Medilodge Of East Lansing

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to prevent significant weight loss in two residents who were reviewed for weight loss. One resident, who had multiple complex medical conditions including chronic respiratory failure, protein-calorie malnutrition, cerebral palsy, and dependence on a ventilator, experienced a substantial weight loss of 31.1 pounds over four months. This resident was prescribed tube feedings to meet caloric and nutritional needs, but medication and feeding records showed that the resident did not consistently receive the prescribed volume of tube feeding solution on numerous occasions. The registered dietician confirmed that the resident did not receive the required caloric intake for extended periods, and the director of nursing was aware of the issue but could not provide any corrective action that had been taken at the time. Another resident, with a history of stroke, diabetes, heart failure, and dysphagia, lost 14.6 pounds, representing a 13% weight loss in 90 days. Review of this resident's food acceptance records revealed multiple instances where no food acceptance was documented for several meals over the preceding 30 days. The registered dietician could not verify whether the resident had received dietary trays for the meals with missing documentation. The director of nursing confirmed that there were multiple dates and mealtimes without documentation of food acceptance and could not explain the lack of documentation. Both cases demonstrate that the facility did not ensure residents consistently received adequate nutrition and hydration as ordered, either through tube feeding or oral intake. The lack of consistent documentation and follow-through on prescribed nutritional interventions contributed directly to significant weight loss in both residents.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to follow physician orders for the administration of tube feeding solution for one resident, resulting in significant weight loss. The resident, who had multiple complex medical conditions including chronic respiratory failure, protein-calorie malnutrition, cerebral palsy, and dependence on a ventilator, was admitted with a gastrostomy and required tube feeding as per physician orders. Observations and record reviews revealed that the resident was very active at night, often crawling on the floor and chewing on the feeding tube, which led nursing staff to disconnect the tube feeding. Despite these challenges, the prescribed tube feeding volumes were not consistently administered as ordered. Medication records showed multiple instances where the resident did not receive the full prescribed amount of tube feeding solution, and on several occasions, feedings were missed entirely. The resident's weight history indicated a significant decrease, with a loss of 31.1 pounds over four months. The registered dietician confirmed that the resident had not received the required caloric intake from tube feedings during the reviewed period and that this issue had been reported to the Director of Nursing. However, there was no documentation or explanation provided for why the resident did not receive the prescribed nutrition, nor was there evidence of corrective action taken by facility leadership following the incident. The failure to administer tube feedings as ordered directly contributed to the resident's significant weight loss.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to provide sufficient nursing staff to meet the needs of residents, as evidenced by multiple days where staffing levels did not meet the facility's own staffing grid requirements. Staffing records reviewed with the Nursing Scheduler showed repeated shortfalls in both CNA and nurse coverage across various shifts, with some days being up to three staff short. These shortages were documented for several dates and shifts, despite the facility census indicating the need for more staff. Residents reported significant delays in receiving care, including long wait times for call light responses and missed showers. One resident stated she had not received a shower in over a week and often waited up to an hour for assistance, with staff sometimes turning off her call light without returning. Another resident, who required assistance with feeding due to quadriplegia, reported being denied food because staff did not have time to help him. Both residents indicated that these issues were ongoing and had been raised multiple times with facility management and in Resident Council meetings, but no improvements were observed. Direct observations by surveyors confirmed that staff frequently failed to respond to call lights, even when multiple staff members were present and the call lights were audible. On several occasions, staff were seen ignoring call lights while sitting at the nurse's station or walking by without responding. The facility's policy requires any staff member who sees or hears a call light to respond, but this was not followed. Additionally, the facility was unable to produce concern forms related to staffing or call light response issues raised in Resident Council meetings.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to provide routine showers and maintain hygiene for two residents who were unable to perform activities of daily living independently. One resident, a cognitively intact female with chronic medical and psychiatric conditions, reported not receiving a shower for over ten days and stated this was a recurring issue despite multiple complaints to nursing management. Review of her shower records for the month showed only three showers provided, with only one documented refusal. A CNA confirmed that there was no dedicated staff for showers and that workload sometimes made it impossible to provide showers as scheduled. Another resident, who was nonverbal and had severe cognitive and physical impairments, also did not receive scheduled showers. The resident's family reported ongoing concerns and filed a grievance regarding missed showers, which was not responded to by facility staff. Documentation showed significant gaps between showers with no refusals recorded. The ADON confirmed that all residents were scheduled for showers twice weekly but could not provide documentation for refusals or postponements for these two residents.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to appropriately monitor and treat constipation for two residents, resulting in significant negative outcomes, including hospitalization for one resident. For one resident with multiple complex medical conditions, including chronic respiratory failure, COPD, tracheostomy, and diabetes, the medical record showed no bowel movement for several consecutive days. Despite the facility's protocol to notify a physician after three days without a bowel movement, there was no evidence that medication was administered until the sixth day, and the Assistant Director of Nursing (ADON) could not explain the delay in intervention. Another resident, who was non-verbal and had severe cognitive impairment, experienced prolonged periods without documented bowel movements, with gaps of up to ten days. The only intervention noted was the administration of a suppository, which was ineffective. The resident was later found unresponsive with signs of vomiting and respiratory distress, requiring emergency intervention and hospitalization. Hospital records indicated the resident suffered an aspiration event, aspiration pneumonia, and abdominal distension related to constipation, with enteral nutrition being altered due to the event. Interviews with facility staff revealed a lack of clear responsibility and follow-through regarding bowel monitoring and intervention. The ADON and Director of Nursing (DON) both indicated that alerts for missed bowel movements could be cleared by nurses without action, and there was no facility policy or procedure for bowel elimination or constipation management. Additionally, a grievance filed by the resident's family regarding constipation concerns was not addressed or documented with findings or actions, and staff interviews suggested that family involvement may have led to missed communication about bowel movements.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

A deficiency occurred when medication intended for a resident with multiple diagnoses, including stroke, hypertension, dementia, and prostate cancer, was found unattended in a medication cup on top of an isolation cart outside the resident's room. The unattended medication included several pills and a bottle of nasal spray. At the time of discovery, no staff or residents were present in the vicinity of the medication. The medication was later identified as belonging to the resident, who had moderate cognitive impairment as indicated by a BIMS score of 10 out of 15. Facility policy requires that medications be under the direct observation of the person administering them or locked in a storage area or cart during medication administration. However, the medication was left unattended, in violation of this policy. The resident was later observed in the dining room and could not confirm whether he had received his medication that morning. The incident was confirmed through observation, interview, and record review.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that medications were administered according to physician orders for one resident. The resident, who had a complex medical history including chronic respiratory failure with hypoxia, asthma, tracheostomy status, and spastic quadriplegic cerebral palsy, was observed to have missed multiple scheduled doses of critical medications. Specifically, the resident did not receive the prescribed evening dose of Bactrim DS, an antibiotic ordered for pneumonia, as well as scheduled doses of Olanzapine and Klonopin. The medication administration records and incident reports indicated that although these medications were available in the facility's back-up supply, the nurse did not retrieve them for administration. Progress notes reflected that the pharmacy had been called, but there was no documentation of provider notification or consideration of changes to the medication orders to address the missed doses. The Director of Nursing confirmed that the medications in question were present in the back-up supply and acknowledged that the nurse should have administered them from this supply. The resident's medical record lacked documentation regarding any discussion with the provider about extending or adjusting the medication orders due to the missed doses. The failure to administer these medications as ordered was identified through observation, record review, and staff interview, and was corroborated by facility documentation and the resident's medication administration records.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to provide respiratory care in accordance with physician's orders for a resident with chronic respiratory failure, tracheostomy status, and other significant medical conditions. The resident was nonverbal and had limited ability to communicate or understand. Physician orders and hospital discharge instructions required the resident to receive cough assist therapy three times daily to maintain airway patency and lung inflation. Documentation in the Respiratory Administration Record (RAR) showed that the resident missed multiple scheduled cough assist treatments, with reasons cited including lack of tolerance, refusal, being asleep, or being out of the facility. Observations confirmed the presence of a tracheostomy and cough assist machine in the resident's room. Interviews with respiratory therapy staff revealed inconsistent administration of the ordered therapy, with one therapist unable to recall the last time the treatment was attempted. The records indicated at least 20 missed opportunities for cough assist therapy in one month, and additional missed treatments following the resident's hospital readmission, despite ongoing physician orders for the therapy.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

A resident with significant cognitive impairment and total dependence on staff for activities of daily living was admitted with multiple complex medical conditions, including an anoxic brain injury, respiratory failure with tracheostomy, gastrostomy, and a sacral pressure ulcer. Upon admission, the resident was identified as being at risk for skin impairment, and a care plan was developed that included interventions such as turning and repositioning, use of heel boots, application of barrier cream, and use of a pressure redistribution mattress. Despite these planned interventions, repeated observations showed the resident consistently positioned on their back with their head and neck leaning to the left, left ear pressed against the pillow, and heels directly against the mattress. Documentation and interviews revealed that these interventions were not consistently implemented, as the resident was often found without both heel boots in place and was not regularly turned or repositioned as required. The resident developed new pressure ulcers during their stay, including a deep tissue injury on the right heel and an open area on the left ear, both of which were determined to be facility-acquired. The sacral pressure ulcer also worsened, increasing in size and depth, and was noted to have visible bowel movement in the wound image. There were no treatment orders or interventions in place for the new wounds on the right heel and left ear, and the care plan was not updated to address these new areas of skin breakdown. Family members reported that staff were not responsive to concerns about the resident's wounds and that the resident was rarely turned or repositioned during their visits. Staff interviews confirmed a lack of awareness and follow-through regarding the resident's wound care needs and the absence of required equipment, such as heel boots. Record review further indicated inconsistencies and omissions in documentation, including the lack of initial assessment and documentation of the right heel wound upon admission, despite prior hospital records indicating its presence. The DON and Administrator were unable to provide explanations for the lack of implementation of care plan interventions, the absence of timely wound assessments, and the failure to provide necessary treatments for new pressure ulcers. The facility's failure to operationalize its policies and procedures for pressure ulcer prevention and care, as well as the lack of comprehensive assessment and intervention, directly resulted in the development and worsening of pressure ulcers for this resident.

Plan Of Correction

Element 1: Resident 117 areas to right rear malleolus and left outer ear were assessed by the nurse on 5/9/25 with orders for treatments put in place to include heel boots, low air loss mattress, and care plan updated. Resident 117 was discharged on 05/13/2025. Element 2: A skin sweep of current residents, including current residents admitted since 4/25/25, was completed by the Director of Nursing/Designee by 5/14/25 for any new skin areas or skin areas missed on admission. Any new areas noted were assessed, had treatment orders entered, and care plans updated for interventions to prevent and promote healing of wounds. A one-time audit of current residents with wounds was completed to ensure the wounds have appropriate treatment orders and interventions to prevent and promote healing of wounds, including being turned and repositioned. This was completed by the Director of Nursing/Designee by 5/14/25. A one-time audit of residents' most recent Braden score was completed by the Director of Nursing/Designee by 5/14/25, and anyone with a Braden of 10 or below was placed on the yellow dot program for turning and repositioning. Element 3: The QAPI Committee has reviewed the Pressure Ulcer Prevention and Management policy and has deemed it to be appropriate by 5/14/25. The Director of Nursing and/or designee re-educated the Wound Care Nurse and the licensed nurses on the Pressure Ulcer Prevention and Management policy by 5/14/25, with emphasis on turning and repositioning, ensuring wound treatments are being completed, and appropriate interventions are in place to prevent and promote healing of wounds. Also, that all admissions need to have their skin assessed by 2 nurses. Nurse Aides were re-educated on the yellow dot program for turning and repositioning and checking residents' Kardex to ensure interventions are in place. This was completed by Staff Development Coordinator/Designee by 5/14/25. Wounds will be reviewed daily in the morning clinical Monday through Friday to ensure treatments are being completed and weekly in the standard of care meeting to ensure appropriate interventions are in place to prevent and promote wound healing. Admissions will be reviewed daily in the morning clinical Monday through Friday to ensure admission skin assessments are accurate and have been assessed by 2 nurses. Element 4: The Director of Nursing/designee will audit residents with wounds weekly for 4 weeks, then monthly thereafter, to ensure interventions are in place and treatments are being completed to prevent and promote healing of wounds. The Director of Nursing/designee will audit residents with a Braden of 10 or less and residents with wounds weekly for 4 weeks, then monthly thereafter, to ensure they are being turned and repositioned appropriately to prevent and promote healing of wounds. The Director of Nursing/designee will audit admission skin assessments weekly for 4 weeks, then monthly thereafter, to ensure all skin issues present on admission are documented appropriately and their skin has been assessed by 2 nurses. Results will be reviewed monthly by the QAPI Committee until substantial compliance is achieved. The Administrator is responsible for maintaining compliance.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to provide sufficient nursing staff with appropriate competencies and skill sets to meet the care needs of residents, particularly those residing on the ventilator and tracheostomy hallways. Staffing records and interviews revealed that, at times, only three CNAs and three RNs were present to care for all residents on these high-acuity units, with most residents requiring two-person assistance for activities of daily living (ADLs). Staff reported working extended shifts, sometimes up to 18 hours, and being unable to take breaks or complete all required care tasks, such as turning and repositioning residents every two hours. Multiple CNAs confirmed that it was not possible to provide all necessary care due to the heavy workload and insufficient staffing levels. Several residents experienced negative outcomes as a result of inadequate staffing. One resident, who was dependent on staff for all ADLs and assessed as a fall risk, suffered an unwitnessed fall after attempting to get out of bed when incontinent, as they were unable to use the call light and staff could not provide timely assistance. Another resident, also fully dependent and rarely understood, was observed multiple times in the same position in bed and developed a stage 4 pressure ulcer that worsened during their stay. Staff interviews confirmed that residents were not being turned and repositioned as required, and necessary equipment such as heel boots was not consistently available or used. A third resident, admitted with a stage 3 sacral pressure ulcer, developed additional facility-acquired pressure ulcers, including a deep tissue injury on the heel and a pressure ulcer on the ear. Observations and interviews with family and staff indicated that this resident was not being turned or repositioned regularly, and care plan interventions such as the use of heel boots and pressure-relieving mattresses were not consistently implemented. The DON and Administrator acknowledged the worsening of wounds and the lack of consistent interventions but did not provide explanations for the failures. Staff repeatedly stated that the high acuity and total care needs of residents, combined with insufficient staffing, made it impossible to meet required care standards.

Plan Of Correction

Element 1: The facility assessment has been updated by 5/14/25 and reviewed by the QAPI Committee to ensure staffing levels are appropriate to meet the current resident population needs. Current residents with a BIMS of 9 or above and responsible parties for residents with a BIMS of 8 or below were interviewed for any negative outcomes related to needs not being met by the Director of Nursing/Designee by 5/14/25. Residents' concerns were placed on a Quality Assurance form and ran through the Quality Assurance process by 5/14/25. Element 2: Current residents and/or responsible parties have been interviewed to ensure that their needs are being met by the Director of Nursing and/or designee by 5/14/25. Any concerns identified have been addressed immediately. Element 3: The QAPI Committee reviewed the policy, Nursing Services and Sufficient Staff, and deemed it appropriate by 5/14/25. The Regional Director of Operations has re-educated the Administrator, Director of Nursing, and the Scheduler on the Nursing Services and Sufficient Staff Policy, including sufficient staff resident needs. This education will be completed by 5/14/25. During the morning stand-up meeting and as needed, staffing will be reviewed to ensure supervision. Adjustments will be made as needed. Element 4: A weekly audit of 10 residents will be conducted by the Administrator and/or designee to ensure needs are being met timely for 4 weeks and then monthly thereafter until substantial compliance is sustained. Audits will be reviewed by the QAPI committee monthly for 3 months until substantial compliance is met. The Administrator is responsible to maintain compliance.

Penalty

5 days payment denial

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to provide adequate care and services to prevent and promote healing of pressure ulcers for three residents, resulting in worsening wounds, infections, and hospitalizations. All three residents were dependent on staff for all care and were identified as high risk for skin breakdown. The facility did not consistently implement or document required interventions such as turning and repositioning, and there were multiple missed wound treatments as evidenced by gaps in the Treatment Administration Record (TAR) and CNA task documentation. For example, one resident had 42 eight-hour shifts without documented turning and repositioning, and 20 missed wound treatments for facility-acquired pressure wounds. Another resident had 23 eight-hour shifts without documented repositioning and four missed wound treatments for a worsening coccyx pressure wound. A third resident had 37 eight-hour shifts without documented repositioning and 21 missed wound treatments for pressure wounds, with incomplete turning logs maintained by family members as further evidence of lapses in care. The residents involved had significant medical histories, including traumatic brain injury, cerebral vascular accident, acute respiratory failure, and comatose states, making them highly susceptible to pressure injuries. Despite care plans and physician orders specifying frequent turning, repositioning, and wound care, these interventions were not reliably carried out or documented. Wound assessments showed progression of pressure ulcers from initial stages to unstageable or stage 4, with some wounds developing slough, odor, and signs of infection. In several cases, the wounds deteriorated to the point of requiring hospital transfer for advanced wound management, debridement, and treatment of sepsis or osteomyelitis. Interviews with staff confirmed that documentation was incomplete and that staffing shortages contributed to the inability to provide required care. Unit managers and wound nurses acknowledged that there were holes in the TAR and CNA documentation, and that some wound treatments were not recorded as completed. Staff also reported that, at times, there were not enough CNAs to turn residents every two hours as required by care plans. There was no evidence provided by the facility to demonstrate that the worsening or facility-acquired pressure ulcers were unavoidable, despite the presence of appropriate interventions in the care plans.

Plan Of Correction

Element 1 Resident 105 no longer resides in the facility and was discharged to the hospital on 3/26/25. Resident 106 no longer resides in the facility and was discharged to the hospital on 4/1/25. Resident 111 continues to reside in the facility. Her wounds, treatment orders, and care plans were reviewed by the Director of Nursing, Wound Nurse, and wound care provider by 4/25/25 and deemed to be appropriate. An unavoidable assessment was completed due to the resident's wound being expected to decline on admission due to comorbidities and assessment of periwound. Element 2 A skin sweep of current residents was completed by the Director of Nursing/Designee by 4/25/25 for any new skin areas. Any new areas noted were assessed, had treatment orders entered, and care plans updated for interventions to prevent and promote healing of wounds. A one-time audit of current residents with wounds was completed to ensure the wounds have appropriate treatment orders and interventions to prevent and promote healing of wounds. This was completed by the Director of Nursing/Designee by 4/25/25. A one-time audit of residents' most recent Braden score was completed, and anyone with a Braden score of 10 or below was placed on the yellow dot program for turning and repositioning. Element 3 The QAPI Committee has reviewed the Pressure Ulcer Prevention and Management policy and has deemed it to be appropriate by 4/25/25. The Director of Nursing and/or designee educated the Wound Care Nurse and the licensed nurses on the Pressure Ulcer Prevention and Management policy by 4/25/25, with emphasis on the yellow dot program for turning and repositioning, ensuring wound treatments are being completed, and appropriate interventions are in place to prevent and promote healing of wounds. Nurse Aides were educated on the yellow dot program for turning and repositioning and checking the resident kardex to ensure interventions are in place. This was completed by the Staff Development Coordinator/Designee by 4/25/25. Wounds will be reviewed daily in the morning clinical Monday through Friday to ensure treatments are being completed and weekly in the standard of care meeting to ensure appropriate interventions are in place to prevent and promote wound healing. Element 4 The Director of Nursing/designee will audit residents with wounds weekly for 4 weeks, then monthly thereafter, to ensure interventions are in place and treatments are being completed to prevent and promote healing of wounds. The Director of Nursing/designee will audit residents with a Braden score of 10 or less weekly for 4 weeks, then monthly thereafter, to ensure they are being turned and repositioned appropriately to prevent and promote healing of wounds. Results will be reviewed monthly by the QAPI Committee until substantial compliance is achieved. The Administrator is responsible for maintaining compliance.

Penalty

5 days payment denial

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to provide necessary Activities of Daily Living (ADL) care, including bathing, showering, oral care, grooming, and repositioning, for four dependent residents. Documentation and interviews revealed that multiple residents missed several showers, with some going up to 20 days without bathing or showering. Oral care was also frequently omitted, with one resident missing oral care on 51 shifts. In addition, required turning and repositioning for pressure wound prevention was not consistently performed, as evidenced by 42 eight-hour shifts without documentation of this care for a dependent resident. Residents affected had significant medical needs, including traumatic brain dysfunction, cerebral vascular accident, partial paralysis, and dependence on staff for all or most ADLs. One resident with a tracheostomy and contractures was not turned or repositioned as required, and another resident with dentures did not have oral care addressed in their care plan. Documentation reports and care plans confirmed these omissions, and interviews with residents and staff corroborated the lack of consistent ADL care, citing missed showers, oral care, and incontinence care. Staff interviews and grievance forms indicated that chronic understaffing contributed to the deficiencies, with reports of only three to four CNAs on certain shifts, including on units with high-acuity residents. Staff described being unable to meet basic care needs, such as incontinence care and repositioning, at the required frequency. Residents and staff reported submitting grievances and concern forms regarding missed care and staffing shortages, with some improvement only noted in the two weeks prior to the survey.

Plan Of Correction

Element 1 Resident 103 no longer resides in the facility. Resident was discharged home on 3/24/2025. Resident 104 no longer resides in the facility. Resident 104 discharged home on 3/27/2025. Resident 106 no longer resides in the facility. Resident 106 discharged to the hospital on 4/1/2025. Resident 110 continues to reside in the facility. Resident was offered a shower and ADL's including oral care was completed by 4/25/2025. Element 2A A one-time audit of the last 3 days of current residents was conducted to verify that they have received or been offered a shower/bed bath. If a shower/bed bath had not been offered at time of audit, it would be immediately offered and given or documented if refused. This was completed by the Director of Nursing/Designee by 4/25/25. A one-time audit of current residents was conducted to ensure residents received ADL care including oral care by 4/25/25. Anyone that had not received ADL care including oral care was immediately completed and documented on by 4/25/25. This was completed by the Director of Nursing/Designee. Element 3 The QAPI Committee reviewed the policy, Activities of Daily Living and deemed it appropriate by 4/25/25. The Director of Nursing has re-educated the certified nursing assistants and the licensed nurses on the Activities of Daily Living policy with emphasis to showers and ensuring residents are being offered and given showers on their shower days and completing and documenting ADL care including oral care every shift. This education will be completed by 4/25/25. Element 4 The Director of Nursing or Designee will conduct random audits weekly for four weeks and then monthly thereafter until substantial compliance is sustained, to verify that showers/bed baths and ADL care including oral care is being offered, given and/or documented if refused. Audits will be reviewed by the QAPI committee monthly for 3 months until substantial compliance is met. The Administrator is responsible to maintain compliance.

Penalty

5 days payment denial

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure sufficient nursing staff with appropriate competencies and skill sets to meet the needs of its residents, as evidenced by multiple observations, interviews, and record reviews. The census was reported at 69, with a significant portion of residents dependent on staff for care, including a ventilator unit. Several complaints were received by the State Agency alleging insufficient staffing, which resulted in unmet care needs such as failure to prevent worsening of pressure ulcers and avoidable falls with injury. The CMS PBJ Staffing Report also indicated excessively low weekend staffing. Specific resident cases highlighted the impact of insufficient staffing. One resident, with a history of hip fracture and high fall risk, suffered a fall resulting in rib fractures. Staff reported that necessary safety equipment, such as positioning wedges, was not in place at the time of the fall, and the resident's wife had to remain at the bedside due to concerns for safety and confusion. Another resident, dependent on staff for all care, experienced worsening and new pressure ulcers, with documentation showing missed wound treatments and incomplete turning and repositioning logs. Additional residents experienced missed showers, oral care, and repositioning, with documentation reflecting numerous shifts where required care was not provided or not documented as completed. Interviews with staff, residents, and family members consistently reported ongoing staffing shortages, particularly on second and third shifts, leading to basic care needs not being met. Staff described being unable to provide care as frequently as required, with restorative staff being pulled to cover floor duties and managers picking up shifts to meet minimum requirements. Resident council and grievance forms further corroborated concerns about missed care and insufficient staffing, with reports of residents being left in soiled conditions and not receiving scheduled showers or repositioning.

Plan Of Correction

Element 1: The facility assessment has been updated by 4/25/25 and reviewed by the QAPI Committee to ensure staffing levels are appropriate to meet the current resident population needs. Current residents with a BIMS of 9 or above and responsible parties for residents with a BIMS of 8 or below were interviewed for any negative outcomes related to delay in call light response time by the Director of Nursing/Designee by 4/25/25 and did not have any negative outcomes. Residents’ concerns were placed on a Quality Assurance form and ran through the Quality Assurance process by 4/25/25. Element 2: Current residents and/or responsible parties have been interviewed to ensure that their needs are being met by the Director of Nursing and/or designee by 4/25/25. Any concerns identified have been addressed immediately. Element 3: The QAPI Committee reviewed the policy, Nursing Services and Sufficient Staff, and deemed it appropriate by 4/25/25. The Regional Director of Operations has re-educated the Administrator, Director of Nursing, and the Scheduler on the Nursing Services and Sufficient Staff Policy, including staffing to meet resident needs. This education will be completed by 4/25/25. During the morning stand-up meeting and as needed, staffing will be reviewed to ensure supervision. Adjustments will be made as needed. Element 4: A weekly audit of 10 residents will be conducted by the Administrator and/or designee to ensure needs are being met timely for 4 weeks and then monthly thereafter until substantial compliance is sustained. Audits will be reviewed by the QAPI committee monthly for 3 months until substantial compliance is met. The Administrator is responsible to maintain compliance.

Penalty

5 days payment denial

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

A deficiency occurred when staff failed to provide adequate supervision and implement care planned interventions for a resident with a known high risk for falls. The resident, an 82-year-old male with a recent left hip fracture, post-surgical revision, and multiple comorbidities including peripheral vascular disease, hypertension, diabetes, and anemia, was admitted to the facility. The resident's care plan included specific fall prevention interventions such as a low bed, floor mat, non-skid footwear, and placement of wedges at the right shoulder and knee when resting in bed. Despite these interventions being documented, they were not in place at the time of the incident. On the day of the incident, the resident experienced an unwitnessed fall from bed. Staff interviews and documentation revealed that the positioning wedges were not in use and were found on a chair or nightstand, the floor mat was not in place, and the bed was not at its lowest position. The resident was found on the floor, confused, with bleeding from the surgical incision and signs of injury. Staff confirmed that the care planned interventions were not followed, and the resident's confusion and restlessness were known risk factors that had been communicated to the facility by the family. Following the fall, the resident required emergency room treatment and hospital admission, where additional injuries including rib and pelvic fractures were identified. The failure to implement and maintain the prescribed fall prevention measures directly contributed to the resident's fall and subsequent injuries. Staff interviews confirmed a lack of adherence to the care plan and an inability to provide one-on-one supervision despite the resident's high risk status and family concerns.

Plan Of Correction

Element 1: Resident 102 no longer resides in the facility. Resident was discharged to the hospital on 12/15/25. Element 2: A one-time audit of current residents' fall interventions was completed by the Director of Nursing / Designee by 4/25/25 to ensure fall interventions are in place and reflect residents' current needs. Element 3: The QAPI Committee reviewed the Falls Clinical Protocol policy and deemed it appropriate by 4/25/25. The Director of Nursing and/or designee educated the Nurses and C.N.As on the Falls Clinical Protocol policy, with an emphasis on ensuring interventions are in place and that the interventions are noted on the incident reports. This education will be completed by 4/25/25. Element 4: The Director of Nursing/designee will audit 10 residents to ensure fall interventions are in place and will audit residents with falls to ensure that fall interventions in place at the time of the fall were documented on the incident report and that the care plan is updated with new interventions. These audits will be conducted weekly for 4 weeks, then monthly thereafter. Results will be reviewed monthly by the QAPI Committee until substantial compliance is achieved. The Administrator is responsible for maintaining compliance.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure a comprehensive care plan was in place and properly executed for a resident, leading to the development and worsening of pressure ulcers. The resident, who was admitted with diagnoses including knee contractures, was observed without offloading boots, which were supposed to be on at all times as per the care plan. The boots were found on the floor, and staff members were unclear about their responsibility for ensuring the boots were worn, leading to the resident's feet resting directly on the mattress. The resident was observed to have a pressure ulcer on the left trochanter and a coccyx pressure ulcer, both of which were not properly documented or staged in the care plan. The left foot was initially documented as a hematoma but was later identified as a deep tissue injury (DTI). The care plan did not include updated interventions for the pressure ulcers, and there was no evidence of a root cause analysis or interdisciplinary team meetings to address the skin breakdown. Interviews with staff, including CNAs, a COTA, an LPN, and the wound nurse, revealed a lack of clarity and communication regarding the care plan and interventions for the resident's pressure ulcers. The Director of Nursing confirmed that the resident's Kardex indicated the need for offloading boots at all times, but this was not consistently followed. The facility's failure to implement and revise the care plan contributed to the resident's pressure ulcers not being properly managed or prevented.

Plan Of Correction

Element 1 Resident 7 continues to reside in the facility. The skin care plan was reviewed and updated to include the correct classification and staging of current wounds and include appropriate interventions to prevent and promote healing of wounds by the Director of Nursing/Designee by 3/14/25. Element 2 A one-time audit of current residents with wounds was completed to ensure their skin care plans have the correct classification and staging of current wounds and they include appropriate interventions to prevent and promote healing of wounds. This was completed by the Director of Nursing/Designee by 3/14/25. Element 3 The QAPI Committee has reviewed the Comprehensive Care Plan policy and has deemed it to be appropriate by 3/14/25. The Director of Nursing and/or designee educated the Wound Care Nurse and the licensed nurses on the Comprehensive Care Plan policy by 3/14/25 with emphasis on ensuring skin care plans have correct classification and staging of wounds and that they include appropriate interventions to prevent and promote healing of wounds. Nurse Aides were educated on checking resident kardex s and ensuring interventions are in place. This was completed by the Staff Development Coordinator/Designee by 3/14/25. Wounds will be reviewed weekly in standard of care meeting to ensure wounds are classified and staged correctly and interventions are in place to prevent and promote wound healing. Element 4 The Director of Nursing/designee will audit Skin care plans of residents with wounds weekly x4 weeks then monthly thereafter to ensure wounds are classified and staged correctly and interventions are in place to prevent and promote healing of wounds. Results will be reviewed monthly by the QAPI Committee until substantial compliance is achieved. The Administrator is responsible to maintain compliance.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to provide adequate care and services to prevent and promote the healing of pressure ulcers for one resident, resulting in worsening wounds. The resident, who was admitted with diagnoses including knee contractures, was observed without offloading boots, which were supposed to be on at all times as per the care plan. The boots were found on the floor, and staff members, including CNAs and a COTA, were unclear about their responsibility to ensure the boots were worn. Observations revealed pressure ulcers on the resident's left trochanter and coccyx, with the resident's feet resting directly on the mattress without pressure relief. The resident's care plan indicated the need for padded boots to be worn at all times, but this intervention was not consistently implemented. Interviews with staff, including CNAs, LPNs, and the wound nurse, revealed a lack of clarity and communication regarding the responsibility for ensuring the boots were worn. The wound nurse acknowledged that the resident's left foot wound was misidentified as a hematoma instead of a deep tissue injury, and the left trochanter wound was incorrectly documented as a blister rather than an unstageable pressure ulcer. The facility's failure to conduct a root cause analysis or hold care conferences to address the resident's pressure ulcers further contributed to the deficiency. The resident's coccyx pressure ulcer, initially documented as a stage 4, worsened over time, with increased drainage and slough covering the wound bed, rendering it unstageable. The Director of Nursing confirmed that the resident's care plan required the boots to be worn at all times, but this was not effectively communicated or enforced among the staff.

Plan Of Correction

Element 1 Resident 7 wounds were reviewed by the Director of Nursing, Wound Nurse, and wound care provider by 3/14/25, and it was determined reclassification of wounds was appropriate. The Coccyx Wound was reassessed on 3/13/25 by the wound care provider and determined that the wound needed to be reclassified again back to a stage 4 due to the resolving of slough in the wound bed from the previous week. Skin/Wound evaluations and care plans were updated to reflect the correct classification and staging of current wounds and include appropriate interventions to prevent and promote healing of wounds. Element 2 A one-time audit of current residents with wounds was completed to ensure the wounds are classified and staged correctly, and the care plans are updated and include appropriate interventions to prevent and promote healing of wounds. Any wounds not classified correctly were immediately reclassified and care plans updated. This was completed by the Director of Nursing/Designee by 3/14/25. Element 3 The QAPI Committee has reviewed the Pressure Ulcer Prevention and Management policy and has deemed it to be appropriate by 3/14/25. The Director of Nursing and/or designee educated the Wound Care Nurse and the licensed nurses on the Pressure Ulcer Prevention and Management policy by 3/14/25, with emphasis on correct classification and staging of wounds and ensuring that the care plans are updated and include appropriate interventions to prevent and promote healing of wounds. Nurse Aides were educated on checking resident kardexes and ensuring interventions are in place. This was completed by the Staff Development Coordinator/Designee by 3/14/25. Wounds will be reviewed weekly in the standard of care meeting to ensure wounds are classified and staged correctly, care plans are updated, and appropriate interventions are in place to prevent and promote wound healing. Element 4 The Director of Nursing/designee will audit residents with wounds weekly for 4 weeks, then monthly thereafter, to ensure wounds are classified and staged correctly, care plans are updated, and interventions are in place to prevent and promote healing of wounds. Results will be reviewed monthly by the QAPI Committee until substantial compliance is achieved. The Administrator is responsible to maintain compliance.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure proper infection control surveillance for all 62 residents, as it was not monitored, mapped, and documented monthly. The deficiency was identified when the facility was unable to provide complete infection control line listings and color-coded maps for the months of August through December 2024. Specifically, only the line listings for August, September, and October 2024 were available, and only the map for September 2024 was provided. During interviews, it was revealed that no nurse had been performing the duties of the infection control program since November 1st, 2024, due to the absence of the Infection Control Preventionist (ICP). The Director of Nursing (DON) and Assistant Director of Nursing (ADON) admitted that no staff was monitoring the infection control program, and they only reviewed new antibiotic orders during morning meetings without tracking infection clusters. Consequently, there was no infection control monitoring for November 2024.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to develop and implement a person-centered baseline care plan for a resident admitted for a 10-day respite stay. Upon admission, the resident was assessed as a high risk for falls due to various factors, including altered perception, disorganized speech, restlessness, and the use of multiple medications. Despite these identified risks, the care plan only included general interventions such as educating the resident on safety, encouraging the use of a call light, and ensuring the room was free from hazards. However, these interventions were not adequately tailored to address the resident's specific needs, such as wandering, confusion, and improper footwear. The resident experienced a fall on 8/21/2024, which highlighted the inadequacy of the care plan. The interdisciplinary team updated the care plan five days later, but the revisions were insufficient as they did not address the resident's wandering, confusion, or need for proper footwear. Subsequently, the resident had another fall on 8/28/2024, resulting in a hospital transfer due to hip pain. Interviews with facility staff revealed that the resident required close supervision and should have been kept in view in common areas, but these needs were not reflected in the care plan or Kardex, contributing to the resident's falls and injuries.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure accurate completion of Minimum Data Set (MDS) assessments for three residents. For Resident #36, the MDS indicated that the resident received insulin injections during the seven-day look-back period, but a review of the medical record revealed that the resident did not receive insulin during that time. This discrepancy was confirmed by the Regional Director of Assessment Coordination. For Resident #59, the quarterly MDS did not reflect a significant weight loss of 5.8% in one month, despite a Nutrition Evaluation indicating this weight loss. The Regional Director of Assessment Coordination noted that the medical record's weights and vital signs section would show triggers for weight loss. Additionally, Resident #68's MDS inaccurately documented a discharge to a short-term hospital, while a progress note indicated the resident was discharged home with family. The Nursing Home Administrator confirmed the resident was discharged home.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to implement comprehensive care plans for three residents, resulting in potential unmet care needs. Resident #22 was admitted with major depressive disorder and moderate protein calorie malnutrition. Despite a physician's order for a mechanical soft diet with double portions, observations revealed that the resident's meals were not being consumed, and the registered dietician confirmed that the resident should have received double portions, which were not provided. Resident #28, diagnosed with end-stage renal disease and gastroparesis, was observed to have meals lacking the ordered double protein portions and butter/margarine packets, which were necessary due to his increased needs from dialysis. The resident reported weight loss and frequent nausea and vomiting, and the registered dietician confirmed the dietary orders were not being followed, as the resident's meal trays did not include the required items. Resident #4, with a history of dementia, schizophrenia, and a stage 4 pressure ulcer, was found to have a non-functioning air mattress, which was a critical intervention for her wound care. Despite documentation indicating the mattress was functioning, observations and interviews revealed it was not operational, contributing to the resident's reported pain and potential decline in wound healing. The unit manager confirmed the malfunction and replaced the pump only after the surveyor's inquiry, highlighting a lapse in the implementation of care plan interventions.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure the timely collection of an ordered urinalysis for a resident with diagnoses including diabetes and chronic kidney disease. The resident, who was cognitively intact, reported symptoms of cloudy urine and burning with urination on a Monday. A Nurse Practitioner noted the need for a urinalysis, complete blood count, and basic metabolic panel on the following Wednesday. However, the urinalysis result was rejected due to 'Supplies Unavailable,' and the laboratory did not receive the urine sample until the following Sunday night. During interviews, a registered nurse was unsure of the meaning behind the 'Supplies Unavailable' note, and a laboratory representative confirmed the delay in receiving the urine sample. The resident's urinalysis was eventually sent for further testing due to the presence of leukocytes. This delay in collecting and processing the urinalysis represents a deficiency in providing timely care according to the resident's needs and medical orders.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to implement necessary interventions to promote the healing of a pressure ulcer and prevent its worsening for a resident. The resident, a cognitively intact female with multiple diagnoses including a stage 4 pressure ulcer, was observed with a non-functioning air mattress, which was supposed to be a part of her care plan to relieve pressure and aid in wound healing. Despite the care plan requiring the air mattress to be checked each shift, the nursing staff documented that it was functioning even when it was not, as observed by the surveyor over three shifts. The resident reported significant pain associated with the pressure ulcer, and the wound was noted to have worsened slightly over a week. The air mattress pump was found to be non-functional, and the issue was only addressed after the surveyor's inquiry. The facility's staff, including the LPN and Unit Manager, confirmed the malfunction and took steps to replace the pump. However, the failure to ensure the air mattress was functioning as intended contributed to the deficiency in care provided to the resident.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to obtain a physician order for oxygen for a resident, identified as R4, who was observed using oxygen therapy without a documented order. R4, a female resident with a history of respiratory failure, dementia, schizophrenia, cardiac disease, hypertension, kidney disease, stage 4 pressure ulcer, anxiety, and depression, was admitted to the facility and most recently readmitted on 10/15/24. During observations on 10/27/24 and 10/28/24, R4 was seen using a nasal cannula connected to an oxygen concentrator set at 4 liters, without humidified air, and reported discomfort due to dryness. A review of R4's physician orders from 10/15/24 to 10/29/24 showed no evidence of an order for oxygen therapy. Interviews with facility staff, including the Nursing Home Administrator, Registered Nurse, Unit Manager, and Director of Nursing, confirmed the expectation that residents using oxygen should have a physician's order. The Nursing Home Administrator acknowledged the lack of an order for R4 and indicated that the issue would be addressed. The Unit Manager, who had been in the position for only two weeks, was expected to ensure all orders were correctly transcribed following hospital readmissions, but this oversight occurred.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to protect a resident's right to be free from verbal abuse by staff. The incident involved a resident with severe cognitive impairment, who was able to make herself understood and comprehend others. The resident had a history of cerebral infarction, major depressive disorder, and anxiety disorder. On the day of the incident, a Registered Nurse (RN) was reported to have yelled at the resident and blamed her for an ostomy bag that had come off. The RN allegedly grabbed the resident's arm forcefully, causing the resident to cry. A Certified Nurse Assistant (CNA) who witnessed the incident reported it to the Social Worker (SW), who confirmed the resident's account through limited communication. The RN involved in the incident was interviewed and acknowledged being in the room with the resident and the CNA but denied yelling, stating instead that she was firm with the resident. The CNA, however, provided a detailed account of the RN's actions, including yelling and blaming the resident. The SW corroborated the CNA's report by confirming the resident's non-verbal affirmation of the incident. The facility substantiated the abuse claim and terminated the RN's employment following the investigation.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to notify the physician of a change in treatment orders when a resident, who was suspected to have a femoral artery bleed, was not transferred to the emergency room as ordered. The resident, who was cognitively intact and responsible for their own care, was admitted with diagnoses including respiratory failure, tracheostomy status, and severe obesity. On the day of the incident, the nurse observed profuse bleeding from the resident's lower right abdomen and a large blood clot, prompting a physician's order for the resident to be sent to the ER. However, the EMS was unable to transport the resident due to weight limitations, and an alternate ambulance service could not transfer the resident until later. Despite the situation, the Assistant Director of Nursing did not inform the physician that the resident was not transported to the hospital as initially ordered. The medical record did not reflect any notification to the physician about the failure to transfer the resident, and the physician confirmed that they were not made aware of the situation beyond the initial call about the bleeding.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to routinely assess and monitor a change in condition for a resident who was admitted with diagnoses including respiratory failure, tracheostomy status, and morbid obesity. The resident experienced a suspected femoral artery bleed, which was documented in an SBAR on 6/8/24. The nurse observed profuse bleeding and a large blood clot in the resident's abdominal fold, and the physician ordered the resident to be sent to the emergency room. However, due to the resident's weight, EMS was unable to transport him, and an alternate ambulance service was not available until later in the afternoon. Despite the physician's order for hospital transfer, the resident remained in the facility without further orders for treatment, assessment, or monitoring of his condition. The medical record did not reflect that the physician was notified of the failed transfer. The resident's condition worsened, and he began hemorrhaging again early on 6/9/24. Staff frequently checked for bleeding and changed towels, but the resident's blood pressure continued to drop, indicating a lack of adequate monitoring and intervention. The resident's medical record showed a significant drop in blood pressure from 117/70 mmHg on 6/8/24 to 70/42 mmHg on 6/9/24, with corresponding changes in pulse rate. EMS was eventually able to transport the resident to the hospital using a flatbed truck, but the delay and lack of appropriate monitoring and intervention contributed to the deficiency. The physician later stated that if she had been informed of the situation, she would have expected more frequent monitoring of vital signs.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure appropriate treatment orders for a resident with a facility-acquired pressure ulcer on the sacrum. The resident, who had a history of cardiac arrest, respiratory arrest, and anoxic brain damage, developed an unstageable pressure ulcer characterized by slough and granulation tissue. Over the course of several weeks, the ulcer increased in size, and the treatment orders were inconsistent and overlapping. Initially, the treatment involved cleansing the wound, applying collagen, and covering it with hydrofera blue and bordered foam, to be changed every other night. Subsequent orders introduced different treatments, including Dermasyn AG and Medihoney, which were to be applied daily at bedtime. These orders ran concurrently with the original treatment plan, leading to confusion and improper application of treatments. The Director of Nursing acknowledged that the staff was applying treatments incorrectly, with hydrofera being used on an old wound and collagen and Medihoney on the new sacral wound. This inconsistency in treatment orders and application contributed to the deficiency identified during the survey.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to prevent the development of a medical device-related pressure ulcer for a resident, resulting in a deep tissue injury (DTI). The resident was readmitted with multiple diagnoses, including acute respiratory failure and protein-calorie malnutrition, and was dependent on all care. The resident had an indwelling catheter and was at risk for developing pressure injuries but was not on a turning/repositioning program. Initial assessments noted several stage 1 pressure injuries and a bruise on the left buttock, which was later identified as a DTI related to the catheter tubing placement. Observations and interviews revealed that the resident was frequently repositioned due to incontinence and existing wounds. However, the catheter tubing was not properly managed, leading to pressure on the left buttock. The wound nurse and DON assessed the area and initially documented it as a bruise. Despite staff education on proper catheter placement, the area worsened, opening and presenting with deep reddish/purple discoloration. The wound nurse updated the physician and received treatment orders, but the wound continued to deteriorate. Further assessments and interdisciplinary team discussions led to the reclassification of the wound as a DTI. The facility's wound management program included weekly assessments and staff education, but the improper management of the catheter tubing resulted in the development of the pressure ulcer. The resident's care plan was updated to reflect the new wound classification, and the facility continued to monitor and treat the wound.