This citation pertains to intake MI00151590 Based on interview and record review, the facility failed to promptly identify, assess, and contact physician for an acute change in condition for one resident (R902) out of two reviewed for change in condition, resulting in pain and hospitalization. Findings include: A review of intake MI00151590 noted the following, This facility failed to provide [R902] with a timely evaluation of a head injury that likely was the cause of [R902's] mental status change and instead appeared to choose to attempt to sedate them. A review of the medical record revealed that R902 admitted into the facility on 3/10/2025 with the following medical diagnoses, Acute Posthemorrhagic Anemia and Gastrointestinal Hemorrhage. A review of the admission Minimum Data Set (MDS) assessment revealed a Brief Interview for Mental Status(BIMS)assessment score of 15/15 indicating an intact cognition. It was also noted on the MDS that R902 did not have any behaviors on admission. R902 also required staff assistance with bed mobility and transfers. Further review of the progress notes revealed the following, Effective Date: 3/12/2025.Cena (Certified Nursing Assistant) emptied foley catheter at 0600 (6:00 AM) and the bag was 550 [milliliters] and full of blood. Effective Date:3/12/2025. Transition of Care: Apixaban (Blood Thinner) 5 MG twice daily. Monitor for spontaneous bleeding. Effective Date: 3/21/2025. Writer notified by cena that resident had fallen .When asked what happen resident stated, I was trying to get out of bed, to come and tell you that a small bunny came and kissed me. I grabbed the reacher to help me stand and I fell. Effective Date:3/22/205. Resident experiencing brief moment of confusion, c/o dizziness, SPO2(oxygen level) checked 88% RA (Room Air) . Effective Date: 3/24/2024. Pt. (Patient) receiving o2(Oxygen) at 2 lpm (liters per minute), noncompliant with o2 therapy, pt. constantly removes nasal cannula. Pt. constantly removes nasal cannula. Pt. not easily redirected, constantly removing top shirt . Effective Date: .3/26/2025Writer entered resident room and observed resident was sitting on floor opposite side of bed. Resident was trying to put her shoes on. Resident foley was pulled out and laying on the bed .Resident stated [they] were trying to get out of this place .Writer notified DON (Director of Nursing), supervisor and family .Writer is being very uncooperative and combative. Writer notified (Medical Doctor) of resident's combativeness and ordered a onetime order of Haldol 5mg (milligrams) . On 4/2/2025 at 11:24 AM, an interview was conducted with Licensed Practical Nurse (LPN) C. LPN C reported they were R902's nurse on 3/26/2025 and had to send them to the hospital. LPN C reported they had taken care of R902 once before and this was a complete change in behavior for them. LPN C reported R902 was very combative, picking their skin, and attempting to hurt themselves and others. LPN C reported they originally were directed to give R902 Haldol for the new behaviors and then eventually sent them to the hospital. On 4/2/2025 at 12:00, and interview was conducted with Certified Nursing Assistant (CNA) B. CNA B reported that they cared for R902 the day they went to the hospital. CNA B reported they were informed by the nurse that R902 had fallen and when they went in the room R902 was saying that they were trying to kill them and would not calm down. CNA B reported they put R902 at the nurse's station and took turns sitting with them. CNA B reported that R902 was digging in their skin, taking off their oxygen, and picking at their skin. CNA B indicated this was not normal behavior for R902, and they had taken care of them previously. CNA B reported the nurse was on the phone with the Director of Nursing (DON) and they were telling them what to do. CNA B reported R902 was sent out after hitting them and digging and peeling their skin off. On 4/2/2025 at 2:00 PM, an interview was conducted with the DON. The DON was queried if anyone had reported that R902 had a foley bag full of blood as indicated in the progress notes. The DON reported no one reported that to them and they were unsure if the physician team was ever notified. The DON was queried regarding the documented confusion following R902's falls. The DON reported that when someone has a unwitnessed fall, they complete the neurochecks and will send them out if there is a change. The DON reported they know R902 came into the facility with a 15/15 BIMS score but was unsure if there was always some underlying confusion. The DON was asked about giving R902 Haldol, instead of sending them out when there was a change in their behaviors. The DON stated they were unable to answer why the physician made that decision, but they sent R902 out when they began picking their skin and hitting people. A review of a facility policy titled, Change in Condition Notification noted the following, The nurse will notify the resident, the resident's physician/practitioner, and the resident's designated representative when there is: A significant change in the resident's physical, mental, or psychosocial status, such as deterioration which includes life-threatening conditions of clinical complications.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to Intake MI00147833. Based on observation, interview, and record review, the facility failed to ensure a comprehensive nursing assessment was completed and timely acute care emergent hospital transfer for one Resident (R901) of three residents reviewed for care, when R901 sustained a fall with head trauma and bleeding while taking anticoagulant medication. Findings include: A review of a complaint submitted to the State Agency (SA) documented concerns of the facility's failure to assess a change of condition following the fall for R901. A review of R901's medical record revealed, R901 was admitted to the facility on [DATE] and discharged on 10/08/24 with diagnoses that include Quadriplegia and Atrial fibrillation (AFIB). A review of R901's quarterly Minimum Data Set (MDS) assessment dated [DATE], noted R901 with a moderate impaired cognition, functional limitation in range of motion upper as impairment on one side, and lower extremity (hip, knee, ankle, foot) impairment on both sides. A review of R901's medications noted, Eliquis (blood thinner) 2.5mg (milligram), Give 1 tablet by mouth two times a day for AFIB. Start 7/23/23, end indefinite. Monitor for signs and symptoms of bleeding related to use of anticoagulant medication. Start Date: 02/28/2024. A review of R901's Medication Administration Record (MAR) noted, October 1st-9th, the resident was administered the Eliquis as ordered. Further review of R901's medical record revealed, 10/8/2024 11:21(11:21 AM) Incident Note Text: Observed lying on the floor, on [R901's] right side, in front of [R901's] wheelchair. Call light was not in use, but within reach. Assessed for injuries, with the following noted: bruise noted to right eyelid, superficial scrape to right forearm, 4inch, half-moon, skin tear. NP [Nurse Practitioner] into eval, and assisted with placement of steri strips, to approximate tear. Pressure dressing applied. Resident placed into bed with use of mechanical lift. Bed in lowest position, call light in reach. Resident unable to state how [they] fell, secondary to current mental status, due to UTI (urinary tract infection). Writer spoke with dtr (daughter) . Notified physician notified . A review of the 24-hour report noted, 10/08/24. 7am-3pm (shift) Cipro (used to treat infections caused by bacteria) uti (urinary tract infection), IM (intramuscular injection) Rocephin (used to treat many kinds of bacterial infections) x1given, fall shift #1, skin tear RLE (right lower extremity), bruising to R (right) eye area, bruising to tongue. neuro checks. 3pm-11pm (shift) blank. 11pm-7am (shift) hospitalized . On 11/13/24 at 11:41 AM, Registered Nurse (RN) A was asked about the fall of R901. RN A explained they were down on the low 500 hall which was part of her assigned unit and was told that R901 had a fall saying, The Unit Manager, (UM C) and two CNAs (Certified Nursing Assistants) had gotten [R901] in bed. RN A was asked if R901 was able to explain how they fell. RN A stated, No. [R901] was confused. RN A was asked if R901 had any injuries to their head. RN A explained R901 had some bruising to their right eyelid and bit their tongue. RN A was asked how they monitored R901 after the fall. RN A explained, they started Neuro checks (neurological examination, is a series of tests and questions that evaluate the nervous system). On 11/13/24 at 12:39 PM, CNA D and CNA E were asked if they found R901 on the floor. CNA D stated, No, a resident found [R901] on the floor. CNA D and E were about the duration of time that R901 on the floor. They were asked the condition of R901 once they observed R901 on the floor. CNA D explained, R901 was very confused and kept talking about the wheels on the wheelchair and not answering the questions. CNA D and E explained this was unlike R901, R901 was more alert, would use their call light, did not try to stand, or get out of their chair without help. On 11/13/24 at 12:46 PM, UM C was asked about R901's fall. UM C stated when they entered R901's room, R901 was in an awkward position by the mechanical chair. UM C stated, (R901) wasn't speaking right and wouldn't say what happened, R901 was really confused. UM C stated, I went out to get a first aid kit to treat the skin tear. UM C further explained RN A was given the report and took over from there with Nurse Practitioner (NP) B. UM C explained they went back out to the nursing station to start the orders to send R901 out to the hospital. After NP B and RN A exited the resident's room, orders were to start neuro checks and not send the resident to the hospital. On 11/13/24 at 12:55 PM, NP B was asked about the fall and the reason R901 was not sent out to the hospital after a head injury. NP B refer to their progress note and explained she may have not known about the head injuries because she did not reference them in her note. NP B was asked about the procedure for transferring residents to a higher level of care who are prescribed anticoagulant medications, had an unwitnessed fall, with a visible bruise on the head. NP B explained, it all depends on her assessment and if there is a new onset mental status change. NP B was asked how that can be determined for R901 when she had confusion prior to the fall. NP B explained her assessment after the fall was R901 was stable. A review of R901 hospital records dated 10/8/24 at 18:41 (6:41 PM) noted, Medical Decision-Making including ED (emergency department) Course and Interventions Assessment: [R901] . presents to the ER (emergency room) after a seizure . Later in the afternoon [R901] had a witnessed seizure and therefore EMS was called. Upon arrival to the ER the patient was postictal appearing with decreased responsiveness and not following commands. [R901] had clearly bitten [R901's] tongue as [R901] had blood in the mouth and lacerations on the tongue. [R901] does take Eliquis and therefore a level 2 trauma was activated in the setting of fall earlier in the day with seizures now and evidence of trauma, concern for intracranial abnormality. [R901] was evaluated via ATLS (Advanced Trauma Life Support) protocol, and the trauma service was contacted . Shortly after arrival to the ER the patient had another witnessed seizure in the resuscitation area. [R901] was treated with IM (intramuscular) Ativan after which the seizure resolved after approximately 1 minute. After the second seizure [R901] did not return to [R901's] baseline and was having sonorous respirations. During the second seizure [R901] appeared to have bitten [R901's] tongue again as [R901] had more blood in the mouth. The decision was made to intubate the patient for airway protection in the setting of recurrent seizures and unresponsiveness . Further review of R901's medical record pictures revealed, a large deep blood-filled gash on limb, swollen lip, and visible blood indentation of R901's teeth their tongue. On 11/13/24 at 1:30 PM, the Director of Nursing (DON) was asked about the facility's procedure following an unwitnessed fall of a resident on anticoagulants that has a visible head injury. The DON explained to start neuro checks are first, and if anything changes 911 is called. On 11/13/24 at 2:19 PM, the Nursing Home Administrator (NHA) was asked if R901 had any falls within the last six months. The NHA, responded via email No- This is [R901's] only fall ever at the facility. On 11/14/24 at 3:09 PM, Interested Party (IP) explained on 10/08/24, they called the facility to speak with nursing staff because they had a message for [R901] and spoke with [RN A]. IP explained [RN A] stated, I was just looking up your number, [R901] had a fall. The IP explained RN A stated R901 bit their tongue, had a bruise on the eyelid, and a small skin tear that they were treating. IP stated, I didn't understand why [R901] was not being sent out to the hospital, because no one saw [R901] fall. [R901] is paralyzed and would not be able to put [their] arms out to brace during the fall. The IP explained it was obvious R901 had hit their head and needed to go to the hospital. When the family friend went into the room, R901 was lying in bed, their tongue was swollen so badly, R 901 had difficulty eating any food. IP further explained R901 was able to drink the milkshake the family friend brought in. A review of R901's progress notes revealed the following: 10/8/2024 14:41 (2:00 PM) Nursing - Infection Note Cipro continues for tx (treatment) of UTI. No adverse reactions noted. No hematuria or dysuria. Increased confusion noted. NP notified, new order noted for Rocephin 1G IM x 1. Administered at 12pm, right deltoid. Awaiting culture results. Resident is needing assistance with feeding at this time. Extra fluids offered frequently. Neuro checks continue, with previous fall this am. 10/8/2024 14:44 (2:44 PM) Incident Note Text: Med review, new order noted for Rocephin (used to treat bacterial infections) 1G (gram) IM (intramuscular injection) x (time) 1. Administered at 12p (12:00 PM), rt (right) deltoid. Neuro checks in progress and remain within normal limits for resident. 10/8/2024 15:52 (3:52 PM) Progress Note Date of Service: 2024-10-08 Visit Type: Progress Note Transition of Care: Details: Chief Complain confusion, UTI, fall . Patient seen and examined per nursing staff request post fall from electric wheelchair. Patient has a laceration to [their] left lower leg and abrasion to the right forearm. Patient has had recent confusion and restlessness with a positive urine dip and started on Cipro has been sent to lab for culture and sensitivity . Fall from non-moving wheelchair . Unobserved fall .patient sustained laceration to left lower leg and right forearm. Laceration cleansed and Steri-Strips applied with nursing . patient started on Cipro patient continues to have confusion IM Rocephin one-time ordered . [NP B]. 10/8/2024 16:17 (4:17 PM) Nursing Progress Note Text: Upon assessment, tongue noted to be swollen with a bite mark noted to right side of tongue, secondary to fall this am. [RN A]. A review of R901's progress notes did not reveal a reference by NP B of R901's head and tongue injury. Further review of R901's progress notes revealed the following: 10/8/2024 18:09 (6:09 PM) Nursing Progress Note Text: Writer notified by CNA, that resident was having seizure activity. Writer witnessed resident to be having involuntary movements. Writer noted [R901] to be gasping for air, and blood coming from [R901] mouth, secondary to biting [R901's] tongue. Responsive to sternal rub, but agonal breathing noted. 911 phoned . EMS arrived at 5:40, one dose of Narcan administered. Transferred to (name of hospital) via EMS . 10/8/2024 17:56 (5:56 PM) . Summary for Providers Situation: The Change in Condition/s (CIC) reported on this CIC Evaluation are/were: Altered mental status Falls Seizure At the time of evaluation resident/patient . Primary Diagnosis is: Relevant medical history is: CHF (congestive heart failure) Diabetes Chronic Renal Failure/ESRD. Code Status: Adv Directive: Full Cardiopulmonary Resuscitation (CPR). Advance directives are: Resident/Patient had the following medications changes in the past week: Cipro/Rocephin. Resident/Patient is on anticoagulant other than warfarin: Yes . Outcomes of Physical Assessment: Positive findings reported on the resident/patient evaluation for this change in condition were: Mental Status Evaluation: Altered level of consciousness (hyperalert, drowsy but easily aroused, difficult to arouse) Increased confusion (e.g. disorientation). Functional Status Evaluation: Fall . Neurological Status Evaluation: Altered level of consciousness (hyperalert, drowsy but easily aroused, difficult to arouse) Seizure. Nursing observations, evaluation, and recommendations are: . A. Recommendations: IM dose of Rocephin x1, continue with neuro checks, monitor mental status . 10/9/2024 11:04 Nursing - Progress Note Text: IDT (Interdisciplinary Care Team) met to review fall on 10/8/24 at 1030. Nurse reports that resident was sitting in room for 15 minutes before being, summoned to room to observe resident on the floor in room lying on her right side with her back facing the door and feet pointed toward the head of her bed, resident could not describe how she got from her electric wheelchair to the floor. Resident had recent change in condition on 10/6/24. Staff used mechanical lift to put resident in bed for assessment, nurse observed redness to face more so over right eyelid, left lower leg laceration, and right forearm scrape, first aid rendered to skin sites and neuro checks initiated and wnl (within normal limits), nurse notified DON, provider, and family. Care plan reviewed and updated medication review. Resident was sent out to the hospital. A review of R901's death certificate noted they died four days later. Cause of death Traumatic Subdural Hematoma, significant conditions: Oral Anticoagulant therapy, new onset Seizures, Manner of death accident, date of injury 10/08/24, fall, at living facility. A of the facility policy titled, Fall Management Guidelines dated 12/13/23, revealed, POLICY OVERVIEW: The purpose of this policy is to provide guidelines to assist with fall risk identification and fall management of residents in the facility . POST-FALL EVALUATION: If a resident has just fallen or is observed on the floor without a witness to the event, evaluate for possible injuries to the head, neck, spine, and extremities prior to moving the resident. Complete a neurological evaluation using the Neurocheck Evaluation Form when a resident: Has a witnessed fall when the resident has hit their head. Has an unwitnessed fall when a head injury may be suspected or is unknown. After the completion of the initial neurological evaluation with vital signs, continue the evaluations every 30 minutes X 2, every hour x 4, every 4 hours x 6, then every shift x for a total of 3 days . The facility's policy did not address unwitnessed falls with residents that are on anticoagulant medication

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to Intake MI00135407. Based on interview and record review, the facility failed to ensure the assessed number of staff were used during shower care for one resident (R901) of three whose falls were reviewed resulting in a resident fall from a shower bed and sustained bruising, lacerations and bleeding to the face and head. Findings include: A review of a complaint for R901 revealed: On 9/14/23, (R901) had one person assisting (them) in a shower and (R901) was dropped during the shower. (R901) sustained multiple fractures to the nose, jaw and skull. Additional injuries included five fractures to the right eye socket, 18-20 stitches on the forehead and a brain bleed. (R901) is currently at the hospital. The complaint further noted: the aides are overworked with 25 or more residents to care for at times, only one person was used for transfer to the shower bed with the lift, there are not enough lifts to provide timely care and the rails on the shower bed were held up by pins and did not function properly. Further concerns reported included not being fed regularly, not awakened to be fed, not given water consistently and incontinence not cleaned up timely. A review of the facility Risk Management Report dated 09/14/23 at 1:18 PM, documented, Resident observed laying on their right side in shower room after rolling out of the shower chair during a staff assisted shower. Laceration observed to right side of forehead with bleeding .Bruising to right flank and right shoulder, Bruising observed to ridge of nose with nasal bleeding present, 911 was called and resident was taken to (hospital name). Daughter at bedside .Occasional labored breathing, Load moaning or groaning, crying, facial grimacing, rigid, fists clenched, knees pulled up, pulling or pushing away, striking out, unable to console, distract or reassure . On 09/27/23 at 12:03 PM, Unit Manager G was asked about R901's fall and reported: The Certified Nurse Assistant (CNA K) was giving R901 a shower and during the shower R901 fell from the shower bed. The railing went down when the CNA turned R901. A number of nurses responded to the fall. R901 was seen on their right side next to the shower bed. The CNA said they were turning R901 and R901 slipped out of the shower bed. R901 was assessed and treated and then picked up with a carrying blanket and sat into a wheelchair. The daughter was present after the fall. The Unit Manger reported there was nasal bleeding and bruising to the bridge of the nose. The Unit Manager was asked about the care plan status and noted R901 was a two person for the lift but was not sure of the shower bed mobility. Unit Manager G reported the CNA was in the shower room by themselves and was let go (terminated) after the incident. Unit manager G was asked about staffing at the time of the fall and reported there were six regular aides and the one shower aide. There was not a second shower aide. On 09/27/23 at 2:03 PM, the Administrator, Director of Nursing (DON) and an Administer-In -Training were present and R901's fall was reviewed. The Administrator reported the root cause was that only one person was used when two should have been. The Administrator admitted the facility was at fault and had educated staff post the fall. The Administrator also reported it was determined the aide did not intentionally injure R901. On 09/27/23 at 2:48 PM, the DON was asked about the events around R901's fall and reported they had been in a meeting at the time of the fall but did go down to see R901. They could tell the face was split and that R901 had nasal bleeding and the head was wrapped. When asked about the cause the DON reported R901 was a two person assist and only one was in the shower with R901. The DON was asked about staffing and reported it was a work in progress and staff have been hired but not all remained with the facility. On 09/27/23 at 2:52 PM, the Maintenance Supervisor was asked about the shower bed used by R901 during the the fall and reported it was functioning properly at the time. It was also reported that they were unaware if any concerns about the shower bed had been reported as there were none entered in the (maintenance) system. On 09/27/23 at 2:58 PM, CNA I was asked about the normal daily routine for R901 and reported they check on R901 at the start of their shift to see if they are wet and R901 was normally dry, R901 would be left in bed until just before lunch, then they would get R901 up and clean up R901 and combed R901's hair and then put R901 out in the lounge for lunch, then after lunch R901 was taken back to bed and checked on until their shift ends. CNA I reported to be on the unit but did not see the transfer of R901 to the shower bed and was not asked to assist in the shower for R901. CNA I reported they would normally give R901 a bed bath. CNA I reported two persons were used by them during a bed bath and transfers. CNA I reported that the unit R901 resided on was a heavy unit with a lot of lifts and two person residents. CNA I reported days when it is crazy and it not able to get a break unless you force it and may not sit down for their whole shift. On 09/27/23 at 4:23 PM, CNA K was asked about the fall incident with R901 and reported, It was a hectic day. I had to do 12-13 showers by myself. CNA K reported they had been scheduled to do a double shift that day. CNA K reported that the shower bed had been broken for years according to the other aides and nurses. CNA K reported that the hoyer lifts were supposed to be two people but aides operated them with one (staff member) all the time in order to transfer residents and get care done. CNA K reported that the daughter had helped transfer R901 to the shower bed. CNA K commented that the daughter was happy that R901 was getting a shower and had never had a shower. CNA K confirmed they were the seventh aide and was assigned to the showers. CNA K reported that the expectation of the DON was to give showers and not bed baths and do whatever it took to get them done. CNA K reported the other staff , nurse and unit managers watched them push resident in and out of the shower room all day by them selves and did not comment or ask if help was needed. CNA K was asked how the fall occurred and reported that they were turning R901 away from them to further clean R901 and when R901 was turned the rail went down and R901 went onto the floor. CNA K then commented, In that building you have to do everything yourself and reported they did what they thought they were expected and had to do. A review of the record for R901 revealed R901 was admitted into the facility on [DATE]. Diagnoses included Alzheimer's, Dementia, Joint Contractures and Diabetes. A review of the Minimum Data Set (MDS) assessment dated [DATE] indicated severely impaired cognition and the need for extensive assistance of two persons for bed mobility and total assist of two persons for transfers. The need for total care assistance of one person was indicated for locomotion, dressing, and personal hygiene. A review of the nursing care plan ADL (activities of daily living) and mobility deficits related to ongoing health events dated 03/09/20 documented, Bathing Hygiene requires two (person) assist .Bed mobility two person assist . A review of the facilty policy titled, Fall Risk / Injury Prevention approved 06/20/22, documented, It is the policy of this facility to assess every resident for fall risk and provide an environment that is free from accident hazards over which the facility has control, and provides supervision and assistive devices to each resident to prevent avoidable accidents . A care plan will be completed for each resident to address items identified on the fall risk assessment and/or by the IDT team. The care plan will be updated accordingly. The care plan will include interventions, including recommended assistance, consistent with a resident ' s needs, goals, and current standards of practice in order to reduce the risk of an accident . A review of the facility policy titled, Care Plan - Comprehensive and Revision revised 08/25/23 documented, A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident ' s physical, psychosocial and functional needs is developed and implemented for each resident . The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to intake MI00139057. Based on interview and record review, the facility failed to schedule a follow-up urology appointment as indicated upon admission, adequately document assessments immediately prior to and after the initial insertion of an indwelling catheter (tube inserted into the bladder to drain urine), notify the resident's representative when the catheter was inserted, and failed to recognize the need for outside care, for one resident (R1) of three reviewed, resulting in ineffective coordination of care, resident discomfort, catheter-related complications, and hospitalization. Findings include: A review of intake MI00139057 revealed allegations indicating that the resident's representative was not notified when a urinary catheter was initiated; that the facility did not schedule an outside urology appointment as per hospital instruction; that the resident began to experience increased pain and complications from the catheter; and that the facility failed to recognize that R1 needed to be sent to a higher level of care without family/visitor intervention. The intake included, .On 5/9, [R1] called me to tell me that they put a catheter in and he didn't know why .On 5/12, I noticed that [R1's] legs and feet were starting to swell again and I asked to speak to the Dr. again and was told she'd come to see me if she had time. I asked why the catheter was still in and when the urologist appointment was and they said that they didn't schedule one . The intake continued, [On [DATE]] around 5:15 PM, [visitor of R1] got there .took one look at [R1] .could tell he was in pain and extremely lethargic .respiratory rate was fast and .could tell he had [a fever] .[Visitor of R1] asked the nurse about his vitals and asked if [R1's temperature] was taken. The nurse said that when she last checked him, he didn't have a fever .[Visitor of R1 informed the nurse] he has a fever now [asked her to] check again .expressed to the nurse that he looked septic .The nurse made it clear that she was not planning to come in and do another set of vitals and had already called the Dr (Doctor) who was aware of the situation. [Visitor of R1] noticed that he had been throwing up all over the place and had dried throw-up on him . A review of R1's hospital documentation prior to their admission to the facility revealed the following: -[DATE]th, 2023 .Urology Consultation, [DATE] . 1.Bladder unremarkable, prostate enlarged. 2. History of prostate cancer status post radiation therapy in 2004 known to [Outside Urologist B] . 3. BPH (benign prostatic hyperplasia) on Flomax and Proscar (medications to treat enlarged prostate). 4. Rule out urinary retention PVRs (Post-Void Residuals): 292, 121, 168 cc (cubic centimeter also known as mL - milliliters) . 7. Patient to follow-up outpatient with [outside Urologist B] .please continue PVRs if patient is feeling uncomfortable however current PVRs within acceptable range . R1's pre-admission hospital documentation (discharge summary) directed for the resident to follow up with [outside Urologist B] in 1 to 2 weeks. A review of R1's medical record revealed that the resident was admitted into the facility on [DATE] and discharged to the hospital via ambulance (911 called by family) on [DATE]. R1's medical diagnoses upon admission included Unstable Angina, Heart Disease, Anemia, Cardiomyopathy, Thrombocytopenia, Spinal Stenosis, Hypertension, and Benign Prostatic Hyperplasia (BPH) Without Lower Urinary Tract Symptoms. On [DATE], a diagnosis of Retention of Urine, Unspecified, was entered. On [DATE], a diagnosis of Obstructive and Reflux Uropathy, Unspecified, was entered, and on [DATE], a diagnosis of, Neuromuscular Dysfunction of Bladder, Unspecified, was entered. Further review of R1's record revealed that the resident did not have an indwelling urinary catheter in place upon admission. R1's Urinary Incontinence/Dwelling Catheter assessment dated [DATE] indicated that R1 was a candidate for Bladder retraining and experienced functional incontinence (Functional - May be due to physical weakness, poor mobility/dexterity, cognitive impairment, medications. Functional is not related to abnormal urinary tract function). The assessment indicated that mobility was a barrier to toileting for the resident (requires transfer assistance or is non-ambulatory) with no other barriers identified. No additional Urinary/Catheter Assessments were found. A review of R1's orders revealed the following: -F/U (follow up) with [outside Urologist B] in 1 to 2 weeks Urology [Phone Number], Start Date: [DATE]. A review of R1's record revealed that the facility did not coordinate an appointment to see outside Urologist B per the above order and within the 1-2 week timeframe indicated. Additional review of R1's orders revealed: -Nursing please make FU apt with urology ASAP (as soon as possible) to evaluate (name of indwelling catheter) with elevated PVR (Post-Void Residual) .Start Date: [DATE]. A review of R1's progress notes revealed: -[DATE] 01:10 (AM) Nursing - Progress Note .day 2; resident AO x2-3 (alert and oriented to person/place), assist x1, continent of bowel, continent of bladder; urinal at bed side. No S/S (signs/symptoms) of pain or distress observed at this time. Edema observed in BLE (bilateral lower extremities). Vitals checked and charted; within range. Meds given and tolerated. Call light and bed remote within reach; resident able to make needs known. Safety maintained. -[DATE] 09:26 (AM) Physician Team - Progress Note .patient seen and examined with complaints of lower extremity edema, abdominal distention, constipation (patient refused a suppository this morning), patient is on a diuretic normally but this medication was stopped due to acute kidney injury while in hospital, Lasix (diuretic) restarted on [DATE]. Patient's [family/friends] at bedside .patient is complaining of difficulty urinating and frequency with urination and some lower abdominal discomfort, PVRs (Post-Void Residuals, a measurement of urine left in the bladder after elimination) ordered. Previous history of prostate cancer with radiation. Repeat labs. Urinary retention Probably secondary to ileus (decreased gastrointestinal movement). Bladder scans in place .Urinary frequency Possible urinary retention. (Name of indwelling catheter) discontinued at hospital recently .Will check post void residuals -[DATE] 19:01 (7:01 PM) Type: Nursing - Progress Note .Pt. (Patient) was receiving hypodermoclysis (administration of fluids under the skin) when nurse arrived, nurse assessed Pt. abdomen and noticed slight bruising to the area where the needle was inserted into the abdomen with increasing bruising going down Pt. left side of abdomen, Hypodermoclysis was removed from left side of abdomen. Pt also received a bladder scan after voiding over 300cc into the urinal which indicated 100cc of urine (left in bladder) and Pt. did not require catherization. Pt. abdominal X-ray results came back with no obstruction, gas noted, no other findings. A review of R1's record revealed the following order: -Initiate Bladder Scan Qs (every shift) x 3 days. May ISC (Intermittent Straight Catheterization) for scan >300 mL (greater than) every shift for urinary retention for 3 Days Please document: Amt (amount) (mL) of scan, If you had to straight cath Y/N (Yes or No), Amount if ISC in (mL) or NA (Not Applicable) -Start Date- [DATE] 1500. The following information was noted related to the above bladder scan order: 1) [DATE] Evening Shift - 250 mL (on scan), No, N/A. 2) [DATE] Night Shift - 746 mL, Yes, 500 mL (obtained from ISC). 3) [DATE] Day Shift - 232 mL, No, N/A. 4) [DATE] Evening Shift - 108 mL, No, N/A. 5) [DATE] Night Shift - 0 mL, No, N/A. 6) [DATE] Day Shift - 200 mL, No, N/A. 7) [DATE] Evening Shift - 373 mL, Yes, 100 mL (obtained from ISC). 8) [DATE] Night Shift - 243 mL, No, N/A. 9) [DATE] Day Shift - 239 mL, No, N/A. (Order completed). A review of R1's orders, progress notes, and assessments, revealed no nursing progress notes or assessments dated [DATE]. An order to initiate a (name of indwelling catheter) catheter (diagnosis: urinary retention) was entered into R1's record on [DATE]. R1's record did not reveal a corresponding nursing assessment and/or progress note related to the initiation of the catheter and associated findings. An assessment of how R1 tolerated the insertion of the indwelling catheter procedure was not found. Documentation that nursing staff notified the resident's representative upon inserting the catheter was not found. Additionally, orders for the care of the catheter were not entered into the record until [DATE]. Continued review of R1's progress notes revealed: -[DATE] 02:25 (AM) Type: Nursing - Progress Note .UA/C&S (Urinalysis/Culture & Sensitivity) ordered; sample collected, placed in refrigerator in soiled utility on Blossom unit. Oncoming nurse will be notified. (Written by Licensed Practical Nurse (LPN) E). Per R1's orders, the UA/C&S was ordered to rule out a Urinary Tract Infection (UTI). -[DATE] 02:27 (AM) Type: Nursing - Progress Note .Resident had C/O (complaints of chest pain); PRN (as needed) Nitroglycerin given x 1 .Vitals checked and charted; within range .No S/S (signs/symptoms) of distress observed at this time. Call light and bed remote within reach; resident able to make needs known. -[DATE] 11:57 (AM) Type: Physician Team - Progress Note LATE ENTRY .Chief Complaint: Follow-up regarding lab results urinary retention and constipation .Urinary retention Ordered (name of indwelling) catheter placement, Continue current medical management, Monitor output, UA (urinalysis) culture and sensitivity .Follow-up with urologist as recommended . -[DATE] 17:39 Type: Physician Team - Progress Note .Patient had a urinalysis available today and negative .Labs: [DATE] urinalysis, negative nitrates, negative leukocytes, negative glucose, small bilirubin, negative blood, cloudy .Follow-up with urologist as recommended . No progress notes dated [DATE] were noted in the resident's record. -[DATE] 14:37 (2:37 PM) Type: Physician Team - Progress Note .[R1] states his swelling is also improving he feels like his legs feel better. He sitting up in the chair awake and alert patient states he would like to go home. Asoon (sic) .Follow-up with urologist as recommended . No progress notes or assessments dated [DATE] through [DATE] were noted in R1's record. -[DATE] 08:03 (AM) Type: Nursing - Progress Note .Rec'd (received) res (resident) in bed alert and verbal. Able to make needs, concerns, and discomfort known. No SOB (shortness of breath) or labored breathing noted. Denies discomfort .(name of indwelling catheter) cath noted with issues, no return. Writer attempted irrigation of catheter without success. Writer changed (name of indwelling catheter) cath per PRN (as needed) orders. 14fr (14 french - size of catheter tube) 5cc balloon inserted with clearish yellow return noted. (Name of indwelling catheter) cath draining well with no issues. (Name of indwelling catheter) anchor placed on left thigh and (name of indwelling catheter) secured. Res educated on wearing leg bag when up ambulating. Endorsed to oncoming to monitor. Pt has f/u with nephrology today. Oriented to use of call light for assistance. Call light within easy reach. All safety and comfort maintained. The physician order, Nurse may irrigate (name of indwelling catheter)/ Suprapubic catheter for mucus threads and/or plugging with 60ml normal saline; may repeat two times (less than or equal to 60ml must return after each irrigation). four times a day for hematuria, was noted to be initiated on [DATE] at 1:00 PM. -[DATE] 23:29 (11:29 PM) Type: Nursing - Progress Note .Resident stated he was having discomfort with (name of indwelling catheter); writer repositioned and irrigated (name of indwelling catheter). Writer assessed resident during shift; resident stated discomfort has decreased. -[DATE] 18:30 (6:30 PM) Type: Nursing - Progress Note .Resident c/o (complained of) pain around his urethra r/t (related to) his catheter; slight tearing noted. Resident refused to allow writer to irrigate his (name of indwelling catheter) stating it does not work and just wants it to be removed. Writer offered A&D (ointment) to help with friction but resident refused. Logged in Dr. book. -[DATE] 11:34 (AM) Type: Nursing - Progress Note .Pt's (name of indwelling catheter) removed at 1118 (AM), writer will monitor for discomfort. The physician order, PVR if >150ml call Urologist for orders [outside Urologist B] .one time only .Start Date: [DATE] 1618 (4:18 PM). The result of the completed order was 95 mL, documented by LPN D. -[DATE] 15:41 (3:41 PM) Type: Physician Team - Progress Note .Pt examined sorting (sitting) up in chair - he states he feels well patient seen per his request to have his (name of indwelling catheter) catheter discontinued. Patient had (name of indwelling catheter) discontinued early in his stay at the facility had urinary retention and (name of indwelling catheter) was reinserted and patient instructed to follow-up with urologist. Patient states he has a history of prostate cancer with radiation on Flomax finasteride and is followed by a urologist . Per nursing staff urine dip collected for cloudy urine. Patient is asymptomatic. Urine collected from (name of indwelling catheter) catheter and results available .Labs: [DATE] urine dip 500 leuks (leukocytes) .Urinalysis collected for cloudy urine. Positive leuks and blood. Patient asymptomatic will recollect specimen and monitor off antibiotics sent for C&S (culture & sensitivity) .Order placed on chart for nursing to make appointment with urology [outside Urologist B] . -[DATE] 12:16 (PM) Type: Nursing - Progress Note .Pt was bladder scanned by writer. Writer noted 1752 initially on the first scan and then 1522 for the second scan. Writer verbally notified NP (Nurse Practitioner) of findings and (name of indwelling catheter) was placed again. NP stated family should follow up with Urology. Written by LPN D. -[DATE] 13:34 (1:34 PM) Type: Physician Team - Progress Note .Pt examined sorting (sic) up in chair stating he does not feel well. Patient had (name of indwelling catheter) catheter discontinued yesterday for urology. Per nursing staff patient [family] agrees received paper orders and provided to facility requesting to have (name of indwelling catheter) discontinued [DATE] and to straight cath for PVRs greater than 150 per nursing. Patient straight cath 1 time last night. He states he is unable to void this morning. Minimal bladder distention noted. Nursing staff aware and monitoring patient for output and straight cathing per urology orders . Assessments/Plans: Urinary retention (name of indwelling catheter) catheter placed and DC'd (discontinued) [DATE] per urology .Patient due to void and monitor for PVR per urology orders . -[DATE] 16:29 (4:29 PM) Type: Nursing - Progress Note .Writer notified MD at 1530 (3:30 PM) of pt having chest pains, nausea, vomiting and diarrhea. MD gave orders to discontinue Atorvastatin and Nitro; labs CBC (complete blood count) and BMP (basic metabolic profile) and EKG (electrocardiogram); SubQ (subcutaneous) hydration Sodium 0.9% 70 ml/hr and Tigan (anti-nausea medication) 1ML q6hrs IM (every 6 hours) for 3 days. Writer will continue to monitor and will notify MD of any other change of condition. R1's final set of vital signs noted in the record included a pulse of 123 documented at 3:52 PM (outside of normal range [60-120] and abnormal compared to other pulse rates documented for R1 throughout the duration of his stay at the facility). A normal temperature was documented at 3:52 PM. A pain score of 7/10 (indicating moderate to severe pain) was documented at 5:44 PM. -[DATE] 17:56 (5:56 PM) Type: Nursing - Progress Note .Writer spoke to [family] about pt's condition. Writer told [family] of orders given for intervention from MD. [Family] stated [they] wanted [R1] to be sent out after interventions were already in place .[Family] spoke with supervisor and said ok to interventions .[Friends of family] came to nurses station demanding pt to be sent out to [hospital]. [Family] called 911 for pt to leave . Written by LPN D. -[DATE] 14:06 (2:06 PM) Type: Physician Team - Discharge Note .[DATE] ([DATE]) patient had chest pain nausea vomiting diarrhea. Medication changes and diagnostics ordered. Per nursing staff patient's [family] wanted her [R1] to be sent out of facility to hospital. [Family] demanding patient to be sent to [hospital] and called 911. On [DATE] at 12:06 PM, LPN D was interviewed via phone. LPN D confirmed that R1 had not come into the facility with a catheter. When queried regarding the procedure for determining if a catheter is to be placed, LPN D stated she thinks that an indwelling urinary catheter is placed if a resident requires ISC three times. LPN D stated that ISC occurs when there is >350 mL found in the bladder after the patient does/tries to void. When queried regarding the resident experiencing a change in condition and subsequently leaving the facility on [DATE], LPN D explained that R1 had been fine at the beginning of her shift from what she can remember. LPN D stated that later, R1 got sick and was throwing up. LPN D indicated she remembered that a supervisor spoke with the resident's family/visitors that day, but could not recall how the resident appeared prior to leaving the facility or if his vital signs had been abnormal. On [DATE] at 1:15 PM, LPN A, the facility's Infection Preventionist, was interviewed. LPN A was queried regarding the initiation of a urinary catheter after performing PVRs. LPN A stated that the order sets have been revised a few times at the facility, but that the PVR order will typically include instructions on when to place a (name of indwelling catheter) catheter. LPN A indicated that urinary retention is not an appropriate diagnoses for the long-term use of a catheter. LPN A indicated that if it is recommended that a resident follow up with an outside specialist, such as a urologist, the facility staff will help scheduled that appointment. When queried regarding what is expected to be documented upon placing a urinary catheter, LPN A stated that a nursing assessment is expected to be documented along with justification for the use of the catheter. On [DATE] at 2:20 PM, the Director of Nursing (DON) was interviewed. The DON indicated that if a recommended follow-up appointment is not made, she expects there to be documentation in the record as to why. The DON indicated that initiating a (name of indwelling catheter) catheter after PVRs depends on the resident and is at the discretion of the provider. The DON added that facility providers document the reason for (name of indwelling catheter) placement and it is expected that the facility staff help arrange a follow-up appointment with a urologist if recommended by the provider. When queried regarding what is expected to be documented upon placing a urinary catheter, the DON stated that a nursing assessment is expected to be documented along with the justification, What they got out of it (amount of urine) .what color it is, how [resident] tolerated the procedure. The DON also indicated that a resident's representative should be notified when a change in the plan of care occurs, such as the placement of an indwelling catheter. A review of R1's death certificate revealed that R1 died on [DATE]. The death certificate listed the following under, Part I - Enter the chain of events - diseases, injuries or complications - that directly caused the death: a. Septic Shock due to Bacteremia due to, b. Likely Complicated UTI (Urinary Tract Infection) and cholecystitis, c. Renal Failure due to sepsis and coagulopathy, d. Acute systolic congestive heart failure . Approximate Interval between Onset and Death = 1 Week - 10 days . A review of the facility's policy/procedure titled, Catheter Use Overview, issue date [DATE], revealed, If an indwelling catheter is in use, the facility will provide appropriate care for the catheter in accordance with current professional standards of practice and resident care policies and procedures that include but are not limited to: Documentation of the involvement of the resident and/or representative in the discussion of the risks and benefits of the use of the catheter, removal of the catheter when criteria or indication for use is no longer present, and the right to decline the use of the catheter Timely and appropriate assessments related to the indication for use of an indwelling catheter .Insertion, ongoing care and catheter removal protocols that adhere to professional standards of practice and infection prevention and control procedures.,,Response of the resident during the use of the catheter .Ongoing monitoring for changes in condition related to potential catheter-associated urinary tract infections, recognizing, reporting, and addressing such changes . A review of the facility's policy/procedure titled, Catheter Insertion - Indwelling (name of indwelling catheter), issue date [DATE], revealed, .Document procedure in the resident ' s medical record.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to prevent the development of pressure ulcers and implement pressure ulcer interventions for two (R42 and R111) of three residents reviewed, resulting in facility acquired pressure ulcers, the potential for the worsening of existing pressure ulcers, and/or the development of additional skin impairments. Findings include: R111 On 10/13/22 at 11:04 AM, R111 was observed lying in bed on their back with wound dressings observed on both their left and right elbow. R111 was asked about their wound dressings and explained that they are pressure ulcers that were acquired while staying at the facility. R111 detailed the number of pressure ulcers that they have, and explained that the facility staff are supposed to turn and reposition them, but it is not done consistently due to a lack of staffing. A review of R111's medical record revealed that they were admitted into the facility on 5/26/22 with diagnoses that included Stage 4 Pressure Ulcer of Sacral Region, Metabolic Encephalopathy, Legal Blindness and Hypotension. Further review of R111's medical record revealed a Minimum Data Set assessment dated for 8/30/22 that revealed a Brief Interview for Mental Status score of 14/15 indicating an intact cognition. In addition, R111 required extensive assistance of two persons for bed mobility and transfers. Further review of R111's medical record revealed an admission skin assessment dated for 5/26/22 noting the following: Open Coccyx wound (infected), old surgical wound from knee down to ankle, right trochanter hip surgical incision, and chest, 2 small abrasions. Further review of R111's medical record revealed the following progress notes: 6/20/2022 12:46 (12:46 pm) Nursing - Skin/Wound Note. Writer assessed residents left elbow r/t (related to) wound care consult. Resident was admitted with scabs noted to bilat (bilateral) elbows, 'scab peeled off' according to resident. Tx (treatment) in place for wound and protection. 6/30/2022 09:00 (9:00 am) Type: Wound Rounds Note. [R111] seen for follow up wound management. [R111] has a unstageable to the sacrum. Has DTI (Deep Tissue Injury) to both heels. Now has an unstageable to [their] left elbow On the left elbow there is an unstageable wound measuring 3.2cm (centimeters) x 1.5cm that has irregular edges, with slough (dead tissue), scant drainage, no odor, the periwound is intact ASSESSMENT AND PLAN: .3. The patient needs to be turned frequently . 7/26/2022 14:10 (2:10 pm) Type: Physician Team - Progress Note: Patient was seen today, since staff reported sacral wound worsening, also reported there was a scab on the R (right) -elbow that fell off, pt (patient) already on high protein supplements to promote wound healing. 7/28/2022 10:31 (10:31 am) Type: Nutrition/Dietary Note: Pressure ulcer/wound review. Resident has high protein needs for wound healing. Currently on high protein supplements to promote wound healing .Has stg. (stage) 3 rt. elbow (full thickness skin loss), stg. U (unstageable) left elbow . 7/28/2022 21:08 (9:08 am) Type: Wound Rounds Note: Wound Consult Left elbow stg 4 ulcer (deep wound reaching the muscles, ligaments, or bones), refer to, [electronic medical record] moderate drng (drainage), no clinical evidence of infection, surrounding tissue intact, base granular, Recommend Tx: cleanse with 1/4 str (strength) dakins (topical antiseptic), apply silver alginate (wound dressing) cover with ABD QD (every day). Right elbow stg 4 ulcer, refer to [electronic medical record], moderate drng, no clinical evidence of infection, surrounding tissue intact, base granular, Recommend Tx: cleanse with 1/4 str dakins, apply silver alginate cover with ABD QD . 10/6/2022 14:53 (2:53 pm) Type: Wound Rounds Note HPI (History of Present Illness): seeing pt re: multiple wounds .SKIN: .left elbow stg 4 ulcer, refer to [electronic medical record], moderate drng, no clinical evidence of infection, surrounding tissue intact, base granular. Recommend Tx: apply silver collagen gel cover with foam dressing 3x/week. Right elbow stg 4 ulcer, refer to [electronic medical record], moderate drng, no clinical evidence of infection, surrounding tissue intact, base granular. Recommend Tx: apply silver collagen gel cover with foam dressing 3x/week . A review of R111's care plan revealed the following: Actual Pressure Ulcer Formation Related to: Resident was admitted with-- or has pressure ulcer____, with risk for delayed wound healing secondary to progressing comorbidities, Debility and generalized weakness with decreased physical mobility and bowel/ bladder incontinence daily .Date Initiated: 05/27/2022. Interventions: Frequent turning and repositioning Date Initiated: 07/21/2022 Provide surface support and pressure redistribution, position changes, and off loading daily. Date Initiated: 05/27/2022 . Resident #42 (R42) A review of 42's Minimum Data Set (MDS) assessment dated [DATE] revealed that the resident was admitted into the facility on 6/23/20, is severely cognitively impaired, and has medical diagnoses including Fracture of Lumbar Vertebra (history of), Chronic Obstructive Pulmonary Disease, Atrial Fibrillation, Anxiety Disorder, Depression, Pulmonary Hypertension, Osteoarthritis, Alzheimer's Disease, Dementia, Dysphagia, Heart Failure, Muscle Weakness, Glaucoma, Muscle Weakness, and Need For Assistance With Personal Care. A review of R42's medical record indicated that the resident had recently been re-admitted to the facility on [DATE] after being in the hospital for just over a week with pneumonia. A review of R42's skin assessment dated [DATE] revealed that the resident now had a Stage III (full-thickness skin loss) pressure ulcer (no location listed, however, the assessment photo showed the wound on the resident's sacrum). The assessment indicated that the wound was new and present on re-admission from the hospital, however, the After Visit Summary, dated 10/10/22 and corresponding hospital documentation indicated that R42 was admitted into the hospital on [DATE] with a Stage II (partial-thickness skin loss with exposed dermis) sacral pressure injury. R42's skin assessment dated [DATE] indicated that pressure ulcer care to be provided in addition to the wound treatment included, Incontinence management .Positioning Wedge .Turning/repositioning program . R42's current physician orders were reviewed and revealed: -Wound Care Order Site: Buttocks 1) Cleanse wound with NS (normal saline) 2) Pat Dry with Gauze 3) Apply silver alginate 4) Cover with foam (date) .every day shift every Tue, Thu, Sat for wound care AND as needed for wound care .Active 10/10/2022. On 10/11/22 at 1:18 PM, R42 was observed lying in bed on her back with the head of the bed slightly elevated. No positioning wedges were being utilized. On 10/12/22 at 11:56 AM, upon entering the room, R42 was observed lying in bed on her back with the head of the bed in high fowler's position. R42 was moaning/calling out. The resident's blanket was pushed off of her, exposing her incontinence brief. R42 motioned to this surveyor to come closer. R42 was making crying/moaning sounds but was unable at this time to verbalize what was wrong. On 10/12/22 at 11:59 AM, Licensed Practical Nurse (LPN) G and Therapy Staff H entered R42's room. LPN G asked the resident if she was having pain to which she said, Yes, my back, my back. R42 was observed with no offloading devices other than foam boots on her feet. R42 continued to moan out. R42's brief was observed to be saturated with urine, which could be seen from the outside of the brief. LPN G and Staff H boosted the resident up in bed and slightly adjusted her positioning. LPN G asked if that helped R42 feel any better to which the resident responded, Yes, a little bit, not much, not much, not much. The resident was positioned as turned towards her right side but still on her back. R42 indicated that her back still hurt to which LPN G offered medication. R42 accepted and as LPN G went to gather the medication, she was queried regarding the resident's brief being wet. LPN G looked at Staff H and both indicated that they had not even looked at the resident's brief to see if it was wet. On 10/12/22 at 12:05 PM, Agency Certified Nursing Assistant (CNA) I entered the hallway and was queried if R42 had been changed yet this shift (day shift). CNA I indicated that the resident had not yet been changed on this shift. LPN G indicated at this time that R42 has skin breakdown and went back into the room to administer pain medication to the resident. On 10/12/22 at 12:15 PM, LPN G and CNA I provided incontinence care to R42. R42's brief was observed to be saturated with urine. A bordered foam dressing dated 10/11/22 was present on R42's sacrum at this time. The dressing appeared soiled and was not intact i.e. the edges were rolled up on one side, exposing the pressure ulcer. CNA I cleaned R42's skin, applied a clean dry brief, and changed the resident's gown. R42 indicated that she now felt a little bit better. The wound dressing was not replaced with a new dressing before staff left the room, and R42 was left lying in bed with no positioning devices to help offload pressure on her sacral pressure ulcer. On 10/13/22 at 8:49 AM, a wound care observation for R42 was conducted with Wound Care Nurse (WCN) Y and CNA Z. Nurse Y stated that R42 recently went to the hospital and had Excoriation, on her bottom at the time, but was re-admitted with, A full blown pressure ulcer. R42 was observed lying in bed on her back. When queried about a positioning wedge(s) for the resident, Nurse Y indicated that the resident has one that should be utilized. Upon review of R42's sacrum, the same soiled dressing dated 10/11/22 with rolled edges was present. However, upon closer inspection, the dressing appeared to have caused an additional skin tear (flap of skin seen with bright red, wet tissue underneath) on the resident's right buttock that was not present when incontinence care was observed the previous day. When queried regarding the wound dressing, Nurse Y stated that the assigned nurses can change the dressing as needed (PRN). When informed that the same dressing was observed as not intact the previous day during incontinence care, Nurse Y stated she would have expected the dressing to have been changed at that time. Nurse Y added, That's why I put the PRN orders in. When queried about offloading pressure and turning/repositioning R42, Nurse Y put a positioning wedge under the resident's right side and stated she expects the resident to be turned/repositioned every two hours and for pressure to be offloaded on the resident's wound/backside. On 10/13/22 at 9:56 AM and 11:52 AM, R42 was observed lying in bed in the same position as was observed after wound care completion at 8:49 AM. R42's positioning wedge remained under the right side and the resident did not appear to have been moved in bed. On 10/13/22 at 2:40 PM, the Director of Nursing (DON) was interviewed and asked what her expectation of nurses is if a wound dressing is not intact (has rolled up edges and/or soiled). The DON stated she expects nursing to change the dressing PRN if there is an order. The DON further indicated that dependent residents are expected to be turned/repositioned in bed at least every two hours, and she expects a positioning device to be in place to offload pressure if a resident has a skin concern. A review of R42's care plan revealed: -The resident has bladder incontinence r/t (related to) Alzheimer's, Impaired Mobility Date Initiated: 06/29/2020. -BRIEF USE: The resident uses disposable briefs. Change often and prn (as needed). Date Initiated: 06/29/2020. -Clean peri-area with each incontinence episode. Date Initiated: 06/29/2020. -Risk for Pressure Ulcer Formation related to: generalized debility and weakness as evidenced by: decreased mobility in bed and wheelchair, incontinence of bowel and bladder. Resident need staff assistance with incontinence care, turning and re positioning .Date Initiated: 08/08/2022. -Frequent turning and repositioning. Date Initiated: 10/10/2022. -Provide surface support and pressure redistribution, position changes, and off loading daily. Date Initiated: 10/10/2022. -Provide wound care as ordered by physician and wound consult recommendations. Date Initiated: 10/10/2022. A review of the facility's policy/procedure titled, Skin & Wound Policy, dated 04/2022, revealed, .It is .our policy to follow the treatment plans for any wound / skin concerns as ordered by physicians .6. Wound treatments will be provided in accordance with physician orders, including the cleansing method, type of dressing, and frequency of dressing change .8. Dressing changes may be provided outside the frequency parameters in certain situations: a. Feces has seeped underneath the dressing. b. The dressing has dislodged. c. The dressing is soiled otherwise, or is wet .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Deficient Practice Statement #3 Based on observation, interview and record review, the facility failed to supervise a resident during medication administration for one sampled resident (R576) of one resident reviewed for med administration resulting in, medication being taken by the resident without proper supervision. Findings include: On 10/11/22 at 11:21 AM, R576 was observed sitting in their wheelchair, nebulizer mask observed on their table, nebulizer machine on and running. There was no nurse present inside or outside of the room. R576 was asked where the nurse went and stated, They always say they will come back but never do. R576 was asked if the nurse remains in the room during their nebulizer treatments, and they stated, Sometimes they do, and sometimes they don't. A review of R576's medical record revealed that they were admitted into the facility on 9/30/22 with diagnoses that included Viral Pneumonia, Health Failure and Respiratory Failure. Further review of R576's medical record revealed a Minimum Data Set assessment dated [DATE] revealing a Brief Interview for Mental Status score of 10/15 indicating a moderately impaired cognition, and required extensive assistance for Activities of Daily Living. Further review of R576's medical record revealed the following physician's order dated 10/6/22, Ipratropium-Albuterol Solution 0.5-2.5 (3) MG (milligrams)/3ML (milliliters). 3 ml inhale orally four times a day for Asthma SOB (shortness of breath). Further review of R576's medical record did not reveal an assessment indicating that they could self-administer their own medications. On 10/12/22 at 1:05 PM, R576 was observed sitting up in bed with their nebulizer mask covering their mouth. There was no nurse present inside or outside of the resident's room. On 10/13/22 at 2:36 PM, the Director of Nursing was asked whether a nurse should be present during the administration of a nebulizer treatment, and she explained that staff should stay with the resident until their treatment is complete, unless the resident has an assessment indicating that they can self-administer medications on their own. A review of the facility's Nebulizer Treatment policy revealed the following, o) If the patient is deemed appropriate to self-administer medication the nurse will setup the patient with the medication ready for administration. The medication will continue to remain in the medication cart until at which time the patient needs the medication. The nurse does not need to be present in the room for the entire time of administration. (this should be documented with the order or on the plan of care that the patient may self-administer) See self-administration of drug policy #2070 p) At the completion of the treatment, the medication cup is cleaned with water and allowed to air dry. q) Take apart nebulizer. Wash all parts except tubing and finger valve with soap and water. Rinse with water, dry & store . Deficient Practice Statement #1 pertaining to intake MI00131282: Based on observation, interview, and record review, the facility failed to transfer a resident per the plan of care, affecting one (R129) of eight reviewed for accidents, resulting in a large, deep leg laceration that required a transfer to the hospital and 26 sutures. Findings include: A review of a complaint submitted to the State Agency revealed: It was alleged that facility staff failed to properly transfer the resident, resulting in injury. A review of R129's Minimum Data Set (MDS) assessment dated [DATE] revealed that the resident was initially admitted into the facility on 3/9/20 and re-admitted on [DATE], is severely cognitively impaired, and requires extensive to total assistance from staff for activities of daily living (ADLs). R129's medical diagnoses include Subsequent Encounter For Fracture With Routine Healing, Vascular Dementia, Alzheimer's Disease, Type 2 Diabetes Mellitus Without Complications, Dysphagia, Moderate Protein-Calorie Malnutrition, Need For Assistance With Personal Care, Muscle Weakness, Difficulty In Walking, Syncope And Collapse, Anxiety, Edema, Pneumonia, Thrombosis, Respiratory Failure, Laceration Without Foreign Body, Right Lower Leg, Subsequent Encounter, and Sick Sinus Syndrome. A review of R129's care plan revealed: -Transfers: x2 with Hoyer, Date Initiated: 03/09/2020. -Use caution during transfers and bed mobility to prevent striking arms, legs, and hands against any sharp or hard surface., Date Initiated: 03/10/2020. -TRANSFER: The resident requires Mechanical Lift, Date Initiated: 12/29/2021. On 10/11/22 at 1:08 PM, Confidential Witness C was interviewed regarding R129's care at the facility. Witness C expressed concern regarding the resident being transferred in an unsafe manner and sustaining an injury to her leg that required a hospital visit and significant amount of sutures. On 10/11/22 at 1:15 PM, R129's right lower leg was observed to have a large C-shaped scar. On 10/11/22 at 1:49 PM, photos of R129's injury sustained in the facility on 11/25/21 were reviewed and revealed a large, bleeding, C-shaped wound with flap of skin on the resident's right lower leg that extended into the subcutaneous (fatty) tissue. A photo of the wound after closure was also reviewed and revealed that it required an extensive amount of sutures for closure. Bruising was also noted around the injury site. A review of R129's progress notes revealed the following: -11/25/2021 21:43 (9:43 PM) .Writer notified by staff nurse that [R129] had obtained a laceration to .leg during a transfer into bed by CENA (Certified Nursing Assistant - CNA). Upon arrival to room, pt. (patient) was in bed lying on her left side with her right leg wrapped up in a bandage. Bandage pulled back and a deep laceration noted thru to the fatty tissue of about 1.5 inches long with bleeding noted. Pressure bandage in place. EMS (emergency medical service) notified to transport pt. to hospital for eval. (evaluation) and treatment. Nurse notified on call doctor and family. D.O.N (Director of Nursing) notified. -11/25/2021 23:52 (11:52 PM) .late entry approximately 7 pm Cena called me to room found pt with a large skin tear on r (right) lower extremity. Cena said it happened during a transfer. family notified and family notified called [hospital] . -11/26/2021 01:48 (AM) .Resident returned from [hospital] via stretcher for treatment of laceration to RLE (right lower extremity) with 26 sutures . A review of R129's hospital documentation dated 11/25/21 revealed: Pt presents to the EC (emergency center) with c/o (complaint of) laceration resulting from transferring from a wheelchair. Pt denies fall. The laceration is on the R leg, lateral calf area. Bleeding is controlled at this time. Pt is from a nursing home with a language barrier so family member at bedside . .Laceration repair. Date/Time: 11/25/2021 11:49 PM .Risks discussed: Infection, pain, poor cosmetic result, poor wound healing and need for additional repair .Laceration details: .Length (cm): 11.5 .Number of sutures: 26 . The hospital documentation also noted that the patient received a tetanus shot. On 10/13/22 at 9:21 AM, Witness C alerted this surveyor to a new skin alteration to R129's left upper arm. Witness C stated they were called to be notified about the skin tear the day before yesterday, but no one could tell them how it happened. On 10/13/22 at 9:56 AM, Licensed Practical Nurse (LPN) W, the facility's Safety Nurse, was interviewed at R129's bedside and queried regarding the new skin tear to her left upper arm. LPN W stated that he was informed that the skin tear was not present two days ago and that the resident requires a Hoyer lift for transfer. LPN W indicated the skin tear could have been from a transfer, or a blood pressure cuff, and added, But not sure .The resident can't tell us .[R129's] skin is very frail and has gotten a lot of injuries, even just boosting her up [in bed]. LPN W assessed the skin tear which was a large, dark, bruised area with the top layer of skin peeled back, revealing wet, red skin underneath. LPN W stated, It's superficial but I'm sure it burns. LPN W was then queried regarding the injury R129 sustained to her left lower leg on 11/25/21. LPN W indicated he investigated the incident and determined that the resident's assigned CNA was putting the resident in bed by herself. LPN W explained that as the CNA was bringing R129's legs up to put them in bed, the resident's leg was caught on the bed's metal frame. LPN W showed this surveyor the resident's bed frame, which is metal with a hinge in the middle. The edge and hinge of the frame were noted to be quite hard and sharp. LPN W stated that the assigned CNA, CNA DD, transferred R129 by herself even though the resident required two people for transfers at that time, and the CNA also did not use the Hoyer lift. LPN W stated that a facility-wide in-service was conducted after the injury and added, [The laceration] looked bad .like a dog had attacked her. On 10/13/22 at 10:50 AM, CNA DD, who was assigned to care for R129 on 11/25/21, was interviewed via phone. CNA DD was asked what happened with the resident on the date her leg was cut open. CNA DD would not provide any specific details about the incident. CNA DD stated, The aging body is frail and just a touch can open up in the elderly people. CNA DD further stated that nothing that she does is Consciously malicious. CNA DD explained that on the date of R129's injury, she was assigned to care for 20 residents, 9 of whom required a Hoyer lift for transfers (which requires two staff to operate). CNA DD stated, I told them they were giving me too many people to take care of. I was exhausted. CNA DD stated she felt she was put in a difficult position and added, By hurrying up, having too many people to take care of, you end up hurting someone, which you don't want. On 10/13/22 at 1:30 PM, the Nursing Home Administrator (NHA) was interviewed during the Quality Assurance (QA) task review. When queried regarding the injury to R129's leg, the NHA was unable to provide specific details related to the incident since it happened before her arrival to the facility. The NHA did state that multiple in-services were given to staff regarding safe transfers and that there was a full fall monitoring action plan at that time. The NHA added that CNA DD would not fully discuss the incident and subsequently resigned from working at the facility during a disciplinary meeting. On 10/13/22 at 2:40 PM, the DON was interviewed and queried regarding staff following the plan of care for activities of daily living (ADLs) including transfers. The DON stated that if a resident is a two-person assist, that, I'm going to go get help and come back. The DON denied any current concerns related to residents not being transferred appropriately by staff. A review of the facility's policy/procedure titled, Happy Feet Transfer Program, dated 9/29/2017 revealed, POLICY: All residents admitted to the facility shall be evaluated to determine the safest method of transfer. PROCEDURE: .3. The safest method of transfer (bed to wheelchair transfer and toileting transfer) shall be posted in the resident's room. (i.e. bed to wheelchair transfer is x one and toilet transfer is x one, the posting would be x one). (i.e. bed to wheelchair transfer is x one and toilet transfer is x two, the posting would be x one and BR x two) .6. The nurse manager/designee will document the method of transfer in the ADL book and on the care plan . A review of the facility's policy/procedure titled, Fall Risk/Injury Prevention Assessment, dated 10/1/22 revealed, It is the policy of this facility to assess every resident for fall risk and provide an environment that is free from accident hazards over which the facility has control, and provides supervision and assistive devices to each resident to prevent avoidable accidents .The care plan will include interventions, including recommended assistance, consistent with a resident ' s needs, goals, and current standards of practice in order to reduce the risk of an accident . Deficient Practice Statement #2 This citation pertains to intake numbers MI00131431. Based on interview and record review the facility failed to monitor one resident (R23), who was a known elopement risk, of eight residents reviewed for accidents, resulting in the resident exiting the building unbeknown to staff and being located outside of the building, approximately thirty yards from a highly traffic congested road. Findings include: On 10/11/22 at 9:17 AM, an incident/accident report (I/A) was reviewed involving R23 and stated the following, 9/8/22 14:30 (2:30 PM): Nursing Description: Resident went outside facility by themselves through a door not connected to a wanderguard (device that triggers alarms and locks monitored doors). Description: Resident was immediately returned inside facility. Injuries Observed At Time of Incident: No injuries observed at time of incident. On 10/11/22 at 9:30 AM, a review of R23's electronic medical record (EMR) revealed multiple elopement assessments in R23's EMR which indicated that R23 was a High Risk To Wander resident. On 10/11/22 at 9:43 AM, a progress note located in R23's EMR revealed the following, 8/6/2022 18:59 (6:59 PM) Nursing-Progress Note Text: The writer observed resident wandering on 900, [R23] was near the exit door attempting to open the door, the nurse on 300 was paged and the writer redirected the resident back to their appropriate unit .the resident does have a wander bracelet on their right ankle. On 10/11/23 at 9:52 AM, further review of R23's EMR revealed that R23 was originally admitted to the facility on [DATE] with diagnoses that included Cerebral infraction (Stroke) and Dementia. R23's most recent minimum data set assessment (MDS) dated [DATE] revealed that R23 had a severely impaired cognition and required extensive assistance for all activities of daily living (ADLs) other than eating. On 10/12/22 at 10:10 AM, Certified Nursing Assistatnt (CNA) N was interviewed regarding the incident involving R23 on 9/8/22. CNA N indicated that they observed [R23] outside the building in the north parking lot at approximately 2:40 PM, when returning from a scheduled break. CNA N stated, I brought [R23] back inside. The exact location where CNA N indicated that they had found R23 was approximately thirty yards from a highly traffic congested road. On 10/12/22 at 10:30 AM, Nurse P was interviewed regarding the incident involving R23 on 9/8/22. Nurse P indicated that they last saw R23 on the unit at approximately 1:30 PM. Nurse P was unable to provide any other information regarding the incident involving R23. On 10/12/22 at 10:39 AM, Nurse Q was interviewed regarding the incident involving R23 on 9/8/22 and indicated that R23 Frequently propels themselves around the building. I redirect them back to their unit. [R23] is busy. Nurse Q had no specific information related to the incident on 9/8/22. On 10/12/22 at 11:15 AM, Nurse W was interviewed regarding the incident involving R23 on 9/8/23. Nurse W stated, I last saw [R23] sitting in their wheelchair at 2:20 PM, we had a code blue (patient in need of immediate medical attention) on another unit and all the nurses went to help out. [R23] must have gotten out then. Nurse W had no further information regarding the incident. On 10/12/22 at 3:30 PM, the Assistant Director of Nursing (ADON) was interviewed regarding the incident involving R23 on 9/8/23. The ADON indicated that based upon an internal investigation of the incident involving [R23], it is speculated that [R23] exited an deactivated alarmed door on the east side of the building during the time that a code blue was occurring in the building. The ADON further indicated that speculation was that [R23] wheeled themself down a sidewalk on the east side of the building into the east parking lot area where they were found by CNA N who was returning from a break. The ADON stated, Based upon our investigation we believe [R23] was out of the building for approximately twenty minutes. On 10/12/22 at 3:39 PM, the facility reported incident (FRI) and the facility's investigation of the incident was reviewed with the Director of Nursing (DON) and the Administrator (NHA). They were asked what the facility expectation was for monitoring residents and preventing facility elopement. They indicated, that all staff are responsible for monitoring residents. The DON stated, It takes a village. On 10/13/22 at 2:30 PM, a facility policy titled Accident and Incident Report Date Approved: 06/20/2022 was reviewed and stated the following, The purpose of this policy is .(f} to prevent re-occurrence of a similar incident; (g) to provide timely follow-up of corrective measures .