Every finding on record at Archbold Living Camilla

Based on staff interviews, record review, and review of the facility's policy titled, Abuse Prohibition Policy and Procedures and Identifying Sexual Abuse and Capacity to Consent, Facility B failed to ensure one of three Residents (R) (R1) was protected from sexual assault by R2. Specifically, R2 was found in R1's room sitting next to her bed. R1 was naked from the waist down with blood noted to her vaginal area and R2 was later found to have blood on his right middle finger. Subsequently, R1 was sent to the hospital after the sexual assault by R2 resulting in a one-centimeter laceration to her left vaginal wall.The facility's failure to ensure protection from the sexual assault had the potential to result in physical, mental, or psychosocial harm. An Immediate Jeopardy (IJ) was identified on 12/29/2025 at 5:00 pm and was determined to have existed on 11/29/2025 at appropriately 6:09 pm. The facility's Administrator for Facility B was notified that an acceptable IJ removal plan was received on 12/30/2025. The surveyor validated the full implementation of the facility's removal plan, and the Administrator was notified on 12/31/2025 at 5:10 pm that the Immediacy had been removed on 12/19/2025.Findings include:Review of the facility's policy titled Abuse Prohibition Policy and Procedures dated 8/25/2008 revealed, under the section titled Prevention revealed, 3(B). The facility will identify, correct and intervene in situations in which abuse, neglect, exploitation and/or misappropriation of resident property is more likely to occur. This will include an analysis of: 4. The assessment, care planning, and monitoring of residents with needs and behaviors which might lead to conflict or neglect , such as residents with a history of aggressive behaviors, residents who have behaviors such as entering other residents' with self-injurious behaviors, residents with communication disorders, those that require heavy nursing care and/or are totally dependent.Review of the facility's policy titled Identifying Sexual Abuse and Capacity to Consent dated August 2024 under the Policy Statement revealed, A resident's consent to sexual activity is not valid if obtained from a resident who lacks the capacity to consent, or if consent was obtained through intimidation, fear or coercion. Under the Policy Interpretation and Implementation revealed, 5. The facility will conduct an investigation and protect a resident from non-consensual sexual relations anytime there is reason to suspect that the resident does not wish to engage in sexual activity or may not have the capacity to consent.1. Review of the medical records revealed that R1 was admitted to the facility with the following diagnoses that include but were not limited to Alzheimer's disease, hypothyroidism, and atherosclerotic heart disease.Review of R1's Minimum Data Set (MDS) assessment dated [DATE] for Section C (Cognitive Pattern) revealed, a Brief Interview for Mental Status (BIMS) score of three, which indicated severe cognitive impairment.Review of R1's nursing progress notes dated 11/29/2025 revealed that Certified Nursing Assistant (CNA) AA observed R1 door closed and opened the door to see R2 sitting in his wheelchair next to her bed. CNA AA left the room to get the Licensed Practical Nurse (LPN) BB. They both entered R1 room together and R2 was immediately wheeled out and taken to his room. R1 brief was observed lying next to her pillow. LPN BB then lowered the flat sheet and noted that R1 was naked from the waist down. LPN BB performed a skin assessment on R1 and then assisted R1 to a standing position where she noted blood on the sheets. During this assessment, LPN BB observed a moderate amount of blood in the vaginal area and dried blood on the outer skin of the vaginal area. R1 was sent to the hospital for a sexual assault examination.Review of the local hospital records dated 11/29/2025 revealed R1 was treated and discharged to a another facility on 11/29/2025 at 9:21 pm to be evaluated by Sexual Assault Nurse Examiner (SANE) nurse. Review of the SANE examination dated 11/30/2025 at 12:11 am revealed, the sexual assault type as, vaginal penetration with associated symptoms of vaginal bleeding. Further review of the the examination revealed that R1 had a one-centimeter laceration noted to the left vaginal wall without active bleeding.2. Review of the medical records revealed R2 was admitted to the facility with the following diagnoses that included but are not limited to dependence on renal dialysis, end stage renal disease, cardiac arrhythmia, hypertension, syncope and collapse.Review of R2's Minimum Data Set (MDS) assessment dated [DATE] for Section C (Cognitive Pattern) revealed, a Brief Interview for Mental Status (BIMS) score of five, which indicated severe cognitive impairment.Review of R2's nursing progress notes dated 11/29/2025 revealed R2 hand was examined, and LPN BB saw dry red blood on his right middle finger. R2 reported to LPN BB that he did not know why his finger was that color. Law enforcement arrived at facility. R2 was transferred to emergency room for evaluation to an inpatient behavioral unit.Review of [Name] PD Incident Report dated 11/29/2025 under section titled Officer Supplementals when questioned by the officer what occurred in R1's room while the door was closed, R2 revealed that he put his wheelchair beside her bed and placed his fingers into the vagina of R1. The officer then observed blood on a finger from his right hand that appeared to be dried up and stained.Review of the Facility Incident Report Investigation Summary dated 11/29/2025 revealed, that R2 was later discharged from the inpatient behavioral unit to home with family. The report further noted that R2 was issued a 30-day discharge on [DATE]. On 12/4/2025, law enforcement reported formal charges would be filed against R2. During an interview on 12/18/2025 at 11:06 am, LPN BB revealed she was sitting at the nurse's station charting. CNA AA came to the desk to say that R1 room door was closed. She stated that she got up and saw LPN XXX on the hall. LPN XXX stated that R1 was not in her right mind and someone needed to check on her. LPN BB and CNA AA opened the door and peeked inside and at first they didn't see anything strange. R1 had on a jacket and a shirt and a sheet was covering the lower portion of her body from the waist down. She revealed that she and CNA AA came out of the room together. CNA AA then asked her if she had seen the pull-up next to the pillow. She stated to CNA AA that she had not seen the pull-up by the pillow. LPN BB stated that she went back into the room and saw the brief by the pillow. She then moved the sheet and saw that R1 was naked from the waist down. R2 who was sitting in his wheelchair next to R1's bed was rolled out and taken to his room. She revealed that she assisted R1 to standing position while doing a skin assessment and noted blood on the sheets. She went out of the room after the assessment to get LPN XXX who told her to call the Administrator. R1 was examined by her and LPN XXX while CNA AA held the flashlight, and she was able to see a medium amount of dry blood outside of the vagina area. She called the Administrator again to tell her about the blood. She revealed that the Administrator called the police and she completed the paperwork to send R1 to the hospital. She attempted five times to contact R1's family but no answer. She revealed, after the incident, she checked R2's hand and saw dried blood on his middle finger.During an interview on 12/18/2025 at 12:06 pm, CNA AA revealed she observed R1 lying in her bed and R2 sitting in his wheelchair in the doorway of R1's room watching television. CNA AA revealed that she was later walking down the hall and saw R1's room door closed. She revealed that when she went to the door and opened it, R2 was sitting in his wheelchair and R1 was in bed. She then closed the door to go get the nurse to make sure it was okay for R2 to be in R1's room. She revealed they both went to R1's room and shocked to see R1's brief at the head of the bed. While standing in the hallway, she then asked LPN BB if she saw the brief on the bed near the pillow. LPN BB stated that she had not seen the brief by the pillow, and then they both went back into the room. CNA AA stated that she assisted LPN BB with the body assessment, and when the sheet was pulled back, R1 was naked from the waist down and there were streaks of blood on the sheets. She revealed that the brief by the pillow did not have any blood on it. She further revealed when she began putting on a new brief for R1, blood started to leak on the brief. She took off the brief and put that brief in the trash bag. A second brief was placed on R1 and a yellow discharge substance was noted it. She stated when the police came, they completed an assessment for R1 then check R2 and noticed blood on his right middle finger.

Based on staff interviews, record reviews, and review of the facility's policy titled Resident Rights, Standards of Performance Nursing Home Administrator (PPNH), and Standards of Performance Director of Nursing (PPNH), Facility B failed to ensure one of three Residents (R) (R1) was protected from sexual assault by R2. Specifically, Administration failed ensure R1 maintain an environment free from abuse in a manner that efficiently maintained the highest practicable physical, mental, and psychosocial well-being for the resident.The facility's failure to ensure protection from the sexual assault had the potential to result in physical, mental, or psychosocial harm. An Immediate Jeopardy (IJ) was identified on 12/29/2025 at 5:00 pm and was determined to have existed on 11/29/2025 at appropriately 6:09 pm. The facility's Administrator for Facility B was notified that an acceptable IJ removal plan was received on 12/30/2025. The surveyor validated the full implementation of the facility's removal plan, and the Administrator was notified on 12/31/2025 at 5:10 pm that the Immediacy had been removed on 12/31/2025.Findings include:Review of the facility's policy titled Resident Rights dated August 2019 under the section titled Policy Interpretation and Implementation revealed, 1.c. be free from abuse, neglect, misappropriation of property, and exploitation.Review of the facility's policy titled Standards of Performance Nursing Home Administrator revealed, under Required Skills: 1. The Administrator shall exercise general management of the Nursing Home. 5. Be responsible to assure that high standards of quality patient care are maintained.Review of the facility's policy titled Standards of Director of Nursing revealed, under Performance Standards: Makes a conscientious effort to help maintain a clean, safe and secure environment. 1. Review of medical records for R1 revealed, she was admitted to the facility with the following diagnoses that include but were not limited to Alzheimer's disease, hypothyroidism, and atherosclerotic heart disease.Review of the Minimum Data Set (MDS) assessment for R1 dated 9/1/2025 under Section C (Cognitive Pattern) revealed, a Brief Interview for Mental Status (BIMS) score of three, which indicated severe cognitive impairment.Review of R1's nursing progress notes dated 11/29/2025 revealed that Certified Nursing (CNA) AA observed R1 door closed and opened the door to see R2 sitting in his wheelchair next to her bed. CNA AA left room to get Licensed Practical Nurse (LPN) BB. When they both arrived at R1's room together, they observed R1's brief lying next to her pillow. R2 was removed from R1's room and wheeled to his room. LPN BB then lowered the flat sheet and noticed that R1 was naked from the waist down. LPN BB performed a skin assessment on R1 and then assisted R1 to a standing position where she noted blood on the sheets. During this assessment, LPN BB observed a moderate amount of blood in the vaginal area and dried blood on the outer skin of the vaginal area. R1 was sent to the hospital for a sexual assault examination.Review of the examination performed by the Sexual Assault Nurse Examiner (SANE) dated 11/30/2025 at 12:11 am revealed, the sexual assault type as, vaginal penetration with associated symptoms of vaginal bleeding. Further review of the examination revealed that R1 had a one-centimeter laceration noted to the left vaginal wall without active bleeding. 2. Review of R2's medical records revealed, he was admitted to the facility with the following diagnoses that included but are not limited to dependence on renal dialysis, end stage renal disease, cardiac arrhythmia, hypertension, and syncope and collapse.Review of the Minimum Data Set (MDS) assessment for R2 dated 11/11/2025 under Section C (Cognitive Pattern) revealed, a Brief Interview for Mental Status (BIMS) score of five, which indicated severe cognitive impairment.Review of [Name] PD Incident Report dated 11/29/2025 under the Officer Supplementals section, it was revealed when questioned by the officer that R2 stated he put his wheelchair beside R1's bed and placed his fingers into R1's vagina. The officer noted blood on R2's right finger that appeared to be dried up and stained. Review of the Facility Incident Report Investigation Summary dated 11/29/2025 revealed, R2 was later discharged from the inpatient behavioral unit to home with family. Further review revealed, R2 was issued a 30-day discharge on [DATE]. On 12/4/2025, it was reported that law enforcement would file formal charges against R2.During an interview on 12/31/2025 at 2:00 pm, the Administrator revealed that there was no indication of any behaviors that would trigger R2 outcome. The Administrator revealed he had no evidence in his past medial history that would indicate a reason to decline his admission to the facility. The Administrator revealed immediately after the sexual assault, she did a timeline of the incident, in-service on sexual abuse, involved law enforcement and discharged R2 from the facility. The Administrator further revealed, R1 was sent to the hospital for a sexual assault examination.The Director of Nursing (DON) was on leave, and an interview was not obtained.

Based on staff interviews, record reviews, and review of the facility's policy titled Falls and Falls Risk Management, Facility A failed to ensure four of four Residents (R) (R1, R2, R3, R4) reviewed for falls had fall risk assessments, 3 (three)-day post fall follow-up, and/or neurological checks completed to prevent the risks and minimize complications from falls.Findings include:Review of the facility's policy titled Falls and Falls Risk Management, dated August 2019 under the Policy Statement revealed, Based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling. Under the Policy Interpretation and Implementation subsection titled Prioritizing Approaches to Managing Falls and Fall Risk revealed, 1. The staff, with the input of the Attending Physician, will identify appropriate interventions to reduce the risk of falls. If a systematic evaluation of a resident's fall risk identifies several possible interventions, the staff may choose to prioritize interventions, (i.e., to try one or a few at a times, rather than many at once). Under the subsection Monitoring Subsequent Falls and Fall Risk revealed, 1. The staff will monitor and document each resident's response to interventions intended to reduce falling or the risks of falling.1. Review of the medical record revealed R1 was admitted with the following diagnoses that included but were not limited to Alzheimer's disease, type 2 diabetes mellitus, dementia, and unsteadiness on feet.Review of the nursing notes dated 4/16/2025 through 11/30/2025 revealed an entry on 10/9/2025 that indicated, R1 had an unwitnessed fall in the hallway without an apparent injury. There was no evidence that there was a 3-day post fall follow-upon 10/10/2025, 10/11/2025 and 10/12/2025. An entry dated 11/20/2025 revealed R1 had an unwitnessed fall in her room and a neurological assessment was initiated; however, the neurological checks were incomplete and did not follow the correct timing protocol. In addition, there was no evidence of a post fall assessment completed on 11/21/2025, 11/22/2025, and 11/23/2025.Further review of the nursing notes dated 11/26/2025 revealed R1 was lying flat on the floor at bedside. She was noted to have redness to top of left foot, a skin tear to her left elbow. Review of monitoring documentation dated 10/9/2025, 11/19/2025 and 11/26/2025 revealed no evidence of a post fall follow-up.Review physical therapy initial assessment dated [DATE] revealed R1 was a fall risk.Review of R1's medical record revealed, there was no evidence of fall assessments completed. 2. Review of the medical records revealed, R2 was admitted to the facility with the following diagnoses that included but were not limited to cerebral infarction, hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, hypertension, adult failure to thrive and chronic pain.Review of the nursing notes dated 11/19/2025 through 12/5/2025 revealed an entry dated 11/19/2025 that indicated, R2 had an unwitnessed fall in his room without any injuries The neurological checks were incomplete and did not follow the correct timing protocol. In addition, there was no evidence of a 3-day post fall follow-up. An entry dated 11/27/2025 revealed R2 had an unwitnessed fall in his bathroom without injury. There was a follow up on 11/27/2025 for a fall listed on 11/26/2025 and a late entry on 11/28/2025 for 11/27/2025. There was no evidence of a completed 3-day post fall follow-up. An entry dated 12/1/2025 revealed an unwitnessed fall in his room without apparent injury. The neurological checks were incomplete and did not follow the correct timing protocol. In addition, there was no evidence of a 3-day post fall follow-up.Review of R2 fall risk assessments dated 2/1/2023, 5/3/2023 and 8/1/2023. There was no evidence for fall risk assessments for the year of 2024 and 2025.3. Review of the medical records revealed R3 was admitted to the facility with the following diagnoses that included but were not limited to palliative care, cerebral infarction, hypertensive, and dysphasia.Review of the nursing notes dated 10/6/2025 through 10/30/2025 revealed an entry dated 10/7/2025 that indicated R3 had a witnessed fall. There was no evidence of a 3-day post fall follow-up.An interview on 1/8/2025 at 9:43 am with Licensed Practical Nurse (LPN) BB revealed the Certified Nursing Assistant (CNA) reported the fall to her on 10/7/2025. She revealed that she assessed the resident for injuries and notified the physician and responsible party. She confirmed that after a fall, 3-day post fall follow-up should have been completed. LPN BB revealed, when a fall was entered in the computer, it should have populated the 3-day post fall follow-up. She further revealed that fall risk assessments were done on admission and with the monthly summary completed by the nurses. She revealed with any unwitnessed fall or head injuries, that neuro checks should be done. 4. Review of the medical records revealed R4 was admitted to the facility with the following diagnoses that included but were not limited to Alzheimer's disease, dementia, and hypertension.Review of the nursing notes dated 10/10/2025 through 12/4/2025 revealed an entry dated 10/10/2025 that indicated, R4 had an unwitnessed fall. There was no evidence of a 3-day post fall follow-up for 10/12/2025. The neurological checks were incomplete and did not follow the correct timing protocol. An entry dated 12/4/2025 revealed an unwitnessed fall in R4's bathroom without injuries. There was no evidence of the 3-day post fall follow-up and incomplete neurological checks for the unwitnessed fall.Review of R4's care plan revealed, There was a fall dated 10/12/2025 listed on the care plan however, there was no other evidence of documentation related to the fall.An interview on 1/8/2026 at 11:00 am with Registered Nurse (RN) FF revealed that R4 had a fall on 10/10/2025 and her roommate called for help. RN FF stated she assessed R4 for injuries; obtained vital signs and notified the responsible party and physician. She revealed that the post fall documentation is a three day follow up and that she charted her post fall follow up under the nurses note - fall charting tab.An interview on 1/8/2026 at 12:28 pm with the Director of Nursing (DON) revealed that the electronic medical records had a glitch in the system and was not triggering the 3-day post fall follow ups. She revealed that there were a couple of different places to enter the post fall. However, there was one tab with a folder that will trigger the 3-day post fall follow up and that she would see if the electronic medical services would take out the sections that did not trigger the 3-day post falls. The DON further revealed that an unwitnessed fall or falls with head injuries were to have neurological checks and that the computer system did not allow nurses to complete neuro checks. The nurses were to complete the neuro checks on a paper form. The DON stated that she would initiate training so that the nurses know how to complete the neuro checks.An interview on 1/8/2026 at 12:57 pm with the Administrator revealed the expectation was that residents assessments and neurological checks were to be completed and to follow the fall policy.

Based on observation, staff interview, record review and review of the facility's policy titled Perineal Care, Facility A failed to ensure one of four Residents (R) (R8) with pressure ulcers was provided perineal care in a sanitary manner to prevent cross contamination of loose stool to a clean area. This deficient practice had the potential to place the resident at risk for infection.Findings include:Review of the facility policy Perineal Care dated 4/2022 under the section titled, PURPOSE revealed, The purpose of this policy is to cleanse the skin and perineum to promote healing and patient comfort. Under the section titled Policy revealed, It is the policy of (named facility) to provide cleansing of the perineum following voiding, defecation, or during bathing for dependent patients or patients that may need partial assistance.Review of the medical record revealed R8 was admitted to the facility with the following diagnoses that included but are not limited to Alzheimer's disease, heart failure, rhabdomyolysis, cerebral infarction and hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side.Review of R8's Quarterly Minimum Data Set (MDS) assessment dated [DATE] for Section C (Cognitive Patterns) revealed a Brief Interview of Mental Status (BIMS) score of 10 which indicated moderate cognitive impairment; Section GG (Functional Abilities and Goals) revealed, the resident was dependent with toileting hygiene; Section M (Skin Conditions) revealed, she had one unhealed stage 3 pressure.Review of weekly skin assessments dated 12/8/2025 and 12/15/2025 revealed a resolving sacrum wound. Weekly skin assessments dated 12/19/2025 and 12/23/2025 revealed a closed sacrum wound.An observation on 12/29/2025 at 2:15 pm revealed R8's door had an infection control personal protective equipment container (PPE) on the door that was empty except for a partially filled bottle of hand sanitizer. An enhanced barrier sign was posted next to the door. Licensed Practical Nurse (LPN) AA entered the room and R8 asked to be changed. Surveyor observed R8 lying on her back on an air flow mattress with loose stool between her thighs that had leaked from her brief. LPN AA failed to put on a protective gown as a barrier to the loose stool. LPN AA explained to the resident that she was going to clean her. She rolled the soiled incontinent brief toward the back and took wipes to clean the front of the resident. When LPN AA assisted R8 to her side facing the window, she removed the rolled brief and took a clean wipe and began cleaning the buttocks and sacral area. She then took another wipe to clean between her thighs where the loose stool was settling. Afterward using the same wipe, she wiped over R8's buttock and sacral area with the dirty wipe. During an interview on 1/7/2026 at 3:13 pm, LPN AA revealed that she didn't have a bag to put her dirty items into. She confirmed that she took a dirty wipe and wiped over the clean area. She confirmed she did not reclean the sacral and buttock area and admitted that she did not do the procedure correctly and had messed up. LPN AA continued to state that she did not wear a gown because there was not one available, and she was supposed to wear a gown because of the loose stool.

Based on observations, interviews, record review, and review of the facilities' policy titled Administering Medications, Facility B failed to ensure that one of three nurses (Licensed Practical Nurse (LPN) FF) observed during medication administration observation did not pre-set medications in labeled cups for one hall of four halls (100-Hall) resulting in medication error rate of 55.56%.Findings includeReview of the facilities' policy titled Administering Medication dated 10/19/2017 under the Policy Statement revealed, Medications shall be administered in a safe and timely manner, and as prescribed. Under the section titled Policy Interpretation and Implementation revealed, 7. The individual administering the medication must verify the right resident, right medication, right dosage, right time and right method (route) of administration before giving the medication.An observation on 8/8/2025 at 8:22 am, LPN FF was observed coming up the hall with her medication cart. On top of her medication were six plastic labeled cups with room numbers (108, 110, 111) and a letter (A or B) to indicate room and bed of the residents.1. Review of the physician orders for R13 in room [ROOM NUMBER]A revealed eight scheduled medications for the 8:00 am medication administration. Review of the Summary Report Meds/Tx All Shifts PPNH/(Name) revealed eight medications were administered as indicated by LPN FF initials.2. Review of the physician orders for R14 in room [ROOM NUMBER]B revealed four scheduled medications for the 8:00 am medication administration. Review of the Summary Report Meds/Tx All Shifts PPNH/(Name) revealed four medications were administered as indicated by LPN FF initials.3. Review of the physician orders for R10 in room [ROOM NUMBER]A revealed seven scheduled medications for the 8:00 am medication administration. Review of the Summary Report Meds/Tx All Shifts PPNH/(Name) revealed seven medications were administered as indicated by LPN FF initials.4. Review of the physician orders for R16 in room [ROOM NUMBER]B revealed three scheduled medications for the 8:00 am medication administration. Review of the Summary Report Meds/Tx All Shifts PPNH/(Name) revealed two medications were administered as indicated by LPN FF initials. There was no evidence of one medication (Atorvastatin) being administered as indicated as boxed out.5. Review of the physician orders for R6 in room [ROOM NUMBER]A revealed five scheduled medications for the 8:00 am medication administration. Review of the Summary Report Meds/Tx All Shifts PPNH/(Name) revealed five medications were administered as indicated by LPN FF initials.6. Review of the physician orders for R18 in room [ROOM NUMBER]B revealed eight scheduled medications for the 8:00 am medication administration. Review of the Summary Report Meds/Tx All Shifts PPNH/(Name) revealed eight medications were administered as indicated by LPN FF initials. During an interview on 9/10/2025 at 9:27 am, LPN FF confirmed that she had pre-set up her medication for each resident on her assignment. She initially gave a scenario of why her medications were labeled and sitting on the cart as she pushed the cart down the hall. She then stated that the day she decided to do something wrong, she got caught. She continued to state that she had been previously told by the Pharmacist consultant not to do this.During an interview on 9/10/2025 at 2:35 pm, the Director of Nursing (DON) revealed nurses were expected to administer medication per resident. The DON further revealed that nurses were not to label cups and pre-set up the medications for the residents on the hall in advance.During an interview on 9/10/2025 at 3:41 pm, the Administrator revealed nurses were expected to administer medications individually.

Based on observations, interviews, and review of the facilities' policy titled Storage of Medications, Facility A failed to ensure one of one medication storage room did not have expired over the counter (OTC) medications on the shelf and failed to ensure two of two medication carts (Long Hall and the Short Hall) did not have expired medications. In addition, Facility B failed to ensure one of two medication storage rooms (located on Bluebird hall) did not have expired medication on the shelf and failed to ensure one of four medication carts (100-Hall) did not have expired medications. Findings include:Review of the facilities' policy Storage of Medications dated 10/19/2017 under the Policy Statement revealed, The facility shall store all drugs, and biologicals in a safe, secure and orderly manner. Under the section titled Policy Interpretation and Implementation revealed, 4. The facility shall not use discontinued, outdated, or deteriorated drugs or biologicals. All such drugs shall be returned to the dispensing pharmacy or destroyed.(Facility A)1. During an observation on 9/9/2025 at 9:28 am with Registered Nurse (RN) CC in the medication storage room located behind the nursing station revealed the following expired medications:One bottle of probiotic formula with an expiration date of 4/2025.One jar of Fleet glycerin suppositories with an opened date of 2/14/2024 and manufacturer expiration date of 4/2025. There were nine suppositories in the jar. During an interview on 9/9/2025 at 10:12 am, RN CC confirmed that the medications had expired. She continued to state that the facility had a discard bin for all expired or discontinued medications for the pharmacy and the Director of Nursing (DON) destructions. 2. During an observation on 9/9/2025 at 10:42 am with Licensed Practical Nurse (LPN) AA of the Long Hall medication cart revealed, the following expired medications on the cart:One bottle of coated aspirin with an expiration of 8/2024.One bottle of aspirin 325 milligram (mg) with an expiration date of 2/2025.One bottle of thiamine B-1 vitamins with an expiration date of 5/2025.One bottle of aspirin 325 mg with an expiration date of June 2025. 3. During an observations on 9/9/2025 at 10:52 am with RN BB of the Short Hall medication cart revealed, the following expired medications on the cart:One bottle of aspirin 325 mg with an expiration date of 2/2025One bottle of ibuprofen 200 mg with an expiration date of 8/2025One bottle of ferrous sulfate with a fade illegible expiration date. During an interview on 9/9/2025 at 1:00 pm, LPN AA revealed that the nurses was responsible for checking the medication carts for expired OTC medications. During an interview on 9/9/2025 at 1:32 pm, RN BB revealed that all nurses were responsible for checking the medication cart for expired medications. During an interview on 9/9/2025 at 1:23 pm, the DON revealed that the nurse that administer medications were responsible for checking medication expiration dates. The DON further revealed that the medication storage room had a secretary who checked the dates on OTC in the medication storage room. (Facility B)4. During an observation on 9/8/2025 at 10:04 am with LPN II in the medication storage room for 100 Hall and 400 Hall located on Bluebird Hall revealed, one bottle of thiamine vitamin B-1 100 mg with an expiration date of 5/2025. 5. During an observation on 9/8/2025 at 10:16 am with LPN FF of the 100 Hall medication cart revealed [NAME]-Vite tablets with an expiration date of 7/2025, a vial of Lantus insulin with an opened date of 8/6/2025 and expiration date of 9/2/2025. Review of a chart on the medication cart revealed, for an opened vial of insulin dated 8/6/2025, that it would expire on 9/2/2025.During an interview on 9/10/2025 at 2:35 pm, the DON confirmed that the Lantus insulin found on the 100 Hall medication cart expired on 9/2/2025.

Based on observation, staff interview, and facility policy review, Facility B failed to ensure kitchen staff thoroughly cleaned and air-dried pans prior to storage. This failure had the potential to increase the risk of foodborne illness and had the potential to affect residents in one of two buildings (Facility B) who received dietary services. Facility failed to ensure that soap was dispensing into the dishwasher after replacing the dish detergent. These failures had the potential to affect all residents in building B, who consumed food from the kitchen. Findings include: Review of the facility's policy titled, Metz Culinary Management Air Drying of Tableware, Utensils, and Pots and Pans dated 01/07/2025, revealed, Purpose: Items must be allowed to drain and to air-dry before being stacked or stored. Stacking wet items such as pans prevents them from drying and may allow an environment where microorganisms can begin to grow. Procedures: . i. Equipment and utensils shall be air-dried using racks or storage stands in a self-draining position to permit air to pass around the items enabling them to 'air dry'. iii. At no point can items be stored in a wet condition or 'wet nesting' . 1. During an observation on 05/13/25 at 9:40 AM, the Nutritional Services Director (NSD) confirmed 14 pans, 20 inches by 24 inches by 1 inch deep that had been cleaned and stacked for use were still wet when they were unstacked. The pans were found to have been stacked wet and not allowed to completely air dry before stacking. Interview with the NSD at this time, she stated, The pans should be completely dry before being stacked for use. They should not be wet. They need to be re-washed. 2. On 05/15/25 at 12:01 PM, the following observations in the kitchen of Facility A were identified and verified by the Dietary Manager (DM). Observation of the high-temperature dishwasher during lunch revealed that soap was not coming out of the dispenser into the dishwasher. When the DM took the dishwashing dispenser out of its case, the top of it was clogged and nothing was coming out. A new bottle was placed in the dispenser and the dish soap flowed into the dishwasher. Interview on 05/15/25 at 1:28 PM, the DM revealed The dishwasher buzzes when out of soap. It was replaced the night before at dinner. This has never happened before. The soap was not dispensing. Once replaced for a second time, it now works. Interview on 05/15/25 at 1:49 PM, the Administrator B revealed, My expectation is for the dishwasher to be in working order and the dishes cleaned properly.

Based on observation, interview, and policy review, Facility A failed to ensure garbage was properly disposed of and contained which would affect all the residents and staff in one of two buildings (building B). Findings include: Review of the undated facility's policy, Waste/Garbage Storage, Disposal, Cleaning of Containers, and Pest Prevention revealed, Purpose: prevent contamination and the transmission of disease by pests and rodents .The outside compactor is kept closed and locked at all times except when putting trash into it. The area around the compactor shall be kept clean by all who use it. Observation on 05/13/25 at 10:06 AM, with the Dietary Manager (DM) of the area behind the kitchen in building B where the trash dumpsters were located revealed two dumpsters had the lids open on top and side compartment doors open. There was also trash behind the dumpsters consisting of old chairs. Outside of the kitchen door was a trash can filled with boxes that were to be broken down and six empty 35-gallon plastic oil jugs lying on the ground that were to be disposed of in the dumpsters. Interview on 05/13/25 at 10:06 AM, the DM revealed, The lids on the dumpsters and the side compartment doors should have been closed. There should not be chairs behind the dumpsters. The oil jugs need to go in the dumpsters. Interview on 05/15/25 at 1:49 PM, the Administrator B revealed, My expectation is that the dumpster area needs to be clean, and the doors closed.

Based on interviews and review of facility policy, Facility B failed to maintain a Legionella Water Management Program. This deficient practice has the potential to affect all residents in the facility. Findings include: Review of the facility's policy Legionella Water Management Program, dated 08/20/22, indicated, Our facility is committed to the prevention, detection and control of water-borne contaminants, including Legionella .The purpose of the water management program is to identify areas in the water system where Legionella bacteria can grow and spread, and to reduce the risk of Legionnaire's disease .The water management program includes the following elements: A detailed description and diagram of the water system in the facility, including receiving; cold water distribution; heating; hot water distribution; an waste. During an interview on 05/16/25 at 10:15 AM, Engineering (E) stated, We do not have a water diagram for the facility, and we do not have a detailed description of the water system in the facility. I knew that one had to be done, but I had not gotten around to it. Interview on 05/16/25 at 11:09 AM, the Administrator B revealed My expectation is that we follow our policy and CMS guidelines.

Based on interviews, Facility B failed to maintain staff documentation of current COVID-19 vaccination status. This failure had the potential to affect all 132 residents in the facility and all staff. Findings include: Interview with the Director of Nursing (DON) B on 05/16/25 at 12:18 PM revealed We do not have current COVID-19 documentation for our staff members either immunized or not. I did not know that we had to have that documentation. During an interview on 05/16/25 at 12:33 PM, the Administrator revealed, We do not have current vaccination status for COVID-19 for our staff. We provide education, but do not keep staff status.

Based on interview, record review, review of Center for Disease Control (CDC) guidance and policy review, the facility failed to monitor and evaluate antibiotic usage for five of seven residents (Resident (R) 117, R100, R47, R119 and R95) reviewed for antibiotic usage out of 31 sampled residents. This failure had the potential to affect residents in the facility safety related to antibiotic usage. Findings include: Review of an undated, untitled CDC document located at http://uprevent.[NAME].com/2855wp/wp-content/uploads/2018/01/nh-hac_mcgreercriteriarevcomp_2012-1.pdf; revealed, The Core Elements of Antibiotic Stewardship for Nursing Homes indicated, .Improving the use of antibiotics in healthcare to protect patients and reduce the threat of antibiotic resistance is a national priority .Antibiotic stewardship refers to a set of commitments and actions designed to 'optimize the treatment of infections while reducing the adverse events associated with antibiotic use' .CDC also recommends that all nursing homes take steps to improve antibiotic prescribing practices and reduce inappropriate use .Nursing homes monitor both antibiotic use practices and outcomes related to antibiotics in order to guide practice changes and track the impact of new interventions. Data on adherence to antibiotic prescribing policies and antibiotic use are shared with clinicians and nurses to maintain awareness about the progress being made in antibiotic stewardship. Clinician response to antibiotic use feedback (e.g., acceptance) may help determine whether feedback is effective in changing prescribing behaviors. Below are examples of antibiotic use and outcome measures .Process measures: Tracking how and why antibiotics are prescribed .Antibiotic use measures .Tracking how often and how many antibiotics are prescribed .Antibiotic outcome measures .Tracking the adverse outcomes . Review of the facility's policy titled, Antibiotic Stewardship dated 03/2019 revealed, Antibiotics will be prescribed and administered to residents under the guidance of the facility's Antibiotic Stewardship Program .The purpose of our Antibiotic Stewardship Program is to monitor the use of antibiotics in our residents .Changes to antibiotic orders based on culture and sensitivity will be reviewed by the facility infection preventionist or a pharmacist or designee .Lab results will be communicated to the prescriber as soon as available to determine if antibiotic is appropriate . 1. Review of R117's admission Record located under the Profile tab of the electronic medical record (EMR) revealed R117 was admitted to the facility on [DATE]. On 02/05/25 a urine analysis (UA) and culture and sensitivity (C&S) was completed and the physician started R117 on Amoxicillin (antibiotic medication) that did not meet McGeer Criteria, and the C&S was negative. 2. Review of R100's admission Record located under the Profile tab of the EMR revealed R100 was admitted to the facility on [DATE]. On 03/28/25, UA and C&S were ordered and came back as contaminated but was not repeated. Bactrim (antibiotic medication) was started by the physician and did not meet McGeer Criteria. 3. Review of R47's admission Record located under the Profile tab of the EMR revealed R47 was admitted to the facility on [DATE]. On 03/19/25, R47 was started on an antibiotic for respiratory issues did not meet McGeer's Criteria and no testing was completed such as chest x-ray. 4. Review of R119's admission Record located under the Profile tab of the EMR revealed R119 was admitted to the facility on [DATE]. On 04/22/25 a urine analysis (UA) and culture and sensitivity (C&S) was completed and the physician started R119 on Cefdinir (antibiotic medication) that did not meet McGeer Criteria, and the C&S was negative. 5. Review of R95's admission Record located under the Profile tab of the EMR revealed R95 was admitted to the facility on [DATE]. On 04/23/25 a urine analysis (UA) and culture and sensitivity (C&S) was completed and the physician started R95 on an antibiotic that did not meet McGeer Criteria, and the C&S was negative. Interview with the Infection Preventionist Building A (IPBA) on 05/16/25 at 12:07 PM, the IPBA revealed, I do not question the physician about antibiotics. I know that antibiotics are started before cultures are back. I need to follow McGeer's Criteria and educate staff. Interview on 05/16/25 at 1:40 PM , the Medical Director (MD) revealed, I guess we need work in the area of Antibiotic Stewardship. When the MD was asked if he understood the reason why antibiotic stewardship was started, he stated I really haven't thought about it. During an interview on 05/16/25 at 2:12 PM, the Administrator revealed We have to follow McGeer's Criteria and track antibiotic usage. We need to follow policies and procedures for antibiotic stewardship.

Based on interview, record review, and review of the facility's policy, the facility failed to ensure residents were informed of the risk versus the benefits of psychotropic medication use prior to being administered psychoactive medications for two of five (Resident (R) 79, and R38) reviewed for unnecessary medications out of 31 sampled residents. This failures placed the residents at risk for receiving unnecessary medications. Findings include: Review of the facility's policy titled, Resident Rights dated 08/2019 revealed, .1. Federal .laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to: .participate in decision-making regarding his or her care . 1. Review of R79's undated Admitting and Discharge Record provided by the facility revealed admitted to the facility on [DATE] with diagnosis of major depressive disorder. Review of R79's quarterly Minimum Data Set (MDS) with an assessment reference date (ARD) of 04/08/25 and found under the Aspen MDS Viewer revealed a Brief Interview for Mental Status (BIMS) score of 14 out of 15 which indicated the resident was cognitively intact. The MDS also indicated the facility assessed the resident to have active diagnoses which included anxiety disorder, depression, and dementia and that the resident received antipsychotic medication and an antianxiety medication during the assessment period. Review of R79's [Name of contracted behavior health practice] Patient Intake Form dated 01/21/25 and provided by the facility revealed, Consent for Treatment. I consent to .psychological, psychiatric, or other behavioral health services. I understand that behavioral health treatment may result in unexpected side effects, such as intense or uncomfortable emotions, and that it is important that I discuss any reactions to my treatment with my treating clinician. Behavioral health treatment can also provide benefits, such as a significant reduction in feelings of stress and improved self-esteem. I am aware, however, that no guarantees have been made to me about the results of services . The Intake Form was signed by a resident representative and not by the resident and it was signed prior to the resident's admission to the facility. Review of R79's Physician Orders provided by the facility revealed an order dated 01/25/25 for Melatonin [a natural herbal supplement used as a hypnotic medication] 3MG [milligram] tablet oral two tablets by mouth at bedtime for insomnia .mirtazapine [an antidepressant medication 15mg tablet oral one by mouth at bedtime for appetite stimulant. Review of the Physician Orders dated 01/27/25 indicated, Geodon (an antipsychotic medication) 20mg capsule Oral one by mouth BID[twice a day] .for major depressive disorder . and physician orders dated 03/03/25 indicated trazodone (an antidepressant medication) 100mg tablet oral one at bedtime for insomnia . During an interview on 05/15/25 at 9:55 AM, R79 stated she had not been explained the risk versus benefits of any of her medications. The resident also indicated she should be the one the facility's doctor should be explaining her medications to. 2. Review of R38's undated Admitting and Discharge Record, provided by the facility revealed the resident was admitted to the facility on [DATE] with diagnosis of major depressive disorder. Review of R38's annual MDS with an ARD of 04/29/25 and found under the Aspen MDS Viewer revealed a BIMS score of two out of 15 which indicated the resident was severely cognitively impaired. The MDS also indicated active diagnoses which included dementia and depression. The MDS further indicated that the resident received antipsychotic medication and an antidepressant medication during the assessment period. Review of R38's [Name of contracted behavior health practice] Patient Intake Form dated 02/13/23 and provided by the facility revealed, Consent for Treatment. I consent to .psychological, psychiatric, or other behavioral health services. I understand that behavioral health treatment may result in unexpected side effects, such as intense or uncomfortable emotions, and that it is important that I discuss any reactions to my treatment with my treating clinician. Behavioral health treatment can also provide benefits, such as a significant reduction in feelings of stress and improved self-esteem. I am aware, however, that no guarantees have been made to me about the results of services . The Intake Form was signed by a resident representative and it was signed prior to the resident's admission to the facility. Review of R38's Physician Orders, provided by the facility revealed on 03/27/24 the resident was ordered bupropion (an antidepressant medication) ER [extended release] 150mg tablet extended release 24 hour oral one at bedtime for major depressive disorder. Continued review of the Physician orders revealed on 01/21/25, R38 was ordered Seroquel (an antipsychotic medication) 100mg tablet oral one BID. for agitation, Depakote (an anticonvulsant medication used off label to treat mood disorders) ER 500mg tablet extended release 24 hour two tabs [tablets] oral by mouth daily for mood disorder and mirtazapine (an antidepressant medication) 15mg tablet oral one by mouth at bedtime for mood. During an interview on 05/15/25 at 12:51 PM, Infection Preventionist (IPA) reviewed R38 and R79's Intake Form and confirmed that the consent section of both forms did not indicate the risk and benefits for use of any medications. During an interview on 05/16/25 at 1:41 PM, Director of Nursing (DON)A stated she thought education was being provided for psychoactive medication use. DON A stated it was her expectation the resident and/or the resident's representative would have been educated on the risks of each psychotropic medication prescribed prior to the medication being administered. During an interview on 05/16/25 at 2:03 PM, Administrator A stated it was her expectation that anytime a new medication was prescribed to a resident, the resident and/or the resident representative was educated on the medication and the resident and/or resident representative give consent for the medication prior to the use of the medication.

Based on interview, record review, and review of the facility's policy, Facility B failed to ensure residents were informed in advance of their right to attend and participate in their care plan conference for two of four residents reviewed for care planning (Resident (R) 28 and R79) out of 31 sampled residents. This failure placed the residents at risk for their care plans not being person centered. Findings include: Review of the facility's undated policy titled, Care Planning revealed .Our facility's Care planning/Interdisciplinary Team is responsible for the development of an individualized comprehensive care plan for each resident .3. The resident, the resident's family and/or the resident's legal representative/guardian or surrogate are encouraged to participate in the development of and revisions to the resident's care plan. 4. Every effort will be made to schedule care plan meetings at the best time of the day for the resident and family . Review of the facility's policy titled, Resident Rights, dated 08/2019 revealed .1. Federal laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to: .p. be informed of, and participate in, his or her care planning and treatment . 1. Review of R28's undated Admitting and Discharge Record provided by the facility revealed the resident was admitted to the facility on [DATE]. Review of R28's quarterly Minimum Data Set (MDS) with an assessment reference date (ARD) of 03/11/25 revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of four out of 15 which indicated the resident was severely cognitively impaired. On 05/14/25, a request to the Social Service Director (SSD) A to assess R28's mental status score. Review of R28's BIMS completed on 05/14/25 by SSDA revealed R28 was assessed to have a score of 14 out of 15 which indicated the resident was cognitively intact. During an interview on 05/14/25 at 11:4 AM, R28 stated she had not been invited or attended a care plan meeting since her admission. R28 stated this was something she wanted to be a part of. Review of R28's document titled, Care Plan Conference dated 12/31/24 and 03/11/25, and provided by the facility revealed under the Signature section, where the resident was to sign during attendance was blank, which indicated the resident was not present during either meeting. 2. Review of R79's undated Admitting and Discharge Record provided by the facility revealed the resident was admitted to the facility on [DATE]. Review of R79's quarterly MDS with an ARD of 04/08/25 and found under the Aspen MDS Viewer with a BIMS score of 14 out of 15 which indicated the resident was cognitively intact. The MDS also indicated the facility assessed the resident to have active diagnoses which included anxiety disorder. The MDS further indicated the resident received an antipsychotic medication and an antianxiety medication during the assessment period. During an interview on 05/15/25 at 9:55 AM, R79 stated she had not been invited nor attended her care plan conferences since her admission. R79 also stated she would want to attend since she had not been asked about her discharge goals. Review of R79's document titled, Care Plan Conference dated 01/28/25 and 04/08/25, and provided by the facility revealed under the Signature section, where the resident was to sign during attendance was blank, which indicated the resident was not present during either meeting. During an interview on 05/14/25 at 4:39 PM, the Activity Director (AD) stated she was the person responsible for notifying and inviting the residents to their care plan conferences. The AD reviewed the Care Plan Conference documents for both R28 and R79 and confirmed the documents did not contain the residents' signatures to indicate they attended. The AD further stated she had not passed out the invitations inviting the residents to attend. During an interview on 05/16/25 at 1:41 PM, the Director of Nursing (DON) stated it was her expectation that residents were invited to their care plan meetings as the care plan meeting was for the resident to know their expected goals. During an interview on 05/16/25 at 2:03 PM, the Administrator stated it was her expectation that all residents were invited to their care plan conferences.

Based on interview, record review, and facility policy review, Facility A failed to obtain the CMS-10055 (Centers for Medicaid and Medicare Services) Skilled Nursing Facility Advance Beneficiary Notice (SNFABN) and CMS-10123 Notice of Medicare Non-Coverage (NOMNC) for one of five residents (Resident (R) 136) when Part A Medicare services ended. This failure prevented R136 or responsible party from appealing the decision of the facility and/or making an informed decision related to the cost of continued therapy services. Findings include: Review of the facility policy titled Advance Beneficiary Notifications dated 03/2013 revealed, The purpose is to provide instructions for issuing Advance Beneficiary Notice to applicable Medicare patients so that the patient may make an informed decision as to whether they will receive noncovered items or services for which they may have to accept financial responsibility. Review of R136's medical record revealed R136 was admitted to Medicare part A therapy services on (no date listed). R136's last covered day of Part A service was 05/03/25. CMS-10055 and CMS-10123 were emailed to R136's power of attorney (POA) on 04/30/25 at 3:30 PM. The POA did not respond to the email and there was no follow-up by the facility to acquire the beneficiary notification paperwork. Since R136 remained in the facility, Form CMS-10055 SNFABN and CMS Form 10123 NOMNC should have been reviewed by the POA to make an informed decision related to the cost of continuing to receive Part A therapy and how to appeal the decision made by the facility to discontinue Part A therapy services. Interview on 05/15/25 at 1:53 PM, the Administrator revealed, A follow-up to the POA should have been completed by calling to make sure that they had received the email.

Based on interviews, record reviews, and review of the Centers for Medicare and Medicaid Services (CMS) Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual, Facility A failed to provide a timely quarterly Minimum Data Set (MDS) Assessment data submission for one (Resident (R)78) of one resident reviewed for MDS over 120 days old out of a total sample of 31 residents. Findings include: Review of R78's undated Face Sheet provided by the facility revealed R78 was admitted to the facility on [DATE] with a diagnosis of hemiplegia and hemiparesis following cerebral infarction. Review of R78's quarterly MDS Assessment with an Assessment Reference Date (ARD) of 02/24/25 provided by the facility revealed it was completed on 02/25/25. Review of R78's MDS 3.0 Missing OBRA Assessment Report run date 05/07/25 provided by the facility revealed . Last Record Identifiers: . Target Date 12/03/24. During an interview on 05/15/25 at 9:58 AM, the MDS Coordinator (MDSC) B indicated she completed the quarterly MDS on 02/24/25 and submitted it on 02/25/25. MDSCB also indicated she ran the validation report after she submitted the quarterly assessment, however, the validation did not show it was accepted by CMS, and she did not resubmit the MDS. The MDSCB stated she ran the missing MDS 3.0 OBRA assessment report on 05/07/25 but did not understand that report stated the last MDS accepted was the quarterly assessment on 12/03/24. The MDSCB confirmed she resubmitted the assessment on 05/14/25 and the validation report stated it was accepted after the surveyor inquired about the missing assessment. The MDSCB stated she followed the RAI User's Manual which stated MDS assessments must be transmitted within 14 days of the completion date. During an interview on 05/15/25 at 10:36 AM, the Director of Nursing (DON) stated she expected the MDSCB to transmit the MDS assessments within 14 days of the completion date and to run the validation reports after the assessments were submitted to ensure they were accepted by CMS. Review of CMS LTC RAI 3.0 User's Manual, Chapter 5.2 Timeliness Criteria indicated, . Transmitting Data: Submission files are transmitted to the Quality Improvement and Enhancement System (QIES) Assessment Submission and Processing (ASAP) system using the CMS wide area network. Providers must transmit all sections of the MDS 3.0 . Transmission requirements apply to all MDS 3.0 records used to meet both federal . requirements . Assessment Transmission: . All other MDS assessments must be submitted within 14 days of the MDS Completion Date .

Based on observation, interview, record review, and review of the facility's policy, Facility B failed to develop care plans related to bed rail use for two of four residents reviewed for care planning (Resident (R) 28 and R75) out of 31 sampled residents. This failure placed the resident at risk for unmet care needs and increased risks of accidents. Findings include: Review of the facility's undated policy titled, Care Planning revealed, Our facility's Care Planning/Interdisciplinary Team is responsible for the development of an individualized comprehensive care plan for each resident .2. The care plan is based on the resident's comprehensive assessment . Review of the facility's policy titled, Using Care Plan dated 11/2018 revealed, .The care plan shall be used in developing the resident's daily care routines and will be available to staff personnel who have responsibility for providing care or services to the resident. 1. Review of R28's undated Admitting and Discharge Record provided by the facility revealed the resident was admitted to the facility on [DATE]. During an observation on 05/14/25 at 11:12 AM, R28 was lying in bed with raised bilateral ¾ bed rails on her bed. Review of R28's Care Plan provided by the facility revealed a care plan had not been developed related to the use of bed rails. 2. Review of R75's undated Admitting and Discharge Record, provided by the facility revealed the resident was admitted to the facility on [DATE]. During an observation on 05/14/25 at 10:44 AM, R75 was lying in bed with raised ¾ bilateral bed rails on her bed. During an interview on 05/16/25 at 12:53 PM, Minimum Data Set Coordinator (MDSC) A reviewed R28's and R75's Care Plan and confirmed a care plan related to bed rail use was not developed for either resident. MDSCA stated the residents' care plans should have reflected their use of bed rails. During an interview on 05/16/25 at 1:41 PM, the Director of Nursing (DON) stated it was her expectation residents' care plans were reviewed every day to ensure there were no inconsistencies. The DON also stated if the residents have bed rails on their bed, it should be on their care plan that they use bed rails. During an interview on 05/16/25 at 2:03 PM, the Administrator stated it was her expectation that residents who had bed rails would have had a care plan developed to reflect the bed rail use.

Based on interview, record review, and review of the facility's policy, Facility B failed to review and revise residents' care plans for one of four residents review for care planning (Resident (R) 50). R50's care plan was not revised to reflect his current status. This failure placed the resident at risk for unmet care needs. Findings include: Review of the facility's policy titled, Using Care Plan, dated 11/2018 revealed, The care plan shall be used in developing the resident's daily care routines and will be available to staff personnel who have responsibility for providing care or services to the resident .5. Changes in the resident's condition must be reported to the MDS [Minimum Data Set] Assessment Coordinator so that a review of the resident's care plan can be made . Review of R50's undated Admitting and Discharge Record provided by the facility revealed the resident was readmitted to the facility on [DATE]. Review of R50's Physician Orders provided by the facility revealed on 03/31/25 the resident was ordered Diet: NPO [nothing by mouth] Tube Feeding and on 05/08/25 Tube Feeding Osmolite 1.2 @ [at] 20 ml/hr. [milliliters an hour] advancing by 10 cc [cubic centimeters] every 4 hours to goal of 60 cc/hr . The orders did not include any treatments ordered for wounds or pressure. Ulcers. Review of R50's Care Plan provided by the facility revealed .Need/Preference-I have a skin injury to my left and right buttocks. Stage 2 [pressure] because I don't receive the proper nutrition need .Approach: Reduce pressure and friction between myself and my bed or chair .provide me with wound care per POC [plan of care] .use pressure redistribution devices .low air loss mattress (initiated on 01/03/25) .Need/Preference- I can't complete my cares on my own .Approach: I EAT: supervision or touching assistance (initiated on 05/07/25) . Review of R50's Weekly Skin Assessment dated 05/02/25 and provided by the facility revealed, No open areas and that the pressure ulcer was healed in April 2025. During an interview on 05/15/25 at 10:43 AM, the Infection Preventionist (IP) A reviewed R50's care plan and confirmed the resident did not have any wounds or pressure ulcers. IPA confirmed the resident did not have a low air loss mattress. The IP also stated R50 was NPO and received tube feedings. The IP further stated the resident's care plan should have been revised to reflect the resident's current status of no skin issues, having a pressure reducing mattress and not a low air loss mattress, and not indicating the resident consumed food by mouth. During an interview on 05/16/25 at 1:41 PM, the Director of Nursing (DON)A stated it was her expectation that the resident's care plan would have been gone over every day to ensure there were no inconsistencies and that it was correct for continuation of care. During an interview on 05/16/25 at 2:03 PM, Administrator A stated it was her expectation that R50's care plan would have been revised for any change in status to reflect the resident's current status.

Based on interview, record review, and review of the facility's policy, Facility B failed to ensure residents who were dependent on staff for activities of daily living (ADLs) received showers for one of two residents (Resident (R) 28) reviewed for ADLs out of 31 sampled residents. This failure placed the resident at risk for an undignified quality of life. Findings include: Review of the facility's policy titled, Bath, Shower/Tub dated 06/07/24 revealed, The purpose of this procedure are [sic] to promote cleanliness, provide comfort to the resident and to observe the condition of the resident's skin. General Guidelines .5. Baths are given per bath schedule .Documentation. 1. The date and time the shower/tub baths was performed per bath schedule .5. If the resident refused the shower/tub bath, the reasons(s) . Review of R28's undated Admitting and Discharge Record, provided by the facility revealed the resident was admitted to the facility on [DATE]. Review of R28's quarterly Minimum Data Set (MDS) with an assessment reference date (ARD) of 03/11/25 revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of four out of 15 which indicated the resident was severely cognitively impaired. On 05/14/25, a request to the Social Service Director (SSD) A to assess R28's mental status score. Review of R28's BIMS completed on 05/14/25 by SSDA revealed R28 was assessed to have a score of 14 out of 15 which indicated the resident was cognitively intact. During an interview on 05/13/25 at 11:46 AM, R28 stated she wanted to receive showers instead of bed baths; however, the aides only gave her bed baths. Review of R28's untitled shower/bathing documentation records provided by the facility revealed the resident received bed baths on 03/03/25, 03/05/25, 03/06/25, 03/07/25, 03/11/25, 03/12/25, 03/14/25, 03/17/25, 03/20/25, 03/29/25, 04/04/25, 04/07/25, 04/09/25, 04/12/25, 04/13/25, 04/18/25, 04/21/25, 04/22/25, 04/23/25, 04/27/25, 05/01/25, 05/05/25, and 05/11/25. There was no evidence during these documented dates that the resident refused a shower and requested a bed bath. The shower/bathing documentation from 03/01/25 through 05/11/25 documented the resident received one shower. It was documented on 03/10/25 shower given .Resident fussed the entire shower, wanted to use the shower bed but complained the entire time, both CNA [Certified Nursing Assistant] and Restorative Aides bathe resident but resident still complained of itching and continued to scratch her body (buttocks area) until it bled. During an interview on 05/15/25 at 3:36 PM, CNA2 reviewed the shower documentation and confirmed the resident received baths on the above dates and confirmed no documented evidence of shower refusals for the dates. CNA2 stated during showers, R28 does a lot of screaming. CNA2 stated the resident was scared she was going to fall. CNA2 stated that she gives her a bed bath unless she asks specifically for a shower.CNA2 stated if the resident was to refuse a shower, the CNAs should be documenting the refusal on the shower documentation. During an interview on 05/15/25 at 3:44 PM, CNA3 stated R28 did not like using the mechanical lift for transfers. CNA3 also stated that sometimes R28 screamed and complained during showers; however, after the shower, the resident was always satisfied. CNA3 further stated, depending on R28's mood, it was easier for both the CNAs and the resident for the resident just to receive a bed bath. During an interview on 05/16/25 at 1:41 PM, the Director of Nursing (DON)A stated R28 should have been given or offered a shower if that was her preference; however, if the resident refused the shower, the refusal should have been documented. During an interview on 05/16/25 at 2:03 PM, Administrator A stated if a shower was the resident's preference, then a shower should have been offered. If the resident refused the shower and wanted a bed bath instead, it was her expectation the CNAs would have documented the resident refuse the shower.

Based on interview, record review, and policy review, Facility A failed to ensure one of four residents (Resident (R) 73) reviewed for pressure ulcers out of a sample of 31 residents did not develop facility acquired pressure ulcers. This failure to not identify a pressure ulcer until it was a Stage II had the potential to escalate to a higher level causing the resident pain and discomfort. Findings include: Review of the facility's policy titled, Pressure Ulcer dated 01/17 revealed, The purpose is to standardize a system-wide protocol that identifies those patients at risk for breakdown and to provide guidelines to prevent pressure ulcer occurrence .Maintain and improve tissue tolerance to pressure in order to prevent injury. All individuals at risk should have skin inspected every shift, paying particular attention to bony prominences and areas under medical devices . Review of R73's undated admission Record located in the electronic medical record (EMR) under the Profile tab revealed R73 was admitted to the facility on [DATE] with diagnosis that included encounter for palliative care, stroke, and gastrostomy status. Review of R73's annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 03/27/25 located in the EMR under MDS tab revealed a Brief Interview for Mental Status (BIMS) score of zero out of 15 which indicated severe cognitive impairment. Review of weekly skin assessments provided by the facility dated 02/27/25; 03/06/25; 03/13/25; 03/20/25; 03/27/25; and 04/03/25; all stated that there were no open areas to the skin. Review of Wound care documentation provided by the facility stated the acquired date was 03/04/25 and was described as Pressure injury Stage II to Peg Site. Depth is 0.3 cm [centimeter], and the length x width is 3.5 cm x 1 cm. The area is reddened with light drainage. Pressure ulcer resolved on 04/02/25. Interview on 05/14/25 at 1:38 PM, Licensed Practical Nurse/Wound Care (LPN 1/WC) revealed, A note was left at the nurse's station for me to look at R73 for an open area by the peg tube site. When I looked under the plastic external bumper that is next to the skin and holds the tube in place, there was a Stage II pressure ulcer. This did not happen in one day and there was no gauze or foam under the bumper next to the skin. There was not an order for gauze under the plastic bumper, but there is now. I do not know how this was missed on weekly skin assessments or how it was not noticed during routine care of the peg tube site. During an interview on 05/14/25 at 3:10 PM, the Director of Nursing (DON) revealed, It does not state in the facility policy that gauze needs to be placed under the plastic bumper. It states to keep the skin clean and dry. Although, this is considered standard of care and does not require an order. This pressure ulcer would have happened earlier if a sponge or gauze were not used. I think that whoever cared for the resident last, did not use anything and developed. I cannot tell you what happened or why it was not documented by who found it. This is very upsetting. Gastrostomy care is gone over upon orientation on the skills check list. All nurses know proper care for gastrostomy tubes. Interview on 05/15/25 at 1:55 PM, the Administrator revealed, We need to do skin checks and make sure that things are done properly and according to policy and standards.

Based on observation, interview, and record review, Facility A failed to monitor a resident's bathroom door protector to ensure it did not injure the resident until the door was replaced for one of seven residents reviewed for accidents out of 31 sampled residents (Resident (R) 64). This failure had the potential to cause injury to the resident. Findings include: Review of R64's undated Face Sheet, provided by the facility, revealed she was admitted to the facility on [DATE] with diagnoses that included Type 2 diabetes mellitus with hyperglycemia, and atherosclerotic heart disease of native coronary artery without angina pectoris. Review of R64's quarterly Minimum Data Set (MDS) Assessment, with an assessment reference date (ARD) of 03/14/25, provided by the facility, revealed she had a Brief Interview for Mental Status (BIMS) score of 15 which indicated she was cognitively intact. Review of the facility's Work Order, dated 04/16/25, provided by the facility, revealed The panel on the outside of the bathroom door is coming off in room [ROOM NUMBER]. Patient says she keeps getting [sic] her hand on it when she is going in and out of the bathroom. 04/17/25 [Facilities Management Supervisor] went and placed some duct tape on side of door until [he] can get [vendor] here to measure and get new door ordered. Should be here in the next few days. [Vendor] came and measured so door can be ordered. 05/17/25 [Vendor] called and the door that came in was damaged, had to reorder. Observations on 05/13/25 at 12:48 PM in Facility A on 05/14/25 at 1:45 PM with Administrator B, revealed the top edge of R64's white plastic bathroom door protector was not attached to the door and protruded an inch away from the door below the doorknob. During an interview on 05/13/25 at 12:48 PM, R64 stated she kept hitting the inside of her left hand on the edge of the bathroom door protector that was protruding below the doorknob. R64 also stated she had not been injured yet but was worried she would be, so she reported it to the Unit Secretary about a month ago and it had not been repaired yet. During an interview on 05/14/25 at 1:37 PM, the Facilities Management Supervisor stated he received a work order about R64's bathroom door protector on 04/16/25, he applied duct tape to the door protector on 04/17/25, and the new door arrived but was damaged, so it had to be reordered on 05/12/25. The Facilities Management Supervisor also stated he did not monitor the interim intervention to ensure it was still in place to prevent it from harming the resident's hand and did not know the duct tape was missing until today. During an interview on 05/14/25 at 3:46 PM, the Unit Secretary stated R64 reported that she was hitting her hand on the protruding plastic door cover when she opened the bathroom door and then she completed a maintenance work order for it. The Unit Secretary also stated that the Facilities Management Supervisor told her that he placed duct tape on the door until the new door arrived, but she did not know who or when it was removed from the door. During an interview on 05/15/25 at 5:18 PM, the Administrator stated that the interim intervention of applying the duct tape to the bathroom door protector should have been monitored until the permanent solution, the new door, had arrived to prevent the resident from injury.

Based on observations, staff interviews, record review, and a review of the facility's policy titled, Care planning- IDT, Facility A failed to follow residents' baseline care plans directing staff to medicate residents for pain related to wound care for one of three residents (R#402) who received wound care. Actual harm was identified on 5/10/23 when the Wound Care Nurse (WCN) failed to assess and administer medication to R#402 prior to providing wound care treatment, which resulted in pain. Findings included: The facility's policy titled Care planning- IDT, dated July 2020, indicated, Our facility's Care Planning/Interdisciplinary Team is responsible for the development of an individualized comprehensive care plan for each resident. A review of R#402's Face Sheet revealed the facility admitted R#402 on 5/5/23 with a diagnosis of Alzheimer's Disease, Right Parenchymal Contusion, Panniculitis, Unspecified Dementia, unspecified severity with behavioral disturbances and Pressure ulcer of sacral region, Stage 3. A review of the baseline care plan revealed R#402 has an impairment of skin integrity with a goal to regain skin integrity. Interventions include administering pain medication before treatment as needed (PRN). During a wound care observation on 5/10/23 at 9:05 a.m. the WCN was observed to not assess R#402 for pain prior to beginning the treatment. While WCN was applying the Calcium Alginate and Honey to the sacral wound, resident yelled Ouch that hurt, that hurt, hurt. The resident was observed to have facial grimaces and frowning at this time. R#402 was also observed to attempt to move away from the WCN. WCN continued to apply the dressing and did not assess for pain. When surveyor iterated to WCN that resident was complaining of pain, WCN replied yes, she usually does that when the medicine is applied because I have to get it into the wound bed. I usually continue the treatment because it does not take that long to do. I will medicate her after the dressing is complete. After the treatment was completed, WCN did not assess resident for pain. During the interview post treatment, WCN stated that the resident probably should have been medicated prior to the treatment but confirmed that she did not do it. WCN walked away, passed the medication nurse on the hall, and did not ask for medication for R#402. During an interview on 5/10/23 at 9:43 a.m. with Licensed Practical Nurse (LPN) CC it was revealed that R#402 does have PRN pain medication and the WCN did not ask her to medicate R#402 prior to doing the treatment. During an interview on 5/11/23 at 9:32 a.m. with MDS/Care Plan Coordinator revealed that she is responsible for the baseline and comprehensive care plan. She stated that each resident's plan of care is located in the electronic record and the licensed staff has access to the care plans. She further stated that residents are discussed with the team prior to admission and after admission to the facility in their daily Huddle Meeting. She further stated that the wound nurse does not always attend the Huddle Meetings, but she receives the orders on admission. She also stated that the wound nurse is responsible for the initial skin assessment and the weekly wound documentation. Cross refer F697

Based on observation, record review, interview, and review of facility policy Pain Assessment and Management, Facility A failed to stop and address verbal and facial expressions of pain during wound care for one of three residents (R) (R#402) observed for wound care resulting in harm. Actual harm was identified on 5/10/23 when the Wound Care Nurse (WCN) failed to assess and administer pain medication to R#402 prior to providing wound care treatment, which resulted in pain during the treatment. Findings include: A review of the Policy titled Pain Assessment and Management ,dated July 2020, revealed the pain management program is based on a facility-wide commitment to appropriate assessment and treatment of pain based on professional standards of practice, the comprehensive care plan, and the resident's choices related to pain management. 2. Pain management is defined as the process of alleviating the resident's pain based on his or her clinical condition and established treatment goals. Recognizing Pain: 1. Observe the resident (during rest and movement) for physiologic and behavioral (non-verbal) signs of pain. 2. Possible Behavioral Signs of Pain, including: a. verbal expressions such as groaning, crying screaming, b. facial expressions such as grimacing, groaning, clenching of the jaw, etc., f. guarding, rubbing, or favoring a particular part of the body. 4. Ask the resident if he/she is experiencing pain. A review of the clinical record revealed R#402 was admitted to the facility on [DATE] with diagnoses, including but not limited to, Alzheimer's Disease, right parenchymal contusion, panniculitis, unspecified dementia, unspecified severity with behavioral disturbances, pressure ulcer of sacral region stage 3, wedge compression fracture fifth lumbar vertebra suds for fracture with routine heal, and wedge compression fracture T11-T12 vertebra suds for fracture with routine heal. A review of the baseline care plan revealed R#402 has an impairment of skin integrity with a goal to regain skin integrity. Interventions include administering pain medication before treatment as needed (PRN). A review of the physician orders for May 2023 revealed R#402 had current orders for Fentanyl 50 microgram per hour (mcg/Hr) Patch 72 Hour Transdermal one topical every three days for chronic pain, order date 5/5/23; Tramadol HCL 50 milligram (mg) one tab by mouth every six hours as needed for pain, order date 5/5/23; Acetaminophen 325 mg two tabs (650 mg) by mouth every six hours as needed for pain. During an observation on 5/10/23 at 9:05 a.m., the WCN was observed providing wound care for R#402. The WCN did not assess for pain prior to beginning the treatment. While the WCN was applying Calcium Alginate and Honey to the sacral wound, R#402 yelled Ouch that hurt, that hurt, hurt. Resident was observed to have facial grimaces and frowning at this time. R#402 was also observed to attempt to move away from the WCN. WCN continued to apply the dressing and did not assess for pain. When surveyor iterated to WCN that resident was complaining of pain, WCN replied yes, she usually does that when the medicine is applied because I have to get it into the wound bed. I usually continue the treatment because it does not take that long to do. I will medicate her after the dressing is complete. After the treatment was completed, WCN did not assess resident for pain. During the interview post treatment, WCN informed surveyor that resident probably should have been medicated prior to the treatment but she did not do it. WCN walked away, passed the medication nurse on the hall, and did not ask for pain medication for R#402. During an interview on 5/10/23 at 9:43 a.m. with Licensed Practical Nurse (LPN) CC revealed that resident does have PRN pain medication and the WCN did not ask her to medicate R#402 prior to doing the treatment. LPC CC stated she would assess resident for pain and medicate her if it is indicated. Record review revealed resident was medicated for pain and anxiety with the PRN Hydroxyzine Pamoate 25 milligram (mg) and Tramadol 50 mg on 5/10/23 at 9:48 a.m.by LPN CC due to resident complaining of pain. The pain was reassessed at 11:02 a.m. with pain symptoms reduced. The pain level after medication was: six. Actions: Continue to observe. Encourage to rest. Repositioned. 11:05 a.m. Note: Resident states pain level six, 30 minutes after medication. Repositioned with wedge. Will continue to monitor. Pain: Complaining of pain. Intensity of pain: mild. Verbal pain assessment: acceptable level of pain, Frequency of pain: Pain daily, Location of pain: sacrum, back. Quality of pain: Dull, Origin of pain: secondary to medical condition, Manner of expressing pain: Verbal, Alleviating Factors: Position changes, Exacerbating Factors: Prolonged sitting. Non-pharmacological interventions prior to giving pain mediation - repositioned. 11:41 a.m. PRN Med Given - Acetaminophen 325 mg two tabs. 11:44 a.m. Note: Resident was gotten up for therapy and stated to the therapist that she was in pain sitting in the wheelchair. Resident was put back in the bed with a wedge to relieve the pressure on her sacral wound. During an interview on 5/10/23 at 9:43 a.m. with the Director of Nursing (DON) she revealed it is her expectation when a resident complains of pain during wound care that the nurse stop treatment and assess the resident's pain. She stated the residents nurse should be consulted to determine if the resident has anything for pain and if so, the resident should be given the medication and treatment should resume after the medication has had time to be effective. During an interview on 5/10/23 at 10:23 a.m. with the Administrator, it was revealed that it is her expectation that residents are assessed for pain prior to treatment being rendered. The Administrator further stated that if the WCN knew the resident complained of pain during the treatment, the resident should have been premedicated. During a follow-up interview on 5/10/23 at 12:40 p.m. with the WCN, she revealed that she understood how to do wound care. She stated she did ask the resident about pain prior to the surveyor coming into the room. The WCN stated that she was aware that R#402 had PRN pain medications and she should have stopped treatment when she began complaining of pain and asked the nurse to medicate her before continuing the treatment.

Based on record review, and Responsible Party and Physician interviews Facility #2 failed to notify the attending Physician and Responsible Party of newly developed pressure ulcer for one of 12 residents (R#1) reviewed for pressure ulcers. On (MONTH) 17, 2019 a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had caused or had the likelihood to cause serious injury, harm, impairment or death to residents. The facility's Administrator and Director of Nursing for both Facility #1 and Facility #2, and the System Administrator were informed of the Immediate Jeopardy on (MONTH) 17, 2019 at 2:51 p.m. The noncompliance related to the Immediate Jeopardy was identified to have existed on (MONTH) 1, 2019. The Immediate Jeopardy is outlined as follows: During the complaint investigation it was identified that R#1, which resided in Facility #2, was identified as having an open area to her sacrum on (MONTH) 1, 2019; however, treatment was not provided for this wound until (MONTH) 10, 2019. The Physician was not notified of the wound until (MONTH) 24, 2019. The Physician ordered for R#1 to have a wound consultation on (MONTH) 27, 2019. R#1 was seen at the Wound Clinic on (MONTH) 12, 2019, at which time it was observed that the wound was infected, and the resident's wound treatment was changed to Dakin's solution. On (MONTH) 15, 2019, R#1 was sent to the hospital and was admitted to the hospital. The resident's primary admitting [DIAGNOSES REDACTED]. R#1 had to have a central line placed to receive antibiotic treatment. In addition, on (MONTH) 17, 2019, R#1 had to undergo surgical debridement of the Stage IV pressure ulcer on her sacrum and the resident had to have surgery to have a diverting loop [MEDICAL CONDITION]. The Immediate Jeopardy was related to the facility's noncompliance with the program requirements at 42 C.F.R. F580 -- S/S: J -- 483.10(g)(14)(i)-(iv)(15) -- Notify Of Changes (injury/decline/room, Etc.); F657 -- S/S: J -- 483.21(b)(2)(i)-(iii) -- Care Plan Timing And Revision; F658 -- S/S: J -- 483.21(b)(3)(i) -- Services Provided Meet Professional Standards; F686 -- S/S: J -- 483.25(b)(1)(i)(ii) -- Treatment/svcs To Prevent/heal Pressure Ulcer; F867 -- S/S: J -- 483.75(g)(2)(ii) -- Qapi/qaa Improvement Activities Additionally, Substandard Quality of Care was identified with the requirements at F686 -- S/S: J -- 483.25(b)(1)(i)(ii) -- Treatment/svcs To Prevent/heal Pressure Ulcers. At the time of exit on (MONTH) 20, 2019, an acceptable Immediate Jeopardy Removal Plan had not been accepted therefore the Immediate Jeopardy remains ongoing. Findings include: Record review revealed that Resident #1(R#1) was readmitted to Facility #2 on 2/26/18 with [DIAGNOSES REDACTED]. The resident's brother is the Resident's Responsible Party. Review of the Body Check documentation, which was completed by the Certified Nurse Aide's (CNA's) from 5/1/19 through 6/15/19 revealed that on 6/1/19 an entry documented that R#1 had abnormal body check for the sacrum area. The CNA documented that this finding was reported to a License Practical Nurse (LPN). On 6/19/19 a photo of the sacral wound was obtained. The narrative describes the wound tissue type/color as slough and pink. The measurement was 3.5 centimeters (cm) x 1.2 cm and depth unknown. Review of the Nurses' Notes from 6/1/19 through 6/30/19 revealed an entry on 6/24/19 noted that the Physician and family will be notified. An entry dated 6/25/19 documented family was not contacted but a message was left for a non-family member which further investigation revealed was an assisted living facility where R#1 previously resided. Review of the inpatient hospital records dated 7/16/19 revealed a family member was contacted for consent for the diverting [MEDICAL CONDITION] surgery. This was the only documentation that indicated a family member was notified of R#1 sacral wounds. During an interview on 9/10/19 at 2:27 p.m. with Physician HH (R#1's Attending Physician and Medical Director) revealed that any staff concerns about the residents, the staff are s to notify him. Physician HH stated that at one time he received monthly wound reports; however, now he receives sporadic wound reports from the facility. Physician HH revealed that the first time he became aware of the pressure ulcer on R#1's sacrum, was on 6/24/19 when he received a fax. During an interview on 9/26/19 at 5:46 p.m. with the Responsible Party for R#1 revealed that he received a call from the hospital on [DATE] requesting consent for R#1 to have surgery and he was told about R#1's sacral wound at that time. The Family Member confirmed that he had no prior knowledge that R#1 had a pressure ulcer to her sacrum.

Based on observation, record review, and staff interviews, Facility #2 failed to revise and individualize care plans to reflect the current stage of actual pressure ulcers and the facility failed to evaluate care planned interventions to ensure interventions were effective for six of 12 residents (R#1, R#2, R#4, R#5, R#6, R#10) reviewed for pressure ulcers. On (MONTH) 17, 2019 a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had caused or had the likelihood to cause serious injury, harm, impairment or death to residents. The facility's Administrator and Director of Nursing for both Facility #1 and Facility #2, and the System Administrator were informed of the Immediate Jeopardy on (MONTH) 17, 2019 at 2:51 p.m. The noncompliance related to the Immediate Jeopardy was identified to have existed on (MONTH) 1, 2019. The Immediate Jeopardy is outlined as follows: During the complaint investigation it was identified that R#1, which resided in Facility #2, was identified as having an open area to her sacrum on (MONTH) 1, 2019; however, treatment was not provided for this wound until (MONTH) 10, 2019. The Physician was not notified of the wound until (MONTH) 24, 2019. The Physician ordered for R#1 to have a wound consultation on (MONTH) 27, 2019. R#1 was seen at the Wound Clinic on (MONTH) 12, 2019, at which time it was observed that the wound was infected, and the resident's wound treatment was changed to Dakin's solution. On (MONTH) 15, 2019, R#1 was sent to the hospital and was admitted to the hospital. The resident's primary admitting [DIAGNOSES REDACTED]. R#1 had to have a central line placed to receive antibiotic treatment. In addition, on (MONTH) 17, 2019, R#1 had to undergo surgical debridement of the Stage IV pressure ulcer on her sacrum and the resident had to have surgery to have a diverting loop [MEDICAL CONDITION]. The Immediate Jeopardy was related to the facility's noncompliance with the program requirements at 42 C.F.R. F580 -- S/S: J -- 483.10(g)(14)(i)-(iv)(15) -- Notify Of Changes (injury/decline/room, Etc.); F657 -- S/S: J -- 483.21(b)(2)(i)-(iii) -- Care Plan Timing And Revision; F658 -- S/S: J -- 483.21(b)(3)(i) -- Services Provided Meet Professional Standards; F686 -- S/S: J -- 483.25(b)(1)(i)(ii) -- Treatment/svcs To Prevent/heal Pressure Ulcer; F867 -- S/S: J -- 483.75(g)(2)(ii) -- Qapi/qaa Improvement Activities Additionally, Substandard Quality of Care was identified with the requirements at F686 -- S/S: J -- 483.25(b)(1)(i)(ii) -- Treatment/svcs To Prevent/heal Pressure Ulcers. At the time of exit on (MONTH) 20, 2019, an acceptable Immediate Jeopardy Removal Plan had not been accepted therefore the Immediate Jeopardy remains ongoing. Findings include: 1. Record review revealed R#1 had the following [DIAGNOSES REDACTED]. The skin care plan dated 8/16/19 revealed that R#1 had potential for impairment of skin integrity related to environmental factors, internal factors and disease process. A pressure ulcer is present on the sacrum. The Approach listed administer pain medication before treatment as need; assess skin daily and note any changes; treat as ordered; monitor medication effect; monitor use of skin protective device; develop and monitor turning schedule; monitor vital signs as needed; keep clean and dry; measure area; change dressing; instruct on the importance of good skin care; monitor diet intake and ensure adequate hydration; treatment as ordered. There is no evidence of any documentation that the resident's actual Stage IV pressure ulcer had been addressed. Further review revealed that the care plan interventions were not specific for R#1 and there was not any evidence of documentation that the care plan interventions were evaluated for effectiveness. 2. Record review revealed that Resident #2 had the following [DIAGNOSES REDACTED]. Record review revealed that even though wound documentation dated 8/27/18 documented that R#2 had a Stage II and on 9/25/18 and documented that this pressure ulcer had progressed to a Stage III pressure ulcer. Review of the skin impairment integrity care plan dated 4/23/19 does not reflect the actual Stage III pressure ulcer. The interventions listed were treat as ordered; monitor use of skin protective devices; bandage as appropriate; keep clean and dry; change dressing; and instruct on the importance of good skin care. turn every two hours. Further review revealed that the care plan interventions were not specific for R#2 and there was not any evidence of documentation that the care plan interventions were evaluated for their effectiveness. 3. Record review revealed that R#4 had the following [DIAGNOSES REDACTED]. During an observation on 9/6/19 at 8:45 a.m., Observed that R#4 has a left AKA surgical amputation that has an opening on edge of the inner portion along the surgical scar. A sequential observation on 9/10/19 at 11:25 a.m. observed with Licensued (LPN) FF treatment nurse that R#4 had three small open areas (three small Stage II presure ulcers) to the sacrum. Review of the care plan dated 8/30/19 revealed impaired skin related to environmental factors and internal factors. R#4 has a surgical stump wound and pressure ulcer present on his sacrum without mention of the three small openings on R#4's sacrum. The Approach noted is administer pain medication before treatment; treat as ordered; monitor medication effect; monitor use of skin protective devices; bandage as appropriate; develop and monitor turning schedule; keep clean and dry; measure area and change dressings. Further review revealed that the care plan interventions were not specific for R#4 and there was not any evidence of documentation that the care plan interventions were evaluated for effectiveness or that the care plan had been revised to relect the three Stage II pressure ulcers on the residents sacrum. During an interview on 9/10/19 at 12:26 p.m. with LPN NN Minimum Data Set (MDS) Coordinator regarding R#4's pressure ulcer not being stage on the care plan was because it was an oversight. 4. Record review revealed R#5 was admitted to the facility with [DIAGNOSES REDACTED]. Review of the Pressure Wound report revealed that R#5 developed a Stage IV pressure ulcer on 10/10/18 review of the care plan for R#5 dated 9/5/19 revealed R#5 has impairment related to environmental factors and internal factors. A pressure ulcer to the sacrum was listed. The Approach noted are treat as ordered; monitor use of skin protective devices; bandages as appropriated; keep clean and dry; change dressing; instruct on the importance of good skin care. Further review revealed that the care plan revealed that the interventions were not specific for R#5 and there was not any evidence of documentation that the care plan interventions were evaluated for their effectiveness and the care plan was not revised to reflect the pressure ulcer stage and measurements. During an interview on 9/10/19 at 12:26 p.m. LPN NN MDS Coordinator revealed that the stage of R#5's pressure ulcer was not listed on the care plan because it was an oversight. 5. Record review revealed R#6 had [DIAGNOSES REDACTED]. During an observation on 9/6/19 at 9:29 a.m. LPN FF Treatment Nurse and Registered Nurse (RN TT) it was observed that R#6's left fourth toe had black eschar on the bottom. Record review that there was not any evidence of documentation that this pressure ulcer had previously been addressed). There was brownish-black eschar to the outer left heel, surrounded by a pinkish skin tone. LPN FF Treatment Nurse obtained wound measurement which were: Length (L) 8.5 centimeters (cm) x Width (W) 3.5 cm x Depth (D) unknown. LPN FF Treatment Nurse stated that the wound on the resident's heel had resolved; however, it had reopened. Review of the skin integrity care plan dated 8/23/19 A pressure ulcer is present left heel. The care plan Approach listed treat as ordered; monitor use of skin protective devices; bandages as appropriate; keep clean and dry, change dressing. Instruct on the importance of good skin care. Further review revealed that the care plan interventions were not specific for R#6 and there was not any evidence of documentation that the care plan interventions were evaluated for their effectiveness and that the care plan was not revised to reflect the re-opened pressure ulcer on the residents heal or the stage of the pressure ulcer on the resident's toe. During an interview on 9/10/19 at 12:26 p.m. LPN NN MDS Coordinator revealed that the stage of R#6's pressure ulcers were not staged on the care plan because that was an oversight. 6. Record review revealed that R#10 was admitted to the facility with [DIAGNOSES REDACTED]. During a wound care observation on 9/18/19 at 12:22 p.m. with LPN FF Treatment Nurse revealed that R#10 had a stage IV sacral wound. The measurements were L 2.0 cm x 1.6 cm x 2.2 cm. Review of the care plan dated 8/19/19 revealed R#10 has impairment of skin related to environment factors and internal factors. A pressure ulcer is listed as present on the sacrum. The Approach (Interventions) were noted to treat as ordered; monitor use of skin protective devices; bandage as appropriate; keep clean and dry; change dressing; and instruct on the importance of good skin care. Further review revealed that the care plan interventions were not specific for R#10 and there was not any evidence of documentation that the care plan interventions were evaluated for their effectiveness and the care plan was not revised to reflect the Stage IV pressure ulcer on the residents sacrum. During an interview on 9/10/19 at 12:26 p.m. with LPN NN MDS Coordinator revealed that care plans are done on admission, are updated within 14 days, quarterly and as needed and that the stage of R#10's pressure ulcer was not listed on the care plan because it was an oversight. Further interview with LPN NN MDS Coordinator revealed that the interventions for each of the resident's care plans are generic interventions.

Based on observations, staff interviews, record review, and review of the Georgia Nurse Practice Act, Facility #2 failed to ensure that accepted standards of clinical practice were followed to ensure that a newly recognized pressure ulcer received follow up care and ensure that treatment was provided timely for one of 12 (R#1) residents reviewed for pressure ulcers. On (MONTH) 17, 2019 a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had caused or had the likelihood to cause serious injury, harm, impairment or death to residents. The facility's Administrator and Director of Nursing for both Facility #1 and Facility #2, and the System Administrator were informed of the Immediate Jeopardy on (MONTH) 17, 2019 at 2:51 p.m. The noncompliance related to the Immediate Jeopardy was identified to have existed on (MONTH) 1, 2019. The Immediate Jeopardy is outlined as follows: During the complaint investigation it was identified that R#1, which resided in Facility #2, was identified as having an open area to her sacrum on (MONTH) 1, 2019; however, treatment was not provided for this wound until (MONTH) 10, 2019. The Physician was not notified of the wound until (MONTH) 24, 2019. The Physician ordered for R#1 to have a wound consultation on (MONTH) 27, 2019. R#1 was seen at the Wound Clinic on (MONTH) 12, 2019, at which time it was observed that the wound was infected, and the resident's wound treatment was changed to Dakin's solution. On (MONTH) 15, 2019, R#1 was sent to the hospital and was admitted to the hospital. The resident's primary admitting [DIAGNOSES REDACTED]. R#1 had to have a central line placed to receive antibiotic treatment. In addition, on (MONTH) 17, 2019, R#1 had to undergo surgical debridement of the Stage IV pressure ulcer on her sacrum and the resident had to have surgery to have a diverting loop [MEDICAL CONDITION]. The Immediate Jeopardy was related to the facility's noncompliance with the program requirements at 42 C.F.R. F580 -- S/S: J -- 483.10(g)(14)(i)-(iv)(15) -- Notify Of Changes (injury/decline/room, Etc.); F657 -- S/S: J -- 483.21(b)(2)(i)-(iii) -- Care Plan Timing And Revision; F658 -- S/S: J -- 483.21(b)(3)(i) -- Services Provided Meet Professional Standards; F686 -- S/S: J -- 483.25(b)(1)(i)(ii) -- Treatment/svcs To Prevent/heal Pressure Ulcer; F867 -- S/S: J -- 483.75(g)(2)(ii) -- Qapi/qaa Improvement Activities Additionally, Substandard Quality of Care was identified with the requirements at F686 -- S/S: J -- 483.25(b)(1)(i)(ii) -- Treatment/svcs To Prevent/heal Pressure Ulcers. At the time of exit on (MONTH) 20, 2019, an acceptable Immediate Jeopardy Removal Plan had not been accepted therefore the Immediate Jeopardy remains ongoing. Findings include: Review of the Rules and Regulations of the State of Georgia, Rule 410-10-.01 Standards of Practice for Registered Professional Nurse addressed Rule 410-10-.01 (1) The Georgia Board of Nursing defines the minimal standards of acceptable and prevailing nursing practice as including, but not limited to the following enumerated standards of competent practice. (2) The Board recognizes that assessment, nursing diagnosis, planning, intervention, evaluation, teaching, and supervision are the major responsibilities of the registered nurse in the practice of nursing. The Standards of Practice for Registered Professional Nurses delineate the quality of nursing care which a patient/client should receive regardless of whether it is provided solely by a registered nurse in collaboration with other licensed or unlicensed personnel. The Standards are based on the premise that the registered nurse is responsible for and accountable to the patient/client for the quality of nursing care rendered. The Standards of Practice for Registered Professional Nurses shall establish a baseline for quality nursing care; be derived from the Georgia Nurse Practice Act; apply to the registered nurse [MEDICATION NAME] in any setting; and, govern the practice of the licensee at all levels of competency. (a) Standards related to the registered nurse's responsibility to apply the nursing process (adapted from American Nurses Association Code for Nurses and Standards of Practice). The registered nurse shall: 1. Assess the patient/client in a systematic, organized manner; 2. Formulate a nursing [DIAGNOSES REDACTED]. systematic and continuous manner); 3. Plan care which includes goals and prioritized nursing approaches, or measures derived from the nursing diagnoses; 4. Implement strategies to provide for patient/client participation in health promotion, maintenance and restoration; 5. Initiate nursing actions to assist the patient/client to maximize her/his health capabilities; 6. Evaluate with the patient/client the status of goal achievement as a basis for reassessment, reordering of priorities, new goal-setting and revision of the plan of nursing care; 7. Seek educational resources and create learning experiences to enhance and maintain current knowledge and skills appropriate to her/his area of practice. (b) Standards related to the registered nurse's responsibilities as a member of the nursing profession. The registered nurse shall: 3. Communicate, collaborate and function with other members of the health team to provide optimum care. 410-10-.03 Definition of Unprofessional Conduct (1) Nursing conduct failing to meet standards of acceptable and prevailing nursing practice, which could jeopardize the health, safety, and welfare of the public, shall constitute unprofessional conduct. This conduct shall include, but not be limited to, the following: (2) Practice (a) Using inappropriate or unsafe judgement, technical skill, or interpersonal behaviors in providing nursing care; (3) Documentation (a) Failing to maintain a patient record that accurately reflects the nursing assessment, care, treatment, and other nursing services provided to the patient. Review of the undated Standards of Performance Clinical Coordinator - PPNH (Pelham Parkway Nursing Home - effective for Facility #1 and Faciltiy #2) documents that this position requires the following: skill the ability to establish and maintain effective working relation and administrative and medical personnel, employees, the public and other agencies. Must be able to multi-task and meet deadlines and be organized and dependable to monitor and follow through on due dates. Must be highly accountable. Review of the undated Standards of Performance Registered Nurse (PPNH) effective for Facility #1 and Facility #2 revealed the position require the following: skill must possess leadership and supervisory skills and be able to plan, organize, develop, implement and interpret the programs, goals, objectives, policies and procedures that are necessary to providing high quality care. Long Term Care Nurse Core Demonstrate effective clinical skills and utilize the nursing process in planning or providing care for residents of all ages. Review of the 7-3 Assignment Sheet, for Facility #2, dated 6/1/19 through 6/2/19 revealed that Registed Nurse (RN) PP was listed as the RN weekend supervisor and the on call nurse). Review of the Body Check documentation which is completed by the Certified Nurse Aide (CNA) staff dated 5/1/19 through 6/15/19 revealed that on 6/1/19 an entry was documented that R#1 had an abnormal body check for her sacrum. The CNA documented that this finding was reported to a License Practical Nurse (LPN). Further investigation revealed that, due to staff shortage for that shift, that RN PP worked this date as a CNA and performed CNA duties. During an interview on 9/16/19 at 9:36 a.m. with Registered Nurse (RN) PP revealed that on 6/1/19 she worked as a Certified Nursing Assistant (CNA) that day and that she was providing care for R#1, when she saw what looked like an intertriginous lesion, located in the crack of the resident buttocks midway up from the resident's rectum. RN PP described the area as missing skin and looked raw. RN PP stated that she reported this open area to LPN QQ. RN PP stated that normally, she would have informed the treatment nurse but that she could not recall for sure if she had informed the treatment nurse of the skin impairment but that she did tell Licensued Practical Nurse (LPN QQ). Continued interview with RN PP revealed that RN PP emphasized that she worked as a CNA that day, and that it was not her job that day to address the wound, but it was the responsibility of the nurse assigned to the resident to ensure that the opened area was followed up on. A subsequent interview on 9/19/19 at 3:04 p.m. with RN PP revealed that, in addition to working as a CNA, she was the RN supervisor for that weekend, and it was not her job to address the wound, because she had reported the findings to LPN QQ. A subsequent interview on 9/20/19 at 10:05 a.m. with RN PP revealed that the nurse on the hall, should have looked at the wound on R#1's sacrum, taken a picture of the wound, called the family and the doctor. RN PP stated that the Charge Nurse should have followed-up and made sure that this was done. RN PP stated again that she had worked as a CNA and that she reported the wound to the Charge Nurse assigned to that hall. During an interview on 9/20/19 at 10:07 a.m. with the Director of Nursing (DON) revealed that what should have happened, was once the wound was found, a photo should have been taken, the Physician and Family should have been informed, the wound protocol order or physician order [REDACTED].

Based on observation, staff interviews, review of the facility policies titled, No. 86 Subject: Pressure Ulcer Prevention and Treatment Program, NH 151 form 10/10 Nursing Home - Pressure Ulcer Prevention (BRADEN SCORE 18) and/or Wound Treatment Order - For Admission or Status Changes, and the facility policy titled, Integumentary Skin Photographic Documentation, POLICY NO. 1.0 titled, Infection Control Subject: Hand Hygiene, and review of the POLICY NUMBER; 10:01 titled, Subject: Infection Prevention and Control Program, Facility #2 failed to conduct head to toe skin assessments weekly as ordered by the Physician; failed to perform skin checks to identify breakdown timely; and failed to consistently assess the status of the developing sacral pressure ulcer until it was a Stage IV pressure ulcer which required two surgical debridements, a wound VAC (negative pressure wound treatment) and a [MEDICAL CONDITION] for one of 12 (R#1) residents reviewed for pressure ulcers. Facility#2 also failed to perform weekly assessments and failed to document weekly wound descriptions for three of 12 (R#2, R#3, R#4) residents reviewed for pressure ulcers. In addition, Facility #2 failed to ensure that one staff member implemented standard precautions when providing wound care for five of five (R#2, R#3, R#4, R#5, R#6) residents observed for wound care as evidenced by staff failing to wash and/or sanitize hands, and failing to clean scissors before and after use, failing to clean wounds using a clean technique by going from dirty area to clean area while providing wound care. Facility #1 failed to document weekly wound descriptions for two of 12 residents (R#11, R#12) reviewed for pressure ulcers. On (MONTH) 17, 2019 a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had caused or had the likelihood to cause serious injury, harm, impairment or death to residents. The facility's Administrator and Director of Nursing for both Facility #1 and Facility #2, and the System Administrator were informed of the Immediate Jeopardy on (MONTH) 17, 2019 at 2:51 p.m. The noncompliance related to the Immediate Jeopardy was identified to have existed on (MONTH) 1, 2019. The Immediate Jeopardy is outlined as follows: During the complaint investigation it was identified that R#1, which resided in Facility #2, was identified as having an open area to her sacrum on (MONTH) 1, 2019; however, treatment was not provided for this wound until (MONTH) 10, 2019. The Physician was not notified of the wound until (MONTH) 24, 2019. The Physician ordered for R#1 to have a wound consultation on (MONTH) 27, 2019. R#1 was seen at the Wound Clinic on (MONTH) 12, 2019, at which time it was observed that the wound was infected, and the resident's wound treatment was changed to Dakin's solution. On (MONTH) 15, 2019, R#1 was sent to the hospital and was admitted to the hospital. The resident's primary admitting [DIAGNOSES REDACTED]. R#1 had to have a central line placed to receive antibiotic treatment. In addition, on (MONTH) 17, 2019, R#1 had to undergo surgical debridement of the Stage IV pressure ulcer on her sacrum and the resident had to have surgery to have a diverting loop [MEDICAL CONDITION]. The Immediate Jeopardy was related to the facility's noncompliance with the program requirements at 42 C.F.R. F580 -- S/S: J -- 483.10(g)(14)(i)-(iv)(15) -- Notify Of Changes (injury/decline/room, Etc.); F657 -- S/S: J -- 483.21(b)(2)(i)-(iii) -- Care Plan Timing And Revision; F658 -- S/S: J -- 483.21(b)(3)(i) -- Services Provided Meet Professional Standards; F686 -- S/S: J -- 483.25(b)(1)(i)(ii) -- Treatment/svcs To Prevent/heal Pressure Ulcer; F867 -- S/S: J -- 483.75(g)(2)(ii) -- Qapi/qaa Improvement Activities Additionally, Substandard Quality of Care was identified with the requirements at F686 -- S/S: J -- 483.25(b)(1)(i)(ii) -- Treatment/svcs To Prevent/heal Pressure Ulcers. At the time of exit on (MONTH) 20, 2019, an acceptable Immediate Jeopardy Removal Plan had not been accepted therefore the Immediate Jeopardy remains ongoing. Findings include: Review of a Policy No. 86 Subject: Pressure Ulcer Prevention and Treatment Program dated (MONTH) 1996 used by Facility #1 and Facility#2, in pertinent part documents: I. Purpose to standardize a system-wide protocol that identifies those patients at risk for breakdown and to provide guidelines to prevent pressure ulcer occurrence. III. Prevention [NAME] Procedure 1 documents that patients will be assessed according to each care setting for the risk of breakdown by using the Braden scale. These patients with a score less than or equal to 18 will be placed on the Pressure Ulcer Prevention Order (Pressure Ulcer Prevention Orders NS 660) Procedure 2. Maintain and improve tissue tolerance to pressure in order to prevent injury. a. All individual at risk should have a skin inspected every shift, paying particular attention to the bony prominences and areas under medical devices. Bariatric patients should have skin assessed between skin folds. IV. Treatment: 1. Consult the Wound Clinic for a Stage II or greater pressure ulcer. Review of an undated Nursing Home - Pressure Ulcer Prevention (BRADEN SCORE 18) and/or Wound Treatment Order - For Admission or Status Changes documents used for Facility #1 and Facility #2, in pertinent part: 1. Inspect skin for reddened areas and skin breakdown every shift and document changes. If wounds present continue with #17 - #20 18. Photograph wounds every seven days and per policy, mount in binder, document per protocol. 19. Measure wound every week, with change in status, and/or any readmission to facility. Review of the Adult Pressure Ulcer Prevention Orders documents the following, in pertinent part: 1. Assess skin on admission and each shift, 2. Minimize skin exposure to moisture due to incontinence and / or perspiration. 11. Turn and tilt patient every two hours while in bed, wheelchair, or chair bound patients should change position every hour. 15. Photograph wound every seven days and per policy. 17. For complex wound consult Wound Management to evaluate and manage patient's wounds. 1. Resident #1 was readmitted to Facility #2 on 2/26/18 with [DIAGNOSES REDACTED]. Review of the Annual Minimum Data Set ((MDS) dated [DATE] revealed the following: R#1 had a Brief Interview for Mental Status (BIMS) score of 14 indicating that she was cognitively intact, she required extensive assistance for bed mobility, was totally dependent on staff for transfers, G0400 documents that the resident did not have any functional limitation of her upper extremities but that she had limitation with one side of her lower extremities, in section M0150 the resident was assessed to be at risk for developing pressure ulcers. Review of the Quarterly MDS dated [DATE] documented that R#1 had a BIMs score of 14 indicating that she was cognitively intact, required extensive assistance for bed mobility, totally dependent on staff for transfers, G0400 documented that the resident had functional limitation of bilateral upper and lower extremities. Record review revealed a Physician order [REDACTED].#1 to receive weekly head to toe assessments on Saturday mornings and a Physician order [REDACTED]. Review of a Braden scale (a tool used to assess a resident's risk of developing a pressure ulcer) dated 5/8/19 documented a score of 15 (a score less than 16 is considered to be at risk for pressure ulcers). Review of the Body Checks (which is documentation that the Certified Nursing Assistants (CNA's) complete when they provide incontinent care and/or baths) 5/1/19 through 6/15/19 revealed that on 6/1/19 an entry was documented that R#1 had an abnormal body check for her sacrum area. The CNA documented that this finding was reported to License Practical Nurse (LPN) QQ. Further record review revealed that there was not any evidence of any documentation that LPN QQ followed up on the open area on R#1's sacrum. Further review revealed that the CNA who documented the open area to R#1's sacral area was actually a Registered Nurse (RN) that was working as a CNA and was also working, on that date, as the RN Weekend Supervisor. Review of the Treatment Administration Record (TAR) from 5/1/19 through 9/4/19 revealed that the first treatment orders written to provide wound care to the opened area on R#1's sacrum was dated 6/10/19 and documented: Remove dressing from sacral, clean with sal jet, pat dry. Apply Allevyn three times a week. Monday, Wednesday and Friday morning and as needed. This treatment was continued from 6/10/19 until 6/28/19 by the Treatment Nurse. The first wound description of the opened area on R#1's sacrum was not documented until 18 days later on 6/19/19 when a photo of the sacral wound was obtained and documented the following: Location: Sacrum-Lower Spine, Wound Tissue Type/Color: Slough pink, Surrounding Tissue: normal, Healing Progress: Worse. The area of the wound was documented to be: Length: 3.5 centimeters (cm) x width 1.2 cm, with the depth documented as being: Unknown. Review of the weekly Pressure Wounds report (a report used to document pressure ulcers in the facility) for the following dates: 6/9/19 through 6/15/19, and 6/16/19 through 6/22/19 revealed that R1#'s sacral wound was not documented on the Pressure Wound report. On the report dated 6/23/19 through 6/29/19 documented, in error, that the wound to R#1's sacrum was a facility acquired pressure ulcer that developed on 6/14/19 that had worsened and was unstageable. Documentation on the 6/1/19 Body Check documented an open area on 6/1/19. Review of a Resident Care Fax dated 6/24/19 revealed that LPN FF Treatment Nurse faxed Physician HH regarding R#1's sacral pressure ulcer. The fax documented the following: Resident had an intertriginous lesion ([MEDICAL CONDITION] condition of skin folds) on her sacral that has become worse and is now an unstageable wound secondary to slough in wound. I am going to consult PT (Physical Therapy) for possible debridement of slough. If you would like something different please let me know. I will also send picture to wound care for their guidance (sic). Further review revealed that Physician HH (R#1 Attending Physician and Medical Director) responded on 6/27/19 via fax and wrote orders to obtain a wound care consult for R#1. LPN FF Treatment Nurse also sent an email on 6/24/19 to the wound care clinic stating that R#1 had an intertriginous lesion that had turned into an unstageable wound. LPN FF Treatment Nurse asked if they (the wound care clinic) had any suggestions. The wound care clinic responded the same day (6/24/19) with instructions for Facility #2 to start quarter strength Dakin's wet to dry dressing daily. However, further record review revealed that the order for quarter strength Dakin's wet to dry dressing daily was not implemented until 7/1/19 which was seven days later. Review of the Wound Care Clinic Progress notes dated 7/12/19, revealed R#1 went to the scheduled appointment to the wound care clinic as ordered by the Physician. In the Progress Note Details revealed the following documentation: Resident presents with an unstageable pressure ulcer at the sacrum. Documentation under the History of Present Illness revealed the following: that the wound location was on the sacrum with a duration documented to be since (MONTH) 2019. And that it (the resident's pressure ulcer to her sacrum) appears as though they (the facility) have been covering the wound with a foam dressing. The sacral wound measurements obtained by the wound care clinic on 7/12/19 were Length: 11.5 cm x Width: 4 cm x Depth: 2 cm. Further review revealed that the entire wound was malodorous (very unpleasant smell). The wound care clinic recommendation was to cleanse the wound with normal saline, apply skin barrier film to the intact skin surrounding the wound, wet to dry dressings using half strength Dakin's moistened gauze followed by dry gauze, a thick absorbent pad, and [MEDICATION NAME] tape. And to change the dressing daily and as needed for soilage. Continued review of the 7/12/19 Progress note from the Wound Clinic, the patient (R#1) was noted to be [MEDICAL CONDITION] with a heart rate of 118 beats per minute and with a mildly elevated temperature at 99.5 degrees Fahrenheit. The Physical Exam documents: Sacrum with unstageable pressure ulcer. The actual wound entrance is relatively small but there is a fair amount of undermining. The entire wound walls and base is dark and necrotic. I am unable to tap bone today but there is likely only a few mm (millimeters) of tissue covering. The wound's periphery is maroonish in color with sloughy patches and beginning to breakdown, indicating the injury is deep and the wound will likely be much larger as it fully declines. The entire wound is malodorous. The following Physician orders [REDACTED]. Diet: Increase Protein Intake. General Note: Wound is entirely necrotic and malodorous. Will initiate Dakin's for now to see if we can get some of the necrosis cleaned up and for odor management. Review of a Physician order [REDACTED].#1) to an acute care hospital for evaluation. Review of the emergency room record dated 7/15/19 at 12:49 a.m. documents that the Final Primary [DIAGNOSES REDACTED].#1 [MEDICAL CONDITION] secondary to infected sacral decubitus with and additional [DIAGNOSES REDACTED]. Review of a photograph of R#1's sacral pressure ulcer dated 7/15/19 at 1:50 p.m. documents that R#1's pressure ulcer measured the following: Length (L): 20 cm x Width (W): 8 cm x Depth (D): 6.7 cm. Review of an inpatient lab report documents that a wound culture of R#1's sacrum on 7/15/19 with the results documented to be a moderate amount of gram-negative rods, a moderate amount positive cocci, and a few gram-positive rods. The report documented that the bacteria was susceptible to meropenem (an antibiotic). Wound Consultation dated 7/17/19, documents that R#1 underwent debridement of her sacral wound and had placement of a diverting loop [MEDICAL CONDITION]. On 7/18/19 a wound VAC (a negative pressure wound treatment) was placed. Wound culture from the sacral wound grew Pseudomonas aeruginosa and an anerobic culture grew Prevotella. Infectious disease was consulted for assistance with antibiotics. She (R#1) is currently on IV (intravenous) Meropenem (antibiotic). Review of an Infectious Disease Consultant Note dated 7/22/19 documents: Upon presentation, it is noted that the sacral wound had surrounding eschar and a foul smell. She (R#1) was also febrile and had an altered mental status. Review of an Inpatient Wound Progress Note dated 7/30/19 documents the following, in pertinent part: R#1 is a [AGE] year-old female who was sent from the nursing home due to a fever and AMS (altered mental status). She (R#1) was noted to have a foul-smelling sacral ulcer, urinary tract infection, [MEDICAL CONDITION] and leukocytosis and was admitted [MEDICAL CONDITION]. Patient is now s/p (status [REDACTED]. The Physician has asked for wound vac therapy which was started on 7/19/19. Patient is status [REDACTED]. Patient was seen 7/12/19 (in the Wound Clinic) and the wound significantly worsened over the weekend prior to admission (to the acute care hospital). During a wound observation on 9/6/19 at 10:26 a.m. with Physical Therapist Assistant (PTA) EE who was assisted by Licensed Practical Nurse (LPN) FF treatment nurse revealed that the Stage IV pressure ulcer to R#1's sacrum had a pink wound bed with reddish granulation; and that the pressure ulcer measured 16 centimeters (cm) x 6.5 cm x 2.7 cm, there is tunneling at 7-9 o'clock that measured 5.5 cm and tunneling at 3-5 o'clock that measured 1.2 cm. Observation revealed that bone was exposed. During an interview on 9/6/19 at 11:34 a.m. with LPN FF Treatment Nurse revealed that on 6/19/19 she identified the wound on R#1's sacrum to be an unstageable pressure ulcer. However, review of the facility's Treatment Administration Record (TAR) with LPN FF Treatment Nurse revealed that a treatment order was documented on the TAR on 6/10/19. LPN FF Treatment Nurse initially indicated that she did not know who entered the order; however, on further review of the data history information LPN FF Treatment Nurse confirmed that, although she had not notified the Physician of the pressure ulcer until 6/24/19 she had entered a treatment order, for the pressure ulcer to R#1's sacrum, into the TAR on 6/10/19. LPN FF Treatment Nurse stated that the wound started out as an intertriginous lesion but that it got worse. LPN FF Treatment Nurse stated that on 6/24/19 that she sent a care fax to the Physician to let him know of the pressure ulcer and to request if PT (Physical Therapy) could do a wound debridement and she also sent an email to the Wound Care Clinic to ask for advice for the sacrum wound. LPN FF stated that she also implemented the Wound Protocol on 6/24/19. LPN FF continued and stated that the Physician sent instructions on 6/27/19 to send R#1 for a wound care consult. During an interview on 9/10/19 at 11:47 a.m. with Physician GG (Surgeon at the acute care hospital) revealed that R#1 was a nursing home resident with a large infected decubitus ulcer that extended into the buttock and toward the resident's hip then downward toward the resident's rectum. Physician GG stated that he conducted two surgical debridements on R#1's sacral wound. Physician GG stated the resident was incontinent of stool and that the resident had to have a diverting [MEDICAL CONDITION] to keep feces out of the residents sacral wound. Physician GG stated that they had to place a wound Vac on the resident's sacral wound after the [MEDICAL CONDITION] was placed. Physician GG stated that the sacral wound is not a surgical wound but remains a pressure ulcer. During an interview on 9/10/19 at 2:27 p.m. with Physician HH (R#1's Attending Physician and Medical Director) revealed that if staff have any concerns about residents, they are to notify him. Physician HH continued to state that he currently receives sporadic wound reports from the facility. Physician HH revealed that he first became aware of the wound on R#1's sacrum when he received a fax related to the wound and in the fax, the facility was requesting that R#1's wound be debrided. Physician HH explained that he did not want the facility to do a debridement because it was unknown what was under the resident's wound. Physician HH felt that it was in the best interest for R#1 to be seen by the Wound Care Clinic. During an interview on 9/11/19 at 3:01 p.m. with Nurse Practitioner (NP) II at the Wound Care Clinic revealed that R#1 was seen in the clinic on 7/12/19 and she had early signs of the anaerobic bacteria infection and that she initially thought the Dakin's solution would be sufficient. NP II stated that based on the hospital report that they (the Wound Care Clinic) received the anaerobic bacteria was the primary bacteria in the wound and this was caused from R#1 being incontinent of bowel. Subsequent interview on 9/12/19 at 3:30 p.m. with Physician GG revealed that the cause of the infection in the resident's sacral decubitus was most likely due to fecal contamination and that R#1 also had a urinary tract infection. Physician GG stated that if the resident had not had the infected Stage IV pressure ulcer that she would not have needed to have a [MEDICAL CONDITION] placed. Physician GG explained that when he saw R#1 her sacral wound was at an advanced state of decline and that the resident's Stage IV pressure ulcer would be difficult to heal without the diverting [MEDICAL CONDITION]. Physician GG further stated that early interventions for the wound would have helped the wound from declining to the extent that it did. During an interview on 9/16/19 at 9:36 a.m. with Registered Nurse (RN) PP revealed that on 6/1/19 she worked as a Certified Nursing Assistant (CNA) that day and that she was providing care for R#1, when she saw what looked like an intertriginous lesion, located in the crack of the resident buttocks midway up from the resident's rectum. RN PP described the area as missing skin and looked raw. RN PP stated that she reported this open area to LPN QQ. RN PP stated that normally, she would have informed the treatment nurse but that she could not recall for sure if she had informed the treatment nurse of the skin impairment but that she did tell LPN QQ. Continued interview with RN PP revealed that RN PP emphasized that she worked as a CNA that day, and that it was not her job that day to address the wound, but it was the responsibility of the nurse assigned to the resident to ensure that the opened area was followed up on. A subsequent interview on 9/19/19 at 3:04 p.m. with RN PP revealed that, in addition to working as a CNA, she was the RN supervisor for that weekend, and it was not her job to address the wound, because she had reported the findings to LPN QQ. A subsequent interview on 9/20/19 at 10:05 a.m. with RN PP revealed that the nurse on the hall, should have looked at the wound on R#1's sacrum, taken a picture of the wound, called the family and the doctor. RN PP stated that the Charge Nurse should have followed-up and made sure that this was done. RN PP stated again that she had worked as a CNA and that she reported the wound to the Charge Nurse assigned to that hall. During a phone interview on 9/16/19 at 9:55 a.m. LPN QQ revealed that she had resigned and Friday (9/13/19) had been her last day. When asked about R#1's sacral wound that RN PP observed on 6/1/19, LPN QQ revealed that RN PP had come to her and told her that R#1 had a small crack between her buttocks. LPN QQ stated that when she looked at the very top of the resident's tail bone that she didn't see anything that needed treatment. LPN QQ stated she did not inform the treatment nurse of the area because she did not see an open area. During an interview on 9/20/19 at 10:07 a.m. with the Director of Nursing (DON) revealed that what should have happened for R#1, was once the sacral wound was found, a photo should have been taken, the family and the Physician should have been notified, and that the Wound Protocol should have been implemented and treatment should have been started, and that the wound should have been reported to us (us defined as the Administrator and the DON). 2. Resident #2 was admitted to Facility #2 on 8/23/18 with [DIAGNOSES REDACTED]. Review of the Admission Minimum Data Set ((MDS) dated [DATE] revealed the following: R#2 had a Brief Interview for Mental Status (BIMS) score of 00 indicating that she was severely cognitively impaired, she required limited assistance for bed mobility, was totally dependent on staff for transfers, in section M0150 the resident was assessed to be at risk for developing pressure ulcers. Review of the Braden Scale for Predicting Pressure Sore Risk dated 5/23/19 revealed a score of 17 indicating at risk for pressure ulcers. Review of the Nurses Notes dated 8/23/18 revealed that on admission R#2 had a knot with discoloration to the left forehead, discoloration to inside of right leg/left lower leg. There was not any documentation that the resident had any opened skin areas. Review of the CNAs Body Check dated 8/23/18 through 9/30/18 revealed an entry dated 8/27/18 R#2 had an abnormal body check for sacrum. Review of the Weekly Skin Assessments revealed that there were Weekly Skin Assessments dated 9/22/18, 12/13/18, 8/1/19, and 9/5/19 (which documented a dressing to the sacral and a dark area noted to right foot); however, there was not any evidence of documentation that any other skin assessments had been completed for R#2. Review of the Wound Report from 8/24/18 through 9/4/19 revealed that R#2 was admitted on [DATE] without any skin impairments; however, on 8/27/18 the Wound Report there was a photo of the residents pressure ulcer and the following wound description information: Wound Type: Pressure Ulcer, Pressure ulcer has partial thickness loss of skin layers that presents as an abrasion or blister (Stage II), Location: Sacrum-Lower Spine, Wound Tissue Type/Color: pink, Surrounding Tissue: normal, Healing Progress: N/A (new area), Area: Wound measurements were documented to be L 9 cm x W 3 cm x D 0.1 cm. Review of the 9/12/18 Wound Report for R#2 documented the following wound description: Pressure Ulcer: unstageable - wound bed covered by slough and /or eschar, Location: Sacrum-Lower Spine, Wound Tissue Type/Color: Slough Granulation, Surrounding Tissue: normal, Healing Progress: improving, Wound measurements are documented to be: L 7.5 cm x W 7.6 cm x D 3.4 cm. Further record review revealed that from 9/12/18 until 9/25/18 there was not any wound documentation and/or wound photos for this pressure ulcer. On 9/25/18 there is a photo of the wound and a wound description that documents the pressure ulcer is now a Stage III. Wound description documents the following: Wound Type: Pressure Ulcer, Pressure Ulcer: has full thickness of skin lost exposing the Sub Q (subcutaneous: the third innermost layer of skin) tissues(presents as a deep crater (Stage III), Location: Sacrum-Lower Spine, Wound Tissue Type Color: Granulation reddened, Surrounding Tissue: epibole (rolled edges of wound) white, Healing Progress: Improving. Wound measurements are documented to be: L 5.6 cm x W 4 cm, D 2.4 cm, Drainage Type: Sero-Sanguineous, Drainage Amount: heavy. Record review revealed that even though the pressure ulcer had changed from a Stage II to a Stage III the documentation noted that the wound is improving. During a wound care observation on 9/5/19 at 1:36 p.m. with LPN FF Treatment Nurse and Registered Nurse (RN TT) who was assisting LPN FF Treatment Nurse, by holding and positioning the resident during wound care, the following observations were made: During the preparation of the wound supplies, without washing or sanitizing her hands LPN FF Treatment Nurse was observing taking scissors from the top of the uncleaned treatment cart and observed to the cut calcium alginate to be placed on the wound bed of R#2. LPN FF Treatment Nurse took a bundle of paper measuring tapes and removed two measuring tapes from the adhesive binder. LPN FF Treatment Nurse then placed the items needed for wound care on a blue disposable drape. LPN FF Treatment Nurse placed the scissors back on top of the unclean treatment cart and then LPN FF Treatment Nurse entered the resident's room. When LPN FF Treatment Nurse measured the wound bed, LPN FF Treatment Nurse placed the corner of the paper tape directly into the wound bed to obtain the depth. LPN FF measured the pressure ulcer which measured 2.0 cm x 0.8 cm x 0.3cm. However, LPN FF Treatment Nurse did not check the pressure ulcer for any tunneling or undermining. Further observation revealed that LPN FF Treatment Nurse did not wash or sanitize her hands while proving wound care until after she had completed the wound care for R#2 and then after wound care she was observed to use hand sanitizer that was on the wall in the resident's room. During an interview on 9/6/19 at 11:34 a.m., LPN FF treatment nurse revealed that resident developed the Stage 2 in the facility and that R#2 will remain in the same position without moving. During an interview on 9/6/19 at 12:42 p.m. LPN FF Treatment Nurse was asked to explain why the scissors were not cleaned before cutting the calcium alginate and LPN FF Treatment Nurse stated that the scissors were on top of the treatment cart, and that the scissors were left on top of the cart. LPN FF Treatment Nurse continued to state that she never took the scissors into the resident's room. LPN FF Treatment Nurse stated the scissors were to be cleaned before and after use. 3. Resident #3 was admitted to Facility #2 on 11/20/18 with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set ((MDS) dated [DATE] revealed the following: R#3 had a Brief Interview for Mental Status (BIMS) score of 5 indicating that he was severely cognitively impaired, he required total assistance for bed mobility, required extensive assistance for transfers, in section M0150 the resident was assessed to be at risk for developing pressure ulcers. Review of the Braden Scale for Predicting Pressure Sore Risk dated 6/12/19 and 7/19/19 revealed a score of 15 indicating R#3 is at risk for pressure ulcers. Review of the CNAs Body Check form dated 4/1/19 through 5/31/19 revealed that on 4/26/19 an abnormal body check for the sacrum and other being the left heel. There was no documentation to support that a follow-up to this finding was addressed until 5/20/19. Record review revealed that there was not any evidence of documentation of the left foot prior to 5/20/19. Review of the Wound Report dated 5/20/19 revealed the following wound description: Assessment Type: New Wound, Pressure Ulcer: Unstageable - Wound bed covered by slough and /or eschar, Pressure Ulcer: Has partial thickness loss of skin layers that presents as an abrasion or blister (Pressure Stage II) , Location Other Side Left foot, Location Left Heal, Location: left ankle-outer: Lateral Malleolus, Wound Tissue Type/color: Slough Necrotic Eschar, Wound Tissue Type/Cor: pink, Surrounding Tissue: reddened, Surrounding Tissue: normal, Healing Progress: N/A (new area), the flowing wound measurements for these wounds are documented: Left lateral foot: L 3.5 cm x W 3 cm x D Unknown, Area: Left heel: L 2 cm, x W 2.5 cm x D 0.1 cm. Review of the (MONTH) 2019 TAR (Treatment Administration Record) revealed treatment orders dated 5/20/19 to remove dressing form left lateral foot and left heel, clean with normal saline. Apply Allevyn AM (morning) and as needed three times a week. Monday, Wednesday and Friday indicating that there had not been any previous treatments provided for these areas. In addition, further record review revealed that the only evidence of any documentation of weekly skin assessments for R#3 were for the following dates: 6/26/19, 8/7/19, and 9/5/19. Other than these skin assessments there was not any evidence of documentation that R#3 had any other weekly skin assessments completed in the facility. During a wound care observation on 9/5/19 at 1:41 p.m. with LPN FF Treatment Nurse for R#3 revealed the following observations. LPN FF Treatment Nurse cleaned the resident's bedside table top and placed her clean supplies on a blue disposable drape on the bedside table. LPN FF Treatment Nurse put on gloves and removed the tape from the old dressing. Observation revealed that the resident's left lateral foot had an irregular circular shaped with black eschar with approximately 30% yellow slough present. Without washing or sanitizing her hands, LPN FF Treatment Nurse removed her gloves and donned a new set of gloves and then took a vial of normal saline and squirted the normal saline over the wound. The normal saline drained from the wound onto the gauze. Using the same gauze, LPN FF Treatment Nurse wiped the wound and was observed to go from dirty area to clean area, and from clean area to dirty area using the same gauze. During an interview on 9/10/19 at 3:52 p.m. with LPN NN MDS Coordinator revealed that the facility did not have any other skin assessments for R#3 as there had not been any other skin assessments completed for R#3. During an inte

Based record review, staff interviews, and review of the facility policy titled, Quality Assurance Performance Improvement, Facility #2 failed to have a Quality Assessment and Assurance (QAA) committee that effectively provided oversight and monitoring to ensure that staff were performing weekly skin assessments to ensure timely identification and treatment of [REDACTED].#2 failed to ensure that weekly photographs and weekly wound description documentation was being completed and failed to ensure that the Physician and Responsible Party were notified of pressure ulcers in a timely manner. Facility #1 failed to ensure weekly wound descriptions were being completed from 7/1/19 through 8/14/19. On (MONTH) 17, 2019 a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had caused or had the likelihood to cause serious injury, harm, impairment or death to residents. The facility's Administrator and Director of Nursing for both Facility #1 and Facility #2, and the System Administrator were informed of the Immediate Jeopardy on (MONTH) 17, 2019 at 2:51 p.m. The noncompliance related to the Immediate Jeopardy was identified to have existed on (MONTH) 1, 2019. The Immediate Jeopardy is outlined as follows: During the complaint investigation it was identified that R#1, which resided in Facility #2, was identified as having an open area to her sacrum on (MONTH) 1, 2019; however, treatment was not provided for this wound until (MONTH) 10, 2019. The Physician was not notified of the wound until (MONTH) 24, 2019. The Physician ordered for R#1 to have a wound consultation on (MONTH) 27, 2019. R#1 was seen at the Wound Clinic on (MONTH) 12, 2019, at which time it was observed that the wound was infected, and the resident's wound treatment was changed to Dakin's solution. On (MONTH) 15, 2019, R#1 was sent to the hospital and was admitted to the hospital. The resident's primary admitting [DIAGNOSES REDACTED]. R#1 had to have a central line placed to receive antibiotic treatment. In addition, on (MONTH) 17, 2019, R#1 had to undergo surgical debridement of the Stage IV pressure ulcer on her sacrum and the resident had to have surgery to have a diverting loop [MEDICAL CONDITION]. The Immediate Jeopardy was related to the facility's noncompliance with the program requirements at 42 C.F.R. F580 -- S/S: J -- 483.10(g)(14)(i)-(iv)(15) -- Notify Of Changes (injury/decline/room, Etc.); F657 -- S/S: J -- 483.21(b)(2)(i)-(iii) -- Care Plan Timing And Revision; F658 -- S/S: J -- 483.21(b)(3)(i) -- Services Provided Meet Professional Standards; F686 -- S/S: J -- 483.25(b)(1)(i)(ii) -- Treatment/svcs To Prevent/heal Pressure Ulcer; F867 -- S/S: J -- 483.75(g)(2)(ii) -- Qapi/qaa Improvement Activities Additionally, Substandard Quality of Care was identified with the requirements at F686 -- S/S: J -- 483.25(b)(1)(i)(ii) -- Treatment/svcs To Prevent/heal Pressure Ulcers. At the time of exit on (MONTH) 20, 2019, an acceptable Immediate Jeopardy Removal Plan had not been accepted therefore the Immediate Jeopardy remains ongoing. Findings include: Review of the policy titled, SUBJECT: Quality Assurance Performance Improvement Effective Date 11/01/2017 documents the following: It is the policy of the facility to develop a QAPI plan in accordance with Federal Guidelines to describe how the facility will address clinical care, resident quality of life and residents' choice and is based on the scope and complexity of services defined by the Facility Assessment. Procedure 2. The plan describes the process for identifying and correcting quality deficiencies and contains the necessary components such as: a. tracking and measure performance: b. establishing goals and thresholds for performance measurement; c. Identifying and prioritizing quality deficiencies; d. Systematically analyzing underlying causes of systemic quality deficiencies; e. Developing and implementing corrective action or performance improvement activities; and f. Monitoring or evaluating the effectiveness of corrective action/performance improvement activities, and revising as needed. Review of the Facility Assessment Tool revealed the following documentation: Our QAPI plan addresses: Clinical Care, Quality of Life and Resident. Data Sources revealed that pressure ulcers and wounds data analysis frequency is weekly. The Staff meetings, occurrence reporting, QAPI Meeting is noted to include residents, families, staff, QAPI Committee. Facility #2 1. Review of Quality Assurance Performance Improvement (QAPI) for Facility #2 dated (MONTH) 31, 2019 revealed a QA meeting was held. In attendance were the RN QA/PI Coordinator, Clinical Coordinator, DON, ADON, RN Clinical Coordinator and CNA Nursing Services. The meeting was called to order (MONTH) 31, 2019 at 2:30 p.m. The RN Quality Assurance Coordinator, reported on the following QAPI measures, quality measures were looked back for the months of (MONTH) 2019 & (MONTH) 2019. In the minutes, pressure ulcers were discussed. After the discussion of all data submitted as a team, we decided we would develop three PIP's (Performance Improvement Plans) - Pain, UTI's and Pressure ulcers. These PIPs will be initiated during the month of (MONTH) and staff will be educated on current PIPs as they are developed. Further record review revealed that there was not any evidence of any documentation that these three PIP's were developed or rolled out to the facility Facility #2 did not ensure that weekly skin assessments were conducted for R#1, did not ensure thorough wound assessments was completed for R#1, did not ensure that the Physician was notified of the pressure ulcer to R#1's sacrum in a timely manner. Facility #2 failed to ensure that treatment for [REDACTED].#2 failed to revise and update R#1's care plan to reflect the actual pressure ulcer. In addition, Facility #2 did not ensure that daily Certified Nursing (CNA) Body Checks were completed, did not ensure that weekly skin assessments were completed, and failed to ensure that weekly wound assessments descriptive wound documentation was completed for (R#1, R#2, R#3, R#4). In addition, Facility #1 failed to ensure that weekly wound descriptive documentation was completed for R#11 and R#12. (Cross Refer to F580, F657, F658, F686) Facility #2 During an interview on 9/10/19 at 2:27 p.m. with Physician HH (Medical Director) revealed that he does attend the Quality Assurance (QA) meetings. When the meetings were held on Thursday he would attend. The facility cancelled some of the meetings without notifying him. He would arrive to the facility to be informed that the QA meeting was cancelled. He continued that if he cannot attend in person, he will participate via phone to communicate his input. Record review revealed that each facility has their own QA meetings. During an interview on 9/11/19 at 9:56 a.m. RN OO Infection Control/QA at Facility #2 revealed that the concerns that the facility currently has in QA are: Admission, H&P, Monthly charting, Weight audits, Care plans are still ongoing, and that wound care was not in QA and did not have a QAPI plan. During an interview on 9/20/19 at 10:10 a.m. the Administrator DD for Facility #2 revealed that he attended the QA meetings. And that wound care did not trigger for a QAPI. Facility #1 Review of a Pressure Ulcer P & I report for Facility #1 that was held on 8/14/19 with 45 residents in house. The facility completed head to toe assessments. And the facility found one new pressure ulcer was identified with no evidence of any documentation that anything was put in place to address that weekly wound descriptions were not being completed. During an interview with Director of Nursing (DON) BB on 9/9/19 at 3:00 p.m., she stated when she started work at Facility #1 in (MONTH) 2019 and she noticed a problem with the pressure ulcer documentation. She stated the previous treatment nurse was only taking pictures of the wounds with the measurements, but she was not completing weekly descriptive documentation.

Based on observations, staff interviews, record review, review of the facility's infection control logs and policies and procedures, and review of documentation about the facility's surface disinfectant, it was determined that the facility failed to maintain an Infection Control Program that ensured proper infection control and provision of aseptic technique to prevent cross contamination and prevent indirect contact transmission of a blood borne infection or a microscopic pathogen by failing to ensure one licensed nurse practiced effective hand hygiene, and by one nurse on Unit I and six nurses on Unit II failing to clean and disinfect glucometers between residents and, the facility's failure to monitor their infection control policy and procedures to ensure their implementation. These practices effected sixteen insulin dependent, sampled residents but had the potential to effect all of the residents whose blood sugar levels required monitoring. Therefore, it was determined that an immediate jeopardy existed for 37 residents who had diabetes and required fingerstick blood glucose monitoring from July 14, 2010 through July 15, 2010 when a plan of correction was implemented by the facility to remove the jeopardy. Therefore, it was determined that the immediate jeopardy was removed on 7/16/10 and the scope and severity was lowered to an "E" level. However, the facility remains out of compliance in order to ensure that licensed nursing staff continued to implement the correct procedures to clean and disinfect blood glucose testing machines; that supervisory nursing staff continues to monitor to ensure that blood glucose testing machines are clean and disinfected according to the manufacturer's directions; and that the Performance Improvement Committee monitors the facility's interventions to ensure that the infection control policies and procedures are implemented as planned. The Center for Disease Control's (CDC) section "Diabetes Care Procedures and Techniques" of the "Recommended Infection-Control and Safe Injection Practices to Prevent Patient-To-Patient Transmission of Bloodborne Pathogens", recommended that if a glucometer used for one patient must be re-used for another patient, then the device must be cleaned and disinfected. Hand hygiene was to be performed immediately after the removal of (contaminated) gloves and before touching other medical supplies intended for use on other residents. In the Centers for Medicare and Medicaid Services (CMS) October, 2009 "Infection Prevention and Control Training" it was documented that, when cleaning a glucose meter, or any other object potentially contaminated with blood, either a EPA approved germicidal disinfectant which was labeled effective against [DIAGNOSES REDACTED] (TB) or hepatitis B virus (HBV), or a 1:10 bleach to water (minimal) concentration must be used. Alcohol was not included as an EPA approved germicidal disinfectant. The facility had the product, CaviWipes, that was labeled to be used to clean and disinfect hard non-porous surfaces of non-critical patient care equipment and environmental surfaces. The label noted that non-critical equipment did not come in contact with non-intact skin or mucous membranes. The directions for use on the CaviWipes container documented that CaviWipes would clean and disinfect, when used as directed. The cleaning instructions were for staff to use one CaviWipes towelette to pre-clean surfaces. For use as a virucide, including HIV-1, HBV and HCV applications, staff was to use a second CaviWipe towelette to thoroughly wet the surface and ensure the surface remained visibly wet for two minutes at room temperature (69 degrees F.). For tuberculocidal disinfection, staff were to allow the surface to remain visibly wet for three minutes at room temperature. The facility's Infection Prevention and Control Policy and Procedure (revised 3/31/10) documented that the use of CaviWipes to disinfect non-invasive equipment was a two step process that required first cleaning the surface, then disinfecting it. The policy also documented that glucometers must be wiped with an approved detergent/disinfectant daily and when visibly soiled in a two step process. First, the item must be cleaned then disinfected by allowing the surface to remain visibly wet for the period of time determined by the manufacturer to be effective as a disinfectant. During an interview on 7/15/10 at 10:00 a.m., the Director of Nursing stated that this policy and procedure dated 3/31/10 was the policy and procedure that was followed at the nursing home. She said that she had not received the 4/2010 revised policy and procedure until after surveyor inquiry. The facility's Policy and Procedure on Storage, Maintenance, Repair or Replacement of the Accu-Chek Inform System (revised 4/2010) documented a procedure that the meter must be cleaned after each use to prevent the spread of infection between patients/residents. The instructions directed staff to use a soft cloth or pre-moistened wipe dampened with soapy water, 70% [MEDICATION NAME] alcohol solution, 1:10 bleach, or CaviWipes to clean the accu-check inform meter and accessory box. However, there was no information to differentiate the use of any of those solutions as being either effective to clean surfaces and/or effective to disinfect surfaces. There was a "Note:" that if CaviWipes were used to clean and disinfect the meter and accessory box then, staff was supposed to pre-clean with one CaviWipe and disinfect using a second CaviWipe to thoroughly wet the surface of the meter and box so that the surfaces remained visibly wet for three minutes. Unit I According to the "MCC Inservice Sign-in Sheet" dated 6/29/10, licensed nursing staff on Unit I were inserviced on the facility's Infection Prevention and Control Policy and Procedure, and the Policy and Procedure on Storage, Maintenance, Repair or Replacement of the Accu-Chek Inform System. However, it was observed that a licensed nurse did not demonstrate implementation of those procedures during the use of the glucometer. During observations of the medication pass on 7/14/10 from 11:05 a.m. to 11:35 a.m., licensed nurse "AA" only wiped the Accu-Check Inform Meter (glucometer), used to obtain residents' blood sugar levels, with one CaviWipe to clean it between each of the residents "A", "B", "C", and "D". However, nurse "AA" did not disinfect the glucometer between each of those residents. The facility's Policy and Procedure on Infection Prevention and Control for Hand Hygiene was to use either alcohol sanitizer or washing with soap and water to decontaminate hands if they were not visibly soiled before having direct contact with a patient. According to the policy, hand hygiene was supposed to be performed after removing gloves. During observations of the medication pass on 7/14/10 from 11:05 a.m. to 11:35 a.m., licensed nurse "AA" obtained blood sugar levels for residents "A", "B", "C", and "D", and administered medications to resident "E". However, after changing gloves between residents "A", "B", "C", "D", and "E", nurse "AA" failed to wash or sanitize her hands. During an observation on the medication pass on 7/14/10 at 11:35 a.m., the licensed nurse had not washed her hands or used an alcohol sanitizer to clean her hands after removing the gloves used to administer medications to resident "C". She put on clean gloves prior to entering resident "D"'s room to use the glucometer to test the resident's blood sugar level. After completing the test and while wearing the same (contaminated) gloves, the nurse put her hands in her pocket looking for the key to the medication cart, then unlocked it and removed the insulin. She removed her soiled gloves, rubbed her nose and then put on clean gloves without washing her hands. Afterwards, she drew insulin from a vial into the syringe, locked the medication back in the cart with the (contaminated) key that was still in the lock, and put the key back in her (contaminated) pocket. She re-entered the room and administered the insulin to resident "D". During observations of two licensed nurses and interviews with three different licensed nurses on the 7 a.m. to 3 p.m. and/or 3 p.m. to 11 p.m. shifts on 7/27/10, they were able to verbally and physically demonstrate the effective two step method to disinfect blood glucose testing machines according to the CaviWipes manufacturer's directions for its use as a virucide and disinfectant. Unit II 1. During an observation on 7/15/10 at 11:10 a.m., licensed nurse "X" removed the 200 hallway glucometer from the drug room. Then without cleaning and disinfecting it, licensed nurse "X" checked resident #223's blood sugar level with the glucometer. The nurse then wiped the same glucometer off with an alcohol swab and went to resident #220's room. Licensed nurse "X" obtained resident #220's blood sugar level without cleaning and disinfecting the machine. After obtaining resident #220's blood sugar level, nurse "X" did not clean and disinfect the glucometer before she put it back in the plastic storage box. 2. During an observation on 7/14/10 at 4:15 p.m. licensed nurse "Z" removed the 200 hallway glucometer from the plastic storage box. Then without cleaning and disinfecting the machine, she checked resident #204's blood sugar level with the glucometer. The nurse wiped off the front of the glucometer with one CaviWipe and wiped off the back of the glucometer with one CaviWipe. At 4:20 p.m., licensed nurse "Z" resident #220's blood sugar level with the same glucometer then wiped off the front of the glucometer with one Cavi-wipe and the back of the glucometer with one CaviWipe. She failed to follow the manufacturer's directions to effectively disinfect the glucometer. 3. During an observation on 7/14/10 at 4:00 p.m., licensed nurse "Y" removed the glucometer from its plastic box. Then without cleaning and disinfecting the machine, he checked resident #214's blood sugar level with the glucometer. Nurse "Y" then put the glucometer back in the plastic box without cleaning and disinfecting the machine. At 4:12 p.m., nurse "Y" obtained resident #215's blood sugar level with the same glucometer without cleaning and disinfecting the machine. Licensed nurse "Y" then replaced the glucometer back in the plastic storage box. During an observation on 7/14/10 at 4:40 p.m., licensed nurse "Y" removed the glucometer from the plastic box. Then without cleaning and disinfecting the machine, he checked resident #225's blood sugar level with the glucometer. At 4:45 p.m., nurse "Y" obtained resident #222's blood sugar level with the same glucometer without cleaning and disinfecting the machine. Licensed nurse "Y" then replaced the glucometer back in the plastic storage box. 4. During an observation on 7/15/10 at 11:15 a.m., licensed nurse "W" removed the glucometer from the plastic box. Then without cleaning and disinfecting the machine, she checked resident #226's blood sugar level with the glucometer. Nurse "W" then put the glucometer back in the plastic box without cleaning and disinfecting the machine. At 11:20 a.m., nurse "W" obtained resident #222's blood sugar level with the same glucometer without cleaning and disinfecting the machine. Licensed nurse "W" then replaced the glucometer back in the plastic storage box. 5. During an interview on 7/14/10 at 12:15 p.m., licensed nurse "V" stated that she cleaned the glucometer machine between each use with an alcohol wipe. During an observation on 7/15/10 at 11:20 a.m., licensed nurse "V" removed the glucometer from the plastic storage box. He/she cleaned the machine with an alcohol wipe but, did not disinfect the glucometer machine before he/she checked resident #227's blood sugar level with the glucometer. Nurse "V" placed the glucometer back in the plastic storage box without cleaning and disinfecting the machine. At 11:25 a.m., nurse "V" went to resident #213's room to check his/her blood sugar level with same glucometer. Nurse "V" cleaned the glucometer machine with an alcohol wipe and dried it with a paper towel but, did not disinfect the machine before obtaining the resident's blood sugar level. The nurse placed the glucometer back in the plastic case without cleaning and disinfecting the machine. At 11:30 a.m., nurse "V" went to resident # 216's room to check his/her blood sugar level. She removed the glucometer from the plastic box and cleaned it with an alcohol wipe and dried it with a clean paper towel but, did not disinfect the machine before checking the resident's blood sugar level. Licensed "V" then replaced the glucometer back in the plastic storage box. 6. During an observation on 7/15/10 at 11:05 a.m., licensed nurse "U" removed the glucometer from its plastic box. Then without cleaning and disinfecting the machine, she checked resident #224's blood sugar level with the glucometer. Then nurse "U" put the glucometer back in the plastic box without cleaning and disinfecting the machine. Nurse "U" then went to the nurse's station and placed that contaminated glucometer on a charging unit without cleaning and disinfecting the machine. During observations of three licensed nurses between 11 a.m. and 11:30 a.m., and interviews with three licensed nurses between 6:15 a.m. and 11:30 a.m. on 7/27/10, they described and demonstrated only a one step method for "cleaning" the blood glucose testing machine. However, the verbal description and the observations revealed that those nursing staff were thoroughly wiping the machine with a CaviWipe and left it visibly wet for at least 3 minutes between residents. One licensed nurse completed the recommended 2 step method for cleaning and disinfecting the machine after obtaining the blood glucose level for one resident who was on 'contact precautions' The manufacturer's directions noted that wiping the machine's surfaces so that the machine was left visibly wet for 3 minutes would be effective as a virucide and disinfectant. The facility provided an acceptable Credible Allegation of Compliance on 7/15/10 which included the following: The policy and procedures for Storage, Maintenance, Repair or Replacement of the Accu-Chek Inform System that had been revised 4/2010 were provided to the facility and licensed nursing staff. Completed 7/15/10. All licensed nursing staff on Unit I and Unit II were educated by the respective Directors of Nursing (DON) on appropriate cleaning and disinfecting of the glucometer machines with the CaviWipes product. Completed 7/15/10. After reviewing the policy and receiving education, the licensed nursing staff performed a return demonstration. Successful completion of the training was documented on a skills checklist. Completed 7/15/10. No licensed nursing staff would be allowed to perform glucometer testing without successfully completing the additional education and returning the skills demonstration. Implemented 7/15/10. Licensed nurses, who were not on duty or were on leave during the survey, were to be educated with a return skills demonstration by 7/21/10. Completed 7/21/10. A plan was implemented for the DON, charge nurse or MDS coordinator to randomly observe at least 20 glucometer tests per month and report the results to the Performance Improvement committee and Administrator. Implemented 7/15/10. Therefore, it was determined that the immediate jeopardy was removed on 7/16/10 and the scope and severity was lowered to an "E" level. However, the facility remains out of compliance in order to ensure that licensed nursing staff continued to implement the correct procedures to clean and disinfect blood glucose testing machines; that supervisory nursing staff continues to monitor to ensure that blood glucose testing machines are clean and disinfected according to the manufacturer's directions; and that the Performance Improvement Committee monitors the facility's interventions to ensure that the infection control policies and procedures are implemented as planned. Additional findings that were not part of the Immediate Jeopardy included: Unit II Review of the facility's Infection Control Surveillance on 7/15/10 at 10:00 a.m. revealed that the line listings, summaries and/or trending maps were not completed each month from January 2010 through June 2010. In January 2010, there was no evidence of any documentation that identified specific residents who had infections, the type of infection, information about cultures and sensitivities and treatment, organisms, and precautions taken. The February, March, April, May and June 2010 line listings were not consistently completed for the date of onset, type of infection, treatments, organisms and precautions taken. There was no infection control surveillance information for the month of July 2010. During interviews on 7/15/10 at 10:00 a.m. and 11:00 a.m., the Infection Control nurse stated that the line listings, summary and trending maps were to be completed each month. He/she stated that he/she had not completed the trending maps. She said that she was able to identify if there was an outbreak or cluster of infections just by knowing off of the top of her head. After surveyor inquiry, on 7/15/10 at 11 a.m. the Director of Nursing (DON) and Infection Control nurse provided summary information for infections in January through June 2010. The Infection Control nurse stated at that time that those summaries had been on her computer. However, those summaries of infections did not consistently match the information documented on the line listings done each month (i.e., there were residents named on the monthly summary who were not identified on the line listing information.) The DON and Infection Control nurse were not able to explain those discrepancies.

Based on observation, staff interview, and review of the facility's infection control policies and procedures, it was determined that the facility failed to be administered in a manner that ensured that staff were trained and had implemented effective procedures to clean and disinfect glucometers between each resident who received blood glucose level checks by fingersticks, and that all infections were tracked and trended in order for each resident to attain and/or maintain his/her highest practicable physical well-being. Immediate jeopardy was identified on July 14, 2010 after observations of blood glucose testing revealed a failure to clean and disinfect glucometers between residents "A", "B", "C" and "D" on Unit I, and between residents #223 and #220; residents #204 and #220; residents #225 and #222; residents #226 and #222; resident #227; residents #213 and #216; residents #214 and #215; and for resident #224 on Unit II through July 15, 2010 when a plan of correction was implemented by the facility to remove the jeopardy. The facility remained out of compliance at a lower scope and severity of 'E', a pattern of deficiency with the potential for more than minimal harm, for all residents who received blood glucose monitoring in order to complete training of all licensed nursing staff; to ensure that the facility's system for at least 20 random observations of glucometer tests per month was maintained; and to ensure that the findings of the observations were reported to the Administrator and the Performance Improvement committee as planned. Findings include: 1. The facility failed to maintain and Infection Control program that ensured proper infection control and provision of aseptic technique to prevent cross contamination and prevent indirect contact transmission of a bloodborne infection or a microscopic pathogen by failing to ensure that a licensed nurse practiced effective hand hygiene, that seven nurses effectively cleaned and disinfected glucometers for 16 of 37 diabetic residents who required fingersticks for blood glucose monitoring. See F441 for additional information. 2. Although there was documentation that, on 6/29/10, nursing staff had received the infection control information from the policy and procedures revised on 3/31/10 and 4/2010, during an interview on 7/15/10 at 10:00 a.m., the Director of Nursing stated that the policy and procedures dated 3/31/10 was the policy and procedure that was followed at the nursing home for cleaning and disinfecting patient care equipment. She said that she had not received the 4/2010 revised policy and procedure until after surveyor inquiry. 3. The facility's Policy and Procedure on Storage, Maintenance, Repair or Replacement of the Accu-Chek Inform System, revised 4/2010, documented a procedure that the meter must be cleaned after each use to prevent the spread of infection between patients/residents. The instructions directed staff to use a soft cloth or pre-moistened wipe dampened with soapy water, 70% [MEDICATION NAME] alcohol solution, 1:10 bleach, or CaviWipes to clean the accu-check inform meter and accessory box. However, there was no information to differentiate the use of any of those solutions as to their effectiveness to clean surfaces and/or their effectiveness to disinfect surfaces. (i.e., soapy water and alcohol solutions would not effectively disinfect surfaces from bloodborne pathogens). In addition, but not part of the Immediate jeopardy, 4. A review of the facility's "Infection Control Surveillance" revealed that the line listings of residents with infections, summaries and/or trending maps were not completed each month from January 2010 through June 2010. There was no evidence of infection control surveillance for the month of July 2010. See F441 for additional information. The facility provided an acceptable Credible Allegation of Compliance on 7/15/10 which included the following: The policy and procedures for Storage, Maintenance, Repair or Replacement of the Accu-Chek Inform System that had been revised 4/2010 were provided to licensed nursing staff. Completed 7/15/10. All licensed nursing staff on Unit I and Unit II were educated by the respective Directors of Nursing (DON) on appropriate cleaning and disinfecting of the glucometer machines with the CaviWipes product. Completed 7/15/10. After reviewing the policy and receiving education, the licensed nursing staff performed a return demonstration. Successful completion of the training was documented on a skills checklist. Completed 7/15/10. No licensed nursing staff would be allowed to complete glucometer testing without successfully completing the additional education and returning the skills demonstration. Implemented 7/15/10. Licensed nurses who were not on duty or were on leave were to be educated with a return skills demonstration by 7/21/10. Completed 7/21/10. A plan was implemented for the DON, charge nurse or MDS coordinator to randomly observe at least 20 glucometer tests per month and report the results to the Performance Improvement committee and Administrator. Implemented 7/15/10. Therefore, it was determined that the immediate jeopardy was removed on 7/16/10 and the scope and severity was lowered to an "E" level. However, the facility remains out of compliance in order to ensure that licensed nursing staff continue to implement the correct procedures to clean and disinfect blood glucose testing machines; that supervisory nursing staff continues to monitor to ensure that blood glucose testing machines are clean and disinfected according to the manufacturer's directions; and that the Performance Improvement Committee monitors the facility's interventions to ensure that the infection control policies and procedures are implemented as planned.