**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** R80 Record review revealed R80 was a long-term resident of the facility, originally admitted on [DATE]. R80 had a recent hospitalization and they were readmitted back to the facility on 3/18/25. R80's admitting diagnoses included pneumonia, congestive heart failure, chronic kidney disease, major depressive disorder, and gout. Based on Minimum Data Set (MDS) assessment dated [DATE], R80 had a Brief Interview for Mental Status (BIMS) score 9/15, indicative of moderate cognitive impairment. R80 had a guardian (daughter) who was making decisions on their behalf. An initial observation was completed on 6/17/25 at approximately 10:20 AM, R80 was observed in their bed with a brief. They had their eyes closed but opened their eyes when called upon but did not answer to any questions. At approximately 11:15 AM, during a follow up observation from the doorway, R80 was observed with a brief only, no other clothes. Certified Nursing Assistant (CNA) T assigned to care for R80 was observed in the hallway and reported that R80 were not feeling well and did not want any clothes on and they were just trying to keep them comfortable. Later that day, at approximately 1:20 PM, R80 was observed in bed with a lunch tray on their bedside table. The tray had a sloppy joe, potatoes, vegetables and dessert. The servings appeared that they were not eaten. The tray had an empty juice glass. R80 stated that they were not hungry. R80 added that their back was bothering them and they needed someone to reposition them in bed. Review of R80's Electronic Medical Record (EMR) revealed an order dated 6/9/25 for blood tests that included CBC (Complete Blood Count), CMP (Comprehensive Metabolic Panel) and urine tests that included UA C&S (Urinalysis - Culture and Sensitivity). R80 also had an order to start Intravenous (IV) Fluids which was changed hypodermoclysis (fluids administered through skin) on 6/9/25. Review of R80's weight record revealed that R80 had weight fluctuations after they were readmitted back to the facility. The Registered Dietician note dated 6/9/25 revealed that R80 had been eating at more than 51% of their meals and they were going to monitor weights weekly. Review of R80's amount eaten record between 5/30/25 and 6/17/25 revealed 20 entries with less than 50% of intake and 9 entries where R80 refused their meals. There were no additional interventions added to address the recent change until the concern was brought to the facility's attention on 6/17/25. Review of R80's Practitioner progress note dated 6/9/25 read in part, Patient seen and examined per nursing for increase in lethargy and some disorientation .He states he is not hungry. The plan section of the note had multiple orders that included check CBC, CMP and UA C&S, nutritional support, start peripheral IV 0.9 NS (normal saline) etc. Review of R80's lab results dated 6/12/24 revealed multiple abnormal lab values including low hemoglobin, high creatinine, low protein, low sodium, low potassium etc. The results for the urinalysis (including culture and sensitivity) to rule out any infection were not in R80's EMR. Further review of R80's records did not reveal any evidence that the physician or the practitioner were notified of abnormal labs. There was no evidence of urine test results (ordered on 6/9/25) including culture and sensitivity to rule out any potential infection. There was no evidence of follow up by the physician or practitioner. There were no nursing progress notes between 6/1/25 to 6/17/25 with pertinent assessments/follow-ups on recent changes with R80's condition. There was one skin observation note and one care conference between 6/1/25 and 6/17/25. Review of the physician communication book/log revealed one entry for R80 dated 6/8/25 that read in part can we get labs, more lethargic declining . There were no further entries on the log that showed that the abnormal lab results were communicated with the physician/practitioner. An interview with CNA T was completed on 6/17/25 at approximately 11:40 AM. CNA T reported that were familiar with the resident and confirmed that they were assigned to care for R80 during that shift. They added that they typically worked on another unit. They were queried if R80 had their breakfast and how they were doing. CNA T reported that R80 had not been feeling well and they did not want to get dressed. They had put a gown on earlier and R80 had ripped it off. They added that R80 did not eat well and depended on the day and food. They added that R80 had not been feeling well and they were keeping them comfortable. An interview with Licensed Practical Nurse (LPN) C who was assigned to care for R80. They were questioned on how R80 was doing. LPN C reported that R80 refused to eat at times and they gave pain medication some time ago. LPN C also added that R80 function varied depending on the day. An interview with Unit Manager (UM) U was completed on 6/17/25 at approximately 2:35 PM. They were questioned about the R80 recent change in condition and how often physician/practitioners were following up. UM U reported that the practitioner comes into the facility three times/week to see the residents. They added that R80 was seen on 6/9/25 and they ordered labs and fluids that were administered. They were queried about the lab results. They reviewed the EMR and shared the blood test results and checked for urine test results on the lab portal. After reviewing the lab portal UM U reported that they were not able locate the urine test results. They added they believed that sample was picked up, but were not sure what happened. They confirmed that that there was no evidence on EMR and lab portal on what happened with the urine test. They added that they would check with the Director of Nursing (DON) and report back. A follow-up interview with the Unit Manager UM U was completed on 6/18/25 at approximately 8:05 AM. They were questioned if they had any additional information about the urine test results. UM U reported that they spoke with the DON and was notified that the facility had done a dip stick test (a urine dipstick test is a method to analyze urine for various substances and conditions, using a plastic strip with chemical pads that change color to indicate the presence or concentration of specific substances - Source: Mayo Clinic) and the test was negative. They were queried further about the evidence of negative dip stick test results, communication with the practitioner on the urine and abnormal blood test results. They reported that they were having problems with their lab services and they had recently taken over the responsibility for the lab follow up, approximately two weeks ago. They were not in the facility on 6/13/25 and not sure what happened. They added that they were trying to streamline the process and did not provide any further explanation. They were notified of the concern regarding timely/ongoing follow-up with change in condition and notification of physician/practitioner. UM U agreed on the concern and reported that they would be following up with their staff. An interview with R80's guardian was completed on 6/18/25 at approximately 11:45 AM. They added that they lived 45 minutes away from the facility. They added that R80 had been more withdrawn lately, in the last week. The guardian also reported that a staff member from the facility had called earlier today and notified them of the lab results from last week (after the concern was brought to the attention of the facility). An interview with the DON was completed on 6/18/25 at approximately 10:15 AM. The DON was shared on the observations and queried about urine test results that were not completed,the recent change in condition for R80, and the physician/practitioner notification on abnormal labs and their follow up. They reported that all their nursing staff did not have a log in and nursing leadership including the DON, ADON (Assistant Director of Nursing), and their Unit Managers had access. They added that unit managers had printed the labs and left in them in the physician book for review and follow up. They added they completed the urine dip stick test. They did not know if anyone had notified the practitioner of the lab results. The dip stick test results were added to the physician book. The DON did not provide any further explanation. They were notified of the concerns and they agreed and reported that they had already started educating their staff. On 6/18/25 at approximately 12:40 PM, the facility administrator was notified of the concerns with R80's overall change in condition, interdisciplinary team follow-up, physician/practitioner notification and follow up after tests were ordered. The Administrator reported the concerns were shared by the DON and they understood the concerns. A facility provided document titled Notification of Changes Guideline with a revision date of 7/24/19 read in part, Purpose: It is the practice of this facility that changes in a resident's condition or treatment are immediately shared with the resident and/or the resident representative, according to their authority, and reported to the attending physician or delegate (hereafter designated as the physician). The resident and/or their representative will be educated about treatment options and supported to make an informed choice about care preferences when there are multiple care options available. All pertinent information will be made available to the provider by the facility staff. Nurses and other care staff are educated to identify changes in a resident's status and define changes that require notification of the resident and/or their representative, and the resident's physician, to ensure best outcomes of care for the resident. The facility will update physician contact information and resident representative(s) mail, email and phone number periodically for compliance with 483.15 (c) (2). Responsible Party: Clinical Guideline CENTERS FOR MEDICAID AND MEDICARE SERVICES (CMS) - DEFINITIONS Non-Physician Practitioner (NPP): include Nurse Practitioner, Physician Assistant and Certified Nurse Specialist NP - Nurse Practitioner PA - Physician Assistant CNS -Certified Nurse Specialist Significant Change in status - deterioration in health, mental or psychosocial status in life threatening conditions or clinical complications Significant alteration in treatment - A need to alter treatment significantly. A significant treatment alteration includes the need to discontinue an existing form of treatment due to adverse consequences, or to commence a new form of treatment. OBJECTIVE OF THE NOTIFICATION OF CHANGE GUIDELINE The objective of the notification guideline is to ensure that the facility staff makes appropriate notification to the physician and delegated Non-Physician Practitioner and immediate notification to the resident and/or the resident representative when there is a change in the resident's condition, or an accident that may require physician intervention. The intent of the guidelines is to provide appropriate and timely information about changes relevant to a resident's condition or change in room or roommate to the parties who will make decisions about care, treatment and preferences to address the changes. OVERVIEW OF COMPONENTS OF THE GUIDELINE 1. Requirements for notification of resident, the resident representative and their physician: 1) An accident involving the resident, which results in injury and has the potential for requiring physician intervention. 2) A significant change in the resident's physical, mental, or psychosocial status. (i) A significant change includes deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications. 3) A need to alter treatment significantly. (i) A significant treatment alteration includes the need to discontinue an existing form of treatment due to adverse consequences, or to commence a new form of treatment. 2. Requirements for notification of resident and/or resident representative(s), consistent with their authority. (i) A change in room or roommate assignment (483.10 (e) (6). (ii) A change in resident rights under Federal or State law or regulations (483.10 (e) (10). (ii) A change in room or roommate assignment (483.10 (e) (6). (ii) A change in resident rights under Federal or State law or regulations (483.10 (e) (10). (iii) A decision to transfer or discharge the resident from the facility as specified in 483.15 (c) (1) (ii) . Based on observation, interview and record review, the facility failed to notify a physician and monitor and assess a change in condition for two residents (R80, R86) of two residents reviewed for a change in condition. Findings include: R86 A review of the record revealed that on 4/13/25 a progress note was written at 5:07 PM, stated in summary At approx. (approximately) 1320(1:20PM) resident propelled self to go outside to smoke and told staff with resident that she was having a hard time breathing but continued to smoke about half a cigarette, resident then came inside and was taken by activity staff to room. Resident noted to have discoloration and difficulty breathing upon arrival in room at 1330(1:30PM) . At approx. 1334(1:34PM) , resident was assessed by nurses on staff, and was noted to have no pulse and was no longer breathing. Resident NP(nurse practitioner) .notified at approx. 1340(1:40PM). Resident TOD(time of death) was at 1336(1:36PM). EMS (emergency medical services) and .sheriff arrived on scene and retrieved statements from staff and verified resident DNR(do not resuscitate). Resident guardian called and message left for guardian to call back at approx. 1340(1:40PM). Resident guardian called at approx. 1412(2:12PM) again with no answer and message left for guardian to call facility. Resident guardian called again, and message left at approx. 1545(3:45PM) . A review of the record revealed that on 4/12/25 at 3:36 PM, there was a documented oxygen saturation (O2 stat) of 82% (normal is 90-100%). A further review of the record indicated that the medical doctor was not contacted, nor was any interventions put in place or carried out regarding the low reading. R86's Brief Interview for Mental Status Score(BIMs) was an 11 (completed on 4/1/25), which indicated mild cognitive impairment. On 6/17/25 at 10:25 AM, an interview with the Assistant Director of Nursing (ADON) was conducted. The ADON was asked what the facility's policy for a change in condition was, what is considered a change in condition and would they treat a person with the code status of DNR the same a full code. The ADON reported that a change in condition was considered something different from an individual's baseline. The DON explained that the facility staff would assess, take vitals and call the physician, execute orders if any were given and if its life threatening and needs immediate intervention, call 911 to send them out. The ADON reported that, the same assessment would be completed for a person with a DNR code status. On 6/17/25 at 10:45 AM, an interview with Nurse AA was conducted. Nurse AA was asked, who was responsible for taking vital signs for residents and what was the process for a resident who experienced a change of condition. Nurse AA reported that the Certified Nurse Assistant (CNA) was responsible for taking vital signs and supposed to report anything abnormal. For a change in condition, Nurse AA stated they would take vitals, assess the resident, call the physician and family, get orders if any are given, and if it's needed send the resident to the hospital. Nurse AA was asked about R86's decrease in O2 saturation, and if they where aware of the change in condition. Nurse AA reported they did not and that R86 presented how they usually did, short of breath and wanted to smoke. Nurse AA did not recall if someone told them about the decrease in O2 saturation. On 6/17/25 at 11:00AM, CNA Z was called via phone and interviewed. CNA Z was asked what the protocol was when they obtained vital signs that were not within normal limits. CNA Z reported that, normally when a vital sign was out of range, they would report it to the nurse before charting it into the system, because the nurse would recheck them. CNA Z was then asked about the O2 recorded for R86 on 4/12/25 of 82%, CNA Z reported that they told the nurse because it looked wrong, but could not remember the nurse they reported it to. On 6/17/25 at 12:46PM, Activities Aide BB was interviewed and asked how was R86 presenting when they went for the 1 PM smoke break. Activities Aide BB reported that, R86 was coughing a whole lot and could not stop. The Activities Aide BB reported that they told R86 that they should not smoke, but R86 insisted and did. On the way back in, R86 needed help to get back to their room, so the smoke supplies were locked back up and then Activities Aide BB reported they rolled them back to their room, bent down to put their oxygen on, and R86 was blue. Activities Aide BB reported they ran to get the CNA on the unit and then the CNA got the nurse. On 6/17/25 at 11:35 AM, the Director of Nursing (DON) was interviewed and asked what would be expected for staff if a resident had and oxygen saturation of 82%. The DON reported that the nurses usually would send someone out to the hospital with saturations low. The DON was asked what happened with R86 who had an O2 saturation of 82% the day before they expired. The DON reported, they were sure the staff would have done something, (but did not document it), R86 had COPD (Chronic Obstructive Pulmonary Disease) and they would have not made it to the next day at 82%. The DON was asked to provide the information to show what staff did for the resident with a change in their saturation level. The DON reported they understood the concern and did not have any additional documentation to provide.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to prevent a fall with major injury for one Resident (R47) of two residents reviewed for falls. This resulted in actual harm for R47, who sustained a left ankle fracture, and a subsequent infection. Findings include: On 6/16/25 at 9:34 a.m., R47 was observed seated in their manual upright wheelchair in the dining room. R47 was leaning to the right side, with their weight distributed mainly over their right hip. Neither leg was supported by footrests. On 6/16/25 at 9:36 a.m., R47 stated, I was standing up to get in my wheelchair and I fell. I broke my foot a few months ago. I have healed up good .They put metal in it (surgical fixation to anchor the joint). R47 explained they fell transferring from their bed to their wheelchair, and they had to have surgery to fix their foot. R47 showed this Surveyor one finger, and stated, There was one person (staff assisting them), and I think there should have been two (staff assisting them) . Review of R47's Accident and Incident report, dated 12/05/24, revealed R47 had a witnessed fall in their room on 12/05/24 at 6:54 a.m. The report described an unnamed Certified Nurse Aide (CNA) was assisting R47 with a transfer from their bed to wheelchair when their knees buckled, and the CNA lowered R47 to the floor. After the fall, R47 complained of pain in their left ankle. R47 was assisted by two CNAs (Unnamed) back to their wheelchair. An X-ray was ordered to assess for further injury. R47 reported their pain level was 10/10 with 10 the highest pain level. The report revealed R47 was fully oriented. Review of R47's SBAR (Situation, Background, Assessment, and Recommendation) nursing assessment, dated 12/05/24 at 6:59 a.m., revealed, .(R47) had a fall. The fall was witnessed. CNA (one aide unnamed) was assisting resident with transfer from bed to wheelchair. Resident knees buckled and CNA lowered resident to floor .No injury .(R47) current fall score 5/20/25 showed (R47) remains at high risk for falls Review of R47's Minimum Data Set (MDS) admission assessment, dated 9/26/25 (prior to R47's fall with fracture), revealed they were admitted to the facility with diagnoses including stroke, hemiplegia or hemiparesis (one-sided weakness or paralysis), and dementia. The assessment revealed R47 required moderate assistance with bed mobility and transfers. The Brief Interview for Mental Status (BIMS) assessment revealed a score of 12/15, which showed cognitive impairment. Review of R47's MDS significant change assessment, dated 12/27/25, (after their fall), revealed they required moderate assistance for bed mobility (sit to lying) and maximal assistance for transfers, and a BIMS score of 13/15, which showed they were cognitively intact. Review of R47's post-fall evaluation dated 12/05/25 at 7:03 a.m., showed a score of 6, with a score above 5 indicating a resident was at high risk for falls .The report further revealed: There is new pain, post fall. 10/10 (with 10 the highest pain) in (left) ankle There is not a noted pattern to falls. The resident does not have any injury noted. New interventions for this fall that are being implemented: Have 2 CNA's (Certified Nurse Aides) for transfers to decrease risk for falls . Review of R47's 12/08/24 health status noted showed x-ray results shared with on-call provider, and (R47) to stay on bedrest until NP (nurse practitioner) follows up tomorrow. Continue with ice and PRN (as needed) pain medications . It was unclear why the x-ray was taken three days after R47's fall, when they had pain on 12/05/25 when the fall with injury occurred. Review of R47's 12/10/2024 health status note showed R47 stated that ice continued to manage pain in LLE ankle. PMR (Physical Medicine and Rehabilitation Physician) consulted with resident and referred resident to ortho. Review of R47's 12/17/24 health status note showed R47 had an ortho consult on 12/16/24, where R47 was scheduled for an ORIF (open reduced internal surgical fixation for stabilization) of their left ankle, due to minimally displaced bimalleolar fracture of LLE ankle on 12/20/24. Review of R47's 12/21/24 health status note revealed they returned to the facility after surgical fixation of their left ankle, wearing a large cast to their left leg, with elevation prescribed. On 1/03/25 at 10:51 a.m., R47's health status note revealed, (R47) had surgery f/u (follow up) appointment on 12/30/24. Surgeon (orthopedic) reports x-rays show ok healing. Incisions healing well, retained sutures removed and steri strips applied. Resident c/o (complaints of) no pain and wants to weight bear. Physician recommendations are to allow WBAT (weight bear as tolerated) on LLE (left lower extremity) with walking boot on. Bactrim DS (antibiotic was prescribed) BID (twice daily) for 14 days, wound care for wound infection and PT (Physical Therapy) for AAROM (active assistive range of motion) .Resident is to f/u in 2 weeks . This note showed R47 required surgery and an antibiotic for an infection after their fall. On 2/01/25 at 10:15 a.m., R47's IDT (Interdisciplinary Team Note) revealed, IDT met and discussed resident risks. Clinical- (R47) had redness and swelling on incision site. Culture results came back (positive for infection) and ABt (antibiotic) was changed. (R47) encouraged to elevate and keep treatment on incision .Skin - dehisced (reopening) of incision . On 2/21/25 at 10:49 a.m., R47's nursing progress note showed, .(R47) had f/u with Ortho (physician) this date. Ortho reports that (R47) continues to have purulent (thick and milky drainage from a wound, often from an infection) drainage with positive culture. X-ray shows hardware solidly bridged. Ortho ordered continued oral antibiotics for 14 more days at 4x's a day and ordered resident to have scheduled outpatient removal of hardware ASAP (as soon as possible) . Review of R47's 3/16/35 progress note at 3:41 a.m., revealed, Infection Note: (R47) continues on oral ABT (antibiotic) Bactrim .r/t (related to) infected hardware r/t ortho surgery x 2 weeks, until 3/25/25 . Review of R47's Kardex (care instructions to CNAs), accessed 6/17/25, revealed staff were using a mechanical lift/Hoyer lift when transferring R47. On 6/17/25 at 10:16 a.m., R47 was asked to clarify how they were currently transferring. R47 reported staff were using the sit to stand lift, not a Hoyer lift, and stated some staff were transferring them with one person assistance without the sit to stand lift. R47 reported sometimes they felt safe and sometimes they did not feel safe with one-person pivot transfers, depending upon which staff were transferring them. R47 stated they wished staff would always use the sit to stand lift, as it was easier to pull up their pants, as they struggled to stand. On 6/17/25 at 12:28 p.m., CNA D confirmed they regularly worked with R47. CNA D reported they completed a one-person pivot transfer for R47 to get them in and out of bed, or to use the toilet, but used a sit-to-stand lift when R47 was weak. CNA D stated a couple weeks prior they had used a sit-to-stand mechanical lift, as R47 had a urinary tract infection. CNA D stated before R47's fall they were a one-person transfer, as R47 stood up well at that time, and after the fall they required a full body mechanical lift to transfer. CNA D confirmed R47 had increased pain after their fall in December 2025. CNA D was asked if they had told the nurse when R47 was weak with transfers and stated they had not. On 6/17/25 at 2:37 p.m., CNA E was asked how they transferred R47 to and from their bed. CNA E reported they had worked with R47 the other day and stated R47 wanted to go to bed early and required a two-person assisted stand pivot transfer to transfer them from their wheelchair to bed, as R47 was declining. CNA E reported R47 was a one-person transfer prior to their fall. CNA E was asked if they shared with the nurse, management, or therapy R47 was declining, and stated they had not. On 6/17/25 at 5:25 p.m., a phone call was made to Registered Nurse (RN) V, who the nurse the Nursing Home Administrator (NHA) confirmed had worked with R47 at the time of their fall to set up an interview. No call was returned during the survey. On 6/18/25 at 8:34 a.m., this Surveyor requested a full investigation report via email, which would have included a Root Cause Analysis (RCA) for the fall, and witness statements, and a schedule of who worked with R47 on the date of the incident when they fell. On 6/18/25 at 8:36 a.m., CNA F and CNA G were observed transferring R47 from their bed to their manual wheelchair, with R47 granting permission for Surveyor observation. CNA G was observed to assist R47 in sitting up on the edge of their bed from laying down by pulling R47 up by grasping their upper arm. CNA F and CNA G were next observed to stand pivot transfer R47 to their wheelchair by lifting them and grasping them under and around their arms, without a gait belt, both times placing R47 at risk for injury. On 6/18/25 at 8:44 a.m., this Surveyor asked CNA F and CNA G about sitting R47 up from laying down by pulling on R47's right arm and grasping them by the arms during the transfer. CNA G reported using the gait belt scared them and they believed it was more supportive to hold R47 under their arms and hold the back of their pants. Both reported they didn't have extra gait belts handy in the facility, as only therapy used them to transfer residents, and they were not in the closets and bathrooms. Both reported sometimes they used a standing mechanical lift to transfer R47 with a second person and had told nursing management they needed to be using the standing lift with R47, as this was much easier. On 6/18/25 at 9:39 a.m., the Electronic Data file system was viewed, and it was noted R47's fall investigation report nor any witness statements were not loaded. On 6/18/25 at 9:40 a.m., the NHA was asked about the investigation report. The NHA reported they had some documents, which included the SBAR and fall assessments but no investigation report, which was brought to their attention. The NHA reported they would continue to look for the report. The NHA confirmed CNA H was the staff who transferred R47 when they fell, and CNA J assisted after R47's fall on 12/05/24 when they fractured their left ankle. On 6/18/25 at 9:48 a.m., CNA H was asked what happened during a phone interview when R47 fell on [DATE]. CNA H stated they were getting R47 up for the day and normally they used a sit-to-stand mechanical lift with R47 because they maybe had a stroke. CNA H explained they stood R47 up with the sit-to-stand lift, and R47 started to rush them and was standing up and began moving more than they should have been, when they noticed R47 was about to fall. CNA H reported they tried to put R47 back into bed when their legs buckled out and they were still buckled in the lift. CNA H reported they ran out of the room to get CNA I to assist them and said R47 did not fall but was sliding towards the ground. CNA I was asked if there was another way they could have obtained assistance, as leaving R47 in a mechanical lift may have placed them at risk for further injury. CNA H stated they had to leave R47 to get assistance. CNA H reported R47 blamed them for the incident. CNA H reported CNA I came into the room to assist them, and they pulled R47 up in the lift. CNA H explained they had worked with R47 prior to the fall and had not had problems transferring them. Review of R47's Care Plan, accessed 6/18/25, showed at the time of their fall on 12/05/25 they required physical assistance, however the type and amount of physical assistance was not specified, such as one or two person transfers, and how much assistance. There was no mention in the Care Plan at that time (on 12/05/25) of any mechanical lift being designated to transfer R47, only physical assistance, unspecified. On 6/18/25 at 10:03 a.m., CNA I was asked what they observed when R47 fell on [DATE] during a phone interview. CNA I stated they were coming from the nurse's station and CNA H asked them if they could help them get R47 off the floor. CNA I was asked to describe the scene, and stated R47 was on their knees by their wheelchair with their feet bent, and one foot was underneath the wheelchair. CNA I clarified they were absolutely positive there was no lift in the room or near R47. When asked how R47 transferred at that time, CNA I stated R47 required two-person transfers or the sit-to-stand lift, at that time, and further described they were not wearing a gait belt. CNA I stated R47 reported their foot was hurting, however they did not have an x-ray done for one to two days. When asked if anything different could have occurred, CNA I reported CNA H was a newer aide at the time and said they could have asked for assistance. They did not recall the nurse who was working that day. CNA I reported they recalled filling out a witness statement and turning it into nursing management. On 06/18/25 at 10:14 a.m., CNA H was asked who the nurse was on 12/05/24 when R47 fell and stated, I don't remember. CNA H was asked if they were positive they used a sit-to-stand lift to transfer R47 and said Yes. CNA H was asked if they completed a witness statement and responded Yes. On 6/18/25 at 10:29 a.m., the former Assistant Director of Nursing, ADON W, was called, with no return call by the end of the survey. On 6/18/25 at 10:30 a.m., RN V was called a second time, with no return call by the end of the survey. On 6/18/25 at 10:50 a.m., the NHA was emailed another request for any investigation report and or witness statements related to R47's fall on 12/05/24, with no response. Review of R47's Kardex, access on 6/18/25, revealed their transfer status had been changed from a mechanical/full body lift to two-person transfers. Review of R47's therapy records, received from the facility per request, revealed their PT discharge evaluation on 9/21/24 before their fall showed they transferred with partial/moderate assistance from bed to wheelchair and return. On 6/18/25 at 10:37 a.m., the NHA was asked again about the missing investigation report and witness statements, which two staff shared they completed during interviews. The NHA reported they knew they were completed, and they would find them. When asked who oversaw the investigation, the NHA acknowledged the former ADON, ADON W, completed some of the facility documentation, and Unit Manager, LPN A, had assisted them. The NHA was asked if they had another phone number for RN V, and reported the number they called was the same as the phone number the Surveyor had called. The NHA asked this Surveyor to look in the Electronic File System to see what they had loaded. This Surveyor reviewed with the NHA and noted the SBAR, x-rays, and the Rehab physician consult but shared there was no investigation report. The NHA stated they would keep looking for the investigation report and any witness statements. On 6/18/25 at 11:13 a.m., LPN A was asked if they had R47's fall investigation report and witness statements from 12/05/24, and if they investigated R47's fall with left ankle fracture on 12/05/25. LPN 'A shared the ADON W investigated R47's fall on 12/05/24, and explained they had reviewed the fall as well. LPN A reported R47 initially had no complaints of pain, and staff were not aware they were injured. LPN A said they had not been able to find an investigation report or witness statements related to the incidents, although they had reviewed R47's risk management report. LPN A stated R47 was being transferred by two aides from their bed to wheelchair when they were lowered to the floor but then acknowledged upon further review of the risk management report with this Surveyor the report showed one aide transferred R47, and they were assisted up by two CNA's. LPN A reported the left ankle fracture was found after a couple days, when R47 developed pain. This Surveyor shared staff discrepancies from the description of the incident, including CNA H reporting they used a sit to stand lift. LPN A shared there was no report made to them or discovered during their investigation which showed R47 was on a sit to stand lift when the fall with injury occurred on 12/05/24. LPN A confirmed no x-ray was taken until 12/08/25, three days after R47's fall, as they developed pain afterwards, despite the initial reports showing 10/10 pain at the time of the incident. Review of R47's Risk Management (Accident and Incident report), dated 12/05/25, reviewed with LPN A, showed R47 was being transferred by one aide (CNA), and was assisted afterwards by two CNAs. Review of R47's Care Plan, accessed 6/18/25 with LPN A, showed at the time of their fall on 12/05/24, R47 needed physical assistance but the type and amount were not specified. LPN A reported they understood the concern, which could have led to staff inconsistencies with the level of assistance provided. LPN A confirmed therapy would be the department who made changes in the level of assistance typically, and this would not be in the CNA's scope of practice or job responsibilities, so they understood the concern. LPN A stated, Yes, there should be a number in there . designating one- or two-person assistance with transfers. Review of the Medication Administration Treatment (MAR) and (TAR) for the month of December 2024 with RN A revealed R47 had no complaints of pain on 12/05/24 documented, and 5/10 pain on 12/06/24, and 4-5/10 pain on 12/07/25, showing documentation inconsistencies. On 6/18/25 at 11:25 a.m., LPN A was asked about the observation of R47 being transferred on this date (6/18/25) by staff without a gait belt and being handled by their arms. LPN A confirmed staff should have used a gait belt for R47's transfer this morning, and they understood the concern. LPN A stated a gait belt should have been in R47's closet. LPN A was asked why it took three days for R47 to have an x-ray when staff and documentation showed they had some pain when they were injured. LPN A stated they always had generalized pain. LPN A confirmed R47's hardware became infected when their pain increased on 12/21/24 to 9/10, they received an as needed dose of narcotic pain medication (per the MAR), and were transferred out emergently. On 6/18/25 at 11:52 a.m., R47 agreed to a brief follow-up interview, stating, Go ahead. R47 was asked if staff were using a mechanical lift when they were transferred at the time of their fall with fracture on 12/05/24. R47 stated, No. Just one person (transfer assistance). On 6/18/25 at 11:58 a.m., the Rehabilitation Director, Occupational Therapist (OT), J, was asked about staff transferring R47 today (6/18/24) without use of a gait belt for the transfer in their room from bed to wheelchair. OT J stated per standards of practice a gait belt would be recommended to be used for R47, and any resident who needed more than stand by assistance (physical assistance) to transfer. OT J was asked to review the therapy documentation prior and post R47's fall with injury on 12/05/25. OT J reported they did not know this resident personally, as they were newer to their position but the PT in the building was familiar with R47. OT J confirmed R47 required moderate (partial) transfer assistance prior to their fall, and had been picked up by therapy on 5/29/25, and now required maximal assistance. This Surveyor asked if they could interview the physical therapist assistant in the building who had worked with R47 per OT J. No physical therapy staff followed up with this Surveyor by facility exit. On 6/18/25 at 12:09 p.m., the NHA was asked about no investigation report or witness statements being found by LPN A or provided in the Electronic data share system. The NHA reported they knew there was an investigation report with witness statements, and they would follow up with the DON (Director of Nursing) and continue looking for them. This Surveyor followed up with additional emails, including at 12:42 p.m. No investigation report or witness statements were received by survey exit. On 6/18/25 at 1:44 p.m., the NHA was interviewed about R47's fall with major injury, left ankle fracture on 12/05/24, and concerns found related to no investigation report, which would include a root cause analysis, and witness statements. This Surveyor shared concerns related to staff inconsistencies with how they transferred R47 at the time of the fall and currently, and the unsafe transfer observed on 6/18/25 by two staff. This Surveyor shared they were unable to reach RN V or the former ADON W. The NHA confirmed they did not have the investigation report or witness statements, and they were not received by survey exit. The NHA reported they understood the concern related to staff observed transferring R47 without a gait belt on this date and had begun education with staff. They had no additional comment regarding the other concerns. Review of the Policy, Accidents, revised 6/29/21, To ensure the environment is free from accident hazards over which the facility has control and provides supervision and assistive devices to each resident to prevent avoidable accidents through a systemic approach. Accidents: Accident refers to any unexpected or unintentional incident, which results or may result in injury or illness to a resident. This does not include other types of harm, such as adverse outcomes that are a direct consequence of treatment or care that is provided in accordance with current professional standards of practice (e.g., drug side effects or reaction). Avoidable Accident means that an accident occurred because the facility failed to: Identify environmental hazards and/or assess individual resident risk of an accident, including the need for supervision and/or assistive devices. Evaluate/analyze the hazards and risks and eliminate them, if possible, or, if not possible, identify and implement measures to reduce the hazards/risks as much as possible. Implement interventions, including adequate supervision and assistive devices, consistent with a resident's needs, goals, care plan and current professional standards of practice in order to eliminate the risk, if possible, and, if not, reduce the risk of an accident. Monitor the effectiveness of the interventions and modify the care plan as necessary, in accordance with current professional standards of practice . Review of the policy, Gait Belt Use, Effective 11/28/17, revealed, A gait belt is a safety device made of cloth that buckles securely around a resident's waist. The device provides a secure grasping surface to aid during transfer and ambulation. Commonly used for residents who are at risk for falls and those who require assistance during transfer. A gait belt can support a lower ot the floor if the resident begins to fall or loses balance during transfer. A gait belt can support a lower to the floor if the resident begins to fall or loses balance during transfer or ambulation. When combined with proper body mechanics a gait belt improves caregiver safety and prevents back injury .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to intake(s): MI00140190 & MI00140245. Based on interview and record review the facility failed to ensure accurate wound assessments, timely implementation of treatment for identified wounds, coordination of care and wound services and ensure a collaborative approach for wound healing was completed with the dietician for two (R's 501 & 506) of three residents reviewed for pressure wounds, resulting in R506 to have developed an infected unstageable (full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because the wound bed is obscured by slough or eschar) buttocks/sacral wound (after debridement identified as a Stage III- full thickness loss of skin, in which subcutaneous fat may be visible in the ulcer and granulation tissues and rolled wound edges are often present- buttock/sacral wound) that required the resident to be transferred and admitted to the hospital due to sepsis from an infected buttock/sacral ulcer. Findings include: R506 Review of a complaint submitted to the State Agency (SA) documented the concern of the facility to have failed to prevent pressure ulcers which became infected. Review of the medical record revealed R506 was admitted to the facility on [DATE] with a readmission date of 6/6/23 and diagnoses that included: hemiplegia and hemiparesis affecting right dominant side, dementia, and senile degeneration of the brain. A Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 12 and required staff assistance for all activities of daily. Further review of the medical record revealed R506 had an appointed legal guardian in place. Review of a Braden Scale for Predicting Pressure Sore Risk dated 3/22/23, documented a score of 18 which indicated At Risk. Review of the July 2023 Medication Administration Record (MAR) and Treatment Administration Record (TAR) documented the following order Wound Prevention: Apply triad paste daily every day shift for skin . Start Date 6/18/23. Review of a Skin Observation dated 7/8/23 at 1:18 PM, documented in part . Does the Resident have any NEW Skin Issues Observed . Yes . Left gluteal fold- skin tear . Left thigh (rear)- dime size skin tear . Review of the medical record revealed no documentation of the physician to have been notified of the identified skin impairments and no new treatment implemented. Review of Nursing note by the Director of Nursing (DON) dated 7/11/23 at 11:30 AM, documented in part . Resident has NEW skin issue(s) observed. 1 . unstageable, Left buttock - stage III pressure . sacral/coccyx region . resident noncompliant of [NAME] <sic> hygiene repositioning and brief changing . Review of a care plan titled . The resident has potential for impairment to skin integrity . documented . Resident's unwillingness to offload once he is up in his w/c (wheelchair) for the day, can be resistive to check and change . Review of the medical record revealed one incident documented on 3/17/23 of the resident to have been noncompliant with care prior to the identification of the sacral/coccyx wound. Review of the medical record revealed no documentation of treatment implemented for the . unstageable, Left buttock Stage III pressure . sacral/coccyx region . identified on 7/11/23, until more than a week later on 7/19/23. Review of the July 2023 MAR and TAR documented the following order in part, . cleanse left buttock and coccyx with dankins, apply calcium alginate and medi honey and cover with ABD pad. Document any refusals every evening shift every Wed (Wednesday) for skin healing . Start Date- 07/19/2023 . This order was implemented more than a week after the initial identification of the sacral/coccyx wound. Review of the wound consultations revealed the following: On 7/14/23 at 10:49 AM, documented in part . being seen for wound to buttock . Functional Assessment: Total Dependence . Pressure injury of deep tissue of sacral region . Acute moist area with eschar in gluteal fold of sacrum. Unable to perform full assessment. Resident refuses to leave wheelchair . Dietician to participate to optimize nutrition. Report changes to provider. Pressure injury to left buttock, stage2 (Partial-thickness loss of sin with exposed dermis, presenting as a shallow open ulcer) . Unable to perform full assessment. Resident refuses to leave wheelchair 2 open area left buttock. Dressing has small amount of serosanguinous drainage . Pressure injury to the right buttock, stage 2. Active Acute open area right buttock with small open area. Unable to measure size due to resident refusing exam . On 7/18/23 at 4:16 PM, documented in part . Pressure injury of deep tissue of sacral region Active Acute resident sitting in wheelchair - declined exam Monitor wound . Report changes to provider . Pressure injury of left buttock, stage 2 Active Acute resident sitting in wheelchair - declined exam. Monitor wound care . Report changes to provider . Pressure injury of right buttock, stage 2 Active Acute resident sitting in wheelchair - decline exam Monitor Wound care . Dietician to participate to optimize nutrition. Report changes to provider . On 7/21/23 at 10:18 AM, documented in part . being seen for wound to buttock . Pressure injury of deep tissue of sacral region Stable. Chronic Area in gluteal fold moist. Approximate size 2 x 2 x 0.125 inches. Base of wound dark in color . Report changes to provider. Pressure injury of right buttock, stage 2 Stable Chronic Improving. Approx 2 x 1.5 inches . Dietician to participate to optimize nutrition. Report changes to provider . Review of the medical record revealed no documentation of the clarification of the staging of the wounds completed by the DON on 7/11/23 that documented an unstageable and Stage III wounds compared to the clinician assessments as documented on 7/14/23, 7/18/23 and 7/21/23, of the wounds documented as stage 2's. Further review of the medical record revealed no documentation of the dietician to have been notified of R506's wounds and no documentation of the dietician to have acknowledged the development of R506's wounds at that time. Review of a Nursing note dated 7/23/23 at 8:00 PM, documented in part . T (temperature): 101 . BP (blood pressure): 99/54 . P:92 irregular, R (respirations): 40, SPO2% 89%-91% on room air . odor coming from coccyx area . Resident transferred to (hospital name) via ambulance . Review of the hospital documents revealed the following: A Wound Care Progress Note dated 7/26/23 at 5:54 PM, documented in part . unstageable pi (pressure injury) to gluteal cleft that surgery is managing. Stage 3 pi (pressure injury) to left gluteus . A Operative Report dated 7/27/23 at 2:05 PM, documented in part . Sacral Wound Debridement . Preoperative Diagnosis- Unstageable Sacral Wound . Postoperative Diagnosis- Stage 3 Sacral wound, 9 x 5 x 1.5 cm (centimeters) . Sharp excisional debridement was performed to the sacral wound down to and including the presacral fascia. There was a moderate amount of purulent/necrotic fluid that was expressed from the wound . There is noted to be 5 cm (centimeters) of undermining along the 10-11 o'clock region, in order to provide adequate exposure to the wound, the wound was unroofed with exposure of more necrotic tissue that was debrided. The debridement was taken until there was healthy bleeding tissue within the wound bed . The new wound measurement were 9 x 5 x 1.5 cm. Given the size and location of the sacral wound it was decided to place a wound VAC to allow for adequate healing . Findings- 9 x 5 x 1.5 cm stage III sacral wound, Moderate amount of purulent/necrotic fluid expressed from wound . An Infectious Disease Progress Note dated 7/27/23 at 6:18 PM, documented in part . Chief Complaint- EMS (emergency medical services) reports AMS (altered mental status) per NH (nursing home). EMS reports pt (patient) is normally A&Ox3 (alert and oriented times three) . admitted from an extended care facility . due to altered mental status and hypotension. On admission patient was noted to have a . sacral decubitus ulcer which had been foul-smelling and draining purulent drainage. On admission . had leukocytosis and tachycardia. Patient had hypotension, which improved with administration of fluids. He was placed on empiric antibiotics in the form of vancomycin. Blood cultures are pending at this time . The surgical service has seen this patient and there are plans for debridement of the sacral ulcer . Impression . Infected unstageable decubitus ulcer in the coccygeal area, at the natal cleft . Sepsis, secondary to #1 (infected unstageable coccygeal ulcer) . Recommendations . Continue Zosyn 4.5 g (gram) IV (intravenous) every 8 hours, vancomycin (per dosing pharmacy), pending culture results from the OR (operating room) . Monitor temperatures and white blood cell count . Continue local care to decubitus ulcer- anticipate need for further debridement . On 4/3/24 at 3:19 PM, Registered Dietician (RD) E was interviewed and asked their involvement with residents that have pressure wounds. RD E stated they are to be notified once the wound is identified and they complete an assessment on the resident and modify the residents care as necessary. RD E was asked to look into their assessment, files, and notes for any documentation of having to been notified of R506's wounds. On 4/4/23 at 9:17 AM, a follow up interview was conducted with RD E who stated they had not been notified of R506's wounds prior to their hospitalization. RD E stated that usually they are notified when the skin impairment is first identified. On 4/4/24 at 10:17 AM, the Director of Nursing (DON) (who also served as the wound nurse during July 2023) was interviewed and asked how a skin tear initially identified on 7/8/23 could worsen to an unstageable and stage III wounds (buttock/coccyx) in three days without the front-line staff (nurses and aides) to have been able to identify and notify the physician of the worsening of the wound. The DON was also asked to clarify their assessment that was documented on 7/11/23 describing the wound as an unstageable and stage III wound. The DON was asked why treatment was not implemented for the identified wounds from 7/11/23 to 7/19/23 and why the dietician was not notified of R506's wounds to have a collaborative interdisciplinary approach to promote the healing of R506's wounds. The DON stated the facility had up until a month (per the facility's protocol) to ensure the dietician's involvement in wound care and would look into the other concerns and follow back up. At 11:00 AM, the DON returned and stated the coccyx had an unstageable wound and the left buttocks had a stage III wound. The DON stated R506 was a difficult case for them, and the DON pointed out the refusals made by the resident to not be assessed by the wound clinician on the wound care days, the DON was then asked why the facility staff failed to coordinate the wound care for R506 with the wound clinician and the facility staff. The DON was asked how a resident who requires total dependence for all care was placed in their wheelchair every wound clinic day, knowing the resident would refuse to lay back down once in their wheelchair (as documented in the resident's care plan), the DON stated it was the resident's right to get in their wheelchair and right to refuse the wound assessment. The DON stated during the time of July 2023 they had so many issues with the wound physicians/clinicians and ended up changing wound care providers in September 2023. No further explanation or documentation was provided by the end of the survey. R501 A complaint was filed with the State Agency (SA) that alleged when they were noted on or about 1/24/24 that R501 had two pressure sores, one on their penis area and one on their bottom. The complainant noted that they were discharged to the hospital on 2/5/24 and again informed the resident had multiple pressure ulcers in those locations when they arrived at the Hospital. A review of R501's clinical record revealed the resident was initially admitted to the facility on [DATE] and their last admission date was 2/13/24 with diagnoses that included, in part: diabetes, chronic kidney disease, obesity and heart failure. A review of the Minimum Data Set (MDS) dated [DATE] noted the resident's Brief Interview for Mental Status (BIMS) score was 15/15 (intact cognition) and noted the resident needed one to two person assistance for most Activities of Daily Living (ADLs). Review of Section M of the MDS noted the resident did not have a pressure ulcer. Continued review of R501's clinical record, documented, in part, the following: Skin Observation(1/2/24): Resident has NO New skin issues . (authored by the DON). Health Status Note (1/22/24): Writer and wound care nurse notified by aide that resident had a new open area to sacrum and penis. Wound care nurse and writer did observe open area to sacrum noted as shearing r/t (due to) transfers. Open area to penis noted r/t new placement of foley .Wound care NP (nurse practitioner) to eval . *It should be noted that there were no notes in the resident's electronic record that indicated he was see by the wound care NP. Order (1/22/24): Wound Care: Apply Triad paste to open area on penis. One time a day for wound care and every 24 hours as needed for wound care. Care Plan (4/18/23): Focus: The resident has potential skin impairment r/t (related to) incontinence, generalized weakness, history of masd (moisture associated skin damage), pressure and incisions .Interventions: Monitor skin when providing cares, notify nurse of any changes to skin appearance (2/23/17) .Educate resident/family/caregivers of causation factures and measures to prevent skin injury (7/31/23) .Encourage good nutrition and hydration in or to promote heathier skin (7/31/23) .Focus: The resident has actual impairment to skin integrity r/t fx (fracture) with incision, assistance needed with mobility/ADLs .will refuse care until an aide he approves of is available to provide care .Interventions: .Assist to turn and reposition when in bed as tolerated (9/16/2020) . *It should be noted that there were no interventions noted for skin impairment following the discovery of open wounds dated 1/22/24. Hospital Records (2/5/24): ED (emergency department) 2/5/24 .H & P (history and Physical exam) .patient was seen and examined on February 5, 2024 .Assessment and Plan .sacral decubitus ulcer .Will have Wound care evaluate the patient .Wound History: Stage 2 pressure injury coccyx .assessment: Wound Length: 5.5 cm x Wound Width: .6 cm .Wound surface area: 3.3 cm .Wound: Penis: Wound bed tissue assessment: Yellow; sloughing; red; bleeding; painful; fragile .length 1.5 cm .width: 4 cm . R501 returned to the facility on 2/14/24. A skin observation (2/14/24) documented: .scrotum are open areas multiple, Coccyx open area . (Authored by Wound Nurse F). Skin Observation (2/14/24): .Resident has NEW skin issue(s) observed 1 Other (specify)- groin 3 open pressure .Other (specify) penis pressure, right gluteal fold- stage III pressure . Three Skin and Wound Evaluation dated 2/16/24 did not provide necessary information as to the type, location, acquired status, stage. Wound measurements were noted. Wound Evaluations with accompanied photos provided only measurements and noted as undiagnosed. A review of the MAR/TAR noted R501 did not receive any treatments to open areas on the scrotum and/or penis from 2/14/24 through 2/16/24. On 4/4/24 at approximately 10:25 AM, an interview was conducted with the DON. Wound Nurse F was also present during the interview. The DON was asked as to R501's facility acquired pressure ulcers noted on 1/22/24. The DON reported that they believed the only open area found on 1/22/24 was on the resident's penis. When asked if there was any documentation as to the staging and description, location, measurements of the wound as noted, the DON reported that there was not as they believed the wound had healed. When asked if the resident was seen by the Nurse Practitioner (NP), the DON reported No. When asked as to the notes from the Hospital that noted the resident had wounds including those on the coccyx and penis upon admission on [DATE], the DON reported that the pictures were different than the hospital notes. When asked why the assessments were not fully completed upon R501's return from the hospital on 2/14/24, Wound Nurse F reported that they were not fully checked as completed. When asked what treatments were put in place for multiple open areas on the scrotum and/or penis, the DON did not provide a response. A review of the facility policy titled, Skin Protection Guideline (7/7/21), noted, in part: .Purpose: .To ensure residents that admit and reside at our facility are evaluated and provided individualized interventions to prevent, reduce and treat skin breakdown .Evaluation: Our facility applies a process to identify residents with or at risk for developing a pressure injury: upon admission/readmission .Transfer out/in . With significant changes in condition and Routinely .process includes: .Implementing, monitoring and modifying interventions to stabilize, reduce or remove underlying risk factors .Because a resident can develop a PU/PI (pressure ulcer/injury) within hours .the at risk resident needs to be identified and have interventions implemented promptly at attempt to prevent PU/PI .Skin should be assessed as soon as possible .where possible .within the first 2 hours .Planning: An individualized plan of care will be developed based on predicting factors for skin breakdown .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident #240 On 6/6/23 a concern submitted to the Stage Agency was reviewed which alleged R240 did not receive appropriate care/treatments for their pressure ulcer. On 6/8/23 The medical record for R240 was reviewed and revealed the following: R240 was initially admitted to the facility on [DATE] and last readmitted on [DATE] with diagnoses that including Heart failure and Intracerebral hemorrhage. A review of R240's MDS (minimum data set) with an ARD (assessment reference date) of 3/12/23 revealed R240 needed extensive assistance with most of their activities of daily living. R240's BIMS score was 15 indicating intact cognition. A Physicians order dated 2/27/23 and a discontinued date (d/c) of 3/20/23 revealed the following: cleanse stage 2 pressure wound with wound cleanser/ normal saline, pat dry apply santyl cream to wound and cover with dry dressing daily and prn one time a day for wound care. A Physicians order dated 3/1/23 with a d/c date of 3/20/23 revealed the following: : Cleanse coccyx wound with Dakins OR wound cleanser, then apply medihoney gel onto wound bed, cover with a border foam. Must be done Every Monday, weds, fri and PRN every day shift every Mon, Wed, Fri for coccyx wound. A Wound care Nurse Practitioner evaluation dated 3/1/23 revealed the following: Wound Assessment and Plan: Wound #1-Coccyx-unstageable .Treatment-Medihoney Gel .Frequency-M, (Monday), W (Wednesday), F (Friday) and PRN (as needed) A Wound care Nurse Practitioner evaluation dated 3/8/23 revealed the following: Wound Assessment and Plan: Wound #1-Coccyx-unstageable-Multiple bridges .Wound bed-30% eschar .Treatment-Medihoney Gel .Frequency-M, W, F and PRN. A Wound care Nurse Practitioner evaluation dated 3/15/23 revealed the following: Wound Assessment and Plan: Wound #1-Coccyx-unstageable-Multiple bridges .Wound bed-50% eschar .Treatment-Calc Alg (Calcium alginate) Medihoney Gel .Frequency-M, W, F and PRN. Further review of the three Wound care Nurse Practitioner evaluations did not indicate continuing the Santyl treatment to R240's pressure ulcer. A review of R240's March 2023 TAR (treatment administration record) documented R240 had the Santyl treatment being applied every day from 3/1/23 through 3/16/23 and the Medihoney Gel treatment being applied with dakins/wound cleanser on 3/3, 3/6, 3/8, 3/10 and 3/13. On 6/8/23 at approximately 12:45 p.m., during a conversation with Assistant Director of Nursing A (ADON A), ADN A was queried regarding R240's wound care. ADON A indicated R240 only had one wound which was on his sacral coccyx area which was present upon admission. A review of R240's wound treatment was done and ADON A was queried regarding the continuation of the Santyl treatment along with completing the Medihoney treatment after coming the hospital and they indicated they did now know why it was not discontinued. ADON A reported the Santyl treatment was not addressed by the Wound Care Nurse Practitioner on their evaluations and only indicated that Medihoney Gel was to be the treatment for R240's coccyx wound. On 6/8/23 at approximately 1:10 p.m., during a conversation with Wound Care NP E (WCNP E), WCNP E was queried regarding R240's wound on their coccyx and reported that they Initially ordered Medihoney gel on 3/1 then changed the order to Medihoney gel with calcium alginate on 3/15. WCNP E was queired regarding the co-occurring Santyl order for R240's coccyx that was being done every day and on some days being done on same day as the Medihoney Gel treatment and reported that it must have been from hospital and was overlooked/missed and that the treatment for R240's wound was supposed to be Medihoney Gel not Santyl. WCNP E reported that Santyl treatments were not for wounds that contain eschar in which R240's wound had. This citation pertains to intake #'s MI00135735, MI00136041, and MI00136457 Based on observation, interview, and record review, the facility failed to accurately assess skin upon re-admission, document interventions to prevent the worsening of pressure ulcers, and ensure/clairify appropriate treatment orders for pressure ulcers for two residents (R#'s 140 and 240) of three residents reviewed for pressure ulcers, resulting in worsening of pressure ulcers. Findings include: A review of a facility provided policy titled, Skin Management Guideline effective 11/28/17 was conducted and read, Purpose: To ensure residents that are admitted to the facility are evaluated to determine appropriate measures to be taken by the interdisciplinary care team to determine appropriate measures and individualized interventions to prevent, reduce and treat skin breakdown. It is the practice of this facility to properly identify and evaluate residents whose clinical conditions increase the risk for impaired skin integrity, and pressure ulcers; to implement preventative measures; and to provide appropriate treatment modalities for wounds according to industry standards of care . R140 A review of R140's closed clinical record was conducted on 6/7/23 and revealed they admitted to the facility on [DATE], they were sent to the hospital on 2/26/23, re-admitted on [DATE], and again they were sent to the hospital on 3/14/23. R140's diagnoses included: femur fracture, diabetes, dementia, altered mental status, pneumonia, severe protein calorie malnutrition and gastrointestinal hemorrhage. R140's Minimum Data Set (MDS) assessment dated [DATE] indicated R140 had moderately impaired cognition, was non-ambulatory, and required extensive to total assistance from one to two staff members for all activities of daily living. A review of R140's hospital record for the admission from 2/26/23 thru 3/3/23 was conducted and revealed that on 3/1/23 two pressure injuries had been identified. The first wound was documented as a pressure injury to the sacrum and the assessment read, .Wound Bed Tissue Assessment .Dry; Non-blanchable erythema .Peri-Wound Assessment: Red; Peeling .Dressing .Foam . The second wound was documented as a pressure injury to the right heel and the assessment read, Wound Bed Tissue Assessment: Dry; Purple .Dressing: Open to air . A review of R140's re-admission Nursing Evaluation .V -8 dated 3/3/23 was reviewed and No had been marked to the question .Does the resident have skin integrity concerns? . A review of a Daily Skilled Nursing Evaluation - V 5 dated 3/3/23 was reviewed and did not indicate R140 was receiving skilled services for wound care. Section K. on the evaluation read Skin/Wound, and was noted to be blank for the prompt of Additional Skin/Wound Comments: A review of a wound consult dated 3/8/23 by Nurse Practitioner (NP) 'E' was conducted and revealed R140 had an unstageable (full thickness tissue loss in which actual depth of the ulcer is completely obscured by slough (yellow, tan, gray, green, or brown) and/or eschar (tan, brown, or black) in the wound bed) pressure ulcer on their coccyx with yellow slough and an unstageable pressure ulcer on their right lateral heel wound with hard eschar. It was further documented on the consultation form NP 'E' recommended an air mattress, heel boots, and treatments to the affected areas every Monday, Wednesday, Friday, and as needed. The consultation did not indicate the worsening of wounds or development of new wounds would have been unavoidable. A review of R140's physician's orders, treatment administration records, (TAR), and care plans was conducted and indicated the first treatments and care planned interventions for the coccyx and heel wounds were dated 3/8/23. A review of a R140's Certified Nursing Aide Task (CNA) documentation did not indicate any turning and repositioning for R140 nor was there documentation that heel boots or the air mattress were present prior to 3/8/23. A review of R140's Daily [NAME] Reports from 3/3/23 to 3/10/23 was conducted and the [NAME] did not indicate an assignment or a CNA task for an air mattress or heel boots until 3/10/23. On 6/7/23 at 3:17 PM, an interview was conducted with NP 'E', and said their only involvement with R140 was the consultation and the recommendations for treatments and interventions. On 6/8/23 at 9:23 AM, an interview was conducted with the facility's Assistant Director of Nursing (ADON)/Supervisor of the Wound Care Program regarding R140. They said when R140 re-admitted to the facility on [DATE], they did not have any wounds, but they had, areas of concern on their coccyx and right heel. They further reported the hospital wanted both of the wounds left open to air and reported the coccyx wound opened on 3/8/23. They were asked about the two nursing assessments conducted on 3/3/23 and why they did not indicate there were any, areas of concern identified on the skin assessments and they had no explanation. They said they implemented the air loss mattress and heel boots on 3/3/23 upon re-admission. They were asked to provide documentation of the interventions prior to the wound consult on 3/8/23 and the only documentation provided was a PRN (as needed) CNA task for Pressure Reducing Device. The ADON admitted the task was, vague and said the CNA's did not document on the presence of the interventions on their shifts because the task was PRN (as needed).

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to Intake #'s MI00128558, MI00128904 and MI00134127 DPS #1 Based on interview and record review, the facility failed to ensure phyisican ordered follow-up urinary catheter care was provided for one (R806) of six residents reviewed for indwelling catheters resulting in discomfort, blood in the urine, expected infection and hospitalization. Findings include: A complaint was filed with the State Agency on 1/11/23 that alleged in part, .on November 10th (R806) had surgery to get a suprapubic catheter put in. This operation involves putting the catheter through her abdomen . On November 15th they did not bring her to the postoperative follow up appointment . on December 2, she was in the Emergency Room. Her incision was infected and the catheter was clogged . She stayed in the hospital for six days to recover . Review of the closed record revealed R806 was admitted into the facility on 2/9/22 with diagnoses that included: heart failure, schizoaffective disorder and neuromuscular dysfunction of bladder. According to the Minimum Data Set (MDS) assessment dated [DATE], R806 was cognitively intact, required the extensive assistance of staff for all activities of daily living (ADL's) and had an indwelling catheter. Review of R806's suprapubic (SP) catheter care plan revealed an intervention dated 11/29/22 that read, UTI (urinary tract infection): Evaluate resident for S/SX (signs and symptoms) UTI, if appropriate request UA/C&S (urinalysis/culture and sensitivity) and treatment as indicated from Physician. Review of R806's progress notes revealed a nursing note dated 11/10/22 at 6:21 PM read in part, Resident returned from facility after having supra pubic placement . Resident came back with new orders to monitor for bleeding, and supra pubic care orders . Review of R806's hospital discharge paperwork dated 11/10/22 after the SP catheter placement read in part, .Follow-Up Appointment: 8 Days . Medication: cephalexin (Keflex 500 mg (milligrams) oral capsule), 1 CAPLET, Oral, Every 6 Hours . Change your dressing every day. Change the dressing more often if it falls off, becomes dirty, or has absorbed a lot of drainage . Further review of R806's progress notes revealed: A nursing note dated 11/24/22 at 12:53 PM read, .dressing soiled bleeding light discharge coming from site not smell at this time resident says it isuncomfortable [sic] dressing changed . A nursing note dated 11/26/22 at 10:51 PM, Pt (patient) suprapubic has come out of place. Pt voiding in brief . pts urinal bag had no urine noted. Pt needs urology appointment Writer will endorse to incoming nurse. A nursing note dated 12/1/22 at 10:33 AM read, Supra pubic catheter draining straw colored urine. No c/o (complaint of) pain or discomfort. No redness/swelling/tenderness at ostomy site . It should be noted that the creation date of this note was 12/22/22 by the Director of Nursing (DON), 20 days after R806 was discharged from the facility. A SBAR (Situation, Background, Assessment, and Recommendation) note dated 12/2/22 at 1:59 PM read, resident supra pubic not draining. UTI expected. Attempted to get sample unable to get urine return . Signs and Symptoms: Has hematuria (blood in urine). Has urinary hesitancy . A nursing note dated 12/2/22 at 4:06 PM read, Resident presenting with complaints of discomfort in her bladder region. Nurse assessed resident noted an odor from supra pubic site, sentiment [sic] in foley line and bag, distended bladder . new order to flush foley and send for UA. Nurse attempted to flush catheter with no return. New order to change supra pubic, unsuccessful attempt resident complaining of too much pain. New order to send resident to ER (emergency room) . Review of R806's November 2022 Medication Administration Record (MAR) revealed the antibiotic cephalexin had not been ordered or given. On 4/26/23 at 1:15 PM, Receptionist E, who was in charge of making outside appointments was interviewed and asked if R806 had a follow-up appointment with the surgeon after having a SP catheter. Receptionist E explained she did not keep a record of appointments she made. When asked if there was any log or record kept of resident appointments, Receptionist E explained after a resident was discharged , she would shred the record. On 4/27/23 at 1:03 PM, the DON was interviewed and asked if R806 had been sent for a follow-up appointment after the SP catheter placement. The DON explained they had not received the discharge paperwork until R806's family member brought it to them, it was uploaded into their computer system on 11/17/22. When questioned if they had contacted the Urologist's office as it was standard to follow-up with an Urologist after a surgical procedure, the DON had no answer. The DON was asked when progress notes on 11/24/22 and 11/26/22 documented problems with R806's SP catheter, why there was no follow-up with Urology. The DON had no answer. DPS #2 Based on interview and record review, the facility failed to provide bladder training per orders one (R809) of six residents reviewed for indwelling catheters resulting in R809 being pressured to get an indewlling catheter. Findings include: Review of a complaint filed with the State Agency on 1/27/23 revealed allegations that read in part, .Resident may have to have a catheter put in because the facility does not have enough staff to provide assistance to him . Review of the closed record revealed R809 was admitted into the facility on 1/27/23 with diagnoses that included: cord compression, epilepsy and neurogenic bladder. According to a Brief Interview for Mental Status (BIMS) tool dated 1/27/23, R809 was cognitively intact. Review of a nursing admission assessment dated [DATE] at 6:00 PM read in part, .Resident is alert. Resident is orientated x4 (person, place, time & situation) . Resident is incontinent of bladder. Resident does not have urinary symptoms/concerns . Review of R809's progress notes revealed: A nursing note by Registered Nurse (RN) D dated 1/26/23 at 8:30 read in part, order received (Nurse Practitioner - NP G) to insert indwelling catheter as resident has ongoing urinary incontinence, and hs (history) of urinary retention . A nursing note by RN D dated 1/26/23 at 9:05 PM read in part, Resident refused to have foley catheter inserted- I don't need one, I want to use the urinal- Explained that although he is voiding on his own it it [sic] difficult to measure the volume of urine and that he has a history of retaining urine, still refuses tohave [sic] indwelling catheter and insists on using the urinal. Review of R809's hospital discharge paperwork dated 1/26/23 read in part, .Spinal Cord Injury (SCI): Managing Your Bladder: After an SCI, your bladder may not work the same way as before. During your rehab (rehabilitation), your healthcare team gave you a bladder program to help you adjust to and manage these changes. Going forward, it'll be up to you to follow this program on a regular basis. By taking control of your body and managing your bladder, you'll help prevent accidents, infections, and other complications . Neurogenic Bladder: .Start on bladder program including IC (intermittent catheterization) Q4 (every 4 hours) if patient doesn't void or PVRs (post-void residual) > (greater than) 250cc (cubic centimeters), keep IC volumes < (less than) 400cc . On 4/26/23 at 3:54 PM, NP G was interviewed by phone and asked if urinary incontinence was an acceptable reason to order an indwelling catheter. NP G explained she would never order a catheter for incontinence, but retention would be a reason for a catheter. NP G was asked about the order for a catheter for R809. NP G explained the nurses would call her a home and ask her about catheters. On 4/26/23 at 5:00 PM, RN D was interviewed and asked why she thought R809 needed an indwelling catheter. RN D explained the hospital had been using straight catheterization on a regular basis for residual urine, and the facility thought an indwelling catheter might be less a risk of infection and a better way to measure output. On 4/27/23 at 1:22 PM, the DON was interviewed and asked why they wanted an indwelling catheter for R809 when IC catheterization and PVR's were used at the hospital for bladder training. The DON explained they did not have a bladder scanner at the facility, so they could not do PVR's. The DON was asked why the facility agreed to accept R809 when they were not able to provide his bladder training. The DON explained he was not involved in R809 coming to the facility. Review of a facility policy titled, Urinary Indwelling Catheter Management Guideline dated 11/28/17 read in part, .To ensure resident who enter our facility without an indwelling catheter are not catheterized unless the resident's clinical condition demonstrates and meets standard of practice supporting his justification . Urinary retention that cannot be treated or corrected medically or surgically, for which alternative therapy is not feasible and which is characterized by: 1. Document post void residual volumes in a range over 200 ml (milliliters)/ 2. Inability to manage the retention / incontinence with intermittent catheterization . Intermittent catheterization is preferable to indwelling catheterization . Additional care practices should include: .Monitoring post void residual .

This citation pertains to Intake MI00134127 Based on interview and record review, the facility failed to ensure three physician ordered anticonvulsant medications were available for one (R809) of three residents reviewed for medications resulting in R809 statements of feeling unsafe and wanting to go to the hospital. Findings include: Review of the closed record revealed R809 was admitted into the facility on 1/27/23 with diagnoses that included: cord compression, epilepsy and neurogenic bladder. According to a Brief Interview for Mental Status (BIMS) tool dated 1/27/23, R809 was cognitively intact. Review of hospital discharge paperwork dated 1/27/23 read in part, Medication List: .(carBAMazepine 200 mg (milligrams) oral tablet), 1 Tab (tablet), By Mouth, Two times daily . (brivaracetam 100 mg oral tablet), 1 Tab, By Mouth, Two times daily . (lamoTRIgine 100 mg oral tablet), 1 Tab, By Mouth, Two times daily . Epilepsy - Last seizure reported 2-3 months ago . 12/29: Continue Carbamazepine 200 mg (milligrams) BID (two times a day), Lamotrigine 100 mg BID, Brivaracetam 100 mg BID; On seizure and aspiration precautions . Review of R809's January 2023 Medication Administration Record (MAR) revealed: Brivaracetam Oral Tablet 100 MG, Give 1 tablet by mouth two times a day for seizures. Order Date 1/26/23 at 6:40 PM. None were given, boxes were marked with the code 09 for Other/See Nurse Notes. carBAMazepine Oral Tablet 200 MG, Give 1 tablet by mouth two times a day for seizures. Order Date 1/26/23 at 6:15 PM. None were given, boxes were marked with the code 09. lamoTRIgine Oral Tablet 100 MG, Give 1 tablet by mouth two times a day for seizures. Order Date 1/26/23 at 6:56 PM. The 8:00 AM dose on 1/27/23 was marked as given. The 5:00 PM dose on 1/27/23 was marked with the code 09. Review of R809's Medication Administration progress notes revealed R809's medications were On order. Review of a Health Status Note dated 1/27/23 at 5:49 PM read in part, Resident stated he was calling 911 because he did not feel safe. Writer, nurse and management explained pharmacy delivery times with medications . Resident stated he was going tothrow [sic] himself out of bed to break his neck. Resident stated he will do harm to himself at any expense . Resident requested to call 911 because he was going to harm himself . Review of a Discharge/Transfer Summary note dated 1/27/23 at 6:05 PM read in part, Resident transported by EMS (Emergency Medical Services) to hospital for evaluation . On 4/26/23 at 5:00 PM, Registered Nurse (RN) D was interviewed and asked how often medications were delivered by pharmacy. RN D explained they received two deliveries a day, approximately 5:30 PM and sometime on the midnight shift . to get medications delivered during the midnight shift, orders needed to be put in by 7:00 PM. to get medications by 5:00 PM, ordered needed to be put in before 11:00 AM. On 4/27/23 at 9:17 AM, Assistant Director of Nursing (ADON) C was interviewed by phone and asked why R809 did not get his ordered anticonvulsant medications. ADON C explained the hospital had sent prescriptions for the Carbamazepine and the Lamotrigine, but did not send one for the brivaracetam, so that was part of the delay. When asked if controlled substance medications could be sent with an emergency supply until a controlled medication form (C2) could be filled out by a physician, ADON C agreed it could. ADON C was asked why the two medications with prescriptions were not available. ADON C had no explanation. On 4/27/23 at 1:22 PM, the Director of Nursing (DON) was interviewed and asked about R809 not receiving his anticonvulsant medications. The DON explained pharmacy delivers medications at 5:00 AM and 5:00 PM. The DON was asked if medications could be requested at other times. The DON explained they could call pharmacy after 7:00 PM to try to get additional medications on the 5:00 AM shipment, or else pharmacy would have to make another shipment of medications to the facility. When asked why R809's anticonvulsant medications were not requested to be drop shipped by the pharmacy, the DON had no answer. The DON was asked if R809's feelings of being unsafe and wanting to harm self to go to the hospital could have been exacerbated by a known epilepsy diagnosis, and at 5:49 PM knowing two doses of three anticonvulsant medications should have been given (six pills), and only one pill had been given at 8:00 AM, and it was unknown when the medications would be at the facility. The DON agreed R809 might have been anxious about his medications. Review of a facility policy titled, Pharmacy Services for Nursing Facilities dated April 2018 read in part, .Providing routine and timely pharmacy service as contracted, and emergency pharmacy service 24 hours per day, seven days per week. a. Emergency or stat medications are available for administration no more than [4] hour(s) after the order is received by the pharmacy .