Every finding on record at Ascension Living Via Christi Village Mclean

The facility reported a census of 32 residents, with 12 residents sampled for advanced directives (a written document, which indicates the medical decisions for health care professionals when the person could not make their own decisions). Based on observation, interview and record review, the facility failed to ensure one resident's advanced directives were thoroughly completed when Resident (R)34 had a do not resuscitate (DNR- or no code, a legal document or order that means the person does not desire resuscitative measures) which was only signed by two licensed nurses as a verbal order and lacked a physician signature rendering it invalid. This placed the resident at risk for an impaired right to have advance directives honored. Findings included:- R34 's Electronic Health Record (EHR) revealed diagnoses of dementia (progressive mental disorder characterized by failing memory, confusion), depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), and anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear). R34's Annual Minimum Data Set (MDS), dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score of zero, which indicated severely impaired cognition. The MDS recorded no behaviors. R34 was totally dependent with activities of daily living (ADL) including bathing, toileting, dressing, footwear, transfers, and personal hygiene. The MDS recorded R34 required maximal assistance with oral care and moderate with assistance with eating. The MDS recorded R34 received an antianxiety (a class of medications that calm and relax people), and an antidepressant (class of medications used to treat mood disorders) on a routine basis. R34's Psychotropic Drug Use Care Area Assessment (CAA) documented R34 had significant behaviors and remained on multiple medications to help manage. Staff would continue to monitor for behaviors and undesired effects related to her medication. She was on hospice services and was anticipated to have a decline in all care areas. R34's Quarterly Minimum Data Set, dated [DATE], documented the resident had a BIMS score of zero, which indicated severely impaired cognition. R34 was totally dependent with all ADLs. The MDS recorded R34 received antianxiety and antidepressant on a routine basis, and no behaviors. R34's Care Plan 10/16/24 documented R34 would have advance directives reviewed upon admission and at least annually. R34's Physician's Orders documented a DNR order, date ordered 10/16/24. R34's EHR, under the scanned document section, revealed a DNR, signed 09/15/22 by two nurses, that lacked a physician or provider signature. During an observation on 08/13/25 at 08:50 AM, R34 was sitting in her high-back wheelchair, and she had her right-hand splint on. During an interview on 08/13/25 at 10:00 AM, Licensed Nurse (LN) G reported that the Social Service Designee (SSD) X was responsible for obtaining the advanced directives for the residents. LN G reported that all DNRs required a physician's signature. During an interview on 08/13/25 at 04:00 PM, SSD X reported she was responsible for completing the advanced directives and stated that R34's current DNR, dated 09/15/22, in the EHR lacked a physician's signature. During an interview on 08/14/25 at 04:30 PM, Administrative Nurse D reported that she expected the DNRs to be signed by the physician. The facility's policy Advanced Directives dated 06/2025 documented it is the policy of Ascension Living to inform residents/resident representatives about Advance Directives, to assist those who wish to complete Advance Directives, honor choices identified in the Advance Directives, and to maintain records in accordance with federal, state law, and community policy.

The facility reported a census of 32 residents. The sample included 12 residents. Based on interview and record review, the facility failed to ensure the correct and complete Beneficiary Protection Notification forms were issued to one of three residents reviewed, Resident (R) 27. This placed the resident at risk for uninformed decisions.Findings included:- On 08/13/25 a review of the Skilled Nursing Facility Advance Beneficiary Notice of Non-Coverage Form CMS-20052 (SNF ABN) revealed the facility lacked a completed form for R27. R27's Notification of Medicare Non-Coverage Form 10123(NOMNC- the form used to notify Medicare A participants of their rights to appeal and the last covered date of service) was signed on 05/21/25. Last covered day of service was 05/23/25. R27 remained in the facility for long-term care.R27's 05/08/25 Progress Note at 01:48 PM documented R27 was admitted from hospital for skilled nursing care/rehab.R27's 05/23/25 Physical Therapy Discharge Summary documented R27 was discharged from physical therapy to reside in this long-term care facility. Goal partially met with level of assistance with the use of a front-wheeled walker, stand-stepping with cues for safety awareness to decrease risk for falls.During an interview on 08/13/25 12:45 PM, Administrative Staff A reported she could not locate the SNF ABN for R27 and would continue to try to locate the form. Administrative Staff A reported she expected to have required ABNs completed prior to discharge from therapy.The facility did not provide a policy on Beneficiary Protection Notifications.

The facility reported a census of 32 residents. The sample included 12 residents, which included five residents reviewed for unnecessary medications. Based on observation, interview, and record review, the facility failed to ensure that Resident (R) 34's as-needed antianxiety (a class of medications that calm and relax people) medication had a 14-day stop date, or a specified duration, and physician rationale for the extended duration. This deficient practice placed the affected resident at risk for adverse effects associated with the use of psychotropic (alters mood or thoughts) medications.Findings included:R34 's Electronic Health Record (EHR) revealed diagnoses of dementia (progressive mental disorder characterized by failing memory, confusion), depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), and anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear).The 11/05/24 Annual Minimum Data Set (MDS) documented resident had a Brief Interview for Mental Status (BIMS) score of zero, which indicated severely impaired cognition. The MDS recorded no behaviors. R34 was totally dependent on staff with activities of daily living (ADL), including bathing, toileting, dressing, footwear, transfers, and personal hygiene. The MDS recorded R34 required maximal assistance with oral care and moderate assistance with eating. The MDS recorded R34 received an antianxiety and antidepressant (class of medications used to treat mood disorders) on a routine basis.The 11/07/24 Psychotropic Drug Use Care Area Assessment (CAA) documented R34 had significant behaviors and remained on multiple medications to help manage. Staff would continue to monitor for behaviors and undesired effects related to her medication. The CAA noted R34 was on hospice services at that time, and she was anticipated to have a decline in all care areas. The 05/06/25 Quarterly Minimum Data Set documented the resident had a BIMS score of zero. R34 was dependent on staff assistance with all ADLs. The MDS recorded R34 received antianxiety and antidepressant on a routine basis, and no behaviors. R34's Care Plan documented interventions on 10/16/24, which directed staff to monitor behaviors and observe for patterns or triggers. Staff were instructed to redirect and remove R34 from overstimulation, offer snacks, or take her to the restroom. The plan instructed staff to monitor and document the effectiveness of mood enhancement medications. Staff were instructed to intervene as necessary to ensure the safety of the resident and others. The plan directed staff to administer medications as ordered and monitor for effectiveness and adverse side effects. Staff were instructed to talk with R34 in a calm voice when her behavior was disruptive and redirect the resident with the above interventions if the resident was crying and upset. The plan noted an intervention dated 06/11/25, which directed staff to continue as-needed (PRN) lorazepam (anti-anxiety medication). R34s Physician's Orders documented an order for Ativan (lorazepam) 0.5 milligram (mg), give 0.5mg by mouth every four hours PRN for anxiety/restlessness, date ordered 11/04/24. The order lacked a stop date or specified duration. R34's Medication Regimen Review (MRR) reviewed from 01/30/25, documented R34 had an as-needed lorazepam order, and no rationale and duration was noted. The MRR recommended to discontinue the PRN lorazepam, as it was past the 14-day limit per Centers for Medicare & Medicaid Services (CMS). The MRR noted if the lorazepam was to continue, a face-to-face rationale for continued need and expected duration was required. A Physician Response to the MRR dated 02/17/25 during a face-to-face visit documented the PRN lorazepam was for an expected duration greater than six months for a rationale of anxiety and agitation: R34 yelled and had increased anxiety. The response lacked a specified duration. R34's Physician Progress Note dated 02/17/25 lacked documentation regarding the PRN lorazepam. R34's Behavior Progress Notes reviewed from 02/01/25 through 08/14/25, R34 had three documented episodes of uncontrolled crying and laughing episodes that required no PRN medications. During an observation on 08/13/25 08:50 AM, R34 sat in her high-back wheelchair. She wore a right-hand splint. During an interview on 08/14/25 at 07:39 AM, Certified Nurse Aide (CNA) M reported R34 had no behaviors and stated that R34 laughed and smiled quite often. During an interview on 08/13/25 at 10:00 AM, Licensed Nurse (LN) G reported that R34 was in hospice, and she did not require a stop date for her as-needed lorazepam.During an interview on 08/13/25 at 01:17 PM, Administrative Nurse D reported that R34 was a hospice resident and did not require a stop date for the lorazepam. She also reported that the consulting pharmacist would recommend a stop date and believed that R34's physician had completed a face-to-face in February 2025. The facility's policy Psychotropic Medication dated 06/2025 documented Psychotropic medications will be prescribed at the lowest possible dosage for the shortest period of time and are subject to gradual dose reduction and re-review. The need to continue as-needed orders for psychotropic medications beyond the 14 days requires the practitioner document the rationale for the extended order and the specific duration of the as-needed order.

The facility had a census of 32 residents. The sample included 12 residents, with one resident reviewed for hospitalization. Based on interview and record review, the facility failed to provide a written bed hold policy and failed to issue a written notification as soon as practicable for transfers of Resident (R) 39. This placed the resident at risk for impaired rights related to returning to the facility. Findings included:Review of the Electronic Health Record (EHR), documented R39 had diagnoses acute hypoxia (a condition characterized by a relatively sudden onset inadequate supply of oxygen that are usually severe), and respiratory failure (a condition where the lungs can't adequately provide enough oxygen to the body or remove enough carbon dioxide, leading to potentially dangerous levels of oxygen and/or carbon dioxide in the blood).R39's 05/17/25 Entry Minimum Data Set (MDS) documented a Brief Interview of Mental Status (BIMS) score of 15, which indicated intact cognition. The MDS documented R39 was totally dependent on staff for transfers, toileting, and lower-body dressing. The MDS documented R39 required oxygen and bilevel positive airway pressure (BiPAP- a noninvasive ventilator that helps breathing). R39's 05/17/25 Progress Note at 11:56 PM documented R39's family requested R39 be transferred to the hospital for an evaluation. R39's EHR lacked evidence the facility provided a bed hold notice or written notification of the transfer to R39 and/or his representative.During an interview on 08/14/25 at 01:54 PM, Licensed Nurse (LN) H reported that she would complete a bed hold form and would have the family or resident sign the form if they could. LN H said if the transfer was emergent, the bed hold form would not be completed.During an interview on 08/14/25 at 01:57 PM, Social Service Designee (SSD) X reported Administrative Staff B, the Business Office Manager (BOM), would complete a bed hold form when a resident transferred to the hospital. During an interview on 08/14/25 at 02:02 PM, Administrative Staff B reported she would only do a verbal bed hold over the phone with the responsible party or the resident when they transferred to the hospital. Administrative Staff B said nursing would provide the bed hold form; however, the form did not state the cost of the room. Administrative Staff B reported she did not have a completed bed hold for R39. During an interview on 08/14/25 at 02:30 PM, Administrative Staff A stated the expectation was for staff to complete a bed hold for every transfer. Administrative Staff A said if the transfer was an emergency, staff would send it to the family the next business day or call them for a bed hold. Administrative Staff A said the nurse also sends a bed hold with the resident when they go to the hospital, but there is no rate on the form, and the resident or the responsible party could call the facility if they want to do a bed hold.The facility's policy Bed-Holds and Returns dated 01/2024, documented at the time of transfer for hospitalization or therapeutic leaves, the nursing facility must provide to the residents or resident representatives written notice which specifies the duration for the bed hold. The current bed-hold and return policy established by the state (if applicable) will apply to residents in the community. Prior to a transfer, written information will be given to the residents and the resident representatives that explains the duration of the bed-hold, the reserve bed payment policy as indicated by the state plan, and the details of the transfer.

The facility had a census of 32 residents. The sample included 12 residents. Based on observations, interviews, and record review, the facility failed to provide services to meet professional standards of care when staff signed a treatment order as completed but did not complete the treatment for Resident (R) 15. This placed the resident at risk for delayed healing and infection. Findings included:- R15 's Electronic Health Record (EHR) revealed diagnoses of depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), and diabetes mellitus (DM-when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin).R15's 05/27/25 Annual Minimum Data Set (MDS) documented a Brief Interview of Mental Status (BIMS) score of seven, which indicated severely impaired cognition. The MDS documented R15 required moderate assistance for bathing, toileting, lower body dressing, and footwear. The MDS documented R15 had one venous stasis ulcer (lesion of the lower leg due to poor circulation) and required a non-surgical dressing and application of ointment/medication. R15's 06/03/25 Functional Abilities (Self-Care and Mobility) Care Area Assessment (CAA) documented R15 continued on multiple restorative programs to maintain the resident's level of function. R15's 06/03/25 Cognitive Loss/Dementia CAA documented R15 required prompting throughout the day for activities and when to complete activities of daily living (ADLs). R15's 10/01/24 Care Plan documented R15 was anticipated to have persistent and/or recurring wounds to both lower extremities related to diabetes and lymphedema (swelling caused by accumulation of lymph). R15's 06/16/25 Care Plan documented staff were to provide treatment as ordered. R15's Physician Orders ordered the wounds to anterior(front) left lower extremity, medical (towards the middle) right lower extremity, and right medial ankle were cleansed with wound cleanser and soaked gauze for 10 minutes, then apply Skin-prep (liquid skin protectant) to peri-wound (skin surrounding the wound), apply Opticell AG (antibacterial wound dressing) to wound bed, cover with pad dressing, secure with kerlix and tape, change daily and as needed until resolved, dated ordered 06/21/25.R15's 08/13/25 Treatment Administration Record documented that Licensed Nurse (LN) G signed off completed treatment at 01:36 PM in the EHR for both lower extremities' wound care. During an observation on 08/13/25 at 09:38 AM, R15 pulled down her dressing on her left leg. Observation revealed serosanguineous (semi-thick blood-tinged) drainage on the dressing as she pulled it towards her left foot from her knee. R15 then scratched at the area, removed the ace wrap, and placed the dressing and wraps on the dining room table. Certified Nurse Aide (CNA) M walked by R15 two times but did not intervene. During an observation on 08/13/25 at 10:10 AM, CNA N removed the ace wrap and dressing from the dining room table and took them to R15's room; the tablecloth remained on the table. CNA N reported that R15's dressing was still intact on R15's legs. During an observation on 08/13/25 at 01:55 PM, R15 sat in the dining room for lunch, then for an activity. Her left lower leg dressing remained off, and serosanguinous drainage remained on her left leg. During an interview on 08/13/2025 04:12 PM, CNA O reported that if a wound was missing a dressing, the staff would let the nurse know. During an interview on 08/13/225 at 04:51 PM LN G reported she signed off the order for R15's lower extremity treatment earlier that day, around 01:30 PM, and confirmed she had not completed the wound treatment even though she signed it as completed. LN G reported she was not aware that R15 had taken the dressing off her left leg earlier that day. LN G reported that the wound treatment was ordered for 08:00 AM daily and went on to say, that ship has not sailed yet and I don't know why they schedule treatments for that time as we cannot get those done at 08:00 AM LN G reported she was too busy administering medications and would get the treatment completed before she left today. During an interview on 08/13/25 at 05:00 PM, Administrative Nurse F said she expected the staff to sign off on an order only after it was completed. The facility's policy Guidelines for Charting and Documentation, dated 01/2024, documented that services provided to the resident, or changes in the resident's medical or mental condition, shall be documented in the resident's medical record. A legal record that protects the resident, care providers, and the community. Entries shall reflect the date, the time, and the signature and title of the person recording the data.

The facility reported a census of 32 residents. The sample included 12 residents with one dependent resident reviewed for activities of daily living (ADLs). Based on observation, interviews, and record review the facility failed to provide ADL care including grooming of facial hair for Resident (R) 9. This placed the resident at risk for impaired dignity and poor hygiene. Findings included:- R9's Electronic Health Record (EHR) revealed diagnoses of Parkinson's disease (a slowly progressive neurologic disorder characterized by resting tremors, rolling of the fingers, masklike faces, shuffling gait, muscle rigidity, and weakness) and depression (a mood disorder that causes a persistent feeling of sadness and loss of interest). R9's 11/26/24 Annual Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) score of 12, which indicated moderately impaired cognition. The MDS noted R9 required set-up assistance for personal hygiene and oral care. The MDS noted R9 required moderate assistance with toileting, standing, and transfers. The 12/05/24 Functional Abilities (Self-Care and Mobility) Care Area Assessment (CAA) documented R9 continued occupational therapy and has been on and off therapy for a significant amount of time. With the progression of his Parkinson's, R9 was anticipated to continue to decline in function, which may be significant if he or his representative decide to discontinue therapy services; there may be a decline despite therapy interventions as well. The 05/27/25 Quarterly MDS documented a BIMS of 12, R9 required supervision with bathing and walking. R9 was independent in the remainder of ADLs. R9's Care Plan documented an intervention dated 06/06/24, which directed the resident required limited assistance from one of the staff with HYGIENE/ORAL CARE. The plan lacked direction related to having or removal of facial hair. R9's Point of Care documentation for tasks documented R9 had a shower completed on 08/02/25 and 08/06/25, and R9 required total assistance. A N, which indicated no, was documented under showers from 08/07/25 through 08/17/25. R9's Point of Care documentation for facial hair removal tasks from 08/01/25 through 08/14/25 was documented as Y, which indicated yes. The task directed staff to check and trim facial hair as necessary. R9's Point of Care documentation for refusal of care from 08/01/25 through 08/14/25 was documented as N. During an observation on 08/12/25 at 11:32 AM, R9 had prominent beard stubble on his face as he sat in the dining room for his lunch. During an observation on 08/14/25 at 07:30 AM, R9 was at the dining room table eating breakfast. R9 still had prominent beard stubble on his face. During an interview on 08/12/25 at 02:31 PM, R9 reported he wished he could shave himself and stated he would not do well because his hands shake. He stated he would need help from the staff. During an interview on 08/14/25 at 07:46 AM, CNA M reported residents were offered shaves on their bath days. During an interview on 08/14/25 at 10:50 AM, CNA N reported R9 could not shave himself; he would be shaved on shower days. CNA N said, R9 was showered and shaved on that day. CNA N stated staff should offer R9 a shave or shave him when requested. During an interview on 08/14/25 at 02:27 PM, Administrative Nurse F reported R9 would refuse a shower often. She expected staff to offer and complete facial hair on residents who required assistance. Administrative Nurse F reported that R9's personal hygiene for shaving was not addressed on his care plan. Administrative Nurse F reported that a Y charted in point of care documentation in HER would be a yes that the facial hair was completed when she reviewed the CNA documentation in EHR. The facility's policy Shaving the Resident dated 01/2024 documented the purpose of this procedure was to promote cleanliness and provide skincare. Review the resident's care plan to assess for any special needs of the resident. Document the date and time of the shave, and how the resident participated in the procedure.

The facility reported a census of 32 residents; the sample included 12 with five residents reviewed for unnecessary medications and related monitoring. Based on observation, interview, and record review revealed the facility failed to monitor and respond to Resident (R)14 and R36 for lack of bowel movements. This placed the residents at risk for complications including constipation and bowel obstruction. Findings included:- R14's Electronic Health Records (EHR), under the Physician Orders (POS), documented diagnoses which included dementia (a progressive mental disorder characterized by failing memory and confusion), hypothyroidism (a condition characterized by decreased activity of the thyroid gland), hypovolemia (abnormally low circulating blood volume), and constipation (difficulty passing stools),R14's 4/15/25 Annual Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) score of nine, indicating moderate cognitive impairment. The MDS noted R14 was frequently incontinent of bowel, without a toileting program, and/or constipation.The Urinary Continence and Indwelling Catheter Care Area Assessment (CAA), dated 04/20/25, documented the resident was incontinent of bowel and bladder. She did not usually know when she needed to be toileted. R14's Care Plan dated 7/13/25, directed staff to provide check and change for incontinent episodes. R14's POS listed in the EHR documented the resident had an order for MiraLAX Powder (laxative), 17grams (gm)/scoop, by mouth, daily, mixed in 8eight ounces of water or liquid for constipation ordered 10/29/24. Review of R14's bowel movement frequency in the EHR dated 07/16/25 through 8/14/25 revealed the resident exceeded three days/72 hours without a bowel movement and/or treatment from 07/26/25 through 08/02/25 (seven consecutive days).On 08/12/25 at 01:48 PM, R14 sat at the dining room table adjacent to her room. She verbalized no concerns. On 08/14/25 at 08:30 AM, Licensed Nurse (LN) H administered R14's morning medication. She confirmed the resident was taking routine medications to treat constipation, but frequently refused her medications. LN H stated the administrative nursing staff generated a report daily to inform the nursing staff of residents that failed to have a bowel movement every three days. She stated when staff were made aware of the lack of a bowel movement within that timeframe, the nurses should initiate interventions to treat constipation, which included an assessment and Milk of Magnesium (laxative- a substance that eases the passage of stool). On 08/14/25 at 09:46 AM, Certified Nurse Aide (CNA) P reported sometimes R14 would refuse care. CNA P stated the CNAs should notify the nurse if the resident does not have a bowel movement during the shift, and document it in the EHR. She reported she was not aware R36 had issues with constipation. CNA P said the administrative nursing staff created a report for the nurses to monitor the frequency of bowel movements, and the nurses then initiated treatment if the resident did not have a bowel movement in three days. On 08/14/25 at 10:53 AM, Administrative Nurse D confirmed R14 lacked a bowel movement as noted above, which exceeded the three-day period where she would expect the nursing staff to intervene and initiate treatment in accordance with the standard of care. Administrative Nurse D stated staff should initiate interventions of assessment of bowel sounds and, if indicated, initiate prune juice followed by milk of magnesia, and if no results, staff should notify the physician to obtain orders for continued treatment as indicated. She stated the facility lacked a formal protocol with standing orders to follow up on residents without bowel movements for three consecutive days/72 hours. Administrative Nurse D confirmed R36 received a routine daily order to prevent constipation, which the facility should monitor for effectiveness.On 08/14/25 at 11:43 AM, Administrative Nurse F said she ran a daily report to determine when residents lacked a bowel movement for 72 hours/three days, which she reviewed with the nurses who then were expected to follow up with the provider and initiate treatment. Administrative Nurse F said there was not a system in place to ensure monitoring of bowel movement frequency when she was off two days a week, on vacation, or for our consecutive days off, as was the case on the dates noted above. Additionally, she confirmed R 36 received scheduled medications, which had adverse side effects of constipation the facility should monitor.The facility did not provide a policy to address the monitoring of residents to prevent constipation.- R36's Electronic Health Records (EHR), under Physician Orders (POS), dated 07/16/25, documented diagnoses which included pain, hypothyroidism (a condition characterized by decreased activity of the thyroid gland), and constipation (difficulty passing stools).R36's 04/01/25 Annual Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) score of 13, indicating cognitively intact. The MDS noted she required supervision or touching assistance of staff with toilet transfers and partial/moderate assistance of staff for toileting hygiene. She was frequently incontinent of bowel, without a toileting program, and/or constipation. She was occasionally incontinent of bowel without constipation. The resident received scheduled and as-needed (PRN) pain medication, which included opioids (strong narcotic to treat pain).R36's 07/01/25, Quarterly MDS, documented changes in assessment of the BIMS score of 14, indicating cognitively intact, and the resident was always continent of bowel.The Care Area Assessment (CAA)documentation, dated 04/09/25, included the resident was incontinent of bowel and bladder. R36's Care Plan dated 06/26/25, documented staff should administer medications as indicated and monitor for effectiveness and side effects, which included constipation. The plan directed staff R36 required two staff for support for toileting and to offer prompted toileting every two to three hours while the resident was awake; check and change every two hours while sleeping at night.R36's POS, dated 07/16/25, documented the following ordered medications for treatment of constipation:MiraLAX (dissolvable laxative) 17-gram, oral packet, by mouth, daily, for constipation ordered 10/16/24Probiotic Formula (dietary supplement for digestive health) one billion-25, by mouth, daily, for constipationR36's POS dated 07/16/25 documented the following physician-ordered medications with side effects, which included constipationTramadol (pain medication) 50 milligrams (mg) tablet, by mouth, every eight hours for pain, ordered 02/19/25.Lasix (used to promote the formation and excretion of urine) 20 mg, by mouth, daily for edema (swelling), ordered 03/18/25Calcium Carbonate (dietary supplement) 500 mg, by mouth, twice a day for supplement, ordered 12/21/24.Oxycodone (opioid medication) 5.0 mg tablet, by mouth, daily PRN for pain, ordered 12/02/23Review of R36's bowel movements from 07/16/25 through 8/14/25 revealed the resident had more than three days/72 hours without a bowel movement and/or treatment on 07/23/25 through 07/27/25 (four consecutive days) and 07/31/25 through 08/04/25 (four consecutive days).Review of the No BM 9 shifts (8-hour shifts) communities report revealed the facility lacked a report for 07/23/25 through 07/27/25, and 08/01/25 through 08/03/25, to notify the nursing staff of the resident with episodes of no BM for nine shifts/ 72 hours/three consecutive days on those occasions. On 08/12/25 at 01:53 PM, R36 sat in her chair in her room. R36 stated she had no complaints of pain. She reported she usually knew when she needed to go to the bathroom and said staff checked on her and would help her when she needed to use the toilet. On 08/14/25 at 9:46 AM, Certified Nurse Aide (CNA) P stated CNAs should notify the nurse if the resident does not have a bowel movement during the shift and document in the EHR. She reported she was not aware R36 had issues with constipation. CNA P said the administrative nursing staff created a report for the nurses to monitor the frequency of bowel movements, and the nurses then initiated treatment if the resident did not have a bowel movement in three days. On 08/14/225 at 10:53 AM, Administrative Nurse D confirmed R36 lacked a bowel movement as noted above, which exceeded the three-day period where she would expect the nursing staff to intervene and initiate treatment in accordance with the standard of care. Administrative Nurse D stated staff should initiate interventions of assessment of bowel sounds and, if indicated, initiate prune juice followed by milk of magnesia, and if no results, staff should notify the physician to obtain orders for continued treatment as indicated. She stated the facility lacked a formal protocol with standing orders to follow up on residents without bowel movements for three consecutive days/72 hours. Administrative Nurse D confirmed R36 received a routine daily order to prevent constipation, which the facility should monitor for effectiveness.On 08/14/25 at 11:43 AM, Administrative Nurse F said she ran a daily report to determine when residents lacked a bowel movement for 72 hours/three days, which she reviewed with the nurses who then were expected to follow up with the provider and initiate treatment. Administrative Nurse F said there was not a system in place to ensure monitoring of bowel movement frequency when she was off two days a week, on vacation, or for our consecutive days off, as was the case on the dates noted above. Additionally, she confirmed R 36 received scheduled medications, which had adverse side effects of constipation the facility should monitor.The facility did not provide a policy to address the monitoring of residents to prevent constipation.

The facility reported a census of 32 residents. The sample included 12 residents. Based on interviews, observation and record review, the facility failed to utilize Enhanced Barrier Precautions (EBP-infection control interventions designed to reduce transmission of resistant organisms which employ targeted gown and glove use during high contact care) when providing direct care to a Resident (R) 42 with a peripherally inserted central catheter (PICC-a thin, flexible tube that is inserted into a vein in the upper arm and threaded into a large vein above the heart). The facility further failed to ensure adequate hand hygiene during personal care for R3 when staff failed to complete proper hand hygiene. The facility failed to store respiratory equipment in a sanitary manner for R6. These deficient practices had the potential to spread infections to the residents in the facility.Findings included:- Observation on 08/12/25 At 11:54 AM, R6 had oxygen tubing dated 08/03/25 stored in a plastic bag attached to an oxygen concentrator. The plastic bag had a large hole noted on the bottom and side of the bag and the plastic bag laid on R6's floor. Observation on 08/12/25 at 11:59 AM, Certified Nurse Aide (CNA) P provided peri-care to R3. CNA P removed her gloves and applied a clean pair of gloves, but did not perform hand hygiene prior to donning the clean gloves.Observation on 08/13/25 at 09:32 AM, Licensed Nurse (LN) H, applied gloves but no gown, then administered Cefazoline (antibiotic) 2 grams (gm), 100 milliliters (ml) normal saline, every 8 hours for sepsis (a life-threatening systemic reaction that develops due to infections that cause inflammation throughout the entire body) via intravenous (IV-administered directly into the bloodstream via a vein) to R42 through the PICC line. LN H stated she should have worn a gown when providing care to resident on EBP.Observation on 08/13/25 at 10:03 AM, CNA N provided peri-care to R15. CNA N removed her glove from her right hand in between the dirty and clean during peri-care provided and applied a new glove to her right hand without performing hand hygiene. CNA N stated she should have removed both gloves and performed hand hygiene between clean and dirty actions of the task.Observation on 08/13/25 at 10:19 AM, R6 had oxygen tubing dated 08/03/25 stored in a plastic bag attached to an oxygen concentrator. The plastic bag had a large hole noted on the bottom and side of the bag, and the plastic bag laid on R6's floor. Observation on 08/13/25 at 10:23 AM, LN H disconnected R42's IV. She removed her gown, but her gloves remained on as LN H exited R42's room. LN H closed R42's door with the handle, with gloved hands, and walked into the hallway. LN H stated she should have removed gloves and sanitized hands before leaving the resident's room.During an interview on 08/13/25 at 03:28 PM, Administrative Nurse E, the Infection Preventionist nurse, stated they expected staff to wear all required PPE for all residents that had EBP. Administrative Nurse E stated they expected staff to remove all PPE prior to exiting a resident's room and complete hand hygiene.During an interview on 08/14/25 at 10:55 AM, CNA N reported the oxygen tubing storage bag should not be placed on the floor and should not have several holes in the bag.During an interview on 08/14/25 at 11:30 AM, Administrative Nurse E expected staff to remove both gloves after peri-care was performed, perform hand hygiene before applying new gloves to complete peri-care. Administrative Nurse E expected respiratory supplies to be stored in a bag when not in use, placed off the floor with no holes in the bag.The facility's policy Standard and Transmission-Based Precautions dated 06/2025 documented that it is our policy to take appropriate precautions to prevent transmission of pathogens, based on the pathogen's mode of transmission. Hand Hygiene should be performed immediately before touching a patient, before moving from work on a soiled body site to a clean body site on the same resident, after touching a resident or the resident's immediate environment, and immediately after glove removal. Each community will fully implement Enhanced Barrier Precautions. Shall be implemented during high-contact resident care activities when caring for residents who have an increased risk for acquiring and/or transmitting multiple drug-resistant organisms (MDROs- common bacteria that have developed resistance to multiple types of antibiotics), such as a resident with wounds, indwelling medical devices, and residents with colonization with an MDRO.The facility did not provide a policy on the care of respiratory supplies.

The facility reported a census of 35 residents with 15 selected for review which included three residents reviewed for accidents. Based on observation, interview and record review, the facility failed to ensure staff safely transferred two sampled residents, including Resident (R)27 with the required mechanical sit to stand lift which resulted in three metatarsal (bone in toe) fractures and failed to use a gait belt for R10. Findings included: - Review of Resident (R)27's Physician Order Sheet, dated 11/08/23, revealed diagnosis included atrial fibrillation (rapid, irregular heartbeat), chronic kidney disease, congestive heart failure (a condition with low heart output and the body becomes congested with fluid), and history of back fracture. The Admission Minimum Data Set (MDS), dated [DATE], assessed the resident with a Brief Interview for Mental Status (BIMS) Score of 15 which indicated normal cognitive function. The resident required extensive assistance of two staff for transfer. The Fall Care Area assessment dated [DATE] assess the resident had multiple falls in the past six months and was working with therapy services to address her physical and safety awareness status. The Quarterly MDS dated [DATE] assessed the resident with a BIMS score of 8 which indicated moderate cognitive impairment and required extensive assistance of two staff for transfers. The Care Plan revised 10/23/23, contained an entry dated 07/24/23, which instructed staff the resident required extensive assistance of two persons with the sit to stand lift. On 10/23/23, the resident required a full body mechanical lift for transfers. The Care plan updated 10/24/23, instructed staff the resident could bear weight as tolerated with the surgical shoe in place to prevent adverse reaction to her fractured toes. Staff instructed to ensure the resident had nonskid footwear on and to use the sit to stand mechanical lift for transfers. Review of the Facility Complaint Investigation Report number 3654, completed 10/31/23, revealed the following: On 10/22/23, the resident reported pain in her left foot and voiced concern it occurred during a transfer. The resident's physician instructed staff to obtain an x-ray, which showed a possible fracture of her left foot (toes two through four) and was referred to an orthopedics/podiatry for confirmation of the fracture. Upon further questioning, the resident stated to Administrative Nursing Staff E, that CNA MM transferred her without the use of the sit-to-stand lift. Administrative Nursing Staff E and Administrative Staff A interviewed CNA MM, who admitted to transferring the resident without use of the sit-to-stand lift. CNA MM stated the resident's foot got caught in the front wheel of her wheelchair. A Nurse's Note, dated 10/22/23 at 08:34 PM, revealed the resident voiced pain in her left lateral foot, rated an 8 out of 10 with movement or touch. The resident reported to the nurse that her foot was injured during a transfer with the sit to stand lift. A Nurse's Note, dated 10/23/22 at 10:15 AM, revealed the physician assistant made rounds and ordered an x ray of the residents left foot due to pain. The Final Report Xray results, dated 10/23/23, revealed possible acute nondisplaced fractures of the second, third and fourth proximal phalangeal (first bone in the toes) and clinical correlation recommended with follow up x rays to assess for interval healing. A Nurse's Note, dated 10/23/23 at 2:59 PM, revealed the Physician Assistant ordered a referral to orthopedic surgeon due to x ray report of possible left foot acute nondisplaced fracture of the second, third and fourth proximal phalangeal bones. A Physician's Note dated 10/24/23, revealed the resident had edema and pain to her left (foot) digits with no deformity and the Xray showed nondisplaced fracture of the bases of digits two through 4. A Physician's Order, dated 10/24/23, instructed staff to apply a surgical shoe to the resident's left foot. Interview, on 11/13/23 at 10:42 AM with the resident revealed the resident had three broken toes on her left foot but could not remember how it happened. The resident had support hose on both legs and the surgical shoe on her left foot. The resident stated the toes were not as painful now but were very painful when the incident occurred. Interview, on 11/23/23 at 02:45 PM, with Administrative Staff A, revealed the facility investigated the allegation and discovered the Certified Nurse Aide (CNA)MM, transferred the resident on 10/22/23 without the required sit to stand mechanical lift, which resulted in her foot injury. Observation, on 11/14/23 at 11:20 AM, revealed Certified Nurse Aide (CNA) P and CNA Q transferred the resident with the sit to stand lift without incident. CNA P stated the resident has always been transferred with the either the sit to stand lift or full body lift. Interview on 11/14/23 at 07:13 PM, with CNA MM, confirmed that on 10/22/23, she transferred the resident from her bed to wheelchair with a gait belt and no other staff assistance. During the transfer the resident's foot got caught on the wheelchair wheel. CNA MM confirmed the resident required a sit to stand lift for transfers, but the resident wanted to be transferred quickly. CNA MM stated she transferred the resident without the sit to stand lift prior to this incident without difficulty. Interview, on 11/15/23 at 11:09 AM, with Administrative Nurse E, confirmed the resident had three left foot fractured metatarsals two through four when her foot got caught on the wheelchair wheel due to CNA MM's inappropriate transfer of the resident on 10/22/23. Administrative Nurse E confirmed CNA MM did not use the sit to stand lift for the resident's transfer on 10/22/23, and admitted she transferred the resident without the lift on previous transfers. Interview, on 11/14/23 at , with Medical Consultant GG, revealed she would expect staff to transfer the resident as care planned to prevent injury. The facility policy Using the Care Plan dated 01/2023, instructed staff to develop the resident's daily care routines and is available to associates providing care and services. The facility policy Safe Lifting and Moving of Patients, dated 01/2022, instructed staff to use appropriate techniques and devices to lift and move residents. The facility failed to ensure staff provided safe transfer for this resident who required extensive assistance of two staff for transfers with the use of a sit to stand mechanical lift, which resulted in fractures of the left foot second, third and fourth digits and pain. 34056 - Review of Resident (R)10's electronic medical record (EMR) revealed diagnoses which included: morbid obesity (a serious health condition resulting from an abnormally high body mass) and schizoaffective disorder (a mental disorder in which a person experiences a combination of symptoms). The Annual Minimum Data Set (MDS), dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. She required extensive assistance of two staff for transfers. Her balance was not steady, and she was only able to stabilize with staff assistance. She had no falls since her prior assessment. The Falls Care Area Assessment (CAA), dated 12/09/22, documented the resident was at a high risk for falls. The Quarterly MDS, dated [DATE], documented the resident had a BIMS score of 15, indicating intact cognition. She required extensive assistance of one staff for transfers and had steady balance. She had no falls since her prior assessment. The care plan, revised 09/26/23, instructed staff the resident required limited assistance of two staff for transfers. Review of the resident's electronic medical record (EMR) revealed fall assessments, dated 10/05/23, 09/06/23 and 06/06/23, which placed the resident at a moderate risk for falls. Review of a Fall Report, dated 10/02/23, provided by the facility, documented the resident had a non-injury fall in the shower room on 10/02/23 at approximately 06:50 AM. After Certified Nurse Aide (CNA) O finished dressing the resident and putting her shoes and socks on, following her shower, the resident got up out of the shower chair to transfer to her wheelchair. The resident stated she could not stand any longer and fell to the floor and then to her side. CNA O had not utilized a gait belt during the transfer. On 11/15/23 at 11:54 AM, CNA O stated she had not used a gait belt at the time of the fall, but she should have used one with the resident. On 11/15/23 at 11:13 AM, Administrative Nurse D stated the staff should always use a gait belt while transferring residents. The facility policy for Safe Lifting and Moving of Patients, retrieved 11/2023, included: In order to protect the safety and well-being of residents and to promote quality care, this community uses appropriate techniques and devices to lift and move residents. The facility failed to properly transfer this dependent resident with a gait belt, which resulted in a non-injury fall.

The facility reported a census of 35 residents. Based on observation, record review and interview, the facility failed to prepare and serve food under sanitary conditions, to the residents of the facility appropriately to prevent the potential for food borne bacteria. Findings included: - During an initial tour of the kitchen on 11/14/23 at 10:03 AM, the following areas of concern were noted: 1. The white freezer had food debris on the bottom shelf. 2. The ice machine drainage pipe lacked an air gap and rested directly touching on the grate of the floor drain. 3. The stationary can opener had dried, sticky food debris on the tip and on the surrounding holding device. 4. A large fan which blew directly onto the shelf where pots and pans were placed to dry, had a heavy build-up of dust and debris on the cage surrounding the blades. The fan was on and blowing at the time of the initial tour and again on a follow up visit to the kitchen. The facility policy for Sanitation and Infection Prevention/Control, revised 01/2023, included: A basic sanitation inspection is conducted at least once per month to ensure that established procedures are being followed and that sanitation standards are maintained. Cleaning schedules and frequencies are revised based on inspection findings. The facility failed to prepare and serve food under sanitary conditions, to the residents of the facility appropriately to prevent the potential for food borne bacteria.

The facility reported a census of 35 residents. Based on observation, interview and record review, the facility failed to maintain an effective infection control program with the failure to ensure sanitary storage of clean linen in the beauty shop, lack of housekeeping staff knowledge of cleaning products for clostridium difficile (a spore producing highly transmissible bacteria), use of expired sanitizing wipes, and unsanitary catheter care for resident (R)33. Findings included: - Observation, on [DATE] at 09:30 AM, during the environmental tour of the facility, revealed the beauty shop contained plastic wrapped clean towels placed directly on the floor. Administrative Staff A stated she would expect all staff to ensure towels were stored off the floor to prevent contamination. Furthermore, interview, on [DATE] at 11:30 AM, with Housekeeping Staff W, revealed she did not know what cleaning solutions were required to clean an isolation room for clostridium difficile and thought the nursing staff would provide the cleaning supplies. Housekeeping Staff W obtained a container of sanitizing wipes from the storeroom and stated staff used the wipes for general cleaning. The expiration date on three of these containers was expired with date of [DATE]. An opened container of the same wipes was on the nurses' station with the expiration date [DATE]. Interview on [DATE] at 01:00 PM, with Administrative Nurse D, revealed she would expect housekeeping staff to know what cleaning products to use for clostridium difficile isolation rooms. Administrative Nurse D stated staff use wipes containing bleach for cleaning an isolation room for clostridium difficile. Administrative Nurse D confirmed the general cleaning wipes were expired and should be replaced. The facility policy Cleaning and Disinfection of Environmental Surfaces dated ,d+[DATE], instructed staff to clean environmental surfaced according to the current CDC (Center for Disease Control) recommendations. If an EPA (Environmental Protection Agency) registered sodium hypochlorite (bleach) product was not available a generic version of sodium hypochlorite may be used. The facility policy Infection Prevention and Control program dated ,d+[DATE], instructed staff to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable diseases and infections. The facility failed to maintain an effective infection control program to ensure staff stored towels in a sanitary manner, had knowledge of cleaning products required for clostridium infections, and ensured stock cleaning items were not past the expiration date to prevent the spread of infections. 34056 - The undated Physician Order Sheet (POS) for Resident (R)33 documented a diagnosis of neuromuscular dysfunction of the bladder (when a person lacks bladder control due to brain, spinal cord, or nerve problems). The Admission Minimum Data Set (MDS), dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. He had an indwelling urinary catheter (a thin tube inserted into the bladder to drain urine). The Urinary Incontinence and Indwelling Catheter Care Area Assessment (CAA), dated [DATE], documented the resident had an indwelling urinary catheter and required staff assistance to maintain it. The care plan, dated [DATE], instructed staff the resident required assistance with the indwelling urinary catheter. Review of the resident's electronic medical record (EMR) revealed a physician's order, which included: Catheter care every shift, ordered [DATE]. On [DATE] at 08:55 AM, Certified Nurse Aide (CNA) M entered the resident's room to empty his catheter bag. CNA M disconnected the nozzle from the port of the catheter bag and placed it inside a used urinal. The tip of the nozzle came into direct contact with the inside of the urinal multiple times while 400 cubic centimeters (ccs) of urine was drained from the bag into the urinal. CNA M then wiped the tip of the nozzle with a peri-wipe cloth and reconnected the nozzle into the port of the catheter bag. On [DATE] at 08:55 AM, CNA M stated this was how she always emptied the resident's catheter bag and always used a peri-wipe to cleanse the nozzle before reinserting into the port of the catheter bag. On [DATE] at 11:13 AM, Administrative Nurse D stated it was the expectation that staff not allow the tip of the nozzle to contact with the inside of the urinal while draining urine from the catheter bag. The facility policy for Catheter Care, Urinary, revised ,d+[DATE], included: Avoid contact of the drainage spigot with the nonsterile container while draining urine. The facility failed to properly drain the urine from the catheter bag into the urinal for this dependent resident with an indwelling urinary catheter.

The facility reported a census of 35 residents. Based on observation, interview and record review, the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents and staff regarding the parameter of the kitchen floor containing trash and debris. Findings included: - During an initial tour of the kitchen on 11/14/23 at 10:03 AM, the following area of concern was noted: The parameter of the kitchen floor contained food and trash debris throughout. On 11/15/23 at 10:01 AM, Dietary staff BB confirmed the kitchen floor needed to be cleaned around the parameter. The cleaning schedule for the kitchen, used as a cleaning policy, revealed the kitchen floor was to be mopped every shift. The facility failed to provide a safe, functional, sanitary and comfortable environment for residents and staff.

The facility reported a census of 35 residents. Based on observation and interview, the facility failed to ensure the beauty shop exhaust ventilation remained in good working order for the residents of the facility. Findings included: - Observation, on 11/14/23 at 02:30 PM, with Beauty Shop Operator V, revealed she did not know if the beauty shop had an exhaust fan, but that she provided very few permanents that would create foul odors. Observation, on 11/15/23 at 09:03 AM, with Maintenance Staff U and Administrative Staff A during the environmental tour, revealed the ventilation exhaust fan was non-working. Administrative Staff A stated the fan was checked once a year and staff did not report that fan was not working, and the damper was probably non-functioning. The facility lacked a policy for maintenance of the beauty shop exhaust fan. The facility failed to ensure the beauty shop exhaust fan was maintained in good working order as required for the residents of the facility who utilize the beauty shop.

The facility reported a census of 35 residents with 15 selected for review which included six residents observed for medication administration. Based on observation, interview and record review, the facility failed to ensure appropriate storage of one Resident (R)19's inhaler of the six residents observed. Findings included: - Review of Resident (R) 19 Physician Order Sheet, dated 11/10/23, instructed staff to administer Advair disckus (an inhaled medication containing a steroid and broncho dilator) 100/50 micrograms one inhalation twice a day for chronic obstructive pulmonary disease (COPD- progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing). Observation, on 11/14/23 at 08:08 AM, revealed Licensed Nurse (LN) H, prepared to administer morning medications to Resident (R)19. LN H could not find the resident's inhaler in R19's box in the medication cart. LN H looked in the resident's room and was unable to find the inhaler. The resident was sitting at the common dining room table. LN H noted the inhaler in a flower arrangement on the table the resident sat at. Interview, with the resident revealed she used the inhaler at supper 11/13/23, and staff must have picked it up and placed it in the flower arrangement. Interview, on 11/15/23 at 11:30 AM, with Administrative Nurse E, revealed she would expect staff to store medications appropriately. The facility policy Storage of Medications, dated 12/2021, instructed staff to store medications in an order manner in resident assigned cabinets and drawers of carts to prevent the possibility of mixing of medications of several residents. Staff were responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner. The facility failed to ensure staff stored this resident's inhaler in a safe, sanitary manner to prevent the spread of infection, or inadvertent use by another resident.

The facility reported a census of 15 residents. The facility had one central kitchen where food was stored and prepared for one dining room. Based on observation, staff interview, and record review, the facility failed to store food under sanitary conditions which could affect all the facility residents. Findings included: - During the initial tour of the central kitchen on 12/03/20 at 09:15 AM, revealed in the dried food pantry, a bag of mashed potatoe flakes and a large bag of cereal, both were open with no date. A cart used for sandwiches had Swiss cheese with a use-by date of 12/02/20, a container of sliced onions with a use-by date of 11/29/20, a container of sliced tomatoes with a use-by date of 11/29/20, a container of shredded lettuce with a use-by date of 12/01/20 and a container of shredded cheese with no date on it. These food items were removed and disposed of by Dietary Staff B. Tour on 12/03/20 at 09:15 AM, of the walk-in refrigerator contained a large bag of lettuce and a bag of dill past the use-by date of 11/29/20. On a shelf in the central kitchen, a large containers of parsley, cornmeal, and lentil beans were past the use-by date. Dietary Staff A then removed all the food items and disposed of them into the trash can. During an interview on 12/03/20 at 09:30 AM, Dietary Staff A reported staff were to date food with a use-by date when opened. He acknowledged the food items found were outdated, and he removed the items. Review of the facility policy titled Food Purchasing and Storage updated 01/2019 documented food must be date marked if it is prepared on site and refrigerated, or commercially processed foods must be date marked after the original container is opened. The facility failed to store food under sanitary conditions by ensuring food was not utilized outside of the expiratory dates.

The facility had a census of 33 residents, with five residents selected for sample. Three sampled residents discharged /transferred from the facility to another facility within the past two months. Based on interview and record review, the facility failed to communicate appropriate information (contact information of the practitioner responsible for care of the resident, resident representative information including contact information, Advance Directive information, all special instructions for ongoing care, and/or comprehensive care plan goals) to the receiving health care facility for three of three residents. (Resident (R) 1, R4, and R5) Findings included: - Resident (R)1 admitted to the facility on [DATE] and transferred to another long term care (LTC) facility on 08/27/19. Discharge/transfer documents included an 08/27/19 Discharge Instructions for Care with specific sections included for documentation of R1's information. The document lacked information related to R1's prescribed diet, physician contact information, pharmacy name/contact information, follow up appointments scheduled for R1, and a signature of the person who completed the form. An 08/27/19 Universal Transfer Form also included specific sections to record information about R1. The document lacked information related to laboratory testing and results, advanced directives, fall history while residing at the facility, cognitive status, use of antibiotics within the previous two weeks, follow up appointments, and the resident's skin condition at the time of discharge. During a confidential interview on 09/10/19 at 03:50 PM, a former resident's unidentified family member reported the facility failed to advise the receiving facility of scheduled medical/surgical appointments upon transfer which resulted in the resident missing the appointments. During an interview on 09/11/19 at 03:30 PM, Administrative Nurse D reported the advanced directive and diet information could be found on the copies of orders sent with the resident upon transfer/discharge. Administrative Nurse D confirmed the receiving facility should not have to sort through multiple documents in order to find out basic information about residents. The facility's 12/2016 Transfer or Discharge, Preparing a Resident for policy directs nursing staff to prepare the discharge summary and post-discharge plan of care. The policy lacks guidance related to completion of the discharge forms and/or required information that should be provided to the receiving facility. The facility failed to communicate appropriate information about R1 (current diet, physician contact information, pharmacy name and contact information, follow up appointments, laboratory test results, advanced directives, fall history while residing at the facility, cognitive status, use of antibiotics in the previous two weeks, and skin condition at the time of transfer) to the receiving health care facility upon transfer. - Resident (R) 4 admitted to the facility on [DATE] and discharged to another long term care (LTC) facility on 07/30/19. Discharge/transfer documents included an 07/29/19 Universal Transfer Form which included specific sections to record information about R4. The document lacked information related to a summary of the resident's inpatient course while at the facility, cognitive status for decision making, diet orders, follow up appointments, use of antibiotics within the previous two weeks, and skin condition at the time of discharge. During a confidential interview on 09/10/19 at 03:50 PM, a former resident's unidentified family member reported the facility failed to advise the receiving facility of scheduled medical/surgical appointments upon transfer which resulted in the resident missing the appointments. During an interview on 09/11/19 at 03:30 PM, Administrative Nurse D reported the advanced directive and diet information could be found on the copies of orders sent with the resident upon transfer/discharge. Administrative Nurse D confirmed the receiving facility should not have to sort through multiple documents in order to find out basic information about residents. The facility's 12/2016 Transfer or Discharge, Preparing a Resident for policy directs nursing staff to prepare the discharge summary and post-discharge plan of care. The policy lacks guidance related to completion of the discharge forms and/or required information that should be provided to the receiving facility. The facility failed to communicate appropriate information about R4 (summary of the resident's stay at the facility, cognitive status for decision making, diet orders, follow up appointments, use of antibiotics within the previous two weeks, and skin condition at the time of discharge) to the receiving health care facility upon transfer. - Resident (R) 5 admitted to the facility on [DATE] and discharged to another long term care (LTC) facility on 08/27/19. Discharge/transfer documents included an 08/27/19 Discharge Instructions for Care with specific sections included for documentation of R1's information. The document lacked information related to R5's follow up appointments. Transfer documents also included an 08/27/19 Universal Transfer Form which included specific sections to record information about R5. The document lacked information related to laboratory testing and results while a resident at the facility, advanced directives, recent falls, a summary of the resident's inpatient course, cognitive status for decision making, current use of antibiotics and/or use of antibiotics in the previous two weeks, and follow up appointments. During a confidential interview on 09/10/19 at 03:50 PM, a former resident's unidentified family member reported the facility failed to advise the receiving facility of scheduled medical/surgical appointments upon transfer which resulted in the resident missing the appointments. During an interview on 09/11/19 at 03:30 PM, Administrative Nurse D reported the advanced directive and diet information could be found on the copies of orders sent with the resident upon transfer/discharge. Administrative Nurse D confirmed the receiving facility should not have to sort through multiple documents in order to find out basic information about residents. The facility's 12/2016 Transfer or Discharge, Preparing a Resident for policy directs nursing staff to prepare the discharge summary and post-discharge plan of care. The policy lacks guidance related to completion of the discharge forms and/or required information that should be provided to the receiving facility. The facility failed to communicate appropriate information about R5 (follow up appointments, lab tests and results, advanced directives, recent falls, a summary of the resident's stay at the facility, cognitive status for decision making, and current use of antibiotics and/or use of antibiotics in the previous two weeks) to the receiving health care facility upon transfer.

The facility had a census of 33 residents, with five residents selected for sample. Based on observation, interview, and record review the facility failed to maintain a peripherally inserted central catheter (PICC- a form of intravenous access that can be used for a prolonged period of time) for one of five sampled residents. (Resident (R) 3) Findings included: - Resident (R)3 admitted to the facility on [DATE] following hospitalization for multiple rib fractures which resulted from a fall at home. The 09/05/19 Admission Nursing Assessment noted the presence of a peripherally inserted central catheter line in R3's right upper arm. The 09/05/19 physician orders [REDACTED]. R3's initial care plan initiated at the time of admission on 09/05/19 lacked mention of the PICC line in the right upper arm. An 09/08/19 Interdisciplinary Note written at 04:41 PM described the removal of the PICC line to R3's right upper extremity. Review of medication administration records and treatment records for the time period from 09/05/19 - 09/08/19 lacked evidence of flushes and/or care of the PICC line during that three day time period. During an interview on 09/11/19 at 10:00 AM, R3's unidentifed family member reported she told staff about the presence of the PICC line on the date of admission on 09/05/19. According to the unidentified family member, she advised nurses on several occasions the need to flush the line two or three times a day to prevent a blood clot. The unidentified family member reported, No one listened to me. I just knew he would get a blood clot since they weren't taking care of it. During an interview on 09/11/19 at 03:30 PM, Administrative Nurse D reported the admitting nurse noted the presence of the PICC line in R3's right upper arm but failed to contact the physician to either get an order to continue the PICC line or remove it. Administrative Nurse D confirmed the PICC line remained in R3's right upper arm until 09/08/19 when staff obtained a physician's orders [REDACTED]. In response to a request for policy related to routine care/maintenance of a PICC line, the facility provided an undated Infusion Maintenance Table which included specific types of intravenous devices, including PICC lines. That document listed maintenance requirements for different types of PICC lines, including routine flushes of the lines with normal saline and/or injection of [MEDICATION NAME], a substance that prevent blood clot formation. The facility failed to have a physician's orders [REDACTED]. monitor/flush the PICC line for a three day time period.

The facility census total 32 with 14 residents in the sample. Based on observation, interview and record review the facility failed to inform 4 residents of their right to formally file a complaint to the State of Kansas and the 4 residents were unaware of the location of the Ombudsman contact information. (#1, #7, #8, #12) Findings included: - Interview with residents #1 #7, #8, #12 in a resident council meeting held on 7/1/19 revealed the residents were not aware of the location of the Ombudsman contact information, or the location of information on how to file a complaint with the State of Kansas. Observation of the facility during entrance on 7/2/19 revealed no obvious location of list of names, addresses (mailing and email), and telephone numbers of all pertinent State regulatory and informational agencies, resident advocacy groups such as the State Survey Agency, the State licensure office, and the State Long-Term Care Ombudsman program, or information and contact information for filing grievances or complaints concerning any suspected violation of state or federal nursing facility regulations. Interview with social service staff A on 7/8/19 at 8:23 AM revealed that he/she did not always go over on how to file a formal complaint with the State or how to contact the Ombudsman. The facility recently went through a remodel and the informational posters were removed from the walls and were not put back up. The information that was posted on the walls was obviously too high for a resident in a wheelchair to read. Review of the policy regarding complaints and grievances dated 12/20/17 revealed the purpose of the policy was to provide residents and family members/legal representatives the opportunity to voice complaints and grievances, posters will be available and posted prominently throughout the community with contact information for independent entities or governmental agencies. The facility failed to post required notices in a conspicuous place for residents and visitors to know the contact information of the ombudsman and state agencies in filing a complaint.

The facility had a census of 32 residents with 14 included in the sample. Based on observation, interview and record review the facility failed to use the services of a registered nurse for at least 8 consecutive hours a day, 7 days a week by not having an registered nurse scheduled to work on 5 of the 30 days in (MONTH) 2019. This had the potential to affect all residents. Findings included: - Review of the nursing schedule and day sheets for 6/1/19- 7/1/19 revealed no registered nurse (RN) coverage for the required 8 hour tour of duty on 6/1/19, 6/2/19, 6/9/19, 6/22/19, 6/23/19 with only licensed practical nurse's (LPN) scheduled to work. During an interview on 7/3/19 at 9:57 a.m., administrative nurse C reviewed the schedule and day sheets for the month of (MONTH) 2019 and confirmed no RN coverage was available on the listed days. Staff C reported he/she was of the understanding that the facility just had to have an RN available on call but not physically in the building. The facility failed to provide a policy regarding registered nurse coverage on the weekend as requested on 7/8/19. The facility failed to ensure the use of a registered nurse for at least 8 consecutive hours a day, 7 days a week by not having a registered nurse scheduled to work 5 days in (MONTH) 2019.

The facility census totaled 32 residents with 14 residents in the sample. Based on interview and record review the facility failed to ensure 1 of 5 residents reviewed did not receive unnecessary medications due to the failure of staff to document blood sugars and the associated units of insulin administered according to the ordered sliding scale, as well as scheduled insulin. (#20) Findings included: - Review of the history and physical revealed resident #20 had a [DIAGNOSES REDACTED]. Review of the admission minimum data set ((MDS) dated [DATE] revealed a brief interview for mental status (BIMS) score of 13 indicating intact cognition, and the resident received insulin medication daily out of the 7-day observation period. Review of the 14-day MDS revealed a BIMS score of 15 indicating intact cognition, and the resident received insulin medication daily out of the 7-day observation period. Review of the physician orders [REDACTED]. 60-200 (0 units) 201-250 (2 units) 251-300 (3 units) 301-350 (4 units) 351-400 (5 units) >400 (6 units) Review of the physician orders [REDACTED]. Review of the physician orders [REDACTED]. Review of the (MONTH) 2019 electronic Medication Administration Record [REDACTED] [MEDICATION NAME] was not given as ordered on 6/12, and 6/18. Humalog was not administered AC Breakfast on 6/18, and no blood sugars were documented on 6/12, and 6/18. Humalog was not administered AC Lunch on 6/7, 6/10, 6/11, 6/12, 6/17, 6/18, and no blood sugars were documented on 6/7, 6/10, 6/11, 6/12, 6/17, 6/18, and 6/28. Humalog was not administered AC Dinner on 6/6, 6/7, and 6/10, and no blood sugars were documented on 6/6, 6/9, 6/10, and 6/18. Humalog was not administered HS on 6/9, 6/11, 6/17 and 6/22, and no blood sugars were documented on 6/17, and 6/22. During an interview on 7/3/19 at 11:40 AM, licensed nursing staff B stated the resident received insulin on a sliding scale. Staff B stated he/she expected blood sugars, and the amount of insulin given according to the sliding scale to be documented on the EMAR. During an interview on 7/8/19 at 3:10 PM, administrative nursing staff C stated he/she expected nursing staff to complete documentation for blood sugars on the EMAR as ordered. Review of the Obtaining a Fingerstick Glucose Level policy last revised 12/2017 revealed staff obtaining blood sugars should record blood sugar results in the resident's medical record and were to follow community policies and procedures for appropriate nursing interventions regarding blood sugar results (if resident was on sliding scale coverage). The facility failed to ensure resident #20 did not receive unnecessary medications due to the failure of staff to document blood sugars and the associated units of insulin administered according to the ordered sliding scale, as well as scheduled insulin.

The facility census totaled 33 residents with 9 residents sampled. Based on observation, interview and record review the facility failed to ensure that resident(s) who entered the facility without pressure ulcers (injury to skin and underlying tissue resulting from prolonged pressure on the skin) did not develop pressure ulcers for 3 of 5 residents in regards to redevelopment of pressure ulcers on both heels for resident #2, worsening of reddened areas to multiple open areas on left buttock for resident #3, worsening of reddened area to open area on the coccyx for resident #4 and development of an deep tissue injury (a pressure-related injury to subcutaneous tissues under intact skin. Initially, these [MEDICAL CONDITION] have the appearance of a deep bruise with purple or maroon localized area of discolored intact skin or blood-filled blister) on the right heel for resident #4. The facility also failed to promote healing of a pressure ulcer for resident #1 in regards to lack of timely repositioning, absence of a dressing and lack of appropriate supplies to cleanse the wound. Findings included: - Resident #2's signed physicians orders dated 4/12/16 included the following Diagnosis: [REDACTED]. The significant change MDS (minimum data set) dated 11/6/15 identified the resident with a BIMS (brief interview for mental status) score of 15, indicating cognition intact. The resident required extensive assistance of 1 staff for all ADLs (activities of daily living) except for eating which he/she did independently. The facility utilized both formal and clinical assessments to determine the resident had a risk for pressure ulcer development (injury to skin and underlying tissue resulting from prolonged pressure on the skin) and currently had 4 stage 1 pressure ulcers (Intact skin with non-blanchable redness of a localized area usually over a bony prominence). The MDS identified the following measures were in place for pressure ulcer prevention; a pressure relieving device for the chair, turn and reposition program, nutrition and hydration interventions in place and the application of dressings (with or without topical ointment) to the feet. The significant change MDS dated [DATE] identified the resident with a BIMS score of 12, indicating moderately impaired cognition and required extensive assistance for ADLs except eating. The resident was assessed as at risk for pressure ulcer development, had 2 unhealed stage 1 pressure ulcers. An interview with administrative nurse R on 5/2/16 at 1:38 pm confirmed the pressure ulcers were to the resident's heels and were deep tissue injuries not stage 1. He/she said the information had copied from the previous MDS and was not accurate. The resident used a pressure reducing device on the chair and bed, pressure ulcer care, a turning and repositioning program and had, nutrition and hydration interventions in place. Review of the Cognition CAA (care area assessment) dated 2/9/16 revealed the resident had increased confusion and had increased difficulty making decisions. He/she would try to cover the problem by saying well what do you think. The resident's BIMS score went from 15 to 12. Review of the ADL CAA dated 2/9/16 indicated the resident required limited to extensive assist with bed mobility, transfers, toileting, ambulation, and personal hygiene. Review of the Nutritional CAA dated 2/9/16 revealed the resident consumed 75% of the meals with a diet of no added salt and low concentrated sweets. Review of the Pressure Ulcer CAA dated 2/9/16 identified the resident had 2 stage 1 deep tissue pressure ulcers (a pressure-related injury to subcutaneous tissues under intact skin. Initially, these [MEDICAL CONDITION] have the appearance of a deep bruise with purple or maroon localized area of discolored intact skin or blood-filled blister) to his/her heels. He/she required assistance with bed mobility but could make slight changes in position independently. Review of the care plan dated 10/30/15 revealed functional status of extensive assist with bed mobility, transfers and ambulation with a wheelchair used for locomotion. The care plan included a problem titled, skin-bunions to feet with no identification of pressure ulcer risk and no reference to the stage 1 red non-blanchable pressure ulcers on both heels. Under the treatment intervention for the buttocks dated 10/30/15 were directions to staff to apply skin prep to both heels every shift. The care plan directed staff to: encourage the resident to go shoeless when possible and make sure his/her shoes were loose fitting, assist the resident to turn and reposition and encourage the resident to reposition throughout the day as he/she liked to sit in a recliner in front of the TV in the living room. The care plan did not direct staff of how often to ensure the resident changed positions. The nutritional care plan included an intervention dated 1/29/16 for gelatin twice a day for skin health, serve a low concentrated no added salt diet, record food intake and offer substitutes for uneaten food and the resident usually consumed 75% of meals. On 3/30/16 the facility added protein powder twice a day. The care plan lacked any pressure reducing devices. Hospital transfer orders dated 10/30/15 indicated the resident returned to the facility following surgical repair of the left neck of the femur bone (referred to a hip) and the transfer orders included apply skin prep to both reddened heels for protection. The orders also included vitamin C supplement 500 mg (milligrams) daily for wound healing, multivitamin with minerals supplement 1 daily for wound healing and staff to perform skin assessment and foot checks weekly. Review of the pressure ulcer monitoring sheets revealed on 10/30/15 the facility identified the resident with two stage 1 pressure areas characterized by red non-blanching skin. The area on the left heel measured 2 cm (centimeters) by 1 cm and the right heel measured 2 cm by 0.9 cm. On 12/16/15 staff documented both heel areas as healed. Pressure ulcer monitoring sheets dated 1/28/16 identified new development of black deep tissue injury to both heels. The left heel measured 2.5 cm by 1.5 cm described as black deep tissue injury and the right heel measured 1 cm by 2 cm described as black deep tissue injury. The pressure ulcer monitoring sheets reflected weekly monitoring as planned and showed improvement with indication on 4/24/16 of both heels as healed. Staff sent a fax to the physician stating the areas were healed and asked to discontinue the treatment. Then on 4/25/16 at 8:00 am licensed nurse L sent a faxed request to the physician to reinstate the treatments for skin prep to both heels after observation of the areas revealed the areas were not healed and remained on both heels. Observation on 4/21/16 at 9:00 am revealed the resident sat on the couch in the lounge area watching TV with gripper socks on both feet and both feet were flat on the floor. At 9:17 am the resident remained seated on the couch with the right leg extended so the heel rested on the floor and the left foot remained flat on the floor On 4/21/16 at 12:33 pm observation revealed the resident sat on the couch in the lounge area watching TV with gripper socks on and his/her feet flat on the floor. At 12:46 pm the resident remained on the couch watching TV with his/her feet flat on the floor. At 1:10 pm the resident dozed while seated on the couch and both legs were extended out allowing both heels to rest directly on the floor with no pressure relieving devices in place. Observation at 1:30 pm and at 1:42 pm revealed the resident remained sleeping on the couch with his/her heels on the floor Observation on 4/25/16 at 7:08 am revealed direct care staff B and direct care staff C provided morning cares. Observation with licensed nurse L revealed pressure ulcers still present on both heels as evidenced by left inner heel with a dime sized dark hard skin place and the right outer heel had an area the size of a pencil eraser of dry hard black skin in a linear shape. At 8:12 am licensed nurse N identified the areas as pressure ulcers and obtained the following measurements: left inner heel measured 1 cm (centimeter) by 1 cm of black dried hard skin and classified the area as unstageable, the right outer heel measured 1.8 cm by 0.8 cm of black dried hard skin which nurse N also classified as unstageable. On 4/25/16 at 8:33 am observation revealed the resident positioned on his/her right side in bed facing the door with a pillow to the back and heel protectors in place. Observations at 8:48 am, 9:00 am, 9:17 am, 9:40 am, 9:58 am, 10:10 am, 10:25 am and 10:48 am revealed the resident remained in the same position. At 11:03 am licensed nurse L confirmed the resident remained in the same position since the care provided earlier that morning. Observation at 11:05 am revealed direct care staff B and direct care staff C entered the room, transferred the resident to the wheelchair and then to the toilet Interview on 4/25/15 at 8:33 am with direct care staff B revealed when the resident first came from the hospital he/she had red heels but the redness went away. Care staff B did not know when or how the current areas started but confirmed prior to them developing, staff only put a pillow under the heels and the heel protectors started after the pressure ulcers were found. On 4/21/16 at 3:42 pm direct care staff F said the resident liked to sit on the couch all the time. Staff F did not know if the resident had pressure ulcers on his/her heels but said at night the nurse put skin prep on the resident's bunion. Staff F said the facility started using the heel protectors recently but before we would try to put a pillow under the resident's heels. Staff F said he/she honestly could not say staff always elevated the resident's feet on pillows. On 4/25/16 at 7:00 am licensed nurse L reported the areas on the resident's heels were healed and the treatment discontinued the day before. Further interview at 7:10 am with licensed nurse L revealed the staff recently started application of heel protectors for the resident. He/she did not know if the resident had a pressure reducing device in place before the ulcers developed but he/she expected staff to float every resident's heels. Interview with administrative nurse M on 4/27/16 at 9:35 am confirmed the reoccurrence of pressure ulcers to both heels of the resident. Nurse M reported he/she reviewed the weekly wound documentation the floor nurse completed but did not know the facts surrounding the development of the resident's deep tissue injury pressure ulcers on both heels. Administrative nurse M reported the areas on the heels were avoidable if staff repositioned and elevated heels as planned. He/she did not know the resident when seated on the couch had his/her heels directly on the floor. Interview on 5/2/16 at 9:45 am with physician T revealed the resident had poor circulation which put him/her at high risk for pressure ulcer development and the resident had reddened heels while in the hospital. Physician staff T reported lately when he/she visited the pressure relieving measures were in place, such as the resident in a recliner with his/her feet elevated, but he/she could not say whether those interventions were in place before the sores developed. Physician staff T reported more than likely the areas could have been avoided if the facility had preventative measures in place Review of the facility's policy titled, Prevention Protocol with a revision date of 4/28/10 revealed staff perform pressure ulcer risk assessments and follow protocols based on the results of the assessment which are care planned. These interventions include repositioning of the resident at risk at least every 2 hours while in bed and every hour when in the chair and relieve pressure on heels by using positioning device. The facility failed to develop and implement pressure ulcer prevention for this resident with a history of pressure ulcers to the heels and resident #2 developed avoidable deep tissue injury pressure ulcers on both heels. - Review of resident #3's signed physician orders [REDACTED]. Review of the resident's significant change MDS (minimum data set) dated 1/9/16 revealed a BIMS (brief interview for mental status) score of 3, indicating severe cognition impairment. The resident required extensive assistance with bed mobility, transfers, and toilet use. Always had urinary incontinence and frequent bowel incontinence. Formal and clinical assessments identified the resident at risk for pressure ulcer development. The resident did not have a pressure ulcer. He/she used a pressure reducing device in the chair and applications of ointments/medications other than to his/her feet. Review of the CAAs (care area assessments) dated 1/12/16 revealed the following: Cognition CAA-The resident had a [DIAGNOSES REDACTED]. Urinary incontinence CAA- The resident required assistance with transfers and toileting. The resident may not be able to state his/her toileting need. The Nutritional CAA- The resident required assistance with eating, had a [DIAGNOSES REDACTED]. Pressure Ulcer CAA- The resident required assistance with repositioning, experienced incontinence of both bladder and bowel, and he/she spent most of the time in a chair or wheelchair with a pressure relief cushion to the wheelchair. The quarterly MDS dated [DATE] revealed the same information except the resident required total assist with bed mobility and had frequent bowel and bladder incontinence. Review of the care plan dated 3/29/16 revealed the following directions to staff: Ask short simple questions that could be answered with one or two words, or answered with yes/no. Assess the resident's decisions to ensure the decisions were safe and appropriate. Provide assistance with activities of daily living (ADLs). Encourage the resident to assist with self-care skills as his/her ability permitted. Provide extensive assistance for bed mobility, transfers, and incontinence care. Allow the resident to use a wheelchair and a walker for locomotion. Know the resident did not alert staff when he/she needed toileting; he/she wore an incontinent brief and used a toileting plan. Offer toileting upon arising, before and after each meal, before bed and during night rounds. Provide incontinence care after each episode and apply moisture barrier cream with toileting or incontinence care as needed (PRN). Assist the resident with repositioning after toileting and per toileting schedule. Apply moisture barrier ointment to buttocks for protection twice a day and PRN. Monitor the resident's skin during cares and report any skin findings to the nurse. Assess the resident's skin weekly for color, moisture, texture and turgor and report abnormal findings to the physician and record on pressure ulcer or non-pressure ulcer wound monitoring sheets. Provide the resident with a pressure reducing cushion to the wheelchair and a pressure relieving mattress. The care plan lacked a turning and repositioning program to include specific time intervals for repositioning. It also lacked the resident had pressure ulcers and the treatment they required. Review of the Braden skin risk assessment dated [DATE] identified the resident at risk for pressure ulcer development. Review of the summary of the physician's orders [REDACTED]. On 4/20/16 the physician ordered staff to cleanse the 2 open areas to the left buttock with normal saline, pat dry, apply Hydra-guard (a skin cream that provided a breathable, water-resistant film over dry, cracked skin) 3 times a day and as needed. Staffs were to monitor the site every day and document weekly until healed. Review of the weekly skin assessments revealed on 4/6/16 staff identified no skin issues. The record lacked a skin assessment for the week of 4/13/16. The staff failed to initial the treatment record and identify if they completed the treatment of [REDACTED]. On 4/20/16 staff found 2 areas on the left buttocks: #1 measured 2 cm (centimeters) by 0.5 cm and #2 measured 0.9 cm by 0.5 cm with no drainage or odor and staff described the open areas as dry/scabbed outer edges and a red center. Review of the interdisciplinary progress notes revealed an entry on 4/5/16 and the next entry of 4/20/16. On 4/20/16 at 8:02 pm the nurse wrote a nurse aide reported the resident had skin issues on his/her bottom. The nurse assessed the left buttocks and found 2 open areas (see weekly skin assessment) The nurse documented he/she cleansed the areas with normal saline, patted dry, applied hydra-guard to the areas. The resident wanted to sit in the recliner. Staff off-loaded the affected area with a pillow (not considered a pressure relieving device). On 4/21/16 at 9:00 am observation revealed the resident rested in a recliner in his/her room leaning to the left and the recliner foot rest in the up position. Observation at 9:18 am, 9:30 am, 9:43 am, 10:00 am, 10:17 am, 10:35 am, 10:50 am, 11:03 am, 11:18 am and 11:35 am revealed the resident remained in the same position in the recliner and continued to lean to the left with the foot rest in the up position. Observation at 11:40 am revealed the resident sitting in a wheelchair at the dining room table. On 4/21/16 at 1:10 pm observation revealed the resident rested in the recliner in his/her room with the foot rest up. Observation at 1:20 pm, 1:40 pm, 2:03 pm (shift change), 2:20 pm, 2:35 pm, 2:50 pm, 3:10 pm, 3:18 pm and 3:30 pm the resident remained in the same position in the recliner. At 3:42 pm observation revealed direct care staff J had assisted the resident back to wheelchair from the toilet and had already provided personal hygiene. On 4/25/16 at 8:40 am direct care staff B and direct care staff D assisted the resident to the toilet. Observation revealed 2 open areas on the left inner buttock with no evidence of any creams, ointments or dressing. Staff B and staff D transferred the resident to the wheelchair and propelled him/her to the TV area. At 9:32 am direct care staff B and direct care staff C assisted the resident to bed and helped him/her to lay on his/her right side. Licensed nurse N examined the areas on the left buttocks and reported the resident had a stage 1 (intact skin with non-blanchable redness) pressure ulcer that measured 9.5 cm by 9 cm. The nurse identified 2 open areas within the redness as stage 2 pressure ulcers (partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed and no slough. Pressure ulcer #1 measured 1.5 cm by 1.7 cm and #2 measured 0.6 cm by 1 cm. The nurse did not measure depth on either area. The nurse also identified a stage 1 pressure ulcer on the right buttock which measured 7 cm by 7 cm. Interview on 4/21/16 at 3:42 pm with direct care staff F revealed no awareness of open areas on the resident buttocks. Staff F reported the resident preferred to be in the recliner until bedtime. Staff F said staff assist the resident to the toilet before and after meals and bedtime but he/she did not know if the resident had a risk for pressure ulcer development or needed repositioned more frequently. Interview on 4/25/16 at 8:40 am revealed direct care staff B confirmed the resident had open areas on the buttocks which looked different that day than the day prior. Staff B said the resident had incontinence of both bowel and bladder; staff were to provide incontinent care and then apply hydra-guard cream that he/she got from the nurse. Interview on 4/25/16 at 8:45 am with licensed nurse L revealed awareness of the open areas but did not know if causal factors were determined. Nurse L reported he/she gave staff direction to put hydra-guard on the open areas after each incontinent episode and he/she had not seen the area yet that day. Interview on 4/27/16 at 2:44 pm with licensed nurse O confirmed he/she first knew of the open pressure ulcers on 4/20/16 and the resident had reddened skin in the area off and on. On 4/27/16 at 9:35 am administrative nurse M reported he/she had identified problems with pressure ulcer prevention, management and tracking. Nurse M reported the areas on the resident were initially classified as shearing injuries but were actually pressure ulcers. On 5/2/16 at 9:45 am physician T confirmed the resident's pressure ulcers most likely could have been avoided with proper repositioning and incontinence management. Review of the facility's policy titled, Prevention Protocol with a revision date of 4/28/10 revealed the facility planned for staff to perform a risk assessment and if the resident had a moderate or high risk protocols were implemented and included into care plan. Staff were to reposition the resident at least every 2 hours while in bed. When sitting in a wheelchair, repositioning should occur every 1 hour and the resident taught to shift weight at least every 15 minutes. The facility failed to develop interventions related to adequate repositioning for a resident with reddened skin, failed to follow the policy for repositioning at least every 2 hours, failed to assess the resident's skin weekly as planned which resulted in the resident developing 2 avoidable stage 2 pressure ulcers to the left buttock. - Review of resident #1's signed physician orders [REDACTED]. Review of the quarterly MDS (minimum data set) dated 1/11/16 revealed a BIMS (brief interview for mental status) score of 13 indicating cognition intact, required extensive assistance with bed mobility and personal hygiene but total assistance for transfers, toilet use and dressing. The MDS indicated the resident had an indwelling urinary catheter and was incontinent of bowel. The resident had a stage 4 (full thickness tissue loss with exposed bone, tendon or muscle) pressure ulcers. The significant change MDS dated [DATE] included a BIMS score of 12 indicating moderate cognition impairment, required extensive assistance for bed mobility, dressing, toilet use and personal hygiene with total assistance for transfers. The resident still used an indwelling catheter and was incontinent of bowel with a stage 4 pressure ulcer. Review of the CAA (care area assessment) dated 3/30/16 revealed the following: *Cognition CAA-the resident scored 12 of 15 on current BIMS. He/she had periods of confusion and had increased difficulty with decision making. *The ADL (activities of daily living) CAA indicated the resident required extensive assist to total assist with ADLs. *Urinary Incontinence/Catheter CAA-the resident was incontinent of bowel, required extensive assist with ADLs and had an indwelling catheter for wound healing. *The pressure ulcer CAA identified a stage 4 pressure ulcer present, resident had an air mattress, turning schedule and staff provided incontinent care with each turning as needed. The CAA indicated the resident received wound care from an outside wound care clinic. Review of the care plan with a date of 4/6/16 revealed: Functional state: the resident required extensive assist of staff with bed mobility, can hold on to grab bar when rolled side to side but required full lift when transferring. The care plan for skin identified the resident was admitted on [DATE] with 3 pressure ulcers and on 5/5/15 had 1 stage 4 wound to the sacrum. The plan indicated the resident used an air mattress for the bed and a pressure relief cushion to the chair. The plan directed staff to make daily observations during cares and report any findings of loose or missing dressings to charge nurse. Turn and reposition the resident approximately every 2 hours while in bed and monitor for incontinence. The resident may be up in chair for meals and appointments only and must have pressure re-distribution cushion in the chair when sitting up. Review of the recapitulation of physician's orders [REDACTED]. The physician's orders [REDACTED]. On 4/21/16 at 8:15 am observation revealed the resident rested in bed on his/her back with a slight shift to his/her right and a pillow to the hip area. Observation at 8:55 am revealed the resident remained on his/her back with a slight shift to his/her right and a pillow to the left hip area. Observations at 9:10 am, 9:23 am, 9:40 am, 9:59 am and 10:18 am revealed the resident remained in the same position. At 10:39 am observation revealed direct care staff A and licensed nurse E entered the room to provide care. Direct care staff A turned the resident onto his/her left side and observation revealed the resident was incontinent of loose/liquid stool, had no dressing in place on the coccyx pressure ulcer. Observation revealed fecal material in the wound bed. Direct care staff A confirmed there was no dressing within the incontinent brief or bed linen. Staff A provided incontinent care. At 11:10 am licensed nurse K entered the room to perform the treatment for [REDACTED]. Nurse K poured sterile water onto a couple gauze pads and dabbed at the wound bed visibly removing fecal debris but the wound bed remained with a tint of gray/brownish areas. Nurse K then applied a piece of alginate to the wound bed and covered the alginate with an [MEDICATION NAME] dressing. Interview with direct care staff A on 4/21/16 at 11:30 am revealed he/she helped the resident reposition about 6:00 am when he/she made rounds with the off going shift. Staff A did not know whether the dressing was in place at that time or not as he/she did not do the incontinent care. Direct care staff A confirmed the resident was already on his/her back when staff A assisted the resident to eat. Interview with licensed nurse K on 4/21/16 at 12:00 pm confirmed the resident remained without a position change between 8:15 am and 10:39 am which was 24 minutes past the planned every 2 hours for turning and repositioning. Nurse K confirmed that the wound cleanser spray bottle would have done a better job removing the fecal matter from the wound but felt like he/she had gotten it all with the wet gauze. Nurse K confirmed the previous nurse should have replaced the dressing or if it was not there at bed check the nurse aide should have told the nurse. On 4/25/16 at 9:00 am administrative nurse M reported an expectation for the facility to have in stock all supplies needed for wounds or other treatments and the wound cleanser spray is more effective at debris removal than dabbing with a wet gauze pad. Nurse M said that the nurse aides are expected to report loose or missing dressings to the nurse as soon as possible and the nurse should redress the area as soon as possible. Nurse M reported an expectation that turn and reposition this resident at a minimum of every 2 hours and the resident could probably benefit from more frequent repositioning. The facility's policy titled, Treatment Protocol General dated 4/28/10 directed staff to provide routine treatments according to current standards of practice. The facility failed to ensure staff provided services to promote wound healing by a lack of timely repositioning, absence of dressing which allowed fecal material to contaminate the wound bed and lack of wound care supplies for this resident. - Review of resident #4's February 2016 POS (Physician order [REDACTED]. Review of the significant change MDS (minimum data set) dated 11/16/15 revealed staff assessed the resident to have moderate cognitive impairment. The resident required extensive assistance for all ADLs (activity of daily living), used a Foley catheter (tube inserted into the bladder to drain urine into a collection bag) and had frequent bowel incontinence. The resident measured 62 inches tall and weighed 109 pounds with no known weight loss. The resident had a risk for pressure ulcers with none existing and used a pressure reducing device while in a chair. Review of the ADL(Activity of Daily Living)/Functional Status CAA (Care Area Assessment) dated 11/16/15 revealed the resident required extensive assist of 1-2 people for bed mobility, transfers, locomotion, and toileting. The resident had a fracture to right superior pubic ramus (part of the pelvis) and inferior pubic ramus (part of the pelvis). The resident had indications of pain and could participate with ADLs as tolerated. Review of the Urinary Incontinence CAA dated 11/16/15 revealed the resident had bowel incontinence. He/she required assistance with transfers, ambulation, and toileting needs. He/she had an indwelling catheter in place. He/she had impaired cognitive status and did not alert staff of when he/she needed toileting. Review of the Pressure Ulcer CAA dated 11/16/15 revealed the resident had incontinence of bowel and bladder. He/she had a pressure relief cushion in his/her wheelchair. He/she allowed staff to change his/her position and staff encouraged him/her to do so to relieve pressure. The resident had cognitive impairment and did not remember to change positions on his/her own. He/she had pain in his/her right leg and did not want to lay on his/her right side. Review of the skin care plan with a review date of 2/11/16 revealed the resident had decreased mobility, experienced bowel incontinence and had a stage 3 pressure wound (localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure which extends into the tissue beneath the skin, forming a small crater) to his/her coccyx, and a deep tissue injury to the right heel. Interventions directed staff to: Use a pressure reducing air mattress with bed settings adjusted by weight and then adjusted for resident's comfort by nursing staff (updated 10/2/15). Assess and document skin for color, moisture, texture, and turgor (updated 10/2/15). Assist the resident and reposition after toileting per toileting schedule (updated 10/2/15). Check feet and legs for redness, skin tears, swelling, or pressure areas daily and report any signs of skin breakdown to the nurse (updated 10/2/15). Assess the resident's skin weekly and measure any wounds and report new findings to the physician (updated 10/2/15). Report any skin findings during care to the charge nurse (updated 2/11/16). Apply [MEDICATION NAME] (moisture barrier cream) to be used as ordered (updated 2/11/16). Apply skin prep as ordered to heels (updated 2/11/16). Encourage the resident to go shoeless when possible and make sure the resident's shoes were loose fitting (updated 2/11/16). The care plan lacked interventions concerning wound care for the stage 3 pressure ulcer to the coccyx. Review of the nutrition care plan

The facility reported a census of 35 residents, with 3 residents sampled residents with pressure ulcers or at risk for pressure ulcers. Based on observation, interview and record review, the facility failed to provide 1 of 3 residents with the appropriate care and treatment to promote healing of a pressure ulcer. Resident #3 entered the facility with a Stage 2 pressure ulcer on the coccyx. The facility failed to provide adequate treatment of [REDACTED]. Findings included: - Review of resident #3's admission MDS (Minimum Data Set) dated 12/12/14 revealed a BIMS (Brief Interview for Mental Status) score of 6, indicating severe cognitive impairment. The assessment indicated resident #3 required extensive assistance of 2 staff for bed mobility and toilet use. He/she required total assistance of 2 staff for transfers. The assessment identified resident #3 had a toileting program due to frequent bowel and bladder incontinence. The MDS identified resident #3 had three stage 2 pressure ulcers (partial thickness skin loss involving epidermis, dermis, or both) present upon admission. It identified the resident had a pressure reducing device for the bed and chair, had a turning/repositioning program, nutritional interventions to manage skin problems, pressure ulcer care ,and had an application of dressings to his/her ulcers. The MDS identified the resident had almost constant pain rated at a 7 on a scale from 1 (no pain) to 10 (worst pain imagined). The assessment identified the pain limited day to day activities and made it hard to sleep. Review of resident #3's Pressure Ulcer CAA (Care Area Assessment) dated 12/12/14 included information from the MDS as to why the CAA triggered for further assessment including the three stage 2 pressure ulcers to resident #3's buttocks. The Braden assessment (a pressure risk assessment) indicated the resident had moderate risk for further skin breakdown. The resident had decreased ROM (range of motion) in his/her right lower extremity and used a full body lift for transfers which could cause shearing. It also identified the resident complained of a poor appetite and the dietitian reviewed the resident's record and recommended house shakes TID (three times a day) and Ensure Clear (a supplement) twice a day. Review of resident #3's Care Plan dated 12/12/14 revealed the goal was for the resident to experience improvement in his/her pressure ulcer and the following interventions were in place: *Assess resident #3 daily for skin irritation or breakdown and pay close attention to his/her ears due to oxygen tubing, shoulder blades, elbows, coccyx (the tailbone), and heels. *Apply [MEDICATION NAME] (cream used on the skin to treat fungal infections) daily as per physician order. *Dietary supplements to aide in wound healing as well as Vitamin C and a multi-vitamin. *Triad cream (a paste that absorbs moderate levels of wound exudate) to sacrum wound and peri-wound twice daily and after each incontinence episode Review of a wound clinic physician order [REDACTED]. Apply Criticaid Clear (moisture barrier ointment) to perineal area after stool, incontinence and as needed. Review of a wound clinic physician order [REDACTED]. Review of a wound clinic physician order [REDACTED]. Review of a wound clinic progress note dated 2/11/15 revealed unable to stage resident #3's pressure ulcer to coccyx, minimally at a stage 3. The note indicated mechanical factors and moisture contributory to delayed healing as well as inadequate off-loading with bed support device. Review of the Weekly Pressure Ulcer report revealed: *12/12/14 and 12/17/14 - stage 2 pressure wound to left lower buttocks measuring 1 cm (centimeter) x 1 cm with clear drainage and no pain. *12/24/14 and 12/31/14 - the wound measured 0.5 cm x 0.5 cm *1/7/15 - the wound measured 1.1 cm x 1.5 cm, the tissue appeared yellowish with yellowish drainage and the resident had wound pain. *1/14/15 - the wound measured 3.5 cm x 2.2 cm with yellowish slough (dead tissue that has been shed) with scant yellow drainage and the resident had wound pain. *1/21/15 - the wound measured 3.5 cm x 2.5 cm and the resident had wound pain. *1/28/15 - the wound measured 3.5 cm x 2.5 cm with yellow slough in wound bed and scant yellow drainage, the resident also continued to have wound pain. *2/4/15 - the wound measured 3.2 cm x 1.6 cm with yellow slough and scant yellow drainage, the resident continued to have wound pain. The report indicated a new treatment started on this date. *2/18/15 - the wound was now a stage 3 pressure wound (Full thickness skin loss involving damage to or necrosis of subcutaneous tissue that may extend down to, but not through, underlying fascia. The ulcer presents clinically as a deep crater with or without undermining of adjacent tissue.) The wound measured 2.5 cm x 1.5 cm x 0.2 cm with yellow slough, scant drainage, the resident had wound pain. *3/5/15 - the wound measured 3.5 cm x 3 cm x 0.2 cm with yellow slough, scant drainage and the resident had wound pain. The report indicated the new treatment was not effective. *3/11/15 - the wound measured 3.5 cm x 3 cm x 0.3 cm with yellow slough, slight drainage, and the resident continued with wound pain. During an interview on 3/18/15 at 10:00 a.m., Administrative nurse B provided clarification related to the wound descriptions when he/she reported the " left lower buttock wounds, sacral wounds and coccyx wounds all referred to the same area of skin breakdown even though they are distinctly different areas or the anatomy. During an observation on 3/17/15 at 2:38 p.m. direct care J and licensed nursing staff N assisted the resident using the full lift to change his/her brief. The resident called out with any movement and appeared to be guarded with any movement from the staff. The resident reported his/her pain was a 9/10 (0 being no pain and 10 being the worst pain). Staff medicated the resident with pain medication. During changing of the resident's brief his/her coccyx had no dressing in place. The resident had been incontinent of a loose bowel movement and urine. He/she had a large amount of runny, loose dark bowel movement in his/her perineal area, buttocks, and in the uncovered wound bed, The wound was just larger than a quarter size with partial thickness tissue loss. The edges of the wound were jagged with yellow slough seen in the wound bed. After staff completed perineal care, they placed a clean incontinence brief on the resident without application of barrier cream as directed by the facility's policy. When questioned about failure to apply the barrier cream, staff then removed the clean brief and applied the cream only to the perineal area. Staff did not apply cream to the buttocks or area surrounding the pressure ulcer. Resident #3 ' s wound lacked any covering/dressing when staff applied the clean incontinence brief. Staff N reported the staff had used the resident's last dressing that morning and were out of his/her dressing supplies provided by the wound clinic. An interview on 3/17/15 at 10:42 a.m. with resident #3 revealed his/her buttocks burned and was uncomfortable. The resident reported the wound on his/her buttocks was very large and hurt all the time. An interview on 3/17/15 at 5:05 p.m. with administrative nursing staff B reported he/she expected the staff to have covered the wound with a dressing for protection after incontinence care. During an interview on 3/18/15 at 3:50 p.m. licensed nursing staff N reported the physician order [REDACTED]. Review of the clinical record revealed no evidence of such an order. During an interview on 3/19/15 at 1:45 p.m. physician R reported he/she first saw resident #3 on 1/15/15 in the wound clinic for treatment of [REDACTED]. Physician R assessed the coccyx wound and reported it measured 3.2 cm x 1 cm x 0.1 cm and was an unstageable pressure ulcer. Physician R reported the resident has had a tremendous decline and the delayed healing is a result of incontinence, pressure, and the resident's age. Physician R reported resident #3 sometimes came into the wound clinic with no dressing in place to his/her coccyx and had been incontinent of stool. Physician R reported resident #3 told him/her the resident was incontinent about 4 times a day. Physician R reported on 2/11/15 and 3/2/15 the resident presented to the wound clinic from the facility with incontinent of stool and no dressing in place to coccyx. Physician R reported he/she expected the staff to replace a soiled dressing with a clean dressing. Review of the facility's policy for Skin and Wound Care, revised 04/10, revealed for incontinence the staff were to cleanse the skin and follow with moisturizer and moisture barrier ointment. The policy did not address following physician orders [REDACTED]. The facility failed to provide resident #3 with the appropriate care and treatment to promote healing of a pressure ulcer. Resident #3 entered the facility with a Stage 2 pressure ulcer on the coccyx. The facility failed to provide adequate treatment of [REDACTED].

The facility census totaled 20 with 10 resident sampled. Of those, 2 residents were reviewed for pressure/skin ulcers. Based on observations, interview and record review the facility failed to adequately recognize and assess contributing factors, and failed to implement interventions for a resident at risk for the development of recurrent skin ulcers for 1 of 2 residents who acquired pressure/skin ulcers in the facility. (#13) Findings included: - Review of resident #13's signed admission physician order [REDACTED]. Review of the admission MDS (Minimum Data Set 3.0, a required assessment) dated 10-28-13 revealed a BIMS (Brief Interview for Mental Status) score of 9 indicating moderate cognitive impairment. The MDS indicated the resident required extensive assistance of 2 staff for transfers and extensive assistance of 1 with bed mobility and toilet use. The MDS identified the resident as frequently incontinent of bladder and not at risk for the development of pressure ulcers. It identified the resident did not have any ulcers. Review of the pressure ulcer CAA (Care Area Assessment) dated 11-4-13 revealed the resident had cognitive impairment, required staff assistance to move sufficiently to relieve pressure over any one site, was confined to a bed or chair all or most of the time, and was frequently incontinent of bladder. It also noted the resident needed a special mattress or seat cushion to reduce or relieve pressure and required regular scheduled turning. Review of the care plan dated 10-28-13 included a concern regarding skin condition with interventions to apply moisture barrier cream with toileting or incontinence care as needed. It also directed staff to report any signs of skin breakdown, and for the nurse to complete a weekly skin assessment. The care plan failed to include any interventions to promote healing and prevent the further development of ulcers. Review of the skin integrity guidelines dated 10-23-13 revealed the resident had no past history of pressure ulcers, and no pre-existing signs such as purple or very dark areas. Review of the Braden skin risk assessment dated [DATE] revealed a score of 16 indicating low risk for the development of pressure ulcers. Review of the weekly Pressure Ulcer Report in the TAR (Treatment Administration Record) revealed the following documentation regarding a skin ulcer on the resident's left buttock: 11-8-13 - open ulcer, 1 centimeter (cm) in diameter, red area with partial loss of dermis (The lower or inner layer of the two main layers of cells that make up the skin) 11-11-13 - open ulcer, 1 cm X 0.5 cm - red with partial thickness loss of dermis 11-14-13 - open ulcer,1.5 X 0.5 X 0.2 cm deep - red with partial thickness loss of dermis - Rx (medical prescription) [MEDICATION NAME]. (A barrier ointment) - indicating the wound had gotten larger and deeper. 11-21-13 - 1.75 cm X 1 cm X 0 cm- red with partial thickness loss of dermis no drainage - [MEDICATION NAME] - indicating the wound continued to worsen. Review of the weekly Pressure Ulcer Report in the TAR revealed the following documentation regarding a skin ulcer on the resident's right buttock: 11-14-13 - 1 cm X 0.25 cm - [MEDICATION NAME] (regeneration of the epidermis across a wound surface) 11-21-13- 0.5 cm X 1 cm X 0 cm - red with partial thickness loss of dermis - no drainage - [MEDICATION NAME] ointment. Indicating the wound slightly larger than previous assessment. Nurses note dated 11-18-13 indicated the facility contacted consultant B regarding treatment advice for resident #13 who had open sore(s) to buttocks. The facility waited to contact consultant B for 10 days after the identification of the open sore. Review of the weekly skin assessment record revealed: 10-22-13 no documentation of any area of concern on either buttocks; 11-5-13 no documentation regarding wounds /sores on the resident's buttocks. 11-8-13 documentation regarding left buttocks, and nothing on the right; 11-14-13 documentation regarding wounds on both left and right buttock as well as on 11-21-13. Review of the dietitian note dated 11-13-13 revealed appetite good with meal intake of 75-100%. Skin concern noted on buttocks. Resident would benefit from a multivitamin and mineral supplement and vitamin C for wound healing. Review of the Nurse/physician faxed communication dated 11-11-13 the resident had a small open area to left buttock. May we please have an order for [REDACTED]. Observation on 11-20-13 at 8:19 a.m. direct care staff I and direct care staff J took the resident into his/her room via wheelchair and assisted the resident to the toilet. When the resident stood back up observation revealed 2 open areas, one on each buttock that had a beefy, bright red appearance to the wound bed with no other redness to surrounding skin. After staff provided peri-care they applied a barrier ointment (RISAMINE Ointment) and then sat the resident back into his/her wheelchair. Observation revealed the resident did not have a cushion in the wheelchair to help in relieving pressure. 11-20-13 at 8:37 direct care staff I and J assisted the resident into bed and put a pillow under his/her right side. Observations at 8:42 a.m., 8:59 a.m., 9:09 a.m., 9:23 a.m. same but may have a little so that he is not as high up on his hip. 9:35 a.m. same position, 9:50 a.m., 10:04 a.m., 10:15 a.m., 10:27 a.m., the same position as 9:35 a.m. At 10:34 a.m. the resident had scooted a little to where he/she lay a little more on his/her back but the pillow remained under the resident's right hip. At 10: 45 a.m. resident was the same, 10:55; and 11:07 the same position. At 11:11 a.m. licensed nursing staff K stated he/she did not realize the resident had not been repositioned for two and a half hours and would get someone to help him/her reposition the resident. At 11:14 a.m. licensed nursing staff K and administrative nursing staff D assisted the resident roll to his/her right side with the pillow in place still in place and pulled down the resident pull-up to assess skin. Staff identified no other red or open areas other than the 2 areas already identified Observation on 11-20-13 at 2:43 p.m. the resident sat in his/her recliner without a pressure reducing cushion in it 11-20-13 at 8:28 a.m. direct care staff I stated he/she was not sure what caused the open areas on the resident's buttocks but probably pressure from sitting in the chair so much. On 11-21-13 at 3:55 p.m. direct care staff H reported staff knew the care to provide from report from the other aides and nurses, and from the computer system there is a little review that told staff what to do. The resident had skin breakdown precautions which were to toilet regularly, use moisture barriers, and cleansing well each time. He/she stated the resident was generally continent of bladder and bowel, needed repositioned no fewer than every 2 hours. On 11-25-13 at 1:37 p.m. direct care staff G stated staff reposition the resident so not always in the chair and put pillows under him/her on one side or the other. Staff G stated the resident did not have any type of cushion for wheelchair or bed. On 11-21-13 at 3:33 p.m. administrative nursing staff D stated the resident had a tendency to slide down in his/her recliner, which could cause shearing (force created when the skin of a patient stays in one place as the deep fascia and skeletal muscle slide down). On 11-26 at 7:53 a.m. administrative nursing staff D reported he/she communicated new and ongoing wound concerns with nursing consultant B. They either talk over the phone, by e-mail or he/she will come into the facility. Based upon what administrative nursing staff D had told consultant B, it was determined the open areas were moisture related. Staff D stated the direct care staff had documented the resident as being incontinent of bowel and bladder multiple times in the past 2 weeks. Staff D also stated he/she believed there was a potential for shearing, especially in the wheelchair. He/she also believed the resident was weaker than prior to admission, now had pneumonia and other factors that played a role in the development of the wounds. He /she also stated the resident used to take [MEDICATION NAME] at night per his/her request and that was changed to the day time to try and reduce the incontinence or at least the time frame of being wet to help in skin management. On 11-25-13 at 2:40 p.m. administrative nursing staff C stated the resident's family had problems with open sores on his/her buttocks in the past. Staff C stated the staff put the [MEDICATION NAME] on them to keep moisture off of it and toilet the resident frequently. The resident sits for long periods of time and the facility had discussed cushions with the family because he/she sat so often and the family wanted to wait until later on to get a cushion. On 11-26-13 at 9:38 a.m. administrative nursing staff C stated the facility assess for any indicators of pressure ulcers, contact the wound consultant, and develop a plan according to the facility policy and physician orders. He/she also stated the resident had a history of [REDACTED]. On 11-26-13 at 9:42 a.m. nursing consultant B stated he/she talked over the phone or by e-mail and discussed different treatment plans and options if the physician is agreeable. He/she stated that if the resident had a qualifying wound he/she would ask for measurements and then follow up in about 3 weeks. Consultant B stated that it sound as if the wounds the resident's ulcers were possibly moisture, shearing and positioning related. He/she also stated that it didn't matter what the cause was and if the wounds were a stage 2 now they could develop into a full thickness wound. On 11-25-13 at 4:37 p.m. physician consultant A reported that he/she had not seen the ulcers but for resident #13 yet. Review of the Risk Assessment Screening for skin and wound care dated 4-28-10 revealed facility staff were to screen residents for risk of skin breakdown, implement preventative measures and individualize care plan upon completion of each risk assessment findings. It directed staff to assess for mechanical risk factors present including: A. Pressure- contractures, diminished sensation, paralysis; B. Shear - sliding in bed or chair; C. Friction - difficulty moving self around in bed; and D. Excessive Moisture, incontinence, sweating. The facility failed to adequately recognize and assess contributing factors, and failed to implement interventions to prevent the recurrence of pressure/skin ulcers related to urinary incontinence, shearing, and inability to adequately reposition independently for a resident who developed 2, stage 2 (an open wound: where the outer layer of skin and part of the underlying layer of skin is damaged or lost) ulcers in the facility.