registered Nurse (RN) C stated that she was working the morning that R150 sustained the fall out of bed. RN C stated that she had entered the room of R150 and observed her on the floor next to her bed. RN C reported that the height of the bed was high and not in the low position per the care plan. Review of a Social Services reevaluation dated 2/7/25 reflected R150 had experienced trauma from a nursing care setting and stated, resident fell out of bed, [family member] stated that this was traumatic for the resident. Review of the Physician orders for R150 reviewed a new order dated 2/6/25, after readmission, for oral solution Morphine 0.25 milliliters every four hours for pain. In an interview on 2/20/25 at 1:21 PM, RN G stated that R150 had increased pain after the readmission to the facility, especially with activities of daily living and with repositioning. In an interview on 2/20/25 at 2:16 PM, DON B stated she was contacted the morning of R150's fall. Staff reported R150 was found on the floor after calling out for help and presented with pain and obvious deformity on bilateral lower extremities. DON B interviewed staff and concluded that the plan of care was not followed when the CNA did not ensure that R150's bed was low before exiting the room. DON B confirmed that the CNA received a disciplinary action and education.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review facility failed to: 1) accurately assess, monitor and prevent the development and worsening of pressure ulcers consistent with professional standards of practice to prevent avoidable pressure ulcers; and 2) implement care-planned and non-care-planned interventions for two Residents (R29 and R94) of four reviewed for pressure ulcers, resulting in worsening of pressure wounds requiring re-hospitalization related to wound infection that required use of intravenous antibiotic treatment and multiple debridement's for R94 and development of two facility acquired unstageable deep tissue pressure ulcers, and the increased likelihood for delayed wound healing and/or worsening of wounds and overall deterioration in health status. Findings include: Resident #29(R29) Review of the Face Sheet and Minimum Data Set (MDS) dated [DATE], reflected R29 was a [AGE] year old female admitted to the facility on [DATE], with diagnoses that included alzheimers disease, diabetes, chronic kidney failure, and anxiety. The MDS reflected R29 had a BIM (assessment tool) score of 10 which indicated her ability to make daily decisions was moderately impaired, and he required one person physical assist with locomotion on unit, dressing and toileting. During an observation and interview on 5/08/23 09:37 AM R29 was sitting on side of bed, appeared well groomed an able to answer questions without difficulty. Review of EMR, dated 9/22/22 to current 5/15/23, reflected R29 had a stage 3 coccyx pressure ulcer present on admission. Review of the Skin and Wound Evaluation, dated 5/11/23 reflected area with base of wound observed with no slough noted over base and no evidence of depth measurements. Resident #94(R94) Review of the Face Sheet and Minimum Data Set (MDS) dated [DATE], reflected R94 was a [AGE] year-old male admitted on [DATE] with hospital re-admission related to wound infection 2/2/23 to 2/13/23, hospital re-admission 3/21/23 with diagnosis that included wound infection and re-admission 4/18/23, with diagnoses that included hypertension (high blood pressure), diabetic (high blood sugar), anemia, malnutrition, obstructive uropathy, stage 4 pressure ulcers, and anxiety. The MDS reflected R94 had a BIM (assessment tool) score of 11 that indicated his ability to make daily decisions was minimally impaired, and he required two-person physical assist with bed mobility, transfers, toileting, dressing, hygiene and bathing and one-person physical assist with locomotion on unit. During an observation on 5/08/23 at 10:45 AM, R94 was laying on back in air mattress with eyes closed. R94 appears very thin and pale. Review of the discharge MDS, dated [DATE], reflected R94 had two stage 2 pressure ulcers(partial thickness loss of dermis) on admission [DATE]. Review of the admission MDS, dated [DATE], reflected R94 had two unstageable pressure ulcers, slough and or eschar(non-viable tissue), and two suspected deep tissue injuries on re-admission 1/2/23. Review of the 5-day re-admission MDS from acute care setting, dated 2/19/23, reflected R94 had two stage 4 pressure ulcers(full thickness tissue loss with exposed bone, tendon or muscle) present on admission 2/13/23. Continued review of MDS reflected R94 two suspected deep tissue injuries not present on admission 2/13/23. Review of the Nurse Practitioner Progress Note, dated 1/18/23, reflected R 94 had 0/10 pain scale. Review of the Nursing Progress Note, dated 1/19/23 at 12:06 p.m., reflected, Wound rounds completed with [named facility wound physician]. Left thigh sharps debrided. Treatment order updated with changes as recommended. Plan to reassess next week.(Facility wound Physician consult note scanned into EMR 3/7/23). Review of R94's Nurse Practitioner Progress Note, dated 1/25/23, reflected, CHIEF COMPLAINT pain management and blood glucose . HISTORY OF PRESENT ILLNESSES General: Patient is a [AGE] year-old Male with medical history of fall at home with rhabdomyolysis, right sided abdominal mass, HTN and DM. Patient readmitted after hospital stay for respiratory failure and aspiration pneumonia and fecal impaction. Patient is noted with increased pain with movement and was taking Norco in the past and requested to have medication restarted and scheduled twice a day . Noted with DTI to bilateral heels as well, no open areas but heels are boggy. Will start skin prep and off load heels . Pressure-induced deep tissue damage of unspecified heel: Noted on bilateral heels, skin prep and off load heels . Review of the Nursing Progress Notes, dated 1/30/23 at 1:31 p.m., reflected, wound dressing saturated, large amount of drainage, eschar tissue sloughing off, strong odor. No mention facility wound Physician notified of change in R94's wound. Review of the Nurse Practitioner Progress Note, dated 1/31/23, reflected, CHIEF COMPLAINT pain management . noted with continued pain with movement and dressing changes . Will add MS at low dose for dressing changes and extensive care, otherwise norco is reducing pain . Review of the Physician Progress Notes, dated 2/1/23, reflected R94's pain level was 5 out 10 on pain scale. Review of R94's Nurse Practitioner Progress Notes, dated 2/2/23, reflected CHIEF COMPLAINT: Change in wounds .Patient was noted with foul smelling wounds with increased purulent drainage and wound physician was in house and did debride thigh wound. Based on clinical presentation of wounds and collaboration with wound physician, decision was made to send patient to the hospital for evaluation and treatment of thigh and buttock wounds and need for extensive I&D .Pain Level: 6 .Pressure ulcer of sacral region, unspecified stage: Noted with increased purulent drainage from both sacral and thigh wounds, foul odor and deterioration, sent to ED for evaluation and debridement . Review of the EMR, dated 1/19/23 through 3/2/23, reflected no evidence R94's wounds were evaluated by facility wound physician during weekly rounds on 2/26/23 or wound physician was notified of worsening pressure wounds and development of two preventable facility acquired deep tissue injuries. The EMR reflected no visit notes for facility wound physician dated 2/26/23 by time of survey exit on 5/15/23. Review of R94's Nursing Progress Note, dated 2/13/23 at 11:11 p.m., reflected, Resident admitted from [named] hospital with a sacral and two L hip wounds. A&Ox3, Full code, takes meds whole, house diet, Foley in place(placed on 2/2/23), non-ambulatory,incontinent of bowel . c/o pain of both heels, L hip, and coccyx, PRN medication given, repositioned for some relief of coccyx pain . Review of R94's Nurse Practitioner Progress Notes, dated 2/14/23, reflected, CHIEF COMPLAINT: readmission from hospital . Patient readmitted after hospital stay for necrotizing fasciitis and abscess in left thigh and underwent multiple surgical debridements. Patient had coccyx wound debrideded as well and only has wound vac on thigh wound. Will continue with wound team to monitor and finished antibiotics with one dose after admission. Patient states that oxycodone is effective in treating his pain and will continue at this time .Pain Level: 6 .NECROTIZING FASCIITIS: Continues on antibiotics for one day to complete course, will continue with wound team follow and pain medication . Review of R94's Skin/Wound Progress Note, dated 2/16/23 at 1:48 p.m., reflected, Wound rounds completed with [named facility wound physician] Left thigh wound with wound vac, sacrum is Dakin's packing with gentle foam dressing. Resident also has DTI to bilat heels. Heel boots in place. Plan to reassess next week. Review of the MDS Progress Note, dated 2/16/23 at 5:45 p.m., reflected R94 had reported 6 out of 10 pain over past five days. Review of the Nurse Practitioner Progress Note, dated 2/24/23, reflected, Encouraged to ask for pain medications and did not want to schedule any pain medications at this time. Has PRN roxanol if needed prior to treatments . Review of R94's Progress Note, dated 3/8/23 at 11:07 a.m., reflected, Reviewed Clinical Indicator: Resident receiving antifungal treatment r/t UTI with fungal infection, no adverse effects noted. Resident noted with pressure wound to left thigh with previous necrotizing fasciitis with wound vac in place, wound is improving. Resident with sacral stage4pressure ulcer with slough noted, current progress is stalled, is followed by wound physician, will review potential for woundvac following completion of Santyl treatment for slough. Resident receives multiple supplements to assist in wound management. Resident with right heel DTI,and left heel unstageable wounds. Treatments in place and continues to be followed by wound physician . Review of R94's Nursing Progress Note, dated 3/14/23 at 7:12 a.m., reflected, Guest sacral wound dressing was off patient when CNA change him. Needed to flush the wound with saline to remove fecal matter. Reapplied dressing and noted change of condition. Notified the physician to assess wound. Review of the Physician Progress Notes, dated 3/15/23, reflected R94 had 7 out of 10 pain. Review of R94's facility Wound Physician Consult Note, dated 3/16/23, reflected, A [AGE] year-old male seen and examined at [named] Skilled Nursing Facility with wound care team, wound care nurse, and nurse manager. 1. I was asked to evaluate a sacral area stage 4 pressure area ulceration at 8.9 x 9.4. Black eschar noted. Present on admission. No signs of infection. Periwound area is normal in color and temperature. Antibiotics were started on the patient via primary team undermining noted at 1 o' clock and 4 o' clock. Sloughy tissue noted. Black eschar tissue noted at the wound bed. 2. Left heel deep tissue injury at 3.7 x 3.9. [facility acquired] 3. Right heel deep tissue pressure injury at 3.8 x 4.0. 100% black eschar noted. [facility acquired] 4. Left thigh stage 4 pressure area ulceration at 9.1 x 5.6 with some granulation tissue noted at the wound bed. Treatment currently includes the application of negative pressure wound VAC system. Negative 125 mmHg, negative pressure. Change three times a week and as necessary . Review of R94's Nurse Practitioner Progress Note, dated 3/17/23, reflected, .patient was started on antibiotics for wound infection. Wound on coccyx with purulent drainage and change in odor . No mention facility wound physician was notified of worsening wound changes. Review of the Infection Progress Note, dated 3/17/23 at 2:34 p.m., reflected, Guest continues on Amoxicillin-Pot Clavulanate Tablet 875-125 MG 1tablet PO Q12 hours for Wound infection for 10 Days. Guest continues to have low BP and little output. Peripheral line placed in L hand and IV fluids started. Review of R94's Nurse Practitioner Progress Note, dated 3/21/23, reflected, CHIEF COMPLAINT Change in condition . Patient was noted to have increased fatigue and decreased appetite/fluid intake. Patient agreed to another bag of IV fluids and D5 ordered. Will obtain labs and continues on antibiotics for wound infection. Patient appears weaker and initially declined going to the hospital and declined to discuss code status with SW/nursing. Contacted by DON later in the day and decision was made to send to Ed for further evaluation and likely will need IV antibiotics . Review of R94's Progress Note, dated 4/18/23 at 4:33 p.m., reflected, Resident arrived from [named] hospital on hospice, [named} hospice nurse in and assessed resident. Notified hospice nurse of red drainage noted in foley. Notified unit manager of dressings to BLE and wound nurse to assess tomorrow . Review of R94's Progress Note, dated 4/27/23 at 11:03 a.m., reflected, Resident readmitted from hospital on hospice services with multiple skin integrity concerns. Resident with bilateral heel unstageable pressure ulcers, coccyx is stage 4 with wound vac in place. Left thigh with stage 4 ulcer wound vac present on admission, vac discontinued during wound rounds on 04/20/23. Resident with venous ulcer to right calf with tx in place. Continue with wound physician evaluation for comfort and wound management . Review of R94's Skin/Wound Progress Note, 4/27/23 3:38 p.m., reflected, Wound rounds completed with Dr [named facility wound physician] Wound vac to sacrum dc'd. New orders in place. Plan to reassess next week. (Same day Progress Note reflected wound vac had been discontinued on 4/20/23.) Review of the Treatment Administration Record, dated 4/1/23 through 4/30/23, reflected R94's wound vac was discontinued 4/27/23. Review of R94's Skin/Wound Progress Note, dated 5/4/23 at 11:03 a.m., reflected, Late Entry:Note Text: Wound rounds completed with [named facility wound physician]. Left thigh and bilat heels are improving. Right trochanter deteriorating, sacrum stable .No change to treatment orders. Plan to reassess next week. On 12/26/2022, the resident weighed 156 lbs. On 04/30/2023, the resident weighed 138 pounds which is a -11.54 % Loss. Review of Hospice Start of Care Documentation, dated 4/18/23, reflected R94's weight was 135 pounds. Continued review of the documents reflected, .Reason for hospice referral/admission: Patient sent to emergency room with recurring infection leading to sepsis. Patient has multiple [NAME] [wounds] on bilateral lower extremities sacral region and his left hip. Increasing confusion and worsening vital signs. Patient has recurring aspiration leading to change in diet. Is bed bound continuous losing weight . During an interview on 5/10/23 at 8:22 AM, Licensed Practical Nurse (LPN) AA reported was R94 nurse, and reported wound rounds were on Thursdays and floor nurse completes daily dressings on other days. LPN AA reported R94 had orders for heels and hip treatments that day. During an observation on 5/10/23 at 9:40 AM, LPN AA and Assistant Director of Nursing/wound care nurse(WN) X entered R94 after gathering wound care supplies. WN X reported had been facility wound nurse for six months and worked at the facility for about 1 year. Observed bilateral heel dressings with black intact eschar, cleaned with normal saline and covered with iodine soaked gauze, covered with heel foam and secured with gauze wrap. LPN AA also changed dressing to Right trochanter that was dated 5/9/23 and cleaned with normal saline, applied medihoney and alginate and covered with foam border dressing. Reported plan to complete three other wounds the next day. During an interview on 5/10/23 at 10:00 AM, WN X reported R94's wound vac for sacral and left hip stage 4 pressure ulcers was no longer in place after most recent hospital stay. WN X reported bilateral heels and right trochanter were facility acquired pressure ulcers and reported R94 was admitted with sacral and left hip and right calf wounds. WN X reported R94 had fallen at home and laid in same position for long period of time. WN X reported after admission R94's left hip wound rapid declined and was admitted to the hospital and diagnosed with necrotizing fasciitis after 2/13/23 hospital admission. WN X reported wound measurements taken on every Thursday at wound rounds with use of camera that determines measurements. During an observation and interview on 5/11/23 at 10:22 AM, WN X and Unit Manager (UM) T entered R94s room after WN X gathered supplies reported today was wound rounds and facility wound physician M was no able to be present this week. R94 appeared alert and oriented and answer questions without issues and was positioned in bed on back on air mattress. Dressings were completed by WC X as follows: -right heel-dressing was removed that was dated 5/10/23, saline was used to loosen betadine soaked gauze, 100% black eschar observed, picture taken, applied betadine gauze, foam heel, secured with kerlex wrap. -right calf-old dressing removed, 100% eschar about nectarine size with loose slough edges, picture taken, cleaned with normal saline, applied xeroform, ABD and secured with gauze wrap. -left heel-old dressing removed dated 5/10/23, 100% eschar about nectarine size with loose slough edges, picture taken, betadine soaked gauze/foam/kling. -Observed undated dressing on posterior left calf that was not removed or spoke about. R94 rolled to right side with assist of WN X and UM T and WN X reported R94 had recent bowel movement and staff had reported had removed dressing because it was soiled. -sacral wound was observed opened, directly against soiled brief that was large(about softball size) dark pink tissue with about 10% slough between 9 o'clock and 12 o'clock with exposed bone. WN X reported R94 had another bowel movement and WN X change brief. WN X took a picture of the wound. (no manual measurements observed.) WN X applied silver alginate to R94s sacral wound with no cleaning of wound observed after direct contact with soiled brief with alginate placed about one inch over periwound between 12 o'clock and 6 o'clock and covered with border dressing. -left thigh dressing, dated 5/9/23 removed, 2 border dressings with xerofoam removed. (2 open areas), picture taken, normal saline single use sprayed on wound and dripped into brief, xerofoam, covered with border dressing. -right trochanter-dressing removed dated, dated 5/10/23, picture taken, Normal Saline single use(dripped down to observed open area on right buttock and clean brief, gloved finger applied medihoney to cut alginate placed on wound, and cover border dressing. -added dressing to left buttock, border dressing. R94 was rolled to his back, air mattress with rotation observed with no pillows noted in room for positioning except one with no pillowcase. WN X and UM T started pull up R94's covers and R94, stated, you're not done yet, (followed by long pause) with R94 turned and looked at offloading boots that WN X had placed in chair prior to dressing change), heels happed once, I'll be damned if it will happen again. WN X and UM T uncovered R94, applied boots to bilateral heels, covered, and R94 reported a little pain on backside. During an observation and interview on 5/11/23 at 11:36 am, WN X reported process for wound documentation that included after rounds sit and document same day off phone pictures and paper notes. WN X verified no written notes taken during R94 wound care. WN X reported usually only herself and facility wound physician for rounds unless CNA staff needed for positioning. WN X reported prints off wound notes and provides facility wound physician copy at the following week (Thursday) wound rounds. WN X reported the wound physician then dictates those prior week notes, sends out of the country for dictation and she can obtain notes between 2-3 weeks post actual wound care monitoring. WN X reported measure weekly with picture including height, width and depth. WN X reported depth was observed by eye because she was able to see changes and verified did not obtain manual depth of wounds including R94 sacral wound and reported could start to add to notes. WN X reported did not see that R94 had a dressing on the left posterior calf area and had no knowledge of open area to the left lower leg and WN X asked this surveyor if there was a dressing in place. WN X entered R94's again, observed undated border dressing on R94s posterior left calf. WN X removed border dressing with alginate over appear that appeared very dry but intact at that time. WN X reported unsure why treatment in place with no order and reported may have been in place for protection. Review of the weekly wound notes, dated 12/26/23 through current (5/11/23), reflected R94 had no evidence of depth measurements including wounds with without eschar or significant slough. Continued review of weekly wound round physician notes reflected the same for the visit notes prior to 3/16/23. Review of the EMR reflected no evidence of facility wound physician notes after 3/16/23. Review of R94's skin Care Plan, dated 1/11/23, reflected, [named R94] has actual skin impairment and is at risk for further impaired skin integrity/pressure injury: pressure injuries to - sacrum, left thigh, bilateral heels r/t Hx Necrotizing fasciitis to thigh ulcer, hx of debridement to sacral and thigh ulcers injuries .Goals .Will remain free from complications from pressure, dated 1/11/23 .Interventions . Assist with repositioning every 2 hours and prn Date Initiated: 01/11/2023 . Conduct weekly head to toe skin assessments, document and report abnormal findings to the physician. Date Initiated: 12/22/2022 .Heelz up device to float heels while in bed and assist as needed Date Initiated: 01/11/2023 . Encourage to float heels while in bed and assist as needed, Date Initiated: 01/11/2023 Heel boots to float heels Date Initiated: 01/11/2023 Revision on: 04/27/2023(Heel boots to float heels verbiage added 4/27/23) During an interview on 5/11/23 at 1150 PM, Director of Nursing (DON) B reported would expect physician documentation to be in resident charts(EMR) within seven days. DON B reported would expect wounds to be measured weekly including length, width and depth measurements and reported depth must be taken manually because the camera does not obtain depth. DON B reported nursing staff are not expected to eye ball wound depth. DON B reported not aware physician was provided copy of nurse wound notes seven days after actual observation to dictate then sent out and reported was aware of long delay but not aware physician going by nurse notes. DON B reported infection control duties performed by herself and ADON/WN X. DON B reported WN X completed facility floor surveillance and DON B oversee WN X and is often present to assist with weekly rounds and would expect WC X to use good infection control practices with wound care.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to intake MI00132479. Based on interview and record review, the facility failed to promptly notify the physician in a change of condition in one of three residents reviewed for medication orders (Resident #3), resulting in delayed transfer to the hospital and re-hospitalization due to sepsis. Findings include: Resident #3 (R3) R3's Minimum Data Set (MDS) dated [DATE], revealed she admitted to the facility on [DATE], had a Brief Interview for Mental Status (BIMS, a brief performance-based cognitive screener for nursing home residents) score of 12 (08-12 Moderate Impairment). R3's Hospital Discharge summary dated [DATE] revealed she was alert and orientated to person, place and time; and had the diagnoses of Giant Cell Arteritis (inflammation of blood vessels), vision loss in the right eye, history of stroke, essential hypertension (high blood pressure that was not the result of a medical condition) and type II diabetes mellitus. R3 had presented to the emergency room on 9/17/22 due to a loss of vision in her right eye and scalp tenderness. R3 was discharged from the hospital to the nursing home on 9/28/22 with the plan to return to her home following rehabilitation. In review of R3's September and October 2022 Medication Administration Record (MAR), Norvasc 5 milligrams (mg), Cozaar 100 mg and Metoprolol Tartrate 100 mg daily were prescribed to treat high blood pressure. Weights and Vital Signs (VS) Summary report indicated on 10/02/22 R3's Blood Pressure (BP) at 7:45 AM was 130/67 millimeters of mercury (mm Hg), R3's October 2022 MAR indicated Clonidine 0.1 mg was ordered on 10/02/22 for one dose only due to high blood pressure. In review of R3's care plans, there was no care plans regarding high blood pressure. Post Discharge Plan and Summary dated 10/13/22 revealed R3 was alert and orientated to person, place, and time; her short term and long-term memory were okay, she had met her maximum potential, was independent with ambulation and toileting, was continent of bowel and bladder. In review of R3's Physical Therapy Discharge Summary, R3 was discharged from therapy on 10/15/22 and planned to discharge home from the nursing on 10/16/22; the same document revealed a change of condition was noted two to three days prior to the 10/15/22 visit. Upon arrival for therapy on 10/15/22, R3 was observed in bed with a cold pack on her stomach reported her stomach was hurting. R3 was very lethargic, slow to respond, and demonstrated increased effort to sit up. R3 attempted to don her pants but had to stop due to fatigue and low energy. R3 was not able to eat breakfast or her lunch on 10/15/22. The same note revealed R3 wanted to discharge home the next day, on 10/16/22. Therapist indicated was concerned regarding safety due to change in status. The same evaluation indicated R3's change of condition status, discharge safety and not eating were reported to the nurse. In review of R3's progress notes, there was no indication the physician was notified of R3's change of condition on 10/15/22. Weights and VS Summary report indicated on 10/15/22 R3's BP at 8:40 PM was 163/83 mm Hg and was 178/114 at 9:59 PM. The last blood pressure in R3's medical record was recorded on 10/15/22 at 9:59 PM. In review of R3's progress notes, there was no indication the physician was notified of R3's blood pressures on 10/15/22. The American Heart Association website at http:// www.heart.org/en/health-topics/high-blood-pressure/understanding-blood-pressure-readings, indicated blood pressure numbers of less than 120/80 mm Hg were considered within the normal range and if blood pressure readings exceed 180/120 mm Hg and if any symptoms such as headache, chest pain, nausea/vomiting or dizziness, to call 911 immediately. The same website also instructed contact a health care professional immediately if readings were unusually high and were not experiencing any other symptoms of target organ damage such as chest pain, shortness of breath, back pain, numbness/weakness, change in vision or difficulty speaking, as it could still be a hypertensive crisis. Nurses Note on 10/15/22 at 4:30 PM indicated Zofran for nausea and vomiting had been administered; there was no mention of R3's change of condition reported by therapy or if a head-to-toe nursing assessment was completed. Nurses Note dated 10/16/22 at 3:42 AM indicated the nurse had spoken with on call about R3's change in condition and was encouraged to push fluids and give Zofran as needed and if condition worsens let them know. R3 said stomach pain had subsided and had gotten resident to drink fluids as writer goes in her room. The same noted indicated the nurse had advised the nurse assistant to do the same every time they come in contact with her. The same note did not include how much fluids were accepted or if blood pressures from the night before had been reported to the physician on call. There was no mention of any head-to-toe nursing assessment or if vital signs were obtained. There were no VS documented in R3's medical record since 10/15/22. Licensed Practical Nurse (LPN) P was interviewed on 1/18/23 at 1:00 PM and did not remember what was reported to the physician on 10/16/22. Nurse Practioner (NP) N was interviewed on 1/18/23 at 12:20 PM and stated 10/15/22 was on the weekend and the nurse would have contacted the physician on call. NP N was not able to confirm if R3's abnormal blood pressures from 10/15/22 were reported to the on physician, and that text to the physician only was saved for 30 days. NP N stated if she was notified regardingt R3's blood pressures on 10/15/22 (163/83 and 178/114), she would have ordered clonidine for sure. Nurses Notes dated 10/16/22 at 12:23 PM indicated Director of Nursing (DON) B Spoke with the nurse practioner in regard to R3's declining condition, new orders were received for IV start and 1 Liter bolus of normal saline (NS). Certified Nursing Assistant (CNA) O was interviewed on 1/18/23 at 12:55 PM and stated she worked on 10/16/22 and recalled R3 had been there a few weeks kept declining. CNA O stated she noted a decline in R3's physical and mental capacity. In the morning at the start of her shift, she noted R3 was incontinent of bowel and bladder, was not able to walk, and complained of a lot of pelvic pain. CNA O stated R3 requested an ice pack for her pain. CNA O stated she reported concerns regarding R3's condition twice and told the nurse she needed to be sent to the hospital. The last time she reported to the nurse R3 needed to transfer to the hospital was around noon, and she was transferred 1-2 hours after that. Nurses Notes dated 10/16/22 at 2:30 PM revealed DON B arrived at facility and was met by R3's emergency contact, whom had concerns. R3's emergency contact was informed that orders had been received to postpone discharge and to start IV fluids. Upon entrance to the room, R3 was lying in bed noted to have mottling (bluish-red lace-like pattern under the skin caused by a disturbance of normal blood flow) to both upper and lower extremities, feet, and chest. No capillary refill (method for detecting changes in blood flow that can lead to shock) was noted on her toes, she was alert and talking. DON B indicated in the same note she was unable to obtain a pulse oximetry reading (arterial oxygen saturation), started oxygen at 4 liters via nasal canula (oxygen delivery device), then increased to 10 liters via non-re-breather mask (typically delivered 70 to 100 percent oxygen). DON B's same note indicated she conversed with R3 in regard to her code status and explained that the mottling was a symptom of her body shutting down, resident was a full code, she indicated she wished to remain a full code. Writer explained to resident, that she would need to be transferred to hospital for evaluation and resident agreed. DON B indicated in the same progress note she had completed transfer paperwork and called 911. Emergency Medical Services (EMS) indicated they were already on their way as family had called. EMS arrived and R3 left the nursing home facility at 2:15 PM. In review of R3's medical record, including the transfer record, there were no vital signs documented on 10/16/22. On 1/18/23 at 11:43 AM DON B was interview and stated she came into the facility on [DATE] to start R3's IV. The IV did not get started, R3 was transferred to the hospital. DON B stated R3's vital signs were obtained prior to transfer, but did not know what they were, and confirmed vital signs were not included in transfer assessment details.