Every finding on record at Aviata at Englewood

Based on interviews and record review the facility failed to ensure that 1 resident, (Resident #1), was free from physical abuse resulting from a staff member intentionally hitting the resident's right forearm during care. The findings included:Review of the facility Abuse, Neglect, Exploitation & Misappropriation policy (last revised 11/16/22) states, abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment resulting in physical harm, pain, or mental anguish. The policy further states willful, as used in this definition of abuse means the individual must have acted deliberately, not that the individual must have intended to inflict harm or injury. The policy also states that physical abuse includes hitting, slapping and punching. The policy further states actions, such as striking or kicking a resident, restraining a resident improperly or without authorization, and other such acts which can be seen as causing physical pain to a resident is strictly prohibited.Record review for Resident #1 showed he was admitted on [DATE] with a diagnosis of traumatic subdural hemorrhage (a life-threatening brain injury where blood collect between the brain surface and the outer membrane), diffuse traumatic brain injury, attention-deficit hyperactivity disorder (characterized by persistent patterns of inattention, hyperactivity, and impulsivity that interfere with functioning) and a psychotic disorder with delusions. Resident #1 had a Brief Interview for Mental Status (a tool used to evaluate cognitive function) score of 8 (completed on 1/24/26), indicating moderate cognitive impairment.Review of Resident #1's Care Plan noted, Resident #1 has a mood problem r/t (related to) traumatic brain injury at 9 months old. Psychotic disorder with delusion. Unpredictable behaviors at time (date initiated 2/17/26). Resident #1's Care Plan also stated, resident has a potential for traumatization due to history of trauma secondary to needing to evacuate for Storms/Hurricanes (date initiated 10/15/24). Resident #1's Care Plan further noted Resident #1 has a communication problem r/t TBI (traumatic brain injury). Resident #1 is sometime understood/understands (date initiated 7/17/25) with an intervention to COMMUNICATION: Allow adequate time to respond. Repeat as necessary. Do not rush. Resident #1's Care Plan also noted Resident #1 is dependent on staff for meeting his emotional, intellectual, physical and social needs r/t: cognitive deficits, physical limitation (date initiated 7/26/24) with an intervention of all staff to converse with resident while providing care.Review of a Primary Care note on 3/9/26 documented at 8:19a.m., said per report from nursing staff, during routine evening care while a CNA (Certified Nursing Assistant) was assisting the patient into bed, the patient became acutely agitated and physical aggressive. Staff describe escalation characterized by verbal hostility and resistive behaviors during care. It was subsequently reported that during this interaction, the CNA may have physical struck or forcefully handled the patient. The note further states on physical examination, a localized area of erythema (redness) with superficial (surface of the skin) linear markings was noted on the volar (palm side) aspect of the right forearm, consistent with friction, grab mark, or excoriation-type injury.During an interview on 3/10/26 at 9:33 a.m. Resident #1 said, A nurse slapped me on the arm over and over. Resident #1 said they slapped his arm a few times. Resident #1 observed doing a slapping motion to his right forearm. Resident #1 said they slapped his arm a few times. Resident #1 said there were 2 nurses and they both hit him. Resident #1 said, they were bad. During a telephone interview on 3/10/26 at 9:53 a.m. Resident #1's family member said she got a phone call on Sunday (3/8/26, date of incident) that somebody slapped his arm. She said when she saw Resident #1, he told her that he kicked someone and they hit his arm. She said she spoke with law enforcement, and they told her someone tapped, tapped, tapped his arm while saying don't do that.During a telephone interview on 3/10/26 at 10:37 a.m., CNA Staff B said the nurse said we should lay Resident #1 down. I went to the cafeteria and saw CNA Staff A feeding Resident #1. She said CNA Staff A was tapping on the plate telling Resident #1 to eat. She said CNA Staff A kept tapping on the plate while telling him to eat. She said Resident #1 kept saying no. CNA Staff B said she heard CNA Staff A say no you're going to finish your food to which he took a bite and spit it out. Then CNA Staff B said she observed CNA Staff B wiped his mouth very aggressively and he pushed her away and told her to stop. CNA Staff B said she then pushed the mechanical lift into the room to Resident #1's bedside. She said Resident #1 began to throw a fit when he saw the mechanical lift and said he did not want to lay down. She said CNA Staff A said, we are already here, so you are going to lay down. CNA Staff B said you don't tell CNA Staff A no because she will scream at you, when asked why care was not stopped with Resident #1 refusing. So, I said okay because CNA Staff A was agitated. Resident #1 began kicking the hoyer lift. She said she pulled it away and let him calm down for a second. We then transferred him to the bed, and his feet were hanging off the side. At that time, LPN (Licensed Practical Nurse) Staff D came over to check on us, make sure we were fine and then went back to her one-to-one assignment. CNA Staff B said she went to pick up Resident #1's feet and he full force kicked me in the chest. She said Resident #1 then turned to CNA Staff A, yelled you fucking bitch and then hit her in the clavicle area. She said CNA Staff A then grabbed his arm, twisted it to where his forearm was sticking out and then hit him 4 to 5 times in the same spot. She said, as she doing it she is laughing and grinning as if it was a joke. She was hitting him forcefully. She said she responded by saying CNA Staff A what are you doing?. She said that CNA Staff A then exited the room. CNA Staff B then said LPN Staff D returned to the room. She said she told LPN Staff D what happened and showed her Resident #1's arm to which she replied, I don't want any part of this and walked out. CNA Staff B said she was unable to locate LPN Staff C so she got CNA Staff E to come to the room so she could stay with the resident. CNA Staff E saw the red mark, got a washcloth and put it on Resident #1's arm. CNA Staff B said she then found LPN Staff C, explained that CNA Staff A forcefully slapped Resident #1's arm and it was red. CNA Staff B said LPN Staff C responded, hopefully it goes away. I then contacted Human Resources and was told to take pictures and write a statement. When asked if she had ever witnessed CNA Staff A hit a resident before, she said I've seen her smack resident hands before like how you would smack a kid. This was the first time I had seen her aggressively hit a resident.On 3/10/26 at 11:15 a.m., CNA Staff E said CNA Staff B got her that day because of a red mark on Resident #1's arm. CNA Staff E said she was told by CNA Staff B that CNA Staff A hit Resident #1's arm. CNA Staff E said she went into the room to look at it and Resident #1 had a red mark on his right arm. CNA Staff E said she heard Resident #1 screaming earlier and heard LPN Staff D there.During a telephone interview on 3/10/26 at 1:35 p.m., LPN Staff D said CNA Staff A and CNA Staff B were in the room transferring Resident #1 back to bed. LPN Staff D said Resident #1 was agitated and yelling. LPN Staff D said when she entered the room, CNA Staff B said CNA Staff A got frustrated with him, he hit her and he slapped his arm. LPN Staff D said she saw the red mark on Resident #1's right forearm.During a telephone interview on 3/10/26 at 1:11 p.m., LPN Staff C said CNA Staff B told her Resident #1 punched CNA Staff A and she slapped him on his arm. LPN Staff C said she was with another resident at the time. LPN Staff C said she wasn't able to get there fast enough and CNA Staff B came back with pictures. The pictures showed redness on his arm. LPN Staff C said she then went immediately, assessed Resident #1 and said she saw redness on his right arm.During an interview on 3/10/26 at 2:32 p.m. LPN Staff F said LPN Staff C called her and said there was a staff to resident incident. LPN Staff F then spoke to CNA Staff B about the incident. Human Resources then called me to tell me CNA Staff B was being accused of pinching Resident #1's feet during care. Photographic evidence of Resident #1's right forearm was obtained by the facility showing red marks on Resident #1 arm. During an interview on 3/10/26 at 2:55 p.m. Human Resources said Staff B had called her frantic. She said CNA Staff B said, so I'm not usually a snitch but I just watched CNA Staff A slap Resident #1's arm. I asked what happened and CNA Staff B said CNA Staff A grabbed Resident #1's arm and slapped it during care.During an interview on 3/10/26 at 3:14 p.m., the Assistant Director of Nursing (ADON) said it was reported to her that Resident #1 had been hit on his forearm by CNA Staff A during care. The Director of Nursing (DON) and ADON agreed that physical abuse is zero tolerance. The DON and ADON said their expectation is to deescalate or come back later if a resident is being aggressive, agitated or refusing care. If someone hits a resident, their expectation is to report it immediately, separate them and start an investigation.During an interview on 3/10/26 at 3:26 p.m. the Nursing Home Administrator (NHA) said he got a notification on Sunday (3/8/26) that a CNA witnessed another CNA slap a resident's arm during care. He said the staff had training on how to deal with escalating behaviors and catastrophic reactions. The NHA said if a resident is having these behaviors, his expectation is they try to calm them down. If they are resisting care, we need to report it to the physician, family and supervisor. Staff need to deescalate the situation or do care later.During a telephone interview on 3/11/26 at 11:27 a.m., CNA Staff A said she assisted CNA Staff B with putting Resident #1 to bed after lunch. CNA Staff A said he was kicking, hitting, shouting and flinging the whole time. CNA Staff A said they continued the transfer.CNA Staff A said he always is kicking and shouting so we just put him to bed. CNA Staff A said we always laugh with him because he hits and flings things. CNA Staff A said CNA Staff B was pinching Resident #1's feet during care. CNA Staff A denied hitting Resident #1.

Based on record review and staff and resident interviews, the facility failed to follow Infection Control measures to prevent a potential outbreak of scabies.The findings included:Review of the facility policy titled, Infection Prevention and Control revised October 2018, revealed an infection prevention and control program is established and maintained to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections.Outbreak management includes a process that consists of: determining the presence of an outbreak; managing the affected residents; preventing the spread to other residents; documenting information about the outbreak; reporting the information to appropriate public health authorities; educating the staff and the public; monitoring for recurrences and reviewing the care after the outbreak has subsided; and recommending new or revised policies to handle similar events in the future.Review of the clinical record for Resident #1 revealed an admission date of 6/10/25. Diagnoses included Cerebral infarction (stroke), Spinal lesion, Failure to Thrive, Diabetes and Kidney failure.Review of the Quarterly Minimum Data Set (MDS) Assessment with a target date of 9/19/25 noted the resident scored 15 on the Brief Interview for Mental Status (BIMS), indicative of intact cognition.Review of the progress notes revealed on 10/17/25, the Advanced Practice Registered Nurse (APRN) assessed Resident #1 for a complaint of a rash underneath his thighs.Review of the Medication Administration Record (MAR) for October 2025 revealed a physician's order to apply Permethrin 5% external cream (used to treat scabies infections) to the body topically one time a day for rash. The MAR showed documentation Resident #1 was treated with the Permethrin as ordered on 10/22/25.Review of the care plan initiated on 10/28/25 revealed Resident #1 has a Rash/Scabies.The goal was for the resident to verbalize an acceptable level of comfort from itching and will follow the recommended treatment for the alleviation of scabies.On 11/4/2025 at 3:30 p.m., Resident #1 was observed on the patio. He had noticeable bites marks to his arms and legs. In an interview, the resident said he's had the rash for a month. Resident #1 said he received treatment for scabies since he first mentioned it but did not want to go through it again as it burned his skin. The resident said the rash was better since it was treated but he was still itching and needed to see a dermatologist. He said, They need to do something about this itching!. Resident #1 was observed constantly scratching his arms and legs during the interview.Review of the clinical record for Resident #2 revealed an admission date of 2/2/24. Diagnoses included Chronic Obstructive Pulmonary disease, heart disease, and chronic pain syndrome.Review of the Quarterly MDS with a target date of 8/9/25 revealed Resident #2 scored 15 on the BIMS, indicating intact cognition.Review of the progress notes revealed the APRN saw Resident #2 on 10/18/25 for vesicular lesions, some open, around and on her lips. The APRN documented on 10/24/25 Resident #2 was seen for a rash on her arms, hands, face and neck. The areas appear to be a bite in nature but it was less likely scabies since the rash was not disseminated. It did itch but was not painful. The APRN documented the resident received one treatment of Permethrin but no improvement. Resident #2 was using hydrocortisone which seems to help.Review of the care plan initiated on 10/31/25 revealed Resident #2 had a rash/scabies. The goal was for the resident to verbalize an acceptable level of comfort from itching and follow recommended treatment for the alleviation of scabies.On 11/4/2025 at 2:50 p.m., in an interview with Resident #2 said she has been itching for about a month now. She said she was treated for scabies. It was better but she was still itching. She said she has asked multiple staff members to see a dermatologist. She said the cream they give her does not help the itching for long. During the interview, Resident #2 was scratching her right inner forearm where a rash was observed.Review of the clinical record for Resident #3 revealed an admission date of 12/17/22. Diagnoses included Dementia, Cerebral Infarction and Osteoarthritis.Review of the Quarterly MDS with a target date of 8/22/25 revealed Resident #3's BIMS was 08 which indicated moderate cognitive impairment.Review of the progress notes revealed on 10/21/25 the APRN documented Resident #3 had an extensive ongoing rash to the hands, arms, trunk and chest that was consistent with eczema/psoriasis versus fungal infection. She documented it was not responding to treatment. Had failed Triamcinolone (corticosteroid), oral Diflucan (antifungal), over the counter antifungals, Prednisone (corticosteroid). The resident was currently on Methotrexate (used to treat severe psoriasis) and Clobetasol (topical steroid), it does itch less.Review of the care plan initiated on 10/29/25 revealed Resident #3 has a rash/scabies. The goal was to verbalize an acceptable level of comfort from itching and follow recommended treatment for the alleviation of scabies.Review of the MAR for October 2025 revealed a physician's order with a start date of 10/29/25 for, Permethrin External Cream 5% apply to head to toe topically one time only for dry, scaley skin for 1 day. Apply to head to toe topically for rash for 1 day. Wash thoroughly after 8 hours.Further review of the clinical record revealed that on 11/3/25, Resident #3 was seen by the dermatologist. The dermatologist documented that the resident is a new patient who is being seen for a chief complaint of rash located on the arms, face, feet, hands and trunk. The rash is flaking itchy and painful and severe in severity. The rash has been present for months. The impression was dermatitis. Discussed biopsy but unable to perform biopsy due to unable to obtain consent for a procedure from healthcare proxy. Patient will return for follow up will consider biopsy at that time. Advised caregiver to bring necessary paperwork regarding healthcare proxy.On 11/4/2025 at 3:15 p.m., in an interview the APRN said he treated the residents even when their symptoms first started. He said he still did not feel that any of the cases were scabies but he could not prove it because the skin test was not available. He said he agreed that when the first 2 residents were treated for scabies it would have been good practice for the facility to do a full skin sweep of all the residents and interview staff.On 11/4/2025 at 11:58 a.m., an interview was held with the Infection Preventionist and the Director of Nursing (DON) related to onset of rashes, documented scabies and interventions implemented to minimize the risk of spreading potential scabies.The DON said they did not do skin sweeps or isolate residents with symptoms until 10/28/25 when an investigator showed up to investigate a complaint of possible scabies in the facility. The infection preventionist said a total of 29 residents and 15 staff members were treated for scabies. 11 of the 29 residents were treated prophylactically due to being the roommate of a resident with symptoms. She said 7 residents were still symptomatic and would be retreated.

Based on resident and staff interviews, medical record reviews and a facility policy review, the facility failed to protect the resident's right to be free from neglect by leaving the resident unattended during incontinent care and not adequately training staff in resident care, thereby allowing the resident to fall off the bed which resulted in a serious injury for 1 Resident, (Resident #1), of 3 residents reviewed for neglect. The findings included:Review of the facility's policy for Abuse, Neglect, Exploitation and Misappropriation effective 11/30/2014 and last revised 11/16/2022 stated, It is inherent in the nature and dignity of each resident at the center that he/she be afforded basic human rights including the right to be free from abuse, neglect, mistreatment, exploitation and/or misappropriation of property . Neglect is the failure of the center, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress. Examples include failure to take precautionary measures to protect the health and safety of the residents.It was reported on November 12, 2025, that Resident #1 was receiving incontinent care by Staff A, CNA (Certified Nursing Assistant). Staff A, CNA admitted to leaving Resident #1's bedside to dispose of brief and to get towels. Staff A, CNA left Resident #1 lying on her side on the edge of the bed unattended. Resident #1 fell off the bed and obtained a laceration to her head and subdural hematoma (bleeding in the brain) requiring a higher level of care.Medical record review revealed Resident #1 was admitted to the facility on [DATE] with diagnosis including Heart Failure, Atrial Fibrillation, Repeated Falls, Hypothyroidism, Obesity, Hypertension, Aortic Stenosis with insufficiency, Mood disorder, cardiac pacemaker, and Dementia.The Brief Interview for Mental Status (BIMS) Assessment completed on 8/22/2025 revealed a score of 5/15 which indicates severely impaired cognition.The Care Plan Report provided by the facility in effect during the time of Resident #1's fall revealed a requirement that included rolling resident from side to side, side to back, and dependent with 1-2 staff assist.Record review for Resident #1 showed a Nursing Progress Note dated 11/12/2025 at 10:35 a.m., which stated, CNA notified this nurse that resident is on the floor. Upon entry, resident is laying on the floor between bed A&B. A pool of blood observed by resident's head Resident #1 was transferred to hospital via EMS at approximately 10:30 a.m.The facility conducted an investigation of Resident #1's fall. The investigation included a witness statement given by Staff A, CNA which read, I was cleaning up Resident #1 and as I threw away her soiled diapers I went to search for a towel in one of the cabinets. She was on her side the whole time. I didn't have any problems cleaning her before, so I assumed she was OK. She then immediately said she was sliding off the bed. I turned around to help her, but I couldn't reach her in time, and she slid off the bed and fell down. I immediately grabbed the nurse, and I started to help with towels.On 11/24/2025 at 1:06 p.m., during a telephone interview with Staff A, CNA said he was cleaning Resident #1 when he turned away for just a second to throw away her brief and she fell out of bed. He said that he didn't know her very well and was not aware that she required a one to two person staff assist with turning and repositioning. He said before she fell, he hadn't been trained to look up how to find specific information about residents in the Kardex (Computer program accessible by CNA's to access patient information).On 11/24/2025 at 12:30 p.m., during an interview the APRN (Advanced Practice Nurse Practitioner), said he was not present when Resident #1 fell out of bed, but the nurse immediately came and got him. When he saw the resident, she was lying on her back and bleeding from her head. He said Staff A, CNA, was providing care when the resident rolled out of bed. The resident was on blood thinners, so they transferred her out immediately to a higher level of care. She was in the hospital for a couple of days and then returned to the facility. She had a diagnosis of non-surgical subdural hematoma.On 11/24/2025 at 3:48 p.m., the Director of Nursing (DON) said that Staff A, CNA, was performing incontinent care when he went to dispose of a brief and wash his hands. She said Staff A, CNA left the patient laying on her side on the edge of the bed and staff are supposed to ensure residents are in safe position prior to leaving bedside. The Resident was not left in a safe position and this is when Resident #1 fell out of bed. The DON could not verify that Staff A, CNA, had received training for the Kardex prior to Resident #1's fall. She said, I did the training after the fall.On 11/24/2025 at 3:55 p.m., the facility Administrator said he was aware that Resident #1 had received an injury during care but the staff member followed the residents care plan.

Based on record review, and staff interviews, the facility failed to provide adequate supervision to prevent falls with major injury for 1 (Resident #5) of 3 residents reviewed for falls.The findings included: Facility policy titled Falls Management Revision Date 7/29/2019 indicated: Fall mitigation strategies included developing resident centered interventions based on resident risk factors.Record Review of the facility provided incident log revealed Resident #5 had 5 falls between 12/14/25 and 1/6/26.Review of Resident #5's progress notes reveal on 12/14/25 resident was found on the floor and assisted back to bed with no change in condition noted at that time. On 12/16/25 resident was noted in nursing progress note to have inverted left lower extremity and shortening of the left lower extremity. An order was obtained to send Resident #5 out to the emergency room (ER). Resident returned from the ER the same day with a diagnosis of pubis ramus fracture. Nursing progress note on 12/20/25 indicated Resident #5 was found on the floor, half in and half out, of his bathroom. Head to toe assessment revealed no injuries.Nursing progress note on 12/25/25 indicated Resident #5 had an unwitnessed fall and hit his head. No other injuries and no complaint of pain. Order received to send to ER due to being on blood thinner medication. Resident #5 returned from the ER later that same day with no new orders.Nursing progress note on 12/27/25 indicated Resident #5 had an unwitnessed fall and was found lying on his right side on the floor in his room. Resident said he stood up to straighten his bedside table, lost balance and slid down to floor. No injuries at that time.Nursing progress note on 1/6/25 indicate Resident #5 was found sitting on floor in front of his door. Resident said he was trying to close door and ended up sliding down to the floor. Resident #5 sustained a small skin tear to his left knee.Provider's progress note on 1/7/26 indicated Resident #5 had complaints of hip and groin pain. A stat x-ray was ordered and revealed a complete fracture of the left femoral neck with superior lateral displacement. Additionally, a pubis ramus fracture was identified on the imaging. Due to the displacement and complete fracture an order was placed to transfer to the ER. Nursing progress note on 1/10/26 indicated resident was readmitted to the skilled nursing facility following left hip surgery with 38 staples in place.Provider progress note on 1/13/26 indicated Resident #5 had returned to the facility on 1/10/26 following a left hip repair secondary to a mechanical fall. Resident #5's orders included: physical therapy, fall mats, low bed when in bed, and scoop mattress.Certified Nurse Assistant (CNA) Kardex indicated under safety to ensure resident is wearing appropriate footwear/nonskid socks when ambulating or mobilizing in wheelchair and ensure the resident has unobstructed path to the bathroom. Kardex also indicated under bed mobility: bed in low position.Resident #5's care plan addresses fall risk with interventions including bed in low position, appropriate footwear, physical therapy, fall mats, frequent checks every 15 minutes, hand bell to assist with calling staff, offer toileting every 2 hours. On 1/14/26 at 2:59 p.m., Staff F (CNA) said she was taking care of Resident #5. She said she watches for falls and checks on him every 2 hours, but that was not documented anyplace. She said he was a fall risk, and his bed was kept low. On 1/14/26 at 3:01 p.m., Staff G (CNA) said he has worked with Resident #5, and he was an assist to the restroom. Staff G said earlier that day he found Resident #5 standing at the side of his bed. Staff G said Resident #5 hadn't fallen, but he gets on the side of the bed sometimes, he did his own thing. Staff G said Resident #5 hadn't been incontinent. Staff G said he had seen him in bed when he passed his lunch tray and when he went back in to pick it up was when he found him standing at the side of the bed. On 1/14/25 at 1:56 p.m., the Physical Therapist (PT) said they began working with Resident #5 when he came back from the 12/14/25 pelvic fracture. PT said she doesn't think Resident #5 remembers he can't get up by himself anymore. She said he needed assistance, but he tries to get up by himself and doesn't call for help. She said they have tried to educate him as much as possible, did the low bed, added fall mats and several other interventions, but he had a habit of doing what he wanted to do. Saying Resident #5 was very independent minded. PT said they continue to work with him, both Occupational and Physical therapy, trying to reinforce safety awareness. On 1/14/26 at 1:25 p.m., the Director of Nursing (DON) said she was aware of Resident #5's multiple falls. She said all his falls have been unwitnessed and they have placed gripper socks, 15-minute checks, 2-hour toileting, fall mats, scoop mattress, bed in low position, a hand bell to ring, but he gets up and walks on his own. The DON said Resident #5 had dementia, poor safety awareness, was forgetful, had confusion, and was non-compliant. On 1/14/26 at 3:30 p.m., the Administrator said, I don't know what you want us to do, we can't tie him down.

Based on observation, interview and record review the facility failed to ensure staff followed safety precautions to prevent avoidable accidents or potential for accidents for 3 (Residents #892, #66 and #442) of 3 residents reviewed.The findings included:1. Review of Notification of Change in Condition Policies and Procedures effective date 11/30/2014, revision date 12/16/2022 states the Center to promptly notify the Patient/Resident, the attending physician, and the Resident Representative when there is change in the status or condition. The nurse to notify the attending physician and Resident Representative when there is a(n) accidents, significant change in the patient/resident's physical, mental, or psychosocial status. Need to alter treatment significantly: new treatment, adverse consequences, acute condition, or exacerbation of a chronic condition. The nurse to complete an evaluation of the Patient/Resident. Document evaluation in the medical record. Document resident/patient change in condition on 24-hour report. Complete SBAR as indicated.Review of Skin Evaluation Policies and Procedures effective date 11/30/201, revision date 4/1/2017 states a licensed nurse will complete a total body evaluation on each resident weekly, paying particular attention to any skin tears, bruises, stasis ulcers, rashes, pressure injury, lesions, abrasions, reddened areas and skin problems. A licenses nurse will complete a total body evaluation on each resident weekly and document the observation on the Skin Evaluation form. The evaluating nurse must date and sign each review. If a resident is assessed as having a skin problem, the evaluating nurse will initiate the appropriate form. For pressure areas, complete the Pressure Injury Record. For all other skin conditions, complete the Non-pressure Skin Condition Record.1. Review of medical record revealed Resident #892 was admitted to the facility on [DATE] with diagnosis including acute osteomyelitis (bone infections) left ankle and foot, cellulitis (bacterial infections), Peripheral Vascular Disease (reduced blood flow to arms and legs), Non-pressure chronic ulcer of skin of other sites (open sore) with necrosis (dead or dying tissue) of the bone.The admission Minimum Data Set (MDS) Assessment with a target date of 6/5/25 revealed a Brief Interview for Mental Status (BIMS) Resident #892 scored a 15 indicating intact cognition. Review of the Section for Skin Condition revealed there was no burn on admission. On 6/23/25 at 9:00 a.m., observed Resident #892 with tan bandage to right inner thigh. 6/22 was written in black felt marker on the bandage edge. The resident said he spilled the hot coffee the facility served him and he got the burn. The resident said it happened about a week ago and the facility knew about it. Resident stated the facility placed the 6/22 bandage over the burn. (photographic evidence obtained)On 6/24/25 at 9:07 a.m., observed Resident # 892 with new, undated bandage to right inner thigh. (photographic evidence obtained)Review of Treatment Administration Record (TAR) revealed weekly skin sweeps every day shift every Sunday dated 6/1/25. Treatment administration record 6/22/25 was signed by Registered Nurse (RN) Staff B.Review of Weekly Skin Integrity by the facility revealed 6/1/25 open areas to left lower extremity, treatment in place; 6/10/25 left lower leg venous ulcer being treated/followed by wound care; 6/15/25 left lower leg venous ulcer being treated followed by wound care/treatment in place; There was no weekly skin integrity completed for 6/22/25.On 6/24/25 at 04:02 p.m., Registered Nurse (RN) Staff B said she heard about Resident #892 spilling his coffee on his leg. Staff B stated, It looks like a burn. She said she did not place a bandage over it and she did not document on it. Staff B checked the resident's orders and said there was no order to place a bandage on the right thigh or any treatment order for the burn. Staff B said with an injury like a burn you need to call the doctor, document a change in condition assessment, notify the next of kin, and write an order for any treatment. On 6/24/25 at 4:15 p.m., in an interview with the Assistant Director of Nursing (ADON) RN, she said she did not know about the burn the resident got at the facility. On 6/24/25 at 4:21 p.m., in an interview with Staff E, RN, Unit Manager (UM) said she did not know about the burn to Resident # 892's right inner thigh. She said she did not know who placed the bandage on the burn. She said someone should have notified the physician, obtained an order, completed a change in condition, and initiated an incident report. Staff E, RN UM said there should always be a treatment order to apply a bandage.On 6/24/25 at 5:07 p.m., the Director of Nursing (DON) said it was very concerning there was no order, no treatment, and it was not reported. She stated, No nothing. She said the burn should have been reported. She stated, You can tell it's a burn, it's a good size.On 6/25/25 at 12:12 p.m., observed a wound to Resident #892's right inner/upper thigh. The wound was approximately 2.5 inches in length by 2 inches in width. The top layer of skin had peeled away revealing bright pink flesh. (photographic evidence obtained). On 6/25/25 at 3:22 p.m., in an interview with the DON and the Regional Nurse they said there was no investigation for the burn because it was not reported by the nurse(s). They said they just began an investigation. They said they started education on change in condition, initiating an incident report in risk management, notifying the physician and emergency contact. They said they completed a full house skin sweep and are collecting staff statements as part of the investigation. On 6/26/2025 at 2:45 p.m., in an interview with Staff B RN, she said she was the nurse for Resident #892 on 6/20/2025, 6/21/2025, and 6/22/25. She said she didn't complete a Weekly Skin Assessment because she was too busy that Sunday and didn't get around to it. 2. Review of medical record revealed Resident # 66 was admitted to the facility on [DATE] with diagnosis including but not limited to Acute embolism (an obstruction of a blood vessel by a floating clot) and thrombosis (when a clot forms inside a blood vessel) of left tibial vein (deep vein in your lower leg), congestive heart failure (heart doesn't pump blood as well as it should), generalized anxiety disorder, muscle weakness, and difficulty walking.The admission Minimum Data Set (MDS) Assessment with a target date of 5/12/25 revealed a Brief Interview for Mental Status (BIMS) Resident #66 scored a 15 indicating intact cognition.Review of care plan dated 5/23/25 reveals Resident #66 has an alteration in usual functional performance in mobility/transfer status related to congestive heart failure, anxiety, depression, weakness, and impaired mobility. Interventions include chair to bed, bed to chair transfer Resident #66 is dependent with staff assist.The admission Minimum Data Set Assessment with a target date of 5/12/25 noted the resident was dependent on staff for chair to bed transfer (Helper does all of the effort. Resident does none of the effort to complete the activity). Review of CNA Kardex indicated Resident #66 is dependent with staff assist for transferring.Review of the facility list of residents who require a mechanical lift with assist of 2 staff to transfer from chair to bed, bed to chair include resident #66. On 6/23/25 at 2:13 p.m., Certified Nursing Assistant (CNA) Staff C, was observed in the room with Resident #66 and the Hoyer Lift. (A Hoyer Lift is a type of mechanical lift whereby 2 staff are recommended while using in healthcare facilities.) Resident #66 was sitting in a wheelchair. Staff C said he operated the Hoyer Lift alone while he transferred Resident #66 about 6 feet from the bed to the wheelchair. He said he knew he was supposed to have another staff with him, but he could not find anyone, so he transferred the resident with the Hoyer Lift alone. On 6/23/25 at 2:20 p.m., the DON asked Staff C if he transferred Resident #66 with the Hoyer Lift by himself. Staff C confirmed he used the Hoyer Lift without another staff. The DON said Staff C had just completed the Skills training including Hoyer Lifts and should have known better. The DON said the staff are trained to use 2 for the Hoyer Lifts. The CNA did not follow the training. Review of Mechanical Lift Skills Competency Assessment bullet #2 states 2 staff members are used during transfer. Review of Mechanical Lift Skill Competency Assessment for Staff C, CNA 3/12/25 reveals Staff C is competent to perform a mechanical life transfer independently and without supervision. The Competency Assessment was evaluated and signed for by the DON on 3/12/25.On 6/23/25 at 2:30 p.m., the DON started education on safe use of the full body mechanical lift using two staff members. Review of the facility's Fall Management policy and procedure, dated 11/30/2014, with a revision date of 7/29/2019, stated in the overview: A fall refers to unintentionally coming to rest on the ground, floor, or other lower level, but not as the result of an overwhelming external force . Unless there is evidence suggesting otherwise, when a resident is found on the floor, a fall is considered to have occurred .Post Fall Strategies: 1. Resident will be evaluated and post fall care provided. 2. Initiate neurological checks as per policy or directed by physician order. 3. Notify the physician and resident representative. 4. Re-evaluate fall risk utilizing the Post Fall Evaluation. 5. Update Care plan and Nurse Aide Kardex with intervention(s). 6. Initiate post fall documentation every shift for 72 hours. Review of the facility's incident log revealed on 6/9/25 the facility conducted a fall investigation for Resident #442. Review of the facility's investigation related to Resident #442's fall revealed on 6/7/25 around 3:00 a.m., Resident #442's roommate was awakened by Resident #442 falling out of his bed and hitting the floor. Resident #442's roommate called for help, and a female Certified Nursing Assistant (CNA) came to the room, saw Resident #442 on the floor and went to get Resident #442's nurse, Licensed Practical Nurse (LPN) Staff A. The investigation noted: LPN Staff A came to the room a couple of minutes later with a male CNA. LPN Staff A asked Resident #442 several questions and put Resident #442 back into his bed. Staff A did not document in Resident #442's medical record that he was found on the floor on 6/7/25 around 3:00 a.m. LPN Staff A did not assess Resident #442 prior to placing the resident back in bed, did not initiate neurological checks as per facility policy, did not complete a Post Fall Evaluation form, and did not notify Resident #442's primary care physician (PCP) and resident representative. LPN Staff A LPN did not inform Registered Nurse (RN) Staff B that Resident #442 was found on the floor around 3:00 a.m. that morning as required during the morning shift change report. RN Staff B entered Resident #442's room around 12:30 p.m. The resident stated that he was nauseous and had a headache. Resident #442's roommate informed RN Staff B that Resident #442's headache could be related to the fall he had that morning. Resident #442 verified he sustained a fall that morning. RN Staff B notified the Advanced Practice Registered Nurse of Resident #442's fall and complaint of nausea and headache. The APRN Said she was not notified of the fall and would be at the facility within 45 minutes to assess the resident. He issued an order for Zofran to control Resident #442's nausea and vomiting. The APRN arrived at the facility, assessed Resident #442 and issued an order to transfer Resident #442 to an acute care hospital for further evaluation. The APRN documented the hospital admitted Resident #442 with a diagnosis of head injury/concussion. On 6/25/2025 at 11:30 a.m., in an interview RN Staff B said on 6/7/25 LPN did not inform her Resident #442 had fallen that morning. RN Staff B stated she was not aware of the resident's fall until 12:30 p.m. when he complained of nausea and reported the fall to her. She assessed Resident #442 and notified The APRN of the resident's fall and complaint of nausea and headache. She said when a resident falls, they are required to conduct a fall evaluation at that time and provide post-fall care. RN Staff B said that the nurse should notify the physician, the resident's family, the Unit Manager, the DON and/or the Assistant Director of Nursing as soon as possible. The nurse should also initiate neurological checks if they think the resident hit their head during the fall. On 6/25/25 at 12:00 p.m., in an interview the APRN said on 6/7/25 RN Staff B notified him via text of Resident #442's fall that occurred at approximately 3:00 a.m. that morning. He gave an order for medication for the resident's nausea and vomiting and came to the facility to assess Resident #442. The APRN said Resident #442 was stable when he assessed him but issued an order to transfer him to the hospital for further evaluation. Resident #442's representative was at the facility and chose to drive him to a hospital of their choice. The APRN said when a resident has a fall, the nurse is required to conduct a post-fall assessment, notify the resident's primary care physician, initiate neurological checks, document their assessment and physician orders in the resident's medical record. The APRN confirmed LPN Staff A did not notify him or the physician of Resident #442’s fall. On 6/25/25 at 1:45 p.m., a joint interview was conducted with the DON and the ADON to review the process following a resident’s fall and review Resident #442’s fall investigation. The DON and ADON said their investigation verified that LPN Staff A did not document the resident's fall, did not follow post-fall protocol and did not notify the physician or on-coming shift for post-fall management.

Based on observation, interview and record review the facility failed to provide infection control standards for 2 (Residents #83 and #893) of 2 residents reviewed with urinary catheters.The findings included:Review of Infection Control Policies and Practices dated 2001, revised 2018 states the facility's infection control policies and practices are intended to facilitate maintaining a safe, sanitary and comfortable environment and to help prevent and manage transmission of diseases and infections. Bullet # 2 states the objectives or our infection control policies are to (a) prevent, detect, investigate, and control infections in the facility. Bullet #4 states All personnel will be trained on our infection control policies and practices upon hire and periodically thereafter, including where and how to find and use pertinent procedures and equipment related to infection control.Review of Urinary Catheter Policies and Procedures dated 11/30/2014, revised 9/19/2017 states Foley bag to be covered by a privacy bag to preserve dignity of resident and tubing should be off the floor.1. Review of medical record revealed Resident # 83 was initially admitted to the facility on [DATE], the most recent admission date on 6/5/25 with diagnosis including retention of urine (when the bladder doesn't empty completely), unspecified, other obstructive (blocking) and reflux uropathy (urine flows backwards), and sepsis (serious infection).The admission Minimum Data Set (MDS) Assessment with a date of 6/7/25 revealed a Brief Interview for Mental Status (BIMS) score of 12, indicating moderate cognitive impairment.Review of the current physician orders revealed Foley catheter size 16 French (Fr)/30 milliliter (mL) for diagnosis obstructive and reflux uropathy dated 5/14/25. Catheter-bag change as needed dated 5/2/25. Review of the medication administration records (MAR) showed Resident #83 is currently being treated for a urinary tract infection (UTI) identified on 6/22/25 with Levaquin (antibiotic) oral tablet 750 milligrams (mg) once a day for 10 days. Review of care plan initiated 5/15/25 revealed Resident #83 has an indwelling Foley catheter related to obstructive and reflux uropathy. The care plan goal (1) revealed the resident will be/remain free from catheter-related trauma through the review date (2) The resident will show no signs or symptoms of urinary infection through the review date. On 06/23/25 at 10:15 a.m., observed Resident #83 laying in bed. The urinary catheter drainage bag was laying on the floor next to the bed. On 6/23/25 at 10:18 a.m., Certified Nursing Assistant (CNA) Staff F went to the room and said the drainage bag should not be laying on the floor. The CNA said it is an infection control issue because of the germs on the floor. The CNA positioned the urinary drainage bag off the floor by hooking it onto the bedframe. Review of care plan on 6/24/25 revealed Resident #83 has a urinary tract infection related to ESBL (bacteria) in urine. Interventions include contact isolation: wear gowns and mask when changing contaminated linens. Place soiled linens in bags and close bag tightly before taking to laundry. Give antibiotic therapy as ordered. 2. Review of medical record revealed Resident #893 was admitted to the facility on [DATE] with diagnosis including but not limited to urinary tract infection and unspecified dementia. The MDS Assessment with a target date of 6/26/25 revealed a short- and long-term memory problems. Resident is alert to person only.Review of progress note dated 6/21/25 at 2:24 p.m., revealed nursing is reporting today that the resident has not much to void and is concern for potential retention.Review of progress note dated 6/24/25 at 12:14 p.m., revealed the resident developed urine retention over the weekend and Foley was inserted.Review of medical record revealed order 6/22/25 for Foley catheter, diagnosis: urinary retention. Size: 16Fr/5mL.On 6/23/25 at 9:56 a.m., observed Resident #893 with urinary catheter drainage bag without a privacy bag, laying on the floor. *On 6/23/25 at 10:01 a.m., the Director of Nursing (DON) was made aware of the catheter drainage bag laying on the floor next to the resident's bed. The DON stated, Yeah, I need to get that off the floor.*photographic evidence obtained

Based on observation, review of the clinical record, review of facility's policies and procedures, resident and staff interviews, the facility failed to provide the necessary care and services to maintain personal hygiene for 5 (Resident #7, #10, #24, #55 and #60) of 20 residents reviewed for activities of daily living (ADLs). The findings included: 1. Review of the clinical record revealed Resident #7 had a readmitted [DATE] with diagnoses including dementia, anxiety and muscle weakness. The Admission Minimum Data Set (MDS) (standardized assessment tool that measures health status in nursing home residents) with an assessment reference date of 11/30/22 documented Resident #7 required extensive assistance for personal hygiene and limited assistance for bathing. The MDS noted Resident #7's cognitive skills for daily decision making were moderately impaired. The care plan initiated on 12/1/21 noted staff were to provide a full bed bath when a shower could not be tolerated and to check nail length, trim and clean nails on bath days and as necessary. Review of the Certified Nursing Assistant (CNA) shower schedule showed Resident #7 was scheduled for showers on the evening shift on Tuesdays, Thursdays, and Saturdays. On 1/3/23 at 1:54 p.m., Resident #7 was observed in his wheelchair in the day room. The resident's fingernails were long, extending 1/2 inch from the base, with a brown substance under the nail beds. The resident said he did not like to have his nails long. Resident #7 looked disheveled with a beard growth of approximately three days. On 1/4/23 at 8:50 a.m., Resident #7 was observed in bed wearing the same clothing as 1/3/23. There were pieces of food on the right side of his shirt from the morning meal. On 1/5/23 at 9:05 a.m., Resident #7 was observed in bed wearing the same clothing from 1/3/23 and 1/4/23. Review of the CNA documentation for November 2022 documented Resident #7 received a bed bath on 11/19/22 and 11/24/22, refused bathing on 11/22/22 and received a partial bed bath on 11/26/22. The CNA documentation showed no additional documentation Resident #7 received his scheduled showers or bed baths. Review of the CNA documentation for December 2022 documented resident #7 received a bed bath on 12/1/22. The CNA documentation showed no additional documentation Resident #7 received scheduled showers or bed baths for December 2022. On 1/4/23 at 9:16 a.m., CNA Staff B, said the CNA documentation since September 2022 was completed by hand on paper and was located in a white binder at the nurse's station. The CNA said they were charting on the computer now. A review of the CNA Binder showed one CNA ADL Tracking Form for Resident #7 without a date to indicate the month or the year the form was completed. On 1/4/23 at 9:28 a.m., Unit Manager Licensed Practical Nurse (LPN) Staff A said the CNAs were documenting ADLs in the CNA books on paper. LPN Staff A verified there was no date, including the month and year on the CNA forms. LPN Staff A said the sheets in the book were for December 2022 and said she would take the book and date the forms. On 1/4/23 at 9:42 a.m., the Director of Nursing (DON) said the CNA forms in the CNA binder were for the month of December 2022. The DON confirmed there was no date on any of the forms in the binder and without a date there was no way to verify when the forms were completed. On 1/5/23 at 10:31 a.m., the DON confirmed Resident #7's fingernails extended approximately 1/2 inch with an accumulation of brown substance underneath. 2. Review of the clinical record revealed Resident #24 had a readmitted [DATE] with diagnoses including dementia, anxiety, and muscle weakness. The Admission MDS with an assessment reference date of 11/28/22 documented Resident #24 required extensive assistance for personal hygiene and bathing. The MDS noted Resident #24 had no impairment in cognitive skills for daily decision making. The care plan initiated on 2/27/19 noted Resident #24 preferred bed baths three times a week and as necessary. On 1/3/23 at 11:00 a.m., Resident #24 was observed in her room in bed. The resident's fingernails were approximately 1/2 inch in length and there was brown substance under nail beds. Resident # 24 said a girl here was supposed to cut them every week but sometimes she does not get them done. She said she receives bed baths but not as often as she would like. Resident #24 said sometimes, I don't get my scheduled bed baths. On 1/4/23 at 12:58 p.m., Resident #24 said was observed in bed dressed in the same clothing as the previous day (1/3/23). The resident said, I don't always get my bed baths. Resident #24 said the CNA said maybe if she had time this afternoon, she would give her a bath. Resident #24 fingernails were long with brown substance under the nails. She said, they will be cut today, I hope. Review of the CNA shower schedule showed Resident #24 was scheduled for bed baths on the day shift on Mondays, Wednesdays, and Fridays. Review of the CNA documentation showed no documentation Resident #24 received the scheduled bed baths for November and December 2022. On 1/5/23 at 9:55 a.m., the DON said the expectation for CNA's was to follow the shower schedule and document the care provided. The DON said, if a resident declined care, then the nurse was to document it in a progress note. 41905 3. Review of the Policies and Procedures for Bathing/Showering (N1130) revised 9/1/17 revealed assistance with showering and bathing will be provided at least twice a week and as needed to cleanse and refresh the resident. The resident shall be asked on admission to establish a frequency schedule for bathing. On 1/3/23 at 11:06 a.m., Resident #60 said she is supposed to get a shower twice a week but the last time she had a shower was on 12/26/22 when she had loose stools. She said she was not permitted to shower without staff because she could slip and fall. She said she recently refused showers at 7:00 a.m., and 11:00 p.m., because it was too early and too late. She said she wanted to have a shower twice a week like she is supposed to. Review of the South Station Shower List revealed Resident #60 was scheduled to receive showers on Fridays 7-3 shift and Tuesdays 3-11 shift. Review of the Skin Observation sheets for Resident #60 revealed on 12/3/22 Resident #60 refused a shower and requested to be showered in the morning. Resident #60 also refused a shower on 12/17/22 and received a shower on 1/5/23. No other skin observation was noted in the binder for Resident #60. On 1/5/23 at 10:07 a.m., the Director of Nursing said the certified nursing assistants (CNAs) should be documenting personal hygiene care on individual Skin Observation sheets. On 1/5/23 at 3:34 p.m., Resident #60 said when she was admitted to the facility four months ago, showers were not mentioned. She said she assumed she would get a shower once a week, but her showers are not even that often. On 1/6/23 at 9:30 a.m., Certified Nursing Assistant Staff I said residents are supposed to get showers twice a week or whenever they want one. She said Resident #60 required assistance with showers. On 1/6/23 at 9:48 a.m., Licensed Practical Nurse Staff A said the CNAs did not tell her Resident #60 refused showers. She would write a progress note about the refusal so the interdisciplinary team was aware of the refusal via the 24 hour report. On 1/6/23 at 10:10 a.m., the Director of Nursing (DON) acknowledged the lack of showers for Resident #60. She said the CNAs are to shower according to the Shower List and document findings on the Skin Observation sheets contained in the binder at the nurse's station. On 1/6/23 at 2:00 p.m., the DON said she reviewed Resident #60's progress notes and there was nothing about Resident #60 refusing showers. 46824 4. Clinical record review for Resident #55 revealed a date of admission of 11/17/22. The Admission MDS dated [DATE] noted the resident's cognition was intact. The MDS noted it was very important for the resident to choose what clothes to wear, and choose between a shower, tub bath, bed bath or sponge bath. Resident #55 was dependent on staff for bathing. Resident #55 Care plan, revised on 9/24/22, stated the resident has an ADL self-care performance deficit related to diagnosis of low back pain, Muscular Dystrophy, Hiatal Hernia, Impaired balance, and limited mobility. The goal was to improve the current level of function in ADL tasks. The interventions included checking nail length, trimming and cleaning on bath day, and, as necessary, providing a sponge bath with a full bath or shower cannot be tolerated; the resident requires total assistance from one-two staff with bathing. The South station shower schedule noted Resident #55's showers were scheduled on Tuesdays, Thursdays and Saturdays during the day shift. The ADL tracking sheet revealed Resident #55 received three partial baths and no showers for December 2022. On 01/3/23 at 10:22 a.m., Resident # 55 stated, today is the 11th day without a shower. I asked for a shower today, and they said they don't have any soap. On 01/4/23 at 9:15 a.m., resident #55 stated, I did not shower yesterday or today, now 12 days. He said he asked the Certified Nursing Assistant who said once the state leaves, they will be able to shower him because they will have more time. On 1/5/23 at 9:39 a.m., CNA Staff D said she has been working in the facility through an agency on and off for five years. She confirmed there was a shower book at the nursing station to check daily for scheduled showers. She said she did not recall resident #55 ever refusing care. On 1/5/23 at 10:31 a.m., the Director of Nursing (DON) said she expected showers to be done according to schedule. She said she would speak to the staff right away about Resident #55's showers. On 1/5/23 at 3:01 p.m., the DON reviewed shower logs showing resident #55 had not been showered in 12 days. The DON confirmed showers were a problem and would work on it. On 1/6/23 at 2:31 p.m., Resident #55 stated, I felt like hell when I didn't get showered. It made me feel like I didn't want to be around anyone because I stunk. 22651 5. Review of resident #10 medical records revealed and admitted [DATE] with diagnoses including anxiety disorder and depression. The Admission MDS assessment dated [DATE] noted Resident #10 was cognitively impaired. The care plan initiated on 11/22/22, noted the resident had ADL self-care performance deficits. The interventions included to assist with personal cleaning, grooming and dressing every day and as needed, provide assistance with bathing/showering. On 1/3/23 at 3:19 p.m., observed Resident #10 sitting on the side of the bed. Resident #10 would not answer any questions. Resident #10's hair looked greasy, stringy. The spouse said he could not remember the last time the resident received a shower. The shower schedule noted Resident #10 was to have a shower three times a week, on Mondays, Wednesdays, and Fridays. A review of the electronic CNA documentation for November and December 2022 showed documentation the resident received a partial bath on November 16, 2022. The facility provided a handwritten, undated CNA ADL tracking form with the resident's name with two showers and two partial baths. The form did not document the month. On 1/5/23 at 11:35 a.m., the Regional Nurse Consultant said it appears the resident had one bath in November.

Based on observation, record review, resident and staff interviews, the facility failed to ensure 2 (Resident #61 and #67) of 5 sampled residents for change in condition received appropriate care in accordance with professional standards of practice. The findings included: Facility policy and procedures (N-140) revised 3/3/2021 regarding physician orders stated, the center will ensure that physician orders are appropriately and timely documented in the medical report. The Clinical Nurse 1 job description duty and responsibilities listed conduct a thorough evaluation of each residents' medical status upon admission and throughout the resident's course of treatment and assist in the implementation of an individualized treatment plan for each resident assigned. 1. Clinical record review revealed Resident #61 was admitted to the facility on [DATE]. Diagnoses included Heart Failure, and renal insufficiency. The physician order dated 11/17/2022 specified to apply knee-hi TED hose (compression stockings) to patients' legs bilaterally before patient gets out of bed every morning and remove bilateral knee high ted hose before bed every day. The care plan revised on 12/13/22 noted the resident had edema (swelling) to the legs, shortness of breath upon exertion. Resident #61 was not able to lay flat. The interventions included to apply TED hose as ordered for the edema to the legs. On 1/3/23 at 1:23 p.m., 1/4/23 at 9:03 a.m., and 12:19 p.m., and 1/5/23 at 11:05 a.m., Resident #61 was observed with bilateral lower extremity edema and resident #61 was not wearing compression stockings or TED hose. The skin around her ankles and lower legs was tight and shiny. On 1/4/23 at 9:03 a.m., Resident #61 said she would wear the compression stockings but has not had them since her admission to the facility. On 1/5/23 at 11:14 a.m., Certified Nursing Assistant (CNA) Staff C said she did not recall ever seeing resident #61 with TED hose and did not recall ever seeing TED hose in her room. She said she has never applied TED hose to the resident's legs. On 1/5/23 at 11:30 a.m., Agency Licensed Practical Nurse (LPN) E, confirmed the order for ted hose for Resident #61. She verified the resident was not wearing the ted hose as ordered. 41905 2. Review of the medical record for Resident #67 indicated an initial admitted [DATE]. Review of the of the Weekly Skin Integrity assessment dated [DATE] revealed documentaion of a bilateral lower extremity rash identified by Licensed Practical Nurse Staff J. On 1/3/23 at 3:05 p.m., observed bilateral lower legs of Resident #67. They were swollen and red with areas of dried blood. Resident #67 said the lower legs itch and burn so bad, he scratches them until they bleed. He said the nurse is aware of it, but he has not seen a doctor and the facility is not treating it. (See photographic evidence) On 1/5/23 at 10:27 a.m., Resident #67 said he still had the rash. He lowered his socks to reveal both lower legs swollen with redness and scratches with dried blood. On 1/6/23 at 9:37 a.m., CNA Staff I said she was aware of the condition of Resident #67's lower legs, she did not report it to the nurse as she assumed it was being taken care of. On 1/6/23 at 9:42 a.m., LPN Staff A said she was not aware of Resident #67's lower leg redness and scratching. She said any time a change in skin condition is identified, a progress note is written, and the doctor notified. On 1/6/23 at 10:03 a.m., the Director of Nursing (DON) said she was not aware of Resident #67's bilateral lower leg swelling, redness and scratches. She acknowledged the Weekly Skin Assessment on 1/2/23 identifying a new rash of the lower legs. The DON said the nurse should have also written a progress note and it would have been discussed in the 24-hour report with call to the doctor for direction. The DON said there was no skin treatment for the lower leg condition and this change in condition was overlooked. On 1/6/23 at 12:10 p.m., during a telephone interview LPN Staff J said she identified Resident #67's lower leg swelling, redness and scratching when she worked the night shift on 1/2/23. She said she forgot to write a progress note or contact the physician. She said she has not been back to work at the facility since 1/2/23.

Based on observations, interviews and record review, the facility failed to provide necessary services to prevent a decline in range of motion for 1 (Resident #41) of 2 sampled residents with limited range of motion. On 1/4/23 at 9:40 a.m., Resident #41 was observed in his room sitting in his wheelchair. His right wrist/hand was contracted. The resident was not wearing any positioning device or splinting to the area. Resident #41 said he had a right splint for the contracture, but it was misplaced during the evacuation after Hurricane [NAME] and needs to be remade. He said when he had his splint he wore it daily. Review of the clinical record for Resident #41 revealed the Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #41's cognition was intact. Resident #41 had a diagnosis of Cerebral Palsy. Review of the physician's orders revealed an active order for a right hand splint to be worn daily for 6 hours as tolerated, restorative was to apply/remove every day shift starting 9/11/20. Review of the Interdisciplinary Therapy Screen dated 12/15/22 revealed documentation, As per chart review and discussion with nursing staff, patient with significant increase in muscle tone resulting in increased tightness in right hand and wrist. Splint that was previously used for contracture prevention has been displaced since evacuation for Hurricane [NAME]. On 1/5/23 at 9:22 a.m., Resident #41 was observed in his wheelchair in the hall. He was not wearing a splint on his right hand/wrist. His wrist was bent forming a right angle between his palm and his inner forearm. On 1/5/23 at 4:22 p.m., Restorative CNA Staff F said Resident #41's right wrist splint was misplaced during the evacuation following Hurricane [NAME]. She said Resident #41 was good about wearing the splint and did not refuse to wear it. She said she thought the Rehabilitation Director was ordering another one. She said Resident #41 was not on schedule to receive Restorative Therapy while the splint was being manufactured and had not been on the restorative therapy schedule in a long time. On 1/6/23 at 9:05 a.m., the Rehabilitation Director confirmed Resident #41's splint had been misplaced, and was not sure how long the splint had been missing. The Therapy Director continued, Resident #41's tone has increased, and everything is tighter, indicating he has declined. She said Resident #41 was discharged from Occupational Therapy on 7/8/22. She said the splinting of the right hand/wrist continued but Restorative Therapy was not ordered for Resident #41. On 1/6/23 at 10:26 a.m., the Restorative CNA said the residents evacuated before hurricane [NAME]. She said she has not worked with Resident #41 for range of motion exercises since he was readmitted . The Therapy Department did not refer him.

Based on record review, policy review and staff interview, the facility failed to adequately ensure the immediate safety of other residents after an allegation of abuse to 1 (Resident#1) of 1 resident was reported. This failure allowed the alleged perpetrator access to other vulnerable residents. The findings included: Review of the facility policy Abuse, Neglect, Exploitation and Misappropriation, Document N-1265, Revision date 11/28/17 revealed Immediately upon an allegation of abuse or neglect, the suspect(s) shall be segregated from residents pending the investigation of the allegation. Review of the 5 day Nursing Homes Federal report to the State Survey Agency revealed on 8/26/21 the facility received a phone call from the daughter of Resident #1. She said Resident #1 sent her a text message that a staff member punched her in the stomach. The facility began an investigation which included notifying the police and the Department of Children and Families. Further review revealed the staff member (Licensed Practical Nurse, Staff A) being investigated on 8/26/21 was not immediately suspended pending results of the investigation and was allowed to return to work at the facility on 8/27/21 where he was the assigned staff nurse for residents on the B Hall. On 8/27/21, the staff member was interviewed on site by the police at approximately 11:00 a.m., and was then suspended. On 10/27/21 at 11:14 a.m., in a telephone interview, the facility Director of Nursing confirmed the staff member had not been suspended until mid-morning of the day after the alleged abuse and said I know, I should have suspended him immediately.

Based on observation and resident and staff interviews, the facility failed to maintain a safe, sanitary, and comfortable environment for residents, staff, and the public by not having clean surfaces; maintaining resident equipment in a sanitary manner; not repairing damaged shower rooms and pantry walls; and having heavily soiled/stained furniture in day room. Not maintaining a sanitary environment has the potential for cross contamination and biological growth (bio-growth). The findings included: On 3/21/21 at 12:40 p.m., in an interview, Resident #80 said he had osteo[DIAGNOSES REDACTED] (infection of the bone) in his left foot, had daily dressing changes, and was on antibiotics. The resident said he was concerned about the housekeeping in his bathroom, the shower rooms, and worried about getting an infection in his foot again. On 3/21/21 at 10:49 a.m., 3/21/21 at 2:21 p.m., 3/22/21 at 8:45 a.m., and 9:09 a.m., while touring the facility the following was observed: room [ROOM NUMBER] had three unlabeled, uncovered wash basins being stored on floor and the base of toilet was heavily stained with black bio-growth. **Photographic evidence obtained** The ceiling vent at room [ROOM NUMBER]'s entrance was heavily soiled with hanging dust, a dresser edge was chipped with exposed wood, and there was an unlabeled wash basin on floor. **Photographic evidence obtained** room [ROOM NUMBER]. The base of the bedside table was heavily stained, there was an unmarked wash basin stored on the floor next to the toilet, an unlabeled, uncovered bedpan was stored on the handrail next to the toilet, and the vent in ceiling was heavily soiled with dust. room [ROOM NUMBER]. The wheelchair at the foot of Bed-A had a heavily stained foam cushion without a cover on the seat, the restroom doorjamb was rusted, and black bio-growth was present on the silicone at the base of the toilet. The ceiling vent at the room's entry and ceiling tile next to vent were heavily coated with dust. **Photographic evidence obtained** room [ROOM NUMBER]. A bottle of unlabeled body rinse was present on the handrail in restroom and an unlabeled uncovered urinal was laying on the tank of toilet. The closet door edges were delaminated with exposed wood. The ceiling vent at the room's entry had hanging dust. **Photographic evidence obtained** room [ROOM NUMBER]. The overbed table base was soiled and rusty, the restroom doorjamb was rusty, a urinal was being stored uncovered on the handrail next to the toilet, and dust was hanging from the vent in the ceiling. **Photographic evidence obtained** room [ROOM NUMBER]. The floor mat was torn and soiled next to Bed-A. The edge of the dresser was delaminated with exposed wood. An unlabeled wash basin was stored on the floor of the restroom next to an uncovered toilet plunger under the sink. The ceiling tile around the sprinkler was delaminated in the restroom, the mirror was heavily de-silvered, the ceiling vent had hanging dust, and the towel bar was missing with exposed sharp edges on the bracket. The cove base was detached from wall next to the entrance door with sharp edges, and the walls were very marred. **Photographic evidence obtained** room [ROOM NUMBER]. Large clumps of dust were hanging from the ceiling vent at the room's entrance. **Photographic evidence obtained** room [ROOM NUMBER]. The floor was observed to be heavily stained with coffee. The resident's beside table base and top were also heavily soiled. On 3/21/21 at 2:06 p.m., Resident #28 said the coffee stain had been there for three days. room [ROOM NUMBER]. The bedside table was heavily soiled. The pole for the tube feeding machine and the bed frame were stained with tube feeding drippage. South shower room. Four unlabeled combs were observed together on the counter, soiled and stained grout in toilet room, a brown substance was present on the wall behind the toilet and in the front of toilet, the wall was cracked and crumbling at the first shower entrance, an unsecured oxygen tank was being stored on the floor next to the sink, the bedside commode covers were being stored on top of one another on the floor under the bench in shower stall 1, and wheelchair parts were on the floor under the bench. An overbed table had 2 nail clippers, an emery board, stacked, uncovered towels, and unlabeled body wash. Debris was present on the floor, two bedside commode buckets were stored on the floor in shower 2, an open container of body wash was stored on the floor, an open package with one razor blade was on the shelf in shower 3, soiled shower chairs, a commode bucket on floor shower 3, torn partially detached shower curtains, and a foul odor coming from drains. **Photographic evidence obtained** On 3/21/21 at 11:07 a.m., Licensed Practical Nurse (LPN) Staff D observed the unsecured oxygen tank, and confirmed it needed to be in a holder and not stored in the shower room. LPN Staff D said she had no knowledge of who placed the tank in the shower or to which resident the oxygen belonged. The North Shower room had a heavy accumulation of dust in the ceiling vents, the floors were heavily soiled with debris, open bottles of body wash were on a shelf, there was a missing towel bar with exposed sharp brackets on the wall of the shower, an uncovered dirty linen bin with soiled linen inside was present in the corner, a foul odor in shower stall 1, and the shower curtains were torn and missing hooks. **Photographic evidence obtained** South Pantry. The ice machine was visibly soiled with dust and debris, the walls had dried food debris on them and the ceiling vent was dusty, there was missing cove base behind the ice machine and refrigerator, the wall behind the ice machine had damaged drywall, and the floor was heavily soiled and had detached cove base. **Photographic evidence obtained** North Pantry. Heavy accumulation of dust present on the ceiling vent, the pantry had food stains on the walls, the metal vent behind the refrigerator had large amount of dust, the floor had a lot of debris, and a hole was present in the wall behind the ice machine. **Photographic evidence obtained** South Nurses Station. A wall mounted fan was heavily soiled with hanging dust and the floor was noted to be heavily soiled with clumps of dust. North Nurses Station. The floor was heavily soiled with stains and clumps of dust. South Day Room. There was debris on the floor behind the TV cabinet and the floor was heavily soiled. North Day Room. There were two heavily soiled armchairs, and a missing section of floor tile with exposed concrete and debris. Public Restroom Female. The ceiling vent had a heavy accumulation of dust. Public Restroom Male. The ceiling vent had a heavy accumulation of dust and a brown stain was present on the wall 3/22/21 thru 3/24/21. On 3/24/21 at 8:30 a.m., a tour of the facility was conducted with the Maintenance Director and Housekeeping Supervisor (HS). The noted concerns were still present during the tour. The HS Supervisor said staff did not have an effective method to clean the dusty vents and would be looking into a better way to do this. She acknowledged it was difficult for the housekeeping staff to clean around resident items that were improperly being stored on the handrails and floor.

Based on observation, policy review, and staff interview the facility failed to maintain the kitchen, nourishment rooms, and activity kitchen in a clean, safe, and sanitary manner that was in good repair by not having clean surfaces in food storage areas, clean surfaces on food preparation equipment, outdated/unlabeled food items, and not maintaining the ice machines in a manner to prevent potential contamination. The findings included: The facility's policy, Ice Machines and Ice Storage Chests, revised January 2012, stated Ice-making machines, ice storage chest/containers, and ice can all become contaminated by unsanitary manipulation by employees, residents and visitors and to help prevent contamination of ice machines Keep the ice scoop/bin in a covered container when not in use. On 3/21/21 at 10:05 a.m., during the initial kitchen tour the following observations were made: heavy accumulation of dust in ceiling vent at kitchen entrance; hole in wall by pipe in dry storage area; and storeroom ceiling vent dusty. The top of the dish machine was soiled with dry salts and debris, and a blue curtain laid on top of the dish machine. The hood above the dish machine was heavily corroded with rust and paint peeling from the metal. Storage/food transport carts had heavily rusted frames and the casters were soiled and rusted. On 3/21/21 at 10:05 a.m., and 3/23/21 at 11:05 a.m., observation revealed the walk-in freezer door did not completely close, creating an accumulation of icy condensation inside of the freezer door and frame. The shelves had debris under them, and floors were heavily stained/soiled. On 3/21/21 at 8:31 a.m., during an observation of south pantry, the area between counter and refrigerator was heavily soiled with spillage and debris and accumulated dust on edge of ice machine. There was broken drywall with a missing cove base behind ice machine with visible bio-growth. The floor was dirty and stained. The sink backsplash was visibly stained. On 3/22/21 at 8:58 a.m., during an observation of north pantry, the floor was heavily soiled with debris, wall was stained/soiled, the sides of the ice machine were soiled, the wall next to ice machine was damaged, and an ice scoop was being stored inside the ice machine. On 3/23/21 at 11:05 a.m., a tour of the kitchen was made with the Dietary Supervisor (DS) and the above concerns were again noted. She confirmed condensation was still present along the freezer door and it did not completely close. The DS said the issue with the freezer door had been ongoing for a couple months and several attempts had been made to repair it. Regarding the rusted equipment, the DS said she had removed 2 carts from use and confirmed the rusted legs of 3 of the carts were still in use. The south pantry was observed, and the DS confirmed there was no handle on the outside of the cover of the ice machine and difficult to close without placing her hand on the inside surface of the lid. Observation of the north pantry ice machine was made, and the DS confirmed there should not be an ice scoop inside the machine and removed it. The tops and sides of the machine still had a heavy accumulation of dust. The DS acknowledged the same issue with being unable to close the cover to the ice machine without potentially contaminating inside of lid. On 3/24/21 at 8:30 a.m., observation of the activity department kitchen revealed the refrigerator had several outdated items: An unopened jar of pizza sauce had a best by date of 9/13/19. **Photographic evidence obtained** An open container of partially green parmesan cheese had a best by date of 7/2/19. **Photographic evidence obtained** An open container of lemon bite pastry had a labeled date of 12/27/20. **Photographic evidence obtained** The cabinet next to the refrigerator had 2 muffin pans soiled with dried food debris. The Activity Director (AD) said she had food related activities and kept those items in the refrigerator. She confirmed the outdated items and removed them from potential use by residents. The AD said she did not know when the muffin pans had been used. On 3/24/21 at 10:34 a.m., in an interview, the Dietary Supervisor and Registered Dietitian confirmed they did not have access to the refrigerator in the activity room and did not monitor it for outdated items.

Based on record review, policy review, and staff interview, the facility failed to properly document and maintain complete and accurate records in the areas of health status and treatments for 3 (Residents #90, #60, #53) of 19 records reviewed. The findings included: The facility's policy and procedure for discharged records (Document MR-135), last revised on [DATE] noted To ensure required discharge documentation in a resident's closed medical record is accurate, complete, dated and signed by the appropriate individuals . Check that the physician's orders [REDACTED]. Check the final nurses' note for pertinent resident information which includes but is not limited to date and time of discharge, pronouncement if ceased to breathe/expired . final disposition. Check deceased resident's records for pertinent resident information, which includes but is not limited to notification of resident's family and physician, resident condition and vital signs prior to death and disposition of possessions and belongings. 1. On [DATE], during the record review of Resident #90's closed death record, it was discovered resident expired on [DATE]. No documentation was found in the resident record about the circumstances around the death event, how she was found or the event in the days and hours before the death. There was no documentation in the nursing progress notes the supervisor or doctor was called and informed of the resident's death. There was no written order to release the body to the funeral home. On [DATE] at 2:25 p.m., in an interview, the Director of Nursing (DON) said the nurse should have charted events surrounding the resident's death, any pertinent issues, call to the doctor and report of the death, family call and notification, when the funeral home was called or the deceased body was picked up. 2. The facility's policy for Administering Medications, revised [DATE], stated If a drug was withheld, refused or given at a time other than the scheduled time, the individual administering the medication should initial and circle the Medication Administration Record (MAR) space provided for that drug and dose. The individual administering the medication initials the resident's MAR on the appropriate line after giving each medication Topical medications used in treatments were recorded on the resident's Treatment Administration Record (TAR). On [DATE], a review of the clinical record for Resident #53 revealed a physician's orders [REDACTED]. The Medication Administration Record (MAR) for [DATE] lacked documentation the 2:00 p.m., dose of [MEDICATION NAME] was administered on ,[DATE] and the evening dose of [MEDICATION NAME] being administered on ,[DATE]. There was no documentation of the Biofreeze being applied on ,[DATE], ,[DATE], ,[DATE], ,[DATE], and ,[DATE]. Review of the February 2021 MAR for Resident #53 revealed there was no documentation of the medications [MEDICATION NAME], Atorvastatin, and bedtime doses of [MEDICATION NAME] and [MEDICATION NAME], being administered on ,[DATE]. The February Treatment Administration Record (TAR) lacked documentation of the Biofreeze being applied topically on ,[DATE], ,[DATE], ,[DATE], ,[DATE], ,[DATE], ,[DATE], ,[DATE], ,[DATE], ,[DATE], and ,[DATE]. Review of the [DATE] MAR for Resident #53 revealed there was no documentation of the medication [MEDICATION NAME] being given on ,[DATE] at 2:00 p.m., on ,[DATE] at 10:00 p.m. and ,[DATE] and ,[DATE] at 2 p.m. There was no documentation of [MEDICATION NAME] being given on ,[DATE] at 1 p.m. The January TAR lacked documentation of the Biofreeze being applied topically on ,[DATE], ,[DATE], ,[DATE], ,[DATE], ,[DATE], and ,[DATE]. 3. On [DATE] Resident #53's physician ordered treatment to the new open area on the resident's left heel. The area was to be cleaned with an antiseptic and a foam dressing to be applied every 48 hours. The resident's TAR lacked documentation of the dressing being done on ,[DATE] as ordered. On ,[DATE], the physician changed the dressing order to cleanse the left heel wound with normal saline, apply calcium alginate and a form dressing on each day shift. There was no documentation of the dressing being done on ,[DATE], ,[DATE], and ,[DATE]. On [DATE] at 12:55 p.m., in an interview, the Regional Nurse confirmed there was no documentation of the treatment being done to Resident #53's left heel until [DATE] after the initial dressing was applied on [DATE]. 4. Review of the clinical record for Resident #60 revealed a physician's orders [REDACTED]. The MAR for February 2021 lacked documentation of the medication [MEDICATION NAME] and [MEDICATION NAME] being administered the evening of ,[DATE]. The MAR for [DATE] lacked documentation of these 2 medications being given on the evening of ,[DATE]. On [DATE] at 1:17 p.m., in an interview, the DON said if a medication was not given then the reason code was to be noted on the MAR and this would prompt the nurse to write a progress note as to why. She confirmed the MARs for Resident #53 and Resident #60 did not indicate the reason for the medications being left blank.

Based on observation, record review, resident and staff interview, the facility failed to provide adaptive equipment necessary to promote psychosocial wellbeing for 1 (Resident #7) of 1 resident identified with a hearing deficit. The findings included: On 3/21/21, review of the clinical record showed a quarterly Minimum Data Set (assessment of resident functional capabilities and health needs) completed on 3/16/21. The assessment noted Resident #7 required a hearing device and had moderate difficulty hearing. The plan of care initiated on 3/17/21 documented Resident #7 had a communication problem due to difficulty hearing with interventions to apply a right ear hearing aid. The Certified Nursing Assistant (CNA) resident care Kardex specified the CNA was to apply the right ear hearing aid. On 3/21/21 at 9:09 a.m., during an initial observation Resident #7 was sitting in a wheelchair in her room, calling out and asking to have her hearing aid put in. On 3/22/21 at 9:16 a.m., during an observation Resident #7 was in her room in bed, she was calling out, I can't hear, I need my hearing aid put in. On 3/22/21 at 1:15 p.m., in an interview, Resident #7 said she wanted someone to put her hearing aid in and said she was not able to hear. Resident #7 was in her room, sitting in her wheelchair and the hearing aid was on the nightstand behind her and out of her reach. On 3/23/21 at 9:52 a.m., observation revealed the hearing aid for Resident #7 was on the nightstand and out of the resident's reach. Resident #7 said she could not hear and asked for the hearing aid. On 3/23/21 at 11:33 a.m., in an interview, CNA Staff B said she was assigned to work on Resident #7's hall very frequently and worked several days a week. Staff B said she worked with Resident #7 all the time and was aware Resident #7 had a hearing device for the right ear. Staff B confirmed she had not applied the hearing device for Resident #7. On 3/24/21 at 10:13 a.m., in an interview, Licensed Practical Nurse Staff A said the CNA's were responsible to assist residents with applying glasses and hearing aids daily and the task would be on the CNA care Kardex. On 2/24/21 at 10:57 a.m., in an interview the Executive Director said the facility had no policy for the application of resident glasses or hearing aids.

Based on observation and interview the facility failed to maintain the garbage storage area in a sanitary condition to prevent the harborage and feeding of pests. The findings include: Observation of the dumpster enclosure outside the kitchen on 8/26/20 at 11:25 a.m., with the Administrator and Maintenance Director, found the enclosure strewn with garbage and food debris from ripped open garbage bags. Maintenance and lawn debris were also strewn around the enclosure. There was evidence of animals rummaging through the garbage. (Photographic evidence obtained) The Administrator acknowledged the garbage was not properly contained and the enclosure was not kept clean.

Based on record review and staff interview, the facility failed to maintain a safe, and sanitary environment for residents, staff and the public by allowing a resident to misuse syringes and leave them unsecured for staff to be potentially injured by a needle. The findings included: Based on record review and staff interview, the facility failed to develop a behavioral plan to include an interdisciplinary approach to address the self-administration of nonprescribed medications and potential IV (into the vein) drug use for 1 (Residents #52) of 3 residents reviewed. The findings included: On 8/30/19 at 9:06 a.m., the DON said Resident #52 was admitted by his physician from the pain clinic. Review of the clinical record for Resident #52 revealed a history of chronic pain and substance abuse. The resident was on Embeda ([MEDICATION NAME]) daily for pain. A skilled nurse's note on 6/3/19 at 9:00 p.m., by Registered Nurse (RN) Staff A documented Resident #52 was seen by a Certified Nursing Assistant (CNA) with a needle. The physician was in the building and notified. The physician witnessed the needles and talked with the resident. Removed needles from resident room and placed in sharps container in locked utility room. At 11:30 p.m., RN Staff A noted physician orders [REDACTED]. On 6/16/19 at 6:00 p.m., RN Staff B documented Resident #52 had a used syringe and 3 pouches with pills in his room. All items were confiscated. The resident denied using IV drugs. The resident was educated in the dangers of using IV drugs as well as putting others at risk. Staff B noted the Director of Nursing (DON) was notified of the incident. On 8/30/19 at 9:00 a.m., the DON said staff thought they saw him with drugs. The DON acknowledged staff had reported paraphernalia such as a spoon with powder residue and syringes that weren't from the facility, but everything was care planned in regards to this behavior. On 8/30/19 at 9:06 a.m., the DON said his pain control physician did drug testing, Resident #52's bloodwork did not show any drugs other than the medications prescribed. Resident #52's medical condition is being carefully monitored. No change in medical condition has been observed. Documentation of education to resident. Offer was made to be transferred to drug rehabilitation unit, Resident #52 refused. Physician discontinued prescribed medication. No one has reported observing him shooting up again. The facility staff has requested to go through his things, he declines. Resident #52 wants to go home. Discharge to home has been arranged. Facility staff have been educated on universal precautions. On 8/30/19 at 10:15 a.m., Resident #52's care plan was reviewed. The problem of self-administering unknown medications was not identified. Licensed Practical Nurse (LPN) Staff C was present and confirmed this finding. Staff C said she was not witness to any of this behavior so did not develop a care plan for potiential IV drug use. On 8/30/19 at 3:00 p.m., the Social Services Director (SSD) said she developed resident behavioral care plans and was familiar with Resident #52 . She had not been informed of any issue with IV drug use or self-administering unknown medications in his room. The SSD said she has never been asked to develop any behavioral plan for him to address these issues. On 8/30/19 at 5:34 p.m., reviewed concern for staff and other residents being exposed to used uncapped needles in Resident #52's room. The Administrator acknowledged the concern and said he would be addressing the issue.

Based on observation and interview, the facility failed to ensure evening snacks were made available for 4 (Residents #10, #33, #13 and #64) of 4 residents interviewed and as reported by the resident council. The findings included: In an interview on [DATE] at 2:57 p.m., Resident #10 said she was a diabetic and usually needed a snack at bedtime. The resident said the nurse aides did not offer snacks at night. The resident there were no snacks specifically prepared for diabetics, but the aides would sometimes bring something if requested. An observation of the bedtime passing of snacks was conducted on [DATE] at 7:00 p.m. The evening nurse supervisor said the nurse aides were supposed to ask the residents if they would like a snack. Aides were observed going in and out of rooms from 7:00 p.m. to 8:15 p.m. There was no observation of an aide carrying a sandwich or a bowl of pudding into a resident room. In an interview on [DATE] at 7:20 p.m., Certified Nursing Assistant Staff D, showed snacks in both nourishment rooms consisting of: crackers - cheese, graham, and soda; juices; pudding; cold sandwiches - egg, cold cut, and peanut butter and jelly (pb&j). Staff D said the snacks were available for the residents and should be offered when getting a resident ready for bed. In an interview on [DATE] at 7:30 p.m., Resident #10 said she would sometimes ask in the evening for a pb&j or egg salad sandwich. The resident said she had to request the snack from the aides. The resident said she was not offered a snack and had not been offered a snack this evening. In an interview on [DATE] at 7:35 p.m., Resident #33 said, if I ask for it, I will get a snack. The resident said he kept snacks in his room. He said he often ordered a sandwich with his dinner, that came on his meal tray, to be sure he had a snack for later. The aides had not offered the resident a snack this evening. In an interview on [DATE] at 7:40 p.m. Resident #13 said the aides did not ask me if I wanted a snack. She said, I don't think they have ever asked me. The resident said if she asked for a snack some aides would try to find something I can have. The resident said some aides would say they don't have any. No snack offered today. In an interview on [DATE] at 7:45 p.m., Resident #64 said she did not depend on the aides for snacks. The resident said, I don't bother with them. They never offer snacks. The resident said her husband brought treats every other day. Observation of the nourishment rooms on [DATE] at 8:30 a.m., on both nursing units found most of the snacks from the previous evening still on the snack tray and in the refrigerator. In an interview on [DATE] at 8:45 a.m., the Certified Dietary Manager said many of the snacks came back from the nursing unit. He said the dated snacks were put in the refrigerator and reissued until expired. The dietician said there were no programmed snacks for diabetics. She said they should be offered snacks according to the snack schedule of 10:00 a.m., 2:00 p.m., and bedtime. During the resident council Interview on [DATE] at 10:40 a.m., when asked about the food service, the residents in attendance concurred that available snacks were limited. The resident council members said there was not enough milk or juice. They said sometime sandwiches were available but never enough.

Based on resident interview and staff interview, the facility failed to provide food substitutions that accommodate the preferences for residents who do not want the main entrees served for 6 (Residents #10, #11, #19, #38, #404, and #406) of 20 residents interviewed. The findings included: In an interview on 8/5/19 at 2:57 p.m., Resident #10 said she would rather be eating normally. The resident said she often did not like the entrée offered. The resident said she was offered a cold sandwich. The resident said she would like a hot sandwich particularly a hamburger. I would give anything for a hamburger with everything on it. I want something normal and tastes good. The resident said they only have cold sandwiches except for grilled cheese; no hot sandwiches as a substitute for the main item. In an interview on 8/6/19 at 9:20 a.m., Resident #11 said sometimes it was not too good. The resident said the aides would try to find something for me but not always good choices. In an interview on 8/5/19 at 2:30 p.m., Resident #19 said the food was not always good and there were no hot substitutes except for grilled cheese which was often undercooked, cold, doughy and full of butter; that was, soggy like being dipping in milk. The other side of the grilled cheese would be either burnt or too crispy. In an interview on 8/5/19 at 11:44 a.m., Resident #38 said the food was cold. The resident said the grilled cheese was cold, not even warmish. The resident told the Dietary Manager over and over again the food was cold. In an interview on 8/5/19 at 10:41 a.m., Resident #404 said the food was terrible. It did not taste good and was not as hot as it should be. The resident said she did not eat a lot of it because of that. The soup was pretty good, but the rest was not very good. The resident said she was living off of the food that people brought in to her. In an interview on 8/5/19 at 2:31 p.m., Resident #406 said sometimes the food was good, sometimes it was bad. The resident was on a special diet and did not like it. In an interview on 8/7/19 at 2:00 p.m., with dietary manager, the regional manager and the dietician. They acknowledged that the kitchen did not provide hot sandwiches like hamburgers, hot dogs. The managers said the items could be available. The dietary manager said the cycle menu was very limited and repeated every four weeks. He said there were several menu items that the residents did not like. The manager said food committee meetings were held immediately following the resident council meetings and the residents expressed their negative opinions about the food. The managers confirmed there was a limited list of always available substitutions.

Based on observation, document review and staff interview, the facility failed to ensure proper storage/labelling of medications in 2 of 2 medication carts reviewed for proper storage and labeling of medications. This has the potential for expired medications to be administered to residents. The findings included: On 8/5/19 at 1:36 p.m., observation revealed an open [MEDICATION NAME][MEDICATION NAME] for Resident #400 on the North medication cart B. Further observation revealed no evidence of a date the flex pen was opened. At the time of the observation, LPN Staff [NAME] confirmed there was no evidence of a documented date when the [MEDICATION NAME][MEDICATION NAME] for Resident #400 was opened and said she would discard it. Without a date opened, there was no ability to know when the medication had expired. On 8/5/19 at 1:37 p.m., observation revealed an open Humalog insulin vial for Resident #301 on the North medication cart B. Further observation revealed no evidence of a date the insulin vial was opened. At the time of the observation, LPN Staff [NAME] confirmed there was no evidence of a documented date when the Humalog insulin vial for Resident #301 was opened and said she would discard it. Without a date opened, there was no ability to know when the medication had expired. On 8/5/19 at 1:37 p.m., observation revealed an open Humalog insulin vial for Resident #93 on the North medication cart B. Further observation revealed no evidence of a date the insulin vial was opened. At the time of the observation, LPN Staff [NAME] confirmed there was no evidence of a documented date when the Humalog insulin vial for Resident #93 was opened and said she would discard it. Without a date opened, there was no ability to know when the medication had expired. On 8/5/19 at 1:39 p.m., observation revealed an open [MEDICATION NAME] R insulin vial for Resident #400 on the North medication cart B. Further observation revealed no evidence of a date the insulin vial was opened. At the time of the observation, LPN Staff [NAME] confirmed there was no evidence of a documented date when the [MEDICATION NAME] R insulin vial for Resident #400 was opened and said she would discard it. Without a date opened, there was no ability to know when the medication had expired. On 8/5/19 at 1:49 p.m., observation revealed an open [MEDICATION NAME]vial for Resident #38 on the North medication cart A. Further observation revealed no evidence of a date the insulin vial was opened. At the time of the observation, LPN Staff F confirmed there was no evidence of a documented date when the [MEDICATION NAME]vial for Resident #38 was opened and said she would discard it. Without a date opened, there was no ability to know when the medication had expired. On 8/5/19 at 1:51 p.m., observation revealed an open [MEDICATION NAME] 70-30 insulin vial for Resident #406 on the North medication cart A. Further observation revealed no evidence of a date the insulin vial was opened. At the time of the observation, LPN Staff F confirmed there was no evidence of a documented date when the [MEDICATION NAME] 70-30 insulin vial for Resident #406 was opened and said she would discard it. Without a date opened, there was no ability to know when the medication had expired. On 8/5/19 at 1:54 p.m., observation revealed an open Humalog insulin vial for Resident #249 on the North medication cart A. Further observation revealed no evidence of a date the insulin vial was opened. At the time of the observation, LPN Staff F confirmed there was no evidence of a documented date when the Humalog insulin vial for Resident #249 was opened and said she would discard it. Without a date opened, there was no ability to know when the medication had expired. On 8/5/19 at 1:55 p.m., observation revealed an open Humalog insulin vial for Resident #19 on the North medication cart A. Further observation revealed no evidence of a date the insulin vial was opened. At the time of the observation, LPN Staff F confirmed there was no evidence of a documented date when the Humalog insulin vial for Resident #19 was opened and said she would discard it. Without a date opened, there was no ability to know when the medication had expired. On 8/6/19 review of policy 5.3 Storage and Expiration Dating of Medications, Biologicals, Syringes and Needles last revision 07/23/19 noted Facility staff should record the date opened on the primary medication container (vial, bottle, inhaler) when the medication had a shortened expiration date once opened. On 8/8/19 at approximately 12:30 p.m., the facility Regional Nurse said the facility expectation was that all insulins be dated when opened. **Pictures on File**

Based on observation, record review, policy review and staff interview, the facility failed to ensure appropriate alternatives were attempted prior to use of bed rails or document why alternatives attempted failed for 14 (Residents #7, #10, #13, #59, #75, #91, #94, #95, #149, #252, #299, #300, #404 and #406) of 14 residents reviewed for accidents. This had the potential to have bed rails installed when alternatives with less chance of negative consequences could be utilized. In addition, the facility failed to regularly check the mattresses and bed rails for areas of possible entrapment. The findings included: On 8/7/19, review of facility policy Side Rail/Bed Rail, Document Name N-1282, effective date 4/19/19 noted, The Center, will attempt alternative interventions, and document in the medical record, prior to the use of side rail/bed rail. 1. On 8/5/19 at 10:02 a.m., ¼ rails were noted in the up position on bed of Resident #95. On 8/7/19, record review revealed no documentation of alternatives attempted prior to installation or use of side rails. 2. On 8/5/19 at 10:33 a.m., ¼ rails were noted in the up position on bed of Resident #299. On 8/7/19, record review revealed no documentation of alternatives attempted prior to installation or use of side rails. 3. On 8/5/19 at 11:30 a.m., ¼ rails were noted in the up position on bed of Resident #149. On 8/7/19, record review revealed no documentation of alternatives attempted prior to installation or use of side rails. 4. On 8/5/19 at 10:49 a.m., ¼ rails were noted in the up position on bed of Resident #300. On 8/7/19, record review revealed no documentation of alternatives attempted prior to installation or use of side rails. 5. On 8/7/19 at 9:51 a.m., ¼ rails were noted in the up position on bed of Resident #59. On 8/7/19, record review revealed no documentation of alternatives attempted prior to installation or use of side rails. 6. On 8/7/19 at 9:55 a.m., ¼ rails were noted in the up position of Resident #7. Record review revealed a side rail evaluation dated 5/15/19 and 8/1/19 noting side rail alternatives attempted prior to use of bed rails were; bed in low position, reminders to use call light. There was no documentation as to why the alternatives attempted failed. 7. On 8/7/19 at 2:53 p.m., ¼ rails were noted in the up position of Resident #75. Record review revealed a side rail evaluation dated 7/12/19 noting side rail alternatives attempted prior to use of bed rails were; bed in low position, reminders to use call light. There was no documentation as to why the alternatives attempted failed. On 8/7/19, record review revealed no evidence the facility inspected and regularly checked the mattresses and bed rails for areas of possible entrapment. On 8/7/19 at 10:22 a.m., in an interview, the Maintenance Director said they did not regularly check the mattresses and bed rails for areas of possible entrapment. 8. Observation of Resident #10 on 8/5/19 at 2:55 p.m., found 1/4 side rails in the up position on both side at the head of the bed. Record review revealed no side rail evaluation or evaluation for entrapment. No documentation that attempted alternatives failed. Last Side Rail Evaluation dated 5/16/19 with no explanation of trial of alternatives to side rails or why not appropriate. 9. Observation of Resident #13 on 8/6/19 at 3:49 p.m., found 1/4 side rails in the up position on both sides at the head of the bed. The Side Rail Evaluation dated 5/21/19 had no explanation of trial of alternatives to side rails; what was tried and why not appropriate. 10. On 8/5/19 at 1:08 p.m., observed side rails attached to each side of Resident #404's bed in the up position. Resident #404 said that no one asked her if she wanted them on the bed and she did not sign a consent for their use. On 8/6/19 at 3:18 p.m., per record review there was a signed side rail evaluation consent form in chart. Record review revealed no documentation side rail alternatives were attempted. 11. On 8/5/19 at 2:32 p.m., observed Resident #406 lying in bed with bilateral side rails in the up position. Resident #406 said he did not know if he signed a side rail consent. Resident #406 said no one mentioned them, they were just on the bed. On 8/6/19 at 2:10 p.m., observed resident lying in bed, sleeping, bilateral side rails were in the up position. On 8/6/19 at 4:25 p.m., observed bilateral side rails in the up position; resident was lying in bed. Per record review a side rail consent was signed on 7/20/19. On 8/7/19 at 12:32 p.m., per record review, there was no documentaion alternatives were attempted for side rail use. 12. On 8/5/19 at 11:35 a.m., observed side rails in the up position on Resident #94's bed. Resident 94 said she didn't remember anyone speaking to her about side rail use. Per record review, side rail consent form was signed by Resident #94. No documentation was found in the resident record alternatives to side rails were attempted. 13. On 8/7/19 at 11:43 p.m., Resident #91 was observed lying in bed with bilateral bed rails raised on the upper portion of the bed. Resident #91 said the rails were already on the bed when he was admitted and did not recall being offered any alternatives to bed rails. The resident said he didn't really use them in bed but may use them when he got up. Resident #91's record revealed an Admission Data Collection form was completed on 7/11/19 at 5:00 p.m. Under the section Side Rails, the form indicated bilateral upper rails were in use. A Side Rail Evaluation also was completed on 7/11/19, and no alternative to side rails were listed as being attempted. 14. On 8/5/19 at 11:25 a.m., Resident #252 was observed lying in bed with bilateral bed rails raised on the upper portion of the bed. Resident #252 said he did sign a consent for them. Resident #252's record revealed an Admission Data Collection form completed on 7/29/19 at 5:30 p.m., by Licensed Practical Nurse (LPN) Staff E. Under the section Side Rails, the form indicated bilateral upper rails were in use. A Side Rail Evaluation also was completed on 7/29/19 by LPN Staff E, and no alternative to side rails were listed as being attempted. On 8/6/19 at 3:01 p.m., LPN Staff [NAME] confirmed she completed the admission form for Resident #252. She said bed rails were already on the bed and probably raised. When doing the admission paperwork, she asked if he wanted bed rails and that generates the bed rail evaluation form. Staff [NAME] said she did not offer any alternatives to the bed rails and were part of ancillary orders as well. On 8/6/19 at 3:13 p.m., LPN Staff P said residents were asked if they would like bed rails upon admission and were on the data collection form. Orders for side rails were preprinted on the admission physician orders [REDACTED]. She was not aware of any alternatives as rails were already attached to the beds. If a resident did not want bed rails, they would be lowered, and maintenance would remove them. On 8/7/19 at 1:27 p.m., LPN Staff K said when a resident was admitted side rails were usually already on the bed. The resident was asked if they wanted to use them and if said yes, had then sign the consent. She did not offer any alternatives to bed rails and had not been instructed to do so. On 8/7/19 at 1:30 p.m., Registered Nurse (RN) Staff G confirmed there was no evidence of any alternatives being offered and/or attempted prior to bed rail use and the rails were already installed on beds. On 8/7/19 at 2:45 p.m., reviewed the bed rails were being offered on admission and there were no alternatives being attempted prior to their use with the Director of Nursing. She confirmed there was no documentation of alternatives being attempted prior to the installation/use of bed rails.

Based on record review and staff interview, the facility failed to ensure the Quality Assurance (QA) Committee had an effective plan to monitor for continued compliance of deficiencies and issues identified and cited on previous recertification survey and complaint surveys. The deficiencies cited in this survey, previously cited in the last completed annual survey dated 4/15/16 and complaint survey dated 4/15/16, were in regards to coordination of care and complete/accurate resident records. The findings included: Deficient practice at F309 was found again for failure to coordinate care regarding pain management and medication administration as documented for Resident #79 and lack of care coordination for Resident #257 regarding lack of communication between the Licensed Practical Nurse (LPN) and Registered Nurse (RN) concerning dehydration. Deficient practice at F514 was found again cited regarding the facility's failure to ensure clinical records were complete and accurate for 2 of 6 sampled residents by not accurately documenting a resident's resuscitation status for 1 (Resident #180) of 1 resident reviewed for Hospice and not accurately transcribing a medication order for 1 (Resident #79) of 5 residents reviewed for unnecessary medications. On 5/25/17 at 2:21 p.m., the Administrator stated, We have identified a lot of issues in the past year since I've been here. We do a lot of monthly in-services and town hall monthly meetings. We talk about root cause and customer service in addition to doing an immediate in-service if an issue is discovered. Those noted recitations were not identified.

Based on resident interview, staff interview, and record review, the facility failed to coordinate the management of pain medications for 1 (Resident #79) of 5 residents reviewed for medication administration. The lack of pain control for Resident #79 caused medical and psychosocial harm to the resident who was unable to fully participate in physical therapy and activities of daily living due to extreme pain. The facility also failed to provide services consistent with the standards of care recognized within the professional community for dehydration and infection control for 1 (Resident #257) of 1 resident observed for dehydration. Due to the lack of communication between Certified Nursing Assistant (CNA), the Licensed Practical Nurse (LPN) and the Registered Nurse (RN) Resident # 257 was not assessed for her dehydration which progressed to a level which required intravenous (IV) fluids to resolve. The failure to follow proper infection control procedures has the potential to put other residents at risk for infection. The findings included: The Florida Nurse Practice Act (Florida Statute 464.003) for Registered Nurses includes: (20) Practice of professional nursing means the performance of those acts requiring substantial specialized knowledge, judgment, and nursing skill based upon applied principles of psychological, biological, physical, and social sciences which shall include, but not be limited to: (a) The observation, assessment, nursing diagnosis, planning, intervention, and evaluation of care; health teaching and counseling of the ill, injured, or informed . and prevention of illness of others. The Florida Nurse Practice Act for a Licensed Practical Nurse does not include assessment, nursing diagnosis, planning, intervention, or evaluation of care. On 5/24/17, a review of the policy and procedure for Change in Condition dated 11/30/14 documented the primary clinical nurse will communicate to the nurse manager/supervisor any change in resident condition as it occurs. With change in resident status, the clinical nurse will gather all subjective and objective assessment information. The nurse is responsible to complete an assessment of the resident's condition to include vital signs, level of consciousness, and any other symptoms related to the condition and make any judgement calls regarding the course of action to be taken, the need to contact the agent/surrogate/contact person and/or physician, and must document the date, time party is notified, findings, and details of the notification in the nursing notes. 1. The care plan for Resident #79 identified pain locations, including [MEDICAL CONDITION]/[MEDICAL CONDITION] joint disease, diabetes mellitus with [MEDICAL CONDITION], hip pain, left knee pain, right eye pain, and right elbow pain (due to a [MEDICAL CONDITION] elbow dated 5/13/17). The care plan was updated on 5/1/17 with a goal will not have unrelieved episodes of pain daily through next review date. On 5/24/17 at 1:25 p.m., Resident #79 said he was getting 3 strong pain pills per day, but the staff stopped giving him the medication. He said the pain medication (Tylenol) he is getting now is not cutting it. The resident said he has pain related to physical therapy and is not getting enough medication. On 5/24/17 at 1:30 p.m., RN Staff F said the resident asked for Tylenol prior to going to therapy. She said she gave it to him this morning. Staff F said the resident has not asked for the [MEDICATION NAME] yet. Checking the medication cart, Staff F said there is no [MEDICATION NAME] on the cart, but she will check to see if it has been received. Staff F said the resident complains of pain at a level of 5 or 6 on a scale of 1 to 10 with 10 being severe pain. 5/24/17 at 1:48 p.m., the Unit Manager/LPN Staff H checked the medication cart and said the [MEDICATION NAME] is not on the cart. LPN Staff H then called the pharmacist who said they have not received a current order for [MEDICATION NAME]. LPN Staff H checked the medical record for Resident #79 and found the order for [MEDICATION NAME] was faxed a week ago. She said the resident had a fall in the facility and sustained a non-displaced [MEDICAL CONDITION] elbow. LPN Staff H said the doctor had ordered [MEDICATION NAME] for moderate pain. The resident did not like taking the narcotic so on 5/14/17 the doctor changed the pain medication order to [MEDICATION NAME] 50 milligrams (mg), one tablet three times per day as needed for moderate pain. LPN Staff H suggested the medication may be in another medication cart under another resident with the same last name in the facility. The pharmacist said they sent Tramodol to the facility on [DATE]. A review of the Medication Administration Record [REDACTED]. [MEDICATION NAME] 50 mg one tablet three times per day as needed for pain. A review of the actual prescription for [MEDICATION NAME] dated 5/14/17 read [MEDICATION NAME] 50 mg one tablet by mouth three times per day for five days; fifteen tablets, no refills. The MAR indicated [REDACTED] on 5/16/17 at 10:00 a.m. and 9:30 p.m., on 5/17/17 at 2:00 a.m. and 6:00 a.m., on 5/18/17 at 2:00 a.m., 7:00 a.m., and 9:30 p.m., on 5/19/17 at 5:00 a.m., on 5/20/17 at 2:00 a.m., on 5/21/17 at 6:15 a.m. A total of 12 doses were recorded. Beginning on 5/22/17, the nurses documentation revealed the resident was only receiving Tylenol for moderate to severe pain. The resident did not receive the [MEDICATION NAME] medication for pain as ordered. The pain assessment on the MAR indicated [REDACTED]. On 5/24/17 at 2:00 p.m., LPN Staff H checked the controlled medication sign-out sheet and said 13 doses were withdrawn. She confirmed there was no [MEDICATION NAME] on the cart. She confirmed the order was for 5 days, filled and administered, and the order was not renewed. Staff H said no one told her the medication had run out and the resident was still experiencing moderate to severe pain. On 5/25/17 at 9:00 a.m., Care Nurse/LPN Staff G said the resident was complaining of pain so she gave Resident #79 Tylenol this morning during med pass at 8:30 a.m. LPN Staff G said the Tylenol was pain medication in the medication cart for the resident. She said there was no [MEDICATION NAME] available, and she did not know if any more [MEDICATION NAME] was being delivered to the facility for the resident. On 5/25/17 at 9:06 a.m., Resident #79 said he gets rehab daily for his elbow. He said the pain from the rehab on his elbow yesterday was high - a 10 on a scale from 1 - 10. The resident said he is not getting any strong pain medication, and his elbow is in constant pain. At 9:21 a.m., LPN Staff H confirmed the MAR indicated [REDACTED]. She said the MAR indicated [REDACTED]. She again said she should have been told there was no [MEDICATION NAME] on the cart when the resident continued to complain of pain. LPN Staff H said the nurses should have checked the orders and contacted the physician for new orders. At 12:16 p.m., Therapy Assistant Staff I said Resident #79 started therapy on 5/20/17 and is scheduled for treatment 3 days per week. The notes revealed on a pain scale of 1 to 10, (with 10 being extreme pain), the resident is experiencing pain at a 10 out of 10 and 12 out of 10 (excruciating) pain level. Staff I said nursing should be giving the resident pain medication before the treatments. He said the therapy department should tell the nurses when therapy is scheduled so they can prepare the resident. Staff I said this is not happening because the resident complains of pain at an intensity level of 10 of 10 before the therapy session; the resident's pain level after the therapy session is 12. 2. On 5/23/17 at 2:40 p.m., Licensed Practical Nurse (LPN)/Unit Manager Staff A acknowledged Resident #257 was admitted for altered mental status and a urinary tract infection [MEDICAL CONDITION]. She said symptoms sometimes include dehydration. She said Resident #257's spouse was concerned with her low blood pressure and said it could be related to dehydration. She said she was not informed Resident #257 had diarrhea since her admission and may be dehydrated. At 3:05 p.m., LPN Staff N said she checked Resident #257's blood pressure, and it was 90/52. She stated, I notified the physician and was given the order to hold the medication indefinitely, and if her systolic blood pressure was greater than 160 the medication can be resumed. She confirmed she did not write an order. She said she asked Staff A to write it for her. She said she did not notify the DON or a RN to assess the resident. At 3:19 p.m., LPN Staff A confirmed she called the physician about the low blood pressure and received a verbal order. She said LPN Staff N did not tell her about the low blood pressure or tell her she called the physician. She said Resident #257's spouse told her maybe the resident needs intravenous (IV) fluids and thinks that is why her blood pressure was low. LPN Staff A stated, Nursing should have assessed the resident better based on the symptoms. She explained it was not enough to hold the medication; they should have explored the reason why it went low. She confirmed Resident #257 had a significant change in condition. LPN Staff A said she did not notify the Director of Nursing (DON) or a Registered Nurse (RN) to assess the resident. At 4:45 p.m., the DON said any nurse could gather the information and call the doctor. She said the LPN does not need to inform the RN; they are allowed to call the physician themselves. She acknowledged a drop in blood pressure resulting in holding medication is a significant change. She acknowledged a dehydrated resident is a significant condition. She stated, If the physician wanted an assessment done, he would have ordered it because he knows the nurse is an LPN and can't do the assessment. On 5/24/17 at 9:45 a.m., Certified Nursing Assistant (CNA) Staff O said Resident #257 has had diarrhea since her admission. He stated, I did not tell the nurse because it was just diarrhea until 5/19/17 when the diarrhea was foul smelling, yellowish, and gelatinous. He said that is when he notified nursing. He said there was a difference in the resident since getting IV fluids; she looks better, talks more, and has been getting out of bed. At 11:25 a.m., Resident #257's physician said he ordered the IV fluids because she was dehydrated; she had been having loose stools and needed it. He said when a nurse calls him, he is not aware if they are a LPN or RN. He said he usually talks with LPN Staff A and stated, I don't know if she is a LPN or RN. He said when a nurse calls him regarding a resident's condition, he is under the impression the resident has had a full assessment; he does not need to order it. He stated, I have never had to order a RN to do an assessment. The LPN should be getting the RN for the assessment. 3. On 5/22/17 at 12:06 p.m., Certified Nursing Assistants (CNA) Staff J and Staff M were observed in the room with Resident #257. The resident was on contact precautions for [MEDICAL CONDITION] ([MEDICAL CONDITION], an easily transmitted infection concerning the resident's stool). When CNA Staff J and CNA Staff M exited the room, they did not wash their hands. At 12:14 p.m., CNA Staff J said she forgot to wash her hands when she left the room. On 5/25/17, a review of the facility's policy Preventing Spread of [MEDICAL CONDITION] dated 11/30/14 documented the procedure as (1) Wear clean, non-sterile gloves when entering the room of a [MEDICAL CONDITION] infected resident; (2) Clean, non-sterile gowns shall be worn when entering the room of a [MEDICAL CONDITION] resident due to the environmental significance of the organism; . (4) Gloves and gowns shall be removed before leaving the resident's room and hands immediately washed with an antibacterial soap. On 5/25/17 at 9:30 a.m., Registered Nurse (RN) Staff F was observed administering medications to Resident #257. She was observed touching the resident's tray table, handing the medication cup, and taking the empty cup back without wearing any personal protective equipment (PPE). She left without washing her hands, threw the cups away on her medication cart, entered the room again, and dumped some liquid into the resident's sink. She left again without washing her hands and entered her medication cart to remove a piece of equipment. She entered another resident's room without washing her hands.

Based on interview, observation and record review the facility failed to provide sufficient nursing staff and certified nursing assistants to provide the professional care and services needed to maintain the highest practicable well-being of residents for 16 (Residents #34, #150, #85, #82, #146, #70, #106, #113, #40, #98, #45, #71, #78, #252, #238 and #253) of 40 residents reviewed for skin assessment and bathing. The results included: The Florida Nurse Practice Act, Chapter 464.003 defined the practice of professional nursing (Registered Nurse-RN) as the performance of those acts requiring substantial specialized knowledge, judgment, and nursing skill based upon applied principles of psychological, biological, physical, and social sciences which shall include, but not be limited to: the administration of medications and treatments as prescribed or authorized by a duly licensed practitioner authorized by the laws of this state to prescribe such medications and treatments and the 'practice of practical nursing' (Licensed Practical Nurse-LPN), as the performance of selected acts, including the administration of treatments and medications, in the care of the ill, injured, or informed and the promotion of wellness, maintenance of health, and prevention of illness of others under the direction of a registered nurse, a licensed physician, a licensed osteopathic physician, a licensed podiatric physician, or a licensed dentist. The findings included: 1. A review of the records for Resident #34 found the presence of a skin ulceration was documented from the time the resident was admitted on [DATE] until discharged from the facility on [DATE] as followed: Resident #34 was admitted on [DATE]. The Admission/Readmission Data Collection Form dated [DATE] signed by Registered Nurse (RN) Staff C indicated the skin was warm and dry. No skin issues were noted. Staff C documented on the skin evaluation prior to discharge on [DATE], clear skin - no open areas - no discoloration. On [DATE], Licensed Practical Nurse (LPN) Staff B documented on the non-pressure skin condition record the resident developed a wound measuring 1.5 centimeters (cm) in length x 0.4 cm in width x 0.1 cm in depth. Staff B classified the wound as shear not a pressure ulcer. On [DATE], LPN Staff B documented the wound measurements were 2.4 cm in length x 0.4 cm in width x 0.1 cm in depth. Staff B classified the wound as shear not a pressure ulcer. She noted the wound was deteriorating. On [DATE], LPN Staff B documented the wound measurements were 3.3 cm in length x 3.5 cm in length x 0.1 cm in depth. Staff B classified the wound as shear not a pressure ulcer. She noted the wound was deteriorating On [DATE], the attending physician's note stated, On examination of the lower back, the patient had a fairly large decubitus ulcer (another term used for pressure ulcers), which involved her lower back. For further details of measurement, please refer to wound care notes and reviewed them. It seems to be fairly deep and has foul-smelling discharge . On [DATE], LPN Staff B documented the wound measurements were 6 cm in length x 4 cm in width x 1 cm in depth. Staff B classified the wound as shear not a pressure ulcer. She noted the wound was deteriorating On [DATE], the attending physician's note said under the assessment and plan area, Sepsis, probably related to decubitus ulcer. On [DATE], Resident #34 was sent to (hospital) at the request of the health care surrogate. The emergency room note stated, Basically this is an elderly pleasant white female, who was brought to (hospital) because [MEDICAL CONDITION] secondary to decubitus ulcer in the sacral spine area. It was fairly deep and the wound seemed close to the bone. On [DATE] at 3:00 p.m., Unit Manager, LPN Staff A said the resident had a little pressure ulcer on her bottom. She said they were trying to get her to wound care clinic, but the family denied it because they were trying to get her into hospice. The resident was at the end of her life. She refused to eat. The wound was seen by the Assistant Director of Nursing (ADON) who determined it was not improving. On [DATE] at 2:41 p.m., Wound Care Nurse, LPN Staff B said the resident was not seen by a physician. She said she determined the wound was shearing. She said the resident's physician wanted a wound care consult, but the family wanted a hospice consult first. She said the resident went to the hospital to have the wound debrided. She said she does the wound observations. On [DATE] at 2:00 p.m., the resident's attending physician said the resident was a severely demented elderly frail lady who refused to eat and refused a feeding tube. He said he did view the wound on her sacrum. He said he would consider the wound to be a pressure ulcer. He said it was very deep. He said the resident died about three weeks after her admission to the hospital. She was on hospice service at the time of her death. On [DATE] at 10:56 a.m., the ADON revealed she had seen the resident's wound and had spoken with the Health Care Surrogate about it, but did not document an assessment of the wound. As the wound worsened it was not assessed by a RN. The resident was admitted to the hospital for treatment of [REDACTED]. 2. A review of the Certified Nursing Assistant (CNA) - Activities for Daily Living (ADL) tracking form for March of 2016 showed Resident #34 required two person assist with bathing. The form indicated the resident had a partial bath everyday she was in the facility except for [DATE]. She had a bed bath on [DATE]. There were no baths documented on [DATE]. The resident was not getting showers or complete bed baths as scheduled. On [DATE] at 4:28 p.m., Licensed Practical Nurse (LPN) Staff A said a partial bath consisted of bathing the essentials such as the groin and armpits. She said a bed bath consisted of the entire body being washed. On [DATE] at 4:33 p.m., CNA Staff D said a partial bath was a quick clean up and a bed bath was when they washed the whole body. 3. Resident #150's clinical record contained a Minimum Data Set 3.0 (MDS) assessment dated [DATE], indicated the resident was always incontinent of bladder and required extensive assistance of staff for hygiene, toileting, and needed assistance with bathing. The CNA-ADL sheet from [DATE] to [DATE] indicated the resident had not had a shower only partial baths. On [DATE] at 8:40 a.m., CNA Staff JJ said the resident was incontinent of bladder and bowel and he wore a brief. On [DATE] at 8:44 a.m., CNA Staff Q said she was the one who usually did the resident showers. Staff Q said Resident #150 had not had a shower as she had not had someone to assist her. She said she was not aware of any reason the resident would not be able to have a shower. On [DATE] at 9:11 a.m., LPN Staff Z, confirmed the documentation indicated the resident had not had a shower and she did not know the reason for this. 4. On [DATE] Resident #85 said she had to have a shower and it used to be on Tuesday and Thursdays. She said she did not get it anymore. On [DATE] at 4:30 p.m., Resident #85 said if she was getting two showers a week she would have been very happy. She said she was not getting any showers and it was disgusting. She said she wants her hair washed and she wants to get her showers. On [DATE] at 4:20 p.m., Resident's #85's daughter said her mother had been getting a shower when she first was admitted . She said she sent an e-mail to corporate about a month ago and someone from the facility had called her and told her mother would be getting her showers. She said her mother got a shower then it stopped again. She said she didn't know the last time her mother had a shower. She said she thought they needed more help. A review of the Kardex showed documentation for the month of April she had partial baths and no showers. On [DATE] at 3:20 p.m., CNA Staff H said she was familiar with Resident #85 care. She said she liked to get showers, she didn't like to get bed baths. She said she isn't sure how often she got a shower. The resident hadn't said anything to her about not getting a shower or wanting more showers. She said she assisted her when needed and would supervise for the other times. She said she hadn't seen any decline in her ADL care. She said she would write refused in the ADL book if the resident refused the bed bath. She said she would let the nurse know she refused it. On [DATE] at 12:35 p.m., Staff Z said Resident #85 required just one person assist, she was able to a lot for herself. Staff Z said typically showers were twice a week and hers were on Tuesdays and Saturdays. It looked like she had been getting them on Tuesdays, and the other days she got partials. Staff Z said nobody had reported to her the resident hadn't been getting showers, or had refused them. If a resident refused care multiple times the aide should be reporting it to the nurse. The shower team was Staff PP, who was on vacation and Staff Q. They had an assignment. She said Staff Q was doing all the showers and what she didn't get done would be assigned to the ,[DATE] shift. She said no resident has complained to her about not getting a shower. On [DATE] at 4:00 p.m., Staff Z said she was unable to locate any of Resident #85's shower sheets for April. Review of shower sheets for January, February and March revealed shower slips showing showers were given on [DATE]; [DATE]; [DATE]; [DATE], [DATE] - On [DATE]; [DATE]; [DATE], and [DATE] the resident refused, the nurse and unit manager were notified. On [DATE] at 2:23 p.m., Staff Q, on the shower team, said she was half of the shower team, her team mate was out on leave. She has been out about 2 weeks and no one was assigned to replace her. She said it was difficult to keep up with the shower schedule by herself. Staff Q said she worked 5:30 a.m. until 2:00 p.m. and was doing three showers first thing in the morning with the help of ,[DATE] shift for transfers. She said she has the same schedule as when both of them are working. Staff Q said what really happened was, most of time one of them was pulled to the floor and three showers got done; some of the time both of them were pulled and no showers got done. She said today she did her three in the morning and then she was scheduled to do 20 during the day. The showers she didn't get done were to be assigned to the ,[DATE] shift. She said she didn't know if they got done. On [DATE] at 3:15 p.m., Staff P said Resident #85 preferred showers, she had never seen where the resident requested a bed bath. She stated: Resident #85 said she hadn't been showered in a long time. She said she told Staff Z and whatever nurse was working the hallway. She said there was a shower team but when the facility was short staffed they pulled the team and kept the residents from getting their showers. She said she was sick and tired of it because it has been going on for so long. She said it had been going on for at least three months. 5. On [DATE] at 10:19 a.m., Resident #82 said the last two weeks he had not received any showers. He was told the staff who performed this task was on vacation. A review of the Kardex (the Kardex is a form the staff will document if the resident has a shower, partial or bed bath) showed the documentation for the month of April he had partial baths and no showers. 6. On [DATE] at 11:40 a.m., Resident #146 said he was not getting showers. Staff was not following the shower schedule. A review of the Kardex showed the documentation for the month of April he had partial baths and no showers. 7. On [DATE] at 2:45 p.m., Resident #70 said it's been a long time since she had a shower. A review of the Kardex showed the documentation for the month of April she had partial baths and no showers. 8. On [DATE] at 10:57 a.m., Resident #106 said he had one shower since he was admitted to the facility. His wife had to give him bed baths. A review of the Kardex showed the documentation for the month of April he had partial baths and no showers. He was admitted at the facility on [DATE]. 9. On [DATE] at 1:50 p.m., Resident #113 said she had not had any showers for the past week and a half. A review of the Kardex showed the documentation for the month of April she had partial baths and no showers. 10. On [DATE] at 12:42 p.m., Resident #40 said the last time he had a shower was two weeks ago. The Kardex was not available for review. 11. On [DATE] at 1:31 p.m., Resident #98 said she did not get showers. Staff gave her bed baths. A review of the Kardex showed the documentation for the month of April she had partial baths and no showers. 12. On [DATE] at 1:19 p.m., Resident #45 stated They cut out giving me a bath. A review of the Kardex showed the documentation for the month of April he had partial baths and no baths. 13. On [DATE] at 8:27 a.m., Resident #71 said she got one shower since she was admitted to the facility. A review of the Kardex showed documentation for the month of April she had partial baths and one shower. She was admitted to the facility on [DATE]. 14. On [DATE] at 9:55 a.m., Resident #78 said she had a shower about 3 weeks ago. She used to get showers once a week but now it was once every three weeks since there was a staff shortage. A review of the Kardex showed documentation for the month of April she had partial baths and no showers. 15. On [DATE] at 12:16 p.m., Resident #252 had not had a shower since she was admitted to the facility. She would sponge bath herself. A review of the Kardex showed documentation for the month of April she had partial baths and no showers. A review of her medical record showed she was admitted to the facility on [DATE]. 16. On [DATE] at 2:22 p.m., Resident #238's responsible party said she didn't think Resident #238 was getting showers. His hair was not fluffy. A review of the Kardex showed documentation for the month of April showed he had partial baths and no showers. 17. On [DATE] at 2:01 p.m., Resident #253's responsible party said Resident #253 was not sure he was getting showers. She stated I know his hair needs washing terribly. On [DATE] at 3:45 p.m., the Director of Nursing said while reviewing the Kardex form partial meant the CNA's did partial bed baths at bedside. Partial bed baths were washing their face, neck, arms, legs and peri-area. The CNA's on the south unit would do the showers. She was trying to get a shower team. The person on the south unit was on medical leave approximately 3 weeks ago and the shower team on the rehabilitation unit resigned and a CNA who took over about one week ago. On [DATE] at 11:10 a.m., a review of the grievance log was conducted with the social worker. In January there were two grievances from family the residents were not getting showers. One resident was admitted on [DATE] and had not received a shower as of [DATE]. The social worker explained this resident had a cast on her arm. She received a shower when the cast was removed on [DATE]. The social worker was not able to explain why the staff would not bag/wrap the cast so the resident could have a shower. In February the grievance log showed one grievance concerning a resident received two showers in 21 days. In March there were two grievances indicating two residents not getting showers. One resident had not showered since admission. He was admitted on [DATE] and the grievance was recorded on [DATE]. The other grievance showed the resident had no showers and only bed baths.

Based on observation, interview and record review, the facility failed to prevent the development of pressure ulcers and the worsening of pressure ulcers for 2 (Residents #34 and #37) of 4 residents with pressure ulcers. This resulted in harm to the residents. The findings included: 1. A review of the records for Resident #34 found the presence of a skin ulceration was documented from the time the resident was admitted on [DATE] until discharged from the facility on [DATE] as followed: Resident #34 was admitted on [DATE]. The Admission/Readmission Data Collection Form dated [DATE] signed by Registered Nurse (RN) Staff C indicated the skin was warm and dry. No skin issues were noted. Staff C documented on the skin evaluation prior to discharge on [DATE], clear skin - no open areas - no discoloration. On [DATE], Licensed Practical Nurse (LPN) Staff B documented on the non-pressure skin condition record the resident developed a wound measuring 1.5 centimeters (cm) in length x 0.4 cm in width x 0.1 cm in depth. Staff B classified the wound as shear not a pressure ulcer. On [DATE], LPN Staff B documented the wound measurements were 2.4 cm in length x 0.4 cm in width x 0.1 cm in depth. Staff B classified the wound as shear not a pressure ulcer. She noted the wound was deteriorating. On [DATE], LPN Staff B documented the wound measurements were 3.3 cm in length x 3.5 cm in length x 0.1 cm in depth. Staff B classified the wound as shear not a pressure ulcer. She noted the wound was deteriorating On [DATE], the attending physician's note stated, On examination of the lower back, the patient had a fairly large decubitus ulcer (another term used for pressure ulcers), which involved her lower back. For further details of measurement, please refer to wound care notes and reviewed them. It seems to be fairly deep and has foul-smelling discharge . On [DATE], LPN Staff B documented the wound measurements were 6 cm in length x 4 cm in width x 1 cm in depth. Staff B classified the wound as shear not a pressure ulcer. She noted the wound was deteriorating On [DATE], the attending physician's note said under the assessment and plan area, Sepsis, probably related to decubitus ulcer. On [DATE], Resident #34 was sent to (hospital) at the request of the health care surrogate. The emergency room note stated, Basically this is an elderly pleasant white female, who was brought to (hospital) because [MEDICAL CONDITION] secondary to decubitus ulcer in the sacral spine area. It was fairly deep and the wound seemed close to the bone. On [DATE] at 3:00 p.m., Unit Manager, LPN Staff A said the resident had a little pressure ulcer on her bottom. She said they were trying to get her to wound care clinic, but the family denied it because they were trying to get her into hospice. The resident was at the end of her life. She refused to eat. The wound was seen by the Assistant Director of Nursing (ADON) who determined it was not improving. On [DATE] at 2:41 p.m., Wound Care Nurse, LPN Staff B said the resident was not seen by a physician. She said she determined the wound was shearing. She said the resident's physician wanted a wound care consult, but the family wanted a hospice consult first. She said the resident went to the hospital to have the wound debrided. She said she does the wound observations. On [DATE] at 2:00 p.m., the resident's attending physician said the resident was a severely demented elderly frail lady who refused to eat and refused a feeding tube. He said he did view the wound on her sacrum. He said he would consider the wound to be a pressure ulcer. He said it was very deep. He said the resident died about three weeks after her admission to the hospital. She was on hospice service at the time of her death. On [DATE] at 10:56 a.m., the ADON revealed she had seen the resident's wound and had spoken with the Health Care Surrogate about it, but did not document an assessment of the wound. As the wound worsened it was not assessed by a RN. The resident was admitted to the hospital for treatment of [REDACTED]. 2. Review of Resident #37's medical records revealed he was admitted to the facility on [DATE] with a prosthetic left [MEDICAL CONDITION] with non-surgical intervention. An admission assessment was completed on [DATE] and the nurse wrote, resident complaining of pain upon movement. Resident able to feed self, propel self in wheelchair and needs assistant of 1 person with transfers. Resident has no [MEDICAL CONDITION] and his left pedal pulse is palpable. The admission skin assessment noted 2 skin tears and a bruise to the right arm. Both heels were intact and no skin conditions were noted. The facility wrote a care plan for impaired skin on [DATE] for the potential for skin breakdown, rash and excoriation to the heels, buttock and coccyx. The plan of care would be reevaluated on [DATE]. The approaches and interventions to be put in place included: weekly skin checks, encourage showers, encourage repositioning every ,[DATE] hours and incontinent care every ,[DATE] hours. A physician telephone order dated [DATE] for skin prep and to off load heels every shift for 30 days as preventive measure to prevent pressure ulcers. A plan of care was written on [DATE] said Resident #37 refused to move off his back. Nursing is to encourage the resident to reposition every 3 hours while in bed. The only intervention noted was to keep the skin clean and dry. A Braden scale for predicting pressure sore risk form was completed on [DATE] and [DATE]. Resident #37 scored 14 on both assessment dates. The score of 13 or 14 meant a resident was a moderate risk of developing a pressure ulcer. The weekly skin integrity review note on [DATE], [DATE], [DATE] and [DATE] documented both heels and coccyx were intact with no redness or discoloration noted. On [DATE] the skin integrity sheet stated, open blister to the right heel and on [DATE] the form notesd, pressure ulcers to the right and left heel. The nurse called the physician on [DATE] and received a treatment order for an open blister on his right heel. On [DATE] the wound care nurse Staff B documented on the pressure ulcer record form, the left heel had a pressure ulcer measuring 6.0 x 6.0 x 0.1 open blister with a red and black skin color with a small amount serous drainage. On [DATE] she wrote the right heel has a pressure ulcer measuring 2.0 x 4.0 x 0 with black eschar. She wrote both heels were classified as unstageable because they were unable to determine the depth of each wound. A review of wound care nurse Staff B's progress notes found the [DATE] note said, Resident #37 skin tear to his left elbow, upper arm discoloration and giving Resident #37 education related to the risk of only lying on his back. There were no other progress notes by Staff B related to pressure ulcer prevention and/or further education with Resident #37 or his family. Staff B told the floor nurse and certified nursing assistants to notify her immediately if any skin impairment is found. The nursing notes from [DATE] through [DATE] noted Resident #37's skin including his heels as warm, dry and intact. The nursing progress notes did not say Resident #37 was refusing to turn and reposition in his bed or refusing to let staff elevate his heels while in bed. There was no documentation the family was called on [DATE] when the nurse found the pressure ulcers to Resident #37's heels and received the treatment order for the right heel pressure ulcer. On [DATE] at 10:45 a.m., on a phone interview with Resident #37's daughter, she said Resident #37 was admitted to the facility on [DATE] after a fall at home. It was decided not to do surgery at this time and her father was sent to the skilled nursing facility for strengthening and rehabilitation. When Resident #37 was admitted to the facility both his heels and coccyx were intact and he had no skin issues. She would call Resident #37, the facility and his primary care physician almost every day to check on his medical condition and how he was doing. Resident #37 told the daughter on [DATE] the nurse told him both his heels were black, which upset him. It was the first time she heard about the right and left heel pressure ulcers. She spoke to Staff B about the pressure ulcers who told her they found them on [DATE] and didn't know why the nurse did not call her to inform her about the pressure ulcers to both heels. The daughter said she visited the facility from [DATE] through [DATE]. She said her father was out of his bed either in his chair or wheelchair daily and he also attended his therapy sessions daily. She and Resident #37 attended a care plan meeting on [DATE] and no one ever told her during the care plan meeting Resident #37 was refusing care and refusing to reposition while in bed. On [DATE] at 11:45 a.m., North Unit Manager Staff A said she remembered Resident #37 and confirmed the daughter would call either the facility or the physician almost daily about updates to Resident #37's medical condition. She said Resident #37 would refuse to get out of his bed and would not reposition every 2 to 3 hours as required. He also refused to elevate his heels while in bed and would refuse care. She confirmed Resident #37 was admitted to the facility on [DATE] and both heels were intact with no skin issues noted. She also said they had ordered skin prep to both heels to be done every shift for 30 days, starting [DATE], to prevent his heels from breaking down . Staff A confirmed Resident #37's medical records documented both heels were intact until [DATE] when the nurse wrote he had unstageable pressure ulcers to both heels. She further said she was unable to find documentation the nursing staff was applying skin prep to both heels each shift and documentation of the resident not elevating his heels while in bed. She also said she was unable to find documentation the family was notified of the two unstageable pressure ulcers found on [DATE]. On [DATE] at 12:30 p.m., wound care nurse Staff B said Resident #37 was admitted on [DATE] and his heels were both intact. Due to the possibility of pressure ulcers forming she had tried to educate Resident #37 about repositioning in bed every ,[DATE] hours but he was not very receptive and she wrote a note she would try again the next day. She informed the nursing staff to tell her immediately if they found any skin impairment. The practitioner ordered skin prep to both heels every shift to help prevent the formation of pressure ulcers. She said she was not informed by the nursing staff until [DATE] of the unstageable pressure ulcers to both heels. She further said she was unable to find documentation the nursing staff were applying the skin prep to both heels each shift as ordered by the physician. Staff B found reporting and/or documenting in the medical records of any skin changes. She also said she was unable to find documentation Resident #37 was refusing to elevate his heels and refusing to reposition in bed every 2 to 3 hours. On [DATE] at 7:15 a.m., care plan coordinator Staff KK said Resident #37 was admitted to the facility on [DATE] and his heels were intact at the time of admission. She said on [DATE] they had developed a plan of care to prevent skin breakdown to his heels, coccyx and buttocks via weekly skin checks, showers, repositioning in bed every ,[DATE] hours and incontinent care every ,[DATE] hours. The nurses also had an order to apply skin prep to both heels each shift as a preventative measure and were to report any changes to the wound care nurse. After review of Resident #37's medical records Staff B confirmed there was no documentation the nurse was applying the skin prep to both heels every shift as ordered. She also said there was no documentation in the medical record of Resident #37's refusal to elevate his heels while in bed. She confirmed a care plan meeting was held on [DATE] with Resident #37 and his daughter but they did not discuss any possible skin breakdown issues or that Resident #37 was noncompliant with repositioning in bed and/or the elevation of his heels while in bed to prevent skin breakdown. On [DATE] at 8:40 a.m., the Director of Nursing said she had reviewed Resident #37's medical records and said she was able to find a treatment sheet for [DATE] which showed the nurses were doing skin prep and off-loading his heels every shift until [DATE]. She confirmed on [DATE] the facility found 2 unstageable pressure ulcers to the right and left heels. She was unable to find documentation Resident #37 was refusing to elevate his heels while in bed or the nursing staff were applying the skin prep to each heel after [DATE] and reporting any changes and/or changes to his heels prior to the finding of the pressure ulcers to both his heels. The facility did not ensure the resident did not develop pressure sores resulting in harm to the resident.

Based on record reviews, observations, and interviews, the facility failed to coordinate care and ensure a qualified professional assessed non-pressure wounds initially and/or weekly in accordance with facility policy and acceptable standards of practice for 3 (Residents #14, 138 and 150) of 4 residents with non-pressure wounds reviewed. The non-pressure wound for Resident #14 was not assessed properly and worsened within the facility causing harm. The findings included: 1. The facility's policy and procedure titled non-pressure skin condition record dated 11/30/14 indicated staff should document the presence of skin impairment not related to pressure when first observed and weekly thereafter. The procedure said a licensed nurse (is) to sign. The procedure included the licensed nurse documenting the date, size, drainage information, description of the wound edges and the peri-wound area. Under the facility policy titled Skin Evaluation weekly dated 11/30/14 it said a Licensed nurse would complete a total body evaluation of each resident weekly paying attention to any skin tears, bruises, stasis ulcers, rashes, pressure ulcers, [MEDICAL CONDITION], abrasions, reddened areas and skin problems. The policy also says a licensed nurse should document the observation on the Weekly Skin Integrity Review Form and if a resident is assessed as having a skin problem, the evaluating nurse will initiate the appropriate form. The Florida Board of Nursing, Nurse Practice Act Chapter 464 Florida Statues; 464.003 Definitions, (3)(a) 1.Practice of professional nursing (Registered Nurse); is defined as The observation, assessment, nursing diagnosis, planning, intervention, and evaluation of care; Under section 3. (b) Practice of Practical Nursing (Licensed Practical Nurse) means the performance of selected acts, including the administration of treatments and medications, In Florida, a Licensed Practical Nurse (LPN) cannot assess. Current standard of practice indicated a non-pressure wound needs to be assessed and documentation completed at least weekly to determine progress or deterioration. This documented assessment should include at a minimum of the following: date, size, drainage information, description of the wound edges and the peri-wound area. Record review of Resident #14's admission data collection form noted the resident was a new admit to the facility on [DATE] at 10:30 p.m. Review of the admission data collection form noted it was completed by LPN Staff CC. Under the admission data for skin, (section M), the form indicated 2 wounds labeled #1 and #2 was marked on the skin sweep with a written description of the skin impairment. The form also revealed a third mark on the residents coccyx, however, it was not given a site number and a written description of skin impairment was not noted. There was no mention of this third wound in the admission nurses notes or other nurses notes. Non-pressure skin condition records were completed for both wounds #1 and #2, but there was no non-pressure skin condition record completed for the third wound. Record Review of Resident #14's initial care encounter progress notes by the physician dated 2/25/16 under skin noted fragile and no open areas were indicated. Record Review of Resident #14's initial nutrition evaluation and interdisciplinary progress notes dated 2/25/16 under skin status indicated intact. Record Review of Residents #14's weekly skin integrity review completed by LPN Staff T dated 2/25/16 noted a shear to the coccyx. The weekly skin integrity review form says if any skin condition is present, proceed to skin condition record for each site identified. Staff T, LPN, did obtain a physician order [REDACTED]. Record Review of Resident #14's non-pressure skin condition record completed by Wound Care LPN dated 3/1/16 documented a shear was present on admission to the Left Sacrum. The Wound Care LPN documented the size, drainage, wound edges, peri-wound area, and documented the wound in the interdisciplinary progress notes on 3/1/16, 3/7/16; 3/14/16; 3/21/16; 3/28/16; 3/30/16; and 4/6/16. On 3/1/16 the wound was 1.5 centimeters (cm) x 0.4 cm x 0.1 cm. On the 3/28/16 assessment and 3/29/16 progress note it was noted the wound deteriorated since the previous assessment and was now 1 cm x 2.8 cm x 0.1 cm. The wound care physician was brought in to look at the wound on 3/30/16. There was no documentation by a licensed nurse or practitioner which assessed the wound size, drainage, wound edges, peri-wound area, and documented the wound in the interdisciplinary progress notes from admission 2/24/16 through 3/30/16 until the wound deteriorated. Only the Wound Care LPN was assessing the wound on a weekly basis. Record Review of Resident #14's wound care progress notes dated 3/30/16 by the Wound Care Physician said the patient was being followed for a sacral wound since admission,but the wound deteriorated and was now a full thickness trauma wound with a 2.5 cm x 3.5 cm x 0.1 cm depth and black eschar noted. The Wound Care Physician also saw the patient on 4/6/16 and noted the wound had a 2 cm x 3.4 cm x 0.2 cm depth and on 4/13/16 noted the wound had a 2.4 cm x 3.1 cm x 0.5 cm depth. On 4/13/16 at 11:30 a.m., Resident #14's family member said she had concerns the wound was getting worse. She was concerned the patient was always in pain because of the wound. She said a nurse at first told her it was a pressure sore but now they were calling it a trauma wound. On 4/13/16 at 4:50 p.m., the Long Term Care Unit Manager, LPN Staff Z said she was not aware of the wound upon admission and said she has not seen the wound. She said from 3/1/16-3/30/16 the wound was only from shearing and only the Wound Care LPN would document the care. She said as of 3/30/16 it became worse and they called in Wound Care Physician who said it was now a full thickness trauma wound. She said a Registered Nurse will only look at the wound if it becomes a pressure sore. On 4/13/16 at 4:50 p.m., the Assistant Director of Nursing (ADON), said she did not look at the wound. She said since it was not pressure; (she) did not co-sign. She will only go look at the wound if it is a pressure sore. She said floor nurses - either registered nurses or licensed practical nurses can do skin assessments. She then repeated again she did not see the wound when it occurred, but then said since it was now a full thickness trauma wound she has been following it more closely. She said she has nothing documented in the medical record related to this wound. She said is a pressure sore, she would co-sign the Wound Care LPN's work, but this was not a pressure sore so she does not have too. She confirmed there was no documentation in the medical record from 2/25/16-3/30/16 in relation to anyone other than the LPN assessing the wound. On 4/14/16 at 9:51 p.m., the Wound Care LPN said this wound was noted prior to admission on the hospice care plan dated 12/17/15. A review of the previous nursing home medical records dated 2/24/16 and hospice records dated 2/24/16 was unable to find any evidence of an active wound to the coccyx upon transfer. The Wound Care LPN said in the past the ADON wound sign off on all wounds during weekly meetings, but now they only discuss pressure sores. She said the ADON does not check all the wounds on a weekly basis and leaves the wounds other than pressure sore up to her to handle. An interview with the Hospice Registered Nurse (RN) on 4/14/16 at 12:07 p.m. confirmed the wound was not present prior to admission at the previous facility but said a wound was identified upon admission to this facility on 2/25/15. She said she did look at the wound, but there was no depth she could see. At 2:32 p.m. the Hospice RN said her role was not to assess the wounds for the facility and said she was a care coordinator. She will make sure the resident was getting good care and make recommendations but the facility or the wound care physician would do all the assessments and treatments. She said she has never once measured the wound or touched the wound to perform an assessment. She confirmed a full assessment would include assessing the size, drainage, wound edges and the peri-wound area. In am interview on 4/14/16 at 4:00 p.m., the Wound Care Physician said she does not get involved with all wounds until the facility requires her help for the advance wounds. She said since the facility reported the wound as occurring from a shear, she then gives the [DIAGNOSES REDACTED]. She will name the wound based upon the etiology, and in this case they reported it was from the trauma of shearing and that's all the information she was given about occurrence. On 4/15/16 at 9 a.m., the Wound Care LPN said it was her job to only do observations by her license. She said she was the only one looking at the non-pressure wounds until they get worse, then others will get involved. She confirmed she can not do assessments as a LPN. When asked who was assessing the non-pressure wounds, she said I do not know and I will get back to you on that. On 4/15/16 at 10:42 a.m., the Director of Nursing (DON) said they review all wounds in their risk meeting weekly,but they only keep documentation on the pressure sores. She confirmed they only discuss the wounds and there was no physical assessment by a RN on non-pressure wounds. On 4/15/16 at 11:22 a.m., the ADON again confirmed there was no documentation by a RN or practitioner other than an LPN that assessed the wound from admission on 2/24/16-3/30/16. She confirmed the wound for resident #14 did become worse during this time period. She said she only has been physically looking at pressure sores on a weekly basis and she did not physically evaluate all non-pressure wounds on a weekly basis. She confirmed the Wound Care LPN will collect the data and then they just review the wounds in a weekly meeting. On 4/15/16 at 11:22 a.m. the DON said they will have an RN assess all wounds, both pressure and non-pressure, on a weekly basis. 2. On 3/28/16, Resident #138 was diagnosed by LPN Staff B, who was the wound care nurse, to have a shear wound to the mid back. On 3/28/16, Staff B ordered the following treatment on a physician order: mid-spine cleanse with wound cleanser (WC) apply double layer [MEDICATION NAME], change every other day (QOD) and as needed - shear. Review of physician order [REDACTED].#138 revealed mid-spine cleanse with wound cleanser apply double layer [MEDICATION NAME] and change every other day and as needed - shear. There was no physician name or signature on the order. Review of Care Plan identified issue for impaired skin integrity - intact - goal of resident will have intact skin, free of redness, blisters, discoloration and included the intervention to inform physician of any new area of skin breakdown. Record review of the weekly skin integrity review forms dated as follows documents: 3/24/16 - skin intact area to mid-back circled with tx (treatment) (documentation revealed this treatment did not start until 3/28/16) 3/31/16 - area to mid-back circled with tx written in 3/28/16 shear spine 4/7/16 - skin intact - TX mid-back - area to mid back circled with tx 4/14/16 - nothing is checked or written in Record review of the Non-pressure dated: 3/25/16 to spine initial not present on admission. Type: shear; 3/28/16: 2 X 1 X .1, Drainage: amount / type / color / odor - none; periwound area: intact; 4/4/16: 1.6 X 1 X .1, Drainage: Amount: Small/Med; Type: Serous; Odor: none; Color: clear Periwound area: intact. On 4/15/16 at 12:20 p.m., Staff B said wound appeared dry, with brown in the center, the surrounding area was red. There was small amount of drainage on the dressing when removed. On 4/15/16 at 11:55 a.m., Staff B said the area on Resident #138's mid spine happened on 3/28/16. The air mattress was taken away by the Interdisciplinary Team because of a fall. She said she checked the skin sweep books every day. She said the wound must have been reported by a Certified Nursing Assistant. She said Resident #138's physician had not seen the wound. She said she didn't know if anyone else has seen it. She said this was a shear wound. When asked why she didn't think this was a pressure ulcer she stated because this is blanchable. On 4/15/16 at 2:00 p.m., the physician for Resident #138 said he recalled speaking with Staff B about Resident #138. He didn't recall the order but knew it was for a wound. He said if he gave Staff B an order he would see the resident the next time he was in the facility. The physician was asked for a copy of the progress note of the visit and the signed order to the facility. The physician was unable to recall the date of his visit. The physician stated: I am not willing to commit to talking to Staff B about an order or seeing Resident #138 about this. The wound worsened and the LPN did not obtain an assessment from a qualified nurse or a practitioner. 3. On 4/2/16, the night nurse documented in a skilled nursing note Resident #150 had very reddened buttocks and had applied a dry protective dressing to the left buttock and barrier cream to right buttocks. The resident's physician was notified via fax on 4/2/16 and treatment orders were received. On 4/4/16 an order was received to apply barrier cream with zinc to the resident's buttocks every shift and as needed; reposition the resident every 2 to 3 hours; and for a pressure reducing cushion to his chair. On 4/6/16 Resident #150 was seen by the facility's wound physician. The physician documented on a visit report the resident had Developed MASD (moisture associated skin damage) wounds to bilateral buttocks this week. The physician noted the wounds on the resident's right and left buttocks were full thickness (damage extends below all layers of skin into the subcutaneous tissue or beyond) and Incontinence Associated [MEDICAL CONDITION]. The wound on the resident's right buttock measured 5.2 cm in length x 5.5 cm in width x and 0.1 cm in depth. The wound bed was 76% to 100% adherent yellow slough ([MEDICATION NAME] tissue). The wound on the resident's left buttocks measured 9.2 cm in length x 3.1 cm in width x and 0.1 cm in depth. The wound bed was 26% to 50% moist, black eschar, and 26% to 50% adherent yellow slough. The periwound skin for both wounds was described as Moist, Maceration (softening and breaking down of skin resulting from prolonged exposure to moisture). The Resident Assessment Instrument Manual for the MDS 3.0 under section M1040H, defined moisture associated skin damage (MASD) as a result of skin damage caused by moisture rather than pressure. It was caused by sustained exposure to moisture which can be caused, for example, by incontinence, wound exudate and perspiration. It was characterized by inflammation of the skin, and occurred with or without skin erosion and/or infection. MASD was also referred to as incontinence-associated [MEDICAL CONDITION]. Provision of optimal skin care and early identification and treatment of [REDACTED]. On 4/14/16 at 4:00 p.m., the wound physician said she had been seeing Resident #150 for a traumatic wound on his right ankle. She said the resident developed full thickness wounds on his buttocks a couple of weeks ago. The physician said the skin had become macerated most likely from incontinence not perspiration, and needed a more aggressive changing schedule. On 4/14/16 at 4:14 p.m., Resident #150 was observed in bed laying on his back. The head of his bed was elevated 60 degrees, the resident was hunched over, knees were bent and leaning off to the right. An oxygen tubing was hanging off his left ear. The resident was partially covered by a sheet and wearing a brief. On 4/14/16 at 4:17 p.m., CNA Staff GG was observed walking down the hall. Staff GG confirmed he was assigned to take care of Resident #150, but said he had not been in to check the resident since coming on duty at 2:30 p.m. Staff GG said he was not familiar with the resident and had not taken care of him before. Staff GG was asked to check the resident and went to the resident's room. Staff GG applied gloves, adjusted the oxygen tubing to be under the residents nose; pulled down the sheet, and confirmed the resident had a soiled brief. The resident was also observed to be wearing pajama bottoms which were down around his ankles. Staff GG turned the resident onto his left side and removed the brief soiled with urine. The resident was observed to have a wound on his left buttocks 2.0 cm x 4.0 cm in size with yellow slough covering the base of the wound. A second area was noted above this and was 2.0 cm x 0.5 cm in size. The wound was uncovered and in contact with the soiled brief. There was no evidence of any zinc barrier cream over the wound. Staff GG said he was going to alert the nurse of the open area and then would apply barrier cream to the rest of his bottom. Staff GG applied a new brief without cleaning the resident's peri-area. On 4/14/16 at 4:30 p.m., RN Staff HH said she was the full time nurse and took care of Resident #150. Staff HH said she was not aware of any issue with the resident's bottom but would check to see if he had a treatment order to the area. Staff HH checked the treatment record for Resident #150 and said he was to have Silvadine and zinc mixture to his buttocks each shift. Staff HH along with Staff GG observed the resident's bottom. The resident was observed to have loose stool which was seeping into the resident's wound and Staff GG said the resident had been incontinent of urine again. Staff HH said she was going to consult the wound nurse or ADON about the open area on his buttocks. On 4/14/16 at 4:40 p.m., the ADON observed the resident's buttocks area. She said she was aware the resident had some redness/excoriation but was not aware of the open wound. Reviewed with the ADON the resident had been lying on his back wearing a soiled brief; Staff GG had not checked the resident since he came on duty at 2:30 p.m.; and the nurse taking care of the resident was unaware of any skin issues on his buttocks. The ADON acknowledged if the resident's wound was MASD, would not want the area in contact with moisture from urine and feces. On 4/15/16 at 8:37 a.m., CNA Staff II said she was taking care of Resident #150 today. She said the resident was hard to roll over onto his side but was not resistive. She said for the most part he stayed in the position he was placed in. Staff II said she was told in report this morning the resident had a wound on his bottom. She said there were no special precautions, reposition him every 2 hours, and the resident wears a brief. On 4/15/216 at 8:40 a.m., CNA Staff JJ said the resident was incontinent of bladder and bowel and he wore a brief. She said when she positioned the resident on his side he stayed there. Staff JJ said she checked him every 2 hours. She said the resident had a red bottom, no open areas, and was using a barrier cream with zinc with each change. Staff JJ said she checked the resident's Kardex for any care information. On 4/15/16 at 8:56 a.m., Resident #150 was observed laying in bed on his back. There was a urine odor noted in the room. Resident #150's care plan was reviewed and listed the problem of impaired skin integrity related to a wound on the resident's right ankle. The care plan had not been updated to address the problem of the full thickness wounds on the resident's buttocks as a result of MASD or include any new interventions to prevent moisture from being in contact with the resident's skin. The resident's Kardex noted the resident was to be repositioned and checked for incontinence every 2 hours and as needed. The Kardex did not identify the resident had any skin issues or special skin precautions. The CNA Activities of Daily Living sheet from 3/11/16 to 4/15/16 indicated the resident had not had a shower, only partial baths. On 4/15/16 at 9:11 a.m., LPN Staff Z confirmed the documentation indicated Resident #150 had not had a shower and she did not know the reason for this. On 4/15/16 at 9:30 a.m., MDS nurse Staff AA said she was aware Resident #150 had an issue on his bottom; she did the care plan for preventative skin issues; but Staff B wound nurse, did the care plan for active skin issues. Staff AA confirmed there was no care plan that addressed the wounds on the resident's buttocks. Staff AA said she updated the Kardex information for the CNA's and confirmed there was nothing about any skin issues on the Kardex for Resident #150. On 4/15/16 at 11:04 a.m., LPN Staff X said he was the full time nurse and routinely took care of Resident #150. Staff X said the resident had a wound on his buttocks and there was a treatment ordered last night for it. Staff X said he had not seen the wound before. He said the treatment record indicated the resident was to be repositioned every 2 to 3 hours but all residents who were immobile in bed should be. Staff X said he would not really consider that an increase in the turning schedule. Staff X said he had not seen the residents bottom before and the CNA's apply the barrier cream with zinc. The resident's treatment record for April 2016 was reviewed with Staff X. He confirmed there was a treatment order dated 4/6/16, to clean the resident's bilateral buttocks with normal saline and apply a Silvadine/zinc mixture every shift and as needed. Staff X verified he initialed this treatment as being done by him on 4/12/16. Staff X said he still did not recall if there was any open areas or what the resident's bottom looked like. On 4/15/16 at 11:29 a.m., LPN Staff Z said she had done the treatment to the resident's buttocks on 4/8/16. Staff Z said the resident's buttocks had some patchy red areas but no open wounds. The resident developed MASD full thickness wounds on both his buttocks related to his incontinence. The resident's care plan was not updated after this was identified; there was no change in the resident's turning schedule or checking him for incontinence on a more frequent basis; there was no documentation of the resident having a shower since admission to the facility so his skin could be thoroughly cleaned; and not all staff were aware the resident even had any skin issues.

Based on review of facility policies and protocols outlining the standard of practice for pressure sore and wound care management, observations, record reviews, and staff and resident interviews, the facility failed to comprehensively assess pressure sores for 1 (Resident #34) of 4 residents with pressure sores reviewed. The facility also failed to comprehensively assess non-pressure wounds for 3 (Residents #14, #138 and #150) of 4 residents with non pressure wounds reviewed. Residents #34's pressure sore and Resident #14's non-pressure wounds were not assessed appropriately and worsened within the facility causing harm. The findings included: The Florida Nurse Practice Act, Chapter 464.003 defined the practice of professional nursing (Registered Nurse-RN) as the performance of those acts requiring substantial specialized knowledge, judgment, and nursing skill based upon applied principles of psychological, biological, physical, and social sciences which shall include, but not be limited to: the administration of medications and treatments as prescribed or authorized by a duly licensed practitioner authorized by the laws of this state to prescribe such medications and treatments and the 'practice of practical nursing' (Licensed Practical Nurse-LPN), as the performance of selected acts, including the administration of treatments and medications, in the care of the ill, injured, or informed and the promotion of wellness, maintenance of health, and prevention of illness of others under the direction of a registered nurse, a licensed physician, a licensed osteopathic physician, a licensed podiatric physician, or a licensed dentist. 1. A review of the records for Resident #34 found the presence of a skin ulceration documented from the time the resident was admitted on [DATE] until 3/28/16 when the resident was discharged from the facility as followed: On 3/12/16, Licensed Practical Nurse (LPN) Staff B documented on the non-pressure skin condition record the resident developed a wound measuring 1.5 centimeters (cm) in length x 0.4 cm in width x 0.1 cm in depth. Staff B classified the wound as shear not as a pressure ulcer. On 3/14/16, LPN Staff B documented the wound measurements were 2.4 cm in length x 0.4 cm in width x 0.1 cm in depth. Staff B classified the wound as shear not a pressure ulcer. She noted the wound was deteriorating. On 3/21/16, LPN Staff B documented the wound measurements were 3.3 cm in length x 3.5 cm in width x 0.1 cm in depth. Staff B classified the wound as shear not a pressure ulcer. She noted the wound was deteriorating On 3/24/16, the attending physician's note stated, On examination of the lower back, the patient has a fairly large decubitus ulcer (another term used for pressure ulcers), which involves her lower back. For further details of measurement, please refer to wound care notes and reviewed them. It seems to be fairly deep and has foul-smelling discharge . On 3/25/16, LPN Staff B documented the wound measurements were 6 cm in length x 4 cm in width x 1 cm in depth. Staff B classified the wound as shear not a pressure ulcer. She noted the wound was deteriorating On 4/13/16 at 3:00 p.m., Staff A, LPN said the resident had a little pressure ulcer on her bottom when she was discharged from the facility. The MDS assessment of 3/14/16 indicated the resident was at risk for skin breakdown, but had no skin issues. However, the skin issue was noted in the nursing documentation on 3/12/16. The discharge MDS assessment of 3/28/16 indicated there were no unhealed pressure ulcers and no healed pressure ulcers though the nursing and physician progress notes [REDACTED]. The comprehensive assessments did not accurately reflect the resident's condition. 2. The facility's policy and procedure titled non-pressure skin condition record dated 11/30/14 indicated staff should document the presence of skin impairment not related to pressure when first observed and weekly thereafter. The procedure says a licensed nurse (is) to sign. The procedure included the licensed nurse documenting the date, size, drainage information, description of the wound edges and the peri-wound area. Under the facility policy titled Skin Evaluation weekly dated 11/30/14 it said a Licensed nurse will complete a total body evaluation of each resident weekly paying attention to any skin tears, bruises, stasis ulcers, rashes, pressure ulcers, [MEDICAL CONDITION], abrasions, reddened areas and skin problems. The policy also said a licensed nurse should document the observation on the Weekly Skin Integrity Review Form and if a resident is assessed as having a skin problem, the evaluating nurse will initiate the appropriate form. In Florida, a Licensed Practical Nurse (LPN) cannot assess. Current standard of practice indicated a non-pressure wound needed to be assessed and documentation completed at least weekly to determine progress or deterioration. This documented assessment should include at a minimum the following: date, size, drainage information, description of the wound edges and the peri-wound area. Record review of Resident #14's admission data collection noted the resident was admitted to the facility on [DATE] at 10:30 p.m. Review of the admission data collection tool noted it was completed by LPN Staff CC. Under the admission data for skin, (section M), the form indicated 2 wounds labeled #1 and #2 were marked on the skin sweep with a written description of the skin impairment. There form also revealed a third mark on the residents coccyx, however it was not given a site number nor a written description of skin impairment noted. There was no mention of this third wound in the admission nurses notes or the nurses notes. Non-pressure skin condition records were completed for both wounds #1 and #2, but there was not a non-pressure skin condition record completed for the third wound. Record review of Resident #14's weekly skin integrity review completed by LPN Staff T dated 2/25/16 noted a shear to the coccyx. The weekly skin integrity review form said if any skin condition present, proceed to skin condition record for each site identified. LPN Staff T did obtain a physician order [REDACTED]. Record review of Resident #14's non-pressure skin condition record completed by Wound Care LPN dated 3/1/16 documented a shear was present on admission to the left sacrum. The Wound Care LPN documented the size, drainage, wound edges, peri-wound area, and documented the wound in the interdisciplinary progress notes on 3/1/16, 3/7/16; 3/14/16; 3/21/16; 3/28/16; 3/30/16; and 4/6/16. On 3/1/16 the wound was 1.5 centimeters (cm) x 0.4 cm x 0.1 cm. On the 3/28/16 assessment and 3/29/16 Staff CC, LPN progress note it was noted the wound deteriorated since the previous assessment and was now 1 cm x 2.8 cm x 0.1 cm. The wound care physician was brought in to look at the wound on 3/30/16. There was no documentation by a licensed nurse or practitioner who collected data of the wound size, drainage, wound edges, peri-wound area, and documented the wound in the interdisciplinary progress notes from admission 2/24/16 through 3/30/16 until after the wound deteriorated. Only the Wound Care LPN was assessing the wound on a weekly basis. Record review of Resident #14's wound care progress notes dated 3/30/16 by the Wound Care Physician the patient was being followed for a sacral wound since admission, but the wound deteriorated and was now a full thickness trauma wound with a 2.5 cm x 3.5 cm x 0.1 cm depth and black eschar noted. The Wound Care Physician also saw the patient on 4/6/16 and noted the wound had a 2 cm x 3.4 cm x 0.2 cm depth and on 4/13/16 noted the wound had a 2.4 cm x 3.1 cm x 0.5 cm depth. On 4/13/16 at 11:30 a.m., Resident #14's family shared concerns the wound was getting worse. She was concerned the patient was always in pain because of the wound. She said a nurse at first told her it was a pressure sore but now they are calling it a trauma wound. On 4/13/16 at 4:50 p.m., the Long Term Care Unit Manager, LPN Staff Z said she was not aware of the wound upon admission and said she had not seen the wound. She said from 3/1/16-3/30/16 the wound was only from shearing and only the Wound Care LPN would document the care. She said as of 3/30/16 it became worse and they had the Wound Care Physician become involved and it was now a full thickness trauma wound. She said a Registered Nurse will only look at the wound if it becomes a pressure sore. On 4/13/16 at 4:50 p.m., the Assistant Director of Nursing (ADON) said she did not look at the wound. She said since it was not pressure; (she) did not co-sign. She will only go look at the wound if it is a pressure sore. She said floor nurses - either registered nurses or licensed practical nurses can do skin assessments. She then repeated again she did not see the wound when it occurred, but then said since it was now a full thickness trauma wound she had been following it more closely. She said she has nothing documented in the medical record related to this wound. She said it was a pressure sore, she would co-sign the Wound Care LPN's work, but this was not a pressure sore so she does not have too. She confirmed there was no documentation in the medical record from 2/25/16-3/30/16 in relation to anyone other than the LPN assessing the wound. On 4/14/16 at 9:51 a.m., the Wound Care LPN said this wound was noted prior to admission on the hospice care plan dated 12/17/15. Review of the previous nursing home medical records dated 2/24/16 and hospice records dated 2/24/16 was unable to find any evidence of an active wound to the coccyx upon transfer. She said in the past the ADON would sign off on all wounds during weekly meetings, but now they only discuss pressure sores. She said the ADON did not check all the wounds on a weekly basis and left the wounds other than pressure sore up to her to handle. On 4/14/16 at 12:07 p.m., the hospice Registered Nurse (RN) confirmed the wound was not present prior to admission at the previous facility but said a wound was identified upon admission to this facility on 2/25/15. She said she did look at the wound, but at that time she saw there was no depth. At 2:32 p.m., the hospice RN said her role was not to assess the wounds for the facility and said she was a care coordinator. She would make sure the resident is getting good care and make recommendations, but the facility or the wound care physician would do all the assessments and treatments. She said she had never once measured the wound or touched the wound to perform an assessment. She confirmed a full assessment would include assessing the size, drainage, wound edges and the peri-wound area and should be completed by a RN or Physician within the facility. On 4/14/16 at 4:00 p.m., the Wound Care Physician said she did not get involved with all wounds until the facility requires her help for the advanced wounds. She said since the facility reported the wound as occurring from a shear, she then gave the [DIAGNOSES REDACTED]. She would name the wound based upon the etiology, and in this case they reported it was from the trauma of shearing and that's all the information she was given about occurrence. On 4/15/16 at 9:00 a.m., the Wound Care LPN said it was her job to only do observations by her license. She said she was the only one looking at the non-pressure wounds until they got worse, then others would get involved. She confirmed she can not do assessments as a LPN. When asked who was assessing the non-pressure wounds, she said I do not know and I will get back to you on that. On 4/15/16 at 10:42 a.m., the Director of Nursing (DON) said they reviewed all wounds in their risk meeting weekly, but they only kept documentation on the pressure sores. She confirmed they only discuss the wounds and there was no physical assessment by an RN on non-pressure wounds. On 4/15/16 at 11:22 a.m., the ADON again confirmed there was no documentation by an RN or practitioner other than an LPN that assessed the wound from admission on 2/24/16 through 3/30/16. She confirmed the wound for Resident #14 did become worse during this time period. She said she only has been physically looking at pressure sores on a weekly basis and that she did not physically look at all non-pressure wounds on a weekly basis. She confirmed the Wound Care LPN would collect the data and then they just reviewed the wounds in a weekly meeting. 3. On 3/28/16, Resident #138 was diagnosed by LPN Staff B, who was the wound care nurse, to have a shear wound to the mid back. On 3/28/16, Staff B ordered the following treatment on a physician order: mid-spine cleanse with wound cleanser (WC) apply double layer [MEDICATION NAME], change every other day (QOD) and as needed - shear. Review of physician order [REDACTED].#138 revealed mid-spine cleanse with wound cleanser apply double layer [MEDICATION NAME] and change every other day and as needed - shear. There was no physician name or signature on the order. Review of Care Plan identified issue for impaired skin integrity - intact - goal of resident will have intact skin, free of redness, blisters, discoloration and included the intervention to inform physician of any new area of skin breakdown. Record review of the weekly skin integrity review forms dated as follows documents: 3/24/16 - skin intact area to mid-back circled with tx (treatment) (documentation revealed this treatment did not start until 3/28/16) 3/31/16 - area to mid-back circled with tx written in 3/28/16 shear spine 4/7/16 - skin intact - TX mid-back - area to mid back circled with tx 4/14/16 - nothing is checked or written in Record review of the Non-pressure dated: 3/25/16 to spine initial not present on admission. Type: shear; 3/28/16: 2 X 1 X .1, Drainage: amount / type / color / odor - none; periwound area: intact; 4/4/16: 1.6 X 1 X .1, Drainage: Amount: Small/Med; Type: Serous; Odor: none; Color: clear Periwound area: intact. On 4/15/16 at 12:20 p.m., Staff B said wound appeared dry, with brown in the center, the surrounding area was red. There was small amount of drainage on the dressing when removed. On 4/15/16 at 11:55 a.m., Staff B said the area on Resident #138's mid spine happened on 3/28/16. The air mattress was taken away by the Interdisciplinary Team because of a fall. She said she checked the skin sweep books every day. She said the wound must have been reported by a Certified Nursing Assistant. She said Resident #138's physician had not seen the wound. She said she didn't know if anyone else has seen it. She said this was a shear wound. When asked why she didn't think this was a pressure ulcer she stated because this is blanchable. On 4/15/16 at 2:00 p.m., the primary physician for Resident #138 said he recalled speaking with Staff B about Resident #138. He didn't recall the order but knew it was for a wound. He said if he gave Staff B an order he would see the resident the next time he was in the facility. The physician was asked for a copy of the progress note of the visit and the signed order to the facility. The physician was unable to recall the date of his visit. The physician stated: I am not willing to commit to talking to Staff B about an order or seeing Resident #138 about this. The wound worsened and the LPN did not obtain an assessment from a qualified nurse or a practitioner. 4. On 4/2/16, the night nurse documented in a skilled nursing note Resident #150 had very reddened buttocks and had applied a dry protective dressing to the left buttock and barrier cream to right buttocks. The resident's physician was notified via fax on 4/2/16 and treatment orders were received. On 4/4/16 an order was received to apply barrier cream with zinc to the resident's buttocks every shift and as needed; reposition the resident every 2 to 3 hours; and for a pressure reducing cushion to his chair. On 4/6/16 Resident #150 was seen by the facility's wound physician. The physician documented on a visit report the resident had Developed MASD (moisture associated skin damage) wounds to bilateral buttocks this week. The physician noted the wounds on the resident's right and left buttocks were full thickness (damage extends below all layers of skin into the subcutaneous tissue or beyond) and Incontinence Associated [MEDICAL CONDITION]. The wound on the resident's right buttock measured 5.2 cm in length x 5.5 cm in width x and 0.1 cm in depth. The wound bed was 76% to 100% adherent yellow slough ([MEDICATION NAME] tissue). The wound on the resident's left buttocks measured 9.2 cm in length x 3.1 cm in width x and 0.1 cm in depth. The wound bed was 26% to 50% moist, black eschar, and 26% to 50% adherent yellow slough. The periwound skin for both wounds was described as Moist, Maceration (softening and breaking down of skin resulting from prolonged exposure to moisture). The Resident Assessment Instrument Manual for the MDS 3.0 under section M1040H, defined moisture associated skin damage (MASD) as a result of skin damage caused by moisture rather than pressure. It was caused by sustained exposure to moisture which can be caused, for example, by incontinence, wound exudate and perspiration. It was characterized by inflammation of the skin, and occurred with or without skin erosion and/or infection. MASD was also referred to as incontinence-associated [MEDICAL CONDITION]. Provision of optimal skin care and early identification and treatment of [REDACTED]. On 4/14/16 at 4:00 p.m., the wound physician said she had been seeing Resident #150 for a traumatic wound on his right ankle. She said the resident developed full thickness wounds on his buttocks a couple of weeks ago. The physician said the skin had become macerated most likely from incontinence not perspiration, and needed a more aggressive changing schedule. On 4/14/16 at 4:14 p.m., Resident #150 was observed in bed laying on his back. The head of his bed was elevated 60 degrees, the resident was hunched over, knees were bent and leaning off to the right. An oxygen tubing was hanging off his left ear. The resident was partially covered by a sheet and wearing a brief. On 4/14/16 at 4:17 p.m., CNA Staff GG was observed walking down the hall. Staff GG confirmed he was assigned to take care of Resident #150, but said he had not been in to check the resident since coming on duty at 2:30 p.m. Staff GG said he was not familiar with the resident and had not taken care of him before. Staff GG was asked to check the resident and went to the resident's room. Staff GG applied gloves, adjusted the oxygen tubing to be under the residents nose; pulled down the sheet, and confirmed the resident had a soiled brief. The resident was also observed to be wearing pajama bottoms which were down around his ankles. Staff GG turned the resident onto his left side and removed the brief soiled with urine. The resident was observed to have a wound on his left buttocks 2.0 cm x 4.0 cm in size with yellow slough covering the base of the wound. A second area was noted above this and was 2.0 cm x 0.5 cm in size. The wound was uncovered and in contact with the soiled brief. There was no evidence of any zinc barrier cream over the wound. Staff GG said he was going to alert the nurse of the open area and then would apply barrier cream to the rest of his bottom. Staff GG applied a new brief without cleaning the resident's peri-area. On 4/14/16 at 4:30 p.m., RN Staff HH said she was the full time nurse and took care of Resident #150. Staff HH said she was not aware of any issue with the resident's bottom but would check to see if he had a treatment order to the area. Staff HH checked the treatment record for Resident #150 and said he was to have Silvadine and zinc mixture to his buttocks each shift. Staff HH along with Staff GG observed the resident's bottom. The resident was observed to have loose stool which was seeping into the resident's wound and Staff GG said the resident had been incontinent of urine again. Staff HH said she was going to consult the wound nurse or ADON about the open area on his buttocks. On 4/14/16 at 4:40 p.m., the ADON observed the resident's buttocks area. She said she was aware the resident had some redness/excoriation but was not aware of the open wound. Reviewed with the ADON the resident had been lying on his back wearing a soiled brief; Staff GG had not checked the resident since he came on duty at 2:30 p.m.; and the nurse taking care of the resident was unaware of any skin issues on his buttocks. The ADON acknowledged if the resident's wound was MASD, would not want the area in contact with moisture from urine and feces. On 4/15/16 at 8:37 a.m., CNA Staff II said she was taking care of Resident #150 today. She said the resident was hard to roll over onto his side but was not resistive. She said for the most part he stayed in the position he was placed in. Staff II said she was told in report this morning the resident had a wound on his bottom. She said there were no special precautions, reposition him every 2 hours, and the resident wears a brief. On 4/15/216 at 8:40 a.m., CNA Staff JJ said the resident was incontinent of bladder and bowel and he wore a brief. She said when she positioned the resident on his side he stayed there. Staff JJ said she checked him every 2 hours. She said the resident had a red bottom, no open areas, and was using a barrier cream with zinc with each change. Staff JJ said she checked the resident's Kardex for any care information. On 4/15/16 at 8:56 a.m., Resident #150 was observed laying in bed on his back. There was a urine odor noted in the room. Resident #150's care plan was reviewed and listed the problem of impaired skin integrity related to a wound on the resident's right ankle. The care plan had not been updated to address the problem of the full thickness wounds on the resident's buttocks as a result of MASD or include any new interventions to prevent moisture from being in contact with the resident's skin. The resident's Kardex noted the resident was to be repositioned and checked for incontinence every 2 hours and as needed. The Kardex did not identify the resident had any skin issues or special skin precautions. The CNA Activities of Daily Living sheet from 3/11/16 to 4/15/16 indicated the resident had not had a shower, only partial baths. On 4/15/16 at 9:11 a.m., LPN Staff Z confirmed the documentation indicated Resident #150 had not had a shower and she did not know the reason for this. On 4/15/16 at 9:30 a.m., MDS nurse Staff AA said she was aware Resident #150 had an issue on his bottom; she did the care plan for preventative skin issues; but Staff B wound nurse, did the care plan for active skin issues. Staff AA confirmed there was no care plan that addressed the wounds on the resident's buttocks. Staff AA said she updated the Kardex information for the CNA's and confirmed there was nothing about any skin issues on the Kardex for Resident #150. On 4/15/16 at 11:04 a.m., LPN Staff X said he was the full time nurse and routinely took care of Resident #150. Staff X said the resident had a wound on his buttocks and there was a treatment ordered last night for it. Staff X said he had not seen the wound before. He said the treatment record indicated the resident was to be repositioned every 2 to 3 hours but all residents who were immobile in bed should be. Staff X said he would not really consider that an increase in the turning schedule. Staff X said he had not seen the residents bottom before and the CNA's apply the barrier cream with zinc. The resident's treatment record for April 2016 was reviewed with Staff X. He confirmed there was a treatment order dated 4/6/16, to clean the resident's bilateral buttocks with normal saline and apply a Silvadine/zinc mixture every shift and as needed. Staff X verified he initialed this treatment as being done by him on 4/12/16. Staff X said he still did not recall if there was any open areas or what the resident's bottom looked like. On 4/15/16 at 11:29 a.m., LPN Staff Z said she had done the treatment to the resident's buttocks on 4/8/16. Staff Z said the resident's buttocks had some patchy red areas but no open wounds. It was found in record review the resident developed MASD full thickness wounds on both his buttocks related to his incontinence. The resident's care plan was not updated after this was identified; there was no change in the resident's turning schedule or checking him for incontinence on a more frequent basis; there was no documentation of the resident having a shower since admission to the facility so his skin could be thoroughly cleaned; and not all staff were aware the resident even had any skin issues.

Based on interview and record review, the facility failed to provide a comprehensive, accurate, assessment related to skin conditions for 2 (Residents' #14 and #34) of 8 residents reviewed for comprehensive skin condition assessments from a total sample of 39 residents. The findings included: 1. Clinical record review for Resident #14 revealed an admission assessment Minimum Data Set ((MDS) dated [DATE]. The MDS section M1040 under other ulcers, wounds,and skin problems instructions state check all that apply in the last 7 days. If there is no evidence of such problems in the last 7 days, check none of the above. The MDS section M1040 was coded at Z - None of the above were present indicating no other skin conditions were present for Resident #14 from 2/24/16 through 3/1/16. Record review of Resident #14's weekly skin integrity review completed by LPN Staff T dated 2/25/16 noted a shear to the coccyx. Record review of Resident #14's non-pressure skin condition record completed by Wound Care LPN dated 3/1/16 documented a shear was present on admission to the left sacrum. On 4/14/16 at 2:00 p.m., the Long Term Care MDS Coordinator, LPN Staff AA said she was not aware of any skin conditions with the resident when she was admitted . She said she reviewed the chart and saw no skin issues. She said she physically had to look at the resident when doing the MDS skin assessment and helped Resident #14 use the bedpan. She said she looked at the residents coccyx and saw no issues. She said she completed section M on 3/1/16. She confirmed per the MDS manual dated October 2015 - under section 1040G - skin tears, the instructions state: skin tears are a result of shearing, friction or trauma to the skin that causes a separation of the skin layers. They can be partial or full thickness. Code all skin tears in this item. She verified Resident #14's MDS coding was not correct if shearing was identified as present between 2/25/16 and 3/1/16. She said she did not see it so she did not code it. She said since no skin issues were noted in the MDS, it did not trigger a care area assessment for skin conditions. She said since she was an LPN, she collected the data and inputted the data in the MDS. She said then the Assistant Director of Nursing (ADON) Registered Nurse, would sign if the MDS was completed. She said the MDS was signed, verifying assessment completion, by the ADON on 3/7/16. On 4/14/16 at 3:35 p.m., the ADON said she did not check each section to ensure the skin conditions were coded accurately. She just looked to ensure someone completed the MDS section, then signed it as complete. She confirmed the shearing identified should be coded under section 1040G as a skin condition and it was missed by the facility. 2. A review of the records for Resident #34 found the presence of a skin ulceration documented from 2/29/16 when the resident was admitted until 3/28/16 when the resident was discharged from the facility as followed: On 3/12/16, Licensed Practical Nurse (LPN) Staff B documented on the non-pressure skin condition record the resident developed a wound measuring 1.5 centimeters (cm) in length x 0.4 cm in width x 0.1 cm in depth. Staff B classified the wound as shear not as a pressure ulcer. On 3/14/16, LPN Staff B documented the wound measurements were 2.4 cm in length x 0.4 cm in width x 0.1 cm in depth. Staff B classified the wound as shear not a pressure ulcer. She noted the wound was deteriorating. On 3/21/16, LPN Staff B documented the wound measurements were 3.3 cm in length x 3.5 cm in width x 0.1 cm in depth. Staff B classified the wound as shear not a pressure ulcer. She noted the wound was deteriorating On 3/24/16, the attending physician's note stated, On examination of the lower back, the patient has a fairly large decubitus ulcer (another term used for pressure ulcers), which involves her lower back. For further details of measurement, please refer to wound care notes and reviewed them. It seems to be fairly deep and has foul-smelling discharge . On 3/25/16, LPN Staff B documented the wound measurements were 6 cm in length x 4 cm in width x 1 cm in depth. Staff B classified the wound as shear not a pressure ulcer. She noted the wound was deteriorating On 4/13/16 at 3:00 p.m., Staff A, LPN said the resident had a little pressure ulcer on her bottom when she was discharged from the facility. The MDS assessment of 3/14/16 indicated the resident was at risk for skin breakdown, but had no skin issues. However, the skin issue was noted in the nursing documentation on 3/12/16. The discharge MDS assessment of 3/28/16 indicated there were no unhealed pressure ulcers and no healed pressure ulcers though the nursing and physician progress notes [REDACTED]. The comprehensive assessments did not accurately reflect the resident's condition.