Every finding on record at Autumn Care of Norfolk

Based on record review, interviews, and policy review, the facility failed to: 1.) appropriately assess a resident and identify and implement interventions related to wandering and elopement risk for one of two residents (Resident (R) 10) reviewed for elopement out of a total sample of 47. As a result, R10, who had been assessed as an elopement risk prior to a hospital discharge but was not assessed at risk on readmission, exited the facility without staff knowledge 12 days after readmission and sustained a subarachnoid hemorrhage, a severe head injury. R10 remained outside the facility for an unknown period of time before a driver pulled up to the facility, observed him, and alerted staff; and 2.) transfer a resident according to the care plan and monitor her on the commode for one of three residents (R134) reviewed for accidents. R134 was left alone by staff while on a bedside commode and fell off, resulting in a clavicle fracture. An Immediate Jeopardy was identified on 08/19/26 and determined to exist on 03/15/26 in the area of S483.25 Quality of Care, F689, at a Scope and Severity (S/S) of J when R10 exited the facility without staff knowledge and suffered a head injury. The Administrator was notified that Immediate Jeopardy, which also constituted Substandard Quality of Care (SQC), on 08/19/26 at 3:18 PM. The facility was notified that the removal plan they provided was accepted on 08/20/26 at 3:10 PM. The plan of removal included actions of all-staff education regarding the definition of elopement and identifying residents at risk of elopement; licensed nurse education on accurately completing elopement assessments; reassessment of all current residents for elopement risk with updates to care plans to reflect wandering and elopement interventions; and secondary checks of all new admissions and readmissions for accuracy of elopement checks. The survey team validated the implementation of the facility's removal plan through observations, staff interviews, and record reviews, and the Administrator was notified on 08/20/26 at 7:19 PM that the Immediacy had been removed. The scope and severity was lowered to G, isolated, for actual harm. Findings include: 1. Review of R10's admission Record, located under the Resident tab of the electronic medical record (EMR), revealed the resident was admitted to the facility on [DATE] with diagnoses which included vascular dementia, history of falling, and lack of coordination. Further review revealed R10 was discharged to the hospital on [DATE] and readmitted to the facility on [DATE]. Review of R10's Elopement Observation, located under the Observations tab in the EMR, dated 11/12/25, revealed R10 had exit seeking behaviors and was at risk for elopement. Further review revealed an intervention in place was a WanderGuard (a wearable device which activates paired doors to lock to prevent unsupervised exiting). Review of R10's Physician Orders, located under the Orders tab of the EMR, dated 11/12/25, revealed an order for a safety/WanderGuard. Further review revealed the order was discontinued on 02/21/26 when R10 was discharged to the hospital. Review of R10's readmission Observation/Elopement, located under the Observations tab in the EMR, dated 03/04/26, revealed it indicated no history of elopement, wandering, or exit-seeking behaviors. R10 was assessed as not being at risk for elopement. Further review revealed no immediate elopement interventions were in place. Review of R10's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 03/12/26, located under the Resident Assessment Instrument (RAI) tab of the EMR, revealed a Brief Interview for Mental Status (BIMS) score of nine out of 15, which indicated R10 had moderate cognitive impairment. Review of R10's Progress Notes, located under the Notes tab in the EMR, dated 03/15/26 at 11:45 AM and written by Registered Nurse (RN) 5, revealed, [RN5] was passing meds [medications] when the CNA [Certified Nurse Aide] informed me that the resident was outside on the ground. The resident was found in the front of the building next to the curb bleeding from the left side of his face. Resident is A&X4 [alert and oriented to person, place, time, and situation] and c/o [complains] of a mild headache. Review of the facility's Event Report regarding the incident on 03/15/26 revealed, Fall with major injury . Further review revealed the incident was classified as a fall and not an elopement and that there was no summary or conclusion explaining how the facility determined R10 was able to get outside without staff knowledge or how long R10 was outside before staff became aware. Further review of the Notes tab of the EMR revealed that R10 returned from the hospital with a diagnosis of subarachnoid hemorrhage (bleeding in the space between the brain and the tissue covering it) on 03/16/26 at 1:20 AM. Review of R10's Progress Notes, located under the Notes tab in the EMR, dated 03/18/26 at 3:15 PM and written Licensed Practical Nurse (LPN) 8, revealed IDT [interdisciplinary team] Review . Areas To Be Reviewed: Fall . Current interventions in place: Proper Footwear shoes/nonskid socks, New Intervention(s): Other frequent rounding, Additional Notes: Progress note: Fall note 03/15/26: The nurse was passing meds when the CNA informed me that the resident was outside on the ground. The resident was observed in the front of the building next to the curb bleeding from the left side of his face. Resident is alert and oriented times 2-3 times and complain of a mild headache. Obtained vital signs and called 911 . New intervention: Implement frequent rounding to anticipate resident needs. Safety Awareness: Poor Additional Documentation: Staff education to ensure supervision of resident when sitting outside in front area. During an interview on 08/18/26 at 5:33 PM, RN5 revealed she was the nurse assigned to R10 on 03/15/26. She was unsure how R10 got out of the building and recalled she last saw him on the unit in his wheelchair. She remembered being alerted by staff that R10 was outside in front of the facility by the driveway. She stated she went out and saw him on the ground bleeding and his wheelchair toppled over with him. RN5 reported that R10 told her he was going to church. RN5 acknowledged that R10 should not have been outside without being accompanied by staff. She was unsure if staff ever figured out how he got out there or if any changes were put into place after he was found. During an interview on 08/19/26 at 5:23 PM, Licensed Practical Nurse (LPN) 7 stated she completed R10's readmission assessment/elopement assessment on 03/03/26 when he was readmitted back to the facility from the hospital. LPN7 said that staff reviewed orders from the hospital and obtained information from the resident and/or family, along with the physician and staff, to complete the assessment. LPN7 reported she made the determination that R10 was not an elopement risk because he had no history of elopement that she was aware of, and he did not try to elope from the hospital. During an interview on 08/19/26 at 5:49 AM, RN4 stated that when a resident was readmitted from the hospital, staff reviewed and verified hospital orders with the provider. RN4 explained staff also reviewed information from the resident's history and physical, as well as information obtained from hospital nursing staff. RN4 stated staff should also review the resident's prior history at the facility, particularly when the resident has a history of elopement risk. During an interview on 08/19/26 at 6:57 AM, LPN8 stated she documented the progress note related to the IDT meeting that occurred following R10's fall on 03/15/26. LPN8 reported she was unsure whether R10 was permitted to be outside the front of the facility without staff supervision and was unable to confirm whether he was currently, or had previously been, considered an elopement risk. She further stated she was unsure whether R10 currently had a WanderGuard device in place for safety or had ever used one in the past. During an interview on 08/19/26 at 7:24 AM, LPN9 said that R10 had had a decline in functioning over time and that he sometimes forgot which day it was. She stated he was not as alert as he was in the past and that staff needed to monitor him because when he saw something, he would just go. She said he was not an elopement risk and that he did not exit seek but then confirmed that she had documented in progress notes prior to 03/15/26 that R10 was exit seeking and had a WanderGuard in place as a safety precaution. She stated R10 had several WanderGuards placed on him or his wheelchair prior to 03/15/26 because he removed them. She said R10 had a fall after he got outside of the facility, but she was unsure how he was able to get outside. LPN9 was unsure if R10 was currently an elopement risk or if he currently had a WanderGuard in place. During an interview on 08/19/26 at 9:49 AM, CNA6, who was assigned to R10 at the time of the elopement on 03/15/26, reported they were short-staffed on 03/15/26 and had only two or three staff on the floor that day. She remembered that R10 was found outside, but she reported being unsure if it was because he had taken his WanderGuard off again. She stated he had a history of removing his WanderGuard. CNA6 reported that R10 had to be redirected a few times the day of the elopement and said that she let the nurse know to keep an eye on him, but the nurses were passing medications. She stated she was unable to watch R10 because she had other residents who needed care. CNA6 reported that R10 had a history of trying to go outside, but he could be redirected if staff were aware and saw him. During an interview on 08/19/26 at 1:26 PM, CNA7 said she was one of the CNA staff working at the time R10 was found outside on 03/15/26. She said she was on the hall when a man who she believed was a driver for another agency approached the nurse's station and told them there was a man outside lying on the ground in a wheelchair. She said the facility staff were not the ones who identified that R10 was missing or had fallen outside. The driver was there to pick up someone else and happened to observe R10 when he pulled up. Staff went outside, and she remembered seeing R10 lying face down on the ground with his wheelchair slightly on top of him. CNA7 reported being unsure if R10 was an elopement risk or if he ever had a WanderGuard. She could not recall if it was ever determined how R10 got outside or how long he had been out there before the driver saw him. During an interview on 08/19/26 at 2:01 PM, the Director of Nursing (DON) said when a fall with major injury occurred, staff completed the risk tool, obtained statements, and completed an investigation to figure out what happened and how it happened. The facility also educated staff, completed audits, and had an ad hoc Quality Assurance and Performance Improvement (QAPI) meeting. She said they considered the incident that occurred on 03/15/26 to be a fall with major injury and not an elopement since R10 did not leave the facility grounds. At the time of the incident, she said the facility did not feel R10 was an elopement risk but agreed they have not determined how R10 got outside on 03/15/26 or how long he was out there before staff became aware. A review of the facility's policy titled, Elopement Unauthorized Absence Policy, last reviewed 07/2025, revealed, the facility will identify residents with potential and/or actual risk factors for elopement and protect the resident through development and implementation of safety interventions. ln the event of a resident elopement the facility will implement its policies and procedures promptly to locate the resident in a timely manner. Definition- Elopement occurs when a resident leaves the premises or a safe area without authorization (i.e., an order for discharge or leave of absence) and/or any necessary supervision to do so. 2. Review of R134's admission Record, located under the Resident tab of the EMR, revealed the resident was admitted to the facility on [DATE] with diagnoses which included muscle weakness, age related cognitive decline, and need for assistance with personal care. Review of R134's Observation Detail List Report-Section GG Supportive Documentation Tool, located under the Observations tab in the EMR, dated 06/11/25, revealed, [R134] was assessed as dependent (helper does ALL the effort, Resident does none of the effort to complete the activity, Or the assistance of 2 staff or more helpers is required for the resident to complete the activity) on staff for Toileting Hygiene. Review of R134's Care Plan, initiated on 07/14/25 and located under the RAI tab of the EMR, revealed . The resident has an ADL [activity of daily living] self-care deficit as evidenced by generalized weakness . Interventions included transferring with the assistance of two staff with a gait belt. Further review revealed no specific indication for assistance with toileting. Review of R134's Progress Notes, located under the Notes tab in the EMR, dated 09/01/25 at 5:15 AM and written by RN4, revealed that on 09/01/25, R134 had a witnessed fall at 4:20 AM. Staff transferred R134 to the bedside commode and then turned away and left her sitting on the bedside commode alone. R134 reported, I fell asleep while on the toilet. An order was received to send R134 to the emergency room. Further review revealed that on 06/01/26 at 10:00 PM, R134 returned from the hospital with a diagnosis of a closed nondisplaced fracture of left clavicle. Review of facility's Event Report regarding the incident on 09/01/25 revealed, Fall with no major injury . The incident was initially classified as no injury. Further review revealed there was no summary or conclusion identifying what contributed to the fall or that only one staff transferred R134 out of the bed and onto the commode. A new intervention was identified as utilizing two people assist for transferring, although the care plan already identified R134 as requiring two people to assist with transfers. Review of R134's quarterly MDS with an ARD of 08/14/26, located under the RAI tab of the EMR, revealed a BIMS score of nine out of 15, which indicated R134 was moderately cognitively impaired. During an interview on 08/19/26 at 5:49 AM, RN4 said that R134 was considered a high risk for falls and was only alert and oriented to self. RN4 stated R134 required one-to-one assistance, meaning that staff were supposed to always keep her in their line of sight. RN4 stated that R134 required two staff with transferring and would have required two staff to transfer out of the bed and onto the commode on 09/01/25. RN4 said staff were supposed to remain with the resident while she was on the commode and keep her at no more than arm's length. The staff assisting R134 on the morning of 09/01/25 should not have turned their back on her or walked away while R134 was on the commode. An attempted telephone interview on 8/20/26 at 8:55 AM with Certified Nurse Aide (CNA) 8, the staff who provided care to R134 at time of fall on 09/01/25, was unsuccessful. During an interview on 08/20/26 at 4:47 PM, the Director of Nursing (DON) said that on 09/01/25, CNA8 placed R134 on the bedside commode, stepped away to pick up supplies, and left R134 unattended on the commode. CNA8 should have remained close to the resident, and there should have been two staff assisting during the transfer.

Based on observations and interviews, the facility failed to lock the front doors to prevent unauthorized individuals from entering the facility and residents from exiting the facility without staff's knowledge during the night shift. The facility also failed to store items including cleaners, air fresheners, disposable razors, shaving cream, foot spray, baby oil, and staff food where it was not accessible to residents. This failure to maintain a safe environment had the potential to place the 114 residents who resided in the facility at risk for elopement, injury, ingestion of hazardous substances, and exposure to unsafe environmental conditions. Findings include: Observation on 08/19/26 at 5:05 AM revealed the facility's front entrance door was unlocked, allowing entry into the front lobby area that was unsupervised by staff. Entry was also gained through unlocked double doors equipped with a WanderGuard system, providing access to resident hallways without staff inquiry. Upon proceeding down a resident care hallway to the Unit one nurse's station, a nurse was observed standing at a medication cart. After being notified of the presence of the survey team, the nurse stated she would inform the Registered Nurse (RN) 4, the night supervisor. During an interview on 08/19/26 at 5:18 AM, RN4 was informed that the survey team entered the facility through an unlocked front door. RN4 stated the facility's front doors should be locked at night. Observation and interview on 08/19/26 at 5:20 AM of the Unit 1 employee breakroom, with RN4 present, revealed the door to the breakroom was propped open with a trash can to the hallway. Two containers in plastic bags and one 12-ounce spray can of air freshener were observed sitting on a table in this room. When opened, both containers were observed to have food inside of them. RN4 stated it was staff food inside of the containers. Additionally, an insulated bag was observed in a chair in the breakroom. When opened, the bag was observed to contain 14 three and a half ounce cans of air freshener, one five-ounce container of shaving cream, one eight-ounce container of baby oil, one six-ounce can of shaving cream, one 7.3-ounce can of air freshener, one 12-ounce can of shave gel, six disposable razors, and one five-ounce can of foot spray. RN4 stated the breakroom door should be closed and that the two containers of food, the can of air freshener, and the items observed in the insulated bag should not be accessible to residents. Observation and interview on 08/19/26 at 5:25 AM of the Unit 1 Nourishment Room, with RN4 present, revealed the door to this room was open to the hallway. A sign on the door specified Notice: Employees only beyond this point. Observations of a cabinet in the nourishment room revealed there was one 32-ounce spray bottle of State Triple Quick Fresh & Clean Disinfecting Cleaner and two 32-ounce bottles of Comet Cleaner with Bleach. Each of these bottles contained precautionary warning statements on their labels. RN4 stated the door to the nourishment room should not be left open, and the three bottles of chemicals should not be stored in the room's cabinet. RN4 stated that the Unit 1 hallways currently had two residents who exhibited wandering behaviors. During an observation and interview on 08/19/26 at 5:30 AM, the Administrator stated the facility's front doors should be locked at night, and the doors to the employee breakrooms and nourishment rooms should be kept closed. When shown the items that were observed in the Unit 1 nourishment room and employee breakroom with their doors open to the hallway, the Administrator stated the doors to these rooms should be kept closed and the observed items should not be accessible to residents. The Administrator stated the evening receptionist was responsible for locking the facility's front door when she left the facility at 8:00 PM, and staff unlocked the front doors in the morning at 8:00 AM. During an interview on 08/20/26 at 8:20 AM, Receptionist (REC) 2 stated she worked on Monday, Wednesday, and Friday from 4:00 PM to 8:00 PM. REC2 stated her responsibilities included locking the facility's front doors prior to leaving for the night. REC2 stated she was not scheduled to work during the evening of 08/18/26 (Tuesday), so she did not know who was responsible for locking the front doors at night on this date. During an interview on 08/20/26 at 9:58 AM, the Administrator stated a receptionist was not scheduled to work on 08/18/26 from 4:00 PM to 8:00 PM. The nurses were responsible for locking the facility's front doors during this evening, but they failed to do so. During an interview on 08/20/26 at 5:40 PM, the Administrator stated the facility did not have policies which addressed securing the facility at night and for the storage of chemicals and cleaners.

Based on record review, interviews, and facility policy review, the facility failed to ensure Enhanced Barrier Precautions (EBP) were implemented for one of seven residents (Resident (R) 116) reviewed for infection control out of a sample of 47 residents. R116 had a peripherally inserted central catheter (PICC) line, which required EBP; however, there was no EBP order in place. This had the potential to increase the risk of infection and the spread of multidrug-resistant organisms among residents and staff. Findings include: Review of R116's Resident Face Sheet located in the electronic medical record (EMR) under the Resident tab, revealed R116 was admitted to the facility on [DATE] with diagnoses of sepsis and pneumonia. Review of Resident Progress Notes, located under the Progress Notes tab in the EMR and dated 12/23/25, revealed . Resident has a [sic] arm PICC intact. Has an order for IV [intravenous] abt [antibiotics] for sepsis. Review of R116's Care Plan, located under the Resident Assessment Instrument [RAI] tab of the EMR, revealed a problem, dated 12/24/25, which indicated R116 had an infection and had intravenous (IV) antibiotics. An approach, dated 12/24/25, revealed staff should maintain universal precautions when providing patient care. An additional approach directed staff to use transmission-based precautions as ordered; enhanced barrier precautions. Review of R116's Order History, located under the Orders tab in the EMR, revealed an order, dated 12/24/25, for daptomycin (antibiotic) intravenous once a day for 28 days. Review of R116's 5-day assessment Minimum Data Set (MDS), located in the EMR under the Resident Assessment Instrument (RAI) tab with an Assessment Reference Date (ARD) of 12/27/25, revealed the resident had a Brief Interview for Mental Status (BIMS) score 14 out of 15, which indicated intact cognition. Review of R116's Order History, located under the Orders tab in the EMR, revealed there was not an order for Transmission-Based Precautions or Enhanced Barrier Precautions. Review of Resident Orders, received from facility administration, revealed a listing of all residents on Enhanced Barrier Precautions, dated December 2025 and January 2026. The list revealed R116 was not included to indicate that R116 had an order for EBP. During an interview on 08/20/26 at 10:22 AM, the Regional Infection Preventionist stated anyone with a staph (staphylococcus bacteria) infection and/or a PICC line should have EBP indicated by an order. During an interview on 08/20/26 at 11:13 AM, Unit Manager (UM) 1 recalled that R116 had a PICC line. UM1 added that R116 should have been on EBP, which would be indicated in her orders. UM1 stated if EBP was not ordered, she likely did not have it in place. During an interview on 08/20/26 at 12:16 PM, Licensed Practical Nurse (LPN) 6 stated she remembered R116 had a PICC line. LPN6 stated R116 would have been on EBP; however, she was unable to recall if she was. She confirmed if she was, she would have had an order for it. During an interview on 08/20/26 at 4:23 PM, the Director of Nursing confirmed that anyone with a PICC line should be on EBP, which would be confirmed by an order in their record. If the order was not in place, R116 was not on EBP while she was in the facility. Review of facility's policy titled, Enhanced Barrier Precautions, dated 05/18/25, specified EBP are intended to prevent transmission of multi-drug-resistant organisms (MDROs) via contaminated hands and clothing of healthcare workers to high-risk residents during high contact activities. High-risk residents: those with chronic wounds and indwelling devices (such as central lines . ) and for all those colonized or infected with a MDRO currently targeted by the CDC [Center for Disease Control and Prevention]

Based on record review, interviews, and facility policy review, the facility failed to ensure a restorative program recommended upon discharge from physical therapy was initiated and implemented for one of one resident (Resident (R) 58) reviewed for Restorative Program and Rehabilitation. This failure had the potential to cause a decrease in mobility and strength. Findings include: 1. Review of R58's Resident Face Sheet, located in the electronic medical record (EMR) under the Resident tab, revealed R58 was admitted to the facility on [DATE] with diagnoses of schizoaffective disorder, bipolar type and schizophrenia. Review of R58's Physical Therapy Discharge Summary, located under the Therapy tab in the EMR and with services dates of 08/21/25 to 09/12/25, revealed Discharge Recommendations: Pt. [patient] to undergo RNP [restorative nursing program] and positioning. Review of R58's EMR in the Point of Care (POC) section under the Reports tab revealed staff did not document restorative minutes for R58. The Restorative POC was completely empty which indicated the task was not completed for the months of September 2025 and October 2025 prior to therapy resuming services. Review of R58's annual Minimum Data Set (MDS), located in the EMR under the RAI tab, with an Assessment Reference Date (ARD) of 06/05/26, revealed the resident had a Brief Interview for Mental Status (BIMS) score of one out of 15, which indicated severe cognitive impairment. The MDS indicated R58 was dependent on staff for dressing, hygiene, and transfers. During an interview on 08/20/26 at 3:08 PM, the Director of Rehab (DOR) stated she expected floor staff to provide restorative services when a resident was discharged from physical therapy with a recommendation to participate in a restorative program. The DOR further stated that all attempts should be exhausted before a resident was discharged from the restorative program. During an interview on 08/20/26 at 4:07 PM, the Regional [NAME] President of Operations (RVPO) stated no restorative notes could be found for September 2025 and October 2025 for R58. Review of facility's policy titled, Restorative Nursing Referral Process and Policy, dated 02/24/26, specified Residents who benefit from the nursing restorative programs can be identified at the following times .residents who are ready to finish a program of skilled rehabilitation.

Based on observation during medication pass and pour, resident interviews, staff interviews, and clinical record review, the facility staff failed to assure residents were free of significant medication errors for one of 43 residents (Resident #149), in the survey sample. The findings included: The facility staff failed to ensure Resident #149 was administered the IV antibiotic Daptomycin to maintain a therapeutic level in the blood as it eradicated a complicated skin infection. Resident #149 was originally admitted to the facility 1/6/23 after an acute care hospital stay. The resident had never been discharged from the facility. His diagnoses included diabetes, osteomyelitis of the left foot resulting in a partial resection of the remnant of the left second toe, amputation of toes number 3-5 of the left foot. The resident had not been at the facility long enough to have an MDS assessment completed therefore the following information is gleamed from the nursing admission note dated 1/6/23 at 4:13 p.m. The assessment revealed the resident was alert and oriented to person, place, and time, could make his needs known, and his daily decision-making abilities were intact. The assessment also revealed the resident was able to ambulate, complete activities of daily living and self-toilet. On 1/10/23 at approximately 1:53 p.m., Resident #149 stated he was admitted to the facility on Friday 1/6/23 after 4:00 p.m., for antibiotic therapy secondary to a left foot infection resulting in resection of the second toe on the left foot and amputation of toes 3-5. He also stated in August 2022 the left great toe was amputated and he was afraid he would lose his entire foot without the antibiotics administered as he was told by the hospital staff would happen in the rehabilitation facility. The resident further stated the hospital staff stated he would receive antibiotic therapy in the rehabilitation facility for thirty-two days, and he was scheduled to complete the IV antibiotic therapy on 2/7/23. The resident stated he didn't desire to remain in the facility beyond 2/7/23. Resident #149 also stated no one said anything to him about why he wasn't receiving about the antibiotic therapy. A review of Resident #149's physician orders revealed an order dated 1/6/23 at 4:30 p.m., for Daptomycin Solution Reconstituted - Use 378 mg intravenously every 24 hours for Complicated skin and skin structure infections (cSSSI) for 33 administrations. This order was discontinued 1/6/23 at 6:42 p.m. The Medication Administration Record (MAR) was coded Other/Nurses Note, but a review of the nurses notes for 1/6/23, didn't address the IV antibiotic administration. Another order for this medication was dated 1/7/23 at 8:30 p.m. The second order was discontinued 1/9/22 at 5:21 p.m. The MAR for 1/7/23 and 1/8/23 was coded Other/Nurses Note, but again the progress notes failed to reveal a note that the IV antibiotic wasn't administered. A review of the MAR revealed the medication wasn't administered on 1/9/23. The MAR revealed a third order dated 1/10/23 at 5:30 p.m., for Daptomycin Solution Reconstituted - Use 378 mg intravenously every 24 hours for cSSSI for 35 administrations. This order was signed off as administered at 4:39 p.m., on 1/10/23. On 1/13/23 at approximately 4:30 p.m., the above findings were shared with the Administrator, Director of Nursing and two Corporate Consultants. An opportunity was offered to the facility's staff to present additional information, but no additional information was provided, and no further concerns were voiced. Daptomycin injection is used to treat complicated skin and skin structure infections (cSSSI). It is also used to treat infections in the bloodstream (bacteremia), including right-sided infective endocarditis. To help clear up your infection completely, keep using this medicine for the full time of treatment, even if you begin to feel better after a few days. Also, this medicine works best when there is a constant amount in the blood. To help keep the amount constant, you must receive this medicine on a regular schedule. (https://www.mayoclinic.org/drugs-supplements/daptomycin-intravenous-route/description/drg-20063292)

Based on observations, staff interview, and clinical record reviews, the facility staff failed to ensure the physician was informed of the pharmacist Monthly Regimen Review (MMR) recommendation for medication changes for three out of 43 residents (Resident #66, #81, and #2) in the survey sample. The findings included: 1. The facility staff failed to ensure the physician was informed of the pharmacist recommendation to decrease the medication Zantac 20 mg twice a day to 20 mg daily at bedtime. Resident #66 was originally admitted to the facility on [DATE]. Diagnosis included but were not limited to Gastroesophageal reflux disease (GERD). Resident #66's Minimum Data Set (MDS - an assessment protocol) quarterly assessment with an Assessment Reference Date (ARD) of 09/19/22 coded Resident #66 on the Brief Interview for Mental Status (BIMS) with a score of 15 out of a possible score of 15 indicating no cognitive impairment. A review of Resident #66's Medication Administration Record (MAR) for January 2022, revealed an order to administer Famotidine (Zantac) 20 mg tablet - given by mouth two times a day for GERD starting on 09/11/21. A review of the pharmacist Monthly Regimen Review (MMR) for July and August 2022 revealed the recommendation to decrease Zantac to 20 mg daily at bedtime. Further review of Resident #81's clinical record revealed the MMR recommendations were never transcribed. On 01/13/23 at approximately 8:47 a.m., an interview was conducted with the Director of Nursing (DON.) She stated she was not able locate in Resident #66's clinical record that the physician was informed of the above pharmacist recommendations. She stated the physician should have been informed of the recommendations who would accept or decline the recommendations. She stated, if accepted the recommendation is converted into an order then faxed to the pharmacy. An interview was held with the Administrator, Director of Nursing, Assistant Director of Nursing, Regional Director of Clinical Services and [NAME] President of Operations on 01/13/23 at approximately 3:25 p.m., who were informed of the above findings. No further information was provided prior to exit. 2. For Resident #81, the facility staff failed to ensure the physician was informed of the pharmacist recommendation to decrease the medication Zantac 40 mg from twice a day to 20 mg daily at bedtime and decrease Prilosec from 40 mg twice a day to 40 mg daily (30 minutes before food.) Resident #81 was originally admitted to the facility on [DATE]. Diagnosis included but are not limited to Gastroesophageal reflux disease (GERD). Resident #81's Minimum Data Set (MDS - an assessment protocol) quarterly assessment with an Assessment Reference Date (ARD) of 10/08/22 coded the resident's Brief Interview for Mental Status (BIMS) with a score of 13 out of a possible score of 15 indicating moderate cognitive impairment. A review of Resident #81's Medication Administration Record (MAR) for January 2022, revealed the following orders to administer Famotidine (Zantac) 20 mg tablet - given by mouth two times a day for GERD starting on 01/30/22 and Omeprazole (Prilosec) 40 mg - given by mouth twice a day for GERD starting on 01/05/22. A review of the pharmacist Monthly Regimen Review (MMR) for July and August 2022 revealed the recommendations to decrease Zantac to 20 mg daily at bedtime and decrease Prilosec to 40 mg daily (30 minutes before food.) Further review of Resident #81's clinical record revealed the MMR recommendations were never transcribed. On 01/13/23 at approximately 8:47 a.m., an interview was conducted with the Director of Nursing (DON.) She stated she was not able locate in Resident #81's clinical record that the physician was informed of the above pharmacist recommendations. She stated the physician should have been informed of the recommendations who would accept or decline the recommendations. She stated, if accepted the recommendation is converted into an order then faxed to the pharmacy. An interview was held with the Administrator, Director of Nursing, Assistant Director of Nursing, Regional Director of Clinical Services and [NAME] President of Operations on 01/13/23 at approximately 3:25 p.m., who were informed of the above findings. No further information was provided prior to exit. 34306 3. Resident #2 was originally admitted to the facility 3/19/2021 and was readmitted to the facility 7/22/21 after an acute hospital stay. The current diagnoses included; stroke with hemiparesis and a seizure disorder. The quarterly Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 11/9/22 coded the resident as not having the ability to complete the Brief Interview for Mental Status (BIMS). The staff interview was coded for long and short term memory problems as well as severely impaired for daily decision making. The MDS was also coded in section G (Physical functioning) as requiring extensive assistance of one person to total care of one person with all activities of daily living. A review of the Physician's Order Summary (POS) revealed an order dated 07/27/2021 for Aspirin Tablet 325mg. Give 1 tablet via PEG-Tube in the morning for stroke prophylaxis. A review of the Monthly Medication Reviews (MMR) for 12 months revealed on 10/19/22 a licensed pharmacist recommended to reduce the medication Aspirin Tablet 325mg each day to Aspirin Tablet 81mg each day. The licensed pharmacist recommendation further read that lower doses are associated with fewer bleeding complications and have fewer comparable ischemic protection. As of 1/13/23, there was no indication the physician reviewed the recommendation, and/or documented in the resident's medical record if a change will be taken or why no change would take place. On 1/13/23 at approximately 4:30 p.m., an interview was conducted with the Administrator, Director of Nursing and two Corporate Consultants. An opportunity was offered to the facility's staff to present additional information, but no additional information was provided, and no further concerns were voiced.

Based on observations, clinical record review, staff and resident interviews and facility document review, the facility staff failed to provide pharmaceutical services that assured medications were acquired timely to meet the needs of one of 43 residents in the survey sample, Resident #149. The findings included: The facility staff failed to procure the intravenous (IV) antibiotic Daptomycin Solution Reconstituted timely to prevent Resident #149 from missing dosages for a Complicated skin and skin structure infections (cSSSI). Resident #149 was originally admitted to the facility 1/6/23 after an acute care hospital stay. The resident had never been discharged from the facility. His diagnoses included diabetes, osteomyelitis of the left foot resulting in a partial resection of the remnant of the left second toe, amputation of toes number 3-5 of the left foot. The resident had not been at the facility long enough to have an MDS assessment completed therefore the following information is gleamed from the nursing admission note dated 1/6/23 at 4:13 p.m. The assessment revealed the resident was alert and oriented to person, place, and time, could make his needs known, and his daily decision-making abilities were intact. The assessment also revealed the resident was able to ambulate, complete activities of daily living and self-toilet. On 1/10/23 at approximately 1:53 p.m., Resident #149 stated he was admitted to the facility on Friday 1/6/23 after 4:00 p.m., for antibiotic therapy secondary to a left foot infection resulting in resection of the second toe on the left foot and amputation of toes 3-5. He also stated in August 2022 the left great toe was amputated and he was afraid he would lose his entire foot without the antibiotics administered as he was told by the hospital staff would happen in the rehabilitation. A review of Resident #149's physician orders revealed an order dated 1/6/23 at 4:30 p.m., for Daptomycin Solution Reconstituted - Use 378 mg intravenously every 24 hours for Complicated skin and skin structure infections (cSSSI) for 33 administrations. This order was discontinued 1/6/23 at 6:42 p.m. The Medication Administration Record (MAR) was coded Other/Nurses Note, but a review of the nurses notes for 1/6/23, didn't address the IV antibiotic administration. Another order for this medication was dated 1/7/23 at 8:30 p.m. The second order was discontinued 1/9/22 at 5:21 p.m. The MAR for 1/7/23 and 1/8/23 was coded Other/Nurses Note, but again the progress notes failed to reveal a note that the IV antibiotic wasn't administered. On 1/12/23 at approximately 2:40 p.m., an interview was conducted with the Manager for the unit the resident resided on. The Manager stated she was made aware the IV antibiotic wasn't available for administration on 1/9/23 and the pharmacy was contacted. The Manager stated the pharmacy stated they hadn't received an order therefore the order was sent again to the pharmacy and the medication arrived at the facility 1/9/23 at 6:38 p.m. On 1/13/23 at approximately 4:30 p.m., an interview was conducted with the Administrator, Director of Nursing and two Corporate Consultants. An opportunity was offered to the facility's staff to present additional information, but no additional information was provided, and no further concerns were voiced.

Based on observation, resident interview, staff interview, clinical record review, and review of facility documents, the facility staff failed to conduct a comprehensive Minimum Data Set (MDS) assessment within 14 calendar days after admission, for three of 43 residents (Resident #152, #153, and #200), in the survey sample. The findings included: 1. The facility staff failed to complete an admission MDS assessment for Resident #152 within 14 calendar days. Resident #152 was admitted to the facility 12/28/22 after an acute care hospital stay. The resident had never been discharged from the facility. The resident's diagnosis included multiple myleoma. Upon review of the MDS assessment on 1/11/23 under information, the assessment was noted to be incomplete. The admission MDS assessment for Resident #152 should have been completed on 1/10/23. 2. The facility staff failed to complete an admission MDS assessment for Resident #153 within 14 calendar days. Resident #153 was admitted to the facility 12/19/22 after an acute care hospital stay. The resident had never been discharged from the facility. The resident's diagnosis included stroke with right sided weakness. Upon review of the MDS assessment on 1/11/23 under information, the assessment was noted to be incomplete. The admission MDS assessment for Resident #153 should have been completed on 1/2/23. On 1/12/23 at approximately 1:00 p.m., an interview was conducted with the MDS Coordinator. The MDS Coordinator stated the department was short two staff members therefore the MDS assessments had not been completed within the required timeframes. 37828 3. The facility failed to complete an admission (initial) comprehensive assessment timely for Resident #200. The resident was admitted to the nursing facility 12/23/22. Diagnosis for Resident #200 included but are not limited to a wedge compression fracture of second lumbar vertebra and cirrhosis of the liver. A review of Resident #200's MDS assessment revealed the admission assessment was 7 days overdue. An interview was conducted with MDS Coordinator, License Practical Nurse (LPN) #1 on 01/12/23 at approximately 1:17 p.m. After reviewing the resident's MDS assessment, she stated she was aware that Resident #200's MDS was 7 days overdue. She stated the MDS should have been completed by 01/05/23. An interview was held with the Administrator, Director of Nursing, Assistant Director of Nursing, Regional Director of Clinical Services and [NAME] President of Operations on 1/13/23 at approximately 3:25 p.m. No further information was provided prior to exit. The following information was obtained from the Resident Assessment Instrument (RAI)Chapter 2 Pages 20-21 revised October 2019. 01. Admission Assessment (A0310A = 01) The Admission assessment is a comprehensive assessment for a new resident and, under some circumstances, a returning resident that must be completed by the end of day 14, counting the date of admission to the nursing home as day 1 if this is the resident's first time in this facility, OR the resident has been admitted to this facility and was discharged return not anticipated, OR the resident has been admitted to this facility and was discharged return anticipated and did not return within 30 days of discharge.

Based on resident interview, staff interviews, and clinical record review, the facility staff failed to notify the resident, the Physician and/or Practitioner that the scheduled medications were not administered as ordered for one of 43 residents (Resident #149) in the survey sample. The findings included: The scheduled intravenous (IV) antibiotic Daptomycin Solution Reconstituted was not administered on 1/6/23, 1/7/23, 1/8/23 and 1/9/23. Resident #149 was originally admitted to the facility 1/6/23 after an acute care hospital stay. The resident had never been discharged from the facility. The resident's diagnoses included diabetes, osteomyelitis of the left foot resulting in a partial resection of the remnant of the left second toe, and amputation of toes number 3-5 of the left foot. The resident had not been at the facility long enough to have an MDS assessment completed therefore the following information was gleaned from the nursing admission note dated 1/6/23 at 4:13 p.m. The assessment revealed the resident was alert and oriented to person, place, and time, could make his needs known, and his daily decision-making abilities were intact. The assessment also revealed the resident was able to ambulate, complete activities of daily living and self-toilet. On 1/10/23 at approximately 1:53 p.m., Resident #149 stated he was admitted to the facility on Friday 1/6/23 after 4:00 p.m., for antibiotic therapy secondary to a left foot infection resulting in resection of the second toe on the left foot and amputation of toes 3-5. He also stated in August 2022 the left great toe was amputated and he was afraid he would lose his entire foot without the antibiotics administered as he was told by the hospital staff would happen in the rehabilitation facility. The resident further stated the hospital staff stated he would receive antibiotic therapy in the rehabilitation facility for thirty-two days, and he was scheduled to complete the IV antibiotic therapy on 2/7/23. The resident stated he didn't desire to remain in the facility beyond 2/7/23. Resident #149 also stated no one said anything to him about why he wasn't receiving the antibiotic therapy. A review of Resident #149's physician orders revealed an order dated 1/6/23 at 4:30 p.m., for Daptomycin Solution Reconstituted - Use 378 mg intravenously every 24 hours for Complicated skin and skin structure infections (cSSSI) for 33 administrations. This order was discontinued 1/6/23 at 6:42 p.m. The Medication Administration Record (MAR) was coded Other/Nurses Note, but a review of the nurses notes for 1/6/23, didn't address the IV antibiotic administration. Another order for this medication was dated 1/7/23 at 8:30 p.m. The second order was discontinued 1/9/22 at 5:21 p.m. The MAR for 1/7/23 and 1/8/23 was coded Other/Nurses Note, but again the progress notes failed to reveal a note that the IV antibiotic wasn't administered. A review of the MAR revealed the medication wasn't administered on 1/9/23. The MAR revealed a third order dated 1/10/23 at 5:30 p.m., for Daptomycin Solution Reconstituted - Use 378 mg intravenously every 24 hours for cSSSI for 35 administrations. This order was signed off as administered on 1/10/23 at 4:39 p.m. The nurse's notes did not evidence documentation that the resident and the Physician/Practitioner were notified that the scheduled intravenous (IV) antibiotic Daptomycin Solution Reconstituted was not administered on 1/6/23, 1/7/23, 1/8/23 and 1/9/23. On 1/12/23 at approximately 1:15 p.m., an interview was conducted with the onsite Nurse Practitioner (NP). The NP stated she wasn't made aware the resident did not receive the IV antibiotic until 1/10/23. On 1/12/23 at approximately 2:40 p.m., an interview was conducted with the Manager for the unit where the resident resided. The Manager stated she was made aware the IV antibiotic wasn't available for administration on 1/9/23 and the pharmacy was contacted. The Manager stated the pharmacy said they hadn't received an order therefore the order was sent again to the pharmacy and the medication arrived at the facility 1/9/23 at 6:38 p.m. The Manager stated the IV antibiotic should have been administered on the day it arrived to the facility to establish the therapy's pattern. The Manager also stated the resident should have been informed by staff of the status of his antibiotic therapy and what they were doing to ensure the medication became available for administration. On 1/13/23 at approximately 4:30 p.m., the above findings were shared with the Administrator, Director of Nursing (DON) and two Corporate Consultants. The DON stated the resident should have been informed of the status of the antibiotic therapy.

Based on staff interview and review of facility documents, the facility staff failed to inform residents, their representatives, and families of those residing in the facility by 5 p.m., the next calendar day following the occurrence of confirmed infection of COVID-19 or include cumulative updates for residents, their representatives, and families at least weekly with mitigating actions implemented to prevent or reduce the risk of transmission. The findings included: A review of facility documents revealed on 11/25/22 a staff member tested positive for COVID-19 and by 12/1/22 twenty staff were positive for COVID-19. On 11/27/22 twenty-four residents tested positive for COVID-19 and by 12/1/22 a total of 32 residents tested positive for COVID-19. On 12/1/22 the facility's staff issued a letter titled Confirmed or Probable COVID-19 Cases. The letter read unfortunately, despite our efforts, like so many other communities, like ours we too have had additional staff and resident test positive for COVID-19. While this is not unexpected, it still saddens us, and our hearts go out to those affected. The letter failed to include information on mitigating actions implemented to prevent or reduce the risk of transmission, including if normal operations of the facility will be altered; and include cumulative updates for residents, their representatives, and families at least weekly. Between 12/2/22 and 12/8/22 thirteen more staff tested positive for COVID-19 and two more residents tested positive. Again the letter dated 12/8/22 lacked the mitigating actions implemented and cumulative updates for residents, their representatives, and families at least weekly. On 12/13/22 at approximately 1:05 p.m., a copy of the letter to the residents, their representatives, and families was reviewed with the Administrator. The Administrator stated it was the facility's practice to update the residents, their representatives, and families weekly instead of the next calendar day by 5 p.m., after a confirmed case. The Administrator stated the letter reviewed dated 12/1/22 didn't meet regulatory requirements. On 1/13/23 at approximately 4:30 p.m., an interview was conducted with the Administrator, Director of Nursing and two Corporate Consultants. An opportunity was offered to the facility's staff to present additional information, but no additional information was provided, and no further concerns were voiced.

Based on resident and staff interview, clinical record review, and facility documentation, the facility staff failed to ensure one (1) resident (Resident #200) in the survey sample of 43, received rehab services as recommended by the physician. The findings included: Resident #200 was admitted to the nursing facility on 12/23/22. Diagnoses for Resident #200 included but are not limited to wedge compression fracture of second lumbar vertebra. The admission Minimum Data Set (MDS) had not been completed. A review of Resident #200's Physician Order Summary (POS) for January 2022 revealed an order to admit to Skilled Nursing Facility (SNF) for Skilled Care under the care (name of physician) starting 12/26/22. Further review of the POS revealed an order dated 12/26/22 for an evaluation and treatment for Physical, Occupational and Speech therapy. During the initial tour on 01/10/23 at approximately 2:28 p.m., an interview was conducted with Resident #200. Resident #200 stated he was admitted to the facility for rehab services over two (2) weeks ago and he was still waiting. He stated the rehab department stated they were waiting for Department of Veterans Affairs (VA) approval. He stated he checked with the therapy department every day and they continued to tell him the same thing, we are still waiting for the (VA) to get back with us. He stated he did not understand why his rehab was taking so long. On 12/23/22, a physician progress note indicated Resident #200 was transferred from a different nursing facility following hospitalization after a lumbar spinal fracture. The progress note further indicated the following: The resident had participated with therapy and achieved some progress in mobility, requiring one (1) person assist with Activities of Daily Living (ADL) including mobility. The resident is to continue with PT for strengthening and functional mobility. An interview was conducted with the Director of Rehab on 01/13/23 at approximately 9:56 a.m. She stated someone from rehab should have screened Resident #200 within two days after being admitted to the nursing facility on 12/23/22. She said, Resident #200 was screened on 12/28/22 but only after he approached me in hallway requesting to be seen by therapy. We (the facility) were not sure if Resident #200 was here for long-term care (LTC) placement or skilled services. She stated Resident #200 was evaluated and picked up for therapy services on 01/11/23. An interview was held with the Administrator, Director of Nursing, Assistant Director of Nursing, Regional Director of Clinical Services and [NAME] President of Operations on 01/13/23 at approximately 3:25 p.m. No further information was provided prior to survey exit. The facility's policy titled Rehab Therapy Evaluation Policy was revised on 03/01/22. The policy indicated the following: It is the facility policy for evaluation to be completed on approved evaluation forms for each discipline in the rehab electronic software. All sections will be filled out completely and accurately. Prior to the complete of the evaluation, provider orders to complete treatment must be obtained. Procedure read in part: -Evaluation to be completed within 48 hours of admission and by the close of business on the day of evaluating the resident. -Obtain provider order for frequency and duration of therapy services. -Evaluation must be signed by the physician according to payer plan requirements. -Evaluation will become a part of the medical record. -Evaluation will consist of evaluation date, frequency, treatment codes, and duration.

Based on resident record review, staff interviews and facility document review, the facility staff failed to ensure residents on hemodialysis had orders for the treatment as well as transportation to the dialysis center for one of 43 residents in the survey sample, Resident #249. The findings included: Resident #249 was admitted to the facility on [DATE] and discharged on [DATE] to an acute hospital. Diagnoses for Resident #249 included but were not limited to unspecified diastolic congestive heart failure and renal failure with dependence on hemodialysis. The current Minimum Data Set (MDS), a 5-day Scheduled Assessment with an Assessment Reference Date (ARD) of 08/27/21 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 10 out of a possible 15. This indicated Resident #249 cognitive abilities for daily decision-making were moderately impaired. In section G(Physical functioning) the resident was coded as requiring extensive assistance from one person with bed mobility, transfers, dressing, toilet use, personal hygiene, and physical assistance with bathing. Requiring set-up help only with eating. Section O (Special Treatments, Procedures, and Programs) coded the resident as receiving Dialysis. The care plan dated 8/22/21 indicated: Focus- Resident #249 Receives Dialysis Treatment three times weekly related to stage three chronic renal disease. Interventions: Maintain communication with Dialysis staff and physician per routine. Dialysis Monday, Wednesday, and Friday. A review of the September 2021 order summary, Medication Administration Record (MAR), and Treatment Administration Record (TAR) revealed no dialysis orders. The resident's family member complained about missed dialysis appointments and the resident receiving dialysis services at the hospital due to having transportation issues. On 1/13/23 at 1:35 PM, an interview was conducted with the Director of Nursing (DON). She said the person in charge of dialysis transportation was out this week, but that the facility was responsible to set up adequate transportation to and from dialysis treatments and that there should have been a dialysis order for treatment. A review of the nursing progress note dated 9/10/21 at 2:46 PM indicated that Resident #249 had returned to the facility from the hospital transported by medical transport via stretcher. The progress note indicated Patient had dialysis at the hospital. Dialysis days are Tuesday, Thursday, and Saturday. Follow up with Cardiology specialists. These days were different from the dialysis treatment days listed in the resident's care plan. A review of the Medication Administration Note dated 9/11/21 at 5:30 PM., read that the Resident was out for dialysis at the emergency department. A review of a progress note written by the facility Nurse Practitioner (NP) dated 9/14/21 read that due to Resident #249's past missed dialysis appointments he had to go to the emergency room because of issues with transportation. On 1/12/23 at approximately 11:18 AM., an interview was conducted with Licensed Practical Nurse (LPN) #5 concerning Resident #249. She said that she did not remember the resident. On 1/12/23 at approximately 8:22 PM., an interview was conducted with LPN #6 concerning Resident #249. Although the above nursing progress note dated 9/10/21 at 2:46 PM. was written by LPN#6, she stated that she did not remember any issues involving dialysis treatments or transportation problems. On 01/13/23 at approximately 3:25 PM., during an interview with the Administrator, Director of Nursing, and Corporate Consultant, an opportunity was offered to present additional information, but no additional information was provided prior to survey exit.

Based on observation, resident and staff interviews, and clinical record review, the facility staff failed to ensure one of 40 residents (Resident #7) in the survey sample who were unable to carry out activities of daily living received the necessary services to maintain adequate toenail care. The findings include: The facility staff failed to ensure podiatry services were provided to Resident #7. Resident #7 was originally admitted to the facility on [DATE]. Diagnoses for Resident #7 included but not limited to Type II Diabetes Mellitus and Venous Insufficient (chronic/peripheral.) The most recent Minimum Data Set (MDS) was a quarterly assessment with an Assessment Reference Date (ARD) of 12/08/22 coded the resident on the Brief Interview for Mental Status (BIMS) with a score of 9 out of a possible score of 15, which indicated moderate cognitive impairment for daily decision-making. Resident #7 was coded to require total dependence of one with toilet use and bathing, extensive assistance of two with bed mobility, extensive assistance of one with dressing and personal hygiene, and supervision with eating Activities of Daily Living (ADL) care. During the initial tour on 01/10/23 at approximately 2:10 p.m., Resident #7's feet were observed outside of the covers. The great toe on each foot was 1/2 inches thick with redness surrounding the nail bed. There were two (2) toenails missing on the right foot and one toenail missing on the left foot. The resident stated his covers were pulled back over his feet because they (covers) hurt his toenails. The resident stated he has not had podiatry services since he was admitted to the facility. He stated his toenails need to be shaved, not cut because they are long, thick, and painful when touched. On 01/12/23 at approximately 9:05 a.m., an assessment of Resident #7's toenails was made by the Director of Nursing (DON) with this surveyor present. She stated the resident's toenails were thick and needed podiatry services. She also stated there was fungus noted around the nail beds. A review of Resident #7's clinical note dated 01/12/23 revealed the resident was evaluated by the podiatrist on this shift (3p-11p) shift. The note included there were missing toenails to the third and fourth digit on the right foot and on the left third digit the toenail was missing and had scabbed over. The note stated the resident did not want his toenails trimmed due to sensitivity. A new order was given for a wound consult and to apply betadine to toenails. A review of Resident #7's Physician Order Audit Report for January 2023 revealed an order for a podiatry order dated 01/13/23 at approximately 10:13 a.m. The order read for a podiatry consult, please make an outpatient podiatry appointment for nail care for the Resident #7 who has a history of Type II Diabetes. The Social Worker (SW) was interviewed on 01/13/23 at approximately 10:07 a.m., who stated the previous podiatrist was fabricating documents. She stated the podiatrist provided documentation alleging that residents were receiving podiatry care when he never provided services. The SW provided a list that indicated Resident #7 had refused podiatry services on 09/09/22, 10/14/22 and 11/01/22. She said she kept adding Resident #7 to the podiatry list because the resident kept saying the podiatrist never cut/trimmed his toenails. She stated she was approached by a resident who wanted to know when the podiatrist was coming to cut and trim her toenails. She stated the podiatrist had just left the facility and provided documentation on (name of resident mention) that he had just cut and trimmed the resident's toenails which was not true, the resident's toenails were never cut or trimmed. An interview was conducted with CNA #5 on 01/13/23 at approximately 11:38 a.m. She said she started working at the facility about five (5) months ago and Resident #7's toenails were always long and thick. She stated she thought the nurses knew Resident #7's toenails needed to be cut and trimmed. She said she thought some of his toenails fell off but never informed the nurse. She stated that Resident #7's should have been assessed by a licensed nurse. On 01/13/23 at approximately 12:15 p.m., the Regional Director of Clinical Services stated the facility did not have a policy and procedures related to podiatry services or foot care. A final interview was held with the Administrator, Director of Nursing, Assistant Director of Nursing, Regional Director of Clinical Services, and [NAME] President of Operations on 01/13/23 at approximately 3:25 p.m. No further information was provided related to Resident #7's lack of proper toenail care prior to the survey exit.

Based on observation, interview, record review, and policy review, the facility staff failed to ensure two of three residents (Resident (R) 24 and R74) reviewed for Activities of Daily Living (ADL), out of a sample of 34 residents, received nail care. The findings include: A review of the Morning Care/AM Care policy, provided by the facility with a revision date of 09/01/22, revealed Morning care will be offered each day to promote resident comfort, cleanliness, grooming, and general well-being. Residents who are capable of performing their own personal care are encouraged to do so but will be provided with setup assistance if needed. Showers and baths are scheduled three times weekly or more or less often according to resident preference. Continued review of the policy revealed provide nail care supplies and 3. Perform hand hygiene and provide privacy. Use standard precautions, as necessary. 1. During an observation on 01/10/23 at 1:04 PM, revealed R24 had long fingernails with dark debris underneath the nails on the left hand. An observation on 01/11/23 at 4:15 PM with the Director of Nursing (DON), the DON confirmed R24's nails on the left hand were long with debris under the nails and confirmed the nails needed to be trimmed. A review of the electronic medical record (EMR) located under the Diagnoses tab, revealed R24 had diagnoses that included unspecified dementia without behavioral disturbance, psychotic (out of touch with reality) disturbance, mood disturbance and anxiety, muscle weakness, arthritis, and anxiety disorder. A review of the EMR quarterly Minimum Data Set (MDS), located under the MDS tab, with an Assessment Reference Date (ARD) of 12/04/22 revealed a Brief Interview for Mental Status (BIMS) score of seven out of 15 indicating R24 was severely impaired in the cognitive skills for daily decision making. Further review of the MDS revealed R24 required total dependence of one person assistance for personal hygiene. A review of the EMR Care Plan, located under the Care Plan tab and dated 12/19/22, revealed, Non-Compliance r/t [related to] personal care resident has been noted to refusing showers, refusing medications and treatments, and resident has self-care deficit related to cognitive impairment. A review of the EMR Task: Bathing Documentation/Shower Due Tues/Fri 7-3, dated 01/11/23 revealed R24 had not refused showers. A review of the EMR Personal Hygiene: Self Performance - How resident maintains personal hygiene, including combing hair, brushing teeth, shaving, applying makeup, washing/drying face and hands (excludes baths and showers), dated the last 30 days including 01/11/23, revealed that R24 did not decline personal hygiene. 2. During an observation on 01/10/23 at 1:06 PM, revealed R74 with long fingernails and dark debris underneath the nails. An observation on 01/11/23 at 5:13 PM with Registered Nurse RN/Unit Manager (RN) 1, the RN1 confirmed R74's nails were soiled and needed to be trimmed. A review of the electronic medical record (EMR) located under the Diagnoses tab, revealed R74 had adult failure to thrive, anxiety, personal history of transient ischemic attack/cerebral infarction (stroke) without residual deficits, and Parkinson's disease. A review of the EMR admission MDS with an ARD of 09/27/22 revealed a Brief Interview for Mental Status (BIMS) score of 10 out of 15 which indicated R74 was moderately impaired in the cognitive skills for daily decision making. Further review of the MDS revealed R74 required extensive assistance of one person for personal hygiene. A review of the EMR Care Plan, located under the Care Plan tab and dated 10/05/22, revealed He uses a device to communicate, resident is mute. Resident has ADL/self-care deficit related to dx: Parkinson's, impaired cognitive-communication, and generalize weakness. Resident has difficulty communicating r/t aphasia following CVA. Resident is able to verbalize pain via communication device, nonverbal cues, has an ADL Self Care Performance Deficit r/t disease process (Parkinson's) and generalized weakness, resident has a behavior problem r/t refuse ADL care at times and fingernail care at time. A review of the EMR Bathing: Self Performance - How resident takes full-body bath/shower, sponge bath, and transfers in/out of tub/shower (excludes washing of back and hair, located under the Tasks tab dated the last 30 days including 01/11/23, revealed R74 did not decline but received baths/showers. A review of the EMR Personal Hygiene: Personal Hygiene: Self Performance - How resident maintains personal hygiene, including combing hair, brushing teeth, shaving, applying makeup, washing/drying face and hands (excludes baths and showers), located under the Tasks tab dated the last 30 days including 01/11/23, revealed R74 did not decline personal hygiene. In an interview conducted on 01/11/23 at 4:05 PM, the DON stated the residents should get their nails trimmed weekly/during shower days. In an interview conducted on 01/11/23 at 5:13 PM, RN 1 confirmed that R74's fingernails needed to be trimmed and had dark debris underneath the nail bed.

Based on observation of medication pass and pour, staff interviews, clinical record review, and facility documentation, the facility staff failed to ensure they were free of medication error rate of 5 percent (%) or greater. During the medication observation, there were twenty-seven (27) opportunities for error, two (2) medication errors were observed which resulted in a medication error rate of 7.41%. The resident involved in the medication error rate was Resident #66. The findings included: On 01/10/23 at approximately 11:45 a.m., a medication pass and pour observation was conducted with License Practical Nurse (LPN) #4. The LPN was unable to locate Resident #66's Lasix (Furosemide) 40 milligrams (mg) and Metoprolol Tartrate tablet 50 mg inside the medication cart. On the same day at approximately 12:10 p.m., the LPN stated she had contacted the physician to inform the above medications were not available with new orders to hold the above medications until they arrive from pharmacy. The above medications were not administered to Resident #66 as ordered by the physician. Resident #66 was originally admitted to the facility on [DATE]. Diagnoses included but were not limited to Congestive Heart Failure (CHF) and Hypertension (high blood pressure.) Resident #66's Minimum Data Set (MDS - an assessment protocol) a quarterly assessment with an Assessment Reference Date of 09/19/22 coded Resident #66's Brief Interview for Mental Status (BIMS) with a score of 15 out of a possible score of 15 indicating no cognitive impairment. A review of Resident #66 Physician Order Summary (POS) and Medication Administration Record (MAR) for January 2023 revealed the following orders: -Lasix tablet 20 mg to be administered every morning at 9:00 a.m., for CHF. -Metoprolol Tartrate 50 mg - give one day by mouth twice daily at 10:00 a.m., and 10:00 p.m., for high blood pressure. The following medications were in the facility's Omnicell machine: Lasix 20 mg (10 tablets) and Metoprolol Tartrate 50 mg (10 tablets.) An interview was conducted with License Practical Nurse (LPN) #4 on 01/12/23 at approximately 12:31 p.m. She stated she did not administer Resident #66 her scheduled Metoprolol and Lasix because they were not inside the medication cart. LPN #4 was provided a copy of the medication list for all medication that were in the Omnicell machine on 01/10/23. She stated the above medication should have been pulled from the Omnicell machine and administered to Resident #66 as ordered by the physician. On 01/13/23 at approximately 8:47 a.m., an interview was conducted with the Director of Nursing (DON.) She stated the nurse should have checked the Omnicell first to make sure the medications were there to administer Resident #66. She stated if the medications were in the Omnicell, the medications should have been pulled and administered to the resident as ordered by the physician. She said the physician and pharmacy should have been notified only if the medications were not available for administration. An interview was held with the Administrator, Director of Nursing, Assistant Director of Nursing, Regional Director of Clinical Services and [NAME] President of Operations on 01/13/23 at approximately 3:25 p.m. No further information was provided prior to exit. Definitions: -Congestive Heart Failure occurs when the heart muscle doesn't pump blood as well as it should. When this happens, blood often backs up and fluid can build up in the lungs, causing shortness of breath. Certain heart conditions, such as narrowed arteries in the heart (coronary artery disease) or high blood pressure, gradually leave the heart too weak or stiff to fill and pump blood properly (https://www.mayoclinic.org/diseases-conditions/heart-failure/symptoms). -Hypertension is when your blood pressure, the force of your blood pushing against the walls of your blood vessels, is consistently too high (https://medlineplus.gov/ency/article/007365.htm).

Based on a complaint investigation, medical record review, staff interviews and facility document review the facility staff failed to make a [CONDITION(S)] transportation arrangement for 1 of 2 residents in the survey sample, Resident #2. The findings included: Resident #2 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #2 was listed on the facility admission record as her own responsible party. Resident #2's most recent comprehensive Minimum Data Set (MDS) was an admission/5 day with an Assessment Reference Date (ARD) of 1/22/22. Resident #2's Brief Interview for Mental Status (BIMS) was coded a 13 out of a possible 15 indicating the resident was cognitively intact and capable of daily decision making. Under Section O: Special Treatments, Procedures and Programs Resident #2 was coded for [CONDITION(S)] as a resident. Resident #2's Comprehensive Care Plan dated 1/17/22 was reviewed and is documented in part, as follows: Focus: Resident is on hemodialysis related to [CONDITION(S)] ([CONDITION(S)]). Date initiated: 1/17/22. Resident #2's Hospital Discharge Summary dated 1/15/22 was reviewed and is documented in part, as follows: Discharge Procedure Orders: Follow-up with Specialist: Follow-up with your hemodialysis center per routine schedule. On 2/11/22 at 11:00 a.m. an interview was conducted with the Director of Nursing (DON) regarding Resident #2's [CONDITION(S)] transportation. The DON stated, Name (Resident #2) was admitted on [DATE] and her [CONDITION(S)] days were Tuesday, Thursday and Saturday. The first 3 [CONDITION(S)] transports were set up through the hospital. She went on 1/18/22, 1/20/22 and 1/21/22 due to pending snowstorm. The resident's next [CONDITION(S)] day was 1/25/22 and we did not have transport arranged for her. The resident's son was at the facility and he said he would take her so she didn't miss a treatment. The Transportation Scheduler set up transport for the remaining [CONDITION(S)] treatment days. On 2/11/22 at 1:02 p.m. an interview was conducted with the facility's Transportation Scheduler regarding Resident #2's [CONDITION(S)] transportation. The Transportation Scheduler stated, I set up transportation for her (Resident #2) to go to [CONDITION(S)] for January 26th forward. I did not set up transportation on January 25th. On 2/10/22 at 3:09 p.m. a phone interview was conducted with Resident #2's son regarding her [CONDITION(S)] transportation on January 25, 2022. Resident #2's son stated, I went to visit her on January 25th and was made aware that she did not have transportation to [CONDITION(S)], it was never arranged. I told her myself that day to her [CONDITION(S)] treatment. On 2/10/22 and 2/11/22 this surveyor attempted to call Resident #2 and messages were left for a return call, prior to exit no return call was received. Resident #2's Post [CONDITION(S)] Treatment records were reviewed for her facility stay and there was no indication that any [CONDITION(S)] treatments were missed. On 2/11/22 at 1:10 p.m. the Administrator stated that there was no facility policy for arranging resident transportation to [CONDITION(S)]. On 2/11/22 at 2:32 p.m. a pre-exit debriefing was held with the Administrator and the DON where the above information was shared. The Administrator and DON was asked what the facility's expectation was for ensuring transportation for residents to [CONDITION(S)] treatments. The DON stated, We expect for residents to go to [CONDITION(S)] on the day they are scheduled to go and for the transportation to be set up prior to the [CONDITION(S)] treatment. Prior to exit no further information was received. Complaint Deficiency

Based on clinical record review and staff interview, the facility failed to test or ensure testing was completed two times a week for 2 of 2 agency staff; and failed to document in the resident's record that COVID-19 testing was offered, and completed for 3 of 3 residents, (Resident #1, 2, and 3) in the survey sample. The findings included: 1. On 12/29/20 at approximately 1:50 p.m., Registered Nurse (RN) #1 was observed charting at the nurse's station. RN #1 stated the assignment delegated included rooms 102 through 106 and rooms 300 through 311. The assignment included all well residents. Certified Nursing Assistant (CNA) #1 was also observed charting at the nurse's station. CNA #1 stated the assignment delegated included rooms 300 through 305. The assignment included all well residents. The screening document for RN #1 revealed at question #3, no answer for Can those not employed by the facility provide evidence of negative testing within the facility's mandated testing time frame. If no, the individual must be tested before entry. If the facility cannot accommodate testing, entry must be denied. The screening document for CNA #1 revealed at question #3, no answer for Can those not employed by the facility provide evidence of negative testing within the facility's mandated testing time frame. If no, the individual must be tested before entry. If the facility cannot accommodate testing, entry must be denied. An interview was conducted with The Director of Nursing (DON) on 12/31/20 at approximately 12:45 p.m. The DON stated the facility was on a two times per week testing frequency and their staff testing was conducted, 12/24/20 and 12/28/20 for this specific time span. Further review revealed documentation wasn't provided prior to RN #1's entrance onto the resident care area and neither was testing completed by the facility. The DON forwarded a document written by RN #1 dated 12/31/20 which stated I was tested [DATE] and tested negative. The DON acknowledged the test from 12/21/20 wasn't in compliance with facility's mandated testing time frame for a staff member working 12/29/20. Further review revealed documentation wasn't provided prior to CNA #1's entrance onto the resident care area and neither was testing completed by the facility. The DON stated on 1/4/21 that CNA #1 had submitted the most recent COVID-19 test results and the testing date wasn't in compliance with facility's mandated testing time frame for a staff member working 12/29/20. 2. Resident #1 was originally admitted to the facility 5/8/14 and has never been discharged . The current [DIAGNOSES REDACTED]. The quarterly Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 9/14/20 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 14 out of a possible 15. This indicated Resident #1's cognitive abilities for daily decision making were intact. An interview was attempted with Resident #1 on the facility's phone 1/4/21 for there are not resident phones in the rooms. A return call was not received. 3. Resident #2 was originally admitted to the facility 3/29/17 and readmitted [DATE] after an acute care hospital stay. The current [DIAGNOSES REDACTED]. The quarterly Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 11/20/20 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 14 out of a possible 15. This indicated Resident #2's cognitive abilities for daily decision making were intact. An interview was attempted with Resident #2 on the facility's phone 1/4/21 for there are not resident phones in the rooms. A return call was not received. 4. Resident #3 was originally admitted to the facility 9/18/20 and had never been discharged from the facility. The current [DIAGNOSES REDACTED]. The quarterly Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 11/11/20 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 15 out of a possible 15. This indicated Resident #3's cognitive abilities for daily decision making were intact. An interview was attempted with Resident #3 on the facility's phone 1/4/21 for there are not resident phones in the rooms. A return call was not received. The Director of Nursing (DON) was interviewed on 12/31/20 at 12:45 p.m. and stated all residents were tested ; 12/17/20, 12/18/20, 12/21/20, 12/22/20, 12/23/20, 12/24/20 and 12/28/20. Review of Resident #1, #2, and #3's clinical records revealed no written documentation indicating that COVID-19 testing was offered, completed with results or not completed. On 1/4/21 at approximately 10:10 a.m., the above findings were shared with the Administrator and Director of Nursing. The Administrator stated they had no further information to provide. The facility's policy titled COVID-19 Pandemic Management Policy with a revision date of 8/19/20 read under Tracking, Reporting and Documentation: Test results will be tracked and reported as required by local, state and federal entities. All tracking and testing will be secured according to HIPAA requirements. Documentation of resident test results will be retained in the resident health record.

Based on staff interview, facility document review, and clinical record review, it was determined that facility staff failed to provide the required documentation at the time of a transfer to the hospital for three of 44 residents in the survey sample, Residents #13, #33, and #108. The findings include: 1. Resident #13 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #13's most recent MDS (minimum data set) assessment was a significant change assessment with an ARD (assessment reference date) of 6/19/19. Resident #13 was coded as being severely impaired in cognitive function scoring 99 out of possible 15 on the BIMS (Brief Interview for Mental Status) exam. Review of Resident #13's clinical record revealed that he was sent out to the hospital on two occasions; 9/14/19 and 9/15/19. The following note was documented on 9/14/19: Resident had fall this shift. Neuro checks and vitals unable to start at this time due to resident being sent to ER (emergency room ) for evaluation. Will begin neuro check as soon he returns from (Name of hospital). Further review of Resident #13's nursing notes revealed Resident #13 returned to the facility the same day (9/14/19) with antibiotics for a UTI (urinary tract infection). Review of Resident #13's Acute Care Transfer Checklist, failed to evidence that care plan goals were sent with Resident #13 at the time of transfer. The clinical record revealed that Resident #13 had been transferred to the hospital a second time on 9/15/19. The following nursing note was documented in part: .Staff attempted touse (sic) sit to stand lift to put him back to bed noted him urinating on the floor with a large amount of blood and 2 blood clots while in his w/c (wheelchair). Review of Resident #13's Acute Care Transfer Checklist and assessment form dated 9/15/19, failed to evidence that care plan goals were sent with Resident #13 at the time of transfer. On 9/19/19 at 9:52 a.m., an interview was conducted with LPN (Licensed Practical Nurse) # 4, the unit manager. When asked what documents were sent with residents upon transfer to the hospital, LPN #4 stated that nurses should be sending a copy of the facesheet, current medication list, care plan or care plan goals, and bed hold policy upon transfer to the hospital. When asked how to know what documents were sent when a resident is transferred, LPN #4 stated that nursing should fill out an Acute Care Transfer Checklist as well as document in a nursing note what items were sent. LPN #4 confirmed that there was no evidence care plan goals were sent with Resident #13 at the time of both transfers. On 9/20/19 at 12:15 p.m., ASM #1, the Administrator, ASM #2, the ADON (Assistant Director of Nursing), ASM #3, the interim DON (Director of Nursing), ASM #6, the corporate nurse and ASM #7, the corporate executive nurse were made aware of the above concerns. No further information was presented prior to exit. 2. Resident #33 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Resident #33's most recent MDS (minimum data set) assessment was a 14 day scheduled assessment with an ARD (assessment reference date) of 7/2/19. Resident #33 was coded as being cognitively intact scoring 15 out of possible 15 on the BIMS (Brief Interview For Mental Status) exam. Review of Resident #33's clinical record revealed that she had been transferred to the hospital on two separate occasions on 5/19/19 and 6/7/19. Review of Resident #33's SBAR (situation, background, assessment and recommendation) form failed to evidence that care plan goals were sent with Resident #33 at the time of transfer to the hospital. There was no further evidence in Resident #33's clinical record that care plan goals were sent with Resident #33 at the time of transfer on 5/19/19 and 6/7/19. On 9/19/19 at 9:52 a.m., an interview was conducted with LPN (Licensed Practical Nurse) # 4, the unit manager. When asked what documents were sent with residents upon transfer to the hospital, LPN #4 stated that nurses should be sending a copy of the face sheet, current medication list, care plan or care plan goals, and bed hold policy upon transfer to the hospital. When asked how to know what documents were sent when a resident is transferred, LPN #4 stated that nursing should fill out an Acute Care Transfer Checklist as well as document in a nursing note what items were sent. LPN #4 confirmed that there was no evidence care plan goals were sent with Resident #33 at the time of both transfers. On 9/20/19 at 12:15 p.m., ASM #1, the Administrator, ASM #2, the ADON (Assistant Director of Nursing), ASM #3, the interim DON (Director of Nursing), ASM #6, the corporate nurse and ASM #7, the corporate executive nurse were made aware of the above concerns. No further information was presented prior to exit. 3. Resident #108 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Resident #108's most recent MDS (minimum data set) assessment was a five day scheduled assessment with an ARD (assessment reference date) of 8/27/19. Resident #108 was coded as being severely impaired in cognitive function scoring 99 out of possible 15 on the BIMS (Brief Interview for Mental Status) exam. Review of Resident #108's clinical record revealed that he had been transferred to the hospital on [DATE]. Review of Resident #108's Acute Care Transfer Checklist dated 8/15/19, failed to evidence that care plan goals were sent with Resident #108 at the time of transfer. There was no further evidence in the clinical record that care plan goals were sent with Resident #108 at the time of transfer. On 9/19/19 at 9:52 a.m., an interview was conducted with LPN (Licensed Practical Nurse) # 4, the unit manager. When asked what documents were sent with residents upon transfer to the hospital, LPN #4 stated that nurses should be sending a copy of the face sheet, current medication list, care plan or care plan goals, and bed hold policy upon transfer to the hospital. When asked how to know what documents were sent when a resident is transferred, LPN #4 stated that nursing should fill out an Acute Care Transfer Checklist as well as document in a nursing note what items were sent. On 9/20/19 at 12:15 p.m., ASM #1, the Administrator, ASM #2, the ADON (Assistant Director of Nursing), ASM #3, the interim DON (Director of Nursing), ASM #6, the corporate nurse and ASM #7, the corporate executive nurse were made aware of the above concerns. When asked if they wanted to present any additional information, ASM #6 stated that they probably wouldn't be able to find evidence care plan goals were sent. A policy could not be provided regarding the above concern.

Based on observation, staff interview, facility document review and clinical record review, it was determined that facility staff failed to provide activities to support the physical, mental, and psychosocial well-being of two of 44 residents in the survey sample, Resident #96 and #31. The findings Include: 1. Resident #96 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #96's most recent comprehensive MDS (minimum data set) assessment with an admission assessment with an ARD (assessment reference date) of 5/22/19. Resident #96 was coded in Section B (Hearing, Speech , Vision) as being in a persistent vegetative state. Section F (Preferences for Customary Routine and Services) could not be filled out or completed due to the his vegetative state. On 9/10/19 through 9/12/19 several observations were made of Resident #96. He was lying in bed with television on. Resident #96 could not verbally respond when spoken to. Resident #96 appeared to be staring at the ceiling. Review of Resident #96's clinical record failed to evidence that an activity evaluation/assessment was completed. Resident #96's activity evaluation dated 5/18/19 was blank. Review of the only activity note in Resident #96's clinical record was a quarterly note dated 8/15/19 that documented the following: Name of Resident #96 does not participate in any activities .changes to activity focuses: none. Review of Resident #96's care plan with the latest revision on 9/17/19, failed to evidence a care plan for activities. On 9/17/19 at 2:54 p.m., an interview was conducted with Resident #96's responsible party (RP). When asked if staff did anything to help mentally stimulate Resident #96, his RP stated that she visits frequently and that she will talk to him, rub his head, and play music from her phone. Resident #96's RP stated that staff do not do anything with him for mental stimulation. His RP had stated that no one will even exercise him and move his legs while he is in bed. On 9/18/18 at 4:10 p.m., an interview was conducted with OSM #5, the activities director. When asked what type of activities were being provided to Resident #96, OSM #5 stated that sometimes he will read to him, put music on in his room and do one to one conversation with him. OSM #5 stated that he could not do much more due to Resident #96's vegetative state. OSM #5 stated that he will go into his room maybe once or twice a week but that most of the time he is conducting group activities that Resident #96 can not participate in. When asked if he had conducted an activities assessment on Resident #96, OSM #5 stated that he did talk to the wife to obtain information on the Resident's previous likes and dislikes. When asked if that was in the clinical record, OSM #5 stated that he had that assessment and would try to find it. When asked if all residents should have an activity care plan, OSM #5 stated, Yes they should. When asked who was responsible for completing the activity care plan, OSM #5 stated that he was responsible. When asked why Resident #96 did not have an activity care plan, OSM #5 stated that he was not sure and would go check. When asked why Resident #96's quarterly note stated that the resident did not participate in activities, OSM #5 stated that it was because facility staff were not doing anything with him until the wife had requested that staff provide activities to Resident #96. When asked why activities were not being provided to Resident #96 until the wife had to ask, OSM #5 stated that he really didn't think that Resident #96 would want to do activities; that Resident #96 was Kind of just there. OSM #5 then stated that staff would put the television on for Resident #96. OSM #5 was also asked to provided this writer with all activity logs for Resident #96 since admission. On 9/19/19 at 9:27 a.m., further interview was conducted with OSM #5. OSM #5 stated that he could not find the activities assessment or his initial evaluation. OSM #5 also confirmed that there was not an activity care plan for Resident #96. OSM #5 at this time also presented the activity logs for Resident #96. Review of the activity logs from admitted (5/15/19) until 9/19/19 revealed activities were provided to Resident #96 on 7/6/19, 7/7/19 and 9/10/19. All other dates had the following documented for Resident #96 Rm. When asked OSM #5 what Rm meant; OSM #5 stated that Rm meant that Resident #96 was in his room. OSM #5 confirmed that an activity was not be provided if Rm' was documented. On 9/20/19 at 9:52 p.m., an interview was conducted with OSM #2, the RN (registered nurse) MDS coordinator. OSM #2 explained to this writer that if a resident is in a vegetative state and that option is selected under Section B (Hearing, Speech, Vision) of the MDS, that it will disable Section F (activities) of the MDS. OSM #2 stated that she would still expect the activities director to do some type of customized activity assessment and gather data to provide a therapeutic environment for the resident. OSM #2 stated that she would expect to also see an activity care plan for a resident in a vegetative state. On 9/20/19 at 12:15 p.m., ASM #1, the Administrator, ASM #2, the ADON (Assistant Director of Nursing), ASM #3, the interim DON (Director of Nursing), ASM #6, the corporate nurse and ASM #7, the corporate executive nurse were made aware of the above concerns. No further information was presented prior to exit. Facility policy titled,Activity Documentation Policy documents in part the following: The facility will conduct an activity assessment and ensure on-going documentation is maintained for each resident in order to promote the physical, mental, and psychosocial well-being. Procedure: Within 3 days of a resident's admission to the facility, an activity assessment within Point Click Care (PCC) will be conducted to help develop an activities plan that reflects the choices and interests of the resident. The resident's activity assessment is to be conducted by the Activity Department personnel, in conjunction with other staff who will assess related factors such as functional level, cognition, and medical conditions that may affect activities participation. The residents lifelong interests, spirituality, life roles, goals, strengths, needs and activity pursuit patterns and preferences will be included in the assessment .Each resident's Activities Care Plan shall relate to his/her Comprehensive Assessment and should reflect his/her individual needs. 2. Resident #11 was admitted to the facility on [DATE], with a readmission occurring on 12/9/2016. The [DIAGNOSES REDACTED]. Resident #11's most recent MDS (Minimum Data Set) assessment was Quarterly Review scheduled assessment with an ARD (assessment reference date) of 7/4/19. Resident #11's cognitive function score was 99 (unable to assess) on the BIMS (brief interview for mental status) exam. A review of Resident #11's Comprehensive Care Plan, in part, indicated: Focus: Resident #11 is lower functioning, dependent on staff for activities, cognitive stimulation, social interaction related to Dementia. Goal: Resident #11 activities will be adapted to meet their abilities though next review. Resident will be offered small group activities daily through next review. Interventions: Assure activities that are compatible with physical and mental capabilities are being offered. Break up activity projects into small tasks. Monitor and assess the need for any 1:1 activity programming. A review of Resident #11's activity logs from 6/2019 indicate that Resident #11 was located in her bedroom during activities. There was no evidence located within the facility record that activities were provided. On 9/18/2019 at approximately 4:30 p.m. an interview was conducted with the Activities Director regarding the Activities Assessment. The Activities Director stated She went out on 12/16/2016 and was never reactivated in the system when she came back. She does not have an assessment. On 9/19/2019 at approximately 10:12 a.m. an interview was conducted with the Social Worker (SW) who was asked about any of Resident #11's preferences provided by family members. The SW stated Her sister is the Authorized Representative. She did not participate in any Care Plan meetings. She participated in a family meeting on 6/26/2016 regarding medical concerns. The Authorized Representative only had one concern that the water pitchers were too heavy. Facility policy titled,Activity Documentation Policy documents in part the following: The facility will conduct an activity assessment and ensure on-going documentation is maintained for each resident in order to promote the physical, mental, and psychosocial well-being. Procedure: Within 3 days of a resident's admission to the facility, an activity assessment within Point Click Care (PCC) will be conducted to help develop an activities plan that reflects the choices and interests of the resident. The resident's activity assessment is to be conducted by the Activity Department personnel, in conjunction with other staff who will assess related factors such as functional level, cognition, and medical conditions that may affect activities participation. The residents lifelong interests, spirituality, life roles, goals, strengths, needs and activity pursuit patterns and preferences will be included in the assessment .Each resident's Activities Care Plan shall relate to his/her Comprehensive Assessment and should reflect his/her individual needs.

Based on resident interview, staff interviews, clinical record review and facility documentation review the facility staff failed to failed to provide evidence a care plan meeting was held and/or invite 1 of 44 residents to attend their person centered care plan meeting (Resident #264) in the survey sample. The findings included: Resident #264 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Resident #264's Minimum Data Set (MDS-an assessment protocol), a 14-day assessment with an Assessment Reference Date of 08/19/19, coded Resident #264's Brief Interview for Mental Status (BIMS) score of 14 out of a possible score of 15 indicating no cognitive impairment. During the initial tour on 09/17/19 at approximately 11:41 a.m., an interview was conducted with Resident #264 who stated, No one has ever given me a letter or invited me to attend a care plan meeting. An interview was conducted with the Social Worker (SW) on 09/18/19 at approximately 11:24 a.m., who stated, I am not able to provide evidence that Resident #264 was invited to attend her person centered care plan meeting. He said a care plan meeting will be held for Resident #264 as soon as possible; hopefully today. When asked when the initial care plan meeting was held for Resident #264, the SW reviewed Resident #264's clinical record then stated, I am unable to find documentation that a care plan meeting was ever held for (Resident #264). He said the MDS Coordinator should have notified me via email with a date and time for a care plan meeting for Resident #264; which he never received. He said once that information was provided by the MDS Coordinator, I wound have notified the resident and their Responsible Party to schedule a care plan meeting for Resident #264. On 09/18/19 at approximately 12:45 p.m., an interview was conducted with the MDS Coordinator who said she was not aware that Resident #264 did not have a care plan meeting. She said a care plan meeting should have been held on or before day 21 of her admitted . On the same day at approximately 1:00 p.m., the SW said she is unable provide any type of evidence that the SW was made aware when to schedule a care plan meeting for Resident #264. An interview conducted with the SW on 09/19/19 at approximately 9:00 a.m. The surveyor asked, What is the purpose for inviting a resident to attend their person centered care plan meeting. The SW said to ensure active engagement with their care plan decisions. The Administrator, Clinical Director of Operations, Director of Nursing and Assistant Director of Nursing was informed of the finding during a briefing on 09/19/19 at approximately 3:46 p.m. The facility did not present any further information about the findings. The facility's policy titled Care Plan Invitation Letter policy (Revision date: (MONTH) (YEAR)). Policy: The resident and the resident's Responsible Party or legal representative must be invited to attend each of the Interdisciplinary Care Plan Conference for the specified resident. Procedure in part: 1. The Executive Director and Administrator will designate a staff member who will be responsible for completing the care Planning Invitations, for delivering an invitation to the resident, and for mailing an invitation to the Responsible Party or legal representative. 3. The facility designee will deliver an original Care Plan invitation to the resident 5 days prior to the date of the conference, unless he/she has been deemed legally incompetent. A copy of the invitation will be maintained within the medical record as verification hat it was delivered. The facility's policy titled Care Conference (Revision date: (MONTH) (YEAR)). -Procedure in part: B. Each resident shall be invited to participate in their care plan conference. At the resident's discretion, the family shall be invited to participate also. The coordination of the care conference and documentation is the responsibility of the MDS Coordinator or his/her designee. C. All newly admitted residents shall have an initial care plan conference within 7 days following completion of the MDS and no later than 21 days from admission, upon any significant change in condition, quarterly and a full assessment and conference annually.

Based on observation, resident interview, staff interview, and clinical record review the facility staff failed to provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care for 3 of 24 residents (Resident #4, #9 and #16), in the survey sample. 1. The facility staff failed to ensure Resident #4 was medicated sufficiently prior to rendering pressure ulcer care of the sacrum. The facility staff failure to appropriately medicate Resident #4 prior to rending wound care resulted in the resident experiencing excruciating pain revealed by screaming out, crying and tightening buttocks. The faciltiy staff failed to stop the treatment and offer Resident #4 the option to delay care until an acceptable level of comfort was achieved. 2. For Resident #9, the facility staff failed to offer non pharmacological measures (non medication measures such as music, position changing or a back rub) for pain control prior to the administration of pain medications. 3. The facility staff failed to follow physician orders [REDACTED].#16, resulting in a soft bowel fecal impaction which resulted in short term discomfort for Resident #16. The findings included: 1. Resident #4 was originally admitted to the facility 3/26/15 and readmitted [DATE] after an admission to a local acute care hospital. The current [DIAGNOSES REDACTED]. The significant change Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 7/13/15 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 15 out of a possible 15. This indicates Resident #4 cognitive abilities for daily decision making are intact. In section J0100 (Pain Management) Resident #4 was coded as receiving as needed pain medications or was offered and declined pain medications. At section J0400 - J0600 (Pain assessment Interview) Resident #4 stated he experienced occasional pain which was rated 6/10 or moderate pain. The current care plan had a Pain/Comfort Needs care plan secondary to diabetic [MEDICAL CONDITION], pressure ulcer, low back, pressure ulcer stage 3 dated 4/3/15. The goal stated Resident will express relief or decreased discomfort within 20 minutes to 1 hour after pain medication administered as needed through the next review. The interventions were: Administer pain medications as ordered, encourage resident to verbalize pain, frequent repositioning¸ redirect, distraction, observe for verbal/non-verbal indicators of pain, provide a calm and quiet environment. The wound care needs care plan was dated 4/14/15. The goal stated the area to the coccyx will show signs of healing without complications through next review. The interventions stated to assess for pain prior to and after wound care as needed, assess pain as needed, assist to turn in bed, complete wound questionnaire as needed, consults as indicated, monitor nutritional status. Review of the wound care notes written by the treatment nurse reveal Resident #4 had been complaining of mild to moderate pain during cleansing of the wounds and dressing changes since 3/2015. Resident #4's wound care was observed 9/2/15 at approximately 2:20 p.m. The wound care physician cleaned, assessed and measured each wound and the treatment nurse applied the current treatment and dressed each wound. Resident #4 spouse was also present to observe the status and care of the wounds. Prior to beginning wound care for Resident #4 the treatment nurse stated the resident had been pre-medicated with pain medication. The wound care began with the heel and feet wounds. Resident #4 tolerated the procedure well. The spouse viewed the wounds and expressed satisfaction. The spouse was the primary caregiver at home and provided Resident #4 wound care as well. The physician then proceeded to complete the wound care of Resident #4's sacrum. The physician wiped the sacral wound from innermost to outer and Resident #4 tightly contracted the buttocks and screamed out. The physician observed the sacral wound and again wiped it from inner most to outer and again Resident #4 tightly contracted the buttocks, screamed out and was crying. The physician's response to Resident #4 was we are on the downside now then proceeded to measure the wound. The wound care nurse proceeded to apply the ordered treatment and dressing. Resident #4 stated just get it over with. When Resident #4 screamed out, crying, the spouse backed her body close to the privacy curtain, closed her eyes, grimaced and pulled the privacy curtain partially around her. The wound care nurse talked to Resident #4 but did not address Resident #4's response to the pain, by asking if he preferred to wait until later or suggest to the physician the wound care be stopped until an acceptable level of comfort could be achieved. The treatment nurse then applied the ordered treatment and dressing, repositioned Resident #4 in bed and applied the ordered device for his feet/heels. An interview was conducted with Licensed Practical Nurse (LPN) #5 after observation of Resident #4's wound care, on 9/2/15 at approximately 3:15 p.m. The surveyor asked LPN #5 if Resident #4 was medicated prior to the wound care today. LPN #5 stated Resident #4 did not have orders for medication prior to wound care but the Resident had received [MEDICATION NAME] 10/325 milligrams at 10:27 a.m. for pain and the wound care nurse asked that Resident #4 be medicated prior to wound care which would begin at approximately 2:00 p.m. Resident #4 was medicated with Tylenol 1,000 milligrams at 1:30 p.m. LPN #5 stated Resident #4 was administered Tylenol because it was too early to repeat the [MEDICATION NAME]. LPN #5 stated she had been working at the facility for over 1 year and had been responsible for providing wound care to Resident #4 only once; therefore, she was unaware of how Resident #4 tolerated the wound care. LPN #5 stated she addresses Resident #4's pain during rounds and medication passes. LPN #5 further stated she would have to rely on a report from the wound care nurses regarding Resident #4's pain responses during wound care. LPN #5 stated if the wound care nurses had reported Resident #5 pain was not controlled during wound care she would have notified the primary care physician. Resident #4 was interviewed on 9/2/15 at 3:15 p.m. Resident #4 stated going over the sacral wound was most excruciating and couldn't bear to have it postponed since it had to be done, but the pain was unbearable. His wife who was present during the treatment stated it was hard for her to see this strapping man suffer this pain. In the 9/2/15 progress note written by the wound care physician there was a note which stated Resident #4 has a stage 3 pressure wound of the sacrum of at least 58 days duration. There is light sero-sanguinous exudate (bloody drainage). There is no indication of pain associated with this condition. The wound care physician did not order or make recommendations for additional or scheduled pain medication prior to wound care for Resident #4 after she observed his response to the pain during the sacral pressure ulcer wound care. A physician order [REDACTED]. The wound care nurse replied no. The surveyor then asked the wound care nurse who initiated the order and why was the prescription obtained. The treatment nurse stated it was obtained because LPN #1 telephoned the primary physician because of the conversation between the surveyor and Resident #4 primary care nurse regarding pain management interventions associated with wound care. On 9/8/15 at approximately 5:50 p.m. the above findings were shared with the Administrator, Director of Nursing, Assistant Director of Nursing, Staff Development Coordinator and Regional Quality Assurance Nurse. The surveyor asked what were the expectations of the staff when Resident #4 screamed out in pain. The Regional Quality Assurance Nurse stated the expectation was for the physician to recognize the resident's intolerance and stop the procedure. The Regional Quality Assurance Nurse stated the wound care physician cannot order new medications to be administered prior to wound care but it is expected for the wound care physician to make recommendations to the primary physician. The Regional Quality Assurance Nurse also stated it is the expectation of the wound care nurse to recognize intolerance and advocate on behalf of the resident. The Director of Nursing and the assistant Director of Nursing agreed with what the Regional Quality Assurance Nurse stated. The surveyor asked the facility staff present if a Resident was screaming out in pain what would the resident's pain rating likely be assessed? The Assistant Director of Nursing stated between 8 and 10. No pain management policy was provided during the survey. The facility staff provided no additional information was provided prior to the survey team's exit. 2. For Resident #9, the facility staff failed to offer non pharmacological measures (non medication measures such as music, position changing or a back rub) for pain control prior to the administration of pain medications. Resident #9 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Resident #9's most recent Quarterly MDS (minimum data set - an assessment protocol) with an ARD (Assessment Reference Date) of 08/12/15 coded Resident #9 as scoring a 13 on the BIMS (Brief Interview for Mental Status) in Section C, Cognitive Patterns, indicating that Resident #9 was cognitively intact. The resident was coded to require extensive assistance for ambulation and for dressing. Resident #9 was coded as occasionally incontinent of bowel and bladder. Resident's MAR (Medication Administration Record) was reviewed. The MAR revealed that the PRN (as needed) medication [MEDICATION NAME] was given on 8/3/15, twice on 8/5/15, 8/6/15, 8/7/15, 8/13/15, 8/14/15, 8/17/15, 8/19/15, 8/24/15, 8/26/15, and on 8/31/15. Review of the MAR and Nursing Progress Notes revealed no notations of non-pharmacological nursing measures being administered prior to the administration of the [MEDICATION NAME] ([MEDICATION NAME]). The policy and procedure entitled [MEDICAL CONDITION] Drug Use noted the following: 1. Non-pharmacological interventions should be tried first to alleviate the resident's anxiety, behaviors, etc. Such behaviors would include but not be limited to: Diversional activities, Re-direction, Providing food or drink. An interview was conducted on 09/04/15 at approximately 4:55 p.m. with the Corporate Consultant and an interview was conducted on 09/03/15 at approximately 2:30 p.m., with the Assistant Director of Nursing. Both stated: It would be my expectation that the same non-pharmacological measures listed in the [MEDICAL CONDITION] Drug Use policy and procedure be tried before the administration of pain medications. During a briefing held 09/03/15 at approximately 5:15 p.m., the facility administration, consisting of the Administrator and Director of Nursing were informed of the findings. No further information was provided by the facility. 3. The facility staff failed to follow physician orders [REDACTED].#16, resulting in a soft bowel fecal impaction which resulted in short term discomfort for Resident #16. Resident #16 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. enough blood to meet the body's needs) and Chronic Pain. Resident #16's most recent Significant Change MDS (minimum data set - an assessment protocol) with an ARD (Assessment Reference Date) of 08/21/15 coded the Resident #16 as scoring a 09 on the BIMS (Brief Interview for Mental Status) in Section C, Cognitive Patterns, indicating that Resident #16 had moderately impaired cognition. The resident was coded to require extensive assistance for ambulation and for dressing with the assistance of one staff member for assistance. Resident #16 was coded as frequently incontinent of bowel and was coded as having a Foley catheter for urine drainage. During a routine observation of resident #16 on 09/04/15 at approximately 11:30 a.m., Resident #16 yelled, I have to have a BM (bowel movement). I need a bedpan. I haven't had a BM in 3-4 days. At that time the contracted Hospice RN (Registered Nurse) #6 walked into the room. An interview conducted with RN #6 on 09/04/15 at approximately 11:30 a.m. revealed that Resident #16 was placed on a bedpan with the assistance of two people and during that time RN #6 stated that a soft bowel impaction was removed digitally. The RN stated that reasons that Resident #16 may have had a soft bowel impaction could be: lack of musculature to push the bowel movement out, pain medication or anxiety medications. The Hospice RN #6 stated that she did two rectal digital swipes to remove the soft bowel impaction. RN #6 reported that Resident #16 stated she/he felt better after this was done. Review of Resident #16's physician orders [REDACTED]. [MEDICATION NAME] 5 mg Oral Tablet [MEDICATION NAME] coated take 1 tablet by mouth every 24 hours as needed for Constipation Enema 1 bottle Rectal Enema continuous prn (as needed) repeating - Give day 5 if no BM from Laxative Milk of Magnesia 30 milliliters oral suspension continuous prn repeating - give day 3 if no BM Review of Resident 16's Bowel Movement documentation and MAR revealed the following for the month of August 2015 and September 2015 09/04/15 - small smear with soft bowel disimpaction 09/04/15 - small regular BM 09/04/15 - small regular BM 09/03/15 - moderate amount regular BM; [MEDICATION NAME] Rectal Suppository given 09/02/15 ------------- 09/01/15 ------------- 08/31/15 ------------ 08/30/15 ------------ 08/29/15 ---------- 08/28/15 - Day 5 no BM; no Enema given per physician orders 08/27/15 - Day 4 no BM; no [MEDICATION NAME] given per physician orders 08/26/15 - Day 3 no BM; no Milk of magnesia given per physician orders 08/25/15 - Day 2 08/24/15 - Day 1 08/23/15 - Large Hard BM 08/22/15 - Moderate loose BM 08/21/15 - Moderate Regular BM 08/20/15 - Day 3 no BM; No Milk of magnesia given per physician order 08/19/15 - Day 2 no BM 08/18/15 - Day 1 no BM 08/17/15 - moderate amount BM 08/16/15 - Day 4 no BM; No [MEDICATION NAME] given per order 08/15/15 - Day 3 no BM; No Milk of Magnesia given per orders 08/14/15 - Day 2 no BM An interview was conducted with Director of Nursing on 09/04/15 at approximately 5:15 p.m. When asked what policy is followed for bowel regimen, she stated, We follow the physician orders. Per review of August 2015 there was no documentation of physician orders [REDACTED]. Lack of a bowel regimen provided for Resident #16 resulted in a soft bowel impaction on 09/04/15. A briefing was conducted with the administration consisting of the Administrator and the DON on 09/04/15 at approximately 5:15 p.m. to inform them of the findings. No further information was provided.

Based on observations, resident interviews, staff interviews, clinical record review, and review of the facility's policy the facility staff failed to provide an environment free of hazards to prevent accidents for 8 of 24 residents (Residents #14, 12, 7, 15, 18, 21, 9, and 8 ), in the survey sample, and the facility staff failed to secure obtain and record hydrocollator temperatures daily in the rehabilitation department. The findings included: 1. a. The facility staff served coffee at a dangerously hot temperature sufficient to scald and cause second degree burns to the right breast and abdomen of Resident #14. b. The facility staff failed to transfer Resident #14 utilizing the mechanical lift identified by assessment as the most appropriate assistive device to transfer her. Failure to utilize the Total Passive Lift resulted in a fall with a right wrist fracture and increased pain. 2. The facility staff served coffee at a dangerously hot temperature sufficient to scald and cause second degree burns to the thigh of Resident #12. 3. The facility staff failed to utilize the lift during the transfer of Resident #7 on 1/7/15. Failure to utilize the lift resulted in Resident #7 falling and injuring the right foot. The right foot was swollen and painful. 4. The facility staff failed to ensure Resident #15 was safely secured in the facility van to prevent potential injury during transportation. 5. The facility staff failed to ensure the sensor pad alarm was operational to alert staff of Resident #18's movement, who had a history of [REDACTED]. 6. The facility staff failed to ensure supervision was maintained and assistance devices were in place to prevent elopement from facility grounds for Resident #21. 7. For Resident #9, the facility staff failed to provide supervision allowing the resident to crawl out of the bedroom window and onto the facility grounds. 8. Resident #8 did not have a secured storage area for her incendiary device (cigarette lighter) when the smoking materials were not on her person. 9. The facility staff failed to maintain a resident environment as free as possible from accident hazards by not obtaining and recording Hydrocollator temperatures daily in the rehabilitation department. The findings include: 1. Resident #14 sustained second degree burns to her right breast and abdomen after spilling hot coffee during the breakfast meal. The facility staff could not provide documentation that measures were taken to ensure coffee was served at temperatures that would not cause burns or scald if spilled. The facility staff also failed to demonstrate they were implementing preventive measures to prevent further incidents. Resident #14 was originally admitted to the facility 3/19/09 and readmitted [DATE]. The current [DIAGNOSES REDACTED]. The quarterly Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 6/24/15 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 9 out of a possible 15. This indicates Resident #14 cognitive abilities for daily decision making are moderately impaired. In section G (Physical functioning) Resident #14 was coded as requiring extensive assistance of one person with eating. On 9/8/15 at approximately 12:10 p.m. Resident #14 was not observed in the main dining room for the midday meal while other residents consumed their meal there and were served coffee. A medical record review revealed a nurse's note written by the wound care nurse on 9/8/15 at 8:39 a.m. The nurse's notes stated Resident #14 was brought back to room this morning because the resident stated she spilled coffee on the right side of the upper abdomen. Resident #14 was assessed by the wound care nurse and noted to have light redness to the right breast area under the breast and to the right upper quadrant of the abdomen. There was one small area of peeling skin to the right lateral aspect of the right breast measuring 0.4 centimeters (cm) x 1.0 cm x 0.1 cm. Resident #14 was also noted to have peeling skin to the right lateral area of the abdomen. The area measured 1.0 cm x 4.9 cm x 0.1 cm. Placed call to physician's office. New orders were to cleanse sites with Sea Clens (a wound cleaning product), apply Silverdene cream (a sulfa drug used to prevent and treat infections of second- and third-degree burns) to sites with daily dressings. Staff will continue to monitor. An interview was completed with the Nurse Practitioner (NP) on 9/8/15 at approximately 2:20 p.m. The NP stated she was asked to see Resident #14 because the resident spilled coffee on herself during breakfast. The NP stated the assessment revealed Resident #14 sustained second degree burns to the right breast, below the right breast and the abdomen from the coffee spill. The NP further stated she ordered Silverdene cream to treat the burns and directed the staff to administer Percocet (a pain medication used to relieve moderate to severe pain) around the clock. A statement was written by the certified nursing assistant (CNA) #5 and presented to the survey team upon request on 9/8/15 at approximately 3:00 p.m. CNA #5 stated she served Resident #14 the coffee at breakfast. An interview was conducted with CNA #5 on 9/8/15 at 2:40 p.m. CNA #5 stated she just grabbed a cup and poured the coffee straight from the coffee machine put cream and sugar in it and gave it to Resident #14. The statement written by Housekeeper #1 stated she heard Resident #14 holler help, help. Upon approaching Resident #14, Housekeeper #1 observed a coffee stain on the blouse and steam was rising from the spill on the blouse. Housekeeper #1 then notified Unit Manager #2. Housekeeper #1 was interviewed on 9/8/15 at 2:45 p.m. She gave the same account as written in her statement. After the survey team became aware of Resident #14's burns secondary to the coffee spill, the temperature of the coffee in the kitchen was tested on [DATE] at approximately 2:50 p.m. by the dietary staff upon request of the survey team. The reading was 181 degrees. The Dietary Manager stated no one notified the dietary staff of Resident #14's burns after spilling coffee. The Dietary Manager (DM) also stated the facility does not obtain coffee temperatures but the surveyor assigned to inspect the kitchen had brought it to the DM's attention on 9/1/15 at approximately 11:50 a.m. that the coffee temperature was recorded at 167.7 degrees. Three (3) surveyors observed Resident #14's burns as the wound care nurse reassessed the sites on 9/8/15 at approximately 4:40 p.m. Resident #14 was in bed and opened her eyes when spoken to but closed them directly after viewing surroundings. Resident #14 was unable at that time to participate in an interview. As the dressing to the right breast was removed and the breast was lifted by the wound care nurse Resident #14 grimaced and withdrew her body as she whimpered because of the pain. The right breast was with an opened blister which spanned approximately ¾ the width of the lower breast just below the nipple. Fluid filled and opened blisters were also observed to the right upper abdomen (Xerofoam gauze covered this site) and to the middle of the abdomen. Review of the Event Investigation dated 9/8/15 revealed the facility staff did not address the temperature of the coffee; the intervention stated to serve Resident #14 hot beverages in a Kennedy cup (a spill proof, easy to handle, adult sippy cup). There was no documentation the facility had evaluated the safety ramifications of its coffee temperature after a previous report 4 months ago revealed another resident sustained [REDACTED]. On 9/8/15 at approximately 5:50 p.m. the above findings were shared with the Administrator, Director of Nursing, Assistant Director of Nursing, Staff Development Coordinator and Regional Quality Assurance Nurse. No additional information was provided prior to the survey team's exit. b. The facility staff failed to transfer Resident #14 utilizing the mechanical lift identified by assessment as the most appropriate assistive device to transfer her. Failure to utilize the Total Passive Lift resulted in a fall with a right wrist fracture and increased pain. Resident #14 was originally admitted to the facility 3/19/09 and readmitted [DATE]. The current [DIAGNOSES REDACTED]. The quarterly Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 6/24/15 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 9 out of a possible 15. This indicates Resident #14 cognitive abilities for daily decision making are moderately impaired. In section G (Physical functioning) Resident #14 was coded as requiring extensive assistance of one person with transfers. A fall risk assessment was completed for resident #14 on 6/24/15. Resident #14 fall risk score was 9 indicating a moderate risk for falls. The resident's mobility/transfer profile was completed on 6/16/15 and the results reveal Resident #14 required use of the Total Passive lift for transfers. The facility undated Safe Resident Transfer policy stated the sit to stand lift is utilized for residents who require greater than 1+ assistance, understands and follows simple instructions, cooperate with the caregiver during the transfer process, support a portion of their own weight on at least lower extremity . The Total mechanical lift is used for residents who require more assistance or do not meet the criteria of the lesser device. The resident must be able to tolerate a semi-reclined position and weigh less than 420 pounds. The investigative report from the facility reported incident dated 7/14/15 stated the internal investigation regarding Resident #14's fall and injury on 7/13/15 was a result of the assigned certified nursing assistant (CNA) not using proper technique or procedure for transferring the resident. This resulted in Resident #14 falling and sustaining a fractured wrist. The report further stated Resident #14 reported the CNA was in a rush and did not take her time in transferring her. The report further stated the CNA will be terminated for not following facility transferring procedure and misconduct. The remaining staff was educated on the importance of proper lifting procedures. The facility has a Employee Safe Working Practices Agreement which each employee signs prior to working. Agreement #4 reads: if my job involves handling patients, I agree to always use a lift/gait belt, have other assistance as indicated, or use mechanical lifting devices for all patients who require any form of assistance in making movement. The current care plan had a cognitive needs care plan dated 12/20/12. It stated Resident #14 is alert and oriented times 2-3 (person, place, date) but has forgetfulness. The goal stated Resident's safety needs will be met daily by staff through next review. Interventions included; offer simple choices. Resident is able to use call bell, place within reach. Resident assessed as at risk for falls, uses ½ side rails. The current care plan also had a fall risk care plan secondary to poor safety awareness, noncompliance, and cognitive impairment. The care plan was updated 4/10/13 for a fall, 4/29/13 resident refusal of the personal alarm, 1/13/14 for a fall, 5/28/14 chair sensor alarm added, 12/15/14 for a fall, 12/20/14 after the resident was observed on the floor, 4/14/15 personal alarm discontinued, and 7/13/15 for a fall while transferred with the wrong transfer device and adding a personal alarm. The goal is for Resident #14 to have no injuries from falls requiring hospitalization through next review. The interventions include use of bed alarm, verbal recueing, physical therapy screen, floor mats, low bed, mechanical lift for transfers, encourage resident to wait for assistance and transfer only with assistance . The surveyor reviewed the CNA statement which described the event resulting in the fall and fracture dated 7/13/15. The assigned CNA stated Resident #14 refused to go to bed. She had Resident #14 in the sit to stand lift (is assessed to use the Total Passive Lift/Hoyer lift) when she began fighting and swinging her arms therefore Resident #14 was assisted back into the wheelchair . The assigned CNA then stated she went across the hall to assist another resident . The medical record revealed a nurse's note dated 7/13/15 at 8:22 p.m. which stated a certified nursing assistant (CNA) reported to the nursing supervisor and charge nurse Resident #14 was on the floor. The nurse's note further stated Resident #14 said the CNA pushed her down on the floor. Resident #14 was removed from the CNA's assignment. A head to toe assessment was completed and vital signs were obtained. No bruising or injuries were noted but Resident #14 stated the right hand hurt. Orders were obtained to transfer Resident #14 to the acute care hospital emergency department for evaluation and treatment and the responsible party was notified. A nurse's note dated 7/14/15 at 2:44 a.m. revealed Resident #14 returned to the facility from the acute care hospital emergency department with a soft fiberglass splint covered with an ace wrap on the right upper extremity. The x-ray results from the hospital revealed a fracture (break) of the distal radius (wrist) with dislocation (separation of two bones where they meet at the joint) of the distal radius (wrist) and articulating wrist (the bones are moving relative to each other at the joint) and hand volarly (same side as the palm of the hand). The emergency department report dated 7/14/15 at 1:53 a.m. stated (814.00) Wrist fracture right- suspect chronic per patient. The findings were discussed with the patient, will splint and have Orthopedic follow up, will manage pain. The patient stated to the emergency department physician there was a previous surgery to the right wrist to remove part of the bone. The physician stated the pain was mostly in the 3rd/4th digits of the right hand. Suspect chronic wrist fracture, however with new/acute injury . Prescription for analgesic (pain medication) given. The x-ray results revealed a fracture of the distal radius with dislocation of the distal radius and articulating wrist and hand volarly. Resident #14 was to follow up with a local Orthopedic practice for fracture management. Resident #14 was seen by the Orthopedist on 7/29/15 at approximately 2:52 p.m. accompanied by the daughter. The new x-rays revealed an old distal radius and ulna and the radius had developed a nonunion (failure to heal). The new x-ray revealed a closed fracture of the distal end of the right radius with malunion. The orthopedist stated it appeared the old nonunion was disrupted or there is a new fracture. The orthopedist stated because of the pain most likely the fracture was around the nonunion. An interview was conducted with the Director of Nursing on 9/3/15 at approximately 12:05 p.m. The Director of Nursing stated Resident #14 did not sustain a fracture when she fell on [DATE]. The Director of Nursing also stated the emergency department and orthopedist reports were inconsistent. The surveyor asked the Director of Nursing if she or any other staff member had contacted the emergency department physician or the orthopedist for clarification regarding their report so the staff could provide all necessary care for Resident #14. The Director of Nursing stated that would be the Unit Manager's responsibility. The Director of Nursing further stated Resident #14 was wearing the splint and utilizing pain medication for comfort because of the unstable right wrist secondary to polio and a previous fracture at the site in 2008. The Director of Nursing then stated the staff member who caused Resident #14 to fall was terminated for not using the right lift not because Resident #14 sustained a fracture. An interview was conducted with Resident #14's daughter on 9/3/15 at approximately 4:15 p.m. The daughter stated she was unable to meet Resident #14 at the emergency department the night the fall occurred but she had accompanied Resident #14 to all of the follow up appointments with the orthopedist. The daughter stated on the appointment days the facility staff would hand her an envelope of papers and no one from the facility accompanied them to the appointments. The daughter stated she would return the envelope to the facility with the items the orthopedist office inserted. The daughter explained there was no direct communication with the facility staff regarding the outcome of the appointment. The daughter stated Resident #14 had polio which affected the right wrist and the right wrist was fractured in 2008. She further stated Resident #14 had deformity and decreased use of the right hand and wrist. The daughter further stated Resident #14 sustained a new fracture to the right wrist secondary to the fall 7/13/15. On 9/8/15 at approximately 5:50 p.m. the above findings were shared with the Administrator, Director of Nursing, Assistant Director of Nursing, Staff Development Coordinator and Regional Quality Assurance Nurse. No additional information was provided prior to the survey team's exit. The medication administration record revealed from 7/13/15 to 9/8/15 had required 29 doses of a narcotic analgesic for pain control. The surveyor was unable to speak with a representative from the physician's office during the survey but on 9/10/15 at approximately 1:20 p.m. the medical secretary telephoned the surveyor with a report from the orthopedist. The orthopedist stated Resident #14 was under his care from 7/29/15 through 8/17/15 for a new fracture right distal radius fracture sustained on 7/13/15. 2. Resident #12 sustained second degree burns to the left upper thigh after spilling hot coffee during the breakfast meal. The facility staff could not provide documentation that measures were taken to ensure coffee was served at temperatures that would not cause burns or scald if spilled. The facility staff also failed to implement preventive measures to prevent further incidents. Resident #12 was originally admitted to the facility 6/30/14 and readmitted [DATE]. The current [DIAGNOSES REDACTED]. The quarterly Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 8/17/15 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 15 out of a possible 15. This indicates Resident #12 cognitive abilities for daily decision making are intact. In section G (Physical functioning) Resident #12 was coded as requiring extensive assistance of one person with eating, personal hygiene, bathing and dressing. An interview was conducted with Resident #12 on 9/2/15. The surveyor asked Resident #12 to describe what occurred when he sustained the burn to his left thigh. Resident #12 stated he went to the kitchen door and requested a cup of coffee. The kitchen staff member handed him the cup of coffee and let the cup go prior to him grasping it securely and the coffee spilled on his legs. Resident #12 stated he did not report the coffee spill because he was wearing jeans and it did not hurt. An interview was conducted with the Director of Nursing on 9/4/15 at approximately 2:45 p.m. The Director of Nursing stated she was told Resident #12 had a coffee cup he was putting coffee in from the coffee machine when he spilled the coffee. The Director of Nursing stated Resident #12 did not report the coffee spill to the staff. The surveyor asked the Director of Nursing if she had obtained a statement from Resident #12 during the investigation; the Director of Nursing replied she had not but the weekend supervisor did. The Director of Nursing was asked why was Resident #12's account of the event not the same today as documented in the investigation. The Director of Nursing did not answer. The medical record review revealed a nurse's note dated 5/3/15 which read called to Resident #12 room by certified nursing assistant (CNA) and observed circular burn wounds on the left thigh. The skin was intact because the scabs covering the areas (2) that appears to have been open. Resident #12 stated I spilled hot coffee on my leg about 4 or 5 days ago. I think it was Tuesday or Wednesday. I did not tell anybody because it didn't hurt and it doesn't hurt now. This Registered Nurse (RN) cleaned the area thoroughly with wound cleanser and patted dry, area was left open to air. RN instructed Resident #12 to please inform the staff if he noticed any changes in the wound. Charge nurse at bedside and will complete incident report, facility on call notified. A message was left for the treatment nurse to evaluate. The intervention written in the investigation stated Resident #12 was educated to ask for assistance and not to get coffee unassisted. Resident #12 was re-educated on the importance of reporting incidents when they happen. Doors to the dining area are to be closed at all times except when the residents are eating to prevent further incidents. Review of the Facility Reported Incident dated 5/4/15 revealed the facility staff did not address the temperature of the coffee and the above interventions suggest Resident #12 obtained the coffee unassisted, when he stated the kitchen staff handed him the coffee. The Treatment Administration Record revealed Resident #12 received wound care to the left upper thigh until 6/21/15. The treatment order read: cleanse the left upper thigh with Sea Clens, apply Hydrogel, Cover with folded 4x4 followed by telfa dressing every day. According to an American Burn Association document entitled Fire and Burn Safety for Older Adults Educator's Guide, under the heading General Background Information . Risk Factors . Physical Changes, the document read Older adults experience a myriad of physical and cognitive changes associated with the aging process that makes them more vulnerable to fire and burn injuries . there are significant changes in sensory perception. The ability to see, hear and feel potential fire and burn dangers diminishes proportionally as one gets older .Since older adults also have thinner skin, they may experience a much deeper burn than a younger person, when exposed to the same amount of flame or other burn injury source Under the heading Working with the Older Adult Population, the document continues With 12.5% of the population age 65 and older, there is a need to assess and address injury risks affecting them as they age. According to a second document based on the above American Burn Association: The severity of injury with scalds depends on two factors - the temperature to which the skin is exposed and the length of time that the hot liquid is in contact with the skin . When the temperature of a hot liquid is increased to 140 degrees Fahrenheit/60 degrees Celsius. It takes only five seconds or less for a serious burn to occur. Coffee, tea, hot chocolate and other hot beverages are usually served at 160 to 180 Fahrenheit/71-82 Celsius degrees, resulting in almost instantaneous burns that require surgery to heal. The two factors addressed above are underscored in a Burn Foundation document retrieved from the internet which state's Hot Water Causes a Third Degree Burns . .in 1 second at 156 degrees .in 2 seconds at 149 degrees .in 5 seconds at 140 degrees .in 15 seconds at 133degrees. (<https://www.burnfoundation.org/programs/resource.cfm?c=1&a=3>) The facility Accident policy dated 11/1/13 states the intent of this requirement is to ensure the facility provides an environment that is free from accident hazards over which the facility has control and provides supervision and assistive devices to each patient to prevent avoidable accidents. Under Procedure the policy states . 6. The facility will have a process in place to identify hazards and risks. 7. The facility will have a process to evaluate and provide analysis of interventions to be used. 8. The facility will implement interventions to reduce risk from hazards. 9. The facility will provide adequate supervision to prevent accidents. Under Effective ways to avoid accidents the policy states . 4. Develops reporting system that does not place blame on staff member reporting patient risk and environmental hazards. 5. Involve all staff in helping to identify solutions to ensure a safe patient environment. 10. Monitor for effectiveness and modifying interventions when necessary. On 9/8/15 at approximately 5:50 p.m. the above findings were shared with the Administrator, Director of Nursing, Assistant Director of Nursing, Staff Development Coordinator and Regional Quality Assurance Nurse. No additional information was provided prior to the survey team's exit. 3. The facility staff failed to utilize the lift during the transfer of Resident #7 on 1/7/15. Failure to utilize the lift resulted in Resident #7 falling and injuring the right foot. The right foot was swollen and painful. Resident #7 was originally admitted to the facility 12/19/07 and readmitted [DATE]. The current [DIAGNOSES REDACTED]. The quarterly Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 8/10/15 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 5 out of a possible 15. This indicates Resident #7 cognitive abilities for daily decision making are severely impaired. In section G (Physical functioning) the resident was coded as requiring extensive assistance of 1 person with transfers. A skin assessment completed on 12/24/14 reveled Resident #7 had no edema present. A fall risk assessment was completed for resident #7 on 5/27/15. Resident #7's fall risk score was 18 indicating a high risk for falls. The Resident Mobility/Transfer Profile assessment dated [DATE] revealed Resident #7 required the standing and raising lift for all transfers. The current care plan also had a fall risk needs care plan secondary to a history of falls, cognitive impairment, and poor safety awareness. The care plan was dated 9/15/14. The goal was for Resident #7 to have no falls through the next review. The interventions included: keep the call bell within reach, mechanical lift (sit to stand) for transfer. Review of the medical record revealed Resident #7 reported on 1/7/15 at 12:06 p.m. she had fallen the evening of 1/6/15 while being transferred. Resident #7 complained of right lower extremity pain and swelling was observed by the staff. The physician was notified and orders were given to obtain x-rays and peripheral vascular laboratory studies (PVL). Resident #7 had x-rays of the right hip, right femur, right knee and right ankle on 1/8/15. The x-ray results revealed soft tissue swelling of the right ankle but no fractures. A venous doppler study (a test to measure blood flow through blood vessels) was also completed on 1/8/15. It revealed the pain and swelling of the right lower extremity was not because of a blood clot. Review of Resident #7 Medication Administration Record (MAR) for 1/1/15 through 1/31/15 revealed increased intake of the narcotic pain medication Norco. From 1/7/15 through 1/9/15 2 tablets were administered indicating severe pain. On 1/10/15 through 1/11/15 2-3 times a day Resident #7 was medicated for moderate pain. The remainder of the month Resident #7 continued to require administration of 1 or 2 tablets of the narcotic pain medication Norco. The event investigation report dated 1/8/15 stated the assigned certified nursing assistant (CNA) for Resident #7 was interviewed regarding Resident #7's report of falling on the evening of 1/6/15. The report stated the assigned CNA stated Resident #7 did not fall during the transfer on 1/6/15 but she did transfer Resident #7 without using the mechanical lift. The investigative report stated the CNA was given a written warning for not utilizing the mechanical lift when transferring Resident #7. An interview was conducted with Licensed Practical Nurse (LPN) #2 on 9/4/15 at approximately 3:40 p.m. LPN #2 stated Resident #7 is not a reliable reporter but the report was followed up on anyway. LPN #2 stated Resident #7 told her the assigned CNA dropped her last night (1/6/15) and her right foot is painful. LPN #2 stated observation of the right foot also revealed swelling. LPN #2 stated the physician, responsible party and Director of Nursing were notified of the incident. The physician ordered x-rays and PVL studies. LPN #2 stated the assigned CNA reported she did not drop Resident #7 but she was transferred without using the mechanical lift. LPN #2 stated the assigned CNA was given a written warning because she had just began working at the facility when the incident occurred. The facility undated Safe Resident Transfer policy stated the sit to stand lift is utilized for residents who require greater than 1+ assistance, understands and follows simple instructions, cooperate with the caregiver during the transfer process, support a portion of their own weight on at least lower extremity . The Total mechanical lift is used for residents who require more assistance or do not meet the criteria of the lesser device. The resident must be able to tolerate a semi-reclined position and weigh less than 420 pounds. On 9/8/15 at approximately 5:50 p.m. the above findings were shared with the Administrator, Director of Nursing, Assistant Director of Nursing, Staff Development Coordinator and Regional Quality Assurance Nurse. No additional information was provided prior to the survey team's exit. 4. The facility staff failed to ensure Resident #15 was safely secured in the facility van to prevent potential injury during transportation. Resident #15 was admitted to the nursing facility on 6/11/14 with [DIAGNOSES REDACTED]. The most recent Minimum Data Set (MDS) assessment was a quarterly dated 8/24/15 and coded Resident #15 with a score of 5 out of a possible score of 15 on the Brief Interview for Mental Status (BIMS), which indicated the resident was severely impaired in the skills for daily decision making. The resident was not coded for any behavioral or mood disorders. Resident #15 was assessed to require extensive assistance of one staff for transfers and ambulation in a wheelchair and walker (primary modes of transfer). The resident was not steady without staff assistance to move from a seated to standing position, walking, turning around and any surface to surface transfers. The resident had upper and lower impairment in range of motion. She was coded to not have any falls since the last MDS assessment. The MDS assessment dated [DATE] indicated the resident had one fall with no injury. The care plan dated 7/3/14 identified the resident had fall risk needs and required supervision, oversight because of poor sa

Based on observations clinical record reviews, staff interviews, and facility documentation, the facility staff failed to thoroughly conduct skin assessments and identify a pressure ulcer until an advanced Stage for 1 of 23 residents in the survey sample, Resident #14. The facility staff failed to provide evidence or demonstrate they identified Resident #14's right buttock pressure ulcer prior to its first assessed as un-stageable. The findings include: A wound care observation of the right buttock pressure ulcer dressing change was made on 9/5/12 at 11:05 am. The wound care nurse, LPN #3, performed the wound care assisted by the Unit II Nurse Manager. They stated the wound was now a Stage III, but was first found as un-stageable. Brown drainage was observed on the old dressing. When the nurse irrigated the wound with Dakin's solution, she pressed around the opening to express more brown colored drainage. LPN #3 stated the surface opening of the wound was .8 centimeters (cm) x (by) .7 cm but the depth was 6.0 cm, as she cleaned out the wound with a gauge covered cotton tip applicator. She said, "She gets electrotherapy (E-Stim) over the pressure ulcer five days a week. It's healing over the top, but a deep hole remains and you can't visualize inside the wound." A Stage III pressure ulcer is full thickness tissue loss. Slough may be present, but does not obscure the depth of tissue loss. An Un-stageable pressure ulcer had slough (loose dead tissue) and/or eschar (hardened dead tissue). Known, but not stageable due to coverage of wound by slough and/or eschar. Resident #14 was readmitted to the nursing facility on 3/5/12 with [DIAGNOSES REDACTED]. The Re-admission Nursing assessment dated [DATE] indicated in the section entitled list the number, location and stage of each unhealed pressure ulcer(s); if none present, state none present; "None" was entered in the designated block. The resident had a physician's orders [REDACTED]. The ointment was documented on the Treatment Administration Record (TAR) administered by the licensed nurse on every shift from 3/5/12 through 9/7/12; it remained as a current order. On 9/7/12 at 2:15 pm, the wound care nurse LPN #3 stated the Triad ointment was applied as an added protective cream to both buttocks, in addition to Baza cream (moisture barrier). She stated the Certified Nursing Assistants (C.N.A.) apply Baza after each incontinence episode and the licensed nurse applied the Triad three times a day; "It's just an added protection. Once a pressure area is identified, it is to be assessed, the assessment of the area documented, and a call made to the physician with any necessary treatments. When the un-stageable pressure area was identified a new treatment order was established and we follow that order and any changes made to the order. I start the Bates-Jensen Wound Assessment tracking from the very first identification and assessment of a pressure ulcer. Details of treatments, orders and measurements are recorded in the nurse's notes." She stated she took over as the wound care nurse July 23, 2012. She stated the resident's wound was assessed with [REDACTED]. A nursing progress note dated 3/8/12 identified an acquired pressure ulcer, 2.5 centimeter (cm) blister to the left buttock; Baza cream applied. According to the weekly skin checks, this area was noted healed on 4/16/12. A Stage II coccyx was identified on 5/16/12 and documented in the nurse's notes as healed 6/15/12. The Minimum Data Set ((MDS) dated [DATE] coded the resident with one Stage II pressure ulcer. A Stage II pressure ulcer is a partial thickness skin loss presented as a shallow open ulcer with a red or pink wound bed without slough. The ulcer may present as an intact or open/ruptured blister. The most recent Minimum Data Set (MDS) assessment dated [DATE] coded the resident with one Stage II pressure ulcer and one Stage III pressure ulcer. The resident was assessed totally dependent on one staff for bed mobility, personal hygiene and bathing. She required extensive assistance from one staff for transfer. The MDS coded the most severe tissue type for any pressure ulcer with necrotic tissue (Eschar)-black, brown, or tan that adheres firmly to the wound bed or ulcer edges, may be softer or harder than surrounding skin. The revised care plan dated 6/7/12 indicated skin would be monitored during am and pm care. The goal was the resident would not experience skin breakdown through next review. Some of the approaches to accomplish this goal included observe skin daily during care and report findings to nurse; weekly skin checks every week on Monday and Thursday (licensed nurse); Triad ointment to bilateral buttocks [MEDICATION NAME] or treatment measures (licensed nurse); moisture barrier cream after incontinent episode-keep at bedside [MEDICATION NAME] or treatment measures (C.N.A.). A left trochanter Stage II pressure ulcer was recently identified on 8/3/12. The wound was described in the nurse's notes as open and red in color, no drainage or odor. This note was signed by the wound care nurse. As previously mentioned during interview with the wound care nurse, The Bates-Jensen Wound Assessment Tool Report was initiated on 8/3/12 in addition to the nurse's note. The June 14, 2012 Weekly Skin Check by the licensed nurse did not document any new areas. The physician's orders [REDACTED]. An indwelling urinary catheter was ordered: Diagnosis-open wound. The nurse's note did not provide an assessment of the wound, nor was there an initiation of the Bates-Jensen Wound Assessment tracking Tool. The nurse's note dated 6/14/12 indicated the wound measured 1.9 cm by (x) 3.0 cm width and to continue aforementioned treatment regimen. The Bates-Jensen tool was not initiated. The nurse's note dated 6/15/12 indicated an Un-stageable pressure ulcer noted to resident's upper right buttock; wound measures 1.9 cm in width, wound bed contains brown-colored tissue, wound bed is moist with no observable drainage, small amount of brown drainage noted to removed dressing. The Bates-Jensen tool was initiated on 6/15/12 and the pressure ulcer Stage as "un-stageable-slough and/or Eschar: Known but not stageable due to coverage of wound bed by slough and/or Eschar." The length x width was noted 4 cm to less than 16 square (sq) cm; the depth recorded as obscured by necrosis; yellow slough covering 75-100% of the wound with small amount of purulent exudate (thick or thin, opaque, tan/yellow, with or without odor); no granulation tissue present and less than 25% wound [MEDICATION NAME]. On 9/6/12 at 11:40 am, an interview was conducted with Registered Nurse #2 who was the wound care nurse who identified the right buttock pressure ulcer. She stated she did not know who told her about the wound, only that it was un-stageable when first discovered. She said she called the physician to ask for an indwelling urinary catheter because the wound was severe enough to require protection from urinary incontinence. She stated it was the facility practice to make a full assessment upon finding the area, chart the assessment to include the Bates-Jensen tracking form and contact the physician for any treatment orders. On 9/6/12 at 11:50 am, an interview was conducted with a physical therapist. She stated she was asked to provide electrotherapy (E-Stim) over the pressure ulcer to increase local circulation and promote wound healing. She started the treatment on 8/22/12 five days a week. On 9/6/12 at 1:00 pm the Unit II Nurse Manager was interviewed about the right buttock pressure ulcer. She stated adamantly, "I was not aware of an area on the right buttock until 6/15/12." The unit manager stated she very specifically recalled, "When I was called in by (RN#2's name), to take a look at the area; I was floored. I was mad, the spot was very bad. It was an un-stageable area with necrosis and slough. I started asking the questions; When, where, and how! I am here five days a week and did not know about that area. I'm sure I was here during that time because it was identified during a weekday. We strive to find pressure ulcers early, preferably as red or Stage II so we can treat and heal them fast." The UM stated she identified at least 6 staff (3 C.N.A.'s and 3 LPN's) that were assigned the resident and expected skin assessments performed to identify any skin integrity problems, and promptly report them. The Administrator and the Director of Nursing (DON) were interviewed on 9/7/12 at 11:00 am. Two surveyors were present during the interview. They stated they expected the C.N.A.'s to report any problems with skin to the nurse, the UM and expect the nurse to make assessments and take care of it right away. They stated according to the skin checks portion of the clinical record performed by the licensed nurse, there were no areas as of 6/14/12, but the wound care nurse obtains a physician's orders [REDACTED]. The DON stated, "It looks like she identified it on 6/13/12 because she calls the doctor for a Foley (brand name indwelling urinary catheter) order to protect the wound from urine, but you can't tell because she did not document a complete assessment of the right buttock until 6/15/12. She should have provided a complete and full assessment on 6/13/12, if that's when she saw it and started the tracking form immediately." They stated it was the facility's goal to find pressure ulcers at an early stage. The Administrator said, "This is unusual to find it at this stage." The DON nodded her head up and down and responded, "Yes, I agree. The goal is to find pressure areas at an early stage in order to heal them quickly." The right buttock pressure ulcer was surgically debrided (remove dead devitalized tissue) by a physician on 6/21/12. The treatment order to right buttocks was changed on 6/22/12 to cleanse wound with Seaclens, pat dry with 4x4, gently pack with 4x4 along with ? strength Dakins solution (antiseptic solution of sodium hypochlorite developed to treat infected wounds) followed by (f/b) dry dressing and [MEDICATION NAME] (non-stick sterile pad) dressing twice a day. The order changed on 6/25/12 to Seaclens, dry with 4x4, apply normal saline on 4x4 with Santyl f/b dry dressing and [MEDICATION NAME] dressing everyday. On 7/12/12 the treatment order changed to Dakins solution, pat dry with 4x4 then apply wet to dry dressing f/b abdomen pad (high absorbency pad) and tape twice a day. On 7/19/2012 the order went back to normal saline on 4x4 with Santyl (topical enzymatic therapy to remove necrotic tissue) f/b dry dressing and [MEDICATION NAME]. On 8/6/12, the wound was noted as Stage III (full thickness skin loss, may include slough, but does not obscure the depth of tissue loss) on the Bates-Jensen tool and the treatment changed on 8/17/12 to ? strength Dakins solution, loosely pack with Algicell AG (alginate silver dressing for moderate to heavy exuding wounds), cover with [MEDICATION NAME] (absorbent foam) dressing every day. E-Stim was started on 8/22/12 for 5 days/week. The treatment changed on 9/5/12 to ? strength Dakins, loosely pack with [MEDICATION NAME] with silver gel (donates moisture and antimicrobial silver), cover with [MEDICATION NAME] dressing every day. The facility's policy and procedure entitled Pressure Ulcer, Care and Prevention of (undated) indicated the purpose of the policy was to prevent and treat further breakdown of pressure sores. The policy indicated any persistent reddened area that remains after pressure is relieved is at high risk for a pressure ulcer to begin. Documentation could appear on any form used in the facility. Frequency of documentation should follow facility policy: date, time (or shift), as appropriate; condition of the resident's skin, physician notification, if appropriate; If pressure ulcer is present, the licensed nurse is responsible to record condition of the skin, including stage, size, site, depth, color, drainage and odor as well as treatment provided. Notification of the physician is required when a new pressure ulcer is identified as well as when treatment is not effective.