Every finding on record at Ashland Health Services

Based on record review, observation and interview, the facility did not ensure the resident environment remains free of accident hazards as possible and each resident receives adequate supervision and assistance devices to prevent accidents for 1 of 3 residents (R) reviewed. (R1)-R1 was transferred with only 1 person not with the assistance of 2 people, as indicated in R1's care plan to prevent falls.Findings include:The facility policy titled Fall Prevention and Management Guidelines last revised on 7/18/2024, states: The nurse will initiate interventions to help prevent falls on the resident's baseline care plan. a. Implement universal environmental interventions that decrease the risk of the resident falling.R1 was admitted to the facility on [DATE], with a diagnoses including dementia, bipolar disorder, depression, abnormal posture, weakness, unsteadiness on feet, and bilateral osteoarthritis of hip.Minimum Data Set (MDS), dated [DATE], which is a quarterly assessment documents R1 having a Brief Interview for Mental Status (BIMS) score of 6/15, meaning severe cognitive impairment. R1 requires substantial assistance with activities of daily living (ADL). R1 is dependent with toileting and ambulation. R1's care plan last revised on 05/14/26 with a target date 07/31/26 indicates, ADL self-care deficit due to cognition and impacted subcapitellar fracture of the left hip, . Will not develop any complications related to decreased mobility. With an intervention initiated on 04/02/24 and revised on 11/12/25 indicated Transfer: assist of 2 with gait belt.On 06/08/26 at 9:50 AM, Surveyor observed R1 in room, asleep in wheelchair. Surveyor was able to wake R1. R1 indicated she did not currently have any pain but was not able to answer any other questions.On 06/08/26 at 12:51 PM, Surveyor observed R1 in bed asleep with no signs of distress.On 06/08/26 at 1:00 PM, Surveyor interviewed Certified Nursing Assistant (CNA) C, who stated R1 was stiff when transferring her. CNA C initially stated they transferred R1 by themself. After Surveyor asked what R1's Kardex indicated, CNA C read R1's plan of care and stated they sometime use 2. CNA C then stated that CNA D assisted in transferring R1 to bed.On 06/08/26 at 1:06 PM, Surveyor interviewed CNA D who stated they did not assist in transferring R1 into bed. CNA D stated they thought R1 was an assist of 1 to transfer and has been transferring R1 with only 1 person since starting a couple of months ago.Surveyor went back to interview CNA C who then admitted they thought R1 only required 1 person to assist with transferring, and they have been transferring R1 with only 1 person. CNA C stated they were not aware R1 required 2 people to transfer R1.On 06/08/26 at 2:07 PM, Surveyor interviewed Director of Nursing (DON) B and shared interviews of CNAs not following R1's care plan and using 2 staff when transferring R1. DON B stated the expectation would be for staff to follow and implement the plan of care interventions.

Based on interview and record review, the facility failed to ensure it maintained an infection prevention and control program designed to help prevent the development and transmission of communicable disease and infections such as COVID-19. This had the potential to affect all 36 residents.-The facility did not test staff with symptoms of COVID-19. -Staff used soiled cloth for catheter care and used a dropped alcohol wipe to disinfect the catheter of R7. Example 1 The CDC's COVID 19 website lists possible symptoms of COVID 19 which may include: Fever or chills Cough Shortness of breath or difficulty breathing Sore throat Congestion or runny nose New loss of taste or smell Fatigue Muscle or body aches Headache Nausea or vomiting Diarrhea The facility's policy titled Infection Prevention and Control Program, read in part .3. Surveillance: a. A system of surveillance is utilized for prevention, identifying, reporting, investigating, and controlling infections and communicable diseases for all residents, staff, volunteers, visitors, and other individuals providing services under a contractual agreement based upon a facility assessment and accepted national standards. On 08/05/25, Surveyor reviewed the facility's surveillance, including the employee infection line list. Surveyor noted the facility's last COVID 19 outbreak was in 01/2025, and employees were being tested for COVID 19 at that time. Surveyor noted beginning 02/2025, the facility's documentation did not show employee testing for staff exhibiting signs or symptoms of COVID 19. Surveyor noted the following: -02/15/25, Business Office Manager (BOM) E, symptoms of nausea and vomiting, no testing was completed and BOM E returned to work on 02/18/25. -02/19/25, Staff F, symptoms of vomiting with a fever, no testing was completed and Staff F returned to work 02/21/25. -02/25/25, Dietary Staff G, symptoms of vomiting and diarrhea, no testing was completed and Dietary Staff G returned to work on 02/27/25. -03/04/25, Staff H, symptoms of diarrhea and vomiting with a fever, with no return to work date. -03/14/25, Staff I, symptoms of vomiting and diarrhea, no testing was completed, Staff I returned to work on 03/16/25. -04/17/25, Certified Nursing Assistant (CNA) J, symptoms of nausea and vomiting, no testing was completed. CNA J returned to work 04/18/25. -05/21/25, CNA K, symptoms of chest congestion with fever, no testing was completed. CNA K returned to work on 05/22/25. -05/26/25, Staff L, symptoms of chest congestion, cough, and sore throat, no testing was completed. Staff L returned to work on 05/27/25. -07/14/25, Dietary Staff M, cold symptoms, no testing was completed. Dietary Staff M returned to work on 07/15/25. On 08/05/2025 at 12:38 PM, Surveyor interviewed Director of Nursing (DON) B and Infection Preventionist (IP) C. DON B and IP C reported no outbreaks since either have been employed at facility. DON B and IP C stated they use CDC for guidance on infection control. DON B and IP C were unsure if requirement for staff or resident testing is one symptom or more. Surveyor reviewed with DON B and IP C examples from the employee line list, including vomiting, nausea, diarrhea, fever, sore throat, cough, and cold symptoms. DON B and IP C stated they have not been testing staff with symptoms of headache, body ache, fever, vomiting, nausea, etc. DON B and IP C stated they would reach out to the previous DON and possibly the public health department and would get back to Surveyor. On 08/05/2025 at 1:36 PM, Surveyor interviewed DON B. DON B stated they were not testing staff, and stated they are changing the way they do things and will immediately begin testing staff/residents with signs and symptoms of COVID 19. Example 2 Facility policy titled, Catheter Care, dated 3/15/2023 stated in part: Female: 9. gently separate the labia to expose the urinary meatus. 10. Wipe from front to back with a clean cloth moistened with water and perineal cleaner (soap). 11. Use a new part of the cloth or different cloth for each side. 12. With a new moistened cloth, starting at the urinary meatus moving out, wipe the catheter making sure to hold the catheter in place so as to not pull on the catheter . R7 was admitted on [DATE] with a brief interview of mental status (BIMS) score of 15/15 which indicated R7 was cognitively intact. R7 had a diagnosis of neurogenic bladder (happens when an injury or disease interrupts the electrical signals between your nervous system and bladder function). Doctors order to perform catheter care every shift. On 08/05/2025 at 6:58 AM, Surveyor asked CNA D to observe any catheter care that was provided to R7. On 08/05/2025 at 7:23 AM, R7 agreed to allow Surveyor to observe morning cares which included catheter care. CNA D performed proper hand hygiene and put on gown and gloves per enhanced barrier precaution guidelines. CNA D then removed R7’s underwear. CNA D then washed R7’s lower abdomen, abdominal folds and perineum. CNA D then began to clean the insertion site of the catheter with the same gloved hands using the same soiled washcloth. CNA D then informed Surveyor that R7 wears a leg bag drainage system during the day and began to remove the bed drainage bag. CNA D took an alcohol wipe out and dropped it on the floor. CNA D then picked the alcohol wipe from the floor and cleaned the distal (exit) end of the catheter and connected R7’s catheter to the leg bag. On 08/05/2025 at 8:38 AM, Surveyor interviewed CNA D about the observations of the soiled washcloth and alcohol wipe. Surveyor asked CNA D, “Is this acceptable?” CNA D replied, “That is probably not acceptable.” On 08/05/2025 at 8:44 AM, Surveyor explained to the interim Director of Nursing (DON) B the observations made with CNA D using a soiled washcloth to perform catheter care and using the contaminated alcohol wipe to clean the catheter. DON B replied, “That is not acceptable.”

Based on interview, and record review, the facility did not implement a care plan to meet a resident's medical need for 1 of 5 residents (R) 5 reviewed for care plans.-CNA did not follow the care plan by not documenting R5's bowel movement for 2 days.R5 was admitted to the facility on [DATE] with diagnoses that include stroke with left sided paralysis, chronic pain, dementia, traumatic brain injury, epilepsy, anemia, and constipation. Minimum Data Set (MDS), dated [DATE], indicated R5 had a Brief Interview for Mental Status score of 99 meaning severe cognitive impairment. In addition, R5 is dependent on staff for eating, transfers, toileting, and extensive assist for bed mobility. R5 had an activated Power of Attorney for healthcare and finance. R5's care plan, dated 07/28/25, states: Bowel Elimination Alteration: At risk for constipation r/t: lack of exercise, medications. Interventions: Administer medications per MD order and observe effectiveness, . Record BM (bowel movement) . Repost (sp) S&S (signs and symptoms) such as abdominal cramping, diarrhea, n/v (nausea and vomiting), no BM for 3 days. Goal: Will have no complications related to constipation.On 08/05/25 at 1:10 PM, Surveyor spoke with R5's family member (FM) N who reported R5 did not seem usual self today and reported it to the nurse because FM N said, I never saw him like that before. Look how his belly is moving when he is breathing, and eyes look different too. Surveyor observed R5 using abdominal muscles with each breath and eyes open, glossy, and staring at ceiling.On 08/05/25 at 2:28 PM, Surveyor reviewed medications and discovered R5 routinely receives opioids, iron supplement, and antipsychotic medications that place him at high risk for constipation. Current physician orders include: Ferrous Sulfate Elixer 220 mg/5ml. Give 7.5 ml one time a day for anemia. Olanzapine 2.5mg every evening for dementia with behaviors. Hydrocodone- APAP 7.5/325 give one tablet 2 times a day, plus one at bedtime, plus one as needed for pain. Senna Plus 8.6-5mg give one tablet every day for constipation. MiraLAX 17gm by mouth once a day for constipation. Magnesium hydroxide 30ml every 24 hours as needed for constipation. Bisacodyl Suppository 10mg insert 1 rectal every 24 hours as needed for constipation. Fleet Enema 7-19gm/118ml insert 1 application rectally every 24 hours as needed for constipation. Surveyor reviewed R5's BM flow sheet and noted the last normal formed BM was recorded on 07/31/25. From 08/01/25 to 08/05/25, R5 had no BM documented (5 days). Surveyor informed Registered Nurse (RN) O of the findings for R5, and RN O said she would look into it. RN O stated R5's medications were recently decreased because he was having blow outs. On 08/06/2025 at 8:00 AM, Nursing Home Administrator (NHA) A provided updated information showing bowel movements were checked on 08/02/25 and 08/03/25. NHA A reported they contacted Certified Nursing Assistant (CNA) K who reported the computer system was down so unable to mark BMs and reported R5 had 2 large BMs, one on 08/02/25 and one on 08/03/25. Surveyor asked NHA A what the protocol is for following the care plan and documenting BMs if the computer access is down. NHA A said it only happened with CNA K who reported she had asked day shift CNAs to mark the bowel movements but assumed and did not ensure they did. NHA A said in the event of no access, staff are expected to call IT or Think ANEW, which CNA K did do, but did not gain access until Monday when CNA K updated R5's record. NHA A acknowledge CNA K did not follow the care plan when the bowel movements were not documented.

Based on observations, interviews, and record reviews, the facility did not establish and maintain an infection control program designed to help prevent the development and transmission of disease. This has the potential to affect all 40 residents. No surveillance log for staff infections. Staff did not apply gloves prior to entering rooms with residents on contact precautions. Precaution signs posted for Enhanced Barrier Precautions (EBP) and Contact precautions for R34 No process for reporting residents with Methicillin-Resistant Organisms (MRDO) when transporting to other facilities. This is evidenced by: Example 1: Facility policy titled, Infection Surveillance, dated as revised 03/08/23 states: Policy: A system of infection surveillance serves as a core activity of the facility's infection prevention and control program. Its purpose is to identify infections and to monitor adherence to recommended infection prevention and control practices in order to reduce infections and prevent the spread of infections. 1. The Infection Preventionist serves as the leader in surveillance activities, maintains documentation of incidents, findings, and any corrective actions made by the facility and reports surveillance findings to the facility's Quality Assessment and Assurance Committee, and public health authorities when required. 10. Employee, volunteer, and contract employee infections will be tracked, as appropriate, such as influenza or gastrointestinal infection outbreaks. On 06/05/24, Surveyor reviewed the facility's infection control program including surveillance logs. Upon review, Surveyor discovered the only documentation on staff infections and outbreaks was an email Infection Preventionist (IP) L sent to Nursing Home Administrator (NHA) A and Director of Nursing (DON) C stating it was the only information IP L had on the staff infection control and outbreaks. The email documentation includes: Registered Nurse (RN) N tested positive for influenza A on 01/04/24. Symptoms were listed. RN N returned to work 48 hours after symptoms resolved. RN N was off of work for one week. IP L did not document date as to when RN N returned to work. Certified Nursing Assistant (CNA) O tested positive for influenza A on 02/03/24. Symptoms were listed. OP L did not document as to when CNA O's symptoms resolved or when CNA O returned to work. CNA P (student) tested positive for COVID-19 on 02/06/24. CNA P completed clinicals at the facility on 02/05/24. CNA O worked with a few residents on unit 3. Contact tracing with residents conducted on 02/07/24, 02/09/24, and 02/11/24. All residents tested were negative for COVID-19. The email states CNA clinicals were placed on hold. IP L did not document as to how long the CNA clinicals were placed on hold. Surveyor unable to determine if CNA P returned to the facility in accordance with CDC guidelines. Physical Therapy Assistant (PTA) Q tested positive for COVID-19 on 04/07/24. Symptoms were listed. Two negative COVID-19 tests were conducted on PTA Q with no dates listed, contact tracing with residents on 04/08/24, 04/10/24, and 04/12/24 with all negative results. IP L did not document a return-to-work date for PTA Q. On 06/05/24 at 1:30 p.m., Surveyor interviewed DON C and asked about the surveillance logs for staff infections. DON C looked for additional information and admitted there was no other documentation or surveillance logs. DON C stated the facility had an influenza A outbreak starting on 01/25/24, a COVID-19 outbreak 11/01/23 through 12/21/23 and 04/07/24 through 05/28/24. DON C stated the facility will be initiating a performance improvement plan (PIP) on the infection control processes, policies, and surveillance. 46693 Example 2: Facility policy and procedure entitled Infection Prevention and Control Program, last revised 03/14/23, stated in part, A resident with an infection or communicable disease shall be placed on transmission based precautions as recommended by current CDC guidelines. When a resident on transmission-based precautions must leave the resident care unit/area, the nurse shall communicate to all involved departments the nature of the isolation and shall prepare the resident for transport in accordance with current transmission-based precaution guidelines. R24 was admitted on [DATE] with diagnoses that include right sided paralysis, open wound to right lower leg, and methicillin resistant staphylococcus aureus (MRSA). R24's care plan identified that R24 requires assistance of 1 for bathing and toileting and needs assist sometimes with transfers and mobility. The diagnosis for MRSA was found on a lab result collected on 04/16/24 and was not in the care plan or the diagnosis sheet. R34 was admitted on [DATE] with diagnoses that include right sided paralysis, urinary retention, suprapubic urinary catheter, and MRSA. R34's care plan identified that R34 requires assistance of one for bathing, bed mobility, dressing, assist (does not state how many) for transfers requiring a mechanical lift, and assist of 2 for toileting. The diagnosis for MRSA was found on lab result collected on 04/16/24 and was not in the care plan or the diagnosis sheet. On 06/05/24 at 8:31 AM, Surveyor observed CNA G enter R24's room without gloves on. Surveyor noted a sign outside R24's room identifying R24 was on contact precautions and required gloves to be worn prior to entering the room. At 9:23 AM, Surveyor observed CNA G and CNA K enter R34's room that also had a sign outside the room identifying R34 is on contact precautions and staff should have gloves on prior to entering R34's room. Neither CNA donned gloves prior to entering R34's room. Surveyor observed the supply bins outside the room did not have gloves on them. Surveyor asked CNAs where they obtain gloves from and CNA G stated they are usually on top of the bins, but there were none today. We just got the gloves inside the rooms. On 06/05/24 at 9:38 AM, Surveyor interviewed DON C who stated the expectation is for any staff entering rooms with residents on contact precautions they would be wearing gloves. DON C immediately educated the CNAs and ensured all bins were stocked with gloves. Example 3: On 06/05/24, Surveyor noted R34 had two signs, one stating contact precautions and one Enhanced Barrier Precautions (EBP). On 06/05/24 at 12:10 AM, Surveyor interviewed DON C and informed her of two signs on R34's door which was confusing. DON C stated the EBP sign should have been removed. R34 was on contact precautions. Staff would be expected to follow contact precaution guidelines. Example 4: On 06/05/24, Surveyor noted R24 and R34 were both on contact precautions for MDROs. On 06/05/24 at 11:59 AM, Surveyor interviewed Licensed Practical Nurse (LPN) E and asked if they ever transferred residents to the hospital if they need it, which LPN E replied, Yes. Surveyor then asked how do you report to the hospital if a resident has an MDRO. LPN E stated, It should be on their diagnosis sheet. LPN E looked on the diagnosis sheet and care plan for R24 and R34. Neither resident had MDROs identified. LPN E said, I don't see it there. The process absolutely needs to be fixed. Surveyor inquired about the practice for reporting MDROs during transport for which DON C said she was not familiar with it in that particular facility. Surveyor informed DON C about the interview having no system to report MDROs when transferring residents. DON C stated they are hiring a new infection control and prevention staff. DON C plans to train them the correct way and set it all up for the facility.

Based on interview and record review, the facility did not maintain documentation of screening, education, offering, and current Coronavirus 19 (COVID) vaccination status to staff. This has the potential to affect all 40 residents. This is evidenced by: On 06/05/24, Surveyor reviewed the facility's infection control program and policies. The facility policy titled, COVID-19 Vaccination with revised date of 10/27/23 states: Policy: It is the policy of this facility to minimize the risk of acquiring, transmitting, or experiencing complications from COVID-19 (SARS-CoV-2) by educating and offering our residents and staff the COVID-19 vaccine. Policy Explanation and Compliance Guidelines: 1. It is the policy of this facility to have an immunization program against COVID-19 in accordance with national standards of practice. 13. The facility will educate and offer the COVID-19 vaccine to residents, resident representatives, and staff and maintain documentation of such. 17. If a vaccination requires additional doses, the resident, resident representative, or staff member will be provided with current information regarding the additional doses, including any changes in the benefits, risks, or potential side effects associated with the COVID-19 vaccine, before requesting consent for administration of any additional doses. Upon review, Surveyor did not find any documentation of staff screening, education, offering of the covid vaccine, or current COVID-19 vaccination status of staff members. On 06/05/24 at 1:30 p.m., Surveyor interviewed Director of Nursing (DON) C and asked about the documentation of staff screening, education, offering, and current COVID-19 vaccination status. DON C stated there was no documentation, but a performance improvement plan (PIP) will be initiated to correct this deficiency in the infection control program.

Based on interview and record review, the facility failed to submit accurate data to Centers for Medicare and Medicaid Services (CMS) mandatory Payroll Based Journal (PBJ) for quarter 3 2023 (April 1-June 30), quarter 4 2023 (July 1-September 30), and quarter 1 2024 (October 1-December 31). This had the potential to affect all 40 residents. This is evidenced by: On 06/05/24 at 1:00 p.m., Surveyor interviewed Nursing Home Administrator (NHA) A about the low weekend staffing data that was triggered in the PBJ report for the third quarter 2023 (April 1-June 30), fourth quarter 2023 (July 1-September 30), and quarter 1 2024 (October 1-December 31). NHA stated the issues with the data reporting were due to agency staff not punching their hours on the facility time clock, so the accurate hours were not in the facility computer system. Surveyor compared the data with time punches. Surveyor did not identify any concerns related to low weekend staffing coverage. The facility assessment states: Day shift: 2 licensed nurses, 3-5 CNAs Evening shift: 2 licensed nurses, 3-5 CNAs NOC shift: 1 licensed nurse, 2-3 CNAs The data reviewed by Surveyor meets the facility assessment for staffing. Surveyor then reviewed the staff schedules for quarter 4 2023 (July 1-September 30) and compared the data with time punches for the PBJ report, triggering that the facility failed to have licensed nursing coverage 24 hours a day. On 07/04/23 (TU), 07/22/23 (SA), 09/03/23 (SU), 09/16/23 (SA), 09/17/23 (SU), and 09/30/23 (SA), two agency Registered Nurses (RN) failed to punch the facility time clock, and the facility did not have accurate data to submit for the PBJ report. The facility had licensed nursing coverage 24 hours a day. NHA A stated the facility recognized the issue of the agency staff not punching their hours. The facility has put into place the following: 1. Any agency staff has to punch their hours in the facility time clock, 2. The Business Office Manager then compares the punches from the time clock to the schedule of staff who worked, and 3. This information is then compared to the Center for Medicare and Medicaid Services (CMS) staff posting to ensure accuracy in the submission of hours for the PBJ report. On 06/05/24, Surveyor was unable to verify processes facility put in to place were effective in correcting the PBJ errors. The quarter 2 2024 PBJ report (January 1-March 31) was unavailable from CMS for review at time of survey.

Based on interview and record review, the facility did not have a comprehensive system for ensuring 5 (R5, R8, R9, R24, R31) of 5 residents reviewed for immunizations received or were offered the pneumococcal vaccination. *R5 - No documentation of receiving or declining PCV 15 or PCV20. *R8 - No documentation of receiving or declining PCV20 or PPSV23. *R9 - No documentation of receiving or declining PCV20. *R24 - No documentation of receiving or declining PCV15 or PCV20 *R31 - No documentation of receiving or declining PCV15 or PCV20. This is evidenced by: According to the Center for Disease Control. (2024, February 6). Pneumococcal Disease in Adults and Vaccines to Prevent It. CDC Pneumococcal Disease. https://www.cdc.gov/pneumococcal/prevent-pneumococcal-factsheet/index.html#cdc_generic_section_6-vaccination, Two types of vaccines used in the United States help prevent pneumococcal disease in adults: conjugate and polysaccharide vaccines. Recommendations: Center for Disease Control (CDC) recommends pneumococcal conjugate vaccination (PCV15 or PCV20) for Adults [AGE] years or older: All Adults younger than [AGE] years: Those at increased risk for pneumococcal disease If PCV15 is used, it should be followed by a dose of pneumococcal polysaccharide vaccine (PPSV23). Previously vaccinated: Adults who received an earlier pneumococcal conjugate vaccine (PCV13 or PCV7) should talk with a vaccine provider. The provider can explain options available to complete the recommended pneumococcal vaccine series. Adults [AGE] years or older have the option to get PCV20 if they have already received both of the following: PCV13 (but not PCV15 or PCV20) at any age PPSV23 at or after the age of [AGE] years old The facility policy titled, Pneumococcal Vaccine (Series) dated 02/20/23, revised 01/11/24 states: Policy: It is our policy to offer residents and staff immunization against pneumococcal disease in accordance with current CDC guidelines and recommendations. Policy Explanation and Compliance Guidelines: 1. Each resident will be assessed for pneumococcal immunization upon admission. Self-report of immunizations shall be accepted. Any additional efforts to obtain information shall be documented, including efforts to determine the date of immunization or type of vaccine received. 2. Each resident will be offered a pneumococcal immunization unless it is medically contraindicated, or the resident has already been immunized. 4. The resident/representative retains the right to refuse the immunization. Refusals should be documented in the medical record, along with what education was provided and a risk vs benefit discussion. Notify MD (Medical Doctor) if immunization is refused. 5. A consent form shall be signed prior to the administration of the vaccine and filed in the individual's record. 6. The type of pneumococcal vaccine (PCV15, PCV20, or PPSV23) offered will depend upon the recipient's age and susceptibility to pneumonia in accordance with current CDC guidelines and recommendations. On 06/05/24, Surveyor reviewed five residents' pneumococcal immunizations: R5 is [AGE] years old. R5 received the PPCV23 on 10/07/03 and 03/11/16. R5's medical record has no documentation of the facility offering or R5 declining PCV15 or PCV20 vaccine. The recommendation is 1 dose PCV15 OR 1 dose PCV20. Administer either PCV15 or PCV20 at least 1 year after the last PPSV23 dose. If PCV15 is given, no additional PPSV23 doses are recommended. R8 is [AGE] years old. R8 received Prevnar 13 on 11/04/15 and PPSV23 on 09/19/12. R8's medical record has no documentation of the facility offering or R8 declining the PCV20 or PCV23 vaccine since R8 received the PPSV23 vaccine before the age of 65. R9 is [AGE] years old. R9 received Prevnar 13 on 11/17/16 and PPSV 23 dose 1 on 07/11/06. R9's medical record has no documentation of the facility offering or R9 declining the PCV20 vaccine. The recommendation is 1 dose of PCV20 at least 5 years after the last pneumococcal vaccine if the individual received both PCV13 and PPSV23 and the PPSV23 vaccine was received at age [AGE] years or older. R24 is [AGE] years old. R24 declined the PCV13 vaccine. R24 has no other documentation of offering or R24 declining any pneumococcal vaccines. The recommendation is for individuals age [AGE] years or older who have not previously received a dose of PCV13, PCV15, or PCV20: 1 dose of PCV15 or 1 dose of PCV20. If PCV15 is given, 1 year after the PCV15 dose, 1 dose of the PPSV23 should be administered. R31 is [AGE] years old. R31's medical record has no documentation of previous pneumococcal vaccines and no documentation of the facility offering PCV15 or PCV20 if no previous vaccination or no previous vaccination history is known. If PCV15 is given, 1 dose of PPSV23 should be administered 1 year after the PCV15 dose. On 06/05/24 at 1:30 p.m., Surveyor interviewed Director of Nursing (DON) C from a sister facility and asked about the lack of documentation on the residents' pneumococcal vaccines. DON C looked for additional information on the vaccines, but there was no additional information. Surveyor asked DON C why the facility did not offer the residents pneumococcal vaccines. DON C stated there was no excuse, but the facility will put a positive improvement plan (PIP) into place to correct this.

Based on observations, interviews and record reviews, the facility did not administer medications in a safe and effective manner for for 1 out of 1 resident (R1) observed having medications left at bedside. This is evidenced by: R1 has medical diagnoses that include, but are not limited to, chronic pain, chronic post-traumatic stress disorder, long term use of opiate analgesic and alcohol abuse, in remission. The most recent Minimum Data Set Assessment (MDSA) completed for R1 was a quarterly assessment with the ARD (Assessment Reference Date) 3/5/24. According to this MDSA, R1 has a Brief Interview of Mental Status (BIMS) of 15, indicating intact cognition. R1 has no mood indicators or behaviors listed. Surveyor then reviewed R1's care plan and noted the following: - History of substance use disorder as evidenced by history of addiction to alcohol, chronic opioid use. The start date of this problem was 12/4/23 and last revised 2/11/24. Interventions for this problem included: Nurse to remain in room at all times during medication administration due to history of hiding/hoarding medications. This intervention was initiated 2/11/24. On 6/3/24, while observing meal service to resident rooms on the 2nd Hall, Surveyor observed the following: - At 8:02 AM, the meal tray was delivered to R1. Resident is lying on top of the bed fully dressed. Meal remained covered in room. - At 8:06 AM, Licensed Practical Nurse (LPN) E dispensed R1's medications and delivered these in the medication cup in R1's room. - At 8:49 AM, Surveyor entered R1's room to observe meal intake. R1 remained on top of bed stretched out and asleep. Meal was not touched; entree remained covered as well as the beverage glasses and the oatmeal. Sitting in a medicine cup were 11 medications. - At 9:51 AM, R1's breakfast tray remained in room. R1 stated to Surveyor, My stomach is messed up today. I have eaten all I wish to. Until my stomach feels better, I won't be eating or taking my meds. The medications have since been removed from the room. Surveyor then reviewed R1's record for Medication Self- Administration assessments and noted there were three completed as follows: - 2/22/19: Saline Nasal Spray, using daily each nare; Interdisciplinary Team (IDT) Review Summary: Resident able to identify his medication along with the ability to recall why he uses the Saline Nasal Spray. Easily able to demonstrate same. - 3/8/19: 1. clotrimazole cream apply topically to affected area BID 2. Betamethasone cream apply topically to affected area daily 3. Nystatin powder apply topically to affected area BID IDT review of self administration assessment and agree with resident able to self administer creams. Will keep at bedside locked drawer. Care plan to be adjusted. - 5/29/19: Metamucil in the morning and evening. IDT Review Summary: Resident is safe and competent and can self administer metamucil. There were no recent assessments completed and none located for self-administration of pills/capsules. On 6/3/24 at 11:18 AM, Surveyor approached Director of Nursing (DON) C and requested any recent Self-Administration assessments for R1. DON C was assisting Interim DON B during this survey as she is the DON at a sister facility and a former DON at this facility. DON C stated the proper procedure was to assess the resident and then call the physician for orders and put it on the care plan. At 1:54 PM on this same date, DON C approached Surveyor and stated there was no physician order or assessment completed for R1 to determine safety in self-administering medications. DON C stated that a phone call was placed to R1's physician for an order. On 6/3/24 at 1:56 PM, Surveyor approached LPN E and asked how nursing was to determine if a resident could self-administer medications. LPN E stated the resident would have a self-administration assessment completed and a physician order indicating the resident could self-administer their medications. Surveyor asked if one was completed for R1. LPN E searched the computer electronic medical record and then stated there was no assessment completed for R1 and no physician orders listed. Surveyor then asked LPN E why medications were left at R1's bedside if there was no assessment completed to determine R1 was safe to complete taking medications unsupervised. LPN E stated, [R1] took a couple for me when I was standing outside his room and said he would take the rest later. Surveyor then asked LPN E to verify the medications left at bedside and in the medicine cup as being: - Docusate Sodium capsule - Furosemide - Isosorbide Mononitrate Extended Release (ER) - Loratadine - Metoprolol Succinate ER - Tamsulosin - guaifenesin - Omeprazole (2 capsules) - Spironolactone - Acetaminophen At 4:18 PM, DON C approached Surveyor and stated R1's physician will not give an order for R1 to self-administer medications based on resident's history and the medications should not have been left at the bedside by the nurse.

Based on observations, interviews and record reviews, the facility failed to ensure 2 of 2 residents (R31 and R1) reviewed for post-traumatic stress disorder (PTSD) received culturally competent trauma-informed care in accordance with professional standards of practice and accounting for each resident's experience and preferences in order to eliminate or mitigate retraumatization. This is evidenced by: According to Substance Abuse and Mental Health Services Administration (SAMHSA, 2014) (https://www.ncbi.nlm.nih.gov/books/NBK207191/), The impact of trauma can be subtle, insidious, or outright destructive. How an event affects an individual depends on many factors, including characteristics of the individual, the type and characteristics of the event(s), developmental processes, the meaning of the trauma, and sociocultural factors. SAMHSA explains trauma causes immediate and delayed emotional, behavioral, physical, cognitive, and existential reactions. The facility's Trauma Informed Care policy, dated 10/18/22, stated, in part, It is the policy of this facility to provide care and services which, in addition to meeting professional standards, are delivered using approaches which are culturally competent, account for experiences and preferences, and address the needs of trauma survivors by minimizing triggers and/or re-traumatization . Under Policy Explanation and Compliance Guidelines, the policy continued, stating . 4. The facility will collaborate with resident trauma survivors, and as appropriate, the resident's family, friends, the primary care physician, and any other health care professionals (such as psychologists and mental health professionals) to develop and implement individualized care plan interventions. 5. The facility will identify triggers which may re-traumatize residents with a history of trauma. Trigger-specific interventions will identify ways to decrease the resident's exposure to triggers which re-traumatize the resident, as well as identify ways to mitigate or decrease the effect of the trigger on the resident and will be added to the resident's care plan . Example 1 R31 was admitted to the facility 4/2/24 with medical diagnoses that include, but are not limited to, unspecified dementia without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety, bipolar disorder, depression, history of alcohol use and post-traumatic stress disorder-chronic. R31 currently goes to psychiatric counseling, with the last visit being 5/10/24. In reviewing the dictations from these visits, the consultant mentions past trauma but did not indicate what caused the PTSD in R31's life history. Surveyor then reviewed the Admission Psychosocial assessment dated [DATE] that the facility completed. According to this, R31 has diagnoses of bipolar disease, depression, PTSD and insomnia. The following was noted by Surveyor: - The facility checked the box: Prior trauma or history /diagnosis of PTSD: History/ Diagnosis of PTSD and entered, Has history of PTSD- unknown origin; family and [R31] unable to state PTSD diagnosis. - Under Care Planning: Trauma Informed Care is checked Section 2a. Trauma Informed Care: The facility checked the box Focus: At risk for re-traumatization of past event or experience where reminders/triggers of event or experience may cause behavioral changes and/or emotional distress; Goal: Reminder/triggering events will be avoided with minimal impact during stay within the facility. Included in the interventions: Determine, as able the triggers of traumatic event or experience, such as sights, smells, sounds and touch, which may lead to a set of emotional, physiological and behavioral responses that arise in service of survival and safety . Screen for past traumatic events that ay impact physical, emotional and mental well-being . The most recent Minimum Data Set Assessment (MDSA) was a Significant Change in Status assessment dated [DATE]. The documentation completed to justify the significant change was . Resident is determined to be a significant change due to weight loss, behaviors, falls . Behaviors include rejection of care 6 out of 7 days in the past week, poor appetite, 2 recent falls, nurse notes in past 2 days: restlessness, delusions, auditory hallucinations. SS (Social Services) has observed paranoia and suspicion by resident. Family/friend input reveals her dementia and cognition have progressively declined in the past several months. Biweekly appts with psychotherapist . According to the MDSA, R31 has a Brief Interview of Mental Status (BIMS) score of 9, indicating moderately impaired cognitive status. Behaviors identified on this MDSA include verbal behaviors and rejection of care. The mood or depression score for R31 on this assessment was listed as 10/27, indicating moderate depression. R31 has had 2 or more falls without injuries on this assessment and was also listed as having weight loss greater than 5%. In reviewing the weight loss, Surveyor identified that R31 sustained an unprescribed 13.65% weight loss since admission. On 4/2/24, R31 weighed 196.4 pounds and on 5/31/24, weighed 169.6 pounds. Note: According to the National Institute Of Mental Health clinical signs of depression can include poor concentration, feelings of excessive guilt or low self-worth, thoughts about dying or suicide, disrupted sleep, feeling very tired or low in energy or changes in appetite or weight. Surveyor reviewed the care plan developed for R31 and noted the following: 1. At risk for re-traumatization of past event or experience where reminders/triggers of event or experience may cause behavioral changes and/or emotional distress. Diagnosis of PTSD (start date 4/3/24, last revised 5/2/24). Interventions for this plan included: - Determine as able, the triggers of traumatic event or experience, such as sights, smells, sounds and touch, which may lead to a set of emotional, physiological and behavioral responses that arise in service of survival and safety (4/3/24) - Monitor for decreased social interaction and explore opportunities to avoid decline (4/3/24) - Monitor for increased withdrawal, anger or depressive behaviors and explore opportunities to avoid (4/3/24) - Screen for past traumatic events that may impact physical, emotional and mental well-being (4/3/24) 2. Alteration in behavior symptoms related to bipolar, dementia, declining assist with cares (start 4/9/24; last revised 5/2/24). Interventions for this plan included: - Psych referral as needed (5/2/24) - Use consistent approaches when giving care (5/2/24) 3. Cognitive loss as evidenced by short term memory deficit, poor recall related to cognitive impairment (Start 5/20/24) Interventions for this plan included: - Allow adequate time to respond. Do not rush or supply words (5/20/24) - Approach/speak in a calm, positive/reassuring manner (5/20/24) - Attempt to provide consistent routines/caregivers (5/20/24) - Explain each activity/care procedure prior to beginning it (5/20/24) - Identify self when speaking to resident (5/20/24) 4. At risk for changes in mood related to diagnosis of bipolar (start 4/9/24). Interventions for this plan include: - Assess for physical/environmental changes that may precipitate change in mood (4/3/24) - Observe for mental status/mood state changes when new medication is started or with dose changes (4/3/24) - Offer choices to enhance sense of control (4/3/24) - Validate feelings of loss (4/3/24) Note: There are no potential triggers listed in R31's care plan to alert staff to potential retraumatization, how to prevent these or how staff are to intervene. On 4/7/24, the facility documented a clinical follow-up and wrote, . The current status is [AGE] year old . with diagnoses including but not limited to . bipolar disorder . PTSD . insomnia . Res. has unspecified dementia . Denied pain. Mood is pleasant and cooperative this shift . In the above, the facility identified knowledge of R31 having PTSD. This was also noted in further documentation in R31's record. On 4/22/24 at 10:09 AM, the facility documented, . Resident very pleasant. Often refuses cares. Res does self transfer which has resulted in falls. Discharge plan is to return home. Resident voiced concern to writer about wanting to see her therapist . r/t (related to) feelings of giving up. Writer spoke with resident about this and asked if she was having any suicidal thoughts or ideations. Res stated she is not having any suicidal thoughts but would like to have an appointment with her Dr. (doctor) Writer will call and ask for appt. (appointment). The appointment was made for 4/26/24. However, there was still no care plan or PTSD assessment for R31 completed to identify the cause and potential triggers, prevention strategies or individualized approaches. On 4/29/24, the facility documented R31 as having an increase in behaviors or rejection of cares. On 5/13/2024, Social Services documented a review for the significant change in status, and included, Disorganized thought process and inattention switching from one subject to another . poor appetite, feeling tired, low energy, feeling not quite right, down a bit, feeling bad about self, lose of interest in pleasurable activities. is currently seeing . counselor bi-weekly . Behaviors which have increased since last MDS include rejection of care, restlessness, delusions, auditory hallucinations. Writer has observed paranoia and suspicion when staff or visitors walk by . continues on Seroquel, benztropine, Lexapro . Cognition is impaired, poor safety awareness, ST (short term) memory deficit and difficulty staying on subject or task. Multiple falls since last assessment. Attempting to schedule cognitive testing at the memory clinic . On 6/2/24 at 10:25 AM, Surveyor met with R31 and asked if she had an event in her past that affects her today. R31 stated, Oh we all have things as children, I am sure I had something happen. I really don't wish to talk about it. R31 did not appear to have specific knowledge regarding a traumatizing event or chose to not share it with Surveyor. On 6/3/24 at 1:27 PM, Surveyor met with Social Services Director (SSD) D regarding R31 and asked what caused R31's PTSD. SSD D stated that R31 was in the facility this past fall and had been living with a son, who had no insight into R31's PTSD. SSD D affirmed that she had not determined the cause of R31's PTSD. SSD D stated she had tried to contact the psychotherapist on 4/29/24 but had not yet received a return call. SSD D also affirmed she did not complete a follow-up call with the therapist to gain knowledge of R31's PTSD. SSD D continued to state, I reached out today to the psychiatrist who is treating her, had been treating her for many years. The therapist told me that [R31] had a sexual assault as a child with her father . Surveyor then informed SSD D of concerns related to the care plan for R31 with no individualized triggers, prevention strategies or individualized interventions for staff to use, should R31 show retraumatization. Surveyor then asked SSD D why the delay in completing follow-up with psychiatrist to determine the cause of the PTSD. SSD D acknowledged that she should have done follow-up prior to today, and When I didn't receive a call back, I should have kept calling to get the information, but I didn't. The therapist told me that she had been working with [R31] for [AGE] years. It took working with the resident for 6 years before [R31] disclosed the assault as a child to the therapist. The therapist told me that potential triggers for her would be reminiscing about family memories or childhood . On 6/3/24, SSD D completed a Trauma Informed Care Observation that stated, Per therapist/counselor-[R31] is a survivor of childhood sexual and emotional abuse. Sexual perpetrator was her father and her mother was cold and emotionally unavailable to her. Social worker asked [R31] about her PTSD her response was I had some rough times in my life but did not disclose trauma to social worker. When answering the questions below, [R31] answered no to physical or sexual assault. On 6/4/24 at 8:14 AM, Surveyor asked what the practice was in the facility during the admission process and the determination of PTSD. SSD D stated, First we find out what the diagnosis is, sometimes it's in the History and Physical other times in any outside service or therapist dictations. Then I interview resident or family. In this case, I went to the son first, and he didn't know. Yesterday I talked to therapist, who initially saw her for depression and alcohol abuse. I asked therapist yesterday if any triggers to watch for with the worsening dementia. As [R31's] dementia progresses, we may see some of her memories surface . Surveyor informed SSD D of the concern with R31 being admitted two months prior and there was no individualized care plan for staff to refer to, to direct them on how to respond for R31, should retraumatization occur. SSD D stated, Yeah, I know. I contacted therapist on 4/29, and I did not hear back from her. I did not do any follow up. I should have done it before yesterday. I did not ask her why she didn't get back to me. I just should have followed up before now . going forward I will be more individualized with care plans, interview residents more in-depth and follow up with therapists for the residents. On 6/4/24, Surveyor interviewed the following staff who were responsible for R31 on this date: - Licensed Practical Nurse (LPN) F (8:32 AM) - Certified Nursing Assistant (CNA) G (8:55 AM) - Life Enrichment Specialist (LES) I (9:02 AM) - CNA H (1:40 PM) None of the above staff had any knowledge that R31 suffered from PTSD, the cause, what potential triggers could cause retraumatization or what interventions may be effective to dispel behaviors or retraumatization. Example 2 Resident (R) 1 was admitted to the facility 11/26/23 with medical diagnoses that include but are not limited to chronic pain, anxiety disorder, post-traumatic stress disorder-chronic and alcohol abuse, in remission. The facility completed an Admission Psychosocial assessment dated [DATE]. Under Section C Psychosocial-Concerns, Needs, Preferences the assessment states in 1bb. Has flashbacks at times but he is able to work through flashbacks and anxiety when they occur. 1dd. states, Prescribed Diazepam for PTSD. Section C 2. indicates resident practices Native American traditions and spiritual beliefs and values. 5. Prior Trauma and history/diagnosis of PTSD . 5aa PTSD from gang involvement and violence when he lived in Chicago . Under Section D. Care Planning: - Trauma Informed Care is checked 2a. Trauma Informed Care: The facility checked the box Focus: At risk for re-traumatization of past event or experience where reminders/triggers of event or experience may cause behavioral changes and/or emotional distress; Goal: Reminder/triggering events will be avoided with minimal impact during stay within the facility. Included in the interventions: Determine, as able the triggers of traumatic event or experience, such as sights, smells, sounds and touch, which may lead to a set of emotional, physiological and behavioral responses that arise in service of survival and safety . Screen for past traumatic events that may impact physical, emotional and mental well-being . Surveyor reviewed the comprehensive care plan developed for R1 and noted the following problems were included: 1. At risk for behavior symptoms r/t (related to): depression and anxiety (12/7/23; last revised 2/11/24). Interventions for this plan included: - Psych referral as needed (5/2/24) - Use consistent approaches when giving care (12/28/23) 2. Episodes of anxiety as evidenced by hx (history) rejection of care, verbalizations of anxiety and/or pain, heavy breathing r/t: anxiety disorder, PTSD, pain, nightmares. (start date 11/29/23; last revised 3/5/24). Interventions for this plan included: - Engage in relaxation techniques such as massage, breathing, guided imagery (specify) (11/29/23) - Evaluate effectiveness and side effects of medications for possible decrease/elimination of psychotropic drugs PRN (11/29/23) - Identify and decrease environmental stressors (11/29/23) - Offer choices to enhance sense of control (11/29/23) - Psych consult and treatment (11/29/23) 3. Pain in multiple locations evidenced by chronic use of opioid medications, frequent ER (emergency room ) visits for pain r/t chronic pain, anxiety, PTSD. Interventions included: - Adjust times of ADL and treatment activities so that occur after analgesic benefits have been achieved (i.e. therapy, wound dressing changes, etc.) 11/27/23 - Implement non-drug therapies (heat, ice, repositioning) to assist with pain and monitor for effectiveness. (11/27/23; revised 1/22/24) - Report nonverbal expressions of pain such as moaning, striking out, grimacing, crying, thrashing, change in breathing, etc. (11/27/23) 4. History of substance use disorder as evidenced by: History of addiction to alcohol, chronic opioid use (12/4/23; revised 2/11/24). Interventions included: - Discuss coping strategies (12/4/23) - Encourage and allow resident to openly express feelings and to express fears and worries. (12/4/23) - Nurse to remain in room at all times during medication administration due to history of hiding/hoarding medications. (2/11/24) - Promote homelike environment, when possible use familiar objects from home, or objects with sentimental value (family picture, etc) (12/4/23) - Provide information on support groups or addiction treatment (12/4/23) - Report changes in mood and suspected use of substance use to physician. (12/4/23) - Support resident's strengths and provide positive affirmations. (12/4/23) 5. At risk for re-traumatization of past event or experience where reminders/triggers of event or experience may cause behavioral changes and/or emotional distress; PTSD from gang involvement when he lived in Chicago (12/3/23; revised 5/2/24) GOAL: Reminder/triggering events will be avoided with minimal impact during stay within the facility. (12/3/23; revised 1/12/24). Interventions for this plan included: - Determine as able, the triggers of traumatic event or experience, such as sights, smells, sounds and touch, which may lead to a set of emotional, physiological and behavioral responses that arise in service of survival and safety (12/3/23) - Monitor for decreased social interaction and explore opportunities to avoid decline (12/3/23) - Monitor for increased withdrawal, anger or depressive behaviors and explore opportunities to avoid (12/3/23) - Provide a safe environment (12/3/23) - Provide choice-making activities (12/3/23) - Refer to Psychology as indicated (12/3/23) - Screen for past traumatic events that may impact physical, emotional and mental well-being (12/3/23) There were no individualized triggers listed for R1, prevention strategies or individualized interventions for staff to use should R1 display potential retraumatization. A review of the Interdisciplinary Team Progress Notes was completed. Surveyor noted the following: - On 3/5/2024, a Behavior Note was entered and stated, . review of behaviors and psychotropic medications is noted to have 2 episodes of statements of feeling jittery, needing valium, but is signed out more consistently during the past month. He was concerned for having nightmares. Resident has PTSD from his younger years involved in gang wars. Has known episodes of anxiety, nightmares, feels jittery periodically surrounding this. PRN (as needed) valium is effective, updated behavior monitoring to include c/o (complaint of) nightmares, CP (care plan) updated . - On 5/28/2024 a behavior note was entered and included the following, . quarterly review of behavioral status, medications, and diagnoses as relates to psychosocial health. Resident does have diazepam ordered for nightmares and jittery feelings, related to PTSD from his younger years in gang wars. Review of PRN medication admin indicates utilized medication 4 x this month. Resident is aware of his feelings and needs for the medication, requests it for use very intermittently, and is effective in managing his symptoms. Most recent review of medication regimen in April, renewing same orders through October 2024. No changes to cp needed. On 6/4/24, Surveyor noted entries in R1's medical record that were not present when reviewed on 6/3/24 from SSD D. Surveyor noted the following: 1. A Social Services note dated 6/3/2024 at 7:00 PM that included the following, . Quarterly MDS . is alert and orientated with no cognitive deficits noted . diagnosis of Anxiety disorder and PTSD long standing . discussed his mood and anxiety this quarter . mood has been stable . anxiety fluctuates . Grounding techniques have been helpful . at times of increased anxiety r/t (related to) gang trauma-such as opening the window, going outside and breathing the air, listening to the sounds of nature to focus concentration specifically the birds. Declines mental health referral, No I have seen 3 psychiatrists in the past and I don't need to see anyone right now. No documented behavior . More detailed interventions updated on PTSD care plan . 2. Surveyor also noted updates to R1's care plan were made to include: - Certain TV shows with increased violence or portray gang violence may increase his anxiety level or produce nightmares later in the evening. revised 6/3/24) - Grounding techniques have been helpful to [R1] at times of increased anxiety r/t gang trauma-such as opening the window, going outside and breathing the air, listening to the sounds of nature to focus concentration specifically the birds. (6/3/24) On 6/4/24 at 8:14 AM, Surveyor approached SSD D to discuss R1 and the PTSD with the updates made. SSD D stated the process in the facility is First we find out what the diagnosis is, sometimes it's in the History and Physical other times in any outside service or therapist dictations. Then I interview resident or family . Surveyor explained concern over R1 not having an individualized care plan to alert staff of the cause and potential triggers of R1's PTSD. Without an individualized care plan, staff would not know how to intervene. SSD D stated, Yeah, you're right. I didn't do any training with staff, and there weren't any care plan triggers until yesterday. He had a quarterly MDS review and I talked to him yesterday for the assessments and talked to him about his nightmares. I made the updates after I spoke with him. [R1] is trying to not use Valium as much and felt doing the grounding exercises helped, birds and listening to the air. Going forward will be more individualized with care plans, interview residents more in-depth and follow up with therapists for the residents . On 6/4/24, Surveyor interviewed the following staff who were responsible for R1 on this date: - LPN F (8:32 AM) - CNA G (8:55 AM) - LES I (9:02 AM) - CNA H (1:40 PM) None of the above staff had any knowledge that R1 suffered from PTSD, the cause, what potential triggers could cause retraumatization or what interventions may be effective to dispel behaviors or retraumatization.

Based on interview and record review, the facility did not ensure 1 of 2 residents (R23) reviewed was offered sufficient fluid intake to maintain proper hydration. The facility did not have a system in place for tracking daily intakes to ensure R23's fluid intake was adequate. Findings include: Findings: The facility's policy, Hydration, reads in part, The facility offers each resident sufficient fluid, including water and other liquids, consistent with resident needs and preferences to maintain proper hydration and health. 1. The facility will utilize a systemic approach to optimize the resident's hydration status: a. Identifying and assessing each resident's hydration status and risk factors. b. Evaluating/analyzing the assessment information. c. Developing and consistently implementing pertinent approaches. d. Monitoring the effectiveness of interventions and revising them as necessary. 3. Evaluation/analysis: a. The assessment shall clarify the resident's current hydration status and individual risk factors for dehydration or fluid imbalance. 4. Care plan implementation: a. The resident's goals and preferences regarding hydration will be reflected in the resident's plan of care. 5. Monitoring/revision: b. The resident will be monitored for signs and symptoms of dehydration including, but not limited to: viii. Confusion or change in mental status ix. Decreased urinary output x. Abnormal lab values e. The resident will be monitored for conditions that may increase fluid needs: ii. Vomiting or diarrhea iii. Fever/infection iv. Uncontrolled diabetes R23 was admitted to the facility on [DATE], after hospitalization for dehydration, confusion, and weakness. R23's hospital discharge instructions were speech therapy (ST) related to dysphagia (difficulty swallowing), occupational therapy (OT), and physical therapy (PT) for strengthening. Admitting diagnoses to facility included dementia, stroke with left sided paralysis, diabetes mellitus type 2, chronic kidney disease stage 3, dysphagia, and depression. R23's admission Minimum Data Set (MDS) assessment confirmed R23 scored 05/15 during Brief Interview for Mental Status (BIMS), indicating severe cognitive impairment. MDS determined R23 required partial or moderate assistance with eating. On 10/20/23, a dehydration risk screen was completed. The screening tool directed further assessment to be completed for any scores of 10 or higher. R23 scored a 6, as follows: 1. Skin turgor 3 seconds, 1. Ambulates with 2 assist, wheelchair with assistance, 1. Fluid intake/Eating-limited physical assistance, 0. No weight loss, 1. Incontinent of urine, 0. Risk factors: history of dehydration, diarrhea/vomiting in last 7 days, 1. Pre-disposing factors, 1. Medications. Dehydration assessment was not an accurate assessment related to R23's history of dehydration, need for moderate assistance with eating, and documented swallowing difficulty. R23's care plan, dated 10/24/23, included a focus area of: At risk for nutritional status changes related to need for mechanically altered texture and feeding assistance, variable oral intakes, weight loss, low body mass index, and altered skin integrity. Intervention: Encourage and assist as needed to consume foods and/or supplements as ordered. R23's nutrition assessment, dated 10/24/23, calculated R23's fluid needs to be 2040 ml daily. Nutrition assessment confirmed R23 had swallowing difficulty related to coughing during meals. R23's fluid intakes from 10/20/23-12/09/23 ranged from 0-1510 ml of daily fluid. Confirming R23 did not meet his daily fluid intake needs on any days. Documentation confirmed R23's fluid intake was less than 50% of recommended values to maintain proper hydration for 32 of 54 days. There was no evidence R23's fluid intakes were being monitored. There is no care plan for hydration. On 11/20/23, a change in condition evaluation was entered in R23's progress notes related to diarrhea, food/fluid intake, tired, weak, confused, or drowsy. R23's care plan was not updated. On 12/07/23, a progress note was entered to monitor R23 related to increased fatigue, nausea, intermittent emesis, and loose stools. R23's care plan was not updated. From 12/09/23-12/13/23, R23 was hospitalized for difficulty breathing, difficulty swallowing, decreased fluid intake, and vomiting. Hospital discharge summary included diagnoses of hypernatremia (elevated sodium), pneumonia, and urinary tract infection (UTI). Discharge instructions included follow up labs for hypernatremia, fluids changed to nectar thickened, and ST evaluation and treatment. On 12/13/23, a dehydration risk assessment was completed for R23. R23 scored 8, as follows: 0. Skin turgor 3 seconds, 2. Bedbound, 3. Swallowing difficulty, 0. Weight loss, 1. Incontinent of urine, 0. Risk factors: history of dehydration and vomiting/diarrhea, 1. Pre-disposing factors, 1. Medication. Dehydration assessment was not an accurate assessment related to R23's history of dehydration, need for moderate assistance with eating, vomiting/diarrhea, and documented swallowing difficulty. On 12/14/23, R23's primary care physician completed a skilled nursing facility (SNF) visit. PCP's assessment and plan stated, Chronic Kidney Disease Stage 3 with hypernatremia related to free water deficit since hospitalization . Continue to monitor fluid intake and encourage free water intake. R23's care plan was implemented for dehydration. On 12/15/23, a nutrition assessment was completed for R23. Nutrition assessment indicated R23's daily fluid intake needs were 2040 ml. Assessment confirmed R23 had a nutritional problem related to inadequate oral intake. R23's daily fluid intakes from 12/13/23-12/27/23 ranged from [PHONE NUMBER] ml. Confirming R23 did not meet his daily fluid intake needs on any days. Documentation confirmed R23's fluid intake was less than 50% of recommended values to maintain proper hydration for 13 of 15 days. There was no evidence R23's fluid intakes were being monitored. On 12/16/23, a physician order was entered, Would recommend video swallow study to determine objective findings related to integrity of the swallow. On 12/27/23, R23 was sent to the ER related to vomiting, respiratory congestion, and cough. R23 returned to the facility this same date, with diagnosis of UTI. On 01/07/24, R23's record included a progress note that read, Staff reported that he is having reduced urine output with few wet pads. Bladder scan done only 29 ml urine in bladder. There was no documentation related to follow-up of R23's reduced urine output. R23's daily fluid intakes from 12/28/23-01/07/24 ranged from [PHONE NUMBER] ml. Confirming R23 did not meet his daily fluid intake needs on any days. Documentation confirmed R23's fluid intake was less than 50% of recommended values to maintain proper hydration for 11 of 12 days. There was no evidence R23's fluid intakes were being monitored. On 01/28/24, ST notes read, Discussed recommendation of video fluoroscopy swallow study (VFSS) in order to identify if advancement in diet is safe/appropriate. On 02/26/24 and 02/27/24, R23's record confirmed R23 experienced emesis both days. On 03/02/24, R23's record confirmed diagnosis of UTI per urinalysis. R23's care plan was updated with 'UTI,' interventions included: offer and encourage adequate intake of fluids. On 03/07/24, R23's MDS assessment was completed and indicated a health condition of dehydration. R23 did not have a hydration care plan implemented. On 03/07/24, a nutrition assessment was completed for R23. Assessment indicated R23 had experienced a gradual weight loss since admission, swallowing difficulty related to need for nectar thickened liquids, gastrointestinal concerns, and inadequate oral intakes. R23's body mass index (BMI) was 19.9. Nutrition assessment indicated R23's daily fluid intake needs were 1850 ml. R23's care plan was updated with 'Nutrition,' interventions included: provide diet as ordered, pureed and nectar thickened liquids. R23's daily fluid intakes from 01/08/24-03/07/24 ranged from 0-1705 ml. Confirming R23 did not meet his daily fluid intake needs on any days. Documentation confirmed R23's fluid intake was less than 50% of recommended values to maintain proper hydration for 28 of 61 days. There was no evidence R23's fluid intakes were being monitored. On 03/09/24, ST notes read, ST continues to recommend VSFF to determine safety with swallow and to identify if upgrade is safe. On 03/13/24, R23's record confirmed emesis on this date. On 03/16/24, a dehydration risk assessment was completed for R23. R23 scored 13, as follows: 2. Skin turgor 3 seconds, 2. Bedbound, 3. Swallowing difficulty, 0. No weight loss, 1. Incontinent of urine, 3. Risk factors: history of dehydration, history of refusing liquids, diarrhea/vomiting, 1. Pre-disposing factors, 1. Medications. Dehydration assessment was not an accurate assessment related to R23's BMI less than 21 and weight loss. On 04/18/24, ST notes read, ST requested swallow study multiple times. On 05/08/24, R23 completed a bedside swallow study; this was not a VFSS. On 05/24/24, a urinalysis was ordered for R23. Progress notes indicated no urine return from R23. Progress notes indicated R23 had complaints of nausea and vomiting on this date. On 05/29/24, R23 was treated with antibiotics for a UTI. R23's care plan was reviewed, with no new interventions added. On 06/04/24, a dehydration risk assessment was completed for R23. R23 scored 7, as follows: 0. Skin turgor, 1. Ambulate with 2 assist, wheelchair with assistance, 1. Eating, limited physical assistance, 0. No weight loss, 1. Incontinent of urine, 2. Risk factors: history of dehydration and vomiting/diarrhea, 1. Pre-disposing risk factors, 1. Medications. Dehydration assessment was not an accurate assessment related to R23's BMI less than 21, weight loss, and need for moderate assistance with eating. On 06/04/24, a nutrition assessment was completed for R23. Assessment confirmed R23 had a gradual weight change, swallowing difficulty, received pureed and nectar thickened liquids, nutritional problem related to inadequate oral intakes, and gastrointestinal concerns. R23's BMI was 19.3. Nutrition assessment confirmed R23's daily fluid intake needs were 1850 ml. R23's daily fluid intakes from 03/08/24-06/02/24 ranged from 0-1410 ml. Confirming R23 did not meet his daily fluid intake needs on any days. Documentation confirmed R23's fluid intake was less than 50% of recommended values to maintain proper hydration for 52 of 70 days. On 06/04/24 at 1:11 PM, Surveyor interviewed Speech Therapist (ST) U. ST U reported previous ST recommended the video swallow study on 12/16/23. ST U reported the swallow study that was completed on 05/08/24 was a bedside swallow study, not a VFSS. ST U reported beside ST completes bedside swallow studies in the facility. ST U stated a VFSS would help them to know if the reason for difficulty with swallowing is physical, and provide images of pharyngeal, esophagus, and ST U stated, It would help us to determine strategies such as a chin tuck, or type of fluids or foods he can/can't eat. Maybe he doesn't need nectar thickened, maybe its food that is the problem and he could have thin liquids or that coke he is asking for, but we can't determine that with a bedside swallow study only a VFSS. On 06/04/24 at 12:32 PM, Surveyor interviewed Registered Nurse (RN) M. RN M stated, We encourage him to drink fluids because he does not drink enough, we document it in the MAR. (RN checked MAR). Oh sorry, he does not have it in there. So what the CNAs document is what he is receiving at meals, the nurses are not documenting additional intakes. On 06/05/24 at 9:13 AM, Surveyor interviewed Director of Nursing (DON) B. DON B stated, We just reviewed his dehydration assessments. I agree they are not accurate. When we were reviewing the assessments we were scoring him at a 13, and the assessments are like a 7. There is no care plan which is another issue. If this had been done accurately, we would have discussed intakes in weekly or daily stand-up meetings, and reviewed his status, MD would have been updated. We are not doing anything with the data at this time, and the data may not be accurate, as it should be intakes per shift. I think the NP was updated; however it may not have been documented.

Based on observations, interviews and record reviews, the facility failed to ensure staff practiced appropriate hand hygiene during a dressing change for a stage III Pressure Injury (PI) for 1 of 1 resident (R21) reviewed and currently in-house with a PI. The CDC had outlined the following indications for hand washing and the wearing of gloves: A. When hands are visibly dirty or contaminated with proteinaceous material or are visibly soiled with blood or other body fluids, wash hands with either a nonantimicrobial soap and water or an antimicrobial soap and water . F. Decontaminate hands after contact with a patient's intact skin. G. Decontaminate hands after contact with body fluids or excretions, mucous membranes, nonintact skin, and wound dressings if hands are not visibly soiled . J. Decontaminate hands after removing gloves . The CDC continues to direct healthcare workers with the technique of hand hygiene: .2. E. Change gloves during patient care if moving from a contaminated body site to a clean body site . Surveyor reviewed the facility policy titled Clean Dressing Change dated 7/2022. The following was noted: It is the policy of this facility to provide wound care in a manner to decrease potential for infection and/or cross contamination . 7. Wash hands and put on clean gloves .remove the existing dressing .remove gloves .Wash hands and put on clean gloves. Cleanse the wound as ordered .Wash hands and put on clean gloves .dress the wound as ordered .and wash hands . This is evidenced by: R21 has medical diagnoses that include, but are not limited to, cerebral palsy, peripheral vascular disease and a long-standing stage III PI on the outer left ankle (malleolus). R21 was on Enhanced Barrier Precautions related to the wound and a current indwelling Foley urinary catheter. According to the most recent Minimum Data Set Assessment (MDSA), which was a quarterly assessment with an Assessment Reference Date (ARD) of 4/27/24, R21 has a stage III PI. In reviewing the history of this stage III PI, Surveyor identified that R21 has a long standing history of pressure injuries going back to admission of 2/18/21, at which time there was a PI located on the coccyx, and has since resolved. The PI that was currently being treated had an onset date of 8/19/23, of which was documented as an unstageable that measured 1.3 cm (centimeters) L (length) x 1.1 cm w (width). The wound was documented as containing 50% granulation tissue and 50% slough with light amount serous drainage; no odor or tunneling evident with distinct wound edges with a pink periwound tissue. Note: Granulation tissue is new connective tissue and microscopic blood vessels that form on the surfaces of a wound during the healing process. Slough is the yellow/white material in the wound bed. Slough is an accumulation of dead cells and is nonviable tissue that needs to be removed in order for healing to occur. Over time, this wound improved and worsened and on 11/22/23 and 2/7/24, positive cultures for MRSA (Methicillin-Resistant Staphylococcus Aureus) were obtained for the left outer ankle wound. This is an infection caused by a type of staph bacteria that's become resistant to many of the antibiotics used to treat ordinary staph infections. Without eradication of the infection, a wound would be difficult to heal. MRSA most often causes skin infections but it can also cause serious infections in the lungs, heart and bloodstream. The most recent assessment of the wound was documented on 5/28/24 and was measured as being slightly greater than 0.1 L x slightly greater than 0.1 W x slightly greater than 0.1 deep. In reviewing the care plan devised for R21, Surveyor noted the facility initiated a plan for the following: Actual infection: MRSA to wound on outer left ankle. The start date for this plan was 11/30/23 and last revised on 1/8/24. Included in the interventions were: - Encourage resident to use good clean hygiene techniques to avoid cross contamination. - Maintain Contact precautions as indicated. On 6/3/24 at 1:41 PM, Surveyor observed Licensed Practical Nurse (LPN) E complete the treatment and dressing change to the ankle wound. The following techniques were observed: - LPN E sanitized his hands upon entering the room and donned a pair of gloves. - LPN E then removed the old dressing from the left outer ankle. LPN E then removed the gloves but did not wash or sanitize his hands before proceeding to cleanse the wound with antibacterial soap and water contained in a basin. - LPN E then turned on the water faucet and rinsed the basin and filled with clean water. LPN E changed gloves but did not wash or sanitize his hands before donning a clean pair of gloves. LPN E then rinsed the wound of soap and dried the wound. LPN E then applied a Mepilex foam dressing to the wound. - With the same gloves, LPN E opened four dresser drawers to search for clean compression socks. Unable to locate, LPN E then sanitized his hands and left the room in search for clean socks. On 6/4/24, the wound was measured again, and there was no change in the assessment from 5/28/24. On 6/5/24 at 7:45 AM, Surveyor interviewed Interim Director of Nursing (DON) B regarding the expected practice of hand hygiene during treatment changes. IDON B stated, Wash hands before you start anything, then after removing the dirty and before placing the clean, you should wash. Should sanitize or something in between, with each glove change, and then wash again when finished . On 6/5/24 at 7:50 AM, Surveyor approached LPN E and interviewed him regarding his knowledge of hand hygiene with treatments and dressing changes. LPN E correctly identified that the hands should be washed with soap and water for at least 30 seconds and should wash between each glove removal. Surveyor pointed out the treatment observation made and explained that even though LPN E removed gloves at the appropriate times, he did not wash or sanitize hands after removing the soiled gloves. LPN E stated, Oh yeah, I thought I did that, but ok, that's right. I should have.

Based on interview and record review, the facility did not ensure residents received treatment and care in accordance with professional standards of practice for 1 of 12 sampled residents (R23). The facility did not follow physician orders for R23 to obtain a video fluoroscopy swallow study (VFSS) to determine appropriate and safe diet recommendations. Findings: R23 was admitted to the facility on [DATE], after hospitalization for dehydration, confusion, and weakness. R23's hospital discharge instructions were speech therapy (ST) related to dysphagia (difficulty swallowing), occupational therapy (OT), and physical therapy (PT) for strengthening. Admitting diagnoses to facility included dementia, stroke with left sided paralysis, diabetes mellitus type 2, chronic kidney disease stage 3, dysphagia, and depression. R23's admission Minimum Data Set (MDS) assessment confirmed R23 scored 05/15 during Brief Interview for Mental Status (BIMS), indicating severe cognitive impairment. MDS determined R23 required partial or moderate assistance with eating. R23's care plan, dated 10/24/23, included a focus area of: At risk for nutritional status changes related to need for mechanically altered texture and feeding assistance, variable oral intakes, weight loss, low body mass index, and altered skin integrity. Intervention: Encourage and assist as needed to consume foods and/or supplements as ordered. R23's nutrition assessment, dated 10/24/23, confirmed R23 had swallowing difficulty related to coughing during meals. R23's intakes were 50-100%. On 11/20/23, a change in condition evaluation was entered in R23's progress notes related to diarrhea, food/fluid intake, tired, weak, confused, or drowsy. On 12/07/23, a progress note was entered to monitor R23 related to increased fatigue, nausea, intermittent emesis, and loose stools. From 12/09/23-12/13/23, R23 was hospitalized for difficulty breathing, difficulty swallowing, decreased fluid intake, and vomiting. Hospital discharge summary included diagnoses of hypernatremia (elevated sodium), pneumonia, and urinary tract infection (UTI). Discharge instructions included follow up labs for hypernatremia, fluids changed to nectar thickened, and ST evaluation and treatment. On 12/15/23, a nutrition assessment was completed confirming R23's diet was downgraded to pureed with nectar thickened liquids related to dysphagia. R23's intakes were 0-75%. On 12/16/23, a physician order was entered, Would recommend video swallow study to determine objective findings related to integrity of the swallow. On 12/27/23, R23 was sent to the ER related to vomiting, respiratory congestion, and cough. R23 returned to the facility this same date, with diagnosis of UTI. On 01/28/24, ST notes read, Discussed recommendation of video fluoroscopy swallow study (VFSS) in order to identify if advancement in diet is safe/appropriate. On 03/07/24, R23's MDS assessment was completed and indicated a health condition of dehydration. On 03/07/24, a nutrition assessment was completed for R23. Assessment indicated R23 had experienced a gradual weight loss since admission, swallowing difficulty related to need for nectar thickened liquids, gastrointestinal concerns, and inadequate oral intakes. R23's body mass index (BMI) was 19.9. Nutrition assessment indicated R23's intakes were 25-100%. On 03/09/24, ST notes read, ST continues to recommend VSFF to determine safety with swallow and to identify if upgrade is safe. On 04/18/24, ST notes read, ST requested swallow study multiple times. On 05/08/24, R23 completed a bedside swallow study; this was not a VFSS. On 06/04/24, a nutrition assessment was completed for R23. Assessment confirmed R23 had a gradual weight change, swallowing difficulty, received pureed and nectar thickened liquids, nutritional problem related to inadequate oral intakes, and gastrointestinal concerns. R23's intakes were 51-100%. On 06/04/24 at 1:11 PM, Surveyor interviewed Speech Therapist (ST) U. ST U reported previous ST recommended the video swallow study on 12/16/23. ST U was not sure why R23's VFSS was not scheduled shortly after the recommendation on 12/16/24. ST U reported the swallow study that was completed on 05/08/24 was a bedside swallow study, not a VFSS. ST U reported ST completes bedside swallow studies in the facility. ST U stated a VFSS would help them to know if the reason for difficulty with swallowing is physical, and provide images of pharyngeal, esophagus, and ST U stated, It would help us to determine strategies such as a chin tuck, or type of fluids or foods he can/can't eat. Maybe he doesn't need nectar thickened, maybe it's food that is the problem and he could have thin liquids or that Coke he is asking for, but we can't determine that with a bedside swallow study only a VFSS. On 06/05/24 at 8:25 AM, Surveyor interviewed Social Worker (SW) D. SW D confirmed she was responsible for scheduling appointments prior to 02/19/24, as the facility hired new staff on 02/19/24 to assist with scheduling appointments. SW D reported she did not schedule R23's VFSS as R23's family would schedule his appointments. Surveyor requested evidence the facility spoke with R23's family regarding the VFSS recommendation on 12/16/23, and evidence the family agreed or disagreed to schedule the appointment. The facility did not provide evidence requested. R23's appointment had not been scheduled.

Based on interview and record review, the facility failed to ensure a qualified activity professional was hired to direct the activities program and to meet the activity needs of residents. This had the potential to affect all 40 residents in the facility. The facility's Life Enrichment Specialist (LES) I or Activity Director, is not a qualified therapeutic recreation specialist and does not meet the qualifications required to direct the activities program. This is evidenced by: According to Federal Guidelines, the Activity Director must be a qualified therapeutic recreation therapist or must contain one of the following: Is licensed or registered, if applicable, by the State in which practicing; and (A) Eligible for certification as a therapeutic recreation specialist or as an activities professional by a recognized accrediting body on or after October 1, 1990; or (B) Has 2 years of experience in a social or recreational program within the last 5 years, one of which was full-time in a therapeutic activities program; or (C) Is a qualified occupational therapist or occupational therapy assistant; or (D) Has completed a training course approved by the State. The facility policy titled Activities dated 6/1/2017 and last reviewed 7/11/22 stated, in part, It is the policy of this facility to provide an ongoing program to support residents in their choice of activities based on their comprehensive assessment, care plan and preferences. Facility-sponsored group, individual, and independent activities will be designed to meet the interests of each resident, as well as support their physical mental and psychosocial well being .1. Each resident's interest and needs will be assessed on a routine basis. The assessment shall include, but is not limited to: a. RAI (Resident Assessment Instrument) Process: MDS/CAA (Care Area Assessment/Care Plan b. Activity assessment to include resident's interest, preferences and needed adaptations. c. Social history. d. Discharge information, when applicable. 2. Activities will be designed with the intent to: a. Enhance the resident's sense of well-being, belonging and usefulness. b. Promote or enhance physical activity. c. Promote or enhance cognition. d. Promote of enhance emotional health. e. Promote self-esteem, dignity, pleasure, comfort, education, creativity, success and independence. f. Reflect residents's interests and age. g. Reflect cultural and religious interests of the residents. h. Reflect choices of the residents . Surveyor noted activity programs were being conducted throughout the recertification survey in which multiple residents participated and were engaged. On 6/5/24 at 9:58 AM, Surveyor approached Life Enrichment Specialist (LES) I, who is currently the director of activity programming, to interview on her education and experience to direct activity programming. LES I stated she has [AGE] years background as a Certified Nursing Assistant and assumed the role of Activity Director in October 2023. LES I stated she has no education to date but has been reviewing programs for her to enroll in with the Nursing Home Administrator (NHA) A, but to date, has not signed up for any courses. LES I stated she works in activities 30-40 hours each week and completes all the activity programming schedules for the residents. LES I stated that at the present time, there is no one on staff that is overseeing her and the responsibilities she has as the director of activities. On 6/5/24 at 10:02 AM, Surveyor met with NHA A and asked what courses the facility was reviewing for LES I to enroll in to meet the Federal guidelines for activity directors in the State. NHA A stated, I sent LES I course information but LES I hasn't signed up for anything yet. We're looking at several different courses for her to enroll. On 6/5/24 at 10:45 AM, Surveyor again met with LES I and asked what her responsibilities are as they relate to activity programming. LES I stated that she completes all the User Designed Assessments (UDAs), the activity assessments and the life enrichment assessments on admission, which involves personal information, voting, past history, occupation, etc. LES I stated she has two activity aides that she oversees, both work part-time, and meets with them throughout the week to discuss how the programs are working for the residents (likes, dislikes). LES I also stated that she completes cognitive/mental programs and a physical program each day. In addition, LES I also holds the Resident Council Meetings each month, and just started working with Registered Nurse (RN) J, who is the Resident Care Management Director/Minimum Data Set Assessment Coordinator, on how to complete activity sections of the Minimum Data Set (MDS) Assessment. LES I stated that she develops all the activity programming for the residents and coordinates the calendar of activities. Surveyor then reviewed the job description for Life Enrichment Specialist. Under Summary/Objective: Responsible for supervising, creating and providing an exciting life enrichment program appropriate for the physical, social, cultural, spiritual, emotional and recreational needs for each resident. Provides the opportunity for residents to engage in normal pursuits while promoting a successful and well-balanced leisure lifestyle. Work with various disciplines to assist the resident in reaching their highest level of independence. Plans and monitors leisure activities for recreation and therapeutic purposes designed to enhance the quality of life for each resident while maintaining an open working relationship with the resident's center or guardian . Under Essential Functions, the Life Enrichment Specialist responsibilities include but is not limited to: - Plans, develops, organizes, implements, evaluates and directs the activity program. - Assesses individual/group resident/patient needs and develops related meaningful morning, afternoon, evening and special programs. The job description continues to describe the education and experience required for this position and includes, - Must be a qualified therapeutic recreation specialist of an activities professional who is currently licensed or registered, as required, by the State and is eligible for certification as a therapeutic recreation specialist or as an activity's professional by a recognized accrediting body - Two years of experience in a social or Life Enrichment program within the last five (5) years, one (1) of which was a full time in a patient activities program in a health care setting - Completed a training course as approved by the State LES I has no former education to meet the federal guidelines and completes all resident assessments as they relate to activity programming and coordinates, develops and assesses the activity programming throughout the facility. LES I has been in this role for 8 months with no enrollment in a course to meet the guidelines, as of this writing. All resident activity assessments and programming were being completed at the time of survey.

Based on interview, observation and record review, the facility did not ensure all residents received treatment and care in accordance with professional standards of practice for 1 of 1 residents (R9) sampled for skin integrity out of a total sample of 12. R9 developed Moisture Associated Skin Damage (MASD) while residing in the facility. R9's schedule for offloading the area was not followed. R9 was having loose bowel movements that irritate and excoriate the skin; there was no follow up with the provider to reduce the laxatives to promote healing of the MASD. R9's MASD worsened, becoming larger in size and a new area of MASD developed. Findings include: The facility policy titled Pressure and Non-pressure Injuries, dated 8/2/21, states: .For those residents admitted with, or who subsequently developed a pressure injury or impaired skin integrity, they will receive care, treatment, and services that seek to promote healing, prevent infection, and prevent further development of pressure injuries/impaired skin integrity. R9 was admitted to the facility on [DATE]. Diagnoses include dementia, seizures, stroke affecting left side, depression, and anxiety. R9 has an activated Power of Attorney (POA) to assist in making healthcare decisions. A Minimum Data Set (MDS), dated [DATE], confirmed R9 is understood and understands others. R9 scored an 8/15 during Brief Interview for Mental Status (BIMS), indicating moderately impaired cognition. R9's care plan includes the following: 1. Activities of Daily Living (ADLs), interventions include: -12/10/20, I am typically incontinent of bladder, but usually continent of bowel. -1/20/23, Bariatric mattress and bilateral assist bars on bed for positioning and mobility. -1/21/23, Toilet use: . He is to be helped to the TOILET in the shower room per his request, with routine cares, during rounds and as needed. OK for check and change while in bed if he desires. -6/9/23, upright and out of bed for all meals, as patient tolerates. 2. Resident has actual skin integrity break - MASD to coccyx and open area to left buttocks secondary to incontinence-associated dermatitis, interventions include: -2/2/23, Turn and reposition to limit as much time as possible off coccyx. 3. Potential for Constipation related to medications, interventions include: -9/3/20, Monitor for frequency of bowel movements and administer softeners and laxatives as needed per MD orders. 4. Urinary Incontinence, interventions include: -1/21/23, During daytime hours: Provide incontinence and peri care upon waking, 30-60 minutes after all meals, at bedtime. During night hours: must be changed with each round (approximately every 2 hours). On 12/7/22, nursing documented that R9 was .Presenting with bilateral upper and lower extremity weakness, a decline in transfers status and a decline in self-care management skills . R9 was referred for physical and occupational therapies. Surveyor reviewed the Braden Scale for Predicting Pressure Ulcer Risk completed for R9 and noted the following: - 11/13/22 scored R9 as a moderate risk for the development of Pressure Injuries (PI.) - 12/13/22 scored R9 a moderate risk, as above. SKIN INTEGRITY: On 12/18/22, nursing documented .noted redden area on the sacral area with small amount of bleeding . Nurse reported using Mepilex during last dressing change. No dressing intact. This nurse cleaned the area with wound cleanser and dried and applied Mepilex dressing to the sacral area . Note: Surveyor was unable to locate this treatment order in record. On 12/20/22, documentation was noted that R9 had a dark reddish rash with superficial top layer of skin excoriated to gluteal cleft extending 10-12 cm (centimeters) long (L) by 4.5-5 cm wide (W) on both buttocks. On 12/28/22, R9 developed a facility-acquired breakdown to the coccyx. A treatment was ordered by the physician on 12/29/22, but there was no assessment of the area located. There is no documentation describing if this is a pressure injury or MASD. The first measurements of this area after 12/20/22, were dated 2/1/23 in which documentation indicated the area was 9.0 cm L x 15 cm W x 0.1 cm deep. This is 35 days after the area was first noted, with increase in width and depth. On 2/14/23, R9 was seen at the wound clinic in which they ordered R9 to be up in wheelchair for 1 hour at each meal and otherwise in bed to offload coccyx. R9 had no further appointments at the wound clinic. Surveyor then reviewed most recent documentation of the skin breakdown. - 6/9/23 Left buttock 3.5 x 1 cm x 0.1 Note: This area is actually the right buttock, making this entry inaccurate. There is no mention here of the MASD to the coccyx. - 6/12/23: continues with MASD to coccyx. Facility identified a new area to the left buttock, which again, is actually the right buttock. - 6/13/23: treatment order for left buttock (note that actual area is right buttock.) Inaccurate documentation of the location of the MASD continues. - 6/13/23 new treatment orders were received: - COCCYX: cleanse, apply calazime and cover with bordered sacral foam 7.2 x 7.2 dressing every 3 days and as needed for prophylaxis - LEFT BUTTOCKS: cleanse, apply calazime and cover with bordered foam 4 x 4 dressing every 3 days and as needed for prophylaxis (note that actual area is right buttocks.) - 6/19/23, Left buttock MASD angry red, 3.5 cm x 4 cm x 0.1 cm (note that actual area is right buttocks.) Note: This is an increase in size from 6/9/23 - 6/23/23, Left buttock MASD angry red, 3.5 cm x 4 cm x 0.1 cm (note that actual area is right buttock). The angry red description indicates increased inflammation of the skin. Surveyor observed R9 throughout the survey and noted the following: On 6/26/23 at 10:30 AM during the screening process of the survey, R9 was not in his room. Surveyor noted that R9 had a regular mattress on his bed. Surveyor located R9 attending an activity. He was sitting in his wheelchair. At 1:37 p.m., Surveyor observed staff transfer R9 into bed with mechanical lift. Note: According to Wound Clinic orders stated above, R9 is to be up for 1 hour at each meal, then placed into bed in order to offload the pressure sustained to the coccyx. R9 had been observed by Surveyor up in his wheelchair for over three hours. On 6/27/23 at 7:45 AM, R9 was up in his wheelchair in his room. He was assisted to the dining room at 7:48 AM. At 9:18 AM, Surveyor noted R9 was still up in the wheelchair. Surveyor interviewed CNA E (Certified Nursing Assistant) regarding R9's skin condition and care needs. CNA E stated that R9's .butt is horrible, it has been a problem . CNA E continued to state that staff are changing and repositioning him every hour. He is to be up for all meals. CNA E continued to state that R9 has a cushion in the wheelchair and in bed, uses bilateral grab bars for repositioning side to side. She stated that R9 will grab the bars but still needs help by staff. At 11:15 AM, Surveyor observed staff use a mechanical lift to transfer R9 into bed. Surveyor observed incontinence care provided. R9 was observed by Surveyor to be up in wheelchair approximately 3.5 hours. At 2:56 PM, Surveyor interviewed Director of Nursing (DON) B regarding R9's skin. DON B stated that R9's coccyx wound changes, it will improve then worsen. DON B stated that she believes R9 is having increased incontinence, and this is causing his MASD. She confirmed that R9 does not have an air mattress on his bed as he chose to have repositioning bars. According to facility policy, DON B stated that a resident cannot have both an air mattress and repositioning bars. On 6/28/23 at 11:26 AM, Surveyor observed staff providing perineal cleansing on R9, as well as the treatment to the buttocks by DON B. There was a dressing that was intact in which DON B removed. Surveyor observed a large, reddened area, with damage to the top layer of skin across gluteal cleft and extending down and across both buttocks. There was also a small red open area in the fold of the right buttock and right thigh, in which there was no dressing in place. DON B measured the area to be: - Coccyx 12 cm length x 14 cm width. The coccyx last measurement on 2/1/23, was 9 cm long x 15 cm width x 0.1 cm depth. This areas has increased length and width noted on Surveyor observation. - Right Buttock 4 cm length x 3 cm. width. Note: The prior measurement of the right buttock on 6/23/23 was 3.5 cm x 4 cm x 0.1 cm. This indicates worsening of the MASD. BOWELS: R9 was receiving the following medications to prevent constipation: - Miralax 17 grams twice daily for constipation - Milk of Magnesia 30 ml once daily - Docusate sodium 100 mg give two tablets at bedtime - Senna Plus 8.6-50 mg twice daily On 5/7/23, nursing documented that a request was made to the Physician to decrease Miralax (laxative) to once daily related to explosive bowel movements in the evening. The Physician responded to the facility request via facsimile that R9's bowel routine would be addressed on rounds with a visit planned for either 5/10 or 5/17. Facility monitored R9's bowels and Surveyor noted the following: - From 5/1/23-5/31/23, 26 of 29 bowel movements were documented as being watery/diarrhea. - From 6/1/23-6/28/23, 11 of 24 bowel movements coded as watery/diarrhea. The watery diarrhea on a frequent basis would excoritate R9's skin, increasing skin breakdown. As of 6/27/23, Surveyor was unable to locate that R9's bowel routine was addressed. On 6/27/23 at 2:51 PM, Surveyor interviewed DON B regarding request to provider to decrease Miralax to once daily. DON B stated that she did not think provider had completed rounds. DON B requested provider documentation of most recent nursing home rounds. Documentation supports provider completed rounds on 5/18/23 and 6/16/23, with no new orders for laxative medication. On 6/28/23 at 8:57 AM, interview with CNA F, who stated that he works with R9, and he is aware that R9 is on several medications for bowel regulation. CNA F reported that R9 has a bowel movement every few days, maybe every other day, and bowel movements are watery, like diarrhea, and explosive. On 7/6/23 at 2:00 PM, Surveyor interviewed MD N (Medical Doctor for R9). MD N stated that he had several conversations over the past few months regarding the skin damage. He stated that he received a fax from the facility regarding the loose stools and facility wanting to decrease the bowel meds. R9 has long-standing constipation and any changes to the bowel medication routine will cause a potential issue. MD N stated that he dislikes fax messages as they do not allow discussion, so he telephoned the facility and spoke with the nurse on duty at the time. He stated they discussed R9's history of constipation and his normal pattern. MD N stated that R9's normal pattern is that his bowels are loose for 6-7 days then he goes 2-3 days without any bowel movements. He then indicated that he thought the loop was closed on the matter, but it appeared to go sideways and he learned that the loop really wasn't closed after the State Surveyors were in the building. On 6/29/23, he telephoned DON B and discussed R9's bowel program further, after surveyors left the building. MD N stated that he made a small change in R9's bowel program and doesn't want to do any dramatic changes. There is no evidence that follow-up with R9's physician was completed regarding the laxatives R9 is currently receiving, and the ongoing diarrhea and loose stools, which are contributing factors for R9's skin breakdown.

Based on observations and interview, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. This practice had the potential to affect 13 residents residing in the facility. The facility did not provide hand hygiene to the residents before eating meals. This is evidenced by: The facility policy, entitled Dining Experience, dated 07/27/22, states: .Individuals will be provided with proper hand hygiene prior to each meal or snack . On 06/26/23 at 11:40 AM, Surveyors observed hall service meals. No hand hygiene was offered to the residents who ate in their rooms. R25, R27, R19, R7, R20, R10. On 06/26/23 at 11:50 AM, Surveyors observed staff assisting residents in the main dining room with lunch. No observation of staff offering hand hygiene to the residents before eating. No hand wipes or hand sanitizer in the dining room. R29, R9, R13, R15, R3, R6, R17. On 06/27/23 at 7:35 AM, Surveyor observed residents in the dining room getting ready for breakfast. Staff did not offer hand hygiene to the residents before eating breakfast. No hand wipes or hand sanitizer in the dining room. On 06/27/23 at 7:44 AM, Surveyor spoke with R15 who was in the dining room at the time to see if staff help with providing hand cleaning before eating meals. R15 stated the staff cleaned my face and my hands this morning. Surveyor asked if the staff cleaned the resident's hands before eating each meal. Resident stated I'm not sure, but we will see if they do. On 06/27/23 at 7:56 AM, Surveyor continued to observe breakfast being served to the residents in the dining room. No hand hygiene was offered to the residents before starting to eat. On 06/27/23 at 8:32 AM, Surveyor observed the medical records coordinator (MR) G offering disposable towels to the resident to clean their hands and faces after eating. On 06/27/23 at 8:58 AM, Surveyor spoke with MR G and asked if the residents are offered hand hygiene before eating. MR G stated that sometimes residents are provided hand hygiene before eating, but sometimes the hand wipes are not stocked. MR G stated she had to look for the wipes today as they were not in the dining room like they are supposed to be. On 06/27/23 at 10:25 AM, Surveyor interviewed family member (FM) J who is here daily from 8 am until 6 pm. Surveyor asked FM J if he had seen staff offer hand hygiene to the residents before eating. FM J said no, they do not offer hand hygiene to the residents before eating. On 06/28/23 at 8:00 AM, Surveyor asked the Nursing Home Administrator (NHA) A, for the facility's policy on hand hygiene for the residents before eating. On 06/28/23 at 9:05 AM, the NHA A provided the facility policy on the dining experience. NHA A stated they realized hand hygiene was not being offered to the residents before eating, so they started a performance improvement to make sure this was completed. This was started yesterday.

Based on observations, interviews and record reviews, the facility did not ensure 1 of 3 residents (R25) reviewed for Urinary Tract Infections (UTIs) received the necessary treatment and services to prevent infections and to restore continence to the extent possible. R25 is currently being treated for an active UTI with antibiotic therapy. An extended observation was made of 3 hours 49 minutes in which toileting or incontinence care was not provided for R25 to keep R25 clean and prevent infection. This is evidenced by: The Long-Term Care Nursing Desk Reference. HCPro, Inc. Chapter 13, pages ,d+[DATE] offers the following discussion on urinary incontinence in Long Term Care: . Incontinence is a medical problem that is, in many instances, beyond the resident's control. Incontinence is not a normal consequence of aging and can frequently be cured or improved . Most believe that toileting residents every two hours is the best means of keeping them dry, when in fact this is a dated and ineffective method. Effective urinary management is assessment-based and individualized to the resident. Incontinence management is a 'catch' program that keeps residents dry . R25 has Medical Diagnoses that include but are not limited to Fracture of the Right Femur, Cognitive Communication Deficit, Diabetes Mellitus Type 2, Muscle Weakness, Lack of Coordination, Disorders of Bone Density and Structure, Alzheimer's Disease, Dementia, Chronic Kidney Disease (CKD) Stage 3 and Mild Major Depressive Disorder. On [DATE], R25 was diagnosed with a UTI for which antibiotic therapy was prescribed. The most recent Minimum Data Set Assessment (MDSA) was a Significant Change in Status assessment dated [DATE] (Assessment Reference Date). According to this assessment, R25 requires extensive assistance of staff to meet her most basic needs of bed mobility, personal hygiene, toileting, bathing and dressing. R25 is also incontinent of bowel and bladder status. Note: Following discussions with facility staff, the facility did submit a delayed SCS MDSA with ARD of [DATE]. There were no changes noted to the above listed areas of physical functioning of R25 in this new assessment. Observations were made throughout the survey ([DATE] - [DATE]) in which R25 remained on bedrest. Surveyor reviewed the Care Plan (CP) developed for R25 and noted the following plans: 1. Urinary Tract Infection, potential or actual due to: History of urinary tract infections (Initiated [DATE] and last revised [DATE]). The goal for this plan was Urinary tract infection will resolve without complication. Interventions for this plan included: - Assist with toileting or incontinence care as needed 2. I have a physical functioning deficit related to: Self care impairment (Initiated [DATE] last revised [DATE]). Interventions for this plan included: - Assist of one for bed mobility. Provide reminders/cueing to turn and reposition with routine cares, during rounds, as needed and per request. (Initiated [DATE] and last revised 5/ ,d+[DATE]) - Incontinent of bladder. - Sometimes incontinent of bowel - Toilet with assist of two. She isn't always able to make toileting needs known and frequently declines help to use bathroom Offer toileting assistance with routine cares, during rounds, as needed and per request. 3. Alterations in genitourinary system AEB (as evidenced by): Urinary incontinence r/t (related to): impaired mobility & CKD (Initiated [DATE] last revised [DATE]) Interventions for this plan included: - Adjust toileting times to meet resident's needs - Provide assistance with toileting - Provide incontinent care as needed 4. Actual infection UTI (Initiated [DATE]). Interventions for this plan included: - Monitor for side effects from antibiotic therapy and report to physician if present. - Offer and encourage adequate intake of fluids. - staff to use good clean hygiene techniques when providing peri care. Further review of R25's Medical Record revealed the development of Moisture Associated Skin Damage to the Right Buttock on [DATE] On [DATE], Surveyor observed R25 from 6:40 AM - 10:29 AM in which no offers or attempts were made to reposition resident (3 hours 49 minutes). The observation was as follows: - At 6:40 AM, R25 was noted to be lying in bed on her back with the upper part of her body, waist to neck, leaning to her left side. She was asleep and remained in this position until 7:48 AM, when DON B (Director of Nursing) entered the room with R25's meal tray. There was no offloading or toileting completed at that time. Surveyor noted R25 to be at 90 degrees with the meal tray positioned over the bed and in front of the resident. She had a waffle with syrup, scrambled eggs, a bowl of oatmeal, 4 ounces of orange juice, 8 ounces of milk and coffee on the tray in front of her. - At 8:12 AM, R25 was nearly finished with her meal. - At 9:26 AM, Speech Therapy and Occupational Therapy entered the room to work with R25. They were both in the room together and left at 9:36 AM. There was no repositioning of R25 at that time and she was again noted by Surveyor to still be in the 90 degree position in bed. - No additional staff entered the room after the two therapy staff left the room. At 9:10 AM, Surveyor approached CNA D (Certified Nursing Assistant) and asked what R25's care needs were. CNA D stated that R25 is able to perform some of her cares but relies on staff cues. She requires staff assistance for toilet changes and repositioning. When asked if she assisted R25 yet on this date, CNA stated that she did not. She reported to duty at 9:00 AM and was not sure yet, what tasks needed yet to be completed on the unit. At 10:10 AM, Surveyor approached CNA C and asked her what R25's care needs were. CNA C also stated that R25 requires assistance of staff to toilet her, often refuses and is currently being transferred with a mechanical lift related to the recent hip fracture. CNA C stated R25 is incontinent of bowel and bladder and does not inform staff of the need to be changed. CNA C stated R25 was to be repositioned every two hours. Surveyor then asked her why R25 was not yet toileted or given incontinence care for the morning. CNA C stated that when she first came on duty at 6:00 AM, she was told there were staff on the unit doing cares. She learned at 6:20 AM that no staff was actually on the unit so she came down to the unit to work. She indicated she was behind schedule as a result. She had not yet been able to assist R25. After learning that R25 had not yet received toileting or incontinence cares for this morning, CNA C stated she would take care of R25 now. She entered R25's room at 10:15 AM along with CNA D. Upon rolling R25 onto her left side at 10:29 AM, Surveyor noted the incontinent brief was wet with urine, causing a potential for further urinary tract infection issues.

Based on record review, the facility did not ensure accuracy of Minimum Data Set Assessments (MDSA) for 2 of 12 residents (R16 and R25) reviewed. - Resident #16 was admitted [DATE]. An admission MDSA was completed with an Assessment Reference Date (ARD) of 1/6/23 in which several critical areas were left blank and not assessed, including that of Cognitive Status, Mood and Pain. - R25 did not have a Significant Change in Status (SCS) MDSA completed timely. When it was completed, the assessment did not include the development of a Stage II Pressure Injury to the Coccyx or the development of an Unstageable Deep Tissue Injury (DTI) to the heel. This is evidenced by: Example 1 R16 was admitted [DATE] with diagnoses that include but are not limited to Hemiplegia and Hemiparesis following Cerebrovascular Infarction affecting right dominant side, Abnormalities of Gait and Mobility, Difficulty walking, Dysarthria following Cerebrovascular Accident (CVA), Aphasia following CVA, Muscle Weakness, Hypertensive Heart Disease with heart Failure, Acute on Chronic Diastolic (Congestive) Heart Failure and Unilateral Primary Osteoarthritis Left knee. In reviewing R16's medical record, Surveyor noted the Admission MDSA was incomplete. The following areas were left unassessed and blank: 1. Cognitive status- Section C0100 asks the evaluator, Should Brief Interview for Mental Status be conducted? The response was coded as yes However, the following sections in Section C were left blank or incomplete: - Section C0200 Repetition of Three Words - Section C0300 Temporal Orientation - Section C0400 Recall - Section C0500 Brief Interview of Mental Status Score - Section C0600 Should the staff assessment for Mental Status be conducted? - Section C0700 Short-Term Memory - Section C0800 Long-Term memory - Section C0900 Memory/Recall Ability - Section C1000 Cognitive Skills for Daily Decision-Making 2. Mood- Section D0100 asks the evaluator, Should Resident Mood Interview be conducted? The response was coded as Yes however the following sections were not evaluated or completed and left blank: - Section D0200 Resident Mood Interview with D0300 Total Severity Score OR - Section D0500 Staff assessment of mood for non-interviewable resident with D0600 Total Severity Score 3. Section J Health Conditions Section J0100 indicates that resident has been on a scheduled pain medication regimen; Section J0200 asks the evaluator if a pain assessment interview should be conducted. The response was Yes However, the following sections were not evaluated or completed and left blank: - Section J0300 Pain Presence - Section J0400 Pain Frequency - Section J0500 Pain effects on function (difficulty sleeping or limiting day to day activities as a result of pain) - Section J0600 Pain Intensity As of 6/28/23 2:18 PM, Surveyor noted the assessment was not yet modified to reflect R16's true status. Example 2 R25 was admitted [DATE]. Medical Diagnoses for R25 include but are not limited to Diabetes Mellitus Type 2, Cognitive Communication Deficit, Disorder of Bone Density and Structure, Dementia, Polyosteoarthritis, Chronic Kidney Disease- Stage 3, Atherosclerotic Heart Disease and Major Depressive Disorder. On 5/21/23, R25 had a fall and was transferred to the hospital where she was diagnosed with a right hip fracture. R25 returned to the facility on [DATE]. In reviewing the MDSAs completed for R25, Surveyor noted the most recent assessment had an ARD of 3/11/23, which was a SCS assessment. According to the Resident Assessment Instrument, the next assessment was due 6/11/23. This assessment was not yet completed at the time of Survey (6/26/23). On 6/27/23 at 5:07 PM, Surveyor interviewed Staff K via telephone. Staff K is the Corporate Director of Clinical Reimbursement. Staff K stated that she oversees the MDS schedules and has direct discussions with the facilities regarding changes in residents that would constitute a significant change assessment. Staff K stated that she is the main contact for the MDSA's. She stated that when the assessments are completed, she goes over them to ensure accuracy and then she will submit them. Staff K and Surveyor discussed R25 and the fall with hip fracture. Staff K stated that the Team did discuss R25 and determined that R25 is a true significant change and the MDSA should have already been submitted. She will review the MDS to ensure it is completed and will submit later that evening. Surveyor reviewed the SCS MDS on 6/28/23 at 2:32 PM and noted two key areas that were inaccurate. They were: 1. The Stage II Pressure Injury on R25's Coccyx (onset date 6/26/23) was not indicated on this assessment. 2. The Unstageable Deep Tissue Injury (DTI) on R25's heel (onset date of 6/26/23) was not indicated on this assessment.

Based on interviews and record reviews, the facility did not complete and submit a Significant Change in Status (SCS) Minimum Data Set Assessment (MDSA) within 14 days after determining a SCS has occurred for 1 of 12 residents (R25) reviewed for assessments. This is evidenced by: The facility completed a SCS MDS with an Assessment Reference Date (ARD) of 3/11/23 for R25. The next assessment was due 6/11/23. However, R25 experienced a fall and sustained a fracture of the right hip on 5/21/23, significantly altering the plan of care. R25 returned to the facility from the hospital on 5/24/23. The facility completed a SCS MDSA with an ARD of 6/11/23. However, this assessment was not yet submitted as of 6/27/23. On 6/27/23 at 5:07 PM, Surveyor interviewed Staff K via telephone. Staff K is the Corporate Director of Clinical Reimbursement. Staff K stated that she oversees the MDS schedules and has direct discussions with the facilities regarding changes in residents that would constitute a significant change assessment. Staff K stated that she is the main contact for the MDSA's. Staff K stated that when the assessments are completed, she goes over them to ensure accuracy and then she will submit them. Staff K and Surveyor discussed R25 and the fall with hip fracture. Staff K stated that the team did discuss R25 and determined that R25 is a true significant change and the MDSA should have already been submitted. She will review the MDS to ensure it is completed and will submit later that evening. Surveyor explained the regulation is 14 days after the determination that a significant change occurred. Staff K stated, Yeah, I know that, but it's just easier to wait a bit instead of doing a significant change rather than to have to go back and do another one in another two weeks if they improve. Staff K stated that she received an E-Mail from DON B (Director of Nursing) that a SCS MDSA should be completed and that she would provide Surveyor with this E-Mail. On 6/29/23, Surveyor received a copy of this E-Mail. It was submitted to Staff K by DON B on 5/30/23 and indicated that a SCS MDSA should be completed for R25. However, as of the discussion between Surveyor and Staff K on 6/27/23, the SCS MDSA had not yet been submitted.

Based on observations, interviews and record reviews, the facility did not ensure 2 of 4 residents (R25 and R27) reviewed for high risk of Pressure Injury development received the necessary treatment and services to promote healing of existing skin impairments or prevent new pressure injuries from developing. - R25 has an existing PI to her coccyx and a Deep Tissue Injury (DTI) to her right heel. An observation was made of 3 hours 49 minutes in which staff did not offer or attempt repositioning or toileting. - R27 is high risk for the development of PIs. R27 was observed for 4 hours 29 minutes in which she was sitting in a Broda chair without staff offering or attempting to reposition or toilet. This is evidenced by: According to the NPIAP (National Pressure Injury Advisory Panel) 2019, page 115, . Repositioning and mobilizing individuals is an important component in the prevention of pressure injuries. The underlying cause and formation of pressure injuries is multifaceted; however, by definition, pressure injuries cannot form without loading, or pressure, on tissue. Extended periods of lying or sitting on a particular part of the body and failure to redistribute the pressure on the body surface can result in sustained deformation of soft tissues and, ultimately, in tissue damage . According to Wound Care Education Institute (2018), for immobile or bed bound individuals, a full change in position should be conducted a minimum of every two hours. Some individuals require more frequent repositioning due to their high risk status. The facility Policy and Procedure titled Pressure Injuries and Non-Pressure Injuries, dated 8/2/21 and last reviewed/revised 7/20/22 states in part, The center will complete a comprehensive assessment to identify risk factors for the development of pressure injuries and put in place measures intended to achieve the goal of prevention of pressure injuries in our residents . Under the section of Care Planning, the policy states under Activity, . If a resident is chair bound or bed bound, provide good positioning, good support surface and scheduled repositioning in the plan . Example 1 R25 has Medical Diagnoses that include but are not limited to Fracture of the Right Femur, Cognitive Communication Deficit, Diabetes Mellitus Type 2, Muscle Weakness, Lack of Coordination, Disorders of Bone Density and Structure, Alzheimer's Disease, Dementia, Chronic Kidney Disease (CKD) Stage 3 and Mild Major Depressive Disorder. The most recent Minimum Data Set Assessment (MDSA) was a Significant Change in Status (SCS) assessment dated [DATE] (Assessment Reference Date). According to this assessment, R25 requires extensive assistance of staff to meet her most basic needs of bed mobility, personal hygiene, toileting, bathing and dressing. R25 is non-ambulatory related to the recently acquired right hip fracture. R25 is also incontinent of bowel and bladder status. Observations were made throughout the survey (6/26/23 - 6/28/23) in which R25 remained on bedrest. Surveyor reviewed the Braden Scale For Predicting Pressure Sore Risk Assessments completed for R25 and noted the most recent was dated 6/26/2023, which scored R25 a number of 13. According to this assessment scores between 13-14 indicate a moderate risk for the development of a PI. Surveyor reviewed the Care Plan (CP) developed for R25 and noted the following plans: 1. Resident is at risk for skin integrity condition, or pressure sores r/t: Impaired mobility, Thin/Fragile skin (Initiated 5/11/21). The goal of this plan was The Resident will not develop pressure related tissue injury through next care plan review date. Interventions included in this plan were: - Apply alternating pressure air mattress to bed if indicated. Assure proper inflation - check frequently. - Apply pressure reduction chair cushion on wheelchair and pressure reduction mattress on the bed. Ensure cushion is properly placed, clean and dry - Assess skin for redness or pressure related changes with each care encounter. Report any changes immediately - Avoid friction/shearing while repositioning: if Resident is unable to assist, use at least two staff members, use lift sheet, bed should be as flat as possible with lifting. - Frequent repositioning in bed and chair. 2. I have a physical functioning deficit related to: Self care impairment (Initiated 5/12/21 last revised 6/20/23). Interventions for this plan included: - BED MOBILITY: assist x1. Provide reminders/cueing to turn and reposition with routine cares, during rounds, as needed and per request. (Initiated 5/12/21 and last revised 5/ 25/23) - BLADDER: . is incontinent of bladder. - BOWEL: [R25] is sometimes incontinent of bowel - TOILETING: Max assist x 2. She isn't always able to make toileting needs known and frequently declines help to use bathroom Offer toileting assistance with routine cares, during rounds, as needed and per request. 3. Actual impaired skin integrity surgical incision to right hip and open area (Moisture Associated Skin Damage) to right buttocks, pressure injury to right heel. Note: On 6/1/23, this plan was revised to reflect surgical incision to right hip and open area (MASD) to right buttocks. This was again revised on 6/26/23 to reflect the pressure injury to the right heel, but not yet revised to reflect the Stage II PI to the coccyx. Interventions for this plan included: - Dressings in place to buttocks and right heel. If dressing is not in place, or needs to be replaced, notify nurse immediately. - Encourage and assist as needed to turn and reposition; use assistive devices as needed - Float heels as able - Special mattress/cushion on bed/wheelchair (AIR MATTRESS) - Use pillows and/or positioning devices as needed Further review of R25's Medical Record revealed the development of Moisture Associated Skin Damage to the Right Buttock on 6/1/23 and the development of an initial Stage II blister to the right heel on 6/26/23. On 6/27/23, Surveyor observed R25 from 6:40 AM - 10:29 AM in which no offers or attempts were made to reposition resident (3 hours 49 minutes). The observation was as follows: - At 6:40 AM, R25 was noted to be lying in bed on her back with the upper part of her body, waist to neck, leaning to her left side. She was sitting up at a 90 degree angle. She was asleep and remained in this position until 7:48 AM, when DON B (Director of Nursing) entered the room with R25's meal tray. There was no offloading or toileting completed at that time. Surveyor noted R25 to still be at 90 degrees with the meal tray positioned over the bed and in front of the resident. She had a waffle with syrup, scrambled eggs, a bowl of oatmeal, 4 ounces of orange juice, 8 ounces of milk and coffee on the tray in front of her. - At 8:12 AM, R25 was nearly finished with her meal. - At 9:26 AM Speech Therapy and Occupational Therapy entered the room to work with R25. They were both in the room together and left at 9:36 AM. There was no repositioning of R25 at that time and she was again noted by Surveyor to still be in the 90 degree position in bed. - No additional staff entered the room after the two therapy staff left the room. At 10:00 AM, Surveyor approached CNA D (Certified Nursing Assistant) and asked what R25's care needs were. CNA D stated that R25 is able to perform some of her cares but relies on staff cues. She requires staff assistance for toilet changes and repositioning. When asked if she assisted R25 yet on this date, CNA stated that she did not. She reported to duty at 9:00 AM and was not sure yet, what tasks needed yet to be completed on the unit. At 10:10 AM, Surveyor approached CNA C and asked her what R25's care needs were. CNA C also stated that R25 requires assistance of staff to toilet her, often refuses and is currently being transferred with a mechanical lift related to the recent hip fracture. CNA C stated R25 is incontinent of bowel and bladder and does not inform staff of the need to be changed. CNA C stated R25 was to be repositioned every two hours. Surveyor then asked CNA C why R25 was not yet repositioned for the morning. CNA C stated that when she first came on duty at 6:00 AM, she was told there were staff on the unit doing cares. She learned at 6:20 AM that no staff was actually on the unit so she came down to the unit to work. She indicated she was behind schedule as a result. She had not yet been able to assist R25. After learning that R25 had not yet received toileting or repositioning for this morning, CNA C stated she would take care of R25 now. She entered R25's room at 10:15 AM along with CNA D. Surveyor observed the bathing activity. Upon rolling R25 onto her left side at 10:29 AM, Surveyor noted the incontinent brief was wet with urine and there was a soiled dressing on R25's coccyx. CNA C removed the dressing and revealed a Stage II PI over the coccyx bone, surrounded by macerated skin damage extending approximately 2 centimeters (CM) outward. She had an approximately 5 inch surgical wound over her right hip and a Deep Tissue Injury to her right heel that did not contain a dressing. CNA C left the room to report to RN H (Registered Nurse) that a new dressing needed to be applied to R25's coccyx. At 10:31 AM, RN H entered the room to apply Mepilex to the open area. The open area measured approximately 0.5 CM in diameter. RN H also examined the DTI to the right heel. It was flush with the skin and there was no fluid contained to the area. It measured approximately 3.5 cm x 2.0 cm and appeared as a purple bruise. Both CNA D and CNA C were unaware of the DTI or the coccyx wound. Also, RN H stated this was the first she had knowledge of either wounds, even though a dressing was in place on the coccyx. At 10:43 AM, DON B (Director of Nursing) entered the room and stated a dressing of a bordered foam was supposed to be in place and both DON B and RN H searched for the missing dressing in R25's bed and in the heel boots that were sitting on R25's wheelchair. They also searched the garbage can and were unable to locate the old dressing. DON B stated that she removed the boots when she set R25 up for the morning meal. R25 did not want them on through the meal. Surveyor asked DON B what the expectation for dressings to wounds and repositioning R25 was. DON B was reluctant to give Surveyor a time schedule but upon further questioning, stated R25 should be repositioned at least every two hours and whenever a dressing comes off, CNA staff were to notify the nurse to have it replaced. Note: A period of 3 hours and 49 minutes was noted in which R25 was not offered or encouraged to be repositioned. Further review of the Interdisciplinary Progress Notes indicated no entries in which R25 refused repositioning or toileting. Example 2 R27 was admitted on [DATE]. Medical Diagnoses for R27 include, but are not limited to Dementia, Major Depressive Disorder, Obstructive and Reflux Uropathy, Polyosteoarthritis, Generalized Anxiety Disorder and Radiculopathy of the Lumbar Region. On 11/19/22, R27 was admitted to the hospital following a fall in which she sustained a left hip and left elbow fracture. She returned to the facility 11/21/22, and enrolled in Hospice Services on 11/22/22. According to the most recent Minimum Data Set Assessment (MDSA), which was a Quarterly assessment with an Assessment Reference Date of 6/3/23, R27 requires extensive assistance of staff to meet her most basic tasks of bed mobility, toileting, personal hygiene and dressing. She is dependent on staff for bathing and transfers, is non-ambulatory and is incontinent of bowel and bladder function. R27 also has impaired short and long term memory and severely impaired daily decision-making abilities. R27 is 63 inches tall and last recorded weight was on 6/24/2023, in which R27 was 80.2 pounds. Surveyor then reviewed R27's Care Plan and noted the following included concerns: 1. I have a physical functioning deficit related to: Mobility impairment, Self care impairment (Initiated 9/2/22 and last revised 1/5/23) Interventions included: - assist of one for bathing - staff assist for bed mobility. Staff to turn and reposition during routine cares, with rounds, as needed and per request - Incontinent of bowel and bladder - Enrolled in hospice. Work with nursing, IDT and hospice team and family as resident declines to determine level of assist needed to ensure needs are met, with dignity, without having to express them while maintaining comfort. Provide staff assist accordingly - May be up in Broda chair if she chooses. Therapy recommending supervision while in Broda chair. - Total dependence for personal hygiene - Total dependence for toileting; check and change. Assist with routine cares, during rounds, as needed and per her request. - Transfers: may pivot transfer on Right Lower Extremity to chair if she can tolerate movement. Non-weight bearing left upper Extremity. May use Hoyer lift if transfers aren't tolerated. Full body sling size small. 2. Resident is at risk for skin integrity condition, or pressure sores r/t: Impaired mobility, Recent illness/surgery, Thin/Fragile skin (Initiated 9/2/21) Interventions for this plan included: - Frequent repositioning in bed and chair. The most recent Braden Scale For Predicting Pressure Sore Risk was completed for R27 on 12/14/22 and scored R27 a 12, indicating High Risk (High Risk is for scores of 10-12). There were no additional assessments completed after this. On 6/27/23, Surveyor made the following observation: - At 6:40 AM, R27 was sitting up in a Broda chair in the Unit 3 dining room. R27's legs were slightly extended and she was fiddling with the lap blanket over her legs and the straps to the mechanical lift sling, which were under her legs. She remained this way until her meal was served. - At 7:35 AM, R27 was served her meal of a waffle and scrambled eggs with a bowl of cream of wheat, 4 ounce orange juice, 4 ounce health shake and an 8 ounce milk and coffee. Surveyor monitored R27 while she was eating. - At 8:10 AM, R27 had eaten all of the waffle and eggs and one-half of the cream of wheat, She had take approximately 1 ounce of the shake but no other liquids. The meal tray was removed from in front of her. - At 9:01 AM, R27 was still up in the Broda chair at the table in the Unit 3 dining room. No staff had yet approached to offer or encourage toileting or repositioning. - At 9:10 AM, AA M (Activity Aide) began to set the room up for an activity and placed R27 and two other residents into a partial circle. She then left the room to retrieve additional residents. - At 9:30 AM, the activity began, it was Daily Chronicles followed by Exercise. R27 listened intently but did not participate in either program. - At 10:30 AM, the two programs had ended and R27 remained in the room. - At 11: 02 AM, CNA D and CNA C (Certified Nursing Assistants) removed R27 from the dining room and took her to her room to perform cares. Surveyor followed. - R27 was assisted onto the bed via a mechanical lift at 11:09 AM and rolled onto her side at that time to remove her pants and the heavily urine saturated incontinent brief. R27's buttocks was dark red but no open areas were noted. Surveyor continued to observe while CNA C cleansed R27 and placed a clean incontinent brief on her. Surveyor then asked both CNAs what time R27 was assisted to the Broda chair. Neither staff knew the time but stated that R27 was assisted by the night shift staff, which would have been before the day shift started at 6:00 AM. Surveyor then explained that R27 was being observed since 6:40 AM and there were no offers or attempts made to reposition and asked why the cares were not performed for this length of time. CNA C stated that she arrived to work at 6:00 AM and was told there was staff down on the unit doing cares. She learned at 6:20 AM that there was no staff on the unit so she came down. As a result, she was already 20 minutes behind in her tasks. CNA C stated R27 should have been repositioned every two hours but, . I guess we were just busy today. It got really busy. Note: This was a 4 hour 29 minute period of time in which R27 was not offered or attempted toileting or repositioning.

Based on observations, interviews and record review, the facility did not ensure a comprehensive care plan for pain management was achieved for 1 of 12 residents (R) reviewed for care plans (R10). R10 had pain in the perineal area related to vulvar (the outer surface area of female genitals) cancer with radiation burn to the area. The perineal area is the layer of skin between the genitals (vaginal opening) and the anus/sacral area. There was no care plan to direct staff on managing R10's pain. This is evidenced by: Review of the facility policy, entitled Pain Management, dated 8/09/22, states: .The facility .Manage or prevent pain, consistent with the comprehensive assessment and plan of care, current professional standards of practice, and the resident's goals and preferences .Based on the evaluation, the facility ., will develop, implement, monitor, and revise as necessary the interventions to prevent or manage each individual resident's pain beginning at admission. The interventions for pain management will be incorporated into the components of the comprehensive care plan, Facility staff will reassess resident's pain management at established intervals for effectiveness and/or adverse consequences and revise the plan of care as needed . On 6/27/23, Surveyor reviewed R10's medical record to find the following: On 2/03/23, R10 was admitted to the facility with medical diagnoses that include but not limited to, malignant neoplasm of the vulva with radiation burn to the vulva area. R10's Minimum Data Set (MDS) assessment dated [DATE] showed a Brief Interview for Mental Status (BIMS) score of 10. BIMS score ranges from 00-15. 13-15: cognitively intact. 08-12: moderately impaired. 00-07: severe impairment. Surveyor reviewed R10's current pain regimen. According to the physician's orders, R10 had the following orders related to pain control: *Observation: Pain - Observe every shift. If pain is present, complete the pain flow sheet and treat it by trying non-pharmacologic interventions prior to medicating if appropriate. Document in the progress notes. Start date 2/03/23. *Apply a frozen perineal pad to the perineal area for discomfort as needed (PRN) every 3 hours. Start date 3/16/23. *Saline gauze to the perineal area for comfort PRN 3 times daily. Start date 3/16/23. *Gently wash the vulvar and sacral area daily with soap and water, rinse, and pat dry. Apply the Silvadene cream to the vulva one time a day related to burn of unspecified body region, unspecified degree. Start date 3/27/23. *Prophylactic wound care to sacrum - Keep the sacral area covered with sterile bordered gauze wound dressing with an adhesive border 4 x 4 every 3 days and PRN. Apply a thin layer of Vaseline or Aquaphor to the vulvar/vaginal area to protect the skin from urine. Change undergarments frequently throughout the day. Start date 6/26/23. *Monitor areas of impaired skin integrity (perineal area and left lower extremity) - Monitor areas for redness and report evidence of infection such as purulent drainage, swelling, localized heat, increased pain, etc. Start date 6/26/23. *Medicated Pads External Pad (Witch Hazel (Hamamelis Virginiana)) Apply to vaginal area topically PRN for burns related to burn of unspecified body region, unspecified degree. Start date 4/13/23. *Silvadene External Cream 1 % (Silver Sulfadiazine) Apply to the vulva topically everyday shift related to malignant neoplasm of overlapping sites of the vulva. Apply a very thin layer to the vulva daily. Start date 3/16/23. *Tylenol 1000mg every 12 hours PRN for pain. Start date 4/28/23. *Tylenol 500mg two times a day for pain. Start date 2/03/23. *Tramadol 12.5mg every 4 hours PRN for pain related to malignant neoplasm of the vulva. Start date 6/27/23. A review of R10's care plan revealed no comprehensive care plan developed to direct staff in R10's care and needs concerning pain control. A review of R10's Certified Nursing Assistant (CNA) Kardex (care plan) also revealed no information on how to specifically care for R10 during perineal cleaning or information about R10's pain control. On 06/26/23 at 2:59 PM, R10 told this Surveyor that she had pain in the private area. R10 said it hurts her at times while sitting and is worse with having to be cleaned up. R10 said she had pain at this time while sitting up in her wheelchair. R10 had a grimacing facial expression during this time. On 06/27/23 at 11:10 AM, R10 was in the physical therapy room working with physical therapy assistant (PT) I. Surveyor asked R10 if she had any pain in the private area at this time. R10 stated she had some pain in the area now. Surveyor asked PT I if R10 had pain often in that area. PT I said yes, that is where her cancer is located. On 06/27/23 at 12:25 PM, Surveyor interviewed Certified Nursing Assistant (CNA) D concerning R10's pain in the private (perineal) area. CNA D stated R10 had told her it was painful in the area. CNA D stated R10 appeared to be in pain when cleaning the perineal area. Surveyor asked what did CNA D do if R10 was in pain. CNA D said she would tell the nurse that R10 was in pain to see if there was anything the resident could get for the pain. On 06/27/23 at 12:30 PM, Surveyor spoke with Registered Nurse (RN) H concerning R10 being in pain. RN H stated she received in report that R10 had a painful perineal area due to cancer. R10 was getting Silvadene treatment for the area of the pain. RN H said she was unaware of anything else specifically used for R10's perineal pain. RN H said R10 does get scheduled Tylenol for pain. On 06/27/23 at 12:35 PM, Surveyor spoke with the Director of Nursing (DON) B concerning R10's pain in the perineal area. DON B said the pain for R10 was not constant. It was worse when sitting for a long time or during cares. Silvadene was applied as scheduled and medicated pads have been ordered for the pain if needed. DON B stated the area had improved. On 06/28/23 at 7:53 AM, Surveyor spoke with CNA C about how perineal care went for R10 regarding pain. CNA C stated R10 did not have much pain during perineal care, but more so when R10 was sitting. CNA C stated she was extra gentle when doing perineal care to R10 due to vulvar cancer with radiation burn. Surveyor asked how a new CNA would know how to care for R10's perineal area. CNA C stated she would tell the new staff about how to properly care for R10's perineal area and there should be information on the Kardex about this. On 06/28/23 at 8:04 AM, Surveyor spoke with the Nursing Home Administrator (NHA) A to obtain the reviewed documentation for R10. Surveyor asked for R10's care plan concerning pain, CNA Kardex, facility policy on pain management, physician orders, administration records, and pain assessments. On 06/28/23 at 11:22 AM, NHA A provided the requested documentation for R10 to this Surveyor. NHA A stated they just noticed there was no care plan for R10 concerning pain, so they developed one today.

Based on interview and record review, the facility did not ensure correct use of a bed rail, by not following manufacturer's recommendations and specifications for 3 of 6 residents (R1, R5, and R6) utilizing bed rails with an air mattress. The facility failed to assess residents R1, R5, and R6 for the risk of entrapment when using a bed rail, Halo safety ring (Halo,) in conjunction with a new air mattress. Failure to assess the residents for the risk of entrapment with the use of the Halo and the air mattress created a reasonable likelihood for serious harm and resulted in R1 becoming entrapped between the Halo bar and the air mattress and dying from asphyxiation. This created a finding of immediate jeopardy that began on [DATE]. Surveyor notified the facility of the finding of immediate jeopardy on [DATE] at 12 PM. The immediate jeopardy had been removed and corrected on [DATE]. This is being cited as past noncompliance. This is evidenced by: Manufacturer's instructions for the Halo safety ring include, but are not limited to, the following information under the heading of WARNING: Entrapment may occur, proper patient assessment and monitoring, and proper maintenance and use of equipment is required to reduce the risk of entrapment. Each bed system should be evaluated, measured, and tested by your assessment team. Improper assessment of the bed system and failure to evaluate the specific needs of each resident will prevent a correct bed system measurement device evaluation of certain entrapment zones. This improper assessment could lead to the possibility of injury and death. Each resident must be evaluated individually. Mattress compression and gap space creation is the uncontrollable factor in the failure of bed systems. If you improperly measure, assess, or test a resident or his or her bed system, the Halo Safety Ring may not provide adequate protection. If the Halo Safety Ring is installed improperly; it may not provide the intended entrapment protection. Bed systems and each resident should be reevaluated periodically too ensure that the system still provides the resident adequate entrapment protection. 1. R1 admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R1's most recent fall occurred on [DATE], when he fell from his chair. R1's Minimum Data Set (MDS) assessment, dated [DATE], indicated that R1 had a BIMS (Brief Interview for Mental Status) score of 3, meaning R1 was severely cognitively impaired. R1's advanced directives indicated do not resuscitate. R1's care plan indicates - extensive assistance of two staff for repositioning when in bed, a Hoyer lift for transfers, and to place the bed in a low position (which meant approximately 24 inches from the floor). An occupational therapy screen completed on [DATE] noted R1 could not sit independently on the side of bed, and could not reposition independently in bed. R1 has had a Halo Safety Ring bar attached to his bed since 2017. R1's progress notes include that an air mattress was put into place on [DATE]. The care plan indicates that the air mattress was put into place on the bed to assist with healing a stage 2 ulcer on the resident's heel, which had recently developed. When the air mattress was put into place, the facility did not assess the risk of entrapment for the use of the air mattress with the Halo bar. Review of R1's medical record did not reveal any assessment of the use of the Halo bar with the air mattress. No individualized assessment for the risk of entrapment, including evaluating possible areas of entrapment, or measuring and testing by an assessment team, could be located within the medical record. On [DATE] at 3:50 AM, CNA D found R1 deceased . The resident's body was mostly on the floor and his head rested between the halo bar and air mattress. The coroner's report indicates cause of death as accidental death due to asphyxia from the halo device on his bed. The coroner noted: face is dark purple and color, extensive petechiae bilaterally, has an abrasion to the bridge of his nose one to 1.5 inches, abrasion to left chin area about one to 1.5 inches, and an abrasion to right anterior neck area about one to 1.5 inches in area. Small discolored area above left eyebrow and small abrasion above this. There is a noted red substance consistent with blood on the right lower inner aspect of the Halo device. On [DATE] at 3:56 PM, Surveyor interviewed RN C. RN C stated that on the morning of [DATE] at approximately 3:50 AM, CNA D had originally found R1 deceased and had yelled RN C's name, so she came down the hallway towards the voice and met CNA D in the hallway. CNA D told RN C, It's bad. RN C stated she entered the room, and she was shocked. RN C stated that R1's head was wedged between the Halo bar and the mattress. RN C stated that the first thing that came to mind was that R1's neck was broken. RN C stated R1's body was in a prone position; his chin and neck were stuck slightly facing upward. With R1's chin resting on the Bar, his neck was between the bottom rounded part of the bar and the mattress. RN C stated there were no signs of life when she assessed the resident. RN C stated that R1 rarely moved in bed, so for him to have tried to move in bed at all is extremely rare. When asked, RN C stated that at the time of the incident, she was not aware of any physician orders, or assessment for use of R1's Halo bar. 2. Review of R5's medical record indicates he was admitted in 2019 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R5's Minimum Data Set (MDS) assessment, dated [DATE], indicated that R5 had a BIMS (Brief Interview for Mental Status) score of 8, meaning R5 was mildly cognitively impaired. R5 had a Halo bar placed on his bed on [DATE]. On [DATE] the facility placed an air mattress on R5's bed. Review of R5's medical record did not reveal any assessment of the use of the Halo bar with the air mattress. No individualized assessment for the risk of entrapment, including evaluating possible areas of entrapment, or measuring and testing by an assessment team could be located within the medical record until [DATE]. 3. Review of R6's medical record reveals R6 was admitted in 2021 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R6's Minimum Data Set (MDS) assessment, dated [DATE], indicated that R6 had a BIMS (Brief Interview for Mental Status) score of 15, meaning R6 was cognitively intact. R6 had a Halo bar attached to his bed on [DATE]. On [DATE] the facility placed an air mattress on R6's bed. Review of R6's medical record did not reveal any assessment of the use of the Halo bar with the air mattress. No individualized assessment for the risk of entrapment, including evaluating possible areas of entrapment, or measuring and testing by an assessment team could be located within the medical record until [DATE]. On [DATE] at 4:35 PM, Surveyor interviewed DON B who confirmed that there were no assessments for R1, R5, and R6's use of the Halo bars with the air mattress completed prior to the [DATE] incident. The failure to follow manufacturer's recommendations for installing and using bed rails by failing to assess the use of the Halo bar in conjunction with an air mattress created both a reasonable likelihood for serious harm and led to serious harm, thus creating a finding of Immediate Jeopardy. The facility removed the immediate jeopardy on [DATE], when it had completed the following: Reviewed/revised policies and procedures for bed rails/enabler bars. Educated all licensed staff, prior to their next scheduled shift, on proper use of bed rails/enabler bars per facility policy, the process of determining proper use of side rails depending on resident's mental and physical status, and the increased risk of injury and death when bed rails are used improperly. The Inter Disciplinary Team (IDT) reviewed and assessed all residents with bed rails/enabler bars to determine the appropriateness of continued bed rail/enabler bar placement and risk of entrapment. Physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The IDT reviewed and revised the care plans of residents with bed rails/enabler bars to ensure they had resident specific interventions to reflect the identified need for bed rails. The IDT provided education to residents and their responsible parties on the use of bed rails/enabler bars. The facility began monitoring the utilization of bed rails/enabler bars during rounds that will occur weekly for 4 weeks and then monthly for 3 months and then quarterly. Findings will be reported at the monthly quality assurance meetings for a minimum of 3 months.

Based on observation, interview, and record review the facility did not ensure 3 of 13 sampled residents (R6, R8 and R3) received the necessary care and services to maintain skin integrity and/or minimize aspiration and ensure adequate nutrition. R6 had a significant decline in condition including a decline in bowel and bladder Based on observation, interview, and record review the facility did not ensure 3 of 13 sampled residents (R6, R8 and R3) received the necessary care and services to maintain skin integrity and/or minimize aspiration and ensure adequate nutrition. function. Failure to manage R6 increased incontinence lead to the development of MASD (Moisture Associated Skin Damage). During this time there were no changes made to R6's plan of care to manage R6's incontinence to decrease MASD. The areas of MASD continued to deteriorate and R6 developed unstageable pressure injuries the facility defined as a KTU (Kennedy Terminal Ulcer). No changes were made in R6's plan of care. 2 observations revealed R6 was not assisted with incontinence care for a period of 4 hours and 50 minutes and 3 hours and 25 minutes. 2 observations revealed licensed staff were not cleansing R6's wounds prior to applying a new dressing. Additionally, the facility was not consistently documenting the wounds including wound measurements, and wound characteristics according to current standards of practice. R8 had specific swallowing guidelines when eating to prevent aspiration (fluid leaking into the lungs when eating) and improve intake. Observations revealed on 2 occasions staff were not following the swallowing guidelines. It is critical for swallowing guidelines to be followed to ensure food and or fluid do not enter the lung causing pneumonia. R3 required close supervision and verbal cues with eating and did not receive this level of assistance during 4 meal observations. During the 1 meal where R3 was provided with close supervision and verbal cues, he successfully consumed all of his food and had no coughing episodes. This is evidenced by: Example 1 R6 had [DIAGNOSES REDACTED]. On 9/23/16 R6 was readmitted from the hospital with a [DIAGNOSES REDACTED]. R6 was admitted to Hospice services on 10/24/16. An MDS (Minimum Data Set) assessments, dated 7/25/16 indicated R6: ~Required limited to extensive assistance of one person for bathing, dressing, grooming, and using the bathroom; ~Was able to walk with extensive assistance of one person; ~Was occasionally incontinent of bowel and bladder; and ~Had no skin problems. The most current MDS dated [DATE] was a significant change assessment and indicated R6: ~Required extensive assistance of 2 staff persons for all aspects of care including bathing, dressing, grooming using the bathroom and eating; ~Did not walk; ~Was frequently incontinent of both bowel and bladder; ~Had no other skin problems including MASD (Moisture Associated Skin Damage). R6 care plan for incontinence was dated 2/1/16 and the following approaches also dated 2/1/16, .Clean peri-area as resident tolerates with each incontinence episode .observe/document/report .any possible causes of incontinence . R6's CNA (Certified Nursing Assistant) care plan was undated and included ~ .Toileting .Fall 9/15 .q2 (every two) hour toileting .Offer toileting every 2 hours and as needed . Surveyor # completed a review of R6's nursing notes and noted the following. ~9/28/16, .is having loose .stools. Buttocks is reddened and barrier cream is applied . On 9/29/16 a physician ordered barrier cream. ~10/10/16, .spoke with Dr .about residents increase in lethargy . ~10/14/16, .buttocks continues with redness . ~10/20/16, .IDT (Interdisciplinary Team) notes recent weight loss and general decline . By 10/20/16 the facility was aware of R6's decline including redness of the buttocks. In addition to the development of redness on the buttocks, on 10/24/16, the facility identified a decline in R6's bladder continence status. Despite the decline, there were no changes to R6's plan of care to direct staff on how to maintain R6's skin integrity. There were no further nursing notes or wounds notes describing R6's skin condition until 11/22/16. Nursing notes continue. ~11/22/16, .resident noted with MASD to L (left) buttock with excoriations noted. MD updated .NO (new order) for drsg (dressing) . On 11/22/16 a physician order indicated, .MASD to L (left) buttocks, clean with wound wash, apply eclipse (sic) with silicone, change daily and prn (as needed) until clear . There were no further nursing notes describing the MASD. There were no changes to R6's care plan aside from treatment to manage R6's incontinence and prevent further skin breakdown. Surveyor # completed a review of R6's wound notes titled Skin-Weekly Non-Pressure Condition Record dated 12/19/16. .wound nurse assessed area previously though to be worsening MASD today determined it is a KTU with MASD as well, secondary to multiple organ system failure. Resident has an ulcer to upper L (left) posterior thigh measuring 2x2x0.1 (2.0 centimeter long by 2.0 centimeters wide by 0.1 centimeters deep) has yellow slough to entire wound bed, MASD surround, and also has area of multiple excoriation/open area to bilat buttocks and near anus, entire area measure 8x12cm (8.0 centimeters by 12.0 centimeters) total .previously just excoriated MASD, with no measurable open area . This was the first wound note completed by the facility. This was 31 days after the facility identified R6 had wounds on the buttocks. On 12/19/16, an air mattress was placed on R6's bed, however, there were no changes to R6's care plan related to incontinence and moisture management. The air mattress was placed after the development of the wounds. Surveyor # completed a review of the company wound nurses note. This was the only wound note received by Surveyor # that was completed by the wound nurse. The note indicated, .Wound 1 Sacral. Date Onset 12/9/16. assessment Date 12/19/16. Exudate Moderate. Thickness, Full Thickness. Etiology MASD. Size .8.00 x 12.00 (8.0 centimeters by 12.0 centimeters). Depth utd (unable to determine) .Acquisition Non-Pressure .Wound bed: 50% red granular, 40% yellow slough, 10% black necrotic. Periwound: fragile erythemic skin .Started as MASD, now looks like it could be a KTU in this new hospice resident . A KTU is a pressure injury related to poor blood circulation with associated pressure. A KTU is seen at end of life and has a rapid onset with rapid tissue breakdown. Typical life expectancy after a KTU has been identified is 24-48 hours. On 12/19/16 the facility contacted the physician via fax. Surveyor # completed a review of the fax. The fax indicated, .Resident has MASD/Kennedy terminal ulcer to bilat buttocks and upper posterior left thigh .Ok for clean with wound wash, apply eclypse with silicone . This was the same dressing the physician ordered on [DATE]. There were no nursing notes, facility wound notes nor wound notes completed by the wound nurse which described a KTU on both of R6's buttock and upper posterior thigh until 12/30/16, a period of 11 days. Skin-Weekly Non-Pressure Condition Record continue. ~ 12/30/16, .KTU extends now from the L posterior upper thigh around to right buttocks, area has multiple areas of excoriation and multiple open areas as well, entire area of excoriation measure 15x15cm .Partial Thickness .wound bed .Red .Drainage Scant .Deteriorated .not expected to heal per wound care specialist and MD .Continue treatment . R6 MASD deteriorated. There were no changes made to R6's plan of care. Skin-Weekly Non-Pressure Condition Record continue. ~ 1/4/17, .KTU ulcerated/excoriated site goes from L posterior upper thigh around to right buttocks, area has multiple areas of excoriation and multiple open areas as well, entire area of excoriation measures approximately 15x18cm .Partial Thickness .wound bed .Red .Drainage .scant .deteriorated larger, as expected. wound care specialist states current tx (treatment) is most appropriate . R6's MASD again deteriorated. There were no changes made to R6's plan of care. On 1/10/17 beginning at 7:05 a.m. Surveyor # made the following observations. ~ At 7:05 a.m. R6 was seated in a wheel chair in her room. ~ At 8:17 a.m. R6 was noted in the dining room seated at a dining room table. ~ At 9:15 a.m. CNA-A (Certified Nursing Assistant) escorted R6 to her room. ~ At 9:40 a.m. R6 was noted in her room seated in the wheel chair. ~ At 9:50 a.m. Surveyor # observed CNA-F and CNA-G assist R6 into bed utilizing a hoyer lift. R6 was placed into bed at 9:55 a.m. R6 was noted to be incontinent of both bowel and bladder. CNA-F and CNA-G assisted R6 with incontinent care. A dressing on R6's left ischium and left sacrum were removed as they were soiled. During this time Surveyor # noted a large unstageable wound on R6's left sacrum measuring approximately 8.0 cm (centimeters) by 5.0 cm. The wound bed was 100% covered with brown-black eschar (non-viable tissue). Surveyor # also noted an unstageable wound on R6's left ischium approximately the size of a 50 cent piece. The wound bed was 75% brown eschar and 25% yellow slough . Surveyor # also noted an excoriated area on R6's buttock near the anus measuring approximately 7.0 cm by 3.0 cm which had multiple small open areas 100% covered with yellow slough. On 1/10/17 at 10:05 a.m. RN-H (Registered Nurse) entered R6's room. RN-H indicated she was going to complete a dressing change to R6's wounds. RN-H washed her hands, donned a pair of gloves, gathered an Eclypse dressing and applied it to R6's wounds. RN-H did not cleanse R6's wounds prior to applying the dressings. Surveyor # spoke with CNA-G. CNA-G indicated she worked full time on the unit in which R6 resided. Surveyor # spoke with CNA-G about R6's wounds. CNA-G indicated approximately 6 months ago R6 did not require as much care and was up in and walking independently. CNA-G stated R6 developed sores on her feet and since that time has had a significant decline in condition and now requires total care and does not walk. CNA-G indicated R6's buttock wounds started as a small area that was dark pink approximately one to two month ago. CNA-G stated they kept growing and getting bigger. On 1/10/17 at 10:30 a.m. Surveyor # spoke with CNA-F. CNA-F indicated she worked full time on the unit in which R6 resided. CNA-F indicated she assisted R6 with care that morning and assisted R6 into the wheel chair at about 6:30 a.m. CNA-F indicated she had provided no other care to R6 up to the time R6 was assisted to bed at 9:55 a.m. On 1/11/17 at 12:00 p.m. Surveyor # spoke with CNA-G. Surveyor # asked CNA-G if she had assisted R6 with any type of repositioning or toileting on 1/10/17. CNA-G indicated the first time they were able to lay R6 down was right before lunch. According to CNA-F and CNA-G's account, R6 was not repositioned or provided with toileting/incontinence care for 3 hours and 25 minutes. On 1/11/17 beginning at 8:35 a.m. Surveyor , with the assistance of Surveyor , conducted a continuous observation: ~At 8:35 a.m. CNA-G assisted R6 to the dining room. ~At 9:07 a.m. R6 was escorted to her room. From 9:07 a.m. to 9:45 a.m. no staff offered or assisted R6 with repositioning and toileting. ~At 9:45 a.m. LPN-I (Licensed Practical Nurse) and RN-H completed a dressing change on both of R6's feet while R6 was seated in the wheel chair. There was no repositioning or toileting offered or completed. ~From 9:45 a.m. to 10:40 a.m. no staff assisted R6 with repositioning or toileting. ~At 10:40 a.m. RN-J entered R6's room. RN-J completed an assessment. There was no repositioning or toileting assistance provided. ~From 10:40 a.m. until 12:02 p.m. R6 remained in her room. No staff assisted with repositioning or toileting. Surveyor # spoke with RN-J about the cushion in R6's wheel chair. RN-J indicated they had put a Roho cushion in R6's wheel chair, however due to the height of the Roho and safety concerns with R6 falling asleep in the wheel chair they removed the Roho and put a regular cushion in it. ~At 12:02 p.m. CNA-F escorted R6 to the dining room. ~At 12:15 p.m. Surveyor notified the ADON (Assistant Director of Nursing) that R6 had not been repositioned or received incontinence care since 8:35 a.m. Surveyor # requested the ADON notify Surveyor # when staff assisted R6 into bed. Surveyor # also requested ADON measure R6's wounds. ~At 1:20 p.m. Surveyor # observed R6 in her room seated in the wheel chair. CNA-K, CNA-G, and LPN-I were in attendance. ~At 1:25 p.m. CNA-G and LPN-I assisted R6 into bed. R6 was noted to have been incontinent of both bowel and bladder. R6 was seated in the wheel chair from 8:35 a.m. until 1:25 p.m. a period of 4 hours and 50 minutes without being repositioned or assisted with incontinence care. On 1/11/17 at 12:00 p.m. Surveyor # spoke with CNA-G regarding R6's skin management program. CNA-G pulled out her care plan for R6 and indicated staff were to check R6 every 2 hours for incontinence. CNA-G indicated it took 2 CNAs to do this as R6 required a hoyer lift for transfers. CNA-G stated the only way to check R6 was to lay R6 down. CNA-G indicated they had not had the time to lay R6 down earlier. On 1/11/17 at 1:45 p.m. Surveyor # observed The ADON and DON (Director of Nursing) complete a dressing change on R6's left sacral and ischial wounds. The ADON had gathered Eclypse dressings with silicon and wound cleanser. R6 was noted to be incontinent of stool. The ADON completed incontinence care. The ADON obtained a paper ruler and measured the complete area of both wounds and MASD on the right buttock as 12.0 cm by 18.0 cm. Surveyor # questioned the process of measuring. The ADON indicated this was how she always measured the area stating it was how the company wound nurse had done so. Surveyor # requested the ADON to measure each wound separately. Measurements are as follows. ~ Left sacrum measured 9.0 cm by 6.0 cm. The wound bed was 90% covered with eschar and 10% covered with yellow slough. The was [DIAGNOSES REDACTED] surrounding the wound measuring anywhere between 0.5 cm to 3.0 cm. ~ Left ischium measured 5.5 cm by 2.5 cm. The wound bed was 50% eschar, 40% yellow slough, and 10% red beefy tissue. ~ Right buttock near anus had an area of MASD measuring 8.0 cm by 3.0 cm. Within the area of MASD were multiple small open wounds in varying sizes. The wounds as noted the previous day were now stage 2 wounds all with a beefy red wound base. Once the wounds were measured the ADON applied the Eclypse dressings to all areas. The ADON did not cleanse R6's wounds with wound cleanser prior to applying the dressings. On 1/12/17 at 11:30 a.m. Surveyor # spoke with RN-L. Surveyor # asked RN-L about R6 wounds. RN-L indicated the wounds started weeks ago from excoriation due to incontinence. RN-L indicated she felt the wounds were due to incontinence rather than pressure. RN-L also indicated approximately 6 months ago R6 was walking. RN-L indicated R6 has declined significantly in the last few months. RN-L indicated she would expect staff would reposition R6 at least every 2 hours as well as lay down after meals. RN-L indicated she would also expect the care plan to define specific directives for the management of R6's skin. RN-L also indicated she would follow all physician orders for wound care including cleansing wounds prior to applying a dressing. On 1/12/17 at 12:15 p.m. Surveyor # asked the ADON about R6's left sacral and ischial wounds as well as the areas of excoriation on the right buttock. The ADON indicated the wounds initially presented as MASD (Moisture Associated Skin Damage) on the left buttock which progressively got worse. The ADON indicated the company wound nurse looked at the wound and identified it as a KTU. The ADON indicated they have been classifying the area a non-pressure KTU since. On 1/12/17 at 12:50 p.m. Surveyor # spoke with the DON. The DON indicated the ADON completed weekly wound rounds. The DON stated if wounds were deteriorating they should be assessed more than weekly. Surveyor asked the DON about R6. The DON indicated R6 had a KTU due to multi-organ failure. The DON indicated R6's areas were unavoidable and were not caused by lack of care. The DON indicated she felt R6's wounds were being treated appropriately. Example 2 R8 had current [DIAGNOSES REDACTED]. R8's most current MDS (Minimum Data Set) dated 11/4/16 indicated R8 required extensive to total assistance with all aspects of care including eating. On 10/20/16 R8 was evaluated by ST (Speech Therapy). A ST note dated 10/20/16 indicated R8 required ST services in order to maintain nutrition and decrease swallowing difficulties leading to aspiration when eating. A ST discharge note dated 11/16/16 indicated R8 had reduced symptoms of coughing utilizing the strategies of a pureed diet and alternating the temperature of food when assisting R8 to eat. The ST note indicated R8 required these interventions in order to maintain nutrition and decrease swallowing difficulties. R8's nutritional care plan was dated 10/22/15 and revised on 11/11/16. The care plan had the following approaches dated 11/17/16, .pureed diet, nectar liquids, alternate liquids with solids. Alternate cold items with warm items. Include Italian ice with each meal. Begin with Italian ice and alternate throughout meal .to consume highest level of PO (oral) intake . On 1/10/17 at 8:17 a.m. Surveyor # noted R8 seated in the dining room. At 8:30 a.m. R8 received breakfast which consisted of eggs, hot cereal, toast, and Italian ice. R8 was assisted to eat by the MDSC (Minimum Data Set Coordinator). The MDSC assisted R8 to eat most of the eggs, all the cereal, and approximately half of the toast prior to offering R8 Italian ice. The MDSC assisted R8 to eat the entire bowel of Italian ice at the end of the meal. The MDSC did not alternate between the Italian ice and hot foods with each bite per the care plan. On 01/10/17 during the evening meal, Surveyor # observed R8 being fed by RN-P (Registered Nurse). R8 was not served the Italian ice and RN-P did not request it from the kitchen. R8 was not served the 6 ounces of tea per dietary slip and RN-P did not request the tea either. On 1/12/17 at 12:50 p.m. Surveyor # spoke with the DON (Director of Nursing). The DON indicated she expected all staff to follow swallowing guidelines for all residents. Example 3 R3 was admitted to the facility on [DATE] with the following, but not all inclusive, Diagnoses: [REDACTED]. Based on observation, interview, and record review the facility did not ensure 3 of 13 sampled residents (R6, R8 and R3) received the necessary care and services to maintain skin integrity and/or minimize aspiration and ensure adequate nutrition. R6 had a significant decline in condition including a decline in bowel and bladder Based on observation, interview, and record review the facility did not ensure 3 of 13 sampled residents (R6, R8 and R3) received the necessary care and services to maintain skin integrity and/or minimize aspiration and ensure adequate nutrition. function. Failure to manage R6 increased incontinence lead to the development of MASD (Moisture Associated Skin Damage). During this time there were no changes made to R6's plan of care to manage R6's incontinence to decrease MASD. The areas of MASD continued to deteriorate and R6 developed unstageable pressure injuries the facility defined as a KTU (Kennedy Terminal Ulcer). No changes were made in R6's plan of care. 2 observations revealed R6 was not assisted with incontinence care for a period of 4 hours and 50 minutes and 3 hours and 25 minutes. 2 observations revealed licensed staff were not cleansing R6's wounds prior to applying a new dressing. Additionally, the facility was not consistently documenting the wounds including wound measurements, and wound characteristics according to current standards of practice. R8 had specific swallowing guidelines when eating to prevent aspiration (fluid leaking into the lungs when eating) and improve intake. Observations revealed on 2 occasions staff were not following the swallowing guidelines. It is critical for swallowing guidelines to be followed to ensure food and or fluid do not enter the lung causing pneumonia. R3 required close supervision and verbal cues with eating and did not receive this level of assistance during 4 meal observations. During the 1 meal where R3 was provided with close supervision and verbal cues, he successfully consumed all of his food and had no coughing episodes. This is evidenced by: Example 1 R6 had [DIAGNOSES REDACTED]. On 9/23/16 R6 was readmitted from the hospital with a [DIAGNOSES REDACTED]. R6 was admitted to Hospice services on 10/24/16. An MDS (Minimum Data Set) assessments, dated 7/25/16 indicated R6: ~Required limited to extensive assistance of one person for bathing, dressing, grooming, and using the bathroom; ~Was able to walk with extensive assistance of one person; ~Was occasionally incontinent of bowel and bladder; and ~Had no skin problems. The most current MDS dated [DATE] was a significant change assessment and indicated R6: ~Required extensive assistance of 2 staff persons for all aspects of care including bathing, dressing, grooming using the bathroom and eating; ~Did not walk; ~Was frequently incontinent of both bowel and bladder; ~Had no other skin problems including MASD (Moisture Associated Skin Damage). R6 care plan for incontinence was dated 2/1/16 and the following approaches also dated 2/1/16, .Clean peri-area as resident tolerates with each incontinence episode .observe/document/report .any possible causes of incontinence . R6's CNA (Certified Nursing Assistant) care plan was undated and included ~ .Toileting .Fall 9/15 .q2 (every two) hour toileting .Offer toileting every 2 hours and as needed . Surveyor # completed a review of R6's nursing notes and noted the following. ~9/28/16, .is having loose .stools. Buttocks is reddened and barrier cream is applied . On 9/29/16 a physician ordered barrier cream. ~10/10/16, .spoke with Dr .about residents increase in lethargy . ~10/14/16, .buttocks continues with redness . ~10/20/16, .IDT (Interdisciplinary Team) notes recent weight loss and general decline . By 10/20/16 the facility was aware of R6's decline including redness of the buttocks. In addition to the development of redness on the buttocks, on 10/24/16, the facility identified a decline in R6's bladder continence status. Despite the decline, there were no changes to R6's plan of care to direct staff on how to maintain R6's skin integrity. There were no further nursing notes or wounds notes describing R6's skin condition until 11/22/16. Nursing notes continue. ~11/22/16, .resident noted with MASD to L (left) buttock with excoriations noted. MD updated .NO (new order) for drsg (dressing) . On 11/22/16 a physician order indicated, .MASD to L (left) buttocks, clean with wound wash, apply eclipse (sic) with silicone, change daily and prn (as needed) until clear . There were no further nursing notes describing the MASD. There were no changes to R6's care plan aside from treatment to manage R6's incontinence and prevent further skin breakdown. Surveyor # completed a review of R6's wound notes titled Skin-Weekly Non-Pressure Condition Record dated 12/19/16. .wound nurse assessed area previously though to be worsening MASD today determined it is a KTU with MASD as well, secondary to multiple organ system failure. Resident has an ulcer to upper L (left) posterior thigh measuring 2x2x0.1 (2.0 centimeter long by 2.0 centimeters wide by 0.1 centimeters deep) has yellow slough to entire wound bed, MASD surround, and also has area of multiple excoriation/open area to bilat buttocks and near anus, entire area measure 8x12cm (8.0 centimeters by 12.0 centimeters) total .previously just excoriated MASD, with no measurable open area . This was the first wound note completed by the facility. This was 31 days after the facility identified R6 had wounds on the buttocks. On 12/19/16, an air mattress was placed on R6's bed, however, there were no changes to R6's care plan related to incontinence and moisture management. The air mattress was placed after the development of the wounds. Surveyor # completed a review of the company wound nurses note. This was the only wound note received by Surveyor # that was completed by the wound nurse. The note indicated, .Wound 1 Sacral. Date Onset 12/9/16. assessment Date 12/19/16. Exudate Moderate. Thickness, Full Thickness. Etiology MASD. Size .8.00 x 12.00 (8.0 centimeters by 12.0 centimeters). Depth utd (unable to determine) .Acquisition Non-Pressure .Wound bed: 50% red granular, 40% yellow slough, 10% black necrotic. Periwound: fragile erythemic skin .Started as MASD, now looks like it could be a KTU in this new hospice resident . A KTU is a pressure injury related to poor blood circulation with associated pressure. A KTU is seen at end of life and has a rapid onset with rapid tissue breakdown. Typical life expectancy after a KTU has been identified is 24-48 hours. On 12/19/16 the facility contacted the physician via fax. Surveyor # completed a review of the fax. The fax indicated, .Resident has MASD/Kennedy terminal ulcer to bilat buttocks and upper posterior left thigh .Ok for clean with wound wash, apply eclypse with silicone . This was the same dressing the physician ordered on [DATE]. There were no nursing notes, facility wound notes nor wound notes completed by the wound nurse which described a KTU on both of R6's buttock and upper posterior thigh until 12/30/16, a period of 11 days. Skin-Weekly Non-Pressure Condition Record continue. ~ 12/30/16, .KTU extends now from the L posterior upper thigh around to right buttocks, area has multiple areas of excoriation and multiple open areas as well, entire area of excoriation measure 15x15cm .Partial Thickness .wound bed .Red .Drainage Scant .Deteriorated .not expected to heal per wound care specialist and MD .Continue treatment . R6 MASD deteriorated. There were no changes made to R6's plan of care. Skin-Weekly Non-Pressure Condition Record continue. ~ 1/4/17, .KTU ulcerated/excoriated site goes from L posterior upper thigh around to right buttocks, area has multiple areas of excoriation and multiple open areas as well, entire area of excoriation measures approximately 15x18cm .Partial Thickness .wound bed .Red .Drainage .scant .deteriorated larger, as expected. wound care specialist states current tx (treatment) is most appropriate . R6's MASD again deteriorated. There were no changes made to R6's plan of care. On 1/10/17 beginning at 7:05 a.m. Surveyor # made the following observations. ~ At 7:05 a.m. R6 was seated in a wheel chair in her room. ~ At 8:17 a.m. R6 was noted in the dining room seated at a dining room table. ~ At 9:15 a.m. CNA-A (Certified Nursing Assistant) escorted R6 to her room. ~ At 9:40 a.m. R6 was noted in her room seated in the wheel chair. ~ At 9:50 a.m. Surveyor # observed CNA-F and CNA-G assist R6 into bed utilizing a hoyer lift. R6 was placed into bed at 9:55 a.m. R6 was noted to be incontinent of both bowel and bladder. CNA-F and CNA-G assisted R6 with incontinent care. A dressing on R6's left ischium and left sacrum were removed as they were soiled. During this time Surveyor # noted a large unstageable wound on R6's left sacrum measuring approximately 8.0 cm (centimeters) by 5.0 cm. The wound bed was 100% covered with brown-black eschar (non-viable tissue). Surveyor # also noted an unstageable wound on R6's left ischium approximately the size of a 50 cent piece. The wound bed was 75% brown eschar and 25% yellow slough . Surveyor # also noted an excoriated area on R6's buttock near the anus measuring approximately 7.0 cm by 3.0 cm which had multiple small open areas 100% covered with yellow slough. On 1/10/17 at 10:05 a.m. RN-H (Registered Nurse) entered R6's room. RN-H indicated she was going to complete a dressing change to R6's wounds. RN-H washed her hands, donned a pair of gloves, gathered an Eclypse dressing and applied it to R6's wounds. RN-H did not cleanse R6's wounds prior to applying the dressings. Surveyor # spoke with CNA-G. CNA-G indicated she worked full time on the unit in which R6 resided. Surveyor # spoke with CNA-G about R6's wounds. CNA-G indicated approximately 6 months ago R6 did not require as much care and was up in and walking independently. CNA-G stated R6 developed sores on her feet and since that time has had a significant decline in condition and now requires total care and does not walk. CNA-G indicated R6's buttock wounds started as a small area that was dark pink approximately one to two month ago. CNA-G stated they kept growing and getting bigger. On 1/10/17 at 10:30 a.m. Surveyor # spoke with CNA-F. CNA-F indicated she worked full time on the unit in which R6 resided. CNA-F indicated she assisted R6 with care that morning and assisted R6 into the wheel chair at about 6:30 a.m. CNA-F indicated she had provided no other care to R6 up to the time R6 was assisted to bed at 9:55 a.m. On 1/11/17 at 12:00 p.m. Surveyor # spoke with CNA-G. Surveyor # asked CNA-G if she had assisted R6 with any type of repositioning or toileting on 1/10/17. CNA-G indicated the first time they were able to lay R6 down was right before lunch. According to CNA-F and CNA-G's account, R6 was not repositioned or provided with toileting/incontinence care for 3 hours and 25 minutes. On 1/11/17 beginning at 8:35 a.m. Surveyor , with the assistance of Surveyor , conducted a continuous observation: ~At 8:35 a.m. CNA-G assisted R6 to the dining room. ~At 9:07 a.m. R6 was escorted to her room. From 9:07 a.m. to 9:45 a.m. no staff offered or assisted R6 with repositioning and toileting. ~At 9:45 a.m. LPN-I (Licensed Practical Nurse) and RN-H completed a dressing change on both of R6's feet while R6 was seated in the wheel chair. There was no repositioning or toileting offered or completed. ~From 9:45 a.m. to 10:40 a.m. no staff assisted R6 with repositioning or toileting. ~At 10:40 a.m. RN-J entered R6's room. RN-J completed an assessment. There was no repositioning or toileting assistance provided. ~From 10:40 a.m. until 12:02 p.m. R6 remained in her room. No staff assisted with repositioning or toileting. Surveyor # spoke with RN-J about the cushion in R6's wheel chair. RN-J indicated they had put a Roho cushion in R6's wheel chair, however due to the height of the Roho and safety concerns with R6 falling asleep in the wheel chair they removed the Roho and put a regular cushion in it. ~At 12:02 p.m. CNA-F escorted R6 to the dining room. ~At 12:15 p.m. Surveyor notified the ADON (Assistant Director of N

UNCORRECTED AT THE REVISIT Based on observation, record review and interview, the facility failed to ensure 4 of 7 residents (#19, #1, #15, and #10) received assistance and supervision to prevent falls and/or reduce severity of injury in the event of a fall. For Residents #19, #1, #15, and #10 the facility failed to ensure staff: ~Understood and consistently implemented care planned approaches for preventing falls/reducing severity of injuries ~Completed a root cause analysis to understand why falls occurred ~Revised residents' care plans when falls occurred. Resident #19 had 4 falls between 4/22/15 and 11/29/15. The 4/22/15 fall resulted in a compression fracture to her spine. Resident #19 had specific care-planned interventions in place to reduce the number of falls and the severity of injury in the event a fall occurred. On 11/29/15, staff failed to use the care-planned gait belt during transfers. Resident #19 fell , which resulted in a hip fracture and a subdural hematoma (bleed in the brain). Additionally the facility did not analyze Resident #19's falls to determine a root cause, place an immediate intervention or update her care plan based on the root cause of her previous falls. Resident #1 is at high risk for falls, and has had 20 falls with 14 from bed in the last 5 months. The facility has developed a care plan with specific interventions to reduce the number of falls and to reduce the severity of injury in the event of a fall. These interventions were not consistently followed during multiple observations. On one occasion, Surveyor # observed Resident #1 incorrectly positioned in bed without a floor mat in place. Resident #1 was observed by the surveyor to be in the process of falling. The Surveyor intervened and prevented a fall from bed onto the floor from occurring. On 11/30/15 Resident #15 had a fall while being assisted to the bathroom. The CNA (Certified Nursing Assistant) assisting Resident #15 was not using a gait belt during the transfer. It is critical to use a gait belt to support and stabilize residents with weakness and/or balance problems in order to prevent falls. Resident #10 was transferred to and from the toilet by CNA-HH without the use of a gait belt. Gait belt use for all transfers is the industry standard as well as facility standard. Resident #10's care plan also instructed staff to use a gait belt for all transfers. These failure to ensure that care-planned approaches for preventing falls were consistently carried out and the failure to do a root cause analysis to understand why falls occurred and to develop care-planned approaches that addressed specific causes resulted in finding of immediate jeopardy for Residents #19, #1 #15, and #10. The immediate jeopardy began on 11/29/15. The NHA (Nursing Home Administrator) and DON (Director of Nursing) were informed of the immediate jeopardy at 11:10 a.m. on 12/2/15. The immediate jeopardy was removed on 12/2/15, but noncompliance remains at the lower scope/severity level of F (potential for more than minimal harm that is not immediate jeopardy/widespread) while the facility continues to implement its action plan and as evidenced by the following: In addition to the residents in immediate jeopardy, the facility failed to keep the environment free from hazards for all 50 residents in the facility. Resident #23 was observed with an electric blanket draped over his shoulders and on low heat. The facility had not completed a device assessment, but had included a heating pad (not blanket) in the care plan. Hot water temperatures on the Unit 2 and Unit 3, where all 50 residents reside, ranged from 118 to 120.6 degrees Fahrenheit. This is evidenced by: Example #1: Resident #19 was admitted to the facility on [DATE] for rehabilitation due to weakness and deconditioning. Her [DIAGNOSES REDACTED]. The initial Minimum Data Set ((MDS) dated [DATE] indicates Resident #19: ~Is cognitively intact ~Requires extensive assistance of one for bed mobility, transfers, ambulation, dressing, toilet use and personal hygiene. ~Not steady and only able to stabilize with staff assistance for moving from seated to standing, walking, turning around, moving on and off the toilet, and surface to surface transfers. ~Had not experienced any prior falls. The Fall CAA (Care Area Assessment) dated 3/12/15 indicated Triggering Conditions: ~Balance Problems during transition ~Moving seated to standing position: not steady, only able to stabilize with staff assistance ~Walking: not steady, only able to stabilize with staff assistance ~Turning around and facing the opposite direction while walking: not steady, only able to stabilize with staff assistance. ~Moving on and off the toilet: not steady, only able to stabilize with staff assistance ~Surface to surface transfer (transfer between bed and chair or wheelchair): not steady, only able to stabilize with staff assistance ~Resident received antidepressant medication on one or more of the last 7 days. Surveyor # reviewed Resident #19's Interdisciplinary Post Fall Reviews and noted Resident #19 has had 4 falls since admission to the facility. The following was noted: Fall 1: Date of fall: 04/22/15 Time of fall: 8:30 a.m. Description of fall: Admission nurse found resident sitting on her buttocks on the floor of resident's room leaning against closet door with walker laying nearby on the floor. Resident had gripper socks on. Resident states I fell , was walking to the bathroom with walker by myself and fell down. Resident unsure if hit her head. Resident #19 had an x-ray of the back and it was found she had a compression fracture of T12 (the largest of vertebra in the thoracic or mid back). Summary of Interdisciplinary Team: Resident here for possible long term care related to progressive weakness and congestive heart failure. Resident is self determined to direct care and is unaware of her self care needs. Resident was attempting to self transfer with front wheeled walker and fell back on the floor. Noted increased confusion the morning of the fall. Resident usually requests assist for all transfers and needs. Following this fall, the facility implemented alarms. There was no root cause identified in the fall. Although the description of the fall indicated Resident #19 stated she was attempting to go to the bathroom when she fell the interdisciplinary team added alarms to her chair and bed but did not address her toileting needs. Fall 2: Date of fall: 04/30/15 Time of fall: 7:00 p.m. Description of fall: CNA was transferring resident from the toilet to wheelchair when resident went limp so was lowered to the floor. Summary of Interdisciplinary Team (IDT): Resident was admitted on [DATE] for weakness depression congestive heart failure and hypertension (high blood pressure) Resident refuses physical therapy and occupational therapy and prefers to direct her own care. Resident recently had a decline in activities of daily living, mobility and fluid/caloric intake. Significant change in status MDS scheduled. Resident unable to transfer with assist of 2 staff related to weakness and inability to support own weight. A referral was made to Physical Therapy following this fall, however no immediate interventions were implemented. There is no root cause identified for the fall. Although the summary of the fall indicated Resident #19 refuses physical therapy the team recommended a referral to physical therapy as its only new intervention. Fall 3: Date of fall: 06/26/15 Time of fall: 2:20 p.m. Description of fall: CNA was assisting resident off the toilet. Resident stated she became dizzy and was unable to get to her wheelchair. CNA eased resident to the floor. Resident denies pain. does have a tiny mark on her finger with a scant amount of blood-cleansed and Band-Aid applied. Summary of Interdisciplinary Team (IDT): Resident became dizzy and felt weak when assisted by CNA-lowered to the floor-no injury. IDT notes use of daily diuretic and psychoactive medication medications. Resident has history of falls and is currently working with therapy on strengthening. Following the fall, the facility updated Resident #19's transfer status from assist of 1 staff to assist of 2 staff and made a referral to Physical Therapy and Occupational Therapy. There is no root cause identified for the fall. Although the fall description notes Resident #19 felt dizzy and weak there is no evidence the IDT addressed this potential cause. Fall 4: The most recent quarterly Minimum Data Set ((MDS) dated [DATE] indicates the following: ~Cognitively intact ~Requires limited assistance of one for bed mobility, transfers, walking in room, toilet use and personal hygiene. ~Not steady and only able to stabilize with staff assistance for moving from seated to standing, walking, turning, around, moving on and off the toilet, and surface to surface transfers. ~Had not experienced any falls since prior assessment The most recent Fall Risk Evaluation dated 8/25/15 indicated Resident #19 was high risk for falls due to the following: ~History of falling: 1-2 falls in the past 3 months ~Ambulation/Elimination Status: Chair bound, assist with elimination ~Gait/Balance: balance problem while standing, balance problem while walking, decreased muscular coordination, change in gait pattern when walking through doorway, requires the use of assertive devices ~Medications: takes 3-4 medications currently and/or in the last 7 days ~Predisposing Diseases: 3 or more present Resident #19's care plan includes a problem of Requires assistance with activities of daily living. Interventions include Assist of one staff and front wheeled walker for tilting. A second care plan problem states, has potential for injury, impaired ability to self transfer related to ambulation status, gait, balance and need for a gait belt to transfer from bed to toilet, chair and bed. Interventions include, .provide gait belt and assistance of staff for all transfers. Resident #19's Certified Nursing Assistant Care card information noted: ~Assist of 1 for all transfers, toileting and ADL's with Front wheel walker and gait belt. Date of fall: 11/29/15 Time of fall: 10:30 a.m. Description of fall: Was walking off scale after getting weighed. Staff member was assisting off scale when walker got caught on the side of the scale and resident lost balance and fell , landing on her left side. Hit head on floor. Noted to also have swelling of left eyebrow. Keeps stating I'm going to die. Staff member remained with resident and reassurance provided .Resident transferred by EMS (Emergency Medical Service) to MMC (hospital) for evaluation. Summary of Interdisciplinary Team (IDT): After further investigation, IDT notes resident care planned for gait belt and assist of 1 for transfers and ambulation. CNA did not follow care plan and did not use a gait belt. Although the IDT care planned for Resident #19 to be ambulated and transferred with assistance of one staff and a gait belt the CNA failed to implement Resident #19's intervention as stated in her plan of care. Surveyor # reviewed Resident #19's hospital records from 11/29/15 and noted the following: History of present illness: Resident is a [AGE] year old female who fell at the nursing home today. She was evaluated and found to have a left hip fracture and thin subdural hemorrhage (bleeding of the brain) on the right. Surveyor # reviewed the facility policy titled Gait Belt Use dated June 2013. The policy states, to ensure the safety of our residents and employees, therapist or other direct care staff use a gait belt to provide an appropriate level of assistance during skilled rehab treatment, activities of daily living, transfers and/or ambulation. On 12/10/15 Surveyor # asked the Nursing Home Administrator (NHA) who in the facility leads fall investigations. The NHA indicated the IDT reviews resident falls with the Director of Nursing leading the process. The NHA further indicated due to turn over in the DON position Surveyor # should speak with the NHA regarding fall investigations. On 12/10/15 at 11:25 a.m. Surveyor # spoke with the NHA regarding concerns related to falls lacking identification of root cause analysis and appropriate follow up. The NHA indicated in the past when she was the Director of Nursing, she was called when a resident fell . She would discuss with the nurses the importance of root cause of analysis and care plan revisions for each fall. For the past year the NHA has not been involved with the process. The NHA indicated with change over in the Director of Nursing position (2 in the past year) and the lack of continuity, the falls investigations are missing key components of root cause analysis and addition of appropriate interventions based on root cause. On 12/1015 at 11:50 a.m. Surveyor # spoke with the NHA regarding Resident #19's falls in the facility. Each fall was reviewed in its entirety with the following noted: 04/22/15, fall self transferring to bathroom. The NHA indicated the fall does not identify where resident was transferring from, further indicating the intervention of adding alarms may not be appropriate as the team failed to identify a root cause of her fall or address her toileting needs. 04/30/15, Resident went limp in the bathroom and was lowered to the floor. The NHA indicated the team failed to address why Resident #19 went limp in the bathroom, adding no root cause was identified thus the referral to therapy may not be an appropriate intervention based on the root cause. 06/26/15, Resident dizzy and weak again eased to the floor in the bathroom. The NHA indicated the IDT did not identify a root cause. The immediate intervention of a 2 person transfer was an addition to Resident #19's care plan. 11/29/15, Resident fell at weight scale causing hip fracture and subdural hemorrhage. The NHA indicated the team identified the root cause of the fall as failure to use the gait belt. The NHA further indicated an additional cause of the fall as the scale is intended for residents to be wheeled onto not ambulating residents on. The NHA further expressed the immediate intervention was training all staff on the expectation of gait belt use. Surveyor # asked if immediate training occurred related to implementing residents' care plans and appropriate use of the wheelchair scale. The NHA indicated there is no evidence of immediate training. The facility is in process of training staff now. Example #2: Resident #1 has medical [DIAGNOSES REDACTED]. The most recent MDS dated [DATE] indicates Resident #1 requires extensive assistance of staff for bed mobility, transfers, and toilet use. He is incontinent of bowel and bladder function. The MDS also indicates Resident #1 has had falls in the last quarter. Surveyor # reviewed Resident #1's medical record and noted from 6/6/15 to 10/15/15, Resident #1 had 20 falls, 14 of which were out of bed. Resident #1's care plan includes a problem of falls dated 6/6/15. Approaches include: ~Undated, 15 minute security checks ~6/6/15-Bed and chair alarms, low bed ~6/19/15- Hoyer lift for all transfers ~7/20/15- Hipsters on at all times ~7/22/15-Not to be left in the dining room alone ~10/15/15-Floor mat beside the bed when resident is in the bed ~10/15/15-Not to be left alone in room when up in wheelchair The CNA Care Card includes the same approaches as the care plan and also that staff are to position Resident #1 on his left side when in bed with pillows to prevent rolling. The following observations were made by Surveyor # : 1. On 11/24/15 at 9:59 a.m., Resident #1 was assisted to bed from the wheelchair by CNA-C. During this observation, CNA-C transferred Resident #1 with a gait belt and a pivot transfer by himself. He did not use the Hoyer lift. CNA-C stated he was unable to find someone to assist him with a Hoyer transfer. When CNA-C placed Resident #1 into the bed, Resident #1 did not have the hipsters on. CNA-C left the room to retrieve a towel to provide perineal cleansing. CNA-C did not place the floor mat onto the floor prior to leaving. 2. On 11/24/15 at 10:40 a.m., Resident #1 was transferred from the bed to the wheelchair by CNA-HH and CNA-C. The transfer was not completed with the use of the Hoyer lift. Instead, the two staff placed a gait belt around the resident's waist and conducted a pivot transfer to the wheelchair. Resident #1 did not have the hipsters on. When asked about the transfer technique used, CNA-HH stated that the Hoyer lift is to be used for showers only. The care plan and CNA care card indicate the hoyer is to be used for all transfers. At 11:00 a.m., Surveyor # approached CNA-A and asked about Resident #1's transfers. CNA-A stated that the resident is to be transferred with the Hoyer lift at all times. She further stated that she directed both CNA-HH and CNA-C to .follow the Care Card and do what it says on the sheet . At 11:50 a.m., Surveyor # approached CNA-C and asked him about the transfer technique used for Resident #1 at 9:59 a.m. on this date. CNA-C stated, Yeah, I should have used the lift. I could have injured myself or him. 3. On 11/24/15 at 1:25 p.m., Resident #1 was observed in the Princess Pine Dining Room, seated in his wheelchair. Resident #1 did not have the hipsters on. At 1:28 p.m., Surveyor # approached RN-FF (Registered Nurse) regarding interventions for his falls. RN-FF stated Resident #1 was to be a Hoyer lift transfer at all times and because of his extensive fall history, the hipsters are to be worn. A floor mat is also to be placed beside the bed when he is in the bed. 4. On 11/24/15 at 2:00 p.m., Surveyor # observed Resident #1 in bed on his right side. The care plan and CNA care card indicate Resident #1 is to be on his left side with pillows to prevent him from rolling out of bed. 5. On 11/25/15 at 8:40 a.m., Resident #1 was observed in the Princess Pine Dining Room seated in his wheelchair. Resident #1 did not have the hipsters on. 6. On 11/25/15 from 9:58 a.m. - 10:06 a.m., Resident #1 was left alone in the Princess Pine Dining Room with one other resident. CNA-HH entered the room briefly to respond to Resident #1's call out of I want to eat. I want to eat. She ordered the resident a tray but then left the room. Resident #1's care plan indicates he is not to be left alone in the dining room while up in his wheelchair. 7. On 11/30/15 at 7:15 p.m., Resident #1 was observed to be seated in his wheelchair in the Princess Pine Dining Room with CNA-DD seated beside him conducting one-on-one. The hipsters were not on Resident #1. Surveyor asked CNA-DD why Resident #1 did not have the hipsters on. CNA-DD shrugged his shoulders and stated, I don't know. 8. On 12/1/15 at 10:45 a.m., the Surveyor observed Resident #1 in bed, lying on his right side. The floor mat was not next to the bed. Resident #1 was pushing himself to the end of the bed, and his feet were off the sides of the mattress and was about to roll off the bed. Surveyor located the Social Service Director 2 doors down and summoned assistance for Resident #1. On 12/2/15 at 11:35 a.m., the Surveyor approached CNA-F and asked why the floor mat was not placed beside Resident #1's bed on the previous morning (12/1/15). CNA-F stated, That's what we forgot. Yes, he should have had the mat down. Had the surveyor not been in the area, Resident #1 could have experienced a fall with risk of possible serious injuries. 9. On 12/2/15 at 11:24 a.m., the Surveyor walked past Resident #1's room and noted he was crawling out of bed. He was rolling over onto his right side. He had one heel boot off and on the floor, and the other (left foot) was on the floor mat. CNA-GG walked past the room and entered another resident room. She did not look into the room to check for safety with this high risk resident. The Surveyor noted the DON (Director of Nursing) was seated at the nursing desk, approximately 20 feet from the resident's room and asked her to intervene. The DON immediately entered the room and after ensuring the resident's safety, instructed staff to assist him into the wheelchair. Again, had the surveyor not been in the area, Resident #1 could have experienced a fall with risk of possible serious injuries. 10. On 12/3/15 at 11:02 a.m., Resident #1 was in the Princess Pine Dining Room seated in his wheelchair. There were no staff present. At 11:04 a.m., Resident #5 activated her chair alarm and CNA-A responded, then left the room once again. Resident #1 remained alone in the dining room until 11:20 a.m., when RN-FF approached him to wipe his nose. When asked if Resident #1 was able to be left alone in the dining room, RN-FF stated that she didn't think it was a problem. RN-FF then asked CNA-A, who stated that she didn't think Resident #1 needed to have someone present. Care plan interventions clearly state that Resident #1 is not be left unattended in the dining room when he is up in the wheelchair. 11. On 12/7/15 at 8:30 a.m., Resident #1 was noted by the Surveyor to be in bed lying on his right side. The care plan interventions indicate Resident #1 is to be positioned on his left side with pillows to prevent falls from bed. On 12/3/15 at 1:00 p.m., Surveyor # spoke with Family-Z (Resident #1's daughter) about Resident #1's care at the facility. Family-Z stated she and her sister have numerous concerns. She stated of great concern was Resident #1's falls and the facility not following the care plan. She stated that many staff are agency staff and do not know Resident #1. Family-Z stated Resident #1 has had many falls, and felt that if staff were vigilant in supervising him and responding right away, many of the falls may have been prevented. Example #3: Resident #15 has current [DIAGNOSES REDACTED]. The most current MDS (Minimum Data Set) dated 9/9/15 indicated Resident #15's cognition was moderately impaired, required the assistance of 1 to 2 staff persons for all aspects of care except eating, and was not able to maintain balance for transfers without staff support. Resident #15's fall care plan dated 12/13/13 directs staff to use a transfer belt. On 11/30/15 at 7:30 p.m. during the initial tour of the facility LPN-E indicated to Surveyor # Resident #15 had a non-injury fall that evening (11/30/15) as CNA-XX had not used a gait belt during the transfer. On 12/7/15 at 12:00 p.m. Surveyor # spoke with the DON (Director of Nursing). The DON indicated she expected all staff to be using a gait for resident transfers. Example #4: Resident #10 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the care plan titled Transfers and dated 09/17/14 noted Resident #10 required a gait belt and 1 staff for transfers. The facility completed a significant change in status MDS (Minimum Data Set) assessment for Resident #10 on 08/14/15. The MDS assessment noted Resident #10 required extensive staff assistance for transfers, toilet use, dressing, bed mobility, and transfers. On 11/24/15 at 10:27 a.m., Surveyor # observed CNA-HH wheel Resident #10 from the Princess Pine dining room to her room. Resident #10 was wheelchair bound. Resident #10 stated she had to go to the bathroom. Once in the bathroom, CNA-HH instructed Resident #10 to grab onto the bar and stand up from the wheelchair. Resident #10 was unable to successfully stand up and sat back down in the wheelchair. CNA-HH again instructed Resident #10 to use the grab bar and stand up from the wheelchair. Resident #10 stood up from the wheelchair, but was still bent over at the waist and unable to stand up straight. CNA-HH placed both hands on Resident #10's hips and guided Resident #10 to the toilet. Resident #10 was unable to stand long enough for CNA-HH to remove her slacks and underclothes before Resident #10 sat down on the toilet. CNA-HH instructed Resident #10 to stand again using the grab bar. Resident #10 stood up and CNA-HH pulled down Resident #10's slacks and pull up incontinence garment. Resident #10 sat on the toilet for several minutes. CNA-HH instructed Resident #10 to use the grab bar and stand up from the toilet. Resident #10 stood up while CNA-HH provided hygiene and pulled up Resident #10's clothes. Resident #10 pivoted from the toilet to the wheelchair with CNA-HH's guidance. CNA-HH did not place a gait belt on Resident #10 during the 4 transfers observed. On 11/24/15 at 2:20 p.m., Surveyor # interviewed CNA-HH regarding gait belt policy. CNA-HH confirmed she did not use a gait belt during Resident #10's 4 transfers. CNA-HH stated she was employed by an agency and had been working with the residents on Unit 3 full time since 11/03/15. CNA-HH stated she did not know the facility policy on gait belt use. CNA-HH stated Resident #10 did not require a gait belt because she used the grab bar. CNA-HH stated she was unsure if Resident #10's care plan included a gait belt or not. On 11/24/15 at 4:20 p.m., Surveyor # interviewed the DON (Director of Nurses) regarding gait belt use. The DON stated it was facility policy to always use a gait belt for all transfers. These failure to ensure that care-planned approaches for preventing falls were consistently carried out and the failure to do a root cause analysis to understand why falls occurred and to develop care-planned approaches that addressed specific causes resulted in finding of immediate jeopardy for Residents #19, #1 #15, and #10. The facility removed the immediate jeopardy on 12/2/15, by which time it had begun implementing the following: 1. The facility reviewed all residents' transfer status and updated care plans accordingly; 2. Began educating staff on following care plan interventions for transfers and fall interventions; 3. Educated licensed nurses on their responsibility to supervise CNAs and ensure care plans are followed; 4. Developed audit program for monitoring care being provided by staff. The deficient practice continues at a scope/severity of F (potential for harm that is not immediate jeopardy/widespread) as evidenced by the following: Example #5: Resident #23 was admitted to the facility on [DATE] for rehabilitation following a fall. Resident #23 also has multiple sites of arthritis. The facility completed an admission MDS assessment that included a brief mental status exam. Resident #23 scored a 13 out of 15 points and had only minimal problems with recall. Resident #23 is able to make self understood and understand others. Review of the care plan regarding pain and ADLs (Activities of Daily Living) initiated on 11/17/15 noted Resident #23 used a heating pad to control back pain. The care plan also noted Resident #23 had used a heating pad over a long period of time. On 12/01/15 at 12:25 p.m., Surveyor # observed Resident #23 seated in the wheelchair with a maroon electric blanket draped over his shoulders and down his back on the inside of the wheelchair. Surveyor # noted it was a Sunbeam brand and was on low heat. At 12:26 p.m., Surveyor # asked RN-AA (Registered Nurse) what type of heating device was Resident #23 using and she stated she was unaware Resident #23 had any heating device. Surveyor # requested an assessment for this device. There was no assessment provided. On 12/03/15 at 3:00 p.m., Surveyor # interviewed the NHA (Nursing Home Administrator) regarding electric blanket use. The NHA stated there are 2 residents who have electric blankets, but only Resident #23 uses it. The other female resident does not use the heating element, only the blanket. Surveyor # did confirm this statement from the NHA. The NHA stated Resident #23's family brought the electric blanket in because when Resident #23 was at home, he used a heating pad for pain control. The NHA stated Resident #23 was assessed to be safe using the electric blanket and a care plan was developed to monitor this device. The NHA acknowledge the care plan reflected a heating pad, not a blanket and there was no formal assessment only the mental status exam to determine Resident #23's abilities. Example #6 On 12/07/15 beginning at 10:20 a.m., Surveyor # tested and recorded hot water temperatures as follows: ~Thermometer checked at 32.4 in glass of ice water. ~Unit 2 room 37 bathroom sink was 120.6 ~Unit 2 room 44 bathroom sink was 120.3 ~Unit 2 room 21 bathroom sink was 119.3 ~Unit 2 common shower room sink was 120.1 ~Unit 3 room 57 bathroom sink was 118.0 ~Unit 3 room 66 bathroom sink was 118.1 Surveyor # also placed hand under running water of the above rooms checked and found the water to be too hot to keep hand exposed to the water. On 12/07/15 at 11:40 a.m., Surveyor # interviewed MS-TT (Maintenance Staff). MS-TT stated he randomly checks the water temperatures weekly and records them in the computer. MS-TT provided a copy of the temperature logs, but the logs did not include what rooms were checked. Surveyor # asked MS-TT regarding his recordings. MS-TT stated he records the highest temperature found during that week but does not record what resident room was checked. MS-TT stated all water temperatures are controlled by the boiler in the basement and can not be adjusted individually at each sink. MS-TT stated water should be between 110 and 115 degrees Fahrenheit. MS-TT then proceeded to check water temperatures and later reported to Surveyor # his findings were above 115.

UNOCCRECTED AT THE REVISIT Based on observations, record review, and interview the facility did not ensure residents who entered the facility without pressure ulcers remained free of pressure ulcers unless clinically unavoidable. In addition, the facility did not ensure residents with pressure ulcers received care and services to promote the healing of these pressure ulcers. This deficient practiced affected 9 of 9 sampled residents reviewed for pressure ulcers. Resident #2 was to be positioned side to side while in bed due to a recently healed pressure ulcer to her sacrum. Her heels were to be floated as she has current pressure ulcer treatments to her heels and feet. Observations were made for a time period of 6 hours 4 minutes, in which the resident was positioned on her back with her heels against the mattress. The following day, Surveyor # observed a treatment conducted to the resident's heels, and the staff and Surveyor noted a new Deep Tissue Injury to her right lateral foot. Resident #13 is currently being treated for [REDACTED]. As a result, the wound currently being treated had increased in size and a new area of redness formed. Resident #6 was at high risk for the development of pressure ulcers. Resident #6 had a history of [REDACTED].#6 also had current pressure ulcers. The facility did not: ~ Ensure Resident #6's care plan had clear directives to staff on how to manage Resident #6's skin. ~ Consistently follow Resident #6's care plan for positioning and pressure reduction modalities. ~ Change Resident #6's care plan when there was evidence of Resident #6's pressure ulcers deteriorated from a stage I to unstageable pressure ulcers. ~ Document Resident #6's pressure ulcers on a daily basis, including during the time frame Resident #6's pressure ulcer deteriorated. ~ Change modalities for pressure reduction when the pressure reduction device was identified as a source of pressure. As a result, Resident #6 developed avoidable pressure ulcers which demonstrated deterioration and redeveloped pressure ulcers. Resident #11 developed an avoidable unstageable DTI (Deep Tissue Injury) to the right heel on 10/08/15 according to the podiatrist. The facility was unaware of this ulcer until it was brought to the attention of the wound nurse on 11/24/15 by Surveyor # . There was no weekly assessment of the unstageable ulcer and no changes to the care plan once the ulcer was identified on 10/08/15. In addition, Resident #11 was at very high risk for pressure ulcer and was not repositioned or provided pressure ulcer relief for 4 hours and 10 minutes during a continuous observation. In addition, subsequent observations found staff were not implementing approaches to keep Resident #11's heels floating and free of pressure. The first 4 examples represent actual harm. The remaining 7 examples demonstrate a potential for more than minimal harm. Resident #18 was at risk for the development of pressure ulcers. Resident #18's heels were also noted as spongy. Spongy heels are indicative of compromised skin caused by pressure. Spongy heels are a precursor to the development of a pressure ulcer. Despite Resident #18's compromised heels, multiple observations revealed Resident #18's heels were not floating. Resident #15 was at risk for the development of pressure ulcers. Resident #15 also had a history of [REDACTED].#15 was not repositioned in the wheel chair for a period of 5 hours and 25 minutes. When Resident #15 was repositioned, observations revealed compromised skin on Resident #15's buttocks. There was no barrier cream applied to protect and restore Resident #15's skin. Resident #7 was at moderate risk for pressure ulcers and was not repositioned or provided incontinence care for 6 hours and 15 minutes during a continuous observation. Surveyor # requested staff assist Resident #7 with incontinence care as it had been over 6 hours and Resident #7 had an odor of urine and stool. Resident #16 was at risk for pressure ulcers and currently had 2 open areas on the left buttock due to moisture and incontinence. Resident #16 also had a recent history of open areas on her right buttock and sacral area also due to moisture and incontinence. Resident #16 was not offered repositioning or incontinence care for 2 hours and 55 minutes during a continuous observation. Resident #14 went an extended period of time (3 hours 33 minutes) before he was offered or assisted to the bathroom. This is evidenced by: Example #1: Resident #2 has medical [DIAGNOSES REDACTED]. Resident #2 requires extensive assistance of staff to meet her most basic needs of personal hygiene, dressing, and bed mobility. She is dependent on staff for toileting, bathing, and transfers. Resident #2 is always incontinent of bowel and bladder function. She also has a history of pressure ulcers to her buttocks and feet, with a current treatment in place for her feet. The CNA (Certified Nursing Assistant) Care Card states, encourage side to side laying while in bed. Resident #2's care plan includes the following: ~Toilet every 2-3 hours ~Float the residents heels ~No directives on repositioning in bed and no directive on the correct setting of the air mattress. On 11/24/15, Surveyor # observed Resident #2 to be in bed laying on her back at 9:46 a.m. and began a continuous observation. The head of the bed was up approximately 90 degrees. She had slip-socks on each foot and her heels were against the mattress. At 10:50 a.m., No staff had yet entered the room to offer or attempt to reposition Resident #2. She continued to lay as previous noted. At 11:10 a.m., CNA-C entered the room to give Resident #2 water. He pulled her upper body more to the center of the bed, as she was leaning slightly to her left. He then gave her sips of water through a straw and stated he was going to get Resident #2 some applesauce to eat. He then left the room. At 11:20 a.m., CNA-C re-entered Resident #2's room, lowered the head of the bed and checked her brief for incontinence. The brief was saturated. CNA-C then removed the soiled brief, and at 11:25 a.m., CNA-A entered to assist. CNA-A provided Resident #2 with perineal cleansing. Following this task, the two staff placed Resident #2 back onto her back and elevated the head of the bed to 70 degrees. They both then left the room. The resident was not positioned off her buttocks and the heels were not elevated from the mattress. At 12:50 p.m., CNA-C re-entered Resident #2's room with her meal tray. CNA-C left the room at 1:18 p.m. There was no incontinence check prior to the meal and there was no repositioning completed following the meal. The resident remained with the head of the bed at 70 degrees and laying on her back with the heels against the mattress. Resident #2 remained in this position for over two more hours. At 3:25 p.m., Surveyor # approached CNA-YY and asked what Resident #2's care needs are. CNA-YY stated that Resident #2 is to be repositioned every two hours, that she is incontinent of bowel and bladder, and that she has a history of a pressure ulcer on her bottom and spinal areas, and because of this, she was to be repositioned side to side in bed. The Surveyor then informed CNA-YY that Resident #2 was on her back all day with the exception of a roll to the left for a short period to cleanse her buttocks at 11:30 a.m. CNA-YY indicated that Resident #2 is on her list and they (staff) will get to Resident #2 soon. At 3:36 CNA-YY and CNA-SS entered Resident #2's room and provided incontinence care and repositioning. The resident's incontinence brief was saturated, and her buttocks were dark red and wrinkled. At 3:50 p.m., the two staff rolled the resident onto her left side, completely off her buttocks. The Surveyor then requested CNA-YY and CNA-SS to remove Resident #2's slip socks in order to observe the resident's feet. They did as requested. The Surveyor noted that both of the resident's ankles were dark pink to red, from the direct pressure of the mattress. The left outer heel had a quarter coin size spongy area and was also dark red. The left outer foot also had a dark red area approximately the size of a quarter coin piece. The right outer heel had an area of deep redness that measured greater than 7 centimeters (cm) length x 6 cm wide. Resident #2 was positioned onto her back for a period of 6 hours 4 minutes. With the exception of one incontinent check after which she was placed back onto her back. Her heels were not floated as directed. Surveyor # approached RN-FF (Registered Nurse), and explained the observation of Resident #2 and requested that she assess the resident's feet and buttocks for potential breakdown. RN-FF indicated that she would do so. The next morning, 11/25/15 at 8:50 a.m., RN-FF approached Surveyor # and explained that she had assessed Resident #2's buttocks and feet the prior evening, and noted the left mid-foot contained a red non-blanchable (reddened area that does not lighten with pressure) area that was 1.7 cm in length x 1.7 cm width that was not present prior to the Surveyor's observation. She also stated the left lateral heel had a red spongy area measuring 4.2 cm length x 3.6 cm width and was non-blanchable. The right lateral heel measured 7.6 cm length x 6.5 cm width last evening and was red and non-blanchable. The resident's buttocks was clear of any redness. RN-FF also stated that she observed a new DTI to Resident #2's right bottom of foot, just below the 5th toe. She stated that last evening, it measured 2.4 cm length x 1.2 cm width and was gray to black in color and non-blanchable. RN-FF stated this area was not present prior to the Surveyor's observation of not being repositioned for over 6 hours. OBSERVATION #2: On 11/25/15 Surveyor # conducted observations of Resident #2 while she layed in bed. The observation began at 8:55 a.m. after RN-FF showed the Surveyor Resident #2's heels. The resident was laying on her buttocks with her back slightly turned to her left and a bed pillow was positioned against her back. Her buttocks and heels were against the mattress. At 9:58 a.m., Resident #2 was still laying as above. She remained in this position until 12:04 p.m. when CNA-F and CNA-HH repositioned her onto her right side. In this observation, Resident #2 was laying on her buttocks with heels not being floated for a period of 3 hours 9 minutes. Staff did not follow the plan of care directing them to position the resident side to side or float her heels. Example #2: Resident #13 has medical [DIAGNOSES REDACTED]. Resident is currently being treated for [REDACTED]. Resident #13 requires extensive to total assistance of staff to meet her most basic daily tasks of repositioning, toileting, and personal hygiene. Resident #13's Care Plan includes a problem for Pressure Ulcers dated 5/13/14 and last updated on 10/23/15. Staff are to turn and reposition Resident #13 frequently while in bed for comfort and pressure reduction. On 12/1/15 at 9:00 a.m., Surveyor # entered Resident #13's room and spoke with Family-RR. Surveyor observed Resident #13 asleep lying on her back in a RecoverCare Stat 5000C air mattress. The settings for the bed were adjusted to accommodate a person weighing 80 pounds. Surveyor # reviewed Resident #13's weights and noted on 11/29/15, Resident #13 weighed 203.4 pounds. A setting of 80 pounds would not be appropriate as there is not enough air to keep Resident #13 afloat. Thereby permitting pressure to vulnerable areas. At 9:25 a.m., CNA-EE entered the room to provide Resident #13 with morning cares. At 9:40 a.m., CNA-B and RN-FF (Registered Nurse). Together the two CNA staff rolled the resident onto her right side and washed her buttocks. RN-FF changed a dressing to the resident's buttocks. The resident had a dark red area on her right sacrum with evidence of previous breakdown in the form of scar tissue below the red area. RN-FF stated that the area was improved, as it was very macerated and red with many small open areas. RN-FF then measured the wound to be 1.4 centimeters (cm) in length x 0.3 cm width. RN-FF completed the dressing change, then left the room. AT 10:02 a.m., CNA-EE and CNA-B then positioned Resident #13 back onto her back, with a pillow under her calves in order to float her heels. At 10:40 a.m., Resident #13 remained on her back. At 11:15 a.m., the resident was still on her back with the mattress settings still at 80 pounds. At 11:36 a.m., Resident #13 was still on her back and she had not yet received her breakfast tray. Her heels were against the mattress and were not floating. At 12:00 p.m., CNA-F and CNA-B entered Resident #13's room. Together they provided a slight shift to check the incontinent brief, which was dry. The resident was then positioned on her back with a slight left side. Her buttocks remained against the mattress. A neck pillow was then placed between the resident's ankles, but the left heel remained on the mattress. At 4:40 p.m., 6 hours and 38 minutes after the observation began, CNA-HH and CNA-DD entered Resident #13's room in order to provide an incontinence check. The Surveyor asked both staff what cares they have provided Resident #13 since coming on duty. CNA-DD stated that he had not completed anything with Resident #13 until this time. CNA-HH stated that she had assisted CNA-B with incontinence care around 2:30 p.m. However, Surveyor # noted that Resident #13 was in the same position as she was left in at 12:00 p.m. The mattress setting was still at 80 pounds. The two staff then removed the neck pillow that was between the resident's ankles and provided her with perineal cleansing. Her brief was saturated and there was a large amount of feces present. The resident's buttocks was dark pink and pocketing from the brief fabric. The resident was positioned onto her left side. Surveyor # then asked CNA-HH if Resident #13 was to be positioned on her sides at all, or left on her back at all times. CNA-HH stated, Well, yeah, she should be on her sides, I don't know, but she gets restless and tries to put her feet over the bed. At 5:10 p.m., Surveyor # asked RN-FF about Resident #13's care needs. RN-FF stated the resident should definitely be positioned onto her sides, that she is a high risk, and we just healed her bottom from a pressure ulcer. Surveyor # explained the observation and asked RN-FF to assess the Resident #13 again. On 12/2/15 at 11:42 a.m., RN-FF stated that she reassessed Resident #13's buttocks last night after discussion with the Surveyor. RN-FF stated there was no further breakdown. Surveyor # then asked RN-FF about the mattress settings. RN-FF stated she did not know what the settings should be, but that she would check. On 12/3/15 at 11:25 a.m., Surveyor # observed the treatment on Resident #13, completed by RN-FF. ~The right sacrum had a red area that measured 1.4 cm length x 1.4 cm width. This was an increase in size from the previous observation made on 12/1/15. ~The left sacrum now contained a reddened area that measured 0.3 cm length x 0.2 cm width. ~The tissue above the two red areas had irregularly shaped dark red ruddy tissue. Both areas were blanchable with this observation. On 12/7/15 at 1:58 p.m., Surveyor # and the NHA (Nursing Home Administrator), who is also a RN, entered Resident #13's room. The mattress was set at 120 pounds. The NHA stated that she had assessed Resident #13 as requiring the setting to be at 120. She stated and demonstrated to the Surveyor by feeling under the resident's shoulders the firmness of the mattress and the comfort level of the resident. Surveyor # reviewed the mattress manufacturer's instructions. Page 7 gives directions on how to determine the proper setting for each individual resident and states: 1. Begin by placing the head of the bed (HOB) in the appropriate position based on the resident's clinical condition; 2. Select the highest setting or most firm Comfort Adjust setting; 3. Hand Check: Place a hand with 3 fingers if the HOB is at 30 degrees or higher, or 4 fingers if the HOB is lower than 30 degrees, stacked vertically beneath the cells of the mattress and above the safety mattress directly between the lowest point of the resident's sacral area/buttocks. The smallest finger should be resting against the mattress; 4. Sequentially reduce the Comfort Adjust setting to the firmness level where the height of the 3 or 4 fingers can slide with minimal resistance between the resident's sacral area/buttocks and the lower safety mattress. This is the proper Comfort Adjust setting for the resident to assure proper inflation of the air cells and prevent bottoming out of the mattress. 5. Document the resident's Comfort Adjust setting for future reference, and re-evaluate with the Hand Check as the resident's condition warrants. Example #3: Resident #6 had current [DIAGNOSES REDACTED]. Resident #6's most current MDS (Minimum Data Set) was dated 9/25/15. The MDS indicated Resident #6: ~Had a BIMS (Brief Interview for Mental Status) score of 1 indicated a severe cognitive impairment; ~Required extensive assistance of 1 to 2 staff members for all aspects of care; ~Did not walk; ~Was always incontinent of both bowel and bladder; ~Had contractures on both sides of the upper extremity and lower extremity: ~Was at risk for developing a pressure ulcer; and ~Had 1 unstageable pressure ulcer. Resident #6's admission MDS dated [DATE] indicated Resident #6 was at risk for the development of a pressure ulcers and had no pressure ulcers. Resident #6's skin care plan was dated 7/29/15. The care plan included the following undated approaches: .pressure reduction mattress to bed .air .pressure reduction cushion to .wheel chair .Reposition in chair frequently for comfort and pressure reduction Q 2 (every 2 hours) .Turn and reposition while in bed frequently .hover boots .float heels . Surveyor # completed a review an historical skin care plan dated 6/23/15 and noted: ~Undated, .float heels . ~7/2/15, .Air mattress .Blue pressure relief boots . Resident #6's CNA care plan was undated. The care plan had the following approaches: .hover boots in bed .Keen heel float under lower legs to float heels .Resident to lie down after lunch till dinner time . There were no directives on Resident #6's CNA care plan directing staff on how often Resident #6 was to be repositioned. Resident #6's current skin risk assessment was dated 8/19/15. The risk assessment had a cumulative score of 10. This indicated Resident #6 was at high risk for the development of a pressure ulcer. Surveyor # 3 requested all of Resident #6's wound notes since admission. The following was noted: ~7/2/15 Resident #6 was identified as having a facility acquired DTI (Deep Tissue Injury) on the left heel. The pressure ulcer measured 8.5 cm x 5.0 cm (8.5 centimeters by 5.0 centimeters). The wound was described as a fluid filled blister with the lateral edge of the heel black in color. ~7/16/15 the facility described the wound as healed. It was questionable that a DTI could heal in 14 days. 7/22/15, Resident #6 was admitted to the hospital. Resident #6 was readmitted on [DATE]. Wound notes continue: ~7/29/15 the facility identified a DTI to Resident #6's left heel upon a readmission from the hospital measuring 7.5 cm x 4.5 cm. On 10/23/15 the pressure ulcer was noted as healed. ~11/25/15 the facility identified a new facility acquired stage I pressure ulcer to Resident #6's right anterior ankle, right heel, and right great toe. The right ankle measured 1.2 cm x 1.2 cm and was described as dark red non-blanchable. The right heel was noted as red however blanchable. The right great toe was noted as a stage I red non-blanchable area measuring 0.4 cm x 0.7 cm. ~11/25/15 the facility identified a new facility acquired stage I pressure ulcer to Resident #6's left anterior ankle and heel. The left anterior ankle measured 0.4 cm x 0.4 cm and was noted as red and non-blanchable. The left heel had an intact white callous which measured 0.8 cm x 0.4 cm with a stage I non-blanchable dark red area in the center. Distal to the callous were 2 red blanchable areas measuring 3.3 cm x 3.3 cm each. The heel was noted as boggy. There were no changes made to Resident #6's plan of care. On 12/2/15 the left heel and left anterior ankle were noted as healed. Wound notes continue. ~12/2/15 a wound note indicated the pressure ulcers to Resident #6's right anterior ankle and right great toe had deteriorated to unstageable pressure ulcers. The right anterior ankle wound measured 1.0 x 0.6 cm. The right great toe measured 1.7 cm x 0.7 cm. In 7 days, the pressure ulcers to Resident #6's right anterior ankle and right great toe deteriorated from a stage I pressure ulcer to unstageable pressure ulcers. This was indicative of prolonged pressure to both areas. There were no changes made to Resident #6's care plan. Surveyor # completed a review of Resident #6's nurses notes and medication administration records. There was no indication the facility monitored Resident #6's wounds on a daily basis and documented their findings. It is critical that wounds are assessed on a daily basis in order to determine changes in wounds and need for changes in treatment. On 11/24/15 beginning at 9:56 a.m. Surveyor # and # made the following continuous observation: ~9:56 a.m. Resident #6 was noted seated in a wheel chair in the Princess dining room. ~11:33 a.m. AA-J (Activity Aide) escorted Resident #6 from the dining room to an alcove area across from the nursing station. ~11:45 a.m. CNA-HH escorted Resident #6 back into the dining room. ~11:46 a.m. CNA-HH and CNA-A boosted Resident #6 up in the wheel chair utilizing the hoyer sling. CNA-HH then placed Resident #6 at a table in the dining room. A boost is considered a micro change in position and does not constitute off-loading or repositioning. ~11:50 a.m. the noon meal arrived and Resident #6 was assisted to eat. ~1:05 p.m. OT-BB (Occupational Therapist) placed Resident #6 in front of a window in the dining room. ~1:13 p.m. CNA-HH escorted Resident #6 to his room. ~1:16 p.m. CNA-HH and CNA-C assisted Resident #6 into bed. Resident #6 was not repositioned while seated in the wheel chair for a period of 3 hours and 20 minutes. Once in bed, CNA-HH removed Resident #6's hover boots and placed them in Resident #6's wheel chair. Both CNA-HH and CNA-C assisted Resident #6 with incontinence care. CNA-HH and CNA-C positioned Resident #6 onto his back. CNA-HH obtained a Keen positioning device and placed it under Resident #6's calves. CNA-HH did not apply the hover boots as directed by Resident #6's plan of care. At 1:54 p.m. Surveyor # noted the hover boots were still in Resident #6's wheel chair. At 2:25 p.m. Surveyor # noted the hover boots were still in Resident #6's wheel chair. On 12/2/15 at 11:25 a.m. Surveyor # noted Resident #6 was in bed and positioned on his back. Resident #6's hover boots were on however the Pro-Keen wedge was noted sitting on the floor next to Resident #6's bed. On 12/2/15 at 11:35 a.m. Surveyor # and RN-FF observed Resident #6's feet. Surveyor # noted the following. Measurements as noted were obtained by RN-FF. Left Foot ~Anterior left upper ankle had a linear area of deep redness measuring 2.8 cm x 0.4 cm (2.8 centimeters by 0.4 centimeters). ~Left lateral heel had an area of deep redness measuring 1.5 cm x 0.3 cm. ~Left posterior heel had a area of redness measuring 1.5 cm x 2.4 cm. Right foot ~Right great toe had a dark red-brown leathery tissue measuring 1.7 cm x 0.7 cm. ~Anterior right upper ankle had a dark red-brown leathery tissue measuring 1.0 cm x 0.6 cm. The wound was surrounded by 0.5 cm of redness. ~Right heel had an dark pink area measuring 1.6 cm x 1.8 cm. RN-FF indicated the heel was spongy. A spongy or boggy heel is considered one of the first indicators of compromised tissue due to pressure. Wound documentation reviewed by Surveyor # prior to the observation noted the areas to Resident #6's left foot were healed. Surveyor # asked RN-FF about the pressure areas as noted on Resident #6's right and left anterior ankles given their appearance. RN-FF indicated she thought the pressure areas of both Resident #6's right and left anterior ankles was caused by the straps of the hover boots. On 12/2/15 at 12:15 a.m. 40 minutes after first observing Resident #6's right and left anterior ankles Surveyor # noted the areas of redness had not subsided. This was indicative of tissue damage. The facility identified the source of the pressure related wounds to Resident #6's right and left anterior ankle. Despite that, there were no changes made in Resident #6's plan of care. On 12/7/15 at 12:00 p.m. Surveyor # spoke with the DON (Director of Nursing). The DON indicated she expected all staff to follow resident care plans for positioning and off-loading devices. The DON indicated any resident at risk for the development of a pressure ulcer should have some type of pressure reduction modality in place. Surveyor # asked the DON if Resident #6 had ever had a different type of off-loading boot implemented. The DON indicated she was not sure but would check. The DON also indicated all residents including Resident #6 should have their wounds looked at every day. The DON stated if changes were noted in a wound these changes should be documented. Surveyor # received no further information from the facility. Example #4: Resident #11 was admitted to the facility on [DATE] for long term care due to dementia. Other contributing medical [DIAGNOSES REDACTED]. The facility completed a quarterly MDS on 10/14/15. The following data was noted in the assessment: ~never able to understand others or make self understood. ~severely impaired decision making skills. ~required total staff assistance for all areas of ADLs (activities of daily living). ~was nonambulatory. ~was always incontinent of bladder and bowel. ~had no pressure ulcers. ~was receiving pressure relief devices in bed and wheelchair, was on a turning and repositioning program, and was receiving nutrition to manage skin problems. Review of the care plan initiated on 10/14/15 noted Resident #11 had potential for pressure ulcer development. The interventions were to apply bilateral heel float boots at all times, complete full body checks weekly and document any skin problems, pressure reduction devices in bed and wheelchair, turn and reposition frequently, and follow facility policy to prevent and treat skin breakdown. The facility completed a Braden skin at risk assessment on 10/12/15 and identified Resident #11 was at very high risk for developing pressure ulcers due to complete lack of sensory perception, being very moist, being chairfast, being completely immobile, having an inadequate nutritional intake, and being at risk for shear or friction. Review of the podiatry progress note dated 10/08/15 noted Resident #11 had an indurated (red, hard) and bruised right heel. The physician ordered to treat with skin prep daily and update the doctor in 2 weeks. On 11/24/15, Surveyor # noted a physician order [REDACTED].#11's right heel daily and update the physician in 2 weeks. Review of the TAR (Treatment Administration Record) noted Resident #11 did not receive the skin prep treatment 8 times from 10/08/15 through 11/23/15. Surveyor # was unable to locate any pressure ulcer documentation for Resident #11. There was also no care plan developed to treat Resident #11's pressure ulcer on the right heel. There was no evidence the physician was updated after 2 weeks according to the original order. Observation 1 - On 11/24/15 beginning at 9:50 a.m., Surveyor # observed Resident #11 seated in a Broda chair with bilateral boots on her feet. Resident #11 remained in the same potion until 2:00 p.m. when CNA-HH and CNA-SS assist Resident #11 into bed using the mechanical lift. Once into bed, Surveyor # requested to see Resident #11's heels. CNA-HH removed Resident #11's heel protectors and socks. Surveyor # noted a red unstageable DTI on Resident #11's right heel that was irregularly shaped and approximately 1 cm (centimeter) in diameter. The ulcer was nonblancheable. The skin around the wound had an approximate 3 cm area of dry peeling skin. CNA-SS and CNA-HH reapplied Resident #11's socks and heel protectors and floated Resident #11's heels off of the bed with pillows. Resident #11 was not repositioned, provided incontinence care, or pressure relief for 4 hours and 10 minutes. Resident #11's bilateral feet were resting on the solid foot board of the Broda chair during that 4 hour and 10 minute observation. On 11/24/15 at 12:47 p.m., Surveyor # interviewed RN-FF who identified herself as the facility wound nurse. RN-FF stated she was unaware Resident #11 had a pressure ulcer on her right heel. RN-FF stated there had been no assessment of the ulcer on Resident #11's right heel and no changes to the care plan because she was never informed of any pressure ulcers. RN-FF stated she had assumed the wound nurse duties on 11/02/15. On 11/24/15 at 1:50 p.m., Surveyor # interviewed CNA-A regarding care needs of Resident #11. CNA-A stated Resident #11 was totally dependent on staff for all cares including eating, hygiene, repositioning, dressing, and bed mobility. CNA-A stated Resident #11 required a mechanical lift for all transfers and spent her day sitting up in the Broda chair. CNA-A stated Resident #11 was unable to reposition self. On 11/24/15 at 4:20 p.m., Surveyor # interviewed the DON (Director of Nurses) regarding Resident #11's pressure ulcer. The DON stated the nurse who transcribed the podiatrist order on 10/09/15 is no longer employed due to performance problems. The DON stated she was unaware Resident #11 had a pressure ulcer on the right heel. The DON stated the podiatrist was not updated after 2 weeks. On 12/03/15 at 3:50 p.m., Surveyor # interviewed RN-VV who identified herself as the RN who had completed Resident #11's quarterly MDS. RN-VV stated she was unaware of Resident #11's unstageable pressure ulcer on the right heel. RN-VV stated she did not see the podiatrist note dated 10/08/15. Observation 2 - On 11/30/15 at 7:30 p.m. during the initial tour of the facility Surveyor # and LPN-E (Licensed Practical Nurse) observed Resident #11's heels resting directly on the surface of the mattress. LPN-E indicated Resident #11 should have a Pro-Keen wedge under her heels to totally elevate Resident #11's heels off the mattress. According to Resident #11's CNA care plan, Resident #11 should have had both the Pro Keen wedge and heel boots on. Obs

UNCORRECTED AT THE REVISIT Based on observations, interviews, and record reviews, the facility did not ensure 9 of 11 sampled residents reviewed for bladder incontinence received care to promote continence and/or prevent the development of urinary tract infections. Resident #15 was frequently incontinent of bladder. Despite this, no comprehensive bladder assessment completed in order to determine possible contributing factors in order to put appropriate interventions in place to restore continence. Resident #15 was also observed not to receive incontinence care for an extended period of time. Resident #11 was noted to be completely incontinent of bladder. Despite this, no comprehensive bladder assessment completed in order to determine possible contributing factors in order to put appropriate interventions in place to restore continence. Resident #11 was also observed not to receive incontinence care for an extended period of time on more than 1 occasion. Resident #6 was noted to be always incontinent of bladder. Despite this, there was no comprehensive bladder assessment completed in order to determine possible contributing factors in order to put appropriate interventions into place to restore continence. Additionally, there was never an admission assessment completed. Resident #18 was noted to be always incontinent of bladder. Despite this, there was no comprehensive bladder assessment completed in order to determine possible contributing factors in order to put appropriate interventions into place to restore continence. The above 4 examples are being cited at actual harm. The remaining examples meet the definition of potential for more than minimal harm. Resident #16 developed complications of skin erosion due to incontinence or MASD (Moisture Associated Skin Damage). Resident #16 has a history of MASD open areas on the right buttock and sacrum and currently has 2 open MASD areas on the left buttock. Resident #16 went an undetermined amount of time without the appropriate dressing in place. The care plan did not include individualized approaches to restore as much normal bladder function as possible. Resident #16 was not provided toileting for 2 hours and 55 minutes. Resident #7 was dependent on staff for toileting and incontinence care due to dementia. Resident #7 was not provided any toileting or incontinence care for 6 hours and 15 minutes. Resident #7 was also not provided with frontal hygiene once she finally received staff assistance with toileting. Staff did not provide appropriate peri care after Resident #13 experienced an episode of incontinence. Resident #14 went an extended period of time (3 hours 33 minutes) before he was offered or assisted to the bathroom. Resident #1 was not given peri care following incontinence until the Surveyor questioned his incontinent status. This is evidenced by: Example #1: Resident #15 has current [DIAGNOSES REDACTED]. Resident #15's most current MDS (Minimum Data Set) was dated 9/9/15. The MDS indicated Resident #15's cognition was moderately impaired, required the assistance of 1 to 2 staff persons for all aspects of care except eating, and was frequently incontinent of bladder. Resident #15's care plan for incontinence was dated 3/16/10. The care plan directed staff to assist Resident #15 to the bathroom every 2 to 3 hours, including at 5:00 a.m., between 8:00 p.m. and 9:00 p.m. and before naps. Assisting any resident to the bathroom every 2 to 3 hours does not constitute a toileting program designed to promote continence. Surveyor # requested all Resident #15's bladder assessments completed since 2/2/15. Surveyor # received bladder assessments dated 3/26/15 (annual assessment) and 9/9/15 (quarterly assessment). Neither assessment was complete. Neither assessment included voiding patterns. Both assessments contained limited data on which to base an assessment including a physical assessment. It is necessary to complete a comprehensive assessment of residents bladder status in order to implement appropriate interventions in attempt to restore as much bladder function as possible. On 12/1/15 beginning at 7:45 a.m. Surveyor # made the following observations: ~7:45 a.m. Surveyor # noted Resident # 15 was not in her room. Surveyor # made the following observations. ~8:00 a.m. Resident #15 was noted seated in a wheel chair at a table in the main dining room. ~8:35 a.m. Surveyor # noted Resident # 15 was still seated at a table in the main dining room reading the paper. ~9:30 a.m. Surveyor # noted Resident # 15 was still in the main dining room. ~10:14 a.m. Surveyor # noted Resident #15 was still in the main dining room. ~10:20 a.m. Resident #15 was noted in the main dining room playing bean bag toss. ~11:04 RN-G escorted Resident #15 to the unit where Resident #15 resides and administered Resident #15 medications. ~11:15 a.m. RN-G replaced Resident #15 oxygen tank and escorted Resident #15 back to the main dining room positioning Resident #15 in front of the television. ~11:22 a.m. CNA-B approached Resident #15 and adjusted Resident # 15's nasal cannula. ~At 11:47 a.m. AA-L escorted Resident #15 to a table in the dining room to play trivia. ~At 12:10 p.m. Resident #15 received lunch. ~At 12:52 p.m. Resident #15 propelled herself from the main dining room to the unit in which Resident #15 resided. ~At 1:02 p.m. Resident #15 began to propel herself to the hallway where the main dining room was located. Resident #15 was approached by CNA-UU and escorted to the nursing station on unit one. CNA-UU obtained candy and gave it to Resident #15. ~1:09 p.m. CNA-UU began to escort Resident #15 back to the unit in which Resident #15 resided. The NHA (Nursing Home Administration) intercepted Resident #15 and brought Resident #15 to the nursing station on unit where Resident #15 resides. The NHA cued CNA-B to assist Resident #15 to the bathroom. ~At 1:10 p.m. CNA-B assisted Resident #15 to the bathroom located in the shower room. CNA-B cued Resident #15 to stand. CNA-B removed Resident #15's pants and adult brief. Surveyor # noted the adult brief was saturated with urine. Surveyor # also noted Resident #15's buttocks as well as the back of the upper thighs had a deep ruddy red coloration. CNA-B cued Resident #15 to sit on a shower chair. CNA-B placed the shower chair over the toilet and cued Resident #15 to go to the bathroom. Resident #15 was noted to both void and have a bowel movement. CNA-B pulled the shower chair away from the toilet. From the back of the shower chair CNA-B cleansed Resident #15's posterior buttock and posterior peri area. CNA-B placed an adult brief, pulled Resident #15's pants back up and cued Resident #15 to sit back down in the wheel chair. CNA-B did not complete frontal peri care. There was no cleansing of Resident #15's posterior buttock and upper thighs in contact with the shower chair. From 7:45 a.m. to 1:10 p.m. a period of 5 hours and 25 minutes Resident # 15 was not assisted to the bathroom. Resident #15's adult brief was also noted to be heavily saturated with urine. Surveyor # spoke with CNA-B following the observation. Surveyor # asked CNA-B about Resident #15's toileting plan. CNA-B indicated Resident #15 was to be assisted to the bathroom every 2 to 3 hours. Surveyor # also asked CNA-B about Resident #15's peri care. CNA-B indicated she reached up as far as she could into the front. Lack of appropriate peri care increased the likelihood of Resident #15 developing a urinary tract infection. It also increased the likelihood of Resident #15 developing urine related skin issues such as IAD (Incontinence Associated [MEDICAL CONDITION]). Additionally, Resident #15 was noted to have the ability to void when cued. Despite that, there was no individualized toileting plan for Resident #15 to improve Resident #15 ability to remain as continent as possible. On 12/1/15 at 1:30 p.m. Surveyor # spoke with both CNA-A and CNA-F. Both CNA-A and CNA-F were working on the unit where Resident #15 resides. Both CNA-A and CNA-F indicated they had not assisted Resident #15 with any type of care since assisting Resident #15 with morning care. On 12/3/15 at 1:32 p.m. Surveyor # spoke with RN-VV. RN-VV indicated she was the person responsible for completing bladder assessments. RN-VV indicated she completed a comprehensive bladder assessment on admission, annually, and with any significant change MDS. RN-VV indicated if a resident had a decline in bladder function she would also review a residents bladder status however would not complete a comprehensive bladder assessment unless the resident triggered for a significant change MDS. Surveyor # reviewed the facility's comprehensive bladder assessments with RN-VV. Surveyor # questioned the lack of a physical assessment as part of the comprehensive assessment. RN-VV indicated a physical assessment was not part of their assessment. Surveyor # questioned why there were no specific individualized toileting plans for residents. RN-VV indicated she felt timed voiding was not effective as actual voiding times were always different and usually not at the same time. RN-VV indicated she used toileting every 2 to 3 hours instead. On 12/7/15 at 12:00 p.m. Surveyor # spoke with the DON (Director of Nursing). The DON indicated she expected all staff to assist residents to the bathroom in a timely manner. The DON indicated all residents incontinent of bladder should have complete and thorough peri care including frontal peri care. Example #2: Resident #11's current [DIAGNOSES REDACTED]. Resident #11's most current MDS was dated 10/12/15. The MDS indicated Resident #11 had both long and short-term memory problems, required total assistance for all aspects of care, and was always incontinent of bowel and bladder. Resident #11's care plan for incontinence was dated 10/14/15. The care plan directed staff to check and change Resident #11 every 2 to 3 hours. Resident #11's most current bladder assessment was dated 7/22/15. The assessment indicated, .continues with complete I (incontinence) R/T (related to) cognitive status .interventions remain appropriate. The assessment was only the statement as noted above. It contained no data on which to base an assessment including a physical assessment which would drive appropriate interventions in attempt to restore some bladder function. Surveyor # completed a review of Resident #11's most current 3 day voiding pattern data. The data collection started 7/21/15 and ended on 7/23/15. The bladder assessment was completed before Resident #11's voiding patterns were even collected. On 12/1/15 Surveyor # made the following observations. On 12/1/15 at 7:45 a.m. Surveyor # noted Resident #11 was in bed and positioned on her back. On 12/1/15 at 8:25 a.m. Surveyor # noted Resident #11 was in bed and positioned on her back. On 12/1/15 at 8:50 a.m. Surveyor # noted Resident #11 was in bed positioned on her back. On 12/1/15 at 9:45 a.m. Surveyor # observed CNA-A assisted Resident #11 with care. CNA-A indicated she started her shift at 6:00 a.m CNA-A also indicated she had not attended to Resident #11 prior to the time of the observation. CNA-A washed and dried Resident #11's upper torso. CNA-A removed Resident #11's adult brief. The brief was noted to be wet with urine. CNA-A completed peri care. Resident # 11 was not assisted with incontinence care for 3 hours and 45 minutes. It it imperative staff check residents at least every 2 hours and provide incontinence care. There is a greater change for any resident to develop a UTI (Urinary Tract Infection) when left in a urine soaked adult brief. On 12/3/15 at 1:32 p.m. Surveyor # spoke with RN-VV. RN-VV indicated she was the person responsible for completing bladder assessments. RN-VV indicated she completed a comprehensive bladder assessment on admission, annually, and with any significant change MDS. RN-VV indicated if a resident had a decline in bladder function she would also review a residents bladder status however would not complete a comprehensive bladder assessment unless the resident triggered for a significant change MDS. Surveyor # reviewed the facility's comprehensive bladder assessments with RN-VV. Surveyor # questioned the lack of a physical assessment as part of the comprehensive assessment. RN-VV indicated a physical assessment was not part of their assessment. Surveyor # questioned why there were no specific individualized toileting plans for residents. RN-VV indicated she felt timed voiding was not effective as actual voiding times were always different and usually not at the same time. RN-VV indicated she utilized toileting every 2 to 3 hours instead. On 12/7/15 at 12:00 p.m. Surveyor # spoke with the DON (Director of Nursing). The DON indicated she expected all staff to assist residents who are incontinent in a timely manner. Example #3: Resident #6 has current [DIAGNOSES REDACTED]. Resident #6's most current MDS (Minimum Data Set) was dated 9/25/15. The MDS indicated Resident #6, ~ Had a BIMS (Brief Interview for Mental Status) score of 1 indicated a severe cognitive impairment; ~ Required extensive assistance of 1 to 2 staff members for all aspects of care; ~ Did not walk; and ~ Was always incontinent of both bowel and bladder. Resident #6's care plan for bladder incontinence was dated 7/29/15. The care plan directed staff to assist Resident #6 with toileting every 2 hours. Surveyor # requested all of Resident #6's comprehensive bladder assessments since admission on 6/23/15. Surveyor # received one assessment dated [DATE]. It contained limited data on which to base an assessment including a physical assessment. It is critical to complete a comprehensive bladder assessment of residents bladder function in order to implement appropriate interventions in attempt to restore bladder function. On 12/3/15 at 1:32 p.m. Surveyor # spoke with RN-VV. RN-VV indicated she was the person responsible for completing bladder assessments. RN-VV indicated she completed a comprehensive bladder assessment on admission, annually, and with any significant change MDS. RN-VV indicated if a resident had a decline in bladder function she would also review a residents bladder status however would not complete a comprehensive bladder assessment unless the resident triggered for a significant change MDS. Surveyor # reviewed the facility's comprehensive bladder assessments with RN-VV. Surveyor # questioned the lack of a physical assessment as part of the comprehensive assessment. RN-VV indicated a physical assessment was not part of their assessment. Surveyor # questioned why there were no specific individualized toileting plans for residents. RN-VV indicated she felt timed voiding was not effective as actual voiding times were always different and usually not at the same time. RN-VV indicated she utilized toileting every 2 to 3 hours instead. Example #4: Resident #18's current [DIAGNOSES REDACTED]. Resident #18's most current MDS (Minimum Data Set) was dated 11/25/15. The MDS indicated Resident #18; ~Required extensive assistance of 1 to 2 staff persons for all aspects of care except eating; and ~Was always incontinent of bowel and bladder. Resident #18's care plan for incontinence was dated 4/3/13. The care plan directed staff to check and change Resident #18 every 2 hours as well as upon Resident #18's request. Resident #18's most current comprehensive bladder assessment was dated 11/30/15. The assessment was not complete and did not include a physical assessment. A physical assessment is a critical component to a comprehensive bladder assessment in order to determine abnormalities causing incontinence. On 12/3/15 at 1:32 p.m. Surveyor # spoke with RN-VV. RN-VV indicated she was the person responsible for completing bladder assessments. RN-VV indicated she completed a comprehensive bladder assessment on admission, annually, and with any significant change MDS. RN-VV indicated if a resident had a decline in bladder function she would also review a residents bladder status however would not complete a comprehensive bladder assessment unless the resident triggered for a significant change MDS. Surveyor # reviewed the facility's comprehensive bladder assessments with RN-VV. Surveyor # questioned the lack of a physical assessment as part of the comprehensive assessment. RN-VV indicated a physical assessment was not part of their assessment. Surveyor # questioned why there were no specific individualized toileting plans for residents. RN-VV indicated she felt timed voiding was not effective as actual voiding times were always different and usually not at the same time. RN-VV indicated she utilized toileting every 2 to 3 hours instead. Example #5: Resident #16 was admitted to the facility on [DATE] due to chronic back pain, arthritis, and failure to thrive. During the initial facility tour conducted on 11/30/15 at 7:15 p.m., Surveyor # was informed by LPN-NN that Resident #16 had open areas on the buttock, required staff assistance for toileting, and was both continent and incontinent of urine. The facility completed a quarterly MDS assessment on 08/06/15 for Resident #16 and noted the following: ~able to make self understood and understand others. ~no cognitive deficits. ~required extensive staff assist for all ADLs. ~was frequently incontinent of bladder. ~was at risk for pressure ulcers. ~had no MASD (Moisture Associated Skin Damage) skin problems. The facility completed a bladder assessment on 08/31/15 for Resident#16. The assessment noted Resident #16 has stress incontinence. The care plan initiated on 11/24/15 noted Resident #16 had an alteration in urination. The goal was for Resident #16 to maintain dignity and remain clean and dry with staff's assistance. The interventions were to toilet every 2-3 hours, provide perineal care after toileting, observe for any incontinence episodes at regular intervals, and keep call light within reach. There were no individualized approaches to drestore as much bladder function as possible. Review of the medical record noted Resident #16 developed a superficial open area on both buttocks on 09/07/15. The facility noted these ulcers to be MASD. The physician ordered a foam dressing to be changed every 3 days for both treatment and prevention of open areas. The last entry regarding the open areas on the right buttock was 10/07/15 at which time the area was healed. The left buttock has been ongoing. On 12/01/15 at 2:00 p.m., Surveyor # observed CNA-QQ and RN-FF provide ulcer care to Resident #16's buttock. Surveyor # observed Resident #16 without any foam dressing in place. RN-FF assessed the 2 open areas on Resident #16's left buttock. The upper open area measured 0.3 cm by 0.2 cm and the lower open area measured 0.3 cm by 0.1 cm. Both areas were superficial with a pink wound bed. After proper wound cleansing, RN-FF placed a foam dressing over the entire buttock. RN-FF stated the MASD areas are much improved over the past few weeks. On 12/03/15 at 9:15 a.m., Surveyor # interviewed RN-FF regarding Resident #16's skin problems. RN-FF stated Resident #16's open areas were due to MASD. Surveyor # asked how long was Resident #16's open areas uncovered. RN-FF stated she last saw Resident #16's foam dressing on prior to breakfast on 12/01/15. On 12/03/15 beginning at 10:30 a.m., Surveyor # observed Resident #16 seated in the wheelchair in her room. At 1:21 p.m., Surveyor # observed Resident #16 put on the call light and ask for staff assistance to use the toilet. At 1:25 p.m., Surveyor # observed CNA-OO assist Resident #16 to the bathroom. Resident #16 had been incontinent of urine. Resident #16 had a foam dressing on her buttock that was dated for 12/03/15. Resident was not offered or assisted with toileting for 2 hours and 55 minutes. Example #6: Resident #11 was admitted to the facility on [DATE] for long term care due to dementia. Other contributing medical [DIAGNOSES REDACTED]. The facility completed a quarterly MDS assessment for Resident #11 on 10/14/15. The following data was noted in the assessment: ~never able to understand others or make self understood. ~severely impaired decision making skills. ~required total staff assistance for all areas of ADLs (activities of daily living). ~was nonambulatory. ~was always incontinent of bladder and bowel. Review of the care plan initiated on 10/14/15 noted Resident #11 had bladder incontinence. The goal was for Resident #11 to be clean and dry with staff assistance. The interventions were to offer fluids, check and change Resident #11 every 2-3 hours, and provide perineal care twice daily and as needed. On 11/24/15 beginning at 9:50 a.m., Surveyor # observed Resident #11 seated in a Broda chair with bilateral boots on her feet. Resident #11 remained in the same position until 2:00 p.m. when CNA-HH and CNA-SS assisted Resident #11 into bed using the mechanical lift. Once into bed, CNA-HH and CNA-SS assisted Resident #11 with incontinence care. Resident #11 had on 2 briefs, both of which were saturated through to her slacks. CNA-HH provided Resident #11 with incontinence care, donned a clean brief and slacks, and covered Resident #11 with a blanket. Resident #11 was not provided incontinence care for 4 hours and 10 minutes. Example #7: Resident #7 was admitted to the facility on [DATE] for long term care due to Alzheimer's dementia. Resident #7 also had [MEDICAL CONDITION], functional incontinence of bladder/bowel, and arthritis. The facility completed a quarterly MDS assessment for Resident #7 on 09/15/15. The assessment noted the following data: ~had severe impairment with daily decision making skills. ~required extensive staff assistance for all ADLs and was nonambulatory. ~was always incontinent of bladder and bowel. ~was at risk for pressure ulcers, but had no ulcers present. The care plan initiated on 09/15/15 noted Resident #7 was at risk for pressure ulcer development due to incontinence. The interventions included turn/reposition every 2-3 hours. The care plan did not include any incontinence care or toileting instructions. There were no other care plans that addressed Resident #7's incontinence or bladder problems. There was care instruction for the CNA staff to toilet every 2-3 hours and if Resident #7 was awake at 2:00 p.m., she should be toileted. On 11/24/15 beginning at 9:50 a.m., Surveyor # conducted a continuous observation of Resident #7. At 3:50 p.m., Surveyor # entered Resident #7's room and put on the call light. At 3:53 p.m., CNA-YY answered the call light. Surveyor # requested CNA-YY assist Resident #7 with incontinence care. CNA-YY asked CNA-SS to assist her and both staff wheeled Resident #7 into the shower room on Unit 3 South. At 4:05 p.m., CNA-SS and CNA-YY assisted Resident #7 to a standing position using a gait belt and the grab bar in the bathroom. CNA-YY pulled down Resident #7's slacks that were saturated with urine, removed 2 briefs that were also saturated with urine and stool, and assisted Resident #7 onto the shower chair. Resident #7 did not urinate while on the shower chair. CNA-SS provided perineal hygiene while CNA-YY assisted Resident #7 to a standing positioning. CNA-YY stated Resident #7 was always incontinent of bladder and bowel. CNA-SS did not provide frontal perineal cleansing and did not apply any barrier cream to Resident #7's buttock. CNA-YY changed Resident #7's slacks and both RCS staff applied a clean incontinence product. Resident #7 was not offered or provided incontinence care or repositioning for 6 hours and 15 minutes without Surveyor # intervening. According to an interview with CNA-A, Resident #7 had been up in the wheelchair since before breakfast which was approximately 90 minutes before Surveyor # first observed Resident #7. On 11/24/15 at 1:45 a.m., Surveyor # interviewed CNA-A regarding Resident #7's care needs. CNA-A stated she cared for Resident #7 full time and was very familiar with her care needs. CNA-A stated Resident #7 had been up today before breakfast, was always incontinent of bladder and bowel, and required 2 staff to assist with ADLs. Example #7: Resident #13 was recently treated for [REDACTED]. According to her most recent Minimum Data Set Assessment (MDSA) dated 10/23/15, which was a quarterly assessment, Resident #13 requires extensive assistance of staff for her personal hygiene and toileting needs, and is frequently incontinent of bladder function. On 10/9/15, Resident #13 was treated for [REDACTED]. The [MEDICATION NAME] course was repeated at twice the dose (500 mg) on 10/20/15, as the UTI did not resolve. On 10/22/15, the [MEDICATION NAME] was discontinued and a course of Ertapenem Sodium was ordered to be administered daily for 7 days. Ertapenem is administered via the Intravenous route and is used to treat moderate to severe infections. On 12/1/15 at 9:25 a.m., Surveyor # observed CNA-EE assist Resident #13 with cares. The technique observed for frontal peri-care by CNA-EE was as follows: ~ CNA-EE washed down the center of the labia and around the abdominal folds, without changing the section of the washcloth; ~ She then swiped down again and up the center of the labia with the same section of the washcloth; ~ CNA-EE then obtained a second washcloth and repeated the motion, down the center of the labia, then down the right side, and finally rinsed the cloth, and repeated. This technique creates a potential for recontamination of the urinary tract and the potential for the development of a UTI. After cares for Resident #13 were completed, Surveyor # asked CNA-EE about technique. CNA-EE stated that she should have swiped down, then used clean sections of the cloth to wipe each side of the labia. When the technique she used was explained, CNA-EE stated, Yeah, I should be cleaning front to back and change the cloth. On 12/4/15 at 1:15 p.m. Surveyor # spoke with FM-AAA (Family member). FM-AAA indicated she felt Resident #13 developed a UTI as staff did not cleanse her after using the bathroom. FM-AAA indicated since the development of the UTI Resident #13 has had a significant decline in condition. Example #8: Resident #14 has medical [DIAGNOSES REDACTED]. Resident #14 requires extensive assistance of staff to meet his most basic daily tasks of toilet use and personal hygiene. He is frequently incontinent of bladder and bowel function. Resident #14's care plan includes the following approaches: ~Toilet Resident #14 after each meal (8/8/15). ~Offer/Assist to toilet frequently ~Observe for incontinence episodes at regular and frequent intervals ~Schedule toileting every 2-3 hours The CNA Care Card, which is reviewed daily and updated as needed, directs staff to toilet Resident #14 every 2-3 hours. On 12/1/15, Resident #14 was observed by Surveyor # in [MEDICATION NAME] with Surveyor # and # to be up in his wheelchair from 7:55 a.m. - 11:28 a.m. in which no staff approached to offer or assist him with toileting. At 11:28 a.m., CNA-A assisted Resident #14 to the bathroom. Upon standing, Surveyor # noted Resident #14's incontinent brief was saturated and his buttocks and upper posterior thighs were dark red. This is a time period of 3 hours 33 minutes. He was not offered or assisted to the bathroom following his morning meal, as directed in the plans of care, nor was toileting offered frequently. During this task, Surveyor # asked CNA-A what Resident #14's toileting schedule was. CNA-A stated, We should toilet him every two hours. He needs total assistance. Example #9: Resident #1 has medical [DIAGNOSES REDACTED]. Resident #1 requires extensive assistance of staff to meet all his basic daily tasks of personal hygiene and toilet use. He is incontinent of bowel and bladder function. Resident #1's care plan includes an approach to provide incontinence care with each incontinence episode. On 11/24/15 at 9:59 a.m., Surveyor # observed Resident #1 was assisted to bed from the wheelchair by CNA-C. When CNA-C placed Resident #1 into the bed, he did not check the resident for incontinence until the Surveyor asked if the resident was in need of incontinence care. CNA-C then checked for incontinence and found the resident's incontinent brief was saturated. He then provided perineal cleansing for the resident. Surveyor # then questioned CNA-C on the expectation of incontinence management regarding Resident #1. CNA-C stated, Yeah, I should have checked him.

Based on observations, interviews and record reviews, the facility failed to provide appropriate care and services to promote the healing of existing pressure ulcers, prevent development of avoidable pressure ulcers, and prevent development of recurrent pressure ulcers in 4 out of 4 sampled residents. Resident #1 was at high risk for pressure ulcer development and was readmitted with bilateral deep tissue injury (DTI) to heels. There is no evidence that the facility implemented immediate interventions at the time of admission. Assessments were inconsistent and not completed by a Registered Nurse, inappropriate treatments were ordered, treatments were not completed in accordance with accepted standards of practice, and observations were made where Resident #1's heels were not floated for several hours. The DTI to the right heel progressed to stage III pressure ulcer. The above example is being cited at Harm Level 3 or actual harm. The remaining examples are being cited at Harm Level 2. In addition, on 10/13/15, Surveyor # noted a reddened area on Resident #1's left posterior gluteal area. After a seven hour and ten minute continuous observation where Resident #1 did not receive incontinence care or repositioning, the area opened and presented as a stage II pressure ulcer. Resident #5 was assessed as being a risk for the development of pressure ulcers. An observation was made for over six hours in which neither toileting nor repositioning was offered or attempted. Resident #7 was assessed as being a moderate risk for the development of pressure ulcers. An observation was made in which toileting/repositioning was not offered or attempted for 4.5 hours. Resident #6 entered the facility with a Deep Tissue Injury to the left heel that indicated healing. He was then admitted to the hospital and the DTI reappeared. There were four weeks of missing wound documentation regarding the wound. This is evidenced by: Example #1: Resident #1 was admitted on [DATE] and readmitted on [DATE] after sustaining a [MEDICAL CONDITION] requiring surgical intervention. Other [DIAGNOSES REDACTED]. The most recent MDS (Minimum Data Set) assessment dated [DATE], indicates Resident #1 requires extensive assistance with all activities of daily living, does not walk, is always incontinent of bladder and frequently incontinent of bowel. Resident was readmitted to the facility on [DATE] following surgical repair of a [MEDICAL CONDITION]. The Nursing Admission Intake Form completed upon admission (no date), identified DTIs on both the right and left heels. Review of Braden Risk Assessment Scale dated 6/12/15, indicates high risk (score of 12) for developing pressure ulcers. Despite identification of bilateral heel DTIs, the facility did not implement a plan of care to promote the healing of the DTIs. A 6/13/15 night shift nurse's note states, .noticed moderate amount of serosanguineous drainage on sheet at bottom of resident's bed near feet. Writer removed slipper socks to examine feet. Resident noted to have 6 cm diameter round blistered area to right heel that was peeling from heel leaving red raw area open. Writer cleansed entire area of heel with wound cleanser then applied [MEDICATION NAME], sterile gauze & Kerlix to heel/foot. There was no more documentation related to the DTI on the left heel or the now open pressure ulcer on the right heel until 6/16/15. The Non-Pressure Skin Condition Report dated 6/16/15 indicated: ~Left heel 5.5 cm x 5.5 cm x 0.1 cm, Right heel 6.5 cm x 7 cm x 0.1 cm. Characteristics: partial thickness. Wound Bed: red. Exudate Type: Serous. Exudate Amount: scant. Treatment: continue treatment. Pain related to wound: No. No stage was documented as the facility used a form for non-pressure skin issues. There is no indication in the documentation identifying which pressure ulcer has the exudate. Documentation on the report also stated the foot was to be elevated on a pillow to relieve pressure to heal and that Resident #1 was to be repositioned every two hours. These approaches were not added to the care plan. Review of the June treatment record indicates the left heel dressing was changed on 6/16/15 and 6/18/15 when it was documented as healed. It should be noted that the 6/18/15 nurse's note indicates the dressing change was to the right heel which is the heel that is open. Also there is no evidence that the dressing was changed on 6/17/15. On 6/19/15, nursing note indicated Resident #1 experienced a quarter size skin tear to left heel after a fall. On 6/19/15, six days after returning from the hospital with bilateral DTIs to his heels, the facility developed a care plan for Resident #1. The problem, Pressure Ulcers includes approaches of: ~Apply pressure reduction air mattress to bed. ~Apply pressure reduction cushion to chair or wheelchair. ~Reposition in chair frequently for comfort and pressure reduction. ~Turn and reposition while in bed frequently for comfort and pressure reduction. Handwritten in was every 2-3 hours. ~Provide incontinence care after each incontinent episode or per established toileting plan. On 6/21/15, Resident #1 was hospitalized with increased congestion and fever, and was readmitted on [DATE]. Nurse's note documented: admitted with 2 PU (pressure ulcers) on BL (bilateral) heels. There is no assessment of the pressure ulcers upon readmission to the facility. Weekly Pressure Ulcer Record documentation states: ~6/23/15. Right heel 6.5 cm x 4.5 cm, Left heel 5 cm x 3 cm. Depth is documented as 0.1 but does not indicate right or left heel. Undermining: none. Exudate type: none. Wound Bed: red. Surrounding skin color: pink and bright red. Surrounding skin: normal. Pain related to wound: Yes. Again, these descriptions do not indicate which heel was assessed. Neither wound was staged. Dietary, physician, family and care plan was updated. Initial evaluation progress note: 2 areas on heels admitted with. Blister like pressure areas open, clean and assessed per MD (medical doctor) order. Specialty Interventions: Bed, air mattress, wheelchair cushion, specialized wheelchair and positioning devices, pillows. On 6/24/15, the physician ordered [MEDICATION NAME] with gauze and Kerlix wrap to right and left heel daily and as needed. Heel boots on at all times. ~6/30/15 wound documentation includes, Stage: III. Size: Right heel 6.3 cm x 4.4 cm, Left heel 4.9 cm x 3 cm. Depth is documented as 0.1 cm but does not indicate which heel is open. Wound Bed: red. Surrounding skin color: pink, bright red. Pain related to wound: Yes. Response to treatment: improved. Specialty interventions: added heel boots. Progress note: Blister like pressure areas open 0.1, cleansed and dressed per MD order. Heels floating at all times. An LPN completed the assessment. On 7/2/15 the care plan was updated to include Measure and stage wound weekly using the pressure ulcer healing assessment form. Complete a full body check weekly and document. Monitor lab values as ordered. IDT (Interdisciplinary Team) referrals, Registered Dietitian, Physical Therapies and Occupational Therapist. Pressure ulcer treatment as ordered. Handwritten in with no date is Hover boots/float heels at all x's (times). Current CNA assignment sheets indicate that heels floating at all times. Bilateral heel floats on in wheelchair. Bilateral footrests and foot pad on wheelchair. (Occupational Therapy stated he refuses footrests.) ~Wound documentation on 7/7/15 includes, Stage: 0 (no such stage) Right heel: 6.0 x 4.2, Left heel: 4.9 x 2.9. Depth: 0.1 cm (no indication which pressure ulcer). No change in documentation from 6/30/15 assessment. Response to treatment: improved. Weekly progress note: Dressing changes completed. Wound bed red with new skin. Minimal to no drainage. No signs of infection. LPN completed the assessment. On 7/12/15 at 10:30 p.m., a nursing note states, noted lg (large) amount grayish/green drng (drainage) on old drsgs (dressings) removed from heels. On 7/13/15, nursing note stating dressing changes will be every day and as needed. ~Wound documentation on 7/14/15 states, Stage: 0. Right heel measures 5.8 cm x 4 cm. Left heel measures: 4.8 cm x 2.8 cm. Depth 0.1 cm, (no indication which pressure ulcer). There are no other changes in the assessment. The weekly progress note on this same date states the wound beds are red with significant sloughing, no signs or symptoms of infection, dressing changes reviewed, family updated regularly. Response to treatment: improved. No changes in interventions. The progress note does not indicate which pressure ulcer is presenting with slough. When slough is present, the depth cannot be measured. With the presence of slough, one or both of the wounds have deteriorated and can no longer be staged. Treatment was changed on 7/28/15 when the wound declined to a stage III. ~Wound documentation on 7/21/15, Stage: 0, right heel measures 5.5 cm x 4.0 cm. Left heel measures 4.8 cm x 2.8 cm. Depth: blank. No change in other wound characteristics except no pain related to wound. Response to treatment: improved. Weekly progress note: Change dressing, measured, wound area with no signs of infection. Charted update. No nurse signature. ~Wound documentation on 7/28/15, stage III, right heel measures 4 cm x 3 cm. Left heel measures 4 cm x 2.4 cm. Depth 0.5 cm to 0.1 cm (no heel specified). No changes in the characteristics of the wounds. No pain related to the wound. Response to treatment: improved and plan of care updated. Specialty intervention: Specialized wheelchair tilt in space and pillows for repositioning. Weekly wound progress note of the same date states dressing change completed, wound beds red on both heels with new skin, no signs of infection. Significant sloughing of dead dry skin on surrounding skin. MD updated and dressing change orders updated. The RN completed the assessment. On 8/1/15, physician order [REDACTED]. This maintains a moist healing environment and facilitates autolytic debridement. It is to be used in full or partial-thickness wounds with moderate to heavy exudate. Use of the Calcium Alginate is contraindicated in a dry wound or one with minimal exudate. ~Wound documentation on 8/4/15, stage III, right heel measures 3.7 x 2.7 x 0.5. Left heel 3.5 x 2 x 0. Exudate: Serosanguineous. Exudate amount: small. Wound Bed: Red. No other changes were made. Pain related to wound: Yes. Response to treatment: Improved. The presence of exudate/drainage has not been documented since 7/12/15. Although the pressure ulcers appear to be getting smaller, the presence of exudate and pain demonstrates a decline in one or both of the pressure ulcers. The weekly progress note of the same date states, Resident's bilat (bilateral) heels have healed significantly with qd (everyday) dressing changes with calcium alginate and foam wrapped with Kerlix . LPN completed the assessment. ~Wound documentation 8/11/15 states, stage III. Right heel measures 3.5 cm x 2.5 cm x 0 cm. Left heel measures 3 cm x 1 cm x 0 cm. Exudate type: Serosanguineous. Exudate amount scant. Pain: yes. Response to treatment: Improved. Weekly wound note from same date states wound bed red with mild amount of serosanguineous drainage. Right heel more so than left. Resident tolerated dressing change well. Wounds improving. Calcium Alginate with foam. Heels floating at all times. LPN completed the assessment. ~8/18/15. Stage: none. Right heel measures 3 cm x 2.5 cm. Left heel measures 2.4 cm x 5 cm. Exudate scant. Surrounding skin color: pink. Pain: No. No response to treatment. Weekly note: Both heals as healing well. No drainage. Site clean. Calcium Alginate gauze and Kerlix replaced. RN completed the assessment. The treatment of [REDACTED]. ~Wound documentation on 8/25/15 states Stage: none. Right heel measures 2.25 cm x 2.0 cm. Left heel measures 0.5 cm red. Exudate type: Serous. Exudate amount: Scant. Wound bed: red and now yellow. No response to treatment documented. Weekly progress note: Both heels show improvement, very scant drainage on old dressing - serous. Sites cleaned with wound wash, dried and new Calcium Alginate, gauze and Kerlix applied. RN completed the assessment. ~Wound documentation on 9/1/15 states Stage: none. Right heel measures 3 cm x 2 cm. Left heel measures 2 cm x 1 cm. This is an increase from 8/25/15. Exudate type: Serosanguineous. Exudate amount: Scant. Wound bed normal for skin and red. Pain related to wound: yes. Response to treatment: improved. Weekly wound note: Both heels are improving. No drainage on old dressing. Calcium Alginate with Kerlix dressing. RN completed the assessment. Again, the accuracy of the wound assessments comes into question as a scant amount of serosanguineous exudate is documented without any evidence of drainage on the dressing. The wounds continue to appear to have low moisture and would not be appropriate for treatment with Calcium Alginate. ~Wound documentation on 9/8/15 states, Stage: none. Right heel measures 2 cm x 1 cm. Left heel measures 1.0 cm x 0.5 cm. Depth none. Exudate type: none. Exudate amount: none and scant. Pain: yes. Response to treatment: Improved. Weekly wound note: Heels healing well. Resident tolerated dressing change well. Replaced with Calcium Alginate Kerlix dressing. On 9/17/15, the physician order [REDACTED]. There were no wound assessments completed between 9/8/15 and 9/23/15 when the facility started using the computerized weekly pressure form. There was also no nursing notes during this time period describing the wound status. ~Wound documentation on 9/23/15 states, .Suspected Deep Tissue Injury .Right heel measures: 1.8 cm x 1.8 cm x 0.2 cm .Description of site: 25% slough, pink surrounding tissue .Full thickness .wound bed: yellow .Drainage/Exudate: Moderate .Purulent .Odor: present .Pain: yes .Resident response to treatment: improved . .Left heel .0.4 cm x 0.4 cm x and 0.2 cm. Suspected Deep Tissue Injury .Dry and Calloused. The right heel wound, now presenting with slough, an increased depth, moderate purulent drainage and odor demonstrates deterioration of the pressure ulcer. Despite the deterioration, there were no changes made for five days. On 9/28/15, physician order [REDACTED]. ~Wound documentation on 10/1/15 states, .Right heel. Pressure. 1.7 x 1.7 x 0.1 Suspected Deep Tissue Injury .slough present .Wound bed appearance: yellow .Center yellow surrounded by pink/red .Drainage/Exudate .small .Purulent . Odor not present. Wound edges and surrounding skin: normal . RN completed this assessment. ~Wound documentation from 10/2/15 states, Left heel. Pressure 0.4 x 0.4 x 0.1. Suspected Deep Tissue Injury .Dry and nearly healed. Rest of characteristics: normal. pain: no. Response: improved. treatment plan: [REDACTED]. ~Wound documentation on 10/8/15 states, Right heel measures 1.6 x 1.5 x 0.2 .yellow .slough 100% .Drainage: scant .serous .Wound edges: pink . RN completed the assessment. Left heel measures 0.3 x 0.3. Improved. ~Wound documentation on 10/15/15, left heel measures 0.2 x .0.2 Improved. No change in treatment. RN completed this assessment. On 10/13/15 at 11:08 a.m., Surveyor # observed Resident #1 receiving incontinent care while in bed. CNA-A (Certified Nursing Assistant) was completing incontinent cares. Surveyor # observed a red circular area that was approximately the size of a dime just below the left gluteal fold. In addition, the back upper thigh and groin area was very red. The reddened area did not resolve after care was completed. Surveyor # conducted a continuous observation. From 11:25 a.m. until 6:35 p.m., a continuous observation was conducted by Surveyor # with the assistance from Surveyor # . Resident #1 was sitting in his wheelchair on an APOD (Advanced Positioning Orthotic Device) cushion and was not approached by staff to offer or attempt either repositioning or toileting for seven hours ten minutes. An APOD cushion is one that prevents sliding and sacral sitting in a wheelchair. It has the potential to place a greater amount of pressure on the gluteal fold and upper thighs. Surveyor # also observed Resident #1 wearing heel boots. Despite having the boots on, Resident #1's heels were in direct contact with the floor and not floating to relieve pressure and promote healing of the bilateral heel pressure ulcers. On 10/13/15 at 6:40 p.m., Surveyor # relieved Surveyor # from direct observation while CNA-D and CNA-F were starting incontinent care. Resident #1 was lying in bed with head towards the foot of the bed. He was wet with urine and had a bowel movement. The urine smell was strong and the Hoyer sling that was under him was wet. Surveyor # observed the red circular area below the left gluteal fold was now open. Staff seated Resident #1 back into wheelchair as a family member was visiting. Staff did not get the nurse to assess and treat the newly opened pressure ulcer before putting Resident #1 back in his wheelchair. On 10/13/15 at 6:40 p.m., Surveyor # asked CNA-D and CNA-F if day shift told them the last time Resident #1 was repositioned and toileted. CNA-D stated CNA-B had said Resident #1 was last checked and toileted before lunch. CNA-D was unable to say why Resident #1 wasn't repositioned or toileted before now. On 10/13/15 at 7:15 p.m., Surveyor # observed LPN-E completing Resident #1's bilateral heel dressing while resident was sitting in the wheelchair. LPN-E removed the left and right heel dressings that were dated 10/11/15. LPN-E stated, I guess the dressings were not changed last night. The right heel dressing had moderate amount of purulent drainage which had an odor. Observation of the wound bed had yellow slough. LPN-E did say the odor is new. LPN-E stated there was no order to cleanse the wound so she took wet 4 x 4 gauze dressings with the bathroom tap water and dabbed the area. Using tap water is not an appropriate cleaning agent. At a minimum, a wound should be cleansed with normal saline. LPN-E stated, I normally would use a tongue blade to put the Santyl ointment in the wound but there are none available in the room. LPN-E placed a small glob of Santyl ointment, about 0.5 cm in size, on a non-adhesive dressing and wrapped the foot with Kerlix. The left foot had a small amount of dark brown drainage with no odor. LPN-E again cleansed the area with wet 4 x 4 gauze and applied a dry dressing. Surveyor # informed LPN-E that Resident #1 was not repositioned or toileted for seven hours ten minutes. Surveyor # also informed LPN-E of the newly opened pressure ulcer. When asked about staffing LPN-E stated, We never have four CNAs on this unit except to help out with supper. Tonight we have four CNAs. LPN-E stated some of the permanent staff are not that good and the residents suffer. ~Wound documentation on 10/15/15 states nursing completed a Skin - Weekly Non-Pressure Condition Record: 1a. Site: Left thigh (rear). Date of Onset: 10/15/15. New and acquired at the facility. Measures: 0.4 x 0.3 x 0.1. 1b. left rear mid thigh, no signs of infection. Likely caused by friction as resident scoots back and forth in his wheelchair often. 2. Characteristics: 2a. partial thickness. 2b. superficial. 3a. red. 3b. 100% granulation tissue. no odor. Wound edges: pink. surrounding skin: normal. Pain: no Speciality Interventions: W/C cushion an Positioning Device. Pillows and turn and reposition every 2 hours and as needed. These interventions have always been in place. Treatment: changed to border gauze to site change every 3 days and as needed. Notification: Phy, (physician) Nutrition and Family on 10/15/15. On 10/15/15 at 11:30 a.m., Surveyor # interviewed OT-BB (Occupational Therapy) who works for a contracted agency. OT-BB stated she started to work at this facility in August. Since August Resident #1 was in a highback wheelchair with a Roho cushion as he kept sliding out and was being repositioned four to five times a day. He also refused to have the footrests on the wheelchair. In September he was in a Hemi wheelchair with an APOD cushion. Nursing was to keep an eye on him. This worked for him. An Incrediback was applied. This converts a wheelchair to a reclining chair. When asked if he would be a risk for a gluteal/thigh pressure ulcer if he wasn't repositioned she stated, Yes. The incline of the cushion is around that area. On 10/14/15 at 8:30 a.m., Surveyor # interviewed LPN-H. LPN-H stated the facility does not have a wound nurse. LPN-H stated the floor nurses do the measurements weekly and document in the computer. The RN does the assessment. LPN-H stated she does the measurements and checks the dressings every day. To be completely honest with you, I will ask the CNAs if they (the dressings) are intact. The RN responsible is whoever is working at the time the measurements are completed. On 10/14/15 at 5:00 p.m., Surveyor # interviewed the Director of Nurses about the facility's wound care. The DON stated the IDT (Interdisciplinary Team) discusses all wounds in the daily meeting. Surveyor # asked about LPNs completing assessments. The DON stated the RN who is on duty when the wound measurements are completed is to do the assessment. She was unaware that LPNs were completing the assessments. Surveyor # also informed the DON that a dressing was not changed on Resident #1's stage III right heel pressure ulcer on 10/12/15. The DON then called RN-G (Registered Nurse) who was the nurse assigned to Resident #1's care on 10/12/15. RN-G told the DON he was too busy to change the dressing. Example #2: Resident #5 was admitted [DATE] following a right [MEDICAL CONDITION] repair. Medical [DIAGNOSES REDACTED]. The most recent Minimum Data Set (MDS) assessment dated [DATE], indicates Resident #5: requires extensive assistance from staff for transfers, ambulation, personal hygiene, and toileting; is occasionally incontinent of bowel function and frequently incontinent of bladder; and at risk for the development of pressure ulcers. The most current Braden Assessment completed for Resident #5 was dated 10/14/15 with a score 18. A score of 15-18 indicates the individual is at risk for the development of pressure ulcers. Resident #5's care plan dated 1/22/15 includes a problem of pressure ulcers. An approach for this problem is staff are to reposition Resident #5 .frequently for comfort and pressure reduction. On 10/13/15 from 12:20 p.m. to 6:24 p.m., a continuous observation was conducted by Surveyor # with assistance from Surveyor # . It was noted during the six hours and four minutes, no staff approached Resident #5 to offer or attempt either repositioning or toileting. The observation is as follows: ~ At 12:20 p.m., Resident #5 was being assisted with her meal. ~ At 1:00 p.m., the tray was removed. Resident #5 remained in the dining room. ~ At 1:18 p.m., no staff remained in the room, leaving Resident #5 alone with two other residents. ~ From 1:22 p.m. - 3:00 p.m., Resident #5 remained in the dining room. No staff approached the resident to offer or attempt repositioning or toileting. ~ At 3:00 p.m., AA-J approached her and offered the sing-along activity. ~At 3:15 p.m., Resident #5 self-propelling around the halls and into the main unit dining room/ Cornucopia room. She finally placed herself at the Unit 3 nursing station at 3:17 p.m. and continued to read her magazine. AA-J reproached Resident #5 to offer the sing-along activity. Resident #5 attended this activity, which was held in the Princess Pine room. The activity lasted until 4:05 p.m. During this time frame, Resident #5 was very restless, maneuvering her wheelchair throughout the room and into the hall, and back into the room again. At 4:05 p.m., she was rummaging through baskets and shelving within the Princess Pine room. AA-L needed to redirect Resident #5 on several occasions. ~ At 4:15 p.m., the Activity Manager redirected Resident #5 from the main dining room (Cornucopia room) and back into the Princess Pine room, where she gave Resident #5 a busy box filled with fabric swatches. Resident #5 kept herself busy folding these swatches. The Activity Manager then left the room leaving Resident #5 alone. ~ At 4:45 p.m., Resident #5 stood unassisted in front of the fabric swatches on the table and her wheelchair. There was no staff present in the room at the time, but the Director of Nursing (DON) responded to the chair alarm that sounded. The DON assisted Resident #5 to sit in the wheelchair and gave her back the box of fabrics. The DON then left the room and Resident #5 continued with folding the fabrics. ~ At 4:58 p.m., Resident #5 propelled herself out of the Princess Pine room, down the hall, and entered another resident's room. The resident activated her call light after numerous attempts to tell Resident #5 to get out of her room. Staff responded to the call light at 5:00 p.m. and moved Resident #5 back into the Princess Pine room, then left, leaving Resident #5 alone once again. ~ At 5:06 p.m., Resident #5 propelled herself behind the nursing desk on Unit 3. LPN-E (Licensed Practical Nurse) responded by moving Resident #5 back into the Princess Pine room and placed her in front of a table. ~ At 5:16 p.m., the evening meal was served on Unit 3. ~ At 5:21 p.m., Resident #5 was given her meal. No staff assisted Resident #5. ~ At 5:25 p.m., Resident #5 propelled herself out of the Princess Pine room and down the hall. She had not yet eaten any of her food. CNA-CC redirected her back into the Princess Pine room. ~ At 5:50 p.m. CNA-D removed the tray from in front of Resident #5 and ordered her a new tray. ~ At 5:58 p.m., a new tray arrived consisting of a burger between two pieces of bread, cut into quarter slices, a cookie, and eight ounces of milk. Resident #5 took a piece of the sandwich and began to eat. ~ Between 5:58 p.m. and 6:21 p.m., Resident #5 continued to eat all that was served with encouragement from LPN-E. At 6:22 p.m., Surveyor # approached CNA-D and asked to assist Resident #5 to the bathroom. Resident #5 stood at the grab bars in the resident community bathroom off the main hallway. The resident was then assisted to the toilet. Her incontinent brief was wet with urine. Resident #5's frontal perineum was red. Her buttocks was dark pink and wrinkled. CNA-D was asked what Resident #5's toileting plan was. CNA-D stated the resident was to be repositioned and toileted every two hours. She was not aware that Resident #5 was not toileted after lunch. Example #3: Resident #7 has medical [DIAGNOSES REDACTED]. The most recent MDS assessment dated [DATE], indicates Resident #7 requires extensive assistance from staff for transfers, personal hygiene, and toileting; is non-ambulatory; is frequently incontinent of bowel function and always incontinent of bladder. The most current Braden Assessment completed for Resident #7 was dated 6/11/15 with a score of 13. A score of 13-14 indicates the individual is at a moderate risk for the development of pressure ulcers. Resident #7's care plan includes a problem of pressure ulcers dated 3/12/10 and most recently updated on 6/11/15. An approach for this problem is to reposition Resident #7 .every 2-3 hours . On 10/14/15 from the hours of 10:35 a.m. to 3:05 p.m., a continuous observation of Resident #7 was conducted by Surveyor # . It is as follows: ~ At 10:35 a.m., Resident #7 was noted to be up in her wheelchair in the doorway to the Princess Pine room. ~ At 10:40 a.m., Resident #7 propelled herself approximately five feet into the hallway. The beautician then took her to get her hair done. ~ At 11:05 a.m., the beautician returned Resident #7 to the hallway and placed her between the nursing desk and the entrance to the Princess Pine room. ~ At 11:30 a.m., Resident #7 moved herself into the Princess Pine room. She then put her head down again and closed her eyes. ~ At 12:15 p.m., Resident #7 was placed at the table in preparation for the noon meal. ~ At 12:35 p.m., Resident #7 was given her meal. ~At 1:00 p.m., the tray was removed. Resident #7 was left sitting at the table with her clothing protector in her hands. ~ At 1:30 p.m., Resident #7 remained in the Princess Pine room. ~ At 2:00 p.m., Resident #7 remained in the Princess Pine room with her head down and eyes closed. ~ At 2:20 p.m., Resident #7 moved her wheelchair back from the table, then moved the wheelchair forward and up to the table once again, closed her eyes and put her head down once more. ~At 3:05 p.m., CNA-D and CNA-X removed Resident #7 from the Princess Pine room and assisted her into the bed for incontinence care. Surveyor # observed the cares by this staff. The resident's brief was wet with urine. Her frontal perineum was red and her buttocks was dark pink and wrinkled from the moisture. At 3:30 p.m., Surveyor # approached CNA-D and asked about Resident #7's care needs. CNA-D stated they are required to do everything for Resident #7, and that she is incontinent of bowel and bladder and does not ambulate. She stated Resident #7 is to be repositioned and toileted every two to three hours but sometimes refuses. Surveyor asked how the staff document cares being given to each resident. CNA-D pulled up Resident #7's documentation on the Care Tracker from the computer. CNA-D stated, All cares we give are to be documented and the computer notes the time the cares were given. The computer documentation for Resident #7 indicates the last cares provided to Resident #7 was at 8:37 a.m. by CNA-A. Surveyor # informed the DON. Resident #7 was observed for 4 hours 35 minutes in which cares were not attempted. The documentation indicates a longer period of time in which cares were not recorded as being completed. Example #4: Resident #6 was admitted on [DATE]. His medical [DIAGNOSES REDACTED]. The most recent MDS assessment dated [DATE] indicates Resident #6 requires extensive assistance from staff for transfers, personal hygiene, and toileting; is non-ambulatory; and is always incontinent of bowel and bladder function. The most current Braden assessment completed for Resident #6 was dated 8/19/15 with a score of 10. A score of 10-12 indicates the individual is at a high risk for the development of pressure ulcers. The Nursing Admission Intake form completed on 6/23/15, indicates no open areas but that Resident #6 had boggy heels. There is no further documentation of the heels until 7/2/15 in the nurse's notes. This entry includes, .DTI (Deep Tissue Injury) to