Every finding on record at Altercare Thornville Inc.

Based on record review, observation, interview, and policy review, the facility failed to ensure a resident at risk for pressure ulcers had pressure ulcer prevention interventions implemented as per their plan of care. This affected one resident (#2) of three residents reviewed for pressure ulcers. Findings include:Review of Resident #2's medical record revealed the resident was admitted to the facility on [DATE]. His diagnoses included unspecified dementia, heart failure, chronic kidney disease, hypotension, restless leg syndrome, anemia, and muscle weakness. Review of Resident #2's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident's cognition was moderately impaired. No behaviors or rejection of care was noted. He required supervision/ touching assistance with bed mobility and was identified as being at risk for pressure ulcers. Review of Resident #2's care plans revealed the resident had an active care plan in place for being at risk for skin breakdown related to impaired cognition, anemia, liver disease, renal disease, and abnormal weight loss. The care plan originated on 10/02/24. The goal was for the resident to not develop skin breakdown daily by the next review date. The interventions included encouraging/ assisting the resident to float heels as tolerated. That intervention was added on 10/16/24. On 02/18/26 at 9:56 A.M., an observation of Resident #2 noted him to be lying in bed in a supine position with his eyes open. His heels were in direct contact with his mattress and not floated/ offloaded as per his plan of care. On 02/18/26 at 11:13 A.M., an interview with Certified Nursing Assistant (CNA) #109 revealed she did not consider Resident #2 to be at risk for pressure ulcers. She was asked what interventions were in place to help prevent the resident from getting pressure ulcers. She indicated, if they noted the resident was staying in bed too much and not getting up, they would go in and encourage him to get out of bed. She did not mention anything about the need to keep his heels floated when in bed. She was asked to accompany the surveyor to the resident's room to see if he had anything under his heels to help offload them. She pulled his blanket back and confirmed his heels were in direct contact with the mattress and not floated, as per his plan of care. Review of the facility's policy on Pressure Injuries: Assessment, Prevention, and Treatment updated 05/01/25 revealed it was the facility's policy to identify residents at risk for developing pressure injuries, implement interventions to prevent the development of pressure injuries, and provide care for existing pressure injuries. Interventions and preventative measures were to be provided, as indicated, based on resident risk factors.

Based on observation, staff, visitor and resident interview, review of the medical record and policy review, facility failed to ensure a newly identified skin impairment was assessed timely. This affected one resident (#9) of three residents reviewed for wounds. The facility also failed to ensure a change in condition was addressed timely. This affected one resident (#25) of one resident reviewed for change in condition. Facility census was 48. Findings include 1. Review of the medical record for Resident #9 revealed an admission date of 08/25/25. Diagnoses included heart failure, muscle weakness, altered mental status, and diabetes. Review of the plan of care dated 08/25/25 revealed the resident was at risk for skin breakdown with interventions to report signs and symptoms of skin irritation including irritation and report to the physician. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview of Mental Status (BIMS) of 15 indicating intact cognition and required assistance with activities of daily living. Review of physician orders dated 02/15/26 to pad and protect bunion on right foot for preventative every three days until healed and order dated 02/15/26 to remove boot on right foot while resident is in bed and float heal to prevent skin conditions at bedtime. Review progress notes dated 02/15/26 revealed new area found on resident's right foot, pad and protect every three days for preventative all parties aware. Review of wound assessments from 02/01/26 to 02/19/25 revealed no wound assessment was completed. Review of wound reports from 02/01/26 to 02/19/26 revealed no wound report was done. Interview and observation on 02/17/26 at 9:58 A.M. with Resident #9 revealed the resident had a medical boot on his right foot and stated it was due to having surgery on his heel and an amputation of a toe. He reported staff recently told him he had a new open wound on his right foot and placed a bandage over it. He was unsure what type of wound he had, but stated it was from his boot rubbing on his foot. Observation and interview on 02/19/26 at 9:00 A.M. with Assistant Director of Nursing (ADON) #163 removed the boot and observed resident skin on his right foot. Resident had a bandage over the inside of the foot at the sesamoid bone joint. The bandage was removed and identified a red area about the size of a nickel on the boney prominence of the foot. The area did not appear to be open and did not have drainage. The ADON stated she was not aware of the skin impairment as she had been off for the past few days and stated it was from sheering and friction from the boot. She reported the ADON stated it was from sheering and friction of the boot. The ADON confirmed it was documented in the progress note as a new area and in the order as a bunion and she stated she did not believe it was pressure as the foot was not pressing on the boot and was rubbing and sheering skin from the boot. The ADON confirmed the facility did not have a completed assessment or description of the skin impairment and stated she would assess it this date (02/19/26) and reported she had a week to complete the wound/skin impairment assessment. Interview on 02/19/26 at 9:30 A.M. with ADON revealed she did a full assessment of the wound and stated it was non-blanchable. She stated she would contact the medical provider and verify what orders they wanted for treatment and preventative care. She confirmed this would not be classified as a pressure wound. Interview on 02/19/26 at 10:14 A.M. with Director of Nursing (DON) revealed she would expect the nursing staff to assess a new skin impairment/wound and document the assessment on the shift it was identified, including pressure and non pressure wounds. The DON confirmed the assessment should give a description of the wound including size, location, redness, drainage etc. Review of policy titled Skin assessment dated [DATE] revealed facility shall assess and implement interventions to promote skin integrity. Review of policy titled Wound Prevention dated 05/01/25 revealed inspection of skin for signs and symptoms of breakdown or pressure should be conducted by direct care. Whenever possible avoid friction and shearing when caring for a residents including providing padding for casts splints and braces and check for redness. 2.Record review revealed Resident #25 was admitted to the facility on [DATE] with diagnoses including dementia, muscle weakness, and edema. Review of a care plan dated 11/14/23 revealed Resident #25 had impaired ability to perform or participate in daily activity of daily living (ADL) care related to dementia, muscle weakness, depression, chronic kidney disease, polyneuropathy, osteoarthritis, dizziness and giddiness, and history of peripheral vascular disease. The goal was for Resident #25 to participate with ADLs as much as possible and to remain clean, dry, comfortable, and neat in appearance by the target date as well as maintaining current level of ADLs without decline by target date. Interventions included but were not limited to assist with toileting if needed; provide incontinence are as needed; observe/report any decline in ADLs, mobility or cognition; provide assistance with all ADL care and mobility as needed/anticipate resident needs as able and encourage resident to participate with care as tolerated- refer to resident profile for ADL assistance needed; and refer to physical therapy (PT), occupational therapy (OT), speech therapy (ST) of restorative nursing as needed. Review of a care plan dated 11/14/24 revealed Resident #25 was occasionally incontinence of bladder and was at risk for altered dignity, skin breakdown and urinary tract infections. The goal was for Resident #25 to not have alteration in dignity related to urinary incontinence by the target date and to not develop complications related to urinary incontinence such as skin breakdown or urinary tract infections. Interventions included but were not limited to assess quarterly and as needed for any change in elimination patterns; maintain resident dignity when checking/providing incontinence care; and refer to restorative book for toileting program and toileting times if applicable. Review of care plan dated 11/27/23 revealed Resident #25 had impaired cognition, dementia, short-term memory loss, disorientation to time, and a brief interview for mental status (BIMs) score below 13. The goal was for Resident #25 to function at optimum level within limitations. Interventions included but were not limited to administer medication as ordered; introduce self, use calm approach and explain all procedures prior to beginning; and observe and report any changes in mental status or behaviors to physician and keep resident representative informed of resident's status. Review of an MDS dated [DATE] revealed Resident #25 was occasionally incontinent, had moderately impaired cognition, and required supervision to touching assistance for transfers. Review of a care plan dated 01/07/26 revealed Resident #25 had urinary incontinence per tracking/assessment and is a candidate for prompted toileting program. The goal was to reduce incontinence episodes to less than daily by next review date. Interventions included but were no limited to assist/remind resident to wipe after toileting and wash hands to promote hygiene; change clothing/incontinence pads/briefs/linen as needed due to soiling from bladder incontinence and provide incontinence care as needed; explain program to resident as about before beginning and give positive feedback and praise resident for participating in the program; prompt and remind resident for toileting program; provide physical support/assistance for toileting safety as indicated for resident; and review toileting times and program progress quarterly. Review of orders dated 01/21/26 revealed Resident #25 was occasionally incontinent of bladder and always continent of bowel; and required supervision to touching assistance for transfers. Review of bladder function documentation from 01/22/26 through 02/05/26 revealed Resident #25 was incontinent of urine 16 times and was continent of bladder 34 times. Review of a nursing note dated 02/05/26 at 8:43 A.M. by Director of Nursing (DON) revealed new orders were received from Nurse Practitioner (NP) #305 for Resident #25 to have Lasix 20 milligrams (mg) by mouth every afternoon for seven days for lower extremity edema; daily weights for seven days; and a complete blood count/basic metabolic panel on 02/11/26. All parties were made aware. Review of bladder function documentation from 02/06/26 through 02/09/26 revealed Resident #25 was incontinent of urine eight times and continent of bladder five times. Review of a nursing note dated 02/09/26 at 2:50 P.M. by the DON revealed Physician #306 revealed urinary analysis results for Resident #25 with no culture indicated. Review of a provider note dated 02/10/26 by Nurse Practitioner (NP) #305 revealed Resident #25 was being seen for a follow-up visit for chronic conditions including atrial fibrillation, hypertension, and dementia. NP #305 documented no new concerns and no new staff concerns. Review of bladder function documentation from 02/10/26 through 02/12/26 revealed resident #25 was incontinent of bladder six times and continent of bladder six times. Review of a provider note dated 02/12/26 by NP #305 revealed Resident #25 was being seen as a follow up for chronic conditions including anemia, chronic kidney disease and osteoarthritis. NP #305 documented no new staff concerns. Review of a nursing note dated 02/12/26 at 9:39 A.M. by the DON revealed labs were reviewed by NP #305 and all parties were aware. Review of bladder function documentation from 02/13/26 through 02/18/26 revealed Resident #25 was incontinent of bladder 11 times and continent of bladder seven times. Interview on 02/17/26 at 10:00 A.M. with Resident #25 revealed she was confused. Resident #25 had a visitor at the time who was not a representative but stated Resident #25 was off since going home last week and had increased confusion. Interview on 02/18/26 at 2:07 P.M. with Certified Nursing Assistant (CNA) #117 revealed Resident #25 had increased confusion starting on either 02/11/26 or 02/12/26 and thought she was just declining related to her health. Interview on 02/18/26 at 3:16 P.M. with Registered Nurse (RN) #116 revealed a urinalysis was completed on Resident #25 which was negative but there was no additional information in the chart about a change in condition. Interview on 02/19/26 at 8:20 A.M. with Licensed Practical Nurse (LPN) #151 revealed a urinalysis (UA) was completed on Resident #25 because her back had been hurting but the UA was negative. LPN #151 stated she did not have increased confusion and she was at her baseline. Interview on 02/19/26 at 8:43 A.M. with CNA #118 revealed Resident #25 had a change in the last couple weeks. She had a UA completed then went to her family's house for her birthday and was still having a change including being incontinent when she used to get up by herself. CNA #118 stated Resident #25 was now a check and change for the bladder program and she has needed more assistance getting out of bed. Resident #25 was previously supervision to touching assistance for transfers but was requiring a minimum assistance of one staff more often. CNA #118 stated when she identifies a change in condition she notifies the nurse. CNA #118 stated she notified LPN #151 on 02/13/26 of Resident #25's decline. Interview on 02/19/26 at 8:52 A.M. with CNA #134 revealed due to not working as much, she has noticed small changes in Resident #25 including being more forgetful and now requiring a one-staff assist when before she could transfer with supervision. CNA #134 stated she felt the change occurred a few weeks ago. CNA #134 stated Resident #125 is always continent of bowel, but it is hit or miss with bladder. CNA #134 stated she had not reported a change in condition because she figured another staff had likely already reported the change in condition. Observation on 02/19/26 at 9:10 A.M. revealed LPN #151 on the phone and stated, we did the urine on Resident #25 and it was negative but now she is incontinent, what do you want to do? When LPN #151 got off the phone, she stated we are ordering a UA for Resident #25. Review of a nursing note dated 02/19/26 at 9:10 A.M. by LPN #151 revealed she spoke with a provider regarding Resident #25 due to incontinence and a new order was received from NP #305 for a urinalysis and a culture/sensitivity. Interview on 02/19/26 at 9:31 A.M. with CNA #104 revealed Resident #25 had a change at the end of last month (January) because her back started hurting more, she needed more assistance with stand-pivot transfers minimum assist of one when she was supervision before. CNA #104 stated sometimes Resident #25 could still transfer but she would hit the call light to ask for help when needed. CNA #104 stated Resident #25 used to be incontinent every once in a while, but now she is always incontinent to the point she is soaking the bed. CNA #104 stated Resident #25 has gotten more confused because sometimes she would come out of her room asking where she was, who the staff are, and how do they know her. CNA #104 stated the increased confusion started last month but continued to progress. Interview on 02/19/26 at 9:57 A.M. with the DON revealed she did not consider Resident #25's decline to be a change in condition because the incontinence is not new, she had a brief increase in Lasix so that could contribute to the increase incontinence, and her Aricept (medication to slow progression of dementia) so a decline was anticipated. The DON stated to speak with staff who work with Resident #25 daily because they will confirm it isn't a change. Interview on 02/19/26 at 12:53 P.M. with DON revealed she still did not consider Resident #25's decline a change in condition and the staff spoken with during the survey were too close to the resident so it was personal to them but there was not actually a change. The DON stated Resident #25 had therapy in December (2025) but declined to continue. The DON confirmed therapy had not been offered again since the decline because she had refused previously. The DON did not provide any additional evidence to show a complete, thorough assessment of the resident from a nurse or the provider or any documentation to address the change in condition. Review of a policy dated 05/01/25 titled Change in the Residents Condition or Status revealed it is the facility's policy to ensure the resident's attending physician and authorized representative or interested family member are notified of a change in condition including physical, mental, or psychosocial status. A significant change in condition will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions, impacts more than one area of the resident's health status, and requires interdisciplinary review and/or revision to the plan of care. The nurse should record in the medical record information relative to changes in the resident's medical/mental condition or status.

Based on record review and staff interview, the facility failed to ensure a resident receiving medication for hypotension did not receive the medications when his systolic blood pressure (SBP) was greater than 130 millimeters per mercury (mmHg), as per parameters included in his physician's orders. This affected one resident (#2) of five residents reviewed for unnecessary medications. Findings include: Review of Resident #2's medical record revealed the resident was admitted to the facility on [DATE]. His diagnoses included heart failure, atrial fibrillation, and hypotension (low blood pressure). Review of Resident #2's physician's orders revealed the resident had an order to receive Midodrine ( a medication used to treat symptomatic orthostatic hypotension by tightening blood vessels to raise blood pressure) 2.5 milligrams (mg) twice a day. Parameters were included with directions to hold the medication when the resident's SBP was greater than 130 mmHg. The order originated on 01/27/26. Review of Resident #2's electronic medication administration record (eMAR) for January 2026 revealed the resident's Midodrine 2.5 mg that was ordered twice a day was scheduled to be given at 7:00 A.M. and 2:00 P.M. The MAR also included documentation of what the resident's blood pressure was before the administration of the medication. There were five times in January 2026, where the resident's SBP was recorded as having been greater than 130 mmHg, and it was documented that the medication was administered. On 01/27/26 at 2:00 P.M., the resident's SBP was 133 mmHg; on 01/28/26 at 7:00 A.M., the resident's SBP was recorded as being 132 mmHg; on 01/29/26 at 2:00 P.M., the resident's SBP was recorded as being 134 mmHg; on 01/30/26 at 7:00 A.M., the resident's SBP was recorded as being 137 mmHg; and on 01/30/26 at 2:00 P.M., the resident's SBP was recorded as being 135 mm/Hg. All five times, the nurses initialed the eMAR to reflect the Midodrine had been administered, and was not held as per the parameters included with the order. Review of Resident #2's eMAR for February 2026 revealed the resident was administered Midodrine 2.5 mg on 02/16/26 at 2:00 P.M., when his SBP was recorded as having been 133 mm/Hg prior to the medication being given. The nurse initialed the eMAR to reflect the medication was given and was not held per the parameters set in the order. On 02/18/26 at 3:15 P.M., an interview with the facility's Director of Nursing (DON) confirmed Resident #2's physician's orders did include parameters on when to hold the resident's Midodrine used for the treatment of hypotension. She verified the current physician's order was to hold the Midodrine, when the resident's SBP was greater than 130 mmHg. She acknowledged there were six times, since the order had been given, that the resident received Midodrine 2.5 mg, where the medication should have been held per the parameters included in his physician's orders.

Based on observation, staff interview, and record review the facility failed to implement a fall risk intervention for a resident after a fall. This affected one resident (#4) of one resident reviewed for falls. The facility census was 48.Findings include:Review of Resident #4's medical record revealed the resident was admitted on [DATE] and had diagnoses that included dementia, muscle weakness, cognitive communication deficit, cardiac arrhythmia, peripheral vascular disease, and neuropathy. Review of the Brief Interview for Mental Status dated 12/25/25 revealed a score of 09, which indicates moderately impaired cognition. Review of fall risk assessment dated [DATE] revealed the resident had a fall risk score of 18, which indicated a high fall risk. Observation on 02/19/26 at 8:30 A.M. revealed no non-skid strips in Resident #4's room. Review of fall without injury event report dated 01/06/26 revealed Resident #4 had an unwitnessed fall on 01/06/26. Further review of the investigation report revealed the immediate safety measures that needed to be implemented due to the circumstances of the fall were non-skid strips. Interview on 02/19/26 at 8:39 A.M. with the Director of Nursing (DON) stated that she was on the unit when Resident #4's fall happened on 01/06/26. She stated that based on the fall investigation report, the facility should have added non-skid strips to Resident #4's floor near her bed. The DON confirmed that non-skid strips were not present in the room at the time of the interview. The DON confirmed there was no documentation that this intervention was in place. Review of the facility's policy titled Fall Risk Management, dated 05/01/25, revealed it is the facility's policy to conduct a root cause analysis post fall to assist the interdisciplinary team in updating the resident's plan of care with the interventions to reduce the risk of recurrent falls.

Based on observation, record review, and interview, the facility failed to ensure a resident was shaved per preference upon admission to the facility and during first shower. This affected one resident (#54) of two residents reviewed for activities of daily living. The facility census was 48. Findings include:Record review revealed Resident #54 was admitted to the facility on [DATE] with diagnoses including other displaced dens fracture, muscle weakness, and hemiplegia. Review of an order dated 02/15/26 revealed Resident #54 required extensive assistance for bathing and limited assistance for personal hygiene and shaving. Review of a shower sheet revealed Resident #54 received a shower on 02/16/26. Observation on 02/17/26 at 2:35 P.M. revealed Resident #54 was sitting in bed with non-skid socks on, a hospital gown, and his hair was disheveled. Resident #54's facial hair was long and unkempt. Interview on 02/17/26 at 2:35 P.M. with Resident #54 revealed he would like to be shaved, but he did receive a shower though he couldn't remember when. Interview on 02/17/26 at 2:54 P.M. with Certified Nursing Assistant (CNA) #104 revealed Resident #54 was new to her. She got to her shift at 2:00 P.M. and had not cleaned him up. CNA #104 confirmed Resident #54 was wearing a hospital gown, had disheveled hair and his facial hair was grown and needed trimmed. Observation on 02/18/26 at 8:51 A.M. revealed Social Worker (SW) #131 coming out of Resident #54's room stating to a coworker, you should have seen how happy he was when I shaved him yesterday. Interview on 02/18/26 at 9:18 A.M. with Resident #54 revealed he got shaved yesterday and felt much better. Interview on 02/18/26 at 2:05 P.M. with CNA #117 revealed if a new admission came in who had disheveled hair and unkempt facial hair, she would be able to provide hygiene care as soon as the nurse finished with the admission process. CNA #117 confirmed there was plenty of time from Resident #54's admission to 02/17/26 for him to have been shaved. Review of a policy dated 01/2018 titled Shaving a Resident revealed the facility should promote resident hygiene by assisting a resident with removal of facial hair as needed.

Based on medical record review, hospital record review, wound notes, facility and staff interviews, wound physician interview, observation, review of the facility policies, and National Pressure Injury Advisory Panel (NPIAP) information, the facility failed to develop and implement an accurate comprehensive and individualized pressure ulcer program to ensure necessary care and services to prevent the worsening of pressure ulcers for Resident #800 and #300. This affected two residents (#800 and #300) of two residents reviewed for pressure ulcers. The facility census was 47. This resulted in Immediate Jeopardy and serious life-threatening harm to Resident #800, who was assessed as requiring maximum assistance with bed mobility and transfers and was at risk for pressure ulcer development, on 05/04/25 when treatment orders for known pressure ulcers were not obtained timely, orders were entered incorrectly resulting in wrong treatments and pressure ulcer worsening and prevention care was not in place leading to an admission to the hospital for subsequent infection/sepsis. Resident #800 was ultimately placed on hospice due to multiple antibiotic use from worsening of pressure ulcers. This also resulted in Immediate Jeopardy and serious life-threatening harm to Resident #300, who was assessed as requiring maximum assistance with bed mobility and transfers and at risk for pressure ulcer development, on 06/24/25 when the resident was assessed to have a stage 4 (full thickness skin and tissue loss with exposed palpable fascia, muscle, tending, ligament, cartilage or done in the ulcer; slough and/or eschar may be visible) pressure ulcer to the right buttock that previously was a stage 3 (full thickness loss of skin, in which adipose [fat] is visible in the ulcer and granulation tissue and epibole [rolled wound edges] are often present; fascia, muscle, tendon, ligament, cartilage and/or bone are not exposed) the week prior, due to medicated treatments not being placed in the orders for administration from 06/19/25 through 06/23/25. On 08/11/25 at 1:11 P.M., Administrator #41, Regional Nurse #68, Director of Nursing (DON) #40, and Regional Administrator #69 were notified Immediate Jeopardy began on 05/04/25 when the facility failed to provide any treatments as well as accurate treatments and necessary interventions to prevent worsening of pressure ulcers resulting in the hospitalization of Resident #800 for infection/sepsis from pressure ulcers. Resident #800 returned to the facility on [DATE] and was sent back to the hospital for continued inaccurate treatments and necessary interventions to prevent worsening of pressure ulcers on 06/27/25. Resident #800 returned to the facility on [DATE] and was ultimately placed on hospice due to multiple antibiotic use from worsening of pressure ulcers. Immediate Jeopardy also occurred on 06/24/25 when the facility failed to provide the medicated treatment of Leptospermum Honey and Alginate Calcium to be applied daily with a gauze island bordered dressing from 06/19/24 through 06/23/25 to a right buttock stage 3 pressure ulcer measuring 6.8 centimeters (cm) long, 5.4 cm wide and 0.2 cm in depth with moderate serous exudate and 50 percent necrotic tissue. On 06/24/25, the right buttock pressure ulcer was assessed to have worsened to a stage 4 and measured 7 cm long, 5.4 cm wide, and undetermined depth with 20 percent black necrotic(dead) eschar tissue, 50 percent devitalized necrotic tissue and 20 percent slough (dead tissue separating from living tissue). The immediate Jeopardy was removed on 08/11/25 when the facility implemented the following corrective actions: On 08/07/25, Resident #300 was assessed by Wound Care Physician #70 with orders received and followed by a licensed nurse, Assistant Director of Nursing (ADON)/Wound Nurse# 33. On 08/07/25, Resident #800 was assessed by Wound Physician #70 with new orders received and followed by a licensed nurse ADON/Wound Nurse# 33. On 08/07/25 at 10:00A.M., an in-service was completed for ADON/Wound Nurse #33 by DON #40 and Regional Nurse #68 on the policy of Pressure Injuries: assessment, prevention, and treatment and the policy of physician notification. On 08/07/25 at 11:30A.M., an in-service was completed for Minimum Data Set ( MDS) Nurse #42, Registered Nurse (RN) #34, RN #27, RN #56, Licensed Practical Nurse (LPN) #44, LPN #25, LPN # 65, LPN #30, and 26 Certified Nursing Assistants (CNA) by DON #40 on the policy of pressure Injuries: assessment, prevention, and treatment policy; completing head to toe assessment and documenting on skin sheet, if resident has skin alterations; documenting the initial wound observation; and contacting House Physician #66 to obtain treatment orders if not provided from the hospital. Any staff who had not received education as of 08/11/25 will not work until education is completed. All staff had received the education as of 08/11/25. On 08/07/25 at 11:30A.M., an in-service was completed for MDS Nurse #42, RN #34, RN #27, RN #56, LPN #44, LPN #25, LPN # 65, LPN #30 by the DON #40 on notifying physician of any resident change in condition. Any staff who have not received education as of 08/11/25 will not work until education is completed. All staff have received the education as of 08/11/25. By 08/11/25, a whole facility skin sweep was completed for 48 residents to identify any skin alterations by LPN #30 and ADON/Wound Nurse #33. Any residents with new skin alterations were reviewed by the DON #40 and House Physician #66 notified. No new pressure injuries were identified during whole house skin sweep. On 08/11/25 at 11:00 A.M., treatment orders for 48 residents were reviewed by the Regional Nurse #68 to ensure that treatment orders are appropriate for any skin alterations. As of 08/11/25, a list of any residents being followed by the wound care physician will be maintained by DON #40. For newly admitted residents, based on the admission skin assessment, the resident will be added to the wound consult as applicable. For current residents, any new skin alteration identified will be reviewed and added to the wound consult as applicable. On 8/11/25, at 1:30 P.M., an ad hoc Quality Assurance Performance Improvement (QAPI) meeting was held with House Physician/Medical Director #66 and facility leadership DON #40, Administrator #41, MDS/RN #42, ADON/Wound Nurse #33, Regional Administrator #69, and Regional Nurse #68 on pressure ulcer care and plan of correction. An audit to ensure pressure ulcer care is being completed per policy will be conducted for five residents three times a week for four weeks and as needed (PRN) by the DON or designee. Any concerns will be forwarded to the QAPI committee for immediate follow up. An audit to ensure wound consults are accurate on the consult sheet and orders from wound consults are entered appropriately and assigned to the correct physician will be completed once a week for four weeks and PRN by the DON or designee. Any concerns will be forwarded to the QAPI committee for immediate follow-up. An audit to ensure residents being followed by the wound care physician is being maintained by the DON, newly admitted residents are added to the wound consult list as applicable, and current residents with any new skin alterations are added to the wound consult list as applicable will be conducted once per week for four weeks and PRN by the regional nurse consultant or designee. Any concerns will be forwarded to the QAPI committee for immediate follow-up. QAPI plan completed by 08/11/25. Although the Immediate Jeopardy was removed on 08/11/25, the facility remained out of compliance at Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility was still in the process of implementing their corrective action and monitoring to ensure on-going compliance. Findings include: 1. Review of the medical record for Resident #800 revealed an admission date of 04/18/25 at 4:56 P.M. Diagnoses included weakness, cerebral infarction, atrial fibrillation, type 2 diabetes, and chronic kidney disease. Review of Resident #800 ' s hospital discharge summary that was received by the facility and dated 04/18/25, revealed a wound care order for a sacrum area to cleanse the wound with mild soap and water, rinse and pat dry. Apply triad cream at dime thickness and cover with Mepitel One, a wound dressing, to be changed every three days. The summary had no wound measurements, descriptions or classification. No other treatments or open skin areas were documented in the discharge paperwork. Review of Resident #800 ' s Braden Scale for Predicting Pressure Sore Risk, dated 04/18/25, revealed a score of 14 on a scale of six (high risk) to 23 (no risk), which indicated the resident was at moderate risk for skin breakdown. Review of the admission wound goal plan of care, dated 04/18/25, revealed to be admitted with multiple pressure areas with wound prevention and treatment approaches to include encourage to turn and re-position comfortably every two hours, check skin with daily care and bathing weekly. Report any skin concerns to the nurse/Nurse Practitioner/Physician and to record wound measurements weekly. Review of the admission initial wound grid documentation, dated 04/19/25 at 1:22 A.M., revealed a left buttock stage 2 (Partial thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed, without slough or bruising; may also present as an intact or open/ ruptured blister) pressure ulcer scattered areas with moisture associated skin damage (MASD) surrounding it with no measurements. Additional initial wound grid documentation, dated 04/19/25 at 1:25 A.M., revealed a right buttock unstageable (a full thickness skin and tissue loss where the depth of the tissue damage cannot be determined because it ' s obscured by slough or eschar) pressure ulcer that measured 12 cm by 5.8 cm by 0.1cm. There was no documentation of an initial wound grid for the area on Resident #800 ' s sacrum. Review of the physician order dated 04/19/25 at 2:10 A.M. revealed for the right buttock- cleanse with mild soap and water, apply Triad cream a debriding medication) at dime thickness and cover with a Mepitel One dressing and change as needed when soiled/dislodged. This order was active until discontinued on 04/23/25 at 8:33 A.M. by FWN #33. Review of the physician orders dated 04/18/25 through 04/22/25 for Resident #800 resident revealed no wound treatment order for the sacral area as noted on hospital discharge documentation; no wound treatment order for the documented area on admission for the left buttock stage 2 pressure ulcer; and no interventions for general facility pressure ulcer injury prevention and care. Review of the Treatment Administration Record (TAR) for Resident #800 dated 04/18/25 through 04/22/25 revealed no as needed dressing change was completed for the right buttock unstageable pressure injury. Review of the initial wound consult visit by Advanced Practice Registered Nurse (APRN) #71, dated 04/22/25 with no time stamp of visit, revealed Resident #800 had several pressure ulcer areas. Identified was a right buttock unstageable pressure ulcer measuring 11.2 cm by 5.9 cm with undetermined depth with moderate serous exudate and 50 percent necrotic tissue. A treatment plan of Leptospermum Honey and Alginate Calcium to be applied daily with a gauze island bordered dressing. Another identified area was the left buttock unstageable deep tissue injury (DTI) pressure ulcer measuring 8.4 cm by 4.2 cm with undetermined depth with a treatment plan of house barrier cream twice a day. Finally, identified was a coccyx unstageable pressure ulcer measuring 4.2 cm by 1.1 cm by undetermined depth with moderate serous exudate and 100 percent slough. A treatment plan of Leptospermum Honey and Alginate Calcium to be applied daily with a gauze island bordered dressing. There were recommendations for additional care plan items including a low air-loss mattress, offload wounds and reposition per facility protocol. Review of the physician orders for Resident #800, dated 04/23/25 at 9:34 A.M. revealed a treatment for the coccyx pressure ulcer of apply Leptospermum Honey and an island adhesive dressing daily. The treatment to include Alginate Calcium was omitted from the order. The order was discontinued on 04/29/25 at 1:29 P.M. by FWN #33. Review of the physician orders dated 04/22/25 through 04/29/25 revealed on 04/24/25, an alternating low air loss mattress was ordered, but for the left buttock unstageable DTI pressure ulcer treatment plan of house barrier cream twice a day was not ordered as well as no reposition per facility protocol and offloading of the wounds. Review of the TAR for Resident #800 dated 04/23/25 through 04/28/25 revealed the incorrect treatment order was administered for the coccyx unstageable pressure ulcer. Review of the admission Minimum Data Set (MDS) assessment, dated 04/25/25, revealed Resident #800 was alert and oriented. The resident required substantial/maximal assistance with shower/bathe self, bed mobility, toilet hygiene, and transfers and was at risk for pressure ulcer injuries. Review of Wound Physician visit notes, dated 04/29/25 with no time stamp, revealed Resident #800 was seen by APRN #71. Resident #800 to still had several pressure ulcer areas. The right buttock pressure ulcer progressed to a Stage 4 and measured 7.8 cm by 5.9 cm with undetermined depth and moderate serous exudate and 50 percent necrotic tissue. A new treatment plan was for Alginate Calcium and Santyl daily with a gauze island dressing. A surgical excisional debridement was performed due to removal of necrotic tissue and to establish the margins of viable tissue. The left buttock unstageable DTI pressure ulcer measured 7.3 cm by 4.2 cm with undetermined depth. A new treatment plan was for Alginate Calcium and Santyl daily with a gauze island dressing. The coccyx pressure ulcer measured 3.9 cm by 0.9 cm with undetermined depth and moderate serous exudate and 100 percent slough. The new treatment plan was for Alginate Calcium and Santyl daily with gauze island dressing. Recommendations for additional care plan items included to offload wounds and reposition per facility protocol. Review of the physician orders dated 04/29/25 through 05/03/25 revealed the left buttock pressure ulcer treatment of Alginate Calcium and Santyl daily with a gauze island dressing from APRN #71 was not ordered as well as no reposition per facility protocol and offloading of the wounds. The interventions for the risk for skin breakdown dated 04/18/25 were not started until 05/01/25 and included to assist resident with turning and repositioning frequently while in bed and an air mattress. Review of the progress note for Resident #800, dated 05/04/25 at 10:49 A.M., documented the resident was confused and delusional, and the nurse spoke to the 24/7 on call physician line and obtained an order to send resident to the hospital. The resident left the faciity on [DATE] at 11:02 A.M. Review of the hospital documentation for Resident #800 ' s admission on [DATE] revealed cellulitis of decubitus ulcer to the sacral region confirmed by a computed tomography (CT) scan image. Treatment included surgical debridement of the site and broad-spectrum antibiotics for the area. Resident #800 was discharged back to the facility on [DATE] with intravenous antibiotics, but no wound care instructions, measurements, descriptions and classification of any skin areas. Review of the progress note dated 05/09/25 at 5:11 P.M. revealed Resident #800 returned to the facility from the hospital. Review of the admission initial wound grid documentation dated 05/09/25 at 5:39 P.M. revealed a coccyx unstageable pressure ulcer measured 14 cm by 8 cm by 0.6 cm. Review of the admission wound goal plan of care dated 05/09/25 for Resident #800 revealed resident admitted with a high wound risk, with wound prevention and treatment approaches to include encourage to turn and re-position comfortably every two hours. Review of Resident #800 ' s Braden Scale for Predicting Pressure Sore Risk dated 05/09/25 revealed a score of 14 on a scale of 6 (high risk) to 23 (no risk) which indicated the resident was at moderate risk for skin breakdown. Review of the active care plan initiated on 04/18/25 from original admission for Resident #800 revealed at risk for skin break down with no new approaches added since 05/01/25 and included to assist resident with turning and repositioning frequently while in bed and an air mattress. Review of treatment orders for Resident #800 revealed for the coccyx unstageable pressure ulcer, no treatment was in place until 05/10/25 at 12:58 P.M. when the floor nurse obtained an order from Physician #66. This order was discontinued on 05/12/25 at 1:11 A.M. by FWN #33. Review of the physician orders for Resident #800 revealed a written treatment order written by FWN #33 from Wound Doctor #70 entered on 05/12/25 at 1:13 A.M. for the coccyx pressure ulcer to apply a nickel thick layer of Santyl to wound bed and cover with a comfort foam border dressing every three days. This order was discontinued on 05/13/25 at 12:51 P.M. by the FWN #33. Review of the TAR dated 05/12/25 revealed Resident #800 received a treatment completed to the coccyx unstageable pressure ulcer. Review of the medical record revealed no written order from Wound Physician #70 for the coccyx unstageable pressure ulcer to apply nickel thick layer of Santyl to wound bed and cover with a comfort foam border dressing every three days that was written by FWN #33 and entered on 05/12/25. Review of the active physicians ' orders dated 05/09/25 through 05/16/25 for this resident revealed the only intervention for pressure ulcer injury prevention and care was an alternating low air loss mattress. Review of Wound Physician Visit notes revealed Resident #800 was seen by APRN #71 on 05/13/25. Resident #800 had one pressure ulcer area to the coccyx. The area was a stage 4 and measured 11.4 cm by 8.7 cm by 2.4 cm with moderate serous exudate and 30 percent necrotic tissue. The treatment plan was sodium hypochlorite solution (Dakin ' s solution), pack wound with soaked gauze and apply daily abdominal dressing. A surgical excisional debridement procedure was also completed due to removal of the necrotic tissue to establish the margin of viable tissue. There were recommendations for additional care plan items including a low air-loss mattress, to offload wounds and reposition per facility protocol. Review of the physician orders for Resident #800 dated 05/13/25 at 12:56 P.M. entered by the FWN #33 and discontinued on 05/19/25 at 11:41 A.M. by the FWN #33, revealed a treatment for the coccyx stage 4 pressure ulcer for Leptospermum Honey to fill and cover all open areas and cover all areas with Alginate Calcium, cover with an abdominal pad daily. The APRN #71 ' s treatment plan on 05/13/25 was for sodium hypochlorite solution (Dakin ' s solution) to pack wound with soaked gauze and apply daily with abdominal dressing. Review of Resident #800s TAR dated 05/13/25 through 05/18/25 revealed an incorrect treatment completed for the coccyx stage 4 pressure ulcer. Review of the physician order dated 05/16/25 revealed to turn and repositioned every two hours along with the alternating low air loss mattress, but no other pressure ulcer preventions and care. Review of the physician order for Resident #800 dated 05/19/25 at 11:41 A.M. revealed a treatment order for the coccyx stage 4 pressure ulcer to pack wound with Dakin ' s solution-soaked gauze, cover with an abdominal dressing daily. This is the order from 05/13/25 the APRN #71 originally ordered on 05/13/25. This order was discontinued on 06/13/25 at 7:38 A.M. by FWN #33. Review of Wound Physician notes dated 05/20/25 revealed Resident #800 was seen by APRN #71. Resident #800 ' s coccyx stage 4 pressure ulcer measured 11.2 cm by 0.4 cm by 3.2 cm with moderate serous exudate and 30 percent necrotic tissue. The treatment plan was to continue sodium hypochlorite solution (Dakin ' s solution), pack wound with soaked gauze and apply daily with an abdominal dressing. A surgical excisional debridement procedure was also completed due to removal of the necrotic tissue to establish the margin of viable tissue. Recommendations for additional care plan items included low air-loss mattress, to offload wounds and reposition per facility protocol. Review of Wound Physician notes dated 05/27/25 revealed Resident #800 was seen by APRN #71. Resident #800 ' s coccyx stage 4 pressure ulcer measured 7.1 cm by 6.4 cm by 3 cm with moderate serous exudate and 20 percent necrotic tissue. The treatment plan was to continue sodium hypochlorite solution (Dakin ' s solution) to pack wound with soaked gauze and apply daily with an abdominal dressing. A surgical excisional debridement procedure was also completed due to removal of the necrotic tissue to establish the margin of viable tissue. Recommendations for additional care plan items included low air-loss mattress, to offload wounds and reposition per facility protocol. Review of Wound Physician notes dated 06/03/25 revealed Resident #800 was seen by APRN #71. Resident #800 ' s coccyx stage 4 pressure ulcer measured 7.1 cm by 6.2 cm by 2.6 cm with moderate serous exudate and 40 percent slough tissue. The treatment plan was to continue sodium hypochlorite solution (Dakin ' s solution) to pack wound with soaked gauze and apply daily with an abdominal dressing. A surgical excisional debridement procedure was also completed due to removal of thick adherent eschar and devitalized tissue. Recommendations for additional care plan items included low air-loss mattress, to offload wounds and reposition per facility protocol. Review of Wound Physician notes dated 06/10/25 revealed Resident #800 was seen by APRN #71. Resident #800 ' s coccyx stage 4 pressure ulcer measured 6.7 cm by 5.6 cm by 2.4 cm with moderate serous exudate and 20 percent necrotic tissue. The treatment plan was changed to alginate calcium with leptospermum honey apply daily three times a week with a foam border dressing. A surgical excisional debridement procedure was also completed due to removal of necrotic tissue and to establish the margins if viable tissue. Recommendations for additional care plan items included: low air-loss mattress, to offload wounds and reposition per facility protocol. Review of the physician orders for Resident #800 dated 06/10/25 and 06/11/25 revealed the order APRN #71 gave on 6/10/25 to change the treatment to alginate calcium with leptospermum honey apply daily three times a week was not entered. Review of the TAR for Resident #800 for 06/10/25 and 06/11/25 revealed the treatment of Dakin ' s solution was done for the coccyx stage 4 pressure ulcer. Review of Wound Physician notes dated 06/12/25 revealed Resident #800 was seen by Wound Doctor #70. The coccyx stage 4 pressure ulcer measured 7.2 cm by 8.4 cm by 2.4 cm with moderate serous exudate and 20 percent slough tissue. The treatment plan was changed to alginate calcium apply daily three times a week with a foam border dressing. A surgical excisional debridement procedure was also completed due to removal of necrotic tissue and to establish the margins if viable tissue. Recommendations for additional care plan items included low air-loss mattress, to offload wounds and reposition per facility protocol. Review of the physician orders for Resident #800 dated 06/12/25 revealed the new order from Wound Doctor #70 was not entered. The current treatment was still the Dakin ' s solution-soaked gauze. Review of the TAR for Resident #800 dated 06/12/25 revealed the treatment of Dakin ' s solution was done. Review of the physician order dated 06/13/25 at 7:41 A.M. revealed a treatment order for the coccyx stage 4 pressure wound to be filled with generous amount of Leptospermum Honey and apply Alginate Calcium and cover with a foam border dressing daily. This was not the order from Wound Doctor #70 ' s visit on 06/12/25. This order was discontinued on 06/25/25 at 6:45 A.M. by Facility Wound Nurse (FWN) #33. Review of the TAR for Resident #800 dated 06/13/25 through 06/18/25 revealed the incorrect treatment completed for the coccyx stage 4 pressure ulcer. Review of Wound Physician notes dated 06/19/25 revealed Resident #800 was seen by Wound Doctor #70. Resident #800 ' s coccyx stage 4 pressure ulcer measured 5.6 cm by 3.4 cm by 1.8 cm with moderate serous exudate and 20 percent slough tissue. The continued treatment plan was for Alginate Calcium, apply daily three times a week with a foam border dressing. A surgical excisional debridement procedure was also completed due to removal of necrotic tissue and to establish the margins if viable tissue. Recommendations for additional care plan items included low air-loss mattress, to offload wounds and reposition per facility protocol. Review of the physician orders for Resident #800 dated 06/19/25 through 06/24/25 revealed a treatment order for the coccyx stage 4 pressure ulcer wound to be filled with generous amount of leptospermum honey and apply alginate calcium and cover with a foam border dressing daily. This was not the order from Wound Doctor #70 ' s visit on 06/19/25. Review of the TAR for Resident #800 dated 06/19/25 through 06/23/25 revealed incorrect treatments completed for the coccyx stage 4 pressure ulcer. Review of Wound Physician notes dated 06/24/25 revealed Resident #800 was seen by APRN #71. Resident #800 ' s coccyx stage 4 pressure ulcer measured 8.9 cm by 8.7 cm by 1.8 cm with moderate serous exudate and 60 percent necrotic tissue. The treatment plan was changed to Alginate Calcium and Leptospermum Honey, apply daily with a foam border dressing. A surgical excisional debridement procedure was also completed due to removal of thick adherent eschar and devitalized tissue. Recommendations for additional care plan items included a low air-loss mattress, to offload wounds and reposition per facility protocol. Review of the physician orders for Resident #800 dated 06/24/25 revealed the treatment order was correct. Review of the physician order for Resident #800 dated 06/25/25 at 6:51 A.M. entered by the FWN #33 revealed a treatment for the coccyx stage 4 pressure ulcer to apply a nickel thick layer of Santyl and cover with Alginate Calcium and apply a foam border dressing daily. This order was not consistent with the order from APRN #71 ' s visit on 06/24/25. Review of the TAR for Resident #800 dated 06/25/25 through 06/27/25 revealed incorrect treatments ordered were administered for the coccyx unstageable pressure ulcer. Review of the progress note for Resident #800 dated 06/27/25 at 7:59 P.M. revealed the resident had a critically low hemoglobin with a blood pressure of 90/41 blood pressure, pulse 123, a temperature of 97.3 degrees Fahrenheit (F) and oxygen saturation of 97 percent on room air. The nurse spoke to the on-call physician and Resident #800 was sent to the emergency room. Resident #800 left the facility at 8:00 P.M. Review of the hospital documentation for Resident #800 ' s admission revealed a low hemoglobin and severe sepsis. During the hospital stay, a CT scan revealed the sacral decubitus wound extended to the underlying bone with osteomyelitis. The wound culture of the sacral decubitus wound was performed and was positive for Bacteroides fragilis, a rare gram-positive cocci and white blood cells. Intravenous antibiotics were administered throughout Resident #800 ' s stay and surgical debridement of the sacral decubitus wound was completed. The hospital discharge diagnosis was severe sepsis without septic shock from osteomyelitis (infection of the bone) from sacral decubitus wound. Resident #800 discharged back to the facility on [DATE] with oral antibiotics ordered as well as an order for a wound vaccuum system for the sacral decubitus ulcer. Further review of the hospital documentation revealed no orders for the settings of the wound vac and there were no hospital measurements or description of the decubitus ulcer. Review of the progress note dated 07/07/25 at 8:55 P.M. revealed Resident #800 arrived at the facility for readmission. Review of the admission information dated 07/07/25 for Resident #800 revealed no initial wound grid documentation for a sacrum decubitus ulcer by the admitting floor nurse. Review of wound grid documentation for Resident #800, was created on 07/09/25 at 12:42 A.M. by FWN #33 for 07/07/25 at 12:41 A.M., when the resident was not yet at the facility. The document stated Resident #800 had a stage 4 pressure ulcer to the coccyx that measured 8.9 cm by 8.7 cm by 1.8 cm. Review of Resident #800 ' s Braden Scale for Predicting Pressure Sore Risk dated 07/07/25 revealed a score of 13 on a scale of 6 (high risk) to 23 (no risk) which indicated the resident was at moderate risk for skin breakdown. Review of the physician order for Resident #800 for 07/07/25 revealed no treatment for a sacral decubitus ulcer. Review of the wound grid documentation for Resident #800 dated 07/08/25 at 12:45 A.M. by the FWN #33 revealed the coccyx stage 4 pressure ulcer had a wound vacuum in place with continuous suction at 125 millimeters of mercury (mm/HG). Review of the physician order for Resident #800 dated 07/08/25 at 2:54 P.M. revealed an order entered by FWN #33 for the coccyx wound. The order was to cleanse wound bed with normal saline, window frame outside edges of wound with adhesive film, cut black foam to fit wound bed. Fill entire area including undermining. Bridge with green foam using adhesive film under foam and bring it out to the left hip, attaching to port pad. Cover the entire area with additional adhesive film. Apply NPWT @ 125 mm/hg continuous. To be changed Sunday, Tuesday, Thursday and PRN. Review of the medical record for Resident #800 revealed no written order for the wound vac system for the coccyx pressure ulcer, there was no date in the medical record when the wound vac arrived at the facility and when it was placed on the resident to start treatment. Review of the wound grid documentation for Resident #800 dated 07/10/25 at 2:54 P.M. by FWN #33 revealed a coccyx sage 4 pressure ulcer measuring 8.8 cm by 7.8 cm by 0.8 cm with a wound vacuum in place with continuous suction at 125 mm/HG. Review of the care plan revealed a plan for the pressure ulcer to the coccyx was initiated on 07/10/25. Interventions were to perform current treatments as ordered and continue with prevention care plan measures to prevent further skin breakdown. The care plan interventions were not implemented until 07/21/25. Review of the wound grid documentation for Resident #800, dated 07/15/25 at 11:24 P.M. by FWN #33, revealed a coccyx sage 4 pressure ulcer measured 7.2 cm by 6.3 cm by 0.8 cm with a wound vacuum system in place with continuous suction at 125mm/HG. Review of the wound grid documentation for Resident #800 dated 07/17/25 at 10:18 A.M. by FWN #33 revealed a coccyx sage 4 pressure ulcer measured 7.2 cm by 6.3 cm by 0.8 cm with a wound vacuum system in place with continuous suction at 125mm/HG. Review of the wound grid documentation for Resident #800 dated 07/22/25 at 1:12 P.M. by the FWN #33 revealed a coccyx sage 4 pressure ulcer measured 7 cm by 6.2 cm by .8 cm with a wound vacuum system in place with continuous suction at 125mm/HG. Review of the Wound Physician notes dated 07/24/25 revealed Resident #800 was seen by Wound Doctor #70. Resident #800 ' s coccyx stage 4 pressure ulcer measured 7.4 cm by 6.6 cm by 1.4 cm with moderate serous exudate and 20 percent slough tissue. The treatment plan was a wound vacuum system with suction at 125 mm/HG, use black sponge throughout and apply three times a week. A surgical excisional debridement procedure was also completed due to removal of necrotic tissue and to establish the margins if viable tissue. Recommendations for additional care plan items included low air-loss mattress, to offload wounds and reposition per facility protocol. Review of the Wound Physician visit notes dated 07/31/25 revealed Resident #800 was seen by Wound Doctor #70. Resident #800 ' s coccyx stage 4 pressure ulcer measured 7.2 cm by 5.6 cm by 1.2 cm with moderate serous exudate and 20 percent slough tissue. The treatment plan was a wound vacuum system with suction at 125mm/HG, use black sponge throughout and apply three tim

Based on interviews and record reviews, the facility failed to appropriately manage and treat a non pressure skin alteration for one (Resident #100) out of two residents with non pressure skin alterations and obtain daily weights on three (Resident #100, #400 and #500) of three residents reviewed for daily weights. The facility census was 47.Findings include:1.Review of the medical record for Resident #100, revealed an admission date of 02/26/25 and a discharge to home date of 07/03/25. Diagnoses included but were not limited to unspecified fracture of upper end of left tibia, unsteady on feet, muscle weakness, heart failure, chronic kidney disease, stage 3, and anxiety disorder with a new diagnosis of unspecified open wound to right foot 06/02/25.Review of the active care plan for Resident #100 dated 02/26/25 revealed a cardiac impairment related to congestive heart failure.Review of the active physician order for Resident #100 dated 02/26/25 revealed a daily weight once in the morning.Review of the care plan for Resident #300 dated 02/26/25 with interventions started on 03/12/25, revealed at risk for skin breakdown related to diabetes, impaired mobility, and renal disease with interventions including but not limited to observe/report any skin and symptoms of skin irritation such as lack of sensation, tingling or burning feeling, verbal/nonverbal signs of pain, discoloration, edema, excoriation, erythema, and report to physician as needed. Also revealed alteration in blood glucose metabolism related to diagnosis of insulin dependent diabetes mellitus with an intervention including but not limited to observe resident's feet for potential ulcer formation. Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) of 15 out of 15 indicating intact cognition. This resident was also assessed o be at risk for pressure injuries.Review of the wound grid documentation for Resident #100 dated 06/02/25 at 12:51 P.M. by the Facility Wound Nurse #33 revealed a right third toe abrasion, red in color measured 2.2 centimeters (cm) X 1.6 cm X no depth documented.Further review of the wound grid documentation for this resident revealed no documentation of the fourth right toe trauma for 06/02/25. The date/time of being observed for an initial assessment by the Facility Wound Nurse #33 was 06/03/25 at 6:46 A.M. measured 2.1 cm X 1.9 cm X no depth documented and no description of the trauma area. Review of the medical record for Resident #100 did not reveal how the trauma to the right third and fourth toe occurred.Review of the active physician order for Resident #100 dated 06/02/25 at 12:56 P.M. with a discontinuation date of 06/04/25 at 7:00 A.M. by the Facility Wound Nurse #33 revealed a treatment for the right foot, second and third toe- cleanse with normal saline and pat dry. Apply xeroform and an island adhesive dressing daily.Review of the Treatment Administration Record (TAR) for Resident #100 for the date of 06/02/25 and 06/03/25 the treatment order was completed as ordered for the right foot third toe, but no treatment for the right foot fourth toe. Review of the medical record for Resident #100 revealed Wound Clinic visit notes dated 06/23/25 for Resident #100 revealed a right second, third and fourth toe diabetic ulcer all measured as one area at 8 cm X 1.5 cm X 0.2 cm. an order for the right second, third and fourth toe diabetic ulcer wounds to be cleansed with normal saline and to pack wounds with betadine-soaked gauze and apply a dressing daily. Review of the active physician order for Resident #100, dated 06/24/25, entered by the Facility Wound Nurse #33, with a discontinued date of 06/26/25 by the Director of Nursing (DON), revealed the right foot-leave dressing in place until next wound clinic appointment. Do not get wet. Cover for showers.Review of the TAR for Resident #100 revealed from 06/24/25 through 06/25/25, no dressing change was completed for the right second, third and fourth toe diabetic ulcer wounds.Interview on 08/05/25 at 10:25 A.M. with the Facility Wound Nurse #33 verified there was no documentation in Resident #100's medical record for the incident on 06/02/25 regarding the trauma to the right foot third and fourth toe. She interviewed the resident, and she could not remember how it happened. They concluded it must have happened when the resident accidentally dragged her right foot over a non-skid strip. Also verified she did not document the fourth right toe on 06/02/25 and should have as that was when it was discovered and should have been documented for description and measurements.Continued interview on 08/05/25 at 10:31 A.M. with the Facility Wound Nurse #33 verified for Resident #100, the order placed on 06/02/25 through 06/04 25 was a treatment for the right foot second and third toe when the second toe was not a concern, it was the fourth toe and it did not get any treatment for those days. Review of the daily weights in vital signs results for Resident #100 revealed since admission on [DATE], no daily weights were obtained on 03/03/25, 03/10/25, 03/11/25, 03/18/25, 05/13/25 and 06/25/25.2.Review of the medical record for Resident #400, revealed an admission date of 03/27/25. Diagnoses included but were not limited to chronic combined systolic (congestive) and diastolic (congestive) heart failure, altered mental status and general weakness.Review of the active care plan for Resident #400 dated 03/27/25 revealed a cardiac impairment related to congestive heart failure.Review of the active physician order for Resident #400 dated 03/28/25 revealed a daily weight once in the morning due to congestive heart failure.Review of the daily weights in the vital signs results for Resident #400 revealed since admission on [DATE], no daily weights were obtained on 03/28/25, 04/29/25 and 06/10/25.3. Review of the medical record for Resident #500, revealed an admission date of 02/28/25. Diagnoses included but were not limited to muscle weakness, dementia and pulmonary embolism.Review of the active care plan for Resident #500 dated 02/28/25 revealed a risk of fluid imbalance/complications related to edema and diuretic use with no interventions including daily weights.Review of the active physician order for Resident #500 dated 03/04/25 revealed a daily weight once in the morning.Review of the daily weights in the vital sign results for Resident #500 since 03/04/25 revealed no daily weights were obtained on 03/04/25, 04/20/25 and 05/05/25.Interview on 08/05/25 at 3:13 P.M. with the Director of Nursing verified Residents #100, #400 and #800 had missing weights and were not due to refusals, but due to them not being obtained as no documentation could be produced for the dates for the reason they were missed.This deficiency represents non-compliance investigated under Complaint Number 1385838.

Based on interview, record review and policy review, the facility failed to ensure residents had effective pain assessments and management. This affected three ( Resident #100, #300, and #800) of three residents reviewed for pain. The facility census was 47. Findings include:1.Review of the medical record for Resident #100, revealed an admission date of 02/26/25 and a discharge to home date of 07/03/25. Diagnoses included but were not limited to unspecified fracture of upper end of left tibia, unsteady on feet, muscle weakness, heart failure, chronic kidney disease, stage 3, and anxiety disorder with a new diagnosis of unspecified open wound to right foot 06/02/25 and sepsis 06/10/25.Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) of 15 out of 15 indicating intact cognition. Review of the care plan dated 02/26/25 for Resident #100 revealed actual alteration in comfort/pain related to unspecified pain with interventions including but not limited to administer pain medications as ordered/observe for effectiveness and observe for episodes of breakthrough pain and medicate as ordered.Review of the physician orders dated 06/10/25 for Resident #100 revealed oxycodone-acetaminophen 5-325 milligram (mg) one tablet orally every 8 hours as needed for pain on a scale of 5-10 (0 being none and 10 being the worst.Further review of the physician orders revealed no other pain medication ordered as needed for this resident.Review of the medical record for Resident #100 revealed a skin alteration occurred on 06/02/25 at the facility per facility wound grid documentation.Further review revealed in the progress notes, starting on 06/03/25, a wound review: weekly review of this resident's pain scale related to the wound, with a treatment, documented by the Facility Wound Nurse #33. The dates with the pain scales and treatment as medication were: 06/03/25 with a pain rating of 4, 06/10/25 with a pain rating of 5, 06/17/25 with a pain rating of 3 and 06/24/25 with a pain rating of 3.Review of the medication administration record (MAR) for Resident #100 for 06/10/25 pain rating of a 5 revealed no administration of the oxycodone-acetaminophen 5-325 mg.Further review of the MAR revealed for the other dates this resident had wound pain no medications were administered.2.Review of the medical record for Resident #300, revealed an admission date of 05/20/25. Diagnoses included but were not limited to metabolic encephalopathy, altered mental status, muscle weakness, and cerebral infarction.Review of the most recent MDS 3.0 assessment dated [DATE] revealed a BIMS of 14 out of 15 which indicated intact cognition. cognitive intactness. This resident was also assessed to have unhealed pressure ulcers.Review of the care plan dated 05/20/25 for Resident #300 revealed actual alteration in comfort/pain related to abnormal posture with interventions including but not limited to administer pain medications as ordered/observe for effectiveness and observe for episodes of breakthrough pain and medicate as ordered.Review of the physician's orders for Resident #300 revealed for the dates of 05/20/25 through 07/31/25, no as needed pain medications were ordered.Review of the medical record for Resident #300 revealed a skin alteration on admission to the facility per facility wound grid documentation.Further review revealed in the progress notes, starting on 05/27/25, a wound review: weekly review of this resident's pain scale related to the wound, with a treatment, documented by the Facility Wound Nurse #33. The dates with pain scales and treatment as medications were: 06/17/25 pain rating of 4, 06/19/25 pain rating of 4, 06/24/25 pain rating of 3, 07/15/25 pain rating of 4, 07/22/25 pain rating of 4, 07/24/25 pain rating of 3 and 07/31/25 pain rating of 4.3. Review of the medical record for Resident #800, revealed an admission date of 04/18/25. Diagnoses included but were not limited to weakness, cerebral infarction, atrial fibrillation, type 2 diabetes, and chronic kidney disease.Review of the most recent MDS 3.0 assessment dated [DATE] revealed a BIMS of 14 out of 15 indicating cognitive intactness. This resident was also assessed to have a pressure ulcer injury.Review of the care plan dated 04/18/25 for Resident #800 revealed actual alteration in comfort, pain related to pressure ulcers with interventions including but not limited to administer pain medications as ordered/observe for effectiveness and observe for episodes of breakthrough pain and medicate as ordered.Review of the physician's orders dated 04/21/25 for Resident #800 revealed the pain medication of hydrocodone-acetaminophen 5-325mg tablet, one tablet every six hours as needed for severe pain of 6-10.Further review of the orders also revealed for this resident dated 04/23/25, acetaminophen 325 mg tablet, one tablet every 6 hours for mild pain rating 1-5.Further review revealed in the progress notes, starting on 04/22/25 and ending on 05/13/25, a wound review: weekly review of this resident's pain scale related to the wound, with a treatment, documented by the Facility Wound Nurse #33 were not completed weekly for pain assessment. Further review revealed The dates with pain scales and treatment as medications were: 05/13/25 pain rating of a 5, 05/20/25 pain rating of a 5, 06/03/25 pain rating of a 6, 06/10/25 pain rating of a 6, 06/12/25 pain rating of a 6, 06/17/25 pain rating of a 5, 06/19/25 pain rating of a 5, 06/24/25 pain rating of a 5, 07/15/25 pain rating of a 6, 07/17/25 pain rating of a 5, 07/22/25 pain rating of a 6, 07/24/25 pain rating of a 6, and 07/31/25 pain rating of a 6. Review of the MAR for Resident #800 for the dates of wound pain assessment, no as needed pain medication as administered. Interview on 08/07/25 at 2:30 P.M. with Assistant Director of Nursing (ADON) verified no medications were given prior to wound care treatments for pain which is the documentation in the progress notes that the ADON was documenting on for Resident #300 and #100, Resident 300 does not even have anything ordered as needed for pain. Reviewed dates of all wound review templates with medication interventions not completed and no follow up after the wound treatment was completed if still in pain, the floor nurses do a pain scale every shift, but wound nurse does not follow up after and if non pharm does not work, there were two dates for interventions that included repositioning, no follow up was documented that it helped and if other treatment such as medication was needed.Interview on 08/08/25 at 11:40 A.M. with the Facility Wound Nurse #33 verified for Resident #800, there should have been wound pain assessments completed weekly from 04/22/25 through 05/13/25 and she did not verify if the resident received pain medication. Also verified no as needed pain medication was given to this resident from 05/13/25 through 07/31/25 when the resident was assessed to have wound pain.Review of the facility policy titled Pain Assessment and Management updated 05/01/25 revealed it is the facilities policy to assess, monitor, treat and evaluate pain to ensure effective pain management is provided.This was an incidental finding discovered during the course of this complaint investigation.

Based on observation, medical record review, policy review and interview, the facility failed to ensure the facility medication administration error rate was not more than five percent. This affected one resident (#42) of eight residents observed for medication administration with four errors out of 25 opportunities resulting in an error rate of 16%. The census was 47. Findings include: Medical record review revealed Resident #42 was admitted on [DATE] with diagnoses including wedge compression thoracic vertebra fractures, depression, anxiety, atherosclerotic heart disease and constipation. Review of the admission Minimum Data Set assessment dated [DATE] revealed Resident #42 was moderately impaired for daily decision-making. Review of the electronic Physician Orders dated 09/25/25 revealed medications to be administered included chewable aspirin 81 milligrams (mg) for prophylaxis, buspirone 10 (mg) for sadness/anxiety, I-vite (vitamin and mineral) for supplement and senna plus 8.6-50,mg for bowel regimen, bupropion SR 150 (mg), celexa 40 (mg), culturelle 15 billion cell, lactulose 10 grams, aspercreme lidocaine patch, lisinopril 10mg, OsCal 500 (mg) with Vit D3, Miralax 17 gm, and Vitamin C 500 (mg). On 09/25/25 between 8:00 A.M. and 8:14 A.M., observation revealed Registered Nurse (RN) #200 prepared and administered Resident #42's morning medications including enteric coated aspirin 81 (mg), buspirone 5 (mg), and senna 8.5 (mg) and I-vite was not dispensed or administered during the observation. RN #200 was observed leaving her medication administration record open upon entering the resident's room and the electronic MAR was positioned across from the nursing station and not within eye sight of the nurse. RN #200 also left the sealed Aspercreme lidocaine patch on top of the medication cart unsupervised when she went to the resident's room to administer the other medications. At the time of the observation, RN #200 verified she left the Aspercreme lidocaine patch unattended on the top of the medication cart. On 09/25/25 at 2:46 P.M., interview with RN #200 verified she documented she had administered I-Vite to the resident; however she did not administer the medication. RN #200 verified she administered enteric coated ASA and senna to Resident #42 because that was the only form of the medications available to administer in her medication cart, and the buspirone order had been changed from 5 (mg) to 10 (mg) and the old bubble pack containing the 5 (mg) dose was left in the medication cart without a label indicating directions had been changed. RN #200 verified she had not given the ordered dose. RN #200 was observed removing the buspirone 5 (mg) bubble pack from the medication cart, closed the cart drawer, did not lock the medication cart, walked to the medication/storage room beside the nursing station with the bubble pack, unlocked the door and entered the medication/storage room with the door closing behind her. No staff were noted to be within the vicinity of the medication cart and the cart remained unlocked. RN #200 verified the cart was unlocked when she came back out of the medication/storage room. Review of the policy: Specific Medication Administration Procedures dated May 2020 revealed medications were to be administered in a safe and effective manner, all medication storage areas including carts were to be locked at all times unless in use and under the direct observation of approved facility or pharmacy personnel. If medication instructions are changed during the course of therapy, it was the nurse's responsibility to add a direction change notation/sticker directly on the product to indicate as such.

Based on interviews and record reviews, the facility failed to maintain an up to date and complete medical record for three residents (#100, #300 and #800) of three residents reviewed for receiving wound care from an outside wound consultant group. The facility census was 47. Findings include:1.Review of the medical record for Resident #100, revealed an admission date of 02/26/25 and a discharge to home date of 07/03/25. Diagnoses included but were not limited to unspecified fracture of upper end of left tibia, unsteady on feet, muscle weakness, heart failure, chronic kidney disease stage 3, and anxiety disorder with a new diagnosis of unspecified open wound to right foot 06/02/25 and sepsis 06/10/25.Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed resident had intact cognition with a Brief Interview for Mental Status (BIMS) of 15 out of 15. Review of the medical record for Resident #100 revealed a skin alteration occurred on 06/02/25 at the facility per facility wound grid documentation.Further review revealed no Wound Physician visits in her closed record to review.Interview on 08/04/25 at 12:02 P.M. with the Director of Nursing (DON) revealed Resident #100 saw the Wound Physician group a few times during her stay and will get the visit notes from the Facility Wound Nurse #33 as they were not in her chart. 2. Review of the medical record for Resident #300, revealed an admission date of 05/20/25. Diagnoses included but were not limited to metabolic encephalopathy, altered mental status, muscle weakness, and cerebral infarction.Review of the most recent MDS 3.0 assessment dated [DATE] revealed resident had intact cognition with a BIMS of 14 out of 15. Review of the medical record for Resident #300 revealed a skin alteration on admission per facility wound grid documentation.Further review revealed no Wound Physician visits in the record to review.Interview on 08/06/25 at 11:09 A.M. with the Facility Wound Nurse #33 verified Resident #300 did not have any of her Wound Physician visits in her current medical record and should be uploaded after each visit.3. Review of the medical record for Resident #800, revealed an admission date of 04/18/25. Diagnoses included but were not limited to weakness, cerebral infarction, atrial fibrillation, type 2 diabetes, and chronic kidney disease.Review of the most recent MDS 3.0 assessment dated [DATE] revealed resident with intact cognition with a BIMS of 14 out of 15. Review of the medical record for Resident #800 revealed a skin alteration on admission per facility wound grid documentation.Further review revealed no Wound Physician visits in the medical record to review.Interview on 08/06/25 at 1:50 P.M. with Regional Nurse #68 verified Resident #800 did not have the Wound Physician Consultant notes uploaded into their charts and had to access them on the consultant's server, but it is the expectation that the Facility Wound Nurse #33 be uploaded after each visit to keep the residents' chart up to date and current for care.This was an incidental finding discovered during the course of this complaint investigation.

Based on observation, interview and facility policy reviews, the facility failed to ensure proper hand hygiene and medical equipment was sanitized before and after resident use. This affected two residents (#701 and #802), but has the potential to affect all 47 residents residing in the facility. Findings include:Observation on 08/05/25 at 8:35 A.M. with Registered Nurse (RN) #27 revealed her to be preparing medications for Resident #701. She put on a glove to her right hand and proceeded to touch the cart, the residents' medications and the computer all with the same glove on. Once the medications were in the cup, she removed the glove, did not sanitize her hands after locking the cart and entering Resident #701's room. She took Resident #701's blood pressure and pulse ox with a machine she brought into the room. She then administered the residents' medications and proceeded to leave the room without sanitizing her hands and cleaning off the equipment. She returned to the cart at 8:48 A.M. and proceeded to prepare Resident #802's medications following the same steps. She put on a glove to her right hand, proceeded to touch the cart, medications and computer with the same glove, then removed her glove, locked the cart and did not sanitize her hands before entering Resident #802's room to administer medications. She took Resident #802's blood pressure and pulse ox with the same machine she carried into the rooms and did not sanitize them before or after use. She administered Resident #802's medications and left the room without sanitizing her hands.Interview on 08/05/25 at 9:00 A.M. with Registered Nurse #27 verified she should have changed her glove once she touched anything other than Resident #701 and #802's medications, she should have sanitized her hands before and after entering the resident's rooms and she verified she never cleaned the blood pressure and pulse ox equipment before and after each resident.Review of the facility policy titled Hand Washing-Hygiene no date, revealed it is the facility's policy for employees to conduct proper hand hygiene that will aid in the prevention and transmission of infectious diseases. Alcohol/Antimicrobial hand rub may be used in the following situations: before donning gloves, after removing gloves and before preparing or handling medications.Review of the facility policy titled Cleaning of Equipment no date revealed the facility will utilize general disinfecting procedures to prevent and control infection.This was an incidental finding discovered during the investigation for Complaint Number 1385838.

Based on observations, interview, and facility policy, the facility failed to ensure the ice machine was maintained in a sanitary manner. This had the potential to affect all 49 of the residents residing in the facility. The facility identified all 49 residents in the facility as receiving iced beverages from the main kitchen ice machine. Findings include: On 11/12/24 at 8:52 A.M. an observation revealed that the inside of the ice machine in the main kitchen had a red slimy substance next to the prepared ice. On the inside of the ice machine, on the right top near the cooling mechanism, a white crusty build-up was observed. An interview with Dietary Director #163 on 11/12/24 at 8:52 A.M. confirmed the presence of the red slimy substance next to the prepared ice and the white crusty build-up on the right side of the ice machine, near the cooling mechanism. An interview with the Assistant Director of Dietary Services #305 on 11/12/24 at 10:27 A.M. revealed that the ice machine was deep cleaned by an outside company that serviced the machine. The Assistant Director of Dietary Services #305 stated that he had obtained bagged prepared ice for the residents to use for the day. An observation on 11/13/24 at 10:41 A.M. revealed that the red slimy substance had been removed from the ice machine. The white crusty build-up was still observed on the inside of the ice machine on the top right side, near the cooling mechanism. An interview on 11/13/24 at 10:41 A.M. with Assistant Director of Dietary Services #305 confirmed the presence of the white crusty build-up was still on the right side of the inside of the ice machine. On 11/13/24 at 11:50 A.M. the Assistant Director of Dietary Services #305 stated that a company had been called to de-lime the ice machine. A facility policy titled, Ice Machine, dated October 2020, revealed that the ice machines shall be free of rust, lime and mildew at all times.

Based on record review, observation, interview, and policy review, the facility failed to provide a homelike environment and ensure resident equipment was clean and well maintained. This affected four (#3, #13, #37, and #42) of four residents reviewed for environment. The facility census was 49. Findings included: 1. Record review revealed Resident #3 admitted to the facility on [DATE] with diagnoses including heart failure, dysphagia, bipolar disorder, need for assistance with personal care, and intracranial injury without loss of consciousness. Observation on 11/12/24 at 8:39 A.M. revealed Resident #3 was sitting in her wheelchair in the hallway and the wheelchair cushion was caked in food debris and the extended brakes had frayed, gray duct tape on them. Interview on 11/14/24 at 8:00 A.M. with Regional Nurse Consultant #302 confirmed Resident #3's wheelchair cushion was caked in food debris and the extended brakes had frayed, gray duct tape on them. Interview on 11/14/24 at 8:46 A.M. with Physical Therapy Assistant #423 confirmed the tape on Resident #3's extended brakes was frayed. She stated the tape was applied to the brakes for visual cue and the brakes needed new tape. Review of the policy titled General Environmental Policies, dated November 2020, revealed the facility should be maintained in a clean and sanitary manner. 2. Record review revealed Resident #13 admitted to the facility on [DATE] with diagnoses including senile degeneration of the brain, cognitive communication deficit, and dementia. Observation on 11/12/24 at 9:06 A.M. revealed Resident #13's room smelled strongly of urine. Interview on 11/13/24 at 10:23 A.M. with the Minimum Data Set (MDS) Nurse #118 confirmed Resident #13's room smelled strongly of urine. Review of the policy titled General Environmental Policies, dated November 2020, revealed the facility should be maintained in a clean and sanitary manner. 3. Record review revealed Resident #37 admitted to the facility on [DATE] with diagnoses including cerebral infarction, dementia, and atherosclerotic heart disease. Observation on 11/12/24 at 9:13 A.M. revealed Resident #37's bathroom floor had a dark gray stain, approximately three feet long, in front of the toilet, and there was dark brown discolored caulking around the toilet and shower. Interview on 11/14/24 at 8:19 A.M. with Lead Receptionist #146 confirmed Resident #37's floor was stained and the caulking was brown and discolored. Receptionist #146 stated she had attempted to scrub the floors but the stains would not come up. Review of the policy titled General Environmental Policies, dated November 2020, revealed the facility should be maintained in a clean and sanitary manner. 4. Record review revealed Resident #42 admitted to the facility on [DATE] with diagnoses including Alzheimer's disease, depression, and hypertension. Observation on 11/12/24 at 8:48 A.M. revealed Resident #42's bathroom floor was dirty, stained, and had debris on it. There was brown discolored caulking around the shower and toilet, and there were two pink plastic containers on the floor with leaves and dust in them. Interview on 11/14/24 at 8:16 A.M. with Activity Director #164 confirmed Resident #42's floors were stained, the bathroom floor had a build-up of grime, the caulking around the shower and toilet was discolored, and there were pink containers with leaves and dust on the floor. Review of the policy titled General Environmental Policies, dated November 2020, revealed the facility should be maintained in a clean and sanitary manner.

Based on observation, resident interview, staff interview, and policy review, the facility failed to ensure Resident #3 was treated with with dignity during and after dining. This affected one (Resident #3) of one resident reviewed for dignity. The facility census was 49. Findings include: Record review revealed Resident #3 admitted to the facility on [DATE] with diagnoses including heart failure, dysphagia, bipolar disorder, need for assistance with personal care, and intracranial injury without loss of consciousness. Review of the care plan, dated 08/06/21, revealed Resident #3 was to receive supervision during meals or food activities, as needed, and given verbal cues for chewing or swallowing. Review of the Minimum Data Set (MDS) assessment, dated 10/02/24, revealed Resident #3's cognition remained intact and she had no behaviors. The resident required setup or clean-up assistance for eating, was dependent on staff for dressing, and required maximum assistance for personal hygiene. Observation on 11/12/24 at 10:37 A.M. revealed Resident #3 was sitting in her wheelchair in the hallway with food and stains on her shirt, pants, wheelchair cushion, and the floor beneath her. Resident #3 was not wearing a clothing protector. On Resident #3's tray table, there was a two-handled cup with a lid and a spout. Interview on 11/12/24 at 10:37 A.M. with Resident #3 revealed she had to eat in the hallway so the nurse could keep an eye on her because of a recent choking related incident. Observation on 11/12/24 at 12:05 P.M. revealed Resident #3 was in the dining room with two beverages in the two-handled cups with lids and spouts. A dark brown liquid was dribbling down Resident #3's chin. At 12:12 P.M., another resident assisted Resident #3 by using a napkin to clean her face. Observation on 11/13/24 at 10:31 A.M. revealed Resident #3 was seated in the cafe drinking hot chocolate from a two-handled cup with a lid and a spout. The residents purple shirt was damp with spots and stains from the hot chocolate. Observation on 11/13/24 at 4:19 P.M. revealed Resident #3 sitting in the dining room for dinner and wearing a purple shirt with dark brown stains. Resident #3 was wearing a clothing protector and had two, two-handled cups with lids and spouts. When Resident #3 would attempt to take a drink, she had tremors which caused the liquid to shake and splash out of the spout, leaving the drink dribbling down her chin. Resident #3 was served a plate of spaghetti with meat balls and marinara sauce, and the aide cut up the meatballs, but not the noodles. Resident #3 struggled to get the noodles on the weighted utensils and then get the food to her mouth. She continuously dropped noodles on her shoes, socks and on the floor. Resident #3 continued to struggle with eating for approximately five minutes before staff intervened. Interview on 11/13/24 at 4:47 P.M. with Assistant Director of Dietary Services (ADDS) #305 confirmed Resident #3 had dropped food onto herself, including on her shoes. Interview and observation on 11/14/24 at 7:51 A.M. with Resident #3 revealed she was bothered by sitting in the hallway with food and stains on her clothes, wheelchair, and the floor around her, because she did not want people to see her like that. At the time of the interview, Resident #3 was wearing shoes with marinara sauce on them from the previous nights' dinner. The resident was also sitting on a dirty wheelchair cushion caked with food debris. Interview on 11/14/24 at 8:00 A.M. with Regional Nurse Consultant (RNC) #302 confirmed Resident #3's shoes and wheelchair cushion had food debris from the previous night. Interview on 11/14/24 at 8:38 A.M. with Registered Nurse (RN) #160 revealed Resident #3 could get messy during meals and RN #160 would attempt to help her clean up. RN #160 stated she did not feel it was very dignified for Resident #3 to sit in dirty clothes. Review of a policy titled Resident Rights, updated October 2016, revealed the facility's policy was to treat all residents with kindness, respect, and dignity and staff were to make all attempts to ensure residents were treated with kindness, respect, and dignity.

Based on record review, staff interview and facility policy, the facility failed to ensure that advanced directives were prominently placed in Resident #100's and Resident #149's medical records. This affected two (Resident #100 and Resident #149) of two residents reviewed for advanced directives. The facility census was 49. Findings include: 1. Record review revealed Resident #100 was admitted on [DATE] with diagnoses that included surgical aftercare of the digestive system, intestinal obstruction, anemia, depression, gastroesophageal reflux, and malignant neoplasm of the prostate. Review of Resident #100's electronic and physical medical records revealed that a code status was not prominently displayed in either chart. Interview with Registered Nurse (RN) Supervisor #162 on [DATE] at 3:52 P.M. confirmed there were no advanced directives prominently displayed in Resident #100's medical chart. RN Supervisor #162 was unable to identify the code status of Resident #100. RN Supervisor #162 stated that advanced directives were normally found in the front section of the chart. Interview with the Director of Nursing (DON) on [DATE] at 3:57 P.M. also confirmed that there were no advanced directives prominently displayed in Resident #100's medical chart. Review of the facility's policy titled, Advanced Directives, revised [DATE], revealed prior to or upon admission of a resident to the facility, staff should offer the opportunity to form advanced directives or inquire about existing advanced directives. It also revealed if the resident were to indicate that he or she had issued advanced directives about his or her care, documentation of such directive would be recorded in the medical record, and a copy of such directive would be included in the resident's medical record. 47985 2. Record review revealed Resident #149 admitted to the facility on [DATE] with diagnoses including altered mental status, dementia, and congestive heart failure. Review of the electronic medical record and the paper chart revealed Resident #149's code status was not displayed prominently in the medical record. Interview on [DATE] at 3:59 P.M. with the Director of Nursing (DON) confirmed Resident #149's medical records were missing the code status'. She revealed Resident #149 had a code status of Full Code (a medical directive that indicated cardiopulmonary resuscitation (CPR) should be used during the residents care in the event of such emergency) in place, which was now being added to the medical records. Review of the facility's policy titled, Advanced Directives, revised [DATE], revealed prior to or upon admission of a resident to the facility, staff should offer the opportunity to form advanced directives or inquire about existing advanced directives. It also revealed if the resident were to indicate that he or she had issued advanced directives about his or her care, documentation of such directive would be recorded in the medical record, and a copy of such directive would be included in the resident's medical record.

Based on observation, resident interview, staff interview, and policy review, the facility failed to ensure Resident #3 was provided with adaptive equipment for meals per physician orders. This affected one (Resident #3) of one resident reviewed for adaptive equipment. The facility census was 49. Findings include: Record review revealed Resident #3 admitted to the facility on [DATE] with diagnoses including heart failure, dysphagia, bipolar disorder, the need for assistance with personal care, and intracranial injury without loss of consciousness. Review of the care plan, dated 08/06/21, revealed Resident #3 should receive supervision during meals or food activities, as needed, and given verbal cues for chewing or swallowing. The care plan dated 07/28/21 revealed the resident was at risk for altered nutrition related to tremors, dysphagia, and the need for adaptive equipment to facilitate self feeding with interventions that included to apply a left handed weighted glove and a left handed curved spork supplied by the kitchen and for adaptive feeding equipment as ordered per the physician. Review of the Minimum Data Set (MDS) assessment, dated 10/02/24, revealed Resident #3's cognition remained intact and she had no behaviors. The resident required setup or clean-up assistance for eating, was dependent on staff for dressing, and required maximum assistance for personal hygiene. Review of physician orders revealed Resident #3 had an order in place, dated 08/28/24, for a regular plate with plate guards, built up curved utensils, and left upper extremity weighted glove for all meals. Resident #3 also had an order in place, dated 10/28/24, for a no added salt diet with a regular texture and thin liquids in handled cups with straws, a plate with guards, and small portions. Observation on 11/12/24 at 10:37 A.M. revealed Resident #3 was sitting in her wheelchair in the hallway with food and stains on her shirt, pants, wheelchair cushion, and the floor beneath her. Resident #3 was not wearing a clothing protector. On Resident #3's tray table, there was a two-handled cup with a lid and a spout. Interview on 11/12/24 at 10:37 A.M. with Resident #3 revealed she had to eat in the hallway so the nurse could keep an eye on her because of a recent choking related incident. Observation on 11/12/24 at 12:05 P.M. revealed Resident #3 was in the dining room with two beverages in the two-handled cups with lids and spouts. A dark brown liquid was dribbling down Resident #3's chin. At 12:12 P.M., another resident assisted Resident #3 by using a napkin to clean her face. Resident #3 did not have a left upper extremity weighted glove on for the lunch meal. Observation on 11/13/24 at 10:31 A.M. revealed Resident #3 was seated in the cafe drinking hot chocolate from a two-handled cup with a lid and a spout. The residents purple shirt was damp with spots and stains from the hot chocolate. Observation on 11/13/24 at 4:19 P.M. revealed Resident #3 sitting in the dining room for dinner and wearing a purple shirt with dark brown stains. Resident #3 was wearing a clothing protector and had two, two-handled cups with lids and spouts. When Resident #3 would attempt to take a drink, she had tremors which caused the liquid to shake and splash out of the spout, leaving the drink dribbling down her chin. Resident #3 was served a plate of spaghetti with meat balls and marinara sauce, and the aide cut up the meatballs, but not the noodles. Resident #3 struggled to get the noodles on the weighted utensils and then get the food to her mouth. She continuously dropped noodles on her shoes, socks and on the floor. Resident #3 continued to struggle with eating for approximately five minutes before staff intervened. Resident #3 was not wearing a left upper extremity weighted glove for dinner. Interview on 11/13/24 at 4:47 P.M. with Assistant Director of Dietary Services (ADDS) #305 confirmed Resident #3 had orders in place for a left upper extremity weighted glove and cups with handles and a straw. ADDS #305 also confirmed Resident #3 did not have either pieces of her adaptive equipment during the dinner meal and that he had not ever heard of a weight glove. ADDS #305 stated Resident #3 had been making a mess and having a hard time eating, so he requested a therapy referral to nursing. ADDS #305 further confirmed Resident #3 had dropped food onto herself, including on her shoes. Interview and observation on 11/14/24 at 7:51 A.M. with Resident #3 revealed she was bothered by sitting in the hallway with food and stains on her clothes, wheelchair, and the floor around her, because she did not want people to see her like that. At the time of the interview, Resident #3 was wearing shoes with marinara sauce on them from the previous nights' dinner. The resident was also sitting on a dirty wheelchair cushion caked with food debris. Review of a policy titled Adaptive Equipment, revised November 2016, revealed assistive devices shall be offered to residents requiring them to maintain or improve their ability to eat independently. Residents were to be evaluated by therapy to determine the need for assistive devices and obtain a physician's order for the equipment. The tray card and care plan shall be changed to reflect the appropriate assistive devices and nursing would ensure the resident was able to properly use the equipment.

Based on record review, observations, interviews, review of facility policy, and review of equipment manuals, the facility failed to ensure alternating air mattresses were functional and set on the correct settings for pressure ulcer/injury prevention. This affected two (Resident #12 and Resident #13) of six residents reviewed for skin interventions. The facility census was 49. Findings include: 1. Record review revealed Resident #12 admitted to the facility on [DATE] with diagnoses including senile degeneration of the brain, dysphagia, dementia, and chronic obstructive pulmonary disease. Resident #12's record revealed the resident did not have any pressure ulcers. The record further revealed Resident #12 was 114.5 pounds on 06/07/23. Resident #12 was receiving hospice services and did not have additional weights in the record. Review of the Minimum Data Set (MDS) assessment, dated 08/31/24, revealed Resident #12 had a pressure reduction device on her bed. Review of the care plan, dated 01/19/23, revealed Resident #12 was at risk for pressure ulcers/injury related to senile degeneration of brain, heart failure, hyperlipidemia, hypertension, dementia, polyarthritis, and moderate protein-calorie malnutrition. Interventions included, but were not limited to, utilizing an air mattress that could be adjusted to resident comfort. Review of physician orders, dated 01/19/23, revealed Resident #12 had an order for an alternating air mattress to prevent skin breakdown. Observation on 11/12/24 at 8:43 A.M. revealed Resident #12 had an alternating air mattress in place which was unplugged, and the settings were turned to 210 pounds. Resident #12 appeared to weigh less than 210 pounds. Interview on 11/13/24 at 10:28 A.M. with the MDS Nurse #118 confirmed the alternating air mattress was set to 210 pounds. Interview on 11/13/24 at 10:28 A.M with Certified Nursing Assistant (CNA) #130 confirmed the bed had been unplugged, but she had just plugged the bed back in. Review of an undated policy titled, Pressure Injuries: Assessment, Prevention & Treatment, revealed the facility identified residents at risk for developing pressure injuries, implements interventions, and providing care for existing injuries. Interventions included, but were not limited to, using pressure redistribution mattresses. Review of the manual titled, Alternating Pressure and Low Air Loss Mattress Replacement System, revealed the Med Aire Edge Mattress Replacement System was a high quality powered air support surface that was specifically designed for the prevention and treatment of pressure injuries while optimizing patient comfort. 2. Record review revealed Resident #13 admitted to the facility on [DATE] with diagnoses including senile degeneration of brain, cognitive communication deficit, and dementia. Resident #13's record revealed the resident did not have any pressure ulcers. Resident #13 was receiving hospice services and there were no recent weights recorded in the medical record. Review of the Minimum Data Set (MDS) assessment, dated 10/20/24, revealed Resident #13 had a pressure reducing device for her bed. Review of the care plan, dated 05/03/19, for Resident #13 revealed the resident was at risk for skin breakdown related to impaired mobility, impaired cognition, and incontinence, with interventions that included an air mattress. Review of physician orders, dated 11/14/24, revealed Resident #13 had an order in place for an air mattress to the bed surface. Observation on 11/12/24 at 9:06 A.M. revealed Resident #13's alternating air mattress was set to static, normal pressure at 225 pounds. Interview on 11/13/24 at 10:23 A.M. with MDS Nurse #118 confirmed the alternating air mattress was set to 225 pounds, and Resident #13 was likely less than 225 pounds. Review of an undated policy titled, Pressure Injuries: Assessment, Prevention & Treatment, revealed the facility identified residents at risk for developing pressure injuries, implements interventions, and providing care for existing injuries. Interventions included, but were not limited to, using pressure redistribution mattresses. Review of the manual titled, Alternating Pressure and Low Air Loss Mattress Replacement System, revealed the Med Aire Edge Mattress Replacement System was a high quality powered air support surface that was specifically designed for the prevention and treatment of pressure injuries while optimizing patient comfort.

Based on review of medical records, observation, and staff interview the facility failed to ensure fall interventions were in place for Resident #8 per the plan of care. This affected one resident (Resident #8) of two residents reviewed for falls. The facility census was 49. Findings include: Review of Resident #8's medical record revealed an admitted [DATE] and diagnoses including senile degeneration of the brain, dementia, depression, and a history of traumatic brain injury. Review of the physician orders for Resident #8 revealed on 11/09/23, the resident was ordered non-skid strips to the floor in front of the resident's toilet. Review of Resident #8's the care plan, dated 06/05/24, revealed the resident was at risk for falls/injury related to history of falls, incontinence, altered mental status, and impaired gait. Interventions included non-slip strips to the floor in front of the toilet. Observation of Resident #8's bathroom on 11/13/24 at 2:28 P.M. revealed non-skid strips were not present in front of the residents toilet. Interview on 11/13/24 at 2:50 P.M. with the Assistant Director of Nursing (ADON) #127 verified an order for non-skid strips in front of toilet was present in the medical record and she also verified the non-skid strips were not present in front of Resident #8's toilet. ADON #127 further verified that Resident #8 still utilized the toilet in her bathroom.

Based on observation, staff interview, and policy review, the facility failed to store respiratory equipment in a sanitary manner. This affected one (Resident #42) of one resident reviewed for respiratory equipment. The facility census was 49. Findings included: Record review revealed Resident #42 admitted to the facility on [DATE] with diagnoses including Alzheimer's disease, depression, and hypertension. Review of physician orders revealed an order, dated 04/28/24, for Ipratropium-Albuterol solution for nebulization 0.5 milligrams to 3 milligrams for inhalation due to wheezing, cough and congestion every six hours as needed. Observation on 11/12/24 at 10:57 A.M. revealed Resident #42's nebulizer was placed on her floor, plugged into the wall. The nebulizer was covered in small, brown spots. Interview on 11/12/24 at 8:55 A.M. with Lead Receptionist #146 confirmed the nebulizer was covered in small, brown spots and placed on the floor while plugged in. Receptionist #146 stated the nebulizer should not have been on the floor, but at times, Resident #42 would move it. Receptionist #146 also stated the nebulizer needed to be cleaned. Review of a policy titled, Respiratory Therapy- Prevention of Infection, dated November 2019, revealed it was the facility's policy to prevent infection associated with respiratory therapy tasks and equipment among residents and staff. After the completion of nebulizer therapy, the nebulizer container should be removed, rinsed with fresh tap water, and dried with a clean paper towel or gauze sponge. The nebulizer should be reconnected to the administration set-up, the mouthpiece should be wiped with a damp paper towel or gauze sponge, then stored in a plastic bag, marked with the date and the resident's name.

Based on review of the self-reported incident (SRI) and the facility's investigation, review of the facility policy, record review, and staff interviews, the facility failed to immediately report an allegation of staff-to-resident verbal abuse to the Administrator or designee. This affected one (Resident #27) of three residents reviewed for abuse. This had the potential to affect the six other residents (Resident #3, #16, #27, #35, #38, #39, and #40) who were identified by the facility to be on the Alleged Perpetrator's assignment on 10/06/23. The facility census was 40. Findings include: Review of the medical record revealed Resident #27 was admitted on [DATE]. Diagnoses included senile degeneration of brain, displace fracture of right femur, acute respiratory failure with hypoxia, depression, acute kidney failure, anxiety disorder, and dementia. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #27 had severe cognitive impairment. Review of the SRI control number 239906 dated 10/06/23 at 2:00 P.M. revealed there was an allegation of verbal abuse by a staff member to Resident #27 on 10/06/23 at approximately 8:30 A.M. State tested Nursing Assistant (STNA) #100 and STNA #104 reported they were providing care for Resident #27 when STNA #150 (Alleged Perpetrator) entered the room. STNA #150 stated if he is going to act like a little expletive, I will not be giving him a shower today. STNA #150 then left the room. STNA #100 and STNA #104 completed care for Resident #27 and then reported the alleged incident to the nurse. Review of the statement signed by the Administrator on 10/06/23 revealed STNA #150 was interviewed via the telephone on 10/06/23 at 2:30 P.M. STNA #150 denied making the comment in front of Resident #27. A written statement dated 10/06/23 by STNA #104 revealed STNA #100 and STNA #104 were providing care for Resident #27 when STNA #150 walked in the room. Resident #27 pulled the covers over his head. STNA #150 stated I'm not going to give him a shower if he is going to act like a expletive. Between 1:00 P.M. and 1:30 P.M., STNA #150 was yelling down the hall about STNA #100 and STNA #104 making up lies about STNA #150. A resident's family was on the hall. The incident was reported to the front office and the department heads walked STNA #150 out of the facility. A statement dated 10/06/23 revealed Licensed Practical Nurse (LPN) #200 addressed the allegation with STNA #150. STNA #150 denied making the comment. LPN #200 reported there were conflicting stories of whether the comment was made in front of Resident #27 or in the hallway. A statement dated 10/06/23 by STNA #172 revealed STNA #150 had a bad attitude that day (10/06/23). Review of a typed statement by STNA #100 dated 10/09/23 at 10:58 A.M. revealed STNA #150 had been bragging about it being her last day and how much she hated working at the facility. STNA #150 was assigned to Resident #27. About an hour after breakfast, STNA #100 and STNA #104 went into Resident #27's room and saw Resident #27 had not touched his food and was lying in bed. STNA #100 and STNA #104 started getting things ready to provide incontinence care for Resident #27 and get Resident #27 out of bed. STNA #150 walked in to Resident #27's room. As STNA #100 started providing care, Resident #27 pulled the blanket up over his head. STNA #150 stated I am not putting him in the shower if he is going to be a expletive. STNA #100 and STNA #104 reported to the nurse what STNA #150 said. STNA #150 waited for STNA #100 at the nurse's station and STNA #150 screamed she was going to hit and beat STNA #100 and hit everyone in the building. STNA #100 walked away and STNA #150 continued to scream down the hall. A written statement dated 10/13/23 by Licensed Social Worker (LSW) #201 revealed on 10/06/23 around 1:50 P.M., STNA #150 and STNA #103 went to the front office to speak to the receptionist. LSW #201 was not in the meeting but could hear STNA #150 loudly saying the employees were unprofessional. A few minutes after STNA #150 left the office, two STNAs came to the front and stated STNA #150 was yelling and threatening to hit people. LSW #201 contacted the Director of Nursing (DON) and Administrator by telephone. STNA #150 denied calling Resident #27 names in his presence. Interview on 01/03/24 at 11:03 A.M. with STNA #100 revealed Resident #27 got cold when care was provided so he frequently pulled the blankets over his head during care. STNA #100 verified STNA #150 stated if Resident #27 was to going act like a little expletive, STNA #150 would not give Resident #27 a shower. STNA #100 stated after care was provided for Resident #27, STNA #100 and STNA #104 reported what STNA #150 had said in Resident #27's room. Interview on 01/03/24 at 11:10 A.M. with STNA #104 revealed they were in the room providing care for Resident #27 when Resident #150 entered the room and called Resident #27 an expletive. STNA #104 stated the incident was reported to the nurse by STNA #100 and STNA #104. Interview on 01/03/24 at 2:38 P.M. with the Administrator and Director of Nursing verified STNA #100 and STNA #104 reported the alleged allegation of verbal abuse to the nurse, but the nurse did not report the incident to the Administrator or designee because STNA #150 stated they did not make those comments in Resident #27's room. The nurse did not feel it was reportable since there was conflicting reports of what happened. The Administrator verified the incident of alleged verbal abuse occurred around 8:30 A.M. and the Administrator was not notified until around 2:00 P.M. Review of the facility's undated policy titled Abuse, Mistreatment, Neglect, Misappropriation of Resident Property and Exploitation revealed staff should report all incidents/allegations immediately to the Administrator or designee. This deficiency represents non-compliance investigated under Complaint Number OH00149425.

The following deficiency represents an incident of past non-compliance that was subsequently corrected prior to the survey. Based on record review, observation, and interview the facility failed to ensure a safe environment for Resident #71 who had impaired cognition and was at risk for falls. Actual harm occurred on 02/08/22 when Resident #71 fell out of bed and his right knee rested on the electric baseboard heater resulting a third-degree burn to the right anterior knee. This affected one resident (Resident #71) of three residents reviewed to safe environment. The facility census was 45. Findings include: Review of the medical record for Resident #71 revealed an admitted [DATE] with diagnoses including [CONDITION(S)], muscle weakness, cognitive communication deficit, [CONDITION(S)], and diabetes mellitus. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 02/07/22, revealed Resident #71 had impaired cognition and required extensive assistance of two staff for bed mobility, transfers, ambulation. Resident #71 had no wounds. Review of the fall risk assessment dated [DATE] revealed Resident #71 was at moderate risk for falls due to regular incontinence and decrease muscular coordination. Review of the nurse's notes dated 02/08/22 at 8:15 P.M. revealed Resident #71 was found on the right side of his bed, sitting on his buttocks with his back against the bed and his right knee against the electric baseboard heater which was under the window. An injury was noted to Resident #71's right knee (burn), and the on-call physician was notified and gave orders to send Resident #71 to the emergency room due to the degree of injury. On 02/09/22 at 12:22 A.M. Resident #71 returned to the facility with a dressing to the right knee and new orders for pain medications, antibiotic, and a referral to a wound/burn specialist. At 3:36 A.M. the nurse called the hospital and was informed the wound center was called and was expecting a phone call today to set up an appointment. Treatment orders were clarified for the right knee which included [MEDICATION(S)] cream (burn cream), adherent bandage wrapped with gauze (Kerlix), not to be removed until care team could assess. Review of the wound evaluation dated 02/10/22 revealed Resident #71 fell out of bed and his right knee laid against the electric baseboard heater for approximately 15 minutes resulting in a burn to the right anterior knee measuring 12.0 centimeters (cm) by 10.2 cm by depth not measurable. There was light serous drainage, necrotic tissue 60 percent (%) other tissue 40%. Treatment included [MEDICATION(S)] (burn cream) apply once daily, cover with [MEDICATION(S)] (non-adherent dressing), and wrap with Kerlix (gauze roll). The burn was debrided, and a clean dressing was applied. Review of the wound evaluation dated 02/17/22 revealed Resident #71's right anterior knee was a full thickness wound measuring 12.0 cm by 9.0 cm by depth not measurable, thick adherent black necrotic tissue (eschar) 100 %. Continue the same treatment. The burn center to evaluate for excision and graft. Review of the wound evaluation dated 02/24/22 revealed the wound to Resident #71's right anterior knee was 11.8 cm by 8.9 cm by depth not measurable with 100% eschar. Continue the same treatment. During debridement procedure necrotic tissue, muscle and surrounding connective tissue was removed at a depth of 0.3 cm. Review of the orders for March 2022 revealed Resident #71's right knee was to be cleansed with baby shampoo, mild soap and water or normal saline (NS), pat dry, apply a nickel thick layer of Santyl (debridement ointment) followed by moist saline gauze, cover with dry gauze, apply Conform stretch gauze, and wrap with Kerlix gauze. Change daily and as needed if becomes soiled. Observation on 03/03/22 at 9:08 A.M. of Resident #71's electric baseboard heater had the protective cage in place. Interview on 03/03/22 at 2:46 P.M. with Regional Nurse Consultant (RNC) #303, revealed Resident #71 had a fall in his room and his back was up against the bed and is right knee was lying on the electric baseboard heater for approximately 15 minutes. The RNC #303 verified Resident #71 was unable to move his right knee off the electric baseboard heater. RNC #303 revealed Resident #71 was cognitively impaired and had standard fall precautions in place at the time of the fall. Interview on 03/03/22 at 10:20 A.M. with wound physician (DO) #305 revealed Resident #71 received a third-degree full thickness burn on his right knee when he fell out of bed. DO #305 stated he observed the right knee wound on 02/10/22 and treated the wound. DO #305 stated he referred the resident to see a wound specialist for excision of dead tissue and skin graft. The deficient practice was corrected on 02/10/22 when the facility implemented the following corrective actions: · On 02/08/22 at 9:10 P.M. the physician was notified of the severity of the wound for Resident #71 and gave a new order to send Resident #71 to the emergency room for evaluation. · On 02/08/22 at 9:28 P.M. Resident #71 was transported to the emergency room for evaluation. · On 02/09/22 the in-house physician stated he would like the wound physician to evaluate Resident #71's wound and if able to treat in-house. · On 02/10/22 the wound physician evaluated Resident #71's wound. · On 02/10/22 protective cages were installed around all baseboard heaters in resident rooms. · On 02/10/22 education was completed related to baseboard heating units and resident safety. · On 02/10/22 all staff were educated on resident beds and personal items. Staff are to ensure that residents beds are in a low position while occupied. · On 02/10/22 audits were started for resident beds in low position while occupied three times week for four weeks and then as needed. Ensure that protective cages over baseboard heaters are intact, three times a week for four weeks and as needed. Protective cage temperatures are within safe range to ensure resident safety, one time a week for four weeks and then as needed. This deficiency substantiates Complaint Number OH 671.

Based on the unprecedented global pandemic that resulted in the Presidential declaration of a State of National Emergency dated 03/13/20, The Department of Health and Human Services, Center for Medicare and Medicaid (CMS) Memo QSO 20-20-ALL dated 03/20/20, Nursing Home Guidance from the Centers for Disease Control (CDC), record review, review of a facility COVID-19 timeline, review of the county community COVID-19 positivity rate, review of staff time sheets, review of staff screening forms, review of resident and staff COVID-19 laboratory results and rapid point of care (POC) test results, review of the facility COVID-19 procedure policy and staff interview the facility failed to implement effective and recommended infection control practices including the adequate monitoring, testing and prevention of the transmission of COVID-19 in the facility. The facility failed to ensure staff did not provide direct resident care to residents while symptomatic of COVID-19, failed to ensure staff were properly screened for COVID-19 upon entrance into the facility and failed to ensure all staff utilized appropriate personal protective equipment (PPE) during a COVID-19 outbreak to help reduce the spread of COVID-19 throughout the facility. This resulted in Immediate Jeopardy on 09/30/21 when Registered Nurse (RN) #500 who exhibited respiratory symptoms (indicative of COVID-19) on 09/30/21 did not timely notify management staff before working her scheduled night (6:00 P.M. to 6:00 A.M.) shift and providing resident care to 15 residents (#26, #27, #28, #30, #31, #33, #34, #35, #38, #39, #40, #41, #43, #44 and #45) who resided on Unit 2. RN #500 screened herself for COVID-19 at the beginning of her shift on 09/30/21 (screening sheet incorrectly dated 10/01/21) and incorrectly indicated on the form she was negative for symptoms of COVID-19. At the end of her shift on 10/01/21, the Director of Nursing (DON) informed RN #500 she sounded congested and directed RN #500 to complete a COVID-19 point of care (POC) rapid test. The rapid test was completed by the DON and was positive for COVID-19. The RN was informed to quarantine until a polymerase chain reaction (PCR) test was completed. The PCR test (also laboratory dated 09/30/21) was subsequently positive for COVID-19. On 10/04/21 resident testing was completed per facility outbreak testing protocol and three residents (all of whom were exposed to RN #500), Resident #31, #35 and #41 tested positive for COVID-19. Between 10/07/21 and 10/28/21, 12 additional facility residents (#42, #14, #10, #9, #13, #2, #34, #11, #24, #40, #25 and #37) tested positive for COVID-19 in the facility. In addition, the facility failed to ensure all staff followed accepted infection control protocols related to personal protective equipment (mask use). On 11/03/21 at 1:00 P.M. the Administrator, Director of Nursing and Registered Nurse #275 were notified Immediate Jeopardy began on 09/30/21 when RN #500 exhibited respiratory symptoms (COVID-19 symptoms), failed to accurately report these symptoms timely and provided direct care to 15 residents on Unit 2 on 09/30/21. Continued observations during the onsite investigation revealed the facility was not following acceptable infection control practices to prevent the spread of COVID-19 related to proper personal protective equipment (PPE) use. The risk for hospitalization , serious harm and/or death are likely related to a COVID-19 outbreak in the nursing home resident population. This had the potential to affect all 40 residents residing in the facility. The Immediate Jeopardy was removed on 11/04/2021 when the facility implemented the following correction actions: · On 10/01/2021 RN #500 was removed from the schedule. RN #500 remained off work until 10/13/21. · From 10/01/2021 through 11/02/21 the facility conducted contract tracing, completed COVID-19 testing for staff and residents and notified families of the COVID-19 outbreak. A total of 15 residents tested positive for COVID-19 during this time period. · On 11/03/2021, an Ad-Hoc Quality Assessment Performance Improvement (QAPI) meeting was held with the medical director, Executive Director (Administrator), Director of Nursing Services (DON) and facility Infection Preventionist to review the State agency findings and to develop an abatement plan. The facility's screening policy and process was reviewed and determined to be in compliance with CDC recommendations. No changes in the process were made. Staff are assigned to screening duties each shift, and the screener reviews the screening forms. The Administrator and DON provided education to 27 staff members, identified to be responsible for the facility COVID-19 screening, related to the screening policy. · On 11/03/2021 the Administrator and DON initiated education for all staff related to COVID-19 screening and reporting COVID-19 signs and symptoms, including the need to take temperatures and complete the form. The education included if symptoms triggered, staff were to notify the supervisor. By 11/04/21, all facility staff members were educated which included 11 RNs, 4 LPNs, 19 STNAs and 30 additional non-nursing staff. · On 11/04/2021 the Administrator and Regional Vice President of Operations completed an audit for employees who worked in the past 48 hours to ensure COVID-19 screening forms were completed with no adverse symptoms noted. · On 11/04/2021 the Administrator/designee interviewed all employees (61 total) who worked within the last 48 hours to validate employees were not working with symptoms in the past 48 hours. The Administrator audited the screening forms for the employees and verified they were screened by the screener in accordance with facility policy prior to working their shifts. · On 11/04/21 the Administrator implemented a plan for the Administrator/designee to begin conducting audits of screening forms and interviews with staff three times per week for four weeks and as needed after to ensure facility staff were not working with signs and symptoms of COVID-19. Any concerns would be reported to the QAPI Committee for immediate follow-up. Although the Immediate Jeopardy was removed on 11/04/2021, the facility remained out of compliance at Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility was still in the process of implementing their corrective actions and monitoring to ensure on-going compliance. Finding include: Review of the Department of Health and Human Services, Centers for Medicare & Medicaid (CMS) Memo QSO 20-20-ALL dated 03/20/20 revealed The Centers for Medicare & Medicaid Services (CMS) is committed to taking critical steps to ensure America's health care facilities are prepared to respond to the threat of disease caused by the 2019 Novel Coronavirus (COVID-19). As part of CMS guidance, the Focused Infection Control Survey was made available to every provider in the country to make them aware of Infection Control priorities during this time of crisis, and providers and suppliers may perform a voluntary self-assessment of their ability to meet these priorities. The QSO Memo included additional instructions to Nursing Homes. We are disseminating the Infection Control survey developed by CMS and CDC so facilities can educate themselves on the latest practices and expectations. We expect facilities to use this new process, in conjunction with the latest guidance from CDC, to perform a voluntary self-assessment of their ability to prevent the transmission of COVID-19 .We also encourage nursing homes to voluntarily share the results of this assessment with their state or local health department Healthcare-Associated Infections (HAI) Program. Furthermore, we remind facilities that they are required to have a system of surveillance designed to identify possible communicable diseases or infections before they can spread to other persons in the facility, and when and whom possible incidents of communicable disease or infections should be reported (42 CFR 483.80(a)(2)(i) and (ii). Review of the Centers for Medicare and Medicaid (CMS) County Positivity Rate for the week of 09/22/21 through 10/05/21 revealed the county positivity rate was high (red) at 19.3%. 1. On 11/01/21 at 10:23 A.M. interview with the Administrator revealed the facility currently had four COVID-19 positive residents. Two residents (Resident #2 and Resident #25) resided on Unit 1 and two residents (Resident #37 and #40) resided on Unit 2. An additional interview with the Administrator on 11/01/21 at 6:25 P.M. revealed the facility was currently in outbreak testing after a staff member (RN #500) tested positive and then residents on Unit 2 (where RN #500 worked) began to test positive. At the time of this interview, the Administrator denied any staff working with symptoms or COVID-19 positive staff working caused the facility COVID-19 outbreak. The Administrator revealed the facility completed a timeline regarding the facility outbreak but denied having an investigation of the potential root cause analysis for the outbreak. The Administrator revealed the timeline went through 10/04/21 and then stopped because all the additional information, including room changes got too confusing. Review of an undated, untitled document provided by the Administrator and identified as the facility COVID-19 timeline revealed the following information: a. On 10/01/21 RN #500 tested positive for COVID-19 using a COVID Point of Care (POC)/rapid swab. b. On 10/01/21 contact tracing was completed, outbreak testing initiated for residents and staff with no positive results at this time. The timeline document indicated all residents who had contact with RN #500 were vaccinated. c. On 10/01/21 residents and responsible parties were notified of the COVID-19 positive result and visitation guidelines. d. On 10/04/21 resident testing was completed per outbreak testing protocol and three residents, Resident #31, #35 and #41 tested positive and were placed in airborne precautions and a secondary PCR test (a nasal swab test to detect genetic material from a specific organism such as a virus) was completed. e. On 10/04/21 residents and responsible parties were notified of COVID-19 positive results and visitation guidelines. The above facility timeline did not include any evidence RN #500 was COVID-19 tested at any time on 09/30/21 nor did the timeline contain evidence of a negative POC COVID test for RN #500 prior to providing resident care/working her shift on 09/30/21. In addition, the timeline did not include information related to a PCR test for RN #500. The timeline only contained documentation of the positive POC test on 10/01/21. The above information listed in a-e was the exact timeline provided by the facility. Review of the Staff/Visitor Respiratory Illness Screening Form, dated 10/01/21 revealed RN #500 was screened on 10/01/21. RN #500 answered no to the following questions: Have you been exposed to someone positive for COVID in the past 14 days? Do you have a cough? Are you having shortness of breath? Do you have a sore throat? Do you have congestion? Do you have a runny nose? Do you feel fatigued? Do you have diarrhea? Are you nauseated or vomiting? Do you have chills? Do you have muscle pain? Do you have a headache? Have you had a change in your sense of smell? Have you had a change in the taste of food? Have you had an elevated temperature in the past 72 hours? Have you taken [MEDICATION(S)] medications in the past 24 hours (example Tylenol, cold medications, etc)? Is (your) temperature greater than 100.0 degrees Fahrenheit? If no to all questions, proceed to section 2. If yes to one or more questions in this section, the supervisor is to be notified immediately. Review of RN #500's time sheet revealed a punch for 10/01/21 at 6:00 P.M. until 10/02/21 at 6:35 A.M. However, review of Medication Administration Records (MAR) for residents residing on Unit 2 revealed the nurse did not administer medications during this time period. Review of the employee schedule revealed the RN was not scheduled on 10/01/21. RN #500 worked in the facility on 09/30/21 from 6:00 P.M. until 10/01/21 at 6:35 A.M. Review of RN #500's COVID-19 PCR test revealed the specimen was collected on 09/30/21, received at the laboratory on 10/02/21 and completed with a positive result on 10/03/21. On 11/02/21 at 12:48 P.M. interview with the Administrator and Director of Nursing (DON) revealed there were possible discrepancies in RN #500's time sheet (date/time worked) and date/time of PCR testing. The administrative staff revealed RN #500 did not work after her POC test (on 10/01/21) came back positive (although she had worked on 09/30/21 prior to being tested ). The Administrator then reviewed RN #500's time sheet and verified the time sheet was incorrect and stated Staffing Coordinator #250 had to manually enter the employee's time and entered it on the wrong date of 10/01/21. The Administrator also verified RN #500 did not document any medications being administered on the night of 10/01/21. During the interview, the Administrator indicated she was unsure how the COVID-19 outbreak occurred in the facility but verified RN #500 had tested positive on 10/01/21 and then three residents (provided care by RN #500) tested positive on 10/04/21. During the interview, the DON then stated RN #500 did not test on 09/30/21 as part of the facility routine testing and she was unsure why the RN didn't test or why the RN was permitted to work if she didn't test prior to her shift. Further interview revealed the administrative staff believed the PCR test dated 09/30/21 was incorrect and they thought RN #500 might have used an old sticker to label her specimen instead of the correct date which they thought was 10/01/21. Lastly, the DON denied RN #500 had reported congestion as a COVID symptom as instructed on the Staff/Visitor Respiratory Screening Form. On 11/02/21 at 1:35 P.M. telephone interview with RN #500 revealed she worked on 09/30/21 night shift (from 09/30/21 at 6:00 P.M. to 10/01/21 at 6:00 A.M.) but forgot to clock/punch in for the shift as she stated she often forgets to enter her time. RN #500 revealed she was exhibiting congestion at the time she was working but thought it was related to [MEDICATION(S)]/allergy issues and not a symptom related to COVID-19. RN #500 revealed she did not report this symptom to a manager/supervisor and failed to include this symptom on the COVID-19 screening form she completed on 09/30/21 even though she had the symptom at the time the form was completed. RN #500 revealed she screened herself for the shift beginning on 09/30/21 and verified she wrote the incorrect date (10/01/21) on the form. RN #500 revealed the screening form should have been dated 09/30/21. RN #500 revealed she had a routine facility COVID-19 PCR test on 09/30/21 and verified this was why the lab report indicated the specimen was collected on 09/30/21. RN #500 revealed she worked her shift on 09/30/21 with congestion and the following morning (on 10/01/21) the DON told her she sounded congested and needed to take a COVID-19 rapid test. When the DON tested her, the rapid test was positive. During a follow-up interview on 11/03/21 at 1:04 P.M. RN #500 revealed while working on 09/30/21 she wore a surgical mask as N95 masks were not required until residents began testing positive for COVID-19 on 10/04/21. The RN verified she administered medications to all residents on Unit 2 on 09/30/21 with congestion that she did not report to the supervisor because she did not feel it was congestion related to COVID but rather due to [MEDICATION(S)] or allergy issues. During neither interview, did RN #500 report she had any type of negative COVID-19 test on 09/30/21 or 10/01/21. On 11/03/21 at 12:33 P.M. information received from the Administrator revealed it was the facility expectation for staff to report any one or more symptom of COVID to the supervisor immediately as indicated on the staff/visitor respiratory illness screening form. During the investigation, a request was made to review any communication with or notification to the local health department related to the facility COVID-19 outbreak. As of 11/04/21, no information was provided by the facility. Review of the facility COVID-19 Testing Policy, dated 05/04/21 revealed to decrease the risk of transmission and prevention of COVID-19, multiple means of testing may be utilized for individuals requiring testing for COVID-19. High risk exposure referred to exposure of an individual's eyes, nose, or mouth to material potentially containing [CONDITION(S)]-CoV-2. This can occur when staff do not wear adequate PPE during care or interaction with an individual. Conduct COVID-19 Symptom Screening upon entrance to the facility. If positive for symptoms, deny the individual access to the facility. Instruct the individual to have a PCR/POC test completed. If the POC test was negative and the individual does not trigger for symptoms on the screening, they may proceed into the facility. PCR testing was the preferred method of testing for all symptomatic staff (vaccinated or unvaccinated). Review of the facility Screening for COVID-19 Policy, dated 09/17/21 revealed to actively screen all staff for fever and symptoms associated with COVID-19 before starting each shift. Employees would be sent home if they were ill and/or exhibiting signs associated with COVID-19 and then referred to the Employee Health Nurse. The Employee Health Nurse would determine eligibility to return to work using the Centers for Disease Control (CDC) return to work criteria. 2. Review of the Preventative Health Care Report from 09/01/21 through 11/01/21 revealed the following residents had tested positive for COVID-19 (with the date of positive testing noted): On 10/04/21 Resident #31, #35 and #41 tested positive for COVID-19. A Staff Development Sign in sheet, dated 10/04/21 revealed the facility had three COVID positive patients on Unit 2 and the patients had been placed in airborne precautions. The sheet indicated precautions must be followed every time staff entered an isolation room. Gown, gloves, surgical mask over N95 mask and clean eye protection when leaving the room as part of the removal (doffing) process. All staff who enter/work on Unit 2 must wear N95 masks and eye protection. Unit 1 staff and all other staff must wear surgical masks and eye protection. Masks and PPE must be worn properly at all times. Practice hand hygiene frequently, before and after entering resident rooms. Encourage residents to wear masks and social distance when in common areas. Protect yourself and our patients! Report any COVID symptoms immediately to your supervisor. Compassionate care visits continue to our patients. Ensure all visitors are screened at the entrance and have appropriate PPE on (mask and eye protection). This sign in sheet was signed by Dietary #150, Laundry #175, Activities #300, Housekeeping #325, State tested Nursing Assistant (STNA) #350, STNA #375, Dietary #400 and STNA #425. On 10/07/21 Resident #42 tested positive for COVID-19. On 10/11/21, Resident #14 tested positive for COVID-19. On 10/14/21, Resident #10 tested positive for COVID-19. On 10/17/21, Resident #9 and #13 tested positive for COVID-19. On 10/18/21 Resident #2 and #34 tested positive for COVID-19. On 10/20/21 Resident #11 and #24 tested positive for COVID-19. On 10/25/21 Resident #40 tested positive for COVID-19. On 10/26/21 Resident #25 tested positive for COVID-19. On 10/28/21 Resident #37 tested positive for COVID-19. 3. On 11/01/21 at 3:55 P.M. interview with Aide #125 revealed she had worked at the facility about four months but had not yet taken her test to be a state tested nursing assistant (STNA). Aide #125 was observed wearing goggles and a NIOSH approved N95 mask during the interview. During the interview, Resident #24 engaged her call light for staff assistance. NA #125 was observed to walk down the hall to the resident's room and began to apply PPE due to the resident being in isolation airborne precautions. A sign hanging outside the door instructed staff to apply a surgical mask over their N95 mask before entering the isolation room. The NA applied an isolation gown, gloves, and a surgical mask over her already intact N95 mask and entered the resident's room. On 11/01/21 at 4:10 P.M. Aide #125 remained in the room with Resident #24 and #25, removed their trash from their trash cans and placed it in the isolation garbage. She then removed her PPE but did not remove the surgical mask and exited the isolation room. Aide #125 proceeded to walk to the nutrition room located on Unit 1 and entered the code to open the door and opened the door. The surveyor intervened and asked the aide if she was to be wearing the same surgical mask she was wearing in the isolation room and Aide #125 verified the surgical mask from the isolation room should not have been worn outside of the isolation room. On 11/02/21 at 9:39 A.M. interview with the Administrator revealed the facility was not in crisis capacity for PPE. Further interview revealed the facility had never really been at crisis capacity due to the surplus of PPE at the corporate office. Based on current CDC guidance, this eliminated the need for staff to reuse N95 masks between resident rooms while covering them with surgical masks. On 11/02/21 at 11:47 A.M. State tested Nursing Assistant (STNA) #200 was observed standing outside of the isolation room for Resident #24 and #25. STNA #200 was wearing an isolation gown, gloves, and an N95 mask covered with a surgical mask. The STNA was observed to cross the threshold into the resident room. On 11/05/21 at 2:14 P.M. interview with the Local Health Department (LHD) DON #550 revealed the facility had not contacted the LHD with a need for PPE or any concerns indicating they were in a crisis capacity for their PPE. LHD DON #550 revealed if the facility had requested or needed PPE, the LHD would assist in getting/securing additional supplies for the facility. Review of a posted PPE Station Sign revealed the sign included the PPE use and the sequence for putting on PPE. Steps included to first sanitize hands, apply gown, apply surgical mask over N95 mask, sanitize eye protection and apply gloves. Sanitize eye protection with antibacterial soap and water or alcohol wipes prior to entering next room. Report any PPE concerns immediately to your supervisor. Review of Optimizing Masks and Eye Protection in Extended Use Situations Policy, dated 04/26/21 revealed when supplies of N95 masks were limited it may be necessary to optimize N95 masks during these extended use situations to prevent the spread of infection. The facility staff would utilize an N95 mask in the following situations: when caring for a resident in quarantine (a surgical mask over top of the N95 when in the room); when caring for a resident in isolation; when conducting an aerosol generating procedure on a resident (surgical mask over top of the N95 mask); when conducting staff screening, when conducting staff and resident COVID-19 testing and during a facility outbreak all staff when engaging in a patient care encounter. Review of the Disposable Folded N95 NIOSH approved Sekura N95 mask manufacturer's Guidelines revealed no evidence a surgical mask or other covering could be used to prolong the use of the N95 mask. Consideration for Covering N95's to Extend Use, dated 06/16/20 revealed when protection against surface contamination was needed, CDC recommended wearing a cleanable face shield over an N95 FFR. Wearing a surgical mask or cloth covering over an FFR, such as an N95, was not approved or recommended by NIOSH because it was not consistent with the conditions of the approval, therefore voiding the certification, however this is a strategy that can be used in a crisis situation. This deficiency substantiates Complaint Number OH 836.

Based on observation, medical record review, staff interview, facility policy review and review of the National Pressure Ulcer Advisory Panel (NPUAP) information for pressure ulcers, the facility failed to appropriately assess and treat an in-house acquired pressure ulcer for Resident #44. This resulted in Immediate Jeopardy for Resident #44 who developed an in-house acquired open area on the sacrum and the facility failed to timely follow physician orders [REDACTED]. This resulted in actual harm when the resident developed an unstageable pressure ulcer (full thickness tissue loss in which actual depth of the ulcer is completely obscured by slough and/or eschar in the wound bed). The facility failed to implement physician orders [REDACTED]. In addition, the facility failed to provide physician ordered pressure ulcer treatments for Resident #16 and failed to complete weekly skin assessments for Resident #38 ' s pressure ulcer. This affected three of four residents reviewed for pressure ulcers (Resident #16, #38 and #44). The facility identified three residents with pressure ulcers in the facility. The facility census was 42. On 08/19/16 at 10:15 A.M., the Administrator, Regional Director of Operations and Vice President of Clinical Services were notified Immediate Jeopardy began on 06/30/16 when the facility failed to assess a pressure area for Resident #44, failed to notify the physician and failed to timely implement physician orders [REDACTED]. Resident #44 was subsequently sent to the hospital for an elevated temperature and wound infection and had an admitting [DIAGNOSES REDACTED]. The Immediate Jeopardy was removed on 08/19/16 at 10:15 A.M. when the facility implemented the following corrective actions: · Licensed Practical Nurse (LPN) #50, who was made aware of the skin breakdown and did not proceed according to facility wound standards, was terminated on 08/19/16. · On 08/19/16 at 12:00 P.M., the director of nursing (DON), Registered Nurse (RN) #70, and Vice President of Clinical Operations #77 educated all nursing staff (11 nurses and 18 state tested nurse aides (STNA) regarding physician and family notification requirements and timely implementation of physician and treatment orders. · On 08/19/16 at 1:00 P.M., a skin sweep was completed by RNs #71 and #72 of all current residents. No new areas of skin breakdown were identified. · On 08/19/16 at 1:20 P.M., the DON was educated by the Regional Director of Clinical Operations #76 on the requirements of the federal regulation regarding pressure ulcers and the corporation ' s standard and guidelines for wound and skin management. · On 08/19/16, the Regional Director of Clinical Operations #76, Vice President of Clinical Services, #77 and RN #74 completed a review of the STNA skin observation-point of care over the last 30 days to identify any other open areas that had not been addressed prior to 08/19/16. Any issues that were identified were reported to the physician, responsible party, and orders were obtained and implemented for treatment if applicable on 08/19/16. · On 08/19/16, the physician orders [REDACTED].#74. · On 08/19/16 at 12:00 P.M., the DON began educating all licensed nurses and STNAs on the components of performing skin examinations, physician and family notification and treatments as prescribed in accordance with the facility standards. On 08/19/16 all 11 nurses and 18 STNAs were educated. · On 08/19/16, the facility provided education for the STNAs regarding wound prevention which included turning and repositioning. Education was completed by the DON, RN #70 and Vice President of Clinical Services #77 on 08/19/16. · On 08/19/16 at 2:30 P.M., the DON educated all 11 licensed nurses regarding timely implementation of physician orders [REDACTED]. · On 08/19/16 the Regional Director of Clinical Operations #76 or Vice President of Clinical Services #77 will be in the facility daily for two weeks to audit new admissions, weekly skin assessments, STNA skin observations, timeliness of implementation of physician orders [REDACTED]. · Beginning on 08/19/16, the DON, Vice President of Clinical Operations #77, Regional Director of Clinical Operations #76, or the Clinical Educator #75 will randomly audit the skin condition of five residents weekly for four weeks, then five residents every two weeks for two months. If any of the audited residents have identified skin issues, the DON or designee will ensure that correct protocol of wound management, including the documentation and use of prescribed treatments are in place. The Regional Director of Clinical Operations will continue quarterly monitoring to ensure compliance. · Beginning on 08/19/16, the DON, Vice President of Clinical Operations #77, Regional Director of Clinical Operations #76, or the Clinical Educator #75 will randomly audit the physician orders [REDACTED]. The committee will then recommend quarterly monitoring by the Regional Director of Clinical Operations. Although the Immediate Jeopardy was removed on 08/19/16, the facility remained out of compliance at Severity Level 2 (no actual harm with the potential for more than minimal harm that is not Immediate Jeopardy) as the facility was in the process of implementing weekly audits to monitor for on-going compliance. Findings include: 1. Closed medical record review revealed Resident #44 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the medical record revealed there was no initial nursing assessment, no skin assessment and no assessment for the risk of skin impairment. Review of the admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #44 ' s cognition was moderately impaired. The resident required extensive assistance with two-person physical assistance for bed mobility and transfers. The MDS indicated Resident #44 had no pressure ulcers but was at risk for skin breakdown. Resident #44 did not exhibit any behaviors related to rejection of care. Review of the facility ' s form named Skin Observation -Point of Care from dates 06/28/16 through 07/10/16 revealed STNA #41 documented an open area on 06/30/16, 07/01/16 and 07/06/16 and STNA #56 documented an open area on 07/04/16 and 07/06/16. This form did not state location of the open area. There was no mention of any skin breakdown in the medical record except for the Skin Observation-Point of Care form completed by the STNAs. There was no physician notification or treatments initiated for the open areas that were noted by STNAs #41 and #56 until 07/10/16. Review of physician orders [REDACTED].M. revealed an air mattress was to be ordered if Resident #44 ' s sacrum got red. Resident #44 ' s sacrum was already red as evidenced by STNA #41 ' s documentation on 06/30/16. Further review of physician orders [REDACTED]. Review of Resident #44 ' s progress note dated 07/10/16 at 12:20 P.M. revealed a new open area was found to the sacrum measuring 3.0 centimeters (cm.) in length by 5.0 cm. wide with white/black slough noted to the wound bed. A new physician order [REDACTED]. An air mattress was ordered. Resident #44 was turned side to side during the shift. Review of the Wound Progress Record form dated 07/13/16 revealed Registered Nurse (RN) #58 documented Resident #44 ' s wound was an unstageable pressure ulcer measuring 3.0 cm. in length by 3.0 cm. wide and had an eschar area that was hard to the touch. Review of the progress note dated 07/18/16 at 2:31 P.M. revealed RN #58 contacted the physician due to the resident being incontinent of urine and the pressure wound on her coccyx. The physician ordered a Foley catheter to straight drain for wound healing. There was no indication the Foley catheter was placed until 07/19/16 at 12:20 P.M. Review of the Wound Progress Record form dated 07/20/16 revealed RN #58 documented the sacrum wound measured 3.0 cm. in length, 2.5 cm. wide and 2.0 cm. in depth. The wound was noted to have undermining (0.2 cm) present at 2:00 and tunneling was present (2.3 cm) at 11:00. There was no indication in the medical record the physician was contacted regarding the change in wound status until 07/22/16. On 07/22/16 at 12:08 P.M., a progress note was written by RN #58 indicating Resident #44 had been lethargic recently and had a pressure ulcer on the coccyx causing pain. The wound was noted to have a strong odor and green-yellow slough was present. The physician ordered a wound culture, urine collection and laboratory work to check for systemic infection. Review of the wound culture results revealed they were reviewed by RN #58 at 11:18 A.M. on 07/26/16 and indicated there was heavy growth of Proteus Mirabilis and moderate growth of Gram Positive Cocci. There was no indication in the medical record the physician was contacted regarding the wound culture results until 07/27/16 at 4:06 P.M. A progress note written by RN #58 clarified the antibiotic ordered from two separate people (individuals unspecified) and was clarified by Certified Nurse Practitioner (CNP) #60 who ordered [MEDICATION NAME]. There was no indication [MEDICATION NAME] was administered to Resident #44. On 07/28/16 at 4:40 P.M. Resident #44 was sent to the hospital with a low blood pressure, elevated temperature and a wound infection. Resident #44 was sent to the hospital to be evaluated for [MEDICAL CONDITION]. Review of the hospital paperwork on 08/02/16 revealed Resident #44 had debridement of a Stage IV pressure ulcer of the sacrum and was going to receive a wound vac for treatment. Interview with Physical Therapist Assistant #59 on 08/18/16 at 2:05 P.M. revealed she identified a reddened area that was not open on Resident #44 ' s sacrum upon the day of the resident ' s admission to the facility on [DATE] and stated she brought it to the nurse ' s attention. The therapist was unable to recall the name of the nurse she told this to. Interview with the Regional Director of Operations on 08/18/16 between 2:54 P.M. and 3:30 P.M. confirmed there was no initial nursing assessment, including a skin assessment, completed for Resident #44. The Regional Director of Operations confirmed a pressure ulcer risk assessment should have been completed on admission and confirmed the STNA Skin Observation Point of Care form had an open area documented on 06/30/16, 07/01/16, 07/04/16 and 07/06/16. The Regional Director of Operations confirmed a physician order [REDACTED]. The Regional Director of Operations confirmed Resident #44 ' s wound was assessed to be undermining and tunneling and there was no indication the physician was notified of the change in condition. She also confirmed the wound culture results were returned and reviewed by a nurse on 07/26/16 and an antibiotic was not ordered until 07/27/16 and never administered to the resident. Interview with STNA #56 on 08/18/16 at 4:35 P.M. confirmed she worked on 07/04/16 and 07/06/16. She confirmed she documented the open area on Resident #44 ' s sacrum. She stated that when she was taking the resident off the bedside commode, she noticed dry blood and looked to see where it was coming from and noted the location on the resident ' s sacrum. She said the wound was just starting to open up and there were no black areas noted. STNA #56 said she notified LPN #50. Interview with STNA #41 on 08/18/16 at 4:35 P.M. confirmed she noted an open area on 06/30/16, 07/01/16 and 07/06/16 and the location of the open area was on the resident ' s sacrum. She said she remembered when she worked on 07/06/16 the wound was bigger and a little more open. Interview with RN #3 on 08/18/16 at 4:46 P.M. confirmed she worked the night of 07/18/16 and she was not notified a Foley catheter was to be placed for Resident #44. Interview with LPN #6 on 08/18/16 at 5:10 P.M. revealed the Foley catheter was in place on her shift on 07/19/16 but was not functioning properly so she inserted a new Foley catheter on 07/19/16. Interview with RN #58 on 08/18/16 at 5:15 P.M. indicated she resigned from the facility because there was no communication. She stated that RN #16 was the admitting nurse for Resident #44 and said she discussed with RN #16 the lack of admission and skin assessment for the resident. She said the first time she was told about the wound on Resident #44 ' s sacrum was around 07/13/16 and said she got the physician order [REDACTED]. RN #58 said there was no way a wound progresses to black that quickly. She said she was the one who got the physician order [REDACTED].#50 or LPN #6. She confirmed she was the nurse that reviewed the wound culture results and worked diligently getting an antibiotic ordered for the resident because she knew the resident was declining. RN #58 said she faxed the results to the physician ' s office and then found out the physician was on vacation so she faxed it to another physician. The next day (07/27/16) she received two different antibiotic orders, one from Certified Nurse Practitioner (CNP) #60 and the other from a physician. She said she kept calling for clarification and then finally contacted CNP #60 and clarified the antibiotic as [MEDICATION NAME]. RN #58 said she told the floor nurse to pull the [MEDICATION NAME] from the emergency drug kit. Interview with LPN #50 on 08/19/16 at 8:12 A.M. revealed she remembered observing Resident #44 ' s sacrum and stated it was very tiny, red and open. She said she doesn ' t recall notifying the physician of the open area or obtaining a treatment for [REDACTED].#58 telling her to insert a Foley catheter for Resident #44. Interview with RN #16 on 08/22/16 at 9:05 A.M. confirmed she admitted Resident #44 and confirmed she did not complete a nursing assessment or skin assessment on the resident. She stated that she did assist with toileting the resident the day of admission and noted no skin breakdown on the resident ' s sacrum. Review of information from the National Pressure Ulcer Advisory Panel (NPUAP), 2014 defined pressure ulcers as a localized injury to the skin and/or underlying tissue over a bony prominence, as a result of pressure, or pressure in combination with shear. The NPUAP indicated that early assessment of risk factors and the implementation of preventative measures were key. Review of the facility ' s policy and procedure for Pressure Ulcers Wound Care Standards of Practice dated 10/07/04 revealed the standard was pressure ulcers would be observed, evaluated, assessed and treated in accordance with accepted guidelines from the Agency for Healthcare Quality and Research. 2. Review of Resident #16 ' s medical record revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the resident ' s MDS assessment dated [DATE] indicated the resident had clear speech, usually understands others, sometimes made herself understood and had moderate cognitive deficit as indicated by a BIMS score of seven. The MDS indicated the resident required extensive assistance, was incontinent of both bowel and bladder, was at risk for pressure ulcers and had unhealed pressure ulcers. Review of the skin condition and treatment section of the MDS indicated the resident had one Stage III pressure ulcer (full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling), one Stage IV pressure ulcer and one unstageable pressure ulcer with the most severe skin tissue type as eschar. The MDS indicated the facility implemented pressure reducing devices to the bed, nutritional or hydration interventions and pressure ulcer care. Review of Resident #16 ' s Braden scale dated 04/25/16 revealed a score of nine indicating the resident was at a very high risk for skin breakdown. Review of the resident ' s impaired skin integrity plan of care dated 02/01/16 indicated the facility implemented the intervention to complete treatments as ordered by the physician. Review of the resident ' s physician orders [REDACTED]. Apply Hydrocel to the wound bed, apply zinc to the wound edges and reddened surrounding area. Place moist 4x4 inside the wound, cover with three (3) dry 4x4s and top that area with [MEDICATION NAME] dressing. Change the dressing daily and as needed (prn). Review of Resident #16 ' s June, 2016 Treatment Administration Record (TAR) revealed the physician ordered treatment to the Stage IV pressure ulcer of the mid line back was not completed on 06/04/16, 06/05/16, 06/06/16, 06/13/16, 06/14/16, 06/18/16, 06/19/16, 06/20/16, 06/22/16 and 06/27/16. Review of Resident #16 ' s July, 2016 TAR revealed the physician ordered treatment to the resident ' s Stage IV pressure ulcer was not completed on 07/03/16, 07/06/16, 07/12/16, 07/16/16, 07/25/16, 07/26/16 and 07/30/16. Review of the resident ' s August, 2016 TAR revealed the physician ordered treatment to the Stage IV pressure ulcer was not completed on 08/08/16, 08/09/16, 08/12/16, 08/13/16, 08/14/16, 08/15/16 and 08/17/16. On 08/18/16 at 11:00 A.M. interview with LPN #6 revealed the LPN said I don ' t do treatments, corporate does. On 08/19/16 at 3:45 P.M. interview with the Regional Director of Clinical Operations verified the physician ordered treatment to Resident #16 ' s Stage IV pressure ulcer was not completed on the above noted dates. On 08/18/16 at 2:40 P.M. observation of Resident #16 ' s Stage IV pressure ulcer revealed the wound was light pink with no slough, the edges were white and looked like they were beginning to macerate (soften). The wound bed was clean with some foul odor. There was no drainage noted. There did not appear to be any tunneling or undermining. 3. Review of Resident #38 ' s medical record revealed an original admission date of [DATE] with the latest re-admission on 05/31/16 with [DIAGNOSES REDACTED]. Review of the resident ' s quarterly MDS 3.0 assessment dated [DATE] indicated the resident has clear speech, understands others, makes herself understood and has severe cognitive deficit as indicated by a BIMS score of six. The MDS indicated the resident required extensive assistance with activities of daily living (ADLs), always incontinent with both bowel and bladder, at risk for skin breakdown and had an unhealed pressure ulcer. The MDS indicated the resident had a Stage IV pressure ulcer measuring 2.8 centimeters (cm) by 2.8 cm by 1.0 cm with the most severe tissue type being granulation tissue. The MDS indicated the facility implemented pressure reducing devices to the resident ' s bed and chair, a turn and repositioning program, nutrition or hydration interventions and pressure ulcer care. Review of the at risk for developing a pressure ulcer plan of care dated 11/18/15 with the target date of 09/14/16 indicated the facility would complete a weekly skin assessment. Review of the weekly skin inspections failed to provide documented evidence the weekly skin inspections were completed on 03/29/16, 04/11/16, 04/19/16, 04/26/16, 05/03/16, 05/10/16, 05/17/16, 05/24/16, 05/31/16 and 06/14/16. Review of the nursing admission note dated 03/18/16 indicated the resident was assessed as a high risk for skin breakdown as indicated by a Braden Scale score of 12. Review of the skin condition section of the nursing admission assessment indicated no documented issues with the resident ' s skin. Review of the initial wound progress record dated 03/18/16 indicated the resident was readmitted to the facility with a Suspected Deep Tissue Injury (SDTI) to the right buttocks measuring 3.0 cm by 3.0 cm by 0.0 cm. The assessment failed to describe the color of the SDTI on the resident ' s right buttocks. On 08/19/16 at 3:45 P.M. interview with the Regional Director of Clinical Operations verified the resident ' s weekly skin assessments were not completed. This deficiency substantiates Complaint Number OH 119.

Based on observation, staff interview, review of policies and procedures, and medical record review, the facility failed to ensure a resident at high risk for developing pressure ulcers did not develop pressure ulcers, and failed to provide treatment to pressure ulcers when they first developed. This affected one of four residents reviewed for pressure ulcers (Resident #49). The facility identified one resident in the facility with pressure ulcers. The facility census was 47 residents. Actual harm occurred to Resident #49 when facility staff failed to reposition the resident, failed to provide treatment to the pressure ulcers when they developed, and failed to provide incontinence care resulting in the resident developing three avoidable Stage II pressure ulcers. Findings include: Medical record review for Resident #49 revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set (MDS) assessment completed on 01/12/12 revealed the resident had short and long term memory problems, was totally dependant of two people for bed mobility, transfers, toilet use, and hygiene. Review of the MDS assessment revealed the resident used a wheelchair and was always incontinent of bowel and bladder. Review of the MDS assessment revealed the resident was at risk for pressure ulcers and had the treatment of [REDACTED]. Review of a Pressure Ulcer Risk Assessment completed on 01/18/12 revealed the resident was at high risk for the development of pressure ulcers. Review of Resident #49's current physician orders [REDACTED]. An order dated 11/09/10 identified to check and change with care rounds and as needed. An order dated 05/01/11 identified to complete a weekly skin assessment every Saturday. An order dated 07/01/11 identified the resident was to use a specialty wheelchair. Review of Resident #49's plan of care dated 01/12/12 revealed the resident was at risk for pressure ulcers related to immobility and incontinence. Interventions marked included: to assess and record changes in skin, report pertinent changes in the skin to the physician, turn and reposition with care rounds and as needed (prn), provide a specialty mattress, provide incontinence care after each incontinent episodes, minimize pressure over bony prominences, and protective skin barrier cream as ordered. Review of the plan of care for Resident #49 revealed no documented evidence of a plan of care for a current pressure ulcer. Review of Resident #49's plan of care for Bowel and Bladder dated 01/12/12 revealed the resident was at risk for skin breakdown and for further decline in urinary incontinence. Interventions listed included to provide incontinence care after each incontinence episode at least every 2 hours and as needed. Review of Resident #49's plan of care for Activities of Daily Living Self Care Deficit dated 01/12/12 revealed the resident needed assistance or was totally dependant in bed mobility, transfers, dressing, eating, toilet use, hygiene and bathing. Interventions included: turn and reposition, shifting weight to enhance circulation with care rounds and as needed. The plan of care identified an order dated 12/16/10 for [MEDICATION NAME] ointment to coccyx, apply topically every shift as needed. Review of Resident #49's nurses notes from 11/20/11 through 02/02/12 revealed no evidence staff had reported or documented the resident had three open Stage II pressure ulcers to the resident's left buttocks that were observed on 02/02/12. On 02/02/12 at 2:00 PM., review of Resident #49's record revealed no documentation of pressure ulcers to the resident's skin. Observations of Resident #49 revealed the following: On 01/31/12 at 9:20 A.M., the resident was taken out of the dining room seated in a specialized wheelchair and placed in a hallway in front of the 200 hall nurses station. At 11:15 A.M., observation continued and the resident was seated up in her wheelchair in front of the nurses station. Observation revealed the resident had not been repositioned, toileted, or moved in her wheelchair. Observation continued and revealed at 12:00 P.M., the resident was taken directly back to the dining room from the 200 hall in her specialized wheelchair, without staff repositioning the resident in the specialized wheelchair and without checking and changing the resident for incontinence needs. On 02/02/12 at 8:15 A.M., Resident #49 was observed in the dining room seated in her specialized wheelchair. Observation continued and again at 9:20 A.M., the resident was taken directly from the dining room to the 200 hallway and was observed to continue sitting in her specialized wheelchair. Observation revealed the resident was not repositioned in the specialized wheelchair, checked or changed for incontinence needs. Continuous observation was made and at 11:30 A.M., the resident continued to sit in her specialized wheelchair in front of the nurses station and was not observed repositioned, checked or changed for incontinence needs or had pressure off loaded from the resident's buttocks or coccyx. On 02/02/12 at 11:30 A.M., observation of Resident #49 and staff interview with Registered Nurse (RN) #48 confirmed the resident was still seated in the hallway in her specialized wheelchair and had not been repositioned or checked and changed for incontinence needs. RN #48 confirmed Resident #49 had been sitting in her chair since breakfast. RN #48 stated staff only typically reposition the resident when they lay her down between lunch and dinner. RN #48 stated that staff were to use their nursing judgement at this time to know when they should lay the resident down, reposition the resident and check and change the resident. RN #48 stated the resident was on a check and change protocol with care rounds and as needed for incontinence management. Observation continued on 02/02/12 at 11:45 A.M., and revealed Resident #49 continued sitting in her specialized wheelchair in the 200 hallway. Resident #49 was then taken directly from the hallway to the dining room by a State tested Nurse Aide (STNA). Observation revealed the resident was not repositioned or checked or changed by staff and was taken directly to the dining room table. At 12:30 P.M., Resident #49 was still observed seated in her specialized wheelchair in the dining room without being repositioned or checked or changed. Observation continued on 02/02/12 at 2:55 P.M. with the observation of Resident #49's buttocks with STNA #31. The adult incontinence brief was removed and noted to be slightly wet. The observation revealed three open areas on the resident's left buttocks. No dressing covering the open areas was in place and no cream was observed on the area. The open areas observed had deep red wound beds. Measurements were not obtained at this time. Interview with STNA #31 on 02/02/12 at 2:55 P.M. confirmed the three open areas and stated the open areas had been there since Tuesday 01/31/12. STNA #31 confirmed she she did not report the open areas on the resident's buttocks to a staff member. STNA #31 stated she was not directed to treat the areas with Saab ointment ([MEDICATION NAME]), but stated that she applied Saab ([MEDICATION NAME]) cream to the residents open areas at this time. On 02/02/12 at 3:00 P.M., interview with Licensed Practical Nurse (LPN) #7 revealed that she was unaware of the open areas to Resident #49's left buttocks. LPN #7 stated the STNAs had not reported the areas. LPN #7 confirmed Resident #49 was up in her chair on 02/02/12 from 8:15 A.M. to 12:30 P.M., without being repositioned, and without being checked and changed. LPN #7 confirmed Resident #49 now had three open areas noted to her left buttocks. On 02/02/12 at 3:25 P.M., observation of Resident #49 was completed with LPN #7, the Director of Nursing (DON), and RN #48. Resident #49's buttocks were observed covered in a white thick cream. LPN #7 wiped the resident's left buttock clean with wet wipes, in a back and forth direction. Observation and measurements were obtained and revealed an area to the medial left buttocks was a Stage II pressure ulcer that measured 0.8 centimeters (cm) x 0.6 cm x<.01 cm. An area to the upper left buttock was a Stage II pressure ulcer that measured 0.4 cm x 0.6 cm x <.01 cm. An area to the inner left buttock was a Stage II pressure ulcer that measured 0.2 cm x 0.3 cm x <.01 cm. The pressure ulcer areas had a deep red wound bed, superficially open, no slough present, no drainage noted. Three defined perimeters were noted to the wounds. At the time of the observation, interview with the DON confirmed Resident #49 had developed three Stage II pressure ulcers. A Pressure Ulcer is defined as a localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction. A Stage II pressure ulcer is defined as a partial thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed without slough, may also present as an intact or open/ruptured blister. Review of the Skin/Wound Protocol (dated December 2011) revealed the purpose of this protocol was to establish a method of preventing, tracking, treating, and monitoring skin conditions for the individual resident. Guidelines included: Skin/wound issues were reviewed on a daily basis during clinical and administrative stand up, all nursing management staff as well as the administrator were present at these daily meetings, skin sweeps were performed weekly and measurements were completed at that time. A skin tracking form was to be completed by the Director of Nursing for the monthly Medical Director's Report, and any need for a change of order request would be completed by nursing. Review of the Turn and Repositioning policy and procedure (last revised January 2011) revealed the purpose of the protocol was to provide nursing care in accordance with each resident's needs, abilities, and [DIAGNOSES REDACTED]. Guidelines included each resident was assessed upon admission, quarterly, with significant change and when needed for pressure ulcer risk, including ability to reposition per self. Residents were turned and repositioned with care rounds and when needed when the resident was unable to reposition themselves.