**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility did not ensure that 2 of 2 residents (R) reviewed for pressure injuries (PI) (R36 and R8) received care consistent with professional standards of practice to prevent the development of a new pressure injury and promote healing of existing PIs. R36 was at risk for PI development. R36 developed multiple stage 3 PI's. The facility failed to evaluate the effectiveness of current interventions R36 had in place. The facility did not reposition R36 for several hours, did not find PI's until they were at a Stage 3, missed weekly wound treatments, and did not provide proper infection control measures during wound dressing change. R8 was at risk for PI development. R8 developed multiple stage 3 PI's. The facility failed to evaluate the effectiveness of current interventions R8 had in place. The facility did not reposition R8 for several hours, did not find PI's until they were at a Stage 3, missed weekly wound treatments, and did not provide proper infection control measures during wound dressing change. The facility's failure to monitor and re-evaluate R36 and R8 plan of care, implement aggressive PI prevention measures after re-evaluation and monitor the effectiveness of the interventions, ensure R36 and R8 were repositioned per poc or standards of practice, identify PIs prior to Stage 3, complete weekly measurements created a finding of immediate jeopardy which began on 3/4/24. Surveyors notified NHA A (Nursing Home Administrator), DON B (Director of Nursing), and Regional Nurse of the immediate jeopardy on 8/15/24 at 12:58 PM. The immediate jeopardy was removed on 8/15/24; however, the deficient practice continues at a severity/scope of D (Potential for Harm/Isolated) as the facility continues to implement its action plan. Findings include: Guidelines from the National Pressure Injury Advisory Panel (NPIAP) 2016, Pressure Injury Prevention Points, accessed 07, March 2024, Prevention Points | National Pressure Ulcer Advisory Panel (npiap.com), states in part: Turn and reposition all individuals at risk for pressure injury, turn the individual into a 30-degree side-lying position and use your hand to determine if the sacrum is off the bed, ensure that the heels are free from the bed, use heel offloading devices for high-risk pressure injuries. The facility policy entitled, Pressure Injury Prevention and Managing Skin Integrity, dated 08/10/23, states in part: .a. Identify interventions. i. The care and intervention for any identified skin breakdown or wound is intended to prevent any further advancement of the wound or additional skin breakdown. -There will be collaboration with the IDT regarding the presence of breakdown and the intervention plan. -Identification of risk factors present or acquired that compromise skin integrity will be considered . 1. R36 was admitted to the facility on [DATE] with diagnoses including, in part, unspecified dementia, neuromuscular dysfunction of the bladder, cerebral infarction, and diabetes mellitus. R36's Minimum Data Set (MDS) assessment, dated 5/23/23, identified on admission that R36 had a Brief Interview for Mental Status (BIMS) score of 6. This indicated R36 had severe cognition impairment. The MDS assessment also identified R36 required total dependent assistance of two people for bed mobility, taking on and off footwear, rolling left to right, sit to lying, chair to bed, toileting, and for transfers. MDS also indicated that R36 was determined to be at risk for PI's. MDS dated on 2/22/22 indicated that R36 but did not have any active PIs on admission. Surveyor reviewed R36's Activities of Daily Living care plan: BED MOBILITY Initiated on 8/9/24, revised on 8/9/24: -The resident is totally dependent on staff for bed mobility and repositioning and turning in bed 1-2 person assist. TOLIET USE Initiated on 2/23/22 revised on 2/09/23: -2 assist. TRANSFER Initiated on 2/23/22, revised on 2/10/23: -2 assist and Hoyer. Surveyor reviewed R36's IMPAIRED SKIN Care Plan: -Administer treatments as ordered and monitor for effectiveness initiated on 2/23/22. -Blue boots while in bed and chair if possible initiated on 5/4/23. -Follow facility policies/protocols for the prevention/treatment of skin breakdown initiated on 2/23/24. -If up in chair for more than 60 mins, the weight must be off loaded by reclining while sitting in the Broda chair initiated on 10/26/23 and revised on 7/25/24. -Monitor/document/report as needed any changes in skin status: appearance, color, wound healing, s/sx of infection, wound size (length x width x depth), stage initiated on 2/23/22. -Staff to assist with check/change and skincare incontinence initiated on 2/23/22. -Staff to assist with turning and repositioning initiated on 2/23/22, revised on 8/9/24. -The resident needs assistance to turn/reposition, as needed or requested initiated on 2/26/22, revised on 10/25/23. -The resident requires pressure relieving/reducing device/air mattress on bed, and pressure relieving cushion in wheelchair initiated on 2/26/22, revised on 2/9/23. Surveyor reviewed Activities of Daily Living (ADL) CNA Kardex sheet: -If up in chair for more than 60 mins, the weight must be off loaded by reclining while sitting in the Broda chair -Lay resident down after lunch. -Transfer Hoyer with 2 assists. -The resident is totally dependent on staff for bed mobility and repositioning and turning in bed 1-2 person assist. -Staff is to assist with turning and repositioning. -Turn and reposition. limit sitting to 60 minutes. -Turn and reposition resident every 2 hours while in bed. Surveyor reviewed physician orders, which include: .-5/29/22-Blue boots to float heels to be on at all times in bed and when possible, when in chair. -10/24/23- limit sitting to 60 minutes, off load wound every shift. -7/11/24- Complete skin only assessment, ensure that bath is completed and document refusals. -7/15/24-Apply calcium alginate and cover with gauze island dressing daily to left ankle. Every evening shift for IC, Wound care. When doing wound care we need to make sure we are putting a wound note in every time about the location, appearance of wound, drainage, s/sx of infection, pain, and what was applied to the area . Surveyor reviewed wound care notes: -On 7/24/23- Initial assessment of a non pressure wound to the left sacrum, right buttock, and left buttock. There is no description of these non pressure areas, no assessment or measurements describing the non pressure areas. -On 7/31/23-Initial assessment of a Stage III pressure wound to the coccyx full thickness 2.0 cm x 0.5 cm x 0.2 cm. non-pressure wound of the right buttock full thickness 7.0 cm x 1.5 cm x 0.1 cm. Of note, the facility does not mention the left sacrum or left buttock. The facility did not discover R36's coccyx until it was a Stage 3. R36 had already presented with non pressure areas to the left sacrum, and right and left buttocks. This should have put the facility on notice to do robust skin checks on R36 every shift. *Physician recommendations reposition per facility protocol, offload wound, Group-2 Mattress, upgrade offloading chair cushion. Primary dressing: Leptospermum honey apply once daily for 30 days. Foam silicone border apply once daily for 30 days. -On 8/21/23-Wound care assessment was missed. -On 10/23/23-the right buttock non-pressure deteriorated to an unstageable deep tissue injury to the right buttock 4.5 cm x 5.5 cm x 0.1 cm. *Physician recommendations limit sitting to 60 minutes, reposition per facility protocol, off load wound, upgrade offloading chair cushion. Primary dressing: Leptospermum honey apply once daily for 30 days. Gauze island w border apply once daily for 30 days. -On 10/24/23 a physician order was given to limit sitting to 60 minutes, offload wound every shift. -On 10/26/23 intervention put into place on care plan: -If up in chair for more than 60 mins, the weight must be offloaded by reclining while sitting in the Broda chair. On 12/4/23- Right buttock wound was described as a Stage III pressure wound of the right buttock full thickness 4 cm x 1.3 cm x 0.2 cm. (Wound is smaller in size but deeper than it had been on 10/23/23.) *Physician recommendations limit sitting to 60 minutes, reposition per facility protocol, off load wound, upgrade offloading chair cushion. Primary dressing: Leptospermum honey apply once daily for 16 days. Gauze island with border apply once daily for 16 days. -On 12/11/23-Stage III pressure wound of the right buttock full thickness 2 cm x 2 cm x 0.3 cm. Initial assessment of a Stage III pressure wound to the coccyx full thickness 2 cm x 0.5 cm x 0.2 cm. *Physician recommendations limit sitting to 60 minutes, reposition per facility protocol, off load wound, upgrade offloading chair cushion. Primary dressing: Leptospermum honey apply once daily for 9 days. Gauze island w border apply once daily for 9 days. Of note, R36 now presents with two Stage 3 PI's. -On 12/25/23- Wound care assessment was missed. -On 1/24/24-Stage III pressure wound of the coccyx full thickness resolved. -On 2/19/24- Assessment of a Stage II pressure wound to the left Buttock partial thickness 3 cm x 1 cm x 0.05 cm. Of note, R36 is now presenting with third PI, now a Stage 2, to the left buttock. Physician recommendations reposition per facility protocol, off load wound. Primary dressing: Leptospermum honey apply once daily for 30 days. Gauze island w border apply once daily for 30 days. Despite the care planned interventions, R36 continues to develop PI's. There is no evidence in R36's medical record to indicate the Interdiscplinary Team (IDT) evaluated the effectiveness of the current interventions and if the interventions were effective. -On 3/25/24- Wound care assessment was missed. Facility did not re-evaluate effectiveness of current interventions or placed new interventions in place. -On 4/1/24- Stage III pressure wound of the left ankle full thickness 3x2x0.2 cm. Of note, this is the 4th PI for R36. The facility did not discover this PI until it was a Stage 3. Physician recommendations reposition per facility protocol, off load wound, pressure off-loading boot. Primary dressing: Alginate calcium w/silver apply once daily for 30 days. Gauze island with border apply once daily for 30 days. Facility found R36 to have a new stage III PI to the left ankle and no new interventions were put into place. -On 4/29/24- Assessment of Stage II pressure wound to the left buttock partial thickness 1.5 cm x 0.76 cm x 0.1 cm. (Wound is smaller but deeper than it had been on 2/19/24.) *Physician recommendations limit sitting to 60 minutes, reposition per facility protocol, off load wound, upgrade offloading chair cushion. Primary dressing: zinc ointment apply Q-shift 3x day for 9 days. -On 6/17/24- Wound care assessment was missed. -On 6/24/24- Non pressure wound of the right buttock full thickness 4.8 cm x 1.83 cm x 0.1 cm. Physician recommendations reposition per facility protocol, and off load wound. Primary dressing: zinc ointment applies Q-shift 3x day for 16 days. Facility found R36 to have a new non pressure injury to the right buttock and no new interventions were put into place. -On 7/1/24- Stage II pressure wound of the right buttock partial thickness 2.45 cm x 2.02 cm x 0.1 cm. Physician recommendations reposition per facility protocol, and off load wound. Primary dressing: zinc ointment applies Q-shift 3x day for 9 days. Physician ordered: -On 7/11/24 to complete skin only assessment, ensure that bath is completed and document refusals. No other interventions were put into place to off-load the PI area. -On 7/15/24-Apply calcium alginate and cover with gauze island dressing daily to left ankle. Every evening shift for IC, Wound care. When doing wound care, we need to make sure we are putting a wound note in every time about the location, appearance of wound, drainage, s/sx of infection, pain, and what was applied to the area . Wound care notes continue: -7/29/24-Stage III pressure wound of the left ankle full thickness 1.99x0.92x0.2 cm, Stage II pressure wound of the right buttock partial thickness 8.06x4.37x0.1cm. Wound notes indicate that R36's PI to the left ankle and R36's PI to the right buttock is getting bigger and there were no further interventions were put into place. Observations: On 8/13/24 at 8:13 AM, Surveyor observed R36 lying on back supine in bed, staring at ceiling. Surveyor introduced self but R36 did not respond. R36 was non-interviewable. Surveyor observed an air mattress in place on bed. Surveyor observed no pillow under R36's head and R36 lying crooked in bed. On 8/13/24 at 8:20 AM, Surveyor observed CNA K enter R36's room with CNA M. CNA K and CNA M began turning and rolling R36. R36 was lying in bed staring at ceiling with pants pulled down to knees. CNA K looked at brief and stated out loud, Dry, so she is good to get up. CNA K and CNA M began rolling R36 and tucking Hoyer sling under R36. CNA K and CNA M transferred R36 into wheelchair and pushed R36 out to the dining room for breakfast. On 8/13/24 at 9:21 AM, Surveyor observed R36 sitting in lounge after breakfast parked next to TV in Broda chair with Podus boots in place on feet, but feet positioned outwards with R36's ankles applying pressure to ankles bilaterally. Surveyor did not observe staff lay R36 down or reposition R36 for pressure relief interventions. On 8/13/24 at 10:12 AM, Surveyor observed activities staff take R36 outside for the activity. R36 sitting in Broda chair with Podus boots in place on feet but feet positioned outwards with R36's ankles applying pressure to ankles bilaterally. Surveyor did not observe R36 repositioned or toileted. On 8/13/24 at 12:10 PM, Surveyor observed staff take R36 to the dining room for lunch. R36 sitting in Broda chair with Podus boots in place on feet but feet positioned outwards with R36's ankles applying pressure to ankles bilaterally. Surveyor did not observe R36 repositioned or toileted. On 8/13/24 at 1:30 PM, Surveyor observed R36 sitting in dining room for music activities. R36 sitting in Broda chair with Podus boots in place on feet but feet positioned outwards with R36's ankles applying pressure to ankles bilaterally. On 8/13/24 at 2:43 PM, Surveyor interviewed CNA K and asked CNA K if CNA K or CNA M had laid R36 down in bed, checked and changed R36, or repositioned R36 since getting R36 into wheelchair. CNA K indicated that CNA K and CNA M did not have time to lay R36 down or reposition R36 as CNA K and CNA M were swamped with their duties and every time CNA K went to grab R36 to take her to reposition, R36 was in activities. On 8/13/24 at 3:08 PM, Surveyor interviewed CNA O and CNA H and asked if CNA O and CNA H are aware that R36 has not been repositioned or toileted since 8:40 AM. CNA O and CNA H indicated that it was given to them in report from day shift that R36 has not been repositioned or toileted. CNA O and CNA H indicated they could lay R36 down now if Surveyor would like. CNA O and CNA H grabbed Hoyer lift and entered R36's room with R36. CNA O and CNA H transferred R36 from wheelchair to the bed. During observation Surveyor observed R36 grimacing once CNA O and CNA H started lifting R36 up into the air. Once CNA O and CNA H lowered R36 to bed, R36 stopped grimacing. CNA O and CNA H began rolling R36 to the right side and R36 grimaced again and jerked hands close to body. CNA H started pulling Hoyer sling out from under R36. CNA H rolled R36 to the right side and CNA O finished pulling Hoyer sling out. CNA O and CNA H placed pillow under R36's legs, and then covered R36 with sheet. Surveyor observed CNA O and CNA H start to doff (take off) PPE (Personal Protective Equipment) and clean up room to leave. Surveyor interviewed CNA O and CNA H and ask what process they utilize to check to see if R36 has a Bowel Movement (BM). CNA H indicated that R36 is on a bowel routine. Surveyor asked CNA H to clarify what a bowel routine is. CNA H indicated that R36 has a BM in the morning when staff are rolling R36 and usually at night time when rolling. Surveyor asked CNA H if CNA H and CNA O plan on checking R36's brief to see if R36 had BM in brief since CNA H and CNA O were rolling R36 in bed. CNA H and CNA O placed new pair of gloves on and indicated that they would roll R36 now before they leave and check to see if R36 has had a BM. CNA H and CNA O rolled R36 and took brief off. Surveyor observed dried medium BM on R36's bottom. Surveyor also observed R36 to have a reddened purple quarter-size wound on the right buttock. Surveyor did not observe a bandage or covering for R36's wound on the buttock. Surveyor observed CNA O and CNA H clean R36 with wet wash cloths and CNA O applied barrier cream to the lower part of R36's buttocks but did not apply barrier cream on R36's upper buttock area and where the wound is located on R36's right buttock. Surveyor observed CNA H and CNA O reposition R36 to R36's left side and propped a pillow behind R36's hips. Surveyor observed R36 to have Podus boots in place while in bed. On 8/13/24 at 3:52 PM, Surveyor interviewed Registered Nurse (RN) I and asked how often R36 receives wound dressing care. RN I indicated that weekly wound rounds are completed by outside consultant and RN I every Monday of the week. RN I utilizes an app on phone that captures a picture of the wound and calculates measurements that links to the Electronic Health Record (EHR). Surveyor asked RN I if RN I could explain R36's wounds to Surveyor. RN I indicated that R36 has a stage III on ankle that started April 1st, 2024. RN I indicated that interventions put into place is wound care orders, pressure relieving devices such as the air mattress and blue Podus boots, off-loading, and limit 60 minutes up at a time. RN I indicated to Surveyor that RN I is aware that the pressure relieving devices were put into place on admission but RN I indicated that RN I encourages staff to utilize pressure relieving devices. RN I indicated that R36 has a stage II on right buttock that keeps healing and reopening that originally started in October 2023. Surveyor indicated to RN I that through observation on 8/13/24 from 8:20 AM - 3:08 PM Surveyor observed R36 not repositioned or toileted for 6.5 hours. Surveyor asked RN I what expectation would be for staff when repositioning and off- loading R36. RN I indicated that expectation would be to reposition R36 while in bed every 2 hours and if R36 is up in wheelchair that R36 does not stay up for more than 60 minutes at a time for off-loading R36 off of R36's pressure injuries. On 8/14/24 at 7:40 AM, Surveyor observed CNA Z, CNA BB, and CNA AA bring R36 out of room for breakfast. R36 was in a Broda chair. On 8/14/24 at 10:10 AM, Surveyor observed R36 in Broda chair sitting in lounge. Surveyor did not observe staff reposition or toilet R36 between observations. On 8/14/24 at 2:38 PM, LPN L (Licensed Practical Nurse) reviewed supplies and then gathered the contaminated wound cleanser bottle and contaminated calcium alginate package LPN L previously used from R8's wound dressing change and entered into R36's room. LPN L set supplies on bedside table and went into bathroom and grabbed gloves. Surveyor did not observe LPN L wash hands before applying gloves. Surveyor did not observe LPN L don PPE in R36 Enhanced Barrier Precaution (EBP) room. LPN L uncovered R36 and took boot off of R36. Surveyor did not observe LPN L place a barrier down under R36's leg. Surveyor observed a saturated bloody brown tinged meplix rolled half off R36's left ankle wound exposing the left malleolus dime size wound. LPN L removed the saturated dressing and threw in the trash. LPN L set R36's left ankle back down on the contaminated bed. Surveyor observed R36's open wounds on left ankle lay directly down on contaminated mattress sheet. LPN L took gloves off and washed hands for 8 seconds. Surveyor observed 3 open dime size wounds on R36's left ankle. Surveyor observed about a dime size open wound with depth and was noticeable metal hardware like in the wound bed located on R36's left ankle lateral malleolus with eschar noted. Surveyor noted hardware showing in the lateral malleolus, but no measurements of depth were assessed at the time by LPN L. Surveyor noted second dime size open area located superior to the first wound. Surveyor observed third pea size open area located to the left of the second wound on R36's left ankle area. Surveyor asked LPN L when R36 developed the 3 open spots near the left ankle wound observed. LPN L indicated that LPN L thought there was only one open wound. LPN L grabbed scissors and began cutting calcium alginate. LPN L cut two pieces to cover the 3 open wounds on R36's left ankle. LPN L lifted R36's leg up and grabbed a piece of gauze and re-wiped all 3 open wounds with the same piece of gauze. LPN L laid contaminated gauze on R36's mattress. LPN L then took the calcium alginate strips and applied the strips to R36's wounds. Surveyor observed one calcium alginate strip fall onto R36's mattress on top of the contaminated gauze. LPN L picked the fallen strip on the contaminated gauze up and reapplied it to R36's left ankle wound. LPN L then grabbed meplix foam dressing and applied the dressing to R36's left ankle. LPN L reapplied R36's sock and placed Podus boot on R36. LPN L took gloves off and exited R36's room. Surveyor observed LPN L place gauze package, wound cleanser, and scissors in treatment cart. Surveyor observed LPN L only sanitize scissors and did not sanitize wound cleanser bottle or throw the gauze package away that was brought into R36's room. On 8/14/24 at 2:48 PM, Surveyor interviewed LPN L and asked what expectation was for wearing PPE in R36's room on EBP (Enhanced Barrier Precautions). LPN L indicated that LPN L only wears PPE when providing cares for catheter care. Surveyor asked LPN L does LPN L not wear PPE during wound care. LPN L indicated that LPN L did not realize that staff are to wear PPE during wound care. Surveyor asked LPN L if LPN L wore PPE in R36's room when LPN L provided wound care. LPN L indicated that LPN L did not wear PPE in R36 room. Surveyor asked LPN L why LPN L did not clean surface of R36's bedside table before placing wound supplies on bedside table. LPN L indicated that LPN L usually does wipe the bedside tables down, but LPN L did not wipe R36's bedside table off before placing wound supplies down. Surveyor asked LPN L was it common practice to not place a barrier down underneath the wound before completing wound care on R36. LPN L indicated that LPN L usually LPN L will place a barrier pad underneath the residents wound when performing wound care, and LPN L did not place barrier pad underneath R36's left ankle. Surveyor asked LPN L what normal practice is when LPN L dropped the calcium alginate strip unto the contaminated gauze and picked the calcium alginate strip and placed it on R36's open wound. LPN L indicated that LPN L should not have placed the contaminated calcium alginate strip back unto R36's wound. LPN L indicated that LPN L should have re-cut a new strip, but LPN L did not. On 8/14/24 at 2:50 PM, Surveyor interviewed RN I (Registered Nurse) and asked for description of R36's wound bed. RN I indicated that the provider and RN I are aware that there is some kind of hardware in R36's ankle and it is showing but that wound has improved. RN I indicated that R36's left ankle wound is noted to be stage III. Surveyor asked expectation for staff wearing PPE in R36 and R8's room on EBP. RN I indicated that all staff are to wear PPE when providing cares to R36 and R8 as both have open wounds and R36 has catheter. Surveyor asked RN I expectation for staff utilizing wound supplies between residents. RN I indicated that supplies should be used for each resident individually and if there is a supply that is shared that the item is wiped down with antibacterial wipes and sanitized appropriately before using the supplies for other residents. RN I indicated that LPN L should have sanitized wound supplies and not brought in contaminated wound supplies from R8's room into R36 's room. RN I indicated that LPN L not sanitizing the scissors that dropped on the floor was a huge infection control issue and LPN L should never have used to cut calcium alginate for R8's wound without properly disinfecting the scissors. Surveyor asked RN I expectation for staff when changing wound dressings. RN I indicated that proper hand hygiene is performed, bedside tables are sanitized, and barriers are placed under the residents wounds to prevent contamination of the wound. RN I indicated that if there was a break in the infection control measures that staff are to stop and start over to prevent further infection from spreading. Surveyor indicated to RN I that LPN L did not wipe bedside table, did not place a barrier pad underneath residents wound, and allowed a strip of calcium alginate to fall on contaminated mattress and then used the contaminated strip to place in a wound. RN I indicated that LPN L should not have performed the wound dressing change. RN I indicated that both wound dressing changes were not performed correctly by LPN L. On 8/14/24 at 3:15 PM, Surveyor called provider who has been following R36's wound description and measurements every Monday. No answer. Surveyor left message in voicemail. On 8/15/24 at 9:17 AM, Surveyor interviewed DON B and asked expectation for repositioning and toileting residents. DON B indicated that all residents are to be repositioned every two hours who need the assistance. All residents should be helped toilet or toileted if dependent every two hours. On 8/15/24 at 10:39 AM, Surveyor interviewed RN I who indicated that RN I changed R36's ankle wound. RN I indicated that RN I did assess the two new open areas near R36's ankle. RN I indicates that RN I thinks the new open areas were most likely from the gauze island dressing the provider ordered for the dressing change. Surveyor asked where the documentation was for R36's new open areas on ankle. RN I indicated that the two new open areas were not documented. On 8/15/24 at 11:40 AM, Surveyor interviewed the Wound Care Provider and asked Wound Care Provider to explain what Wound Care provider thinks is happening with R36's left ankle PI. Wound care provider indicated R36 has hardware eroded through the ankle - it will be hard to heal. Family elected not to remove the hardware, so it is more of a palliative approach right now. Surveyor asked Wound Care Provider if R36's left ankle PI was due to pressure. Wound Care Provider indicated that R36's left ankle is from pressure, and it could be from external means and a portion could be internal means from the hardware. Surveyor asked Wound Care Provider what expectation is for staff to reposition R36. Wound Care Provider indicated that the expectation would be residents be repositioned frequently as part of the plan of care. Surveyor indicated to Wound Care Provider that R36 was observed sitting in Broda chair for 6 hours not repositioned. Wound Care Provider indicated that if R36 had not been being repositioned then the pressure injury to the left ankle would be avoidable. Surveyor asked Wound Care Provider about the accuracy of the measurements completed on a weekly basis. Wound Care Provider indicated that Wound Care Provider is not allowed to measure but that Wound Care Provider must use the software the facility has. Wound Care Provider indicated that Wound Care Provider does not always agree with the measurements of total surface area. Surveyor indicated that through observation of wound dressing change R36 had two more open areas on the left ankle that were not documented on the 08/12/24 wound assessment measurements. Wound Care Provider indicated that Wound Care Provider did not document the two opens sores as it was related to moisture and bandage adhesive not pressure. 2. R8 was admitted to the facility on [DATE] with diagnoses including, in part, traumatic brain injury affecting right dominant side, contracture of right upper arm, unsteadiness on feet, and weakness. R8's Minimum Data Set (MDS) assessment, dated 3/20/24, identified that R8 had a Brief Interview for Mental Status (BIMS) score of 11. This indicated R8 had moderate cognitive impairment. The MDS assessment also identified R8 is dependent on staff requiring total assistance for toileting hygiene, chair to bed transfer, and lower body dressing. Substantial/maximal assistance with putting on and taking off footwear, rolling from left to right in bed, sitting to lying, lying to sitting, sit to stand, and toilet transfer. MDS also indicated that R8 was determined to be at risk for PI's. Surveyor reviewed R8's Activities of Daily Living care plan: BED MOBILITY Initiated on 2/23/22, revised on 6/27/24 -1 assist. TOLIET USE Initiated on 2/23/22 revised on 7/24/24: -1 assist with EZ-stand. TRANSFER Initiated on 2/23/22, revised on 7/24/24: -1 assist with EZ-stand. Surveyor reviewed R8's STAGE III pressure ulcer to right and left coccyx Care Plan: -Staff to assist with turning and repositioning initiated on 3/21/24. -The resident requires pressure relieving mattress and pressure relieving cushion in w/c. Surveyor reviewed R8's IMPAIRED SKIN Care Plan: -Follow facility protocols for treatment of injury initiated on 6/13/23. -Keep skin clean and dry. Use lotion on dry skin initiated on 6/13/23. -Treatment to skin as ordered initiated on 6/14/23. -Use a draw sheet or lifting device to move resident initiated on 6/13/23. -Use caution during transfers and bed mobility to prevent striking arms, legs, and hands against any sharp or hard surface initiated on 6/13/23. Surveyor reviewed Activities of Daily Living (ADL) CNA Kardex sheet: -Encourage to get out of W/C after lunch. Offer to place in recliner or bed, side lying prefer to release pressure off bottom. -Keep skin clean and dry. Use lotion on dry skin. Surveyor reviewed physician orders include: .-2/17/23-Apply soft boot to the right lower extremity. Float heels while in bed. -8/23/23-Complete skin only assessment one time a day every Monday. -6/4/24- ROHO cushion to be placed in wheelchair at all times. - 7/1/24-Apply Calcium Alginate and cover with foam silicone dressing 3x per week to right and left Ischium. Every evening shift every Mon, Wed, Sat for Infection Control, Wound Care When doing wound care we need to make sure we are putting a wound note in every time about the location, appearance of wound, drainage, s/sx of infection, pain, and what was applied to the area. -7/11/24-Complete skin only assessment, Ensure that bath is completed and document refusals. Every night shift every Thursday for Prophylaxis .If any new skin issues open risk management and complete. Surveyor reviewed Skin Only Evaluation Assessment: -On 2/18/22 admission assessment completed. R8 had no skin issues present on admission. -On 8/12/24 skin only assessment completed. R8 has Stage III pressure injury to the right ischium, and Stage III pressure injury to the left ischium. No documentation on appearance, measurements, or description. -On 8/14/23-Initial assessment of a non-pressure wound to the left ischium full thickness 2 cm x 2 cm x 0.1 cm and a non-pressure wound to the right ischium full thickness 3x2x0.1cm. *Physician recommendations Upgrade offloading chair cushion; Group-2 Mattress; Reposition per facility protocol; Off-Load Wound. Primary dressing: zinc ointment applies Q-shift 3x day for 30 days. -On 8/23/23 physician order to Complete skin only assessment one time a day every Monday. -On 9/4/23- Wound care assessment was missed. -On 9/18/23- Initial assessment of a non-pressure wound to the scrotum partial thic[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility did not ensure that each resident's environment remains as free of accident hazards as possible for 1 of 1 residents (R1). R1 resided in the facility's memory care unit and has a history of tossing her leg onto the heat register next to her bed. On 1/15/24, R1 was found to have placed her foot on the heat register next to her bed. This resulted in burns to R1's left lateral foot (full thickness), left foot (undetermined thickness) and right foot (undetermined thickness) that required physician intervention. The facility does not routinely monitor the temperature of the heat registers. The facility's failure to provide proper safety interventions to prevent accidents and monitor resident's rooms and environment created a finding of Immediate Jeopardy that began on 1/15/24. Surveyor notified the NHA A (Nursing Home Administrator) of the Immediate Jeopardy on 2/1/24 at 6:00 PM. The Immediate Jeopardy was removed on 2/2/24; however, the deficient practice continues at a scope/severity of a E (potential for more than minimal harm/pattern) as evidenced by the observation that an additional 17 residents currently residing in the facility's memory care unit (R6, R7, R8, R9, R10, R11, R12, R13, R14, R15, R16, R17, R18, R19, R20, R21, and R22) had their beds next to the heat registers in their rooms Findings include: According to John Hopkins University (https://www.hopkinsmedicine.org/health/conditions-and-diseases/burns), Both infants and the older adults are at the greatest risk for burn injury . Burns are classified as first-, second-, or third-degree, depending on how deep and severely they penetrate the skin's surface. First-degree (superficial) burns: First-degree burns affect only the epidermis, or outer layer of skin. The burn site is red, painful, dry, and with no blisters. Mild sunburn is an example. Long-term tissue damage is rare and usually involves an increase or decrease in the skin color. Second-degree (partial thickness) burns: Second-degree burns involve the epidermis and part of the dermis layer of skin. The burn site appears red, blistered, and may be swollen and painful. Third-degree (full thickness) burns: Third-degree burns destroy the epidermis and dermis. Third-degree burns may also damage the underlying bones, muscles, and tendons. When bones, muscles, or tendons are also burned, this may be referred to as a fourth-degree burn. The burn site appears white or charred. There is no feeling in the area since the nerve endings are destroyed. Burns that are more severe and extensive need specialized treatment. Because the age of a burn victim and the percentage of the body's surface area that has been burned are the most important factors affecting the outlook of a burn injury, the American Burn Association recommends that burn patients who meet the following criteria should be treated at a specialized burn center: Individuals with partial-thickness burns over 10% or more of the total body surface area (TBSA) Any age with full-thickness burns (emphasis intended). Burns of the face, hands, feet, or groin, or genital area, or burns that extend all the way around a portion of the body. R1 was admitted to the facility on [DATE] and has diagnosis including dementia. Her most recent Minimum Data Set (MDS), dated [DATE], shows that the facility did not conduct a Brief Interview for Mental Status (BIMS) as R1 is rarely understood. R1's fall care plan, dated 7/6/23, states, .is at risk for falls related to confusion .unaware of safety needs. R1 has a history of tossing her legs and feet onto the heat register. The facility documented the following progress notes on 1/15/24: *6:37 AM: Residents left foot was bleeding. Skin was peeling off. Wound cleaned and new dressing applied. *8:27 AM: this writer was notified by night nurse that resident has a wound to her left outer foot. Night nurse stated, I changed her dressing. *9:24 AM: Wound doctor here to assess wounds to bilateral feet. He noted that they are burn wounds to the left lateral foot, left foot and right foot. The wound doctor's notes from 1/15/24 on R1's feet read: *Site 1, Burn wound of the left lateral foot .full thickness .wound size 3 x 9 x.01 cm (length, width, depth), light serosanguineous with 100% granulation tissue. *Site 2, burn wound of the left foot, undetermined thickness .1 x 3 x not measurable cm (centimeters) .dried fibrinous exudate (scab) *Site 3, burn wound of the right foot, undetermined thickness .1 x 3 x not measurable cm .dried fibrinous exudate (scab) A 1/15/24 follow-up investigatory note by the previous Director of Nursing (DON), who is no longer working at the facility, states, Resident has several open areas on the outer aspect of the side of the left foot and some old scabs on the toes. Some areas on the toes are open. There is not current drainage from foot. Resident cannot give history but overnight the resident had kicked foot free of the bed linens and bilateral body pillows. She had flung her foot to the wall register. She screamed out and the night CNA (Certified Nursing Assistant) found her with a bloody foot. She went and got the nurse .One side of the residents bed is up againt (sic) the wall .The bed is up against the register that delivers the heat. At some point the resident was able to [NAME] her left foot out of the bed. Originally, it was thought that she had burned her foot on the register, but the wound did not look like a burn nor was it feasible with where the marks were on her foot and toes. There was blood on the register. When the bed was moved, it was noted that the metal juncture between two registers had been disturbed, most likely became hotter than a pleasant warmth. Upon further inspection the ben [sic] piece of metal and part of the radiator were removed. In the juncture piece, there was a large piece of accordioned skin inside it. It looked like the resident had flung her foot out of the bed and then rubbed it on the rough metal. There were several more small pieces of skin that looked about the size of the wound .The area looks like a scrape or abrasion .Bed was moved and the area will be assessed for new furniture arrangement. Radiator was cleaned and put back together and piece is now fitting the register correctly and safely. Surveyors conducted the following interviews on 2/1/24: *At 12:24 PM, RN H (Registered Nurse), who was the nurse working the night shift into 1/15/24 and wrote the first note on R1's wound, stated that the CNA had gotten her out of bed (time unknown, but close to first shift) and the foot was visibly bleeding. RN H stated that she then put a bandage on R1 and she (R1) began moaning in pain. RN H stated she passed the information onto LPN I (Licensed Practical Nurse). *At 12:34 PM, LPN I stated that she received report as she came onto her first shift on 1/15/24 and RN H reported to her that R1 had a wound on her foot. LPN I stated that she told the wound doctor at that time, as he was in the building and is typically in the building between 6-7 AM when he is rounding. LPN I stated that she assisted the wound doctor with his treatment of R1 and then proceeded to check all the other resident room heat registers on the memory care unit, but did not check R1's. LPN I stated she did not think any of the other registers she checked were hot. *At 12:01 PM, Prioress J (head of the order of nuns) stated that on 1/15/24, LPN I had told her about the wound on R1 and that's when they decided to move the bed away from the register on the wall. Prioress J stated that is when she saw a lot of blood on the heating register and wall and what appeared to be either a chunk of skin or coagulated blood stuck on the heating register. Prioress J stated that she was told that R1 was calling out on the previous shift so the CNA checked her and found the blood and the nurse intervened. Prioress J also stated that after the bed had been moved from the wall and heat register, she checked the register and it didn't seem hot so she believed that R1 had rested her foot on the register and it burned over time. Prioress J stated that maintenance and NHA A (Nursing Home Administrator) began checking all the other heat registers on the unit. *At 9:00 AM, RN K, who provided Hospice services to R1, stated that she arrived to the memory care unit on 1/15/24 on the first shift and was told by a nurse that R1 had burned her foot. RN K went to R1's room and the bed was still against the wall and the radiator. RN K also stated that she was in the room when the bed was moved and she could see blood and skin stuck on the heating register. At that time, she put her hand over the register and she couldn't keep it there, it was so hot. RN K also stated that she looked at R1's wound prior to the wound doctor and R1 pulled away when she (RN K) touched the bandage on R1's foot. RN K stated that the main wound (site 1 as mentioned in wound doctor's note) was a burn. *At 2:00 PM, ML L (Maintenance Lead) stated that he and NHA A began gathering temperatures on 1/15/24 after it was discovered that R1 had burned her foot. ML L stated that they did not write any temperatures down but none were very hot. ML L stated that he has not regularly gathered the temperatures of the heating registers before the incident or after the incident. ML L stated that he regularly checks water temperatures and room air, but does not check the registers unless a complaint is made about the temperature in a resident room. *At 2:07 PM, RN C (with NHA A), who is a clinical nurse consultant, stated that the previous DON's note on 1/15/24 noting R1's injury as an abrasion was not regarded as accurate and considered the wound doctor's assessment and notes to be accurate and correct. NHA A stated that he and ML L took temperature readings of all the heat registers on the memory care unit on 1/15/24 after R1 was burned and no temperatures even reached 100 degrees Fahrenheit and they (NHA A and ML L) ensured all the heat registers were in good order and no parts or jagged edges of the registers were apparent. NHA A stated he did not record the temperatures. NHA A stated that the location of resident beds was due to resident preference and that it would be difficult to move those beds and he didn't believe the heat registers would get very hot and were in good working order. NHA A and RN C stated no staff were educated on the heat registers, where bed should be, or the risks the heat registers posed to residents. On 2/1/24 at 2:21 PM, Surveyor interviewed MD M who stated that when he was asked to look at R1's foot on 1/15/24, he was told by staff that she commonly would swing her leg off the bed and onto the heat register next to the bed. MD M stated that given that answer and what he saw on R1's foot, it was consistent with a burn and treated the wound as such. When asked if it's possible for such a burn to occur over a long period of time if the heat register was warm (vs hot), MD M stated that it was possible. The Michigan State Agency sent a memo to its survey staff in 2004, which noted the following: Based on research by our Health Facilities Engineering Section, it has been determined that a temperature of 125 degrees Fahrenheit is normally acceptable on the surface of a heating unit in a nursing home or long-term care facility. This memo continues by noting, This temperature was determined from information found in ASTM International Standard C1055-03, titled Standard Guide for Heated System Surface Conditions that Produce Contact Burn Injuries. American Society for Testing and Materials (ASTM) Standard C 1055 -03 is largely based on the work of [NAME] and [NAME]. This maximum acceptable temperature is based on a maximum acceptable injury level of a first-degree burn, which is reversible, and causes no permanent tissue damage, and a maximum contact time with the heated surface of 60 seconds, to reflect the slower reaction times of the elderly or the infirm. At this temperature, one must recognize that there is some risk. While those who can react should have sufficient time to remove themselves from contact with the heated surface without sustaining permanent damage, it is incumbent upon the facilities to identify those residents who may be unable to recognize the danger or pull away from the heat source and provide extra protective measures for those residents as needed. (Emphasis added.) https://www.michigan.gov/-/media/Project/Websites/[NAME]/bchs/Folder2/BHS_NHM_Heating_Unit_Temperature1.pdf?rev=0c6e67303a1746349f096eaf0c3ba0d3 The temperature of the heat registers here was less than 125 degrees F. However, as noted in the bolded statement above, it was incumbent upon the facility to recognize the danger that even a lower temperature could pose to a resident who may not be able to feel the heat or recognize that s/he is being burned and especially one with a known history of swinging her leg onto the heat register. The failure to ensure a safe environment for a resident with a history of swinging her leg onto the heat register created a reasonable likelihood for serious harm, resulting in a finding of immediate jeopardy. The facility was aware that R1 burned her foot on the heat register, which was against her bed. Despite this, facility did not take measures to educate staff and did not put measures into place to ensure other residents on the memory care unit were not burned. Surveyors observed 17 of 20 resident beds to be against the wall, sandwiching the heat registers. The facility removed the immediate jeopardy on 2/2/24 when it had completed the following: ~All staff with the exception of the dietary department are educated before their next shift on keeping beds away from the baseboard heat registry. Staff education consisted of the newly created baseboard heat registry protocol. ~All beds in facility have been moved away from baseboard heat registers as of 2/2/2024. No other residents affected. ~ Facility created a baseboard heat registry protocol on 02/02/24 focused on bed clearance in relation to the baseboard heat register. The facility will utilize the risk management tool to investigate incidents, determine the root cause, implement interventions, prevent reoccurrence and ensure the primary physician is notified timely with any changes in condition. Risk management will be reviewed daily on business days by the DON, NHA or designee to ensure compliance. ~All resident rooms will be audited to ensure resident beds are not in close proximity to baseboard heat registries. The audit schedule will follow daily for 1 week, 2x per week for 4 weeks and 1x monthly for 2 months. It is the responsibility of the NHA, DON or Maintenance Lead to ensure compliance. The audit will then be reviewed by the QA committee. The facilty will also audit register temperatures of all rooms in the morning and in the evening. Temperatures will be recorded using an infrared heat gun. It is the responsibility of the Maintenance Lead, NHA, or DON to record temperatures. The audit schedule will be weekly for 8 weeks. The temperature audit will then be reviewed by the QA committee.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On 9/20/23 at 10:07 AM, surveyor interviewed CNA D (Certified Nursing Assistant) who indicated that there have been times she was not able to complete job duties, including baths, due to staffing. On 9/20/23 at 10:22 AM, surveyor interviewed LPN C (Licensed Practical Nurse) regarding staffing, LPN C stated, staff is very frustrated. LPN C indicated that CNA staff report to her that there in not enough time to get showers/baths completed. LPN C indicated there was times she was not able to perform wound care due to staffing issues. LPN C indicated nursing floor staff has to adjust the wound care schedules to allow for nursing floor staff to be able to complete all wound care. Based on observation, interview, and record review the facility failed to ensure that 5 of 13 sampled residents (R2, R10, R13, R9, R14) were free from neglect. Numerous staff expressed concerns about low staffing levels and not being able to provide all needed care because there isn't enough staff. R2 had a history of recurrent Urinary Tract Infections (UTIs). The facility failed to follow the physician orders for monitoring R2's output. The facility does not have evidence that staff provided catheter care to R2 on 4/21/23. On 4/21/23 at 5:00 PM, the facility called 911 after finding R2 unresponsive while delivering her supper tray. Emergency Medical Services (EMS) found R2 covered with ants. According to the emergency room (ER) nurse, there were ants embedded in her skin, the catheter bag was dated 4/12/23 and the urine in the bag did not appear fresh; after removing the foley, thick mucus with blood and black sediments was seen in the urine, which smelled of ammonia. After the sludge came out, the urine continued to drain all over R2's bed. The ER nurse could not measure the amount of urine because it poured all over her bed. R2 was admitted to the hospital in septic shock with urosepsis and a urinary tract infection. The facility's failure to ensure R2 was free from neglect created a finding of immediate jeopardy that began on 4/21/23. Surveyor notified NHA A (Nursing Home Administrator) and DON B (Director of Nursing) of the immediate jeopardy on 9/21/23 at 4:12 PM. The immediate jeopardy was removed on 9/25/23; however, the deficient practice continues as a scope/severity of an E (pattern, potential for no more than minimal harm) as the facility continues to implement its action plan and as evidenced by the following: R10 has multiple stage 3 pressure injuries (PIs) and is at risk for developing more pressure injuries. Surveyor observed R10 for over 5 hours and during this time staff did not assist R10 with repositioning/turning. R13 is at moderate risk for developing pressure injuries and is dependent on staff to meet her needs in repositioning/turning. Surveyor observed R13 lying in bed for over 3 hours and during this time staff did not offer R13 assistance with repositioning and turning. R9 has a history of aspiration pneumonia and Traumatic Brain Injury. R9's Physician Orders and Speech Therapy recommendations to provide supervision while R9 was eating were not followed. Staff also gave R9 the wrong consistency of liquid when he was ordered to have nectar thick liquids. R14 is at risk for falls and requires prompt assistance. R14 indicates waiting 45 minutes or longer for assistance 5-6 times per week, placing R14 at risk for falling. This is evidenced by: The facility policy titled, Abuse, Neglect, Mistreatment and Misappropriation of Resident Property, with a revision date of 12/1/22, indicates, in part: Policy: It is the policy of the facility that each individual will be free from 'Abuse'. The term abuse will be used throughout this Policy and Comprehensive Abuse, Neglect, Mistreatment and Misappropriation of Resident Property Program to relate to: mental, sexual, or physical abuse; neglect; exploitation; involuntary seclusion; misappropriation of individual property; injuries of unknown origin; corporal punishment; or involuntary seclusion. The individual will also be free from physical or chemical restraints imposed for purposes of discipline or convenience and that are not required to treat the individual's medical condition. Procedure: A. Individuals will be protected from abuse, neglect and harm while they are residing at the facility. B. No abuse or harm of any type will be tolerated. C. Individuals and staff will be monitored for Protection. D. The facility will strive to educate staff and other applicable individuals in techniques to protect all parties. E. The facility will encourage and support all individuals, staff, families, visitors, volunteers and individual representatives in reporting any suspected acts of abuse to the Nursing Home Administrator or designee. F. The Nursing Home Administrator or designee will report abuse to the state agency per State and Federal Guidelines. G. The facility will follow the attached Comprehensive Abuse, Neglect, Mistreatment and Misappropriation of Resident Property Program to comply with the seven-step approach to abuse and neglect detection and prevention. H. The abuse Policy and Comprehensive Abuse, Neglect, Mistreatment and Misappropriation of Resident Property Program will be reviewed on at least an annual basis and will be integrated into the facility Quality Assurance and Performance Improvement (QAPI) program. R2 was admitted to the facility on [DATE] as a long term resident to the memory care unit, with diagnoses that include, in part: paraplegia (a paralysis affects all or part of the trunk, legs and pelvic organs), neuromuscular dysfunction of the bladder (a complete disruption of both motor and sensory nervous system control over the bladder), urinary tract infection (an infection in any part of the urinary system that includes the kidneys, ureters, bladder and urethra), colostomy (a surgical operation in which a piece of the colon is diverted to an artificial opening in the abdominal wall to the outside of the body as known as a stoma, so as to bypass a damaged part of the colon), and an unspecified fracture of the lower end of the right femur. R2's change of condition Minimum Data Set (MDS) assessment, dated 4/6/23, indicated a Brief Interview of Mental Status (BIMS) score of 12, indicating moderately impaired cognition. R2's Comprehensive Care Plan indicates, in part; . The resident has an ADL (activities of daily living) self-care performance deficit r/t (related to) paraplegia, date initiated 12/4/22 . Interventions: . AM Routine: The resident's preferred dressing/grooming routine is to get up after breakfast. Bathing/Showering: The resident requires extensive assistance of 1 by staff with bathing. Dressing: The resident requires extensive assistance by 1 staff to dress. Eating: The resident is able to feed herself after set up. Personal Hygiene/Oral Care: The resident requires extensive assistance of 1 with oral/personal hygiene. Transfer: The resident requires Mechanical lift (hoyer) with 2 staff assistance The resident has an indwelling catheter r/t Neurogenic bladder, paraplegia, and pressure ulcer to buttock and hip, date initialed 12/5/23 . Goal: The resident will show no s/sx (signs or symptoms) of urinary infections through review date . Interventions: Monitor and document intake and output as per facility policy. Monitor for s/sx of discomfort on urination and frequency. Monitor/document for pain/discomfort due to catheter. Monitor/record/report to MD (medical doctor) for s/sx UTI: pain, burning, blood-tinged urine, cloudiness, no output, deepening of urine color, increased pulse, increased temp (temperature), urinary frequency, foul smelling urine, fever, chills, altered mental status, change in behavior, change in eating patterns . The resident has pressure ulcer to right and left heel, right and left calf r/t immobility, date initiated 4/18/23 . Interventions: Educate the resident/family/caregivers as to causes of skin breakdown including: transfer/positioning requirement; importance of taking care during ambulating/mobility, good nutrition and frequent repositioning . Reposition every 2 hours and prn (as needed) to relieve pressure . Physician Orders from R2's facility Electronic Health Record (EHR): Start date 12/1/22, Change drainage bag every night shift every 2 weeks on Sat, date bag when changing. Start date 3/22/23, Reposition every 2 hours. CNA or nurse to burp (manually remove gas) osteomyelitis [colostomy] bag every 2 hours with repositioning. Every shift for skin integrity. Start date 3/30/23, Keflex (cephalexin) 500mg, 1 tablet every day for 7 days for UTI. End date 4/6/23. Repeat UA (Urine Analysis) with culture after ATB (antibiotic) therapy for bacteria resolution, one time only for 1 day, start date 4/7/23, located in the TAR. [On 4/9/23, urine culture results that was collected on 4/7/23, indicates 10,000 CFU/ml (colony forming unit per milliliter) Proteus mirabilis, an abnormal result and 10,000-100,000 CFU/ml Enterococcus species, an abnormal result. Note: Colonies greater than 100,000 CFU/ml represents a urinary tract infection.] Start date 4/13/23, Catheter care every shift. (Note: Resident was admitted with a catheter on 12/1/22.) Start date 4/13/23, Monitor catheter output. (Note: No documentation provided of catheter output being monitored.) On 9/20/23 at 5:53 PM, Surveyor interviewed RN J (Registered Nurse). When Surveyor asked RN J who does the catheter care and how often is it completed, she indicated the CNAs (Certified Nursing Assistant) do the care and it is done twice per day. Surveyor asked RN J if a resident came into the facility would you expect the care to be in the care plan; she indicated yes, and would see the reason, the goal, the intervention, a leg strap attachment, and to empty every shift with catheter care. When Surveyor asked RN J if a physician order is needed to monitor intake and output, she indicated no, and stated, it's kinda a given to monitor, there is a standard in the software to click for standing orders for catheters. Surveyor asked RN J the process for obtaining a verbal order from the physician, she indicated the order is put in the software under the order tab, then print out and send the order to the physician's office to be signed. On 9/25/23 at 12:07 PM, Surveyor interviewed Nurse Consultant Z. Surveyor asked Nurse Consultant Z if she would expect staff to follow physician orders, she indicated yes. When Surveyor asked Nurse Consultant Z if a resident has a history of UTIs, if she would monitor the output, she indicated she would, and the catheter care would be performed daily. When Surveyor asked Nurse Consultant Z if staff are checking off boxes of care that is completed, should the staff verify that the care was completed, she indicated yes. R2's CNA Bowel and Bladder Elimination Documentation dated April 2023 provided by the facility indicates documentation performed 23 missed opportunities out of 62 opportunities. R2's CNA Documentation of Bed Mobility, Dressing, Eating, Locomotion off Unit, Personal Hygiene, Toilet Use, Transferring, Bowel and Bladder, Monitor Behavior have blank boxes, indicating no documentation of cares completed during the shift of 2:00 PM-10:00 PM on 4/21/23. On 9/21/23 at 9:46 AM, Surveyor interviewed CNA R. Surveyor asked CNA R how was R2 to care for, she indicated R2 was very nice, able to converse, and that she was [NAME]. CNA R further indicated R2's room was by the nurse's station. Surveyor asked CNA R if she was in R2's room on 4/21/23, she indicated she went in that morning at about 6:00 AM-7:00 AM as R2 is on an overnight check and change schedule. CNA R further indicated when she made rounds, it was so early that she did not move her. When Surveyor asked CNA R when she checked on R2 in the morning round if she looked for cleanliness, she indicated she did not go in the peri area. CNA R indicated that R2 informed her that she did not feel good, she was tired and then CNA R informed the medication technician and the other CNA that R2 did not look good or feel good. Surveyor asked CNA R if R2 was checked on the rest of the day, she indicated she saw R2 a second time about mid-day and that she was sleeping. When Surveyor asked CNA R if R2 ate breakfast or lunch, she was not able to recall. Surveyor asked CNA R if R2 had a shower, and CNA R indicated no. Surveyor asked CNA R is she was assigned to R2, she indicated no. On 9/21/23 at 10:32 AM, Surveyor interviewed CNA S. When Surveyor asked CNA S if she worked on 4/21/23, she indicated she did. CNA S indicated that the 2 CNAS working that day were CNA R and CNA S. CNA S further indicated that each CNA will take a side of the unit and that CNA S was not on that side. When Surveyor asked CNA S if R2 ate at breakfast or lunch, she was not able to recall. When Surveyor asked CNA S if she performed catheter care on R2, she indicated no. Surveyor asked if CNA S charted on R2 on 4/21/23; she indicated that CNA R did not have a log in when she first started, so CNA S would log in and then let CNA R chart on the residents she needed to chart on. Surveyor asked CNA S when she saw R2 on 4/21/23, she stated, The only time I saw her that day was prior to giving her that supper tray. When Surveyor asked CNA S what happened with the supper tray, she indicated she went in to give R2 supper, she did not respond, there was not a nurse on the floor that day, so CNA S called the Former ADON T who then came to the room. On 9/21/23 at 8:05 AM, Surveyor interviewed RN U. When Surveyor asked RN U if she worked on 4/21/23 when R2 was transported to the hospital, she indicated she worked the shift prior. Surveyor asked RN U if R2 had breakfast on 4/21/23; she indicated she could not remember. Surveyor asked RN U if R2 had lunch on 4/21/23: she indicated she did not remember. Surveyor asked RN U who does the catheter care, she indicated the aides usually do the care and stated, I just verify it's done. Surveyor asked RN U if she verified the catheter care was done, she indicated she could not verify as there was staff that did not come in that day. RN U further indicated she tried to take care of as much as she could and then stated, I signed it without even knowing the catheter care was done. (It is important to note that CNA S and CNA R indicated they are the only CNAs on the unit, and neither was assigned to R2. Surveyor cannot identify that catheter care was completed by CNA S and CNA R, and RN U indicates she signed completion of catheter care without verifying.) On 9/21/23 at 10:49 AM, Surveyor interviewed Former ADON T (Assistant Director of Nursing). Surveyor asked Former ADON T to describe the events related to sending R2 to the hospital. She indicated the medication technician came for her, the resident was lethargic. Former ADON T further indicated vital signs were taken and when they pulled back R2's covers, she had little tiny sugar black ants all over her bed. When Surveyor asked Former ADON T who was the CNA taking care of her on 4/21/23, she indicated there were 2 CNAs on the unit but could not recall which CNA. Surveyor asked the Former ADON T if R2 ate lunch, she was not able to recall. When Surveyor asked the Former ADON T if a resident has a history of UTIs should the intake and output be monitored, she indicated yes. Surveyor asked the Former ADON T if R2 was being monitored, she indicated she could not answer without seeing the orders. Surveyor asked the Former ADON T when the last time R2 was checked on, she indicated a CNA informed her they did rounds at 5:00 PM and she was changed due to an incontinent episode. (It is important to note that Surveyor was unable to locate documentation of an incontinence episode for 4/21/23 at 5:00 PM.) Facility provided further information on 10/2/23 a statement dated 4/21/23 from Former ADON T, entitled, Statement on Events on 4/21/23, states, in part; . I interviewed [medication technician's name] as to the last time she had completed cares or seen the resident and she stated that she had completed cares on her just 30 minutes before she came to get me and the resident was fine and did not have ants in her bed at that time. This document is signed by a recoverable signature of Former ADON T. (Surveyor requested the medication technicians contact information on 9/20/23 and was not provided prior to exit. Further, no statement was provided from the medication technician.) Progress Notes from R2's EHR: On 4/21/23 at 5:20 PM, (Of note, this discharge transfer note was written at 7:54 PM), CNA came and reported that resident was unable to speak and normally is verbal. Upon entering the room, resident was staring at the ceiling and unable to speak verbally. She responded to her name but could not squeeze my hands. She responded to painful stimuli with a frown. She was unable to follow directions. Pupils were normal and reactive. VS were 179/82-135-34, 90% on RA (room air). Her heart rate was irregular and elevated. Contacted MD (medical doctor) and order received to send to the ED for evaluation and treatment. Ems arrived and departed via stretcher with the resident enroute to [hospital name] . EMS Notes: Ambulance report dated 4/21/23 indicates the following response times: 5:13 PM Call Received (911 call received) 5:14 PM En Route (heading to the facility) 5:23 PM On scene (at the facility) 5:25 PM At patient 5:36 PM Leave scene (leaving the facility heading to the hospital) 5:48 PM At destination (arrival at the hospital) On 9/20/23 at 7:51 AM, Surveyor interviewed EMT V (Emergency Medical Technician). EMT V indicated they were called by 911 for an unresponsive person. EMT V continues to report to the Surveyor that when they arrived at the facility, staff is supposed to be at the foyer entrance to open the locked doors and there was not, so they had to pry the doors open which set off the alarms. EMT V then walked into R2's room and the staff member in the room introduced herself as a traveler nurse. (Note: This traveler nurse was identified as Former ADON T.) EMT V further described that when she pulled back R2's banket she stated: she was covered in ants, completely covered. EMT V indicated to the Surveyor she initially jumped back and the ADON T stated, Oh my god, if this is how it is here, I'm outta here. EMT V indicated to the Surveyor that she received minimal report, staff did not know the last time of when she was acting different, she asked staff about R2's output and they didn't know, R2's urine was bad and very dark. EMT V asked the facility staff of R2's code status and one staff informed her R2 was a full code, another staff told her R2 was a DNR (Do Not Resuscitate). Surveyor asked EMT V if the family was notified, she indicated the staff said they were going to call and was not sure if they did call. EMT V notified the son while in the ambulance due to the facility unsure if they notified the family and family indicated they would be going to the hospital. On 9/26/23 at 1:51 PM, Surveyor interviewed EMT V again. Surveyor asked EMT V to describe when she pulled back R2's blanket, she indicated after she jumped back and then looked closer, they were ants. R2 was wearing a brief and a T-shirt; the ants were on her lower abdomen and groin. EMT V indicated to the Surveyor she could continue to see them while transporting in the ambulance. The ants were crawling around her, on the cot, and on the sheets. Surveyor asked EMT V approximately how many ants and to describe them, she indicated there were about 50-100, black in color, about a couple of centimeters long. Surveyor asked EMT V the appearance of R2's room, she indicated there was a wadded-up blanket in the corner, R2 did not have many belongings, no wrappers anywhere or laying around. EMT V further indicated there was a meal tray that had a dome cover on it. The first hospital emergency room progress notes dated 4/21/23 timeline of events, states in part: At 6:50 PM, Pt (patient) presents to the ER (Emergency Room) do (sic) to having an unresponsive episode while at the nursing home that she is from. The staff there [their] states that she was LKWT (last known well time) was 1200 (12:00 PM) after lunch. She is usually talking and active. The patient was sleeping since lunch and not active since then. She is paralyzed from the hips on down after having a fall 20 years ago. The patient was stated to have a deficit on the Right Side. The patient is responding to painful stimuli like a sternal rub and the pinch test. They stated that the Right Sided arm weakness and deficit is chronic. The patient is unable to respond to anything that we are asking and is comatose. At 7:00 PM, When the patient arrived, she was covered in ants. EMS stated this is how she was when they got there. At 9:49 PM, When removing the foley catheter that the patient came in with, while taking the NS (normal saline) out of the balloon, the urine started to come out everywhere. The urine was thick, mucusy [mucousy], and smelled like ammonia very badly. After reinserting a new catheter, the urine was very much bloody with specs of sediment easily seen throughout the urine there. The new foley catheter was inserted with little trouble . At 11:50 PM, Abuse/Neglect Screening states, in part; . Clinical/Family/Abuse/Neglect/Exploit May Exist: Yes. Abuse/Neglect/Exploitation Comment: Patient was covered in ants on arrival. The EMS stated that her bed was also covered in ants. Her Foley Catheter was clogged and dirty. See Nursing Progress notes. On 4/22/23 at 12:46 AM, Patient's sons notified of the ants found on the patient and her belongings. They were told by EMS that her bed sheets up at her home were covered in them. On 4/22/23 at 12:53 AM, Patient;s [patients] fully [foley] was very dirty and not clean around the insertion site nd [and] the bag. On the bag it had labeled 04/12. This was changed and removed with [CNA name] and [CNA name] present and in the room helping me. On 4/22/23 at 2:10 AM, Medical Intensive Care Unit (MICU) Admit note, . present to the MICU for septic shock of likely urinary source . Patient was found with somnolent at her nursing home, reportedly covered by ants, so she was taken . as a code stroke . Indwelling foley was removed with a volcano of pus noted around the catheter while removing. After foley exchange, she became more hypotensive and somnolent prompting sepsis work up . On 4/22/23 at 2:20 AM, Blood transfusion started with the consent of the patient's son. On 4/22/23 at 11:24 AM, ER follow up lab result, 4/22/23 lab called reporting that pt had positive blood cultures, + (positive) for gram - (negative) rods. Pt was transferred . On 4/22/23 at 12:29 PM, emergency room physician notes, states, in part; . female presenting with weakness, concern for stoke or possible UTI. Patient was last seen in the noon hour at lunchtime, then reportedly napped in her room and when she was found by the nurse, she was aphasic where she is normally able to speak, had some residual right-sided weakness but now has new left-sided weakness, will open her eyes and sometimes track but is not responding otherwise. Has an indwelling foley catheter that reportedly had darker urine output than usual. No other symptoms reported . She had arrived to the ED (Emergency Department) as a code stroke, however the CT brain and CT head/neck were unrevealing . Patient's foley catheter was replaced by nursing staff. The tip of the foley appeared occluded and there was return of purulent appearing urine She became hypotensive . She was evaluated by our hospitalist . we do not have ICU beds available. Patient will require transfer for higher level of care. A right IJ (Internal Jugular) triple-lumen central line was placed at the bedside per the associated procedure note . patient remained hypotensive . Patient was accepted to transfer . We attempted to transfer her by air . could not fly due to adverse weather conditions. We contacted . EMS . all of which have inadequate staffing to facilitate transfer at this time Patient's children are aware of this . We will continue with vasopressor support at this time. R2 was found to be in septic shock with urosepsis and a UTI. Due to a lack of receiving personal cares, she had black ants embedded in her groin. According to information on the Cleveland Clinic's website: What is septic shock? Septic shock is a serious medical condition that can occur when an infection in your body causes extremely low blood pressure and organ failure due to sepsis. Septic shock is life-threatening and requires immediate medical treatment. It's the most severe stage of sepsis. What's the difference between septic shock and sepsis? Septic shock is the last and most dangerous stage of sepsis. Sepsis can be divided into three stages: sepsis, severe sepsis, and septic shock. Sepsis: Sepsis is life-threatening. It happens when your immune system overreacts to an infection. Severe sepsis: This is when sepsis causes your organs to malfunction. This is usually because of low blood pressure, a result of inflammation throughout your body. Septic shock: Septic shock is the last stage of sepsis and is defined by extremely low blood pressure, despite lots of IV (intravenous) fluids. What causes septic shock? Any infection can lead to sepsis which can then develop into septic shock if it worsens. Not every infection will lead to sepsis or septic shock. But, if an infection causes enough inflammation, it can develop into sepsis. Most of the common infections are from bacteria, but both viruses and fungi can also cause infections and sepsis. Infections can start anywhere but commonly begin in your lungs, bladder, or stomach. What are the risk factors for septic shock? Your septic shock risk increases if you have a weakened immune system which increases your risk for sepsis. People with weakened immune systems include: Newborns. Those over age [AGE]. People who are pregnant. People who use recreational drugs. People with artificial joints or heart valves . What are the complications of septic shock? Septic shock is a very serious medical condition. It's the most severe stage of sepsis. Septic shock can lead to: Brain damage. Lung failure. Heart failure. Kidney failure. Gangrene. Death. https://my.clevelandclinic.org/health/diseases/23255-septic-shock On 9/22/23 at 10:01 AM, Surveyor interviewed MD KK (Medical Doctor). Surveyor asked MD KK the time of the visit on 4/21/23, he indicated he was first at the facility at about 9:00 AM. Surveyor asked MD KK if he had seen any ants on R2 during the wound visit on 4/21/23, he indicated he debrided the wound and looked at her lower legs only. MD KK further indicated he recalls a facility with ants but could not remember. MD KK further indicated that he stayed focused on the area he was working on and could have missed it, but if the ants were in the wound, he definitely would have made a note. On 9/22/23 at 10:15 AM, Surveyor interviewed Former ADON LL. Surveyor asked Former ADON LL if he was present with the wound care visit on 4/21/23, he indicated he was with MD KK. Surveyor asked Former ADON LL if he had seen any ants in R2's bed, he indicated he did not and that R2 was not moved or repositioned. Former ADON LL indicated they pulled the covers back over her feet. On 9/20/23 at 2:19 PM, Surveyor interviewed ER RN W (emergency room Registered Nurse). Surveyor asked ER RN W the events that occurred during the care of R2, he indicated he was informed by EMS that R2 had ants crawling on her and they were going to report it to the state. ER RN W indicated R2 presented to the ER as a code/stroke protocol with right sided weakness, comatose, had the smell of stale urine, like not cleaned recently, like not getting taken care of. ER RN W indicated to the Surveyor that R2 was urgently transported to the CT (computerized tomography) scanner (combines a series of X-ray images taken from different angles around your body) to rule out a stroke. ER RN W indicated to the Surveyor that the facility did not know the last known well check and thought maybe around noon or after lunch on 4/21/23. Upon R2's return from the CT scans ER RN W noted of seeing ants in R2's ER bed and on R2's CT scanner bed and stated: but we didn't think it would keep coming. Surveyor asked ER RN W to continue describing the events, he indicated he informed the physician there was not any urine output for an hour. ER RN W was informed by the physician to remove the foley catheter. ER RN W reports the catheter bag was dated 4/12/23 and the urine in the bag did not appear fresh. ER RN W further explained after removing the foley, thick mucus, that smelled of ammonia, with blood and black sediments that was seen in the urine. After the sludge came out, the urine continued to drain all over R2's bed. Surveyor asked ER RN W approximately how much urine drained and indicated he could not measure because it poured all over her bed and it was something he has never seen before. ER RN W stated to the Surveyor, Clearly, she was not getting the hygienic cares she needed, the foley catheter was filthy itself. Surveyor asked ER RN W to describe the care needed due to the ants, he indicated the ants left their mark on R2's skin, they were embedded, and he had to use a little force to get the ants off. Surveyor asked ER RN W what was further done with the ants, he indicated that he and with the help of aids would turn R2 and change her sheets. Every time we turned her, we would check and cleaned her with wipes and wash cloths to get the ants off. There were more ants each time. Surveyor asked ER RN W if the family had voiced any concerns, he indicated at this point, the sons were irritated with the cares at the facility. ER RN W indicated to the Surveyor that R2 was started on vasopressors due to blood pressures being very low, Zosyn, an antibiotic for UTI, and an intrajugular catheter was inserted for the vasopressors administrations and the blood culture returned from the lab as proteus marabilis positive. ER RN W indicated to the Surveyor that the hospital was full of ICU (Intensive Care Unit) beds and requested several helicopters to transport R2 to another hospital and were not able to fly due to the weather. ER RN W reported to the Surveyor that numerous unsuccessful attempts were made for ground transportation to get R2 to another hos[TRUNCATED]