Every finding on record at Avir at Corpus Christi

Based on observation, interview, and record review, the facility failed to ensure a registered nurse served as the full time Director of Nursing for 1 of 1 facility reviewed for nursing services. The facility failed to designate a registered nurse to serve as the full time DON since 04/25/2026. This failure could place residents at risk of receiving inadequate care, as well as cause a lack of nursing oversight and higher level of care. The findings included: Record review of the DON timecard coverage report from 04/25/2026 through 06/04/2026 indicated there was no DON in facility. The timecard revealed the RNC had been in the facility three days per week (24 hours per week) since the previous DON's last day on 04/24/2026. Record review of the Clinical Staffing Schedules for May of 2026 revealed the DON spot was blank.In an observation on 06/03/2026 throughout the day, the RNC was not observed in the facility.In an observation on 06/04/2026, throughout the day, the RNC was observed rounding in the facility and speaking with the nursing staff throughout the day. In an interview on 06/03/2026 at 3:28 PM, RN-A stated she worked full time as the WCN. RN-A did not remember exactly when the DON's last day was, but it had been a while. She stated LVN-B, who was also the ADON and Infection Control Nurse had been covering for the DON. She stated the RNC came to the facility to help out. RN-A was unsure if or when they would be getting a new DON In an interview on 06/03/2026 at 4:00 PM, the ADON, who was also the IP, stated she was an LVN. She stated she did not remember exactly when the DON's last day was, but it had been a while. The ADON stated she was helping as much as she could, but the RNC had been filling in 2 or 3 days per week to assist until the position was filled. In an interview on 06/04/2026 at 9:47 AM, the SW stated the DON left her position approximately 4 weeks ago, but the ADON was the acting DON until the position was filled. The SW also stated the RNC came in a few days per week to help out. In an interview 06/04/2026 at 11:00 AM, the Administrator stated the RNC came in 3-4 times per week for 8 hours a day (counting her drive time, 8.5 hours per day). The Administrator stated she had been observing the WCN to determine if she would be a good fit for the DON position. She stated the DON position had been posted for a while, but she had not had any good candidates. In an interview on 06/04/2026 at 3:35 PM, the Administrator stated as long as they had an RN in the building for 8 hours of coverage each day the facility was in compliance, and they did not need DON coverage. In an interview on 06/04/2026 at 1:42 PM, the Administrator stated the facility did not have a policy which addressed the DON or DON coverage.

Based on interview and record review, the facility failed to ensure all alleged violations involving abuse, neglect, exploitation, or mistreatment were reported immediately to the appropriate State Agency, but no later than 2 hours after the allegation was made, for 1 of 5 Residents (Resident #2) reviewed for freedom from abuse and/or neglect.The facility failed to report Resident #2's allegation of verbal abuse by a staff member on 05/17/2026. The state agency was notified on 05/19/2026.This failure could result in placing residents at increased risk for further abuse, as well as not receiving a proper or thorough investigation.The findings included:Record review of Resident #2's face sheet, dated 06/04/2026, revealed a [AGE] year-old male with an admission date of 01/09/2026. Pertinent diagnoses included Type 2 Diabetes (a chronic condition which affects how your body metabolizes sugar [glucose], leading to high blood sugar levels and various health complications), and Morbid (severe) Obesity. Record review of Resident #2's care plan, initiated 01/26/2026 revealed a focus for ADL self-care performance deficit related to Dementia (a condition which affects memory, thinking, and the ability to perform daily activities) and Impaired Balance. Interventions included Bed Mobility: Resident #2 was dependent on staff, and Toilet Use: Resident #2 was dependent on staff.Record review of Resident #2's Quarterly MDS assessment, dated 04/16/2026, revealed BIMS score of 15, which indicated intact cognition. The MDS assessment also revealed Resident #2 frequently had urinary incontinence. Record review of Resident #2's progress note, dated 05/18/2026, revealed regarding events from the night before. Resident #2 was upset an aide came in and was rude to him by taking his urinal and slamming the bathroom door after emptying.Record review of the facility's internal investigation, reviewed 06/04/2026, revealed the facility first learned of the incident on 05/19/2026 at 11:45 AM. The narrative revealed Resident #2 reported a CNA may have called him an asshole while exiting the room and allegedly slammed the door. Internal investigation also revealed Resident #2 remained calm and cooperative during subsequent interview and did not express fear of returning staff or retaliation. An in-service regarding abuse and neglect prevention, appropriate communication, resident rights, professional conduct, and documentation expectations was provided. According to the Investigative Process: Resident #2 remained generally consistent he believed he overheard CNA call him an inappropriate name while leaving the room. In an interview on 06/04/2025 at 11:00 AM, the Administrator stated the incident with Resident #2 occurred on 05/17/2026, but she was not informed of the incident until 05/19/2026 in the morning stand-up meeting. The Administrator stated CNA-D was suspended for 2 days pending the investigation, but the investigation was unsubstantiated. She also stated CNA-D was counseled regarding the incident and all staff were in-serviced regarding reporting abuse and neglect immediately, call light response time, documentation, customer service, and resident rights. The Administrator stated Resident #2 admitted to being upset because CNA-D was mumbling under her breath and denied actually hearing what she had said. The Administrator also stated Resident #2 was very with it cognitively and had a BIMS score of 15. She stated he would be able to answer any questions asked of him. The Administrator stated abuse was supposed to be reported immediately, but no later than 2 hours, and the only reason it was not reported in the expected time frame was because she was not made aware of it. In an interview on 06/04/2026 at 1:23 PM, Resident #2 stated he could not remember the exact date and time, but he remembered CNA-D calling him an asshole sometime late at night or early in the morning. He stated he should have handled the situation differently and felt like he should not have reported CNA-D (could not recall her name), but when CNA-D slammed the bathroom door and called him an asshole, it triggered his PTSD. Resident #2 stated he felt like maybe CNA-D was having a bad night, and he should have been more understanding. Resident #2 also stated the CNA was not mumbling under her breath because he had not had his hearing aids in, and if she were mumbling, he would not have been able to hear her. In an interview on 06/04/2026 at 2:48 PM, CNA-D stated it was before midnight when Resident #2 kept staying on the call light to empty his urinal. CNA-D stated she went in there the first 3 times, and then the other CNA went in afterward. The last time CNA-D was in the room she told Resident #2 she had just been in there 10 minutes prior, and he got upset immediately and started making comments. He made the comment aren't you just a delight, and she responded yes, I am, thank you very much. The other CNA went in after her to handle his call light. CNA-D stated she did not bother him or had not gone back into his room after the third time, but the other CNA went back in his room probably 4 or 5 more times. Around 5 minutes to 11:00 PM, the nurse went in Resident #2's room to discuss the situation with the Resident #2, and the resident went crazy and told the nurse he was calling 911 for elder abuse. The police showed up around midnight, spoke to the resident, and left. They were only in Resident #2's room approximately 10 minutes before they left. They never gave the staff any type of report. CNA-D stated she never called him a name and did not slam his door. CNA-D also stated abuse or neglect was supposed to be reported immediately to the Administrator and the charge nurse. Record review of the facility's Resident Rights policy, revised February 2021, revealed Policy Statement: Employees shall treat all residents with kindness, respect, and dignity.Record review of the facility's Abuse, Neglect, Exploitation and Misappropriation Prevention Program Policy, revised April 2021, revealed Policy Statement: Residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual or physical abuse, and physical or chemical restraint not required to treat the resident's symptoms . Policy Interpretation and Implementation: 8. Identify and investigate all possible incidents of abuse, neglect, mistreatment, or misappropriation of resident property. 9. Investigate and report any allegations within timeframes required by federal requirements .

Based on observation, interview, and record review, the facility failed to ensure all drugs and biologicals were labeled and stored appropriately for 1 of 4 medication carts (300 Hall Medication Cart) and 1 of 1 Emergency Crash Cart reviewed for pharmacy services. 1. The facility failed to ensure the 300 Hall Nurse Med-Cart was locked and secured.2. The facility failed to ensure the Emergency Crash Cart was locked and secured. These failures could place residents at risk of taking or ingesting medications and/or medical supplies which could have caused them harm.The findings included:An observation on 06/03/2026 at 11:49 AM of the 300 Hall Medication Cart, parked at the nurses' station, revealed an unlocked cart which was able to be accessed. The lock was popped out, and all drawers were able to be accessed except the narcotic drawer. There were staff behind the nurses' station on the computers, and residents in wheelchairs around the nurses' station. An observation on 06/03/2026 at 11:57 AM of the Emergency Crash Cart, parked in a cubby on the 200 hall, revealed it was unlocked and able to be accessed. There were staff and residents walking up and down the hall. In an interview on 06/04/2026 at 10:44 AM, LVN-B stated she worked on the 300-hall, and she was the one who left the 300-hall medication cart unlocked while she stepped away from it. LVN-B stated she was supposed to lock her medication cart anytime she walked away from it because residents could have accessed medications which did not belong to them and could have caused them harm or to have side effects and become ill. She stated she had been in-serviced over med-carts and med storage many times and knew not to leave the cart unlocked. In an interview on 06/04/2026 at 11:16 AM, LVN-C stated she worked as the staffing coordinator and filled in as the ADON and a floor nurse as needed. She stated she did the majority of the in-services in conjunction with the DON and ADON. She stated she had just recently in-serviced all of the nursing staff about locking their medication carts anytime they stepped away from them. LVN-C stated this was done for patient safety because if a resident ingested medication which did not belong to them, it could have caused them harm. LVN-C also stated if the Emergency Crash Cart contained sharps (needles) or medications, it should have been locked as well. Record review of the facility's Medication Labeling and Storage policy, revised February 2023, revealed Policy Heading: The facility stores all medications and biologicals in locked compartments under proper temperature, humidity and light controls. Only authorized personnel have access to keys . 4. Compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts, and boxes) containing medications and biologicals are locked when not in use, and trays or carts used to transport such items are not left unattended if open or otherwise potentially available to others.

Based on observation, interview, and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment, and to help prevent the development and transmission of communicable diseases and infections for 1 of 5 residents (Residents #1) reviewed for infection control practices.1. The facility failed to ensure the IP, the WCN, and LVN-B knew the proper placement of the PPE cart for Resident #1.2. The facility failed to ensure the physician's order for EBP was obtained prior to placing Resident #1 on precautions. These failures could place residents at risk of cross contamination and/or infection.The findings included: Record review of Resident #1's face sheet, dated 06/03/2026, revealed a [AGE] year-old-male with an original admission date of 06/22/2025 and a current admission date of 03/19/2026. Pertinent diagnoses included Type 2 Diabetes Mellitus (a chronic disorder characterized by high blood sugar levels due to insufficient insulin [a crucial hormone which regulates blood sugar levels and plays a vital role in energy metabolism] production or ineffective use of insulin by the body) with Foot Ulcer.Record review of Resident #1's admission MDS assessment, dated 03/25/2026, revealed a BIMS score of 09, which indicated moderately impaired cognition. The MDS also revealed Resident #1 had a Diabetic Foot Ulcer and received applications of dressings to the feet.Record review of Resident #1's current care plan, initiated 03/30/2026, revealed a care plan focus for EBP with interventions to use gown and gloves during high-contact resident care activities. Gowns will be available outside of the room or in the room for staff to use when performing direct care with Resident #1.Record review of Resident #1's physician order summary, dated 06/03/2026, revealed no order for any type of precautions or isolation. Resident #1's previous orders reveal and order for EBP which was discontinued on 03/05/2026 (previous admission and discharge).During an observation on 06/03/2026 at 2:17 PM of Resident #1's door and the 200 hallway, there was a small EBP sign posted next to Resident #1's door, but there was no PPE cart posted on the outside of Resident #1's room. Upon further inspection, it was noted there was a PPE cart located further down the 200-hall next to another EBP room.In an interview on 06/03/2026 at 3:28 PM, RN-A stated she worked in the facility full time as the WCN. RN-A stated EBPs were utilized to protect both the residents and the staff and prevent cross-contamination and infection. She stated when a resident was on EBP they should have the EBP signage outside of the room, as well as PPE located outside of the room. She stated the EBP order and the PPE was placed by the ADON, who was also the Infection Control Nurse, or the IP.In an interview on 06/03/2026 at 4:00 PM, the ADON, who was also the IP, stated she had always been told or taught as long as there was PPE accessible on the hallway somewhere, then it sufficed for residents who were on EBP. She stated she never knew it had to be located immediately or right outside of the resident's room. The ADON stated she was not sure what the CDC recommendations for EBP-PPE were. She also stated it was either her or one of the floor nurses who typically obtained orders for EBP, as well as placed the PPE. The ADON stated it was just an error, and she must have overlooked obtaining the EBP order because she remembered to hang the sign and update the care plan. In an interview on 06/04/2026 at 10:44 AM, LVN-B stated either the floor nurses or ADON/IP typically obtained EBP orders and placed PPE on the hallways, and she was not sure how an EBP order could have been overlooked.Record review of CDC document: Long-Term Care Facilities: Implementation of Personal Protective Equipment Use in Nursing Homes to Prevent Spread of Multidrug-Resistant Organisms, dated 04/02/2024, revealed the use of gown and gloves for high-contact resident care activities was indicated, when Contact Precautions do not otherwise apply, for nursing home residents with wounds and/or indwelling medical devices regardless of MDRO colonization as well as for residents with MDRO infection or colonization. Post clear signage on the door or wall outside of the resident room indicating the type of Precautions and required PPE (e.g., gown and gloves); For Enhanced Barrier Precautions, signage should also clearly indicate the high-contact resident care activities that required the use of gown and gloves; Make PPE, including gowns and gloves, available immediately outside of the resident room. Website reviewed on 03/19/25 at 4:35 PM: https://www.cdc.gov/long-term-care-facilities/hcp/prevent-mdro/ppe.html?CDC_AAref_Val=https://www.cdc.gov/hai/containment/PPE-Nursing-Homes.htmlRecord review of the facility's Enhanced Barrier Precautions policy, revised February 2025, revealed Policy Statement: Enhanced Barrier Precautions refer to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and glove use during high contact resident care activities. 2. Gloves and gown are applied prior to performing the high contact resident care activity. 12. PPE for EBP's is available outside or inside of the resident rooms.

Based on interview and record review, the facility failed to ensure residents were free of significant medication errors for 2 of 5 residents (Residents #42 and #89) reviewed for pharmacy services. 1. The facility failed to clarify the blood pressure parameters for Resident #42's Midodrine (a medication used to treat hypotension, or low blood pressure) orders started [DATE]. 2. The facility failed to administer Resident #42's and Resident #89's Midodrine per the recommended and prescribed order and blood pressure parameters in August of 2025. These failures could place residents at risk for complications and jeopardize their health and safety. 1. Record review of Resident #42's face sheet, dated [DATE], revealed a [AGE] year-old male with an admission date of [DATE]. Pertinent diagnoses included hypotension (low blood pressure). Record review of Resident #42's admission MDS assessment, dated [DATE], revealed a BIMS score of 15, which revealed intact cognition. The MDS also revealed an active diagnosis of orthostatic hypotension. Record review of Resident #42's physician orders, started [DATE] revealed an order for Midodrine 5 MG, give one tablet by mouth twice per day related to hypotension, no blood pressure parameters listed; a current active order, started [DATE], revealed an order for Midodrine 5 MG, give one tablet by mouth twice per day related to hypotension; Hold for blood pressure greater than 120/60. Record review of Resident #42's care plan, initiated [DATE], revealed a care plan related to hypotension with a goal to remain free of complications through review. Interventions included give medications as ordered. Record review of Resident #42's [DATE] MAR revealed Midodrine 5 MG, give 1 tablet by mouth two times per day related to Hypotension, started [DATE] and stopped [DATE]. Record review further revealed Midodrine was administered during this timeframe with no blood pressure parameters and no blood pressures recorded in the MAR for this medication. Record review of Resident #42's [DATE] MAR revealed Midodrine 5 MG, give 1 tablet by mouth two times per day related to hypotension (this order was used until [DATE]), then changed to Midodrine 5 MG, give one tablet by mouth twice per day related to hypotension, hold for blood pressure greater than 120/60. (this order was started [DATE]). Dates when Midodrine was administered incorrectly included: [DATE] 9:00 AM B/P 122/78 Administered[DATE] 9:00 AM B/P 120/65 Administered[DATE] 9:00 AM B/P 115/65 Administered[DATE] 5:00 PM B/P 109/66 Administered[DATE] 9:00 AM B/P 106/62 Administered[DATE] 9:00 AM B/P 122/62 Administered[DATE] 9:00 AM B/P 117/66 Administered[DATE] 9:00 AM B/P 104/67 Administered[DATE] 9:00 AM B/P 116/70 Administered[DATE] 9:00 AM B/P 111/66 Administered[DATE] 5:00 PM B/P 104/62 Administered[DATE] 5:00 PM B/P 109/62 Administered[DATE] 9:00 AM B/P 116/71 Administered 2. Record review of Resident #89's face sheet, dated [DATE], revealed a [AGE] year-old male admitted [DATE], and readmitted on [DATE]. Pertinent diagnosis included hypotension (low blood pressure). Record review of Resident #89's Quarterly MDS assessment, dated [DATE], revealed a BIMS score of 15, which revealed intact cognition. Record review of Resident #89's active physician orders, started [DATE] revealed an order for Midodrine 10 MG plus 2.5 MG equals 12.5 mg by mouth daily related to hypotension; Hold for blood pressure greater than 110/60. Record review of Resident #89's care plan, initiated [DATE], revealed a care plan related to hypotension with a goal to remain free of signs and symptoms of cardiac problems. Interventions included give medications as ordered. Record review of the Consultant Pharmacist's recommendations dated [DATE] revealed Resident #89 had an order for Midodrine which included parameters to hold if blood pressure was greater than 110/60. Per documentation on the eMAR it appears Midodrine was administered several times during June although blood pressure was over 110/60. Record review of the Consultant Pharmacist's recommendations dated [DATE] revealed Resident #89 had an order for Midodrine which includes parameters to hold if blood pressure was greater than 110/60. Per documentation on the eMAR it appears Midodrine was still being administered several times during July although blood pressure was over 110/60. Record review of Resident #89's [DATE] MAR revealed Midodrine 12.5 MG by mouth daily related to hypotension (started [DATE]), then changed to Midodrine 5 MG, give one tablet by mouth twice per day related to hypotension, hold for blood pressure greater than 120/60. (this order was started [DATE]). Dates when Midodrine was administered inaccurately included: [DATE] 6:00 AM B/P 107/63 Administered[DATE] 6:00 AM B/P 115/66 Administered[DATE] 6:00 AM B/P 100/62 Administered[DATE] 6:00 AM B/P 140/80 Administered[DATE] 6:00 AM B/P 146/89 Administered[DATE] 6:00 AM B/P 128/77 Administered[DATE] 6:00 AM B/P 114/80 Administered[DATE] 6:00 AM B/P 105/68 Administered[DATE] 6:00 AM B/P 97/65 Administered[DATE] 6:00 AM B/P 110/67 Administered[DATE] 6:00 AM B/P 108/66 Administered[DATE] 6:00 AM B/P 117/73 Administered[DATE] 6:00 AM B/P 119/58 Administered[DATE] 6:00 AM B/P 100/64 Administered[DATE] 6:00 AM B/P 92/65 Administered[DATE] 6:00 AM B/P 151/72 Administered Record review of Resident #89's [DATE] MAR revealed Midodrine 12.5 MG by mouth daily related to hypotension (started [DATE]), then changed to Midodrine 5 MG, give one tablet by mouth twice per day related to hypotension, hold for blood pressure greater than 120/60. (this order was started [DATE]). Dates when Midodrine was administered inaccurately included: [DATE] 6:00 AM B/P 93/67 Administered[DATE] 6:00 AM B/P 106/76 Administered[DATE] 6:00 AM B/P 108/72 Administered[DATE] 6:00 AM B/P 91/64 Administered[DATE] 6:00 AM B/P 109/67 Administered[DATE] 6:00 AM B/P 109/67 Administered[DATE] 6:00 AM B/P 99/63 Administered[DATE] 6:00 AM B/P 100/68 Administered[DATE] 6:00 AM B/P 97/62 Administered In an interview on [DATE] at 4:09 PM the DON stated the floor nurses typically put in orders in the electronic chart. The DON stated nurses and staff had been in-serviced over blood pressure medications and following blood pressure parameter guidelines. The DON stated if a resident was given a medication to increase blood pressure, and their blood pressure was already elevated, they could have had a stroke and died. In an interview on [DATE] at 8:34 AM, MA-B stated she was not sure why she gave the Midodrine outside of parameters other than she was not paying attention. She stated Midodrine was used to bring the blood pressure up and if it was administered while the blood pressure was already elevated, it could continue to rise and cause the resident dizziness, blurred vision, to pass out, or possibly have a stroke. She also stated the pharmacy consultant had in-serviced the nurses and medication-aides previously regarding the fact they had been administering the Midodrine outside of parameters, and she was not sure why it continued to be given outside of parameters. She stated maybe she just got in a hurry and was not paying attention. In an interview on [DATE] at 9:10 AM, the ADON stated she started an in-service last month with the nurses and medication-aides regarding administering blood pressure medications within parameters after it was discussed with her by the Consultant Pharmacist. The ADON stated Midodrine was used to raise the blood pressure, and if the blood pressure became too elevated a resident could have a stroke. Record review of the facility's policy Administering Medication, revised [DATE], revealed Medications are administered in a safe and timely manner, and as prescribed. 4. Medications are administered in accordance with the prescriber's orders. 11. The following information is checked/verified for each resident prior to administering medications: b. Vital signs, if necessary.

Based on observation, interviews, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed and 1 of 1 nutrition room for storage, preparation, and sanitation. 1. The facility failed to ensure there were no personal items in the walk-in refrigerator or on the tray line. 2. The facility failed to ensure all items in the walk-in refrigerator were labeled and dated. 3. The facility failed to ensure there was an internal thermometer in the walk-in refrigerator. 4. The facility failed to ensure there was no ice accumulation in the walk-in freezer. 5. The facility failed to ensure that boxes of food in the walk-in freezer were sealed tightly and at least 18 inches from the ceiling. 6. The facility failed to ensure that juice guns were clean and not hanging over the edge of the prep table. 7. The facility failed to ensure all employees entering the kitchen had hairnets on. 8. The facility failed to ensure all electric stove top burners worked. 9. The facility failed to ensure the nutrition room kept up with freezer logs and expired food in a cabinet.10. The facility failed to ensure the cabinet beneath the nutrition room sink was free of leaks, personal items, and trash. These failures could place residents at risk for food contamination and food-borne illness. Findings were: Observation on initial tour of the kitchen on 09/02/25 at 8:15 am revealed two cans of soda on a shelf in the walk-in refrigerator that were not dated or labeled. There were three trays of beverages in the refrigerator that were neither labeled nor dated. There was no internal thermometer in the refrigerator. There was a thick accumulation of ice in the walk-in freezer, forming a 7-inch pyramid under the condenser. There was an 18-pound box of burritos in the walk-in freezer with the contents open to air. There was a 20-pound box of frozen cookie dough in the walk-in freezer with the contents open to air. A box on the top shelf of the walk-in freezer was less than 18 inches from the ceiling. There was a 20-pound box of frozen vegetables in the walk-in freezer with the contents open to air. One of 2 juice guns had a thick, red/black sticky substance in and on the inner nozzle. The 6-burner electric stove top had 2 elements that did not work. The MSA entered the kitchen without a hairnet and walked through the kitchen before this state surveyor stopped him. Observation during a return visit to the kitchen on 09/02/25 at 12:00 pm revealed a 36-ounce Styrofoam cup with a straw in it on the tray line while trays were being plated. Observation of the nutrition room on 09/03/25 at 10:00 am revealed a 10-ounce jar of asparagus had expired on 11/25/25. Documentation on the freezer temperature log had not been done since 08/11/25. The bottom of the cabinet beneath the sink had standing water throughout, a partially filled basin under the plumbing, 2 empty plastic bags, an empty plastic container, a corded coffee maker, and a personal drinking glass sitting in the water in the cabinet. There were black spots in the basin and in the cabinet. The cabinet floor was delaminated. In an interview with the DS on 09/02/25 beginning at 8:20 am, she said the two cans of soda in the walk-in refrigerator belonged to her. She said she was in a hurry when she came in and just set them there. She said the sodas should not have been in the walk-in refrigerator because the transfer of germs from handling the cans could cause cross-contamination to the food and make residents sick. She said staff had been in-serviced on labeling and dating everything in the walk-in refrigerator, freezer, and the regular refrigerator, as well as personal items. She said the internal thermometer for the refrigerator was in there, but she could not find it. She said they used the exterior digital thermometer to log temperatures. She said they were not comparing the external thermometer to the internal thermometers. She said there was no way to know if the temperatures were accurate. She said the ice accumulation in the freezer had been there for a while and had been addressed. She said the freezer had been fixed last month. She said maintenance was supposed to return and inspect it again. She said she was not sure how long the ice had been accumulating. She said boxes should not have been placed within 18 inches of the ceiling of the walk-in freezer because it could pose a fire hazard, and the sprinklers could be impeded. She said the food in the boxes in the walk-in freezer should have been sealed tightly inside the boxes to prevent damage and contamination to the frozen foods, such as frostbite and whatever might have been in the air. She said the juice guns were cleaned daily and did not know what the gunk was in the inner nozzles. She said the juice guns were supposed to be in a holster and not hanging from the machine, where someone or something could rub against the nozzles and contaminate them. She said the electric stove was supposed to be replaced several months ago, and she did not know what had happened, nor had she followed up recently. In an interview with the MSA on 09/02/25 at 8:30 am, he said, I usually wear a hairnet when I'm in the kitchen, I just didn't right now. He said he knew hairnets were required in the kitchen because he had been trained. He said hair was considered dirty and could cross-contaminate food. In an interview with the CK on 09/02/25 at 12:01 pm, she said she knew better than to set her personal drink on the tray line because she knew about cross-contamination and how it could make residents sick. She said she was in a hurry and just set it down because she could see they had already started plating. In an interview with RA on 09/03/25 at 10:03 am she said, she was unaware of the leaking sink in the nutrition room or the expired jar of asparagus. She said housekeeping was responsible for keeping the temperature logs in the nutrition room. In an interview with the MS on 09/03/25 at 10:52 am, he said he was unaware of the nutrition room sink leaking. He said he was going to fix it. He said the process of having kitchen issues repaired or looked at was for someone to tell him. He said the facility utilized an electronic reporting system. In an interview with the DON on 09/03/25 at 4:23 pm she said, the dietary staff was responsible for stocking the nutrition room refrigerator and checking the refrigerator and freezer temperatures in the nutrition room daily. She said the nutrition room refrigerator and freezer logs were monitored by the SC. She said the structural issues were handled by maintenance. She said she had no idea how long the water had been leaking and was standing in the bottom of the cabinet under the sink. She said she was unaware of the water damage and trash under the sink until today. She said the black stuff was probably mold and was very unsanitary. She said she was ultimately responsible for everything in the nutrition room. In an interview with the SC on 09/03/25 at 4:55 pm, she said she was not responsible for monitoring the temperature logs in the nutrition room and did not know who was. She said she was only responsible for the temperature logs in the medication room and did not know who was responsible for the nutrition room temperature logs. In an interview with the HS on 09/04/25 at 9:51 am, she said she had worked at the facility for 7 years. She said housekeeping was not responsible for the temperatures in the nutrition room. She said she thought it was nursing but knew it was not housekeeping. In an interview with the MS on 09/04/25 at 10:30 am, he said he was aware of the ice accumulation in the walk-in freezer. He said it was repaired, but the freezer continued to accumulate ice. He said the repair company was scheduled to return and did not say when. He said new burners for the electric stove were ordered yesterday. An order for the electric stove burners was requested at this time but was not received. Record review of the kitchen daily cleaning lists dated May 2025-September 3, 2025, revealed all dates were checked indicating they were done. The cleaning lists included juice machine. Record review of the freezer repair invoice dated 08/08/25 indicated that a defrost determination switch, defrost clock, and wire connections were repaired. Record review of kitchen in-services/training revealed: 01/2025-Adaptive Equipment, 02/2025-Keeping Food Safe, 03/2025-Mechanical Soft Diet Textures, 04/2025-Refrigeration Food Storage, 05/2025-Standardized Menus, 06/2025-Tray ticket Accuracy, 07/2025-Menu Substitution Guide, 09/02/25-Communication, 09/03/25-Hallway Trays/Carts, 09/04/25-Temperature Logging. Record review of the facility's kitchen policy, dated 11/2022, titled Food Receiving and Storage, stated, Foods shall be received and stored in a manner that complies with safe food handling policies. Refrigerated/Frozen Storage: 1 All foods stored in the refrigerator are covered, labeled and dated ( use by date). Foods and Snacks Kept on Nursing Units: 3. Refrigerators .are monitored for temperature according to state-specific guidelines. Record review of the facility's kitchen policy, dated 11/2022, titled Refrigerators and Freezers, stated this facility will ensure safe refrigerator and freezer maintenance, temperatures, and sanitation, and will observe food expiration guidelines. 1. Refrigerators and/or freezers are maintained in good working condition. 2. Monthly tracking sheets for all refrigerators and freezers are posted to record temperatures. 7. All food is appropriately dated to ensure proper rotation by expiration dates. Use by dates are completed with expiration dates on all prepared food in refrigerators. 10. Supervisors inspect refrigerators and freezers monthly for gasket condition, fan condition, presence of rust, excessive condensation, and any other damage or maintenance needs. Necessary repairs are initiated immediately . Record review of the facility's kitchen policy, dated 2021, titled Employee Sanitary Practices stated all food and nutrition services employees will practice good hygiene and safe food handling procedures. All employees will: 1. Wear hair restraints to prevent hair from contacting exposed food. Record review of the facility's kitchen policy, dated 2021, titled Authorized Personnel in Food Service Department stated the food and nutrition services department is restricted to department employees. 5. Note: . maintenance personnel are exceptions to this policy. References: FDA Food Code 2022 Ch. 2-102.20 Food Protection Manager Certification 2-103 Duties 2-103.11 Person in Charge. The person in charge shall ensure that: (E) .foods are protected from contamination . 2-4 Hygienic Practices 2-401 Food Contamination Prevention 2-401.11 Eating or Drinking: an employee shall eat or drink . only in designated areas where the contamination of exposed food; clean equipment, utensils, and linens; unwrapped single-service and single-use articles; or other items needing protection cannot result. (B) A food employee may drink from a closed beverage container if the container is handled to prevent contamination of: (1) the employee's hands; (2) the container; and (3) Exposed food; clean equipment, utensils, and linens; and unwrapped single-service and single-use articles. Ch. 3-305 Preventing contamination from the premises 3-305.11 Food Storage (A) Except as specified in (B) and (C) of this section, food shall be protected from contamination by storing the food: (1) In a clean, dry location; (2) Where it is not exposed to splash, dust, or other contamination. 4-5 Maintenance and Operation 4-501 Equipment 4-501.11 Good Repair and Proper Adjustment. (A) Equipment shall be maintained in a state of repair and condition that meets the requirements specified under Parts 4-1 and 4-2. 4-602 Frequency 4-602.11 Equipment Food-Contact Surfaces and Utensils. (A) Equipment, food-contact surfaces and utensils shall be cleaned: (5) At any time during the operation when contamination may have occurred. If used with time/temperature control for safety food, equipment food-contact surfaces, and utensils shall be cleaned throughout the day at least every 4 hours.

Based on observations, interviews and record reviews, the facility failed to ensure all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown sources were reported immediately, but not later than 2 hours after the allegation was made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury to the administrator of the facility and to other officials, including to the State Survey Agency in accordance with State law through established procedures for 1 of 6 Residents (Resident #48) reviewed for reporting. In an interview with the ADM on 09/03/25 at 5:33 pm, he said he was informed about the incident with Resident #48 by the DON on or about 08/16/25, and since the DON was taking care of it, he had not remembered it when he and this state surveyor spoke on 09/03/25 at 5:06 pm. He said name-calling was verbal abuse, and he should have reported it to the state and local authorities. The facility did not report an allegation of verbal abuse on or about 08/16/25 per facility policy to the Administrator. Findings were: Record review of Resident #48's face sheet revealed a [AGE] year-old female who was admitted on [DATE]. Diagnoses included high blood pressure, diabetes, kidney disease, liver disease, heart disease, and paraplegia (the inability to voluntarily move the legs and loss of sensation in the lower part of the body, typically due to traumatic spinal cord injury). Record review of Resident #48's quarterly MDS dated [DATE] revealed a BIMS score of 14, indicating she was cognitively intact. She had upper body impairment and contractures. She was independent with eating and oral hygiene with adaptive utensils. She required substantial assistance with toileting, showering, and personal hygiene. She was able to roll left and right in bed using grab bars for assistance. She utilized a manual wheelchair which she could self-propel. She was always incontinent of bladder and bowel. Record review of Resident #48's care plan dated 11/09/22 indicated she had impaired mobility, loss of bowel tone, and physical limitations requiring a mechanical lift for transfers. In an interview and observation with Resident #48 on 09/03/25 at 2:05 pm, she said CNA C called her a dummy in the shower room a couple of weeks ago. She said she used a mechanical lift and was in the sling. She said she was crooked in the sling and wanted to sit up straighter because her head and neck were becoming uncomfortable. She said she was unable to straighten herself out, and that was when CNA C said to her, Sit up, dummy. She said the comment made her feel bad. She said she told the DON about it, and CNA C was no longer allowed to come into her room or shower her. Resident #48 was well-kempt and had no signs of abuse or odors. She said she was not fearful of CNA C, but things were not the same after she called her a dummy. In an interview with the OMB on 09/03/25 at 2:15 pm she said she did not know about the allegation of verbal abuse toward Resident #48 and this was the first time she had been informed of the incident. In an interview with the DON on 09/03/25 at 4:30 pm she said, she was informed by Resident #48 about the incident after it happened a couple of weeks ago. She said she spoke with the ADM about it and, together, decided that CNA C would not be suspended and would not be allowed to care for Resident #48. She said she did not report the incident to state or local authorities. She said name-calling was a form of verbal abuse, but she did not conduct an in-service. She said she did not know why the incident was not reported. She said she thought telling the ADM was enough. The facility's policy for reporting abuse was requested at this time. In an interview with the ADM on 09/03/25 at 5:06 pm, he said he was not informed about an incident with Resident #48. He said he would have remembered a verbal abuse allegation, especially since it was so recent, and would have reported it to the state. In an interview with CNA C on 09/03/25 at 5:24 pm, she said she was not allowed in Resident #48's room since Sunday, 2 weeks ago (08/17/25) because she supposedly called Resident #48 a dummy. She said the DON removed her from Resident #48's room, but she still worked in the same hall. She said she had worked at the facility for 3 years. She said Resident #48 wanted things her way, such as being laid down or showered right away. She said she told Resident #48 she needed help that Friday (08/15/25) due to a staffing change. She said she told Resident #48 she wanted to lay her down right after lunch ( so she could make the 3 o'clock bingo game) instead of her usual nap time after the bingo game. She said Resident #48 told her she did not want to do that. CNA C said, when she got busy, she knew Resident #48 would get an attitude if she did not get her way. CNA C indicated she would get pulled in different directions throughout her shift because the facility changed from 3 CNAs (One for each hall) to 2 with a split (meaning 1 CNA each on 2 halls and 1 CNA worked where needed). She said Resident #48 required a mechanical lift for transfers, and she would have to wait for the second person as required for mechanical lifting. She said Resident #48 did not like having to wait. She said the next day, the SC told her not to go into Resident #48's room again. She said the SC told her the reason was because the DON said she (CNA C) called Resident #48 dumb. CNA C said she was offended because she was a hard worker. She said Resident #48 was mad because she did not get laid down on her time. She said she told the DON they needed to let the residents know about the cut in staff so the residents would better understand their positions and the inability to get things done as they expect. She said Resident #48 was like this with everyone, all shifts. She said Resident #48 only thought dumb was what she said. CNA C said nothing when asked what was really said or if she considered name-calling verbal abuse. In an interview with the ADM on 09/03/25 at 5:33 pm, he said he was informed about the incident with Resident #48 by the DON on or about 08/16/25, and since the DON was taking care of it, he had not remembered it when he and this state surveyor spoke on 09/03/25 at 5:06 pm. He said name calling was verbal abuse, and he should have reported it to the state and local authorities. In an interview with the SC on 09/04/25 at 9:30 am, she said CNA C told her Resident #48 was upset because she did not get her shower right away. She said CNA C was upset because she and Resident #48 always had a good relationship. The SC said she stopped CNA C on her way in because CNA C came in late that day. She said the DON told her to switch CNA C with another CNA (unknown) to care for Resident #48 before the start of the shift (at 2:00 pm) because Resident #48 did not want her in there. She said she did not question or check on Resident #48 after she spoke with the DON. She said she did not know why she did not check on Resident #48 because it could have been more than verbal abuse. She said she did not have an in-service regarding this incident. In an interview with Resident #48 on 09/04/25 at 9:54 am, she said being called a dummy made her feel very uncomfortable. She denied ever requesting CNA C for showers. She said CNA C reminded her of Dr. Jeckel & Mr. [NAME]-one day she was nice the next day she wasn't. She said CNA C was bossy to the other CNAs. She said she told the DON she would feel better if they put CNA C in another hall. She said she sought out the DON and told her the whole story. She said she felt like she was falling because she was tilted to the right in the sling. She said she asked CNA C to pull the sling toward the wall because she felt like she was falling but CNA C did not adjust the sling. She said CNA C told her to put her head back so she could wash her hair, and she did, then leaned to her left to try to pull the sling herself and CNA C told her to put her head back again and that was when she called her a dummy. She said they did not talk after that. In an interview with CNA D on 09/04/25 at 10:12 am, she said she worked at the facility for 11 years. She said she knew Resident #48 well. She said Resident #48 was very much with it (meaning cognitively intact). CNA D said, If Resident #48 said anything, you could go by her word. She said Resident #48 could get frustrated easily but got over it quickly, such as if something she wanted in her closet (or wherever) could not be readily found, or if the menu was wrong. She said staff redirected Resident #48 to get her in a better mood. CNA D said she had worked with CNA C. She said CNA C was easy to get along with and was good with the residents. She said CNA C was real stern, loud, blunt, serious all the time, and could be bossy with the residents and other staff, such as, do this/ do that, why haven't you done this, etc. CNA D said CNA C's demeanor was not like, can you please move, more like move out of the way. CNA D said staff had to talk nicely to the residents. She said she thought it was CNA C's voice that took residents aback. She said name-calling was a form of verbal abuse. She said she was not in-serviced on this incident but had abuse training monthly and was able to say the types of abuse, who to inform, and when. In an interview with the SW on 09/04/25 at 10:36 am, she said she spoke with Resident #48 this morning and yesterday (wellness check) because she had a concern she voiced regarding a staff member. The SW said yesterday was the first time she had heard of a concern from Resident #48. She said the ADM told her he was not aware of Resident #48's concern because it was reported to the DON. She said the ADM told her about a complaint on CNA C while showering that she called her a name, dummy, and she reported it when she came out of the shower to the DON. The SW said she spoke with Resident #48 and she told her the story. She said Resident #48 told her she felt safe and was happy that CNA C was no longer allowed in her room. The SW said she spoke with Resident #48 daily because she was rarely in her room, participating in activities or in the dining room. The SW said she would describe Resident #48 as mentally competent. She said she was not aware of Resident #48 ever having any complaints about anyone else. She said name calling was a form of verbal abuse. She said she did not receive in-services for this incident but had abuse training monthly and was able to say the types of abuse, who to inform, and when. Record review of CNA C's personnel file on 09/04/25 revealed no disciplinary actions related to the incident. Record review of the facility's policy revised 09/2022, titled, Abuse, Neglect, Exploitation, and Misappropriation - Reporting and Investigating stated, All reports of resident abuse (including injury of unknown origin), neglect, exploitation, or theft/misappropriation of resident property are reported to local, state, and federal agencies (as required by current regulations) and thoroughly investigated by facility management. Findings of all investigations are documented and reported. 1. If resident abuse . is suspected, the suspicion must be reported immediately to the administrator and to other officials according to state law and HHSC reporting guidelines. 2. The administrator or the individual making the allegation immediately reports his or her suspicion to the following persons or agencies .3. Immediately is defined as a. within two hours of an allegation involving abuse .6. Upon receiving any allegations of abuse .the administrator is responsible for determining what actions (if any) are needed for the protection of residents. 7. All allegations are thoroughly investigated. The administrator initiates investigations. 10. The administrator is responsible for keeping the resident and their representative informed of the progress of the investigation. 11. The administrator ensures the resident is protected from retaliation or reprisal by the alleged perpetrator .12. Any employee who has been accused of resident abuse is placed on leave with no resident contact until the investigation is complete. 15. The investigator notifies the Ombudsman that an abuse investigation is being conducted and invited to participate in the review process.

Based on interview and record review, the facility failed to ensure a baseline care plan which included the instructions for resident care needed to provide effective and person-centered care was implemented within 48 hours of admission for 1 (Resident #100) of 5 residents reviewed for baseline care plans. The facility did not develop a baseline care plan within 48 hours of admission for Resident #100. This failure could place residents at risk of not receiving person-centered care and/or services to meet their physical and/or psychosocial needs.Findings included: Record review of Resident #100's face sheet, dated 09/02/2025, revealed she was a [AGE] year-old female originally admitted on [DATE], readmitted on [DATE], and discharged on 09/02/2025. Pertinent diagnoses included Chronic Obstructive Pulmonary Disease (a lung condition caused by damage to the airways and alveoli, usually from smoking or other irritants), Dyspnea (shortness of breath), and Dependence on Supplemental Oxygen (Oxygen therapy to help people with lung disease). Record review of Resident #100's orders, dated 08/28/2025, revealed orders for ProAir (medication to help patients with lung disease), Albuterol (a medication used to help increase airflow to the lungs), and admission to Hospice. Record review of Resident #100's baseline care plan, initiated 08/28/2025, revealed the baseline care plan had been added to Resident #100's chart, but it had never been completed. Record review of Resident #100's MDS admission assessment dated [DATE] revealed a BIMS score of 12, which revealed moderately impaired cognition and hospice care. In an interview on 09/03/2025 at 2:07 PM, the MDS nurse stated she should have completed the clinical portion of the baseline care plan for Resident #100, and the rest of the IDT should have completed the other sections, but it was obviously overlooked by everyone. She stated care plans never got overlooked, so she was not sure how this one got overlooked. She stated she had opened and dated it because it was in Resident #100's chart, but it was just never completed. In an interview on 09/03/2025 at 4:09 PM, the DON stated she thought the care plan for Resident #100 just got overlooked. She stated the MDS nurse should have put in the clinical portion of the baseline care plan, and the IDT should have filled in the other sections which belonged to them by discipline. She stated Resident #100 was a frequent flyer, and she had been there so many times, and the staff knew her, so she thought her information just got overlooked. In an interview on 09/04/2025 at 8:34 AM, MA-B stated the care plans were used to determine residents' wants, needs, likes, and/or dislikes. She stated she did not put in or update the care plans, and this was completed by the MDS nurse, the ADON, or the DON. In an interview on 09/04/2025 at 9:10 AM, the ADON stated she helped with the care plans when she needed to update something, but it was mostly created and updated by the MDS nurse, as it was their job to work on care plans. She stated she was not sure why the care plan for Resident #100 was never completed, but she thought it just got overlooked because the resident admitted at the end of the week, and Resident #100's care plan must have gotten missed. The ADON stated without a baseline care plan information regarding Resident #100's care could have gotten overlooked or missed. Record review of the facility's Care Planning - Interdisciplinary Team policy, with a revision date of 12/2024, revealed The Interdisciplinary Team was responsible for the development of resident care plans. The IDT includes, but is not limited to: the resident's attending physician, a registered nurse with responsibility for the resident, a licensed vocational nurse with responsibility for the resident, a nursing assistant with responsibility for the resident, a member of the food and nutrition services, to the extent practicable the resident and/or resident's representative, and other staff as appropriate or necessary to meet the needs of the resident.

Based on interview and record review, the facility failed to ensure dialysis services were provided consistent with professional standards of practice for 1 of 1 resident (Resident #6) reviewed for quality of care. The facility failed to ensure Resident #6 had a physician's order to assess the dialysis shunt or fistula (a dialysis access which allows the removal of waste and extra fluid). The facility failed to monitor Resident #6's dialysis catheter by assessing for the thrill and bruit each shift. These failures could place residents at risk for complications and not receiving proper care and treatment to meet their needs. Findings included: Record review of Resident #6's face sheet, dated 09/04/2025, revealed a [AGE] year-old male with an admission date on 03/09/2022 and readmission on [DATE]. Pertinent diagnoses included End Stage Renal Disease (when the kidneys no longer adequately filter waste products from the blood), Diabetes Mellitus Type 2 (a group of diseases which affect how the body uses blood sugar), and Dependence on Renal Dialysis (process of removing excess water, solutes, and toxins from the blood when the kidneys can no longer perform those functions naturally). Record review of Resident #6's quarterly MDS assessment, dated 06/20/2025, revealed Resident #6 was understood and was able to understand others. The MDS assessment indicated Resident #6 had a BIMS score of 15, which indicated his cognition was intact. The MDS assessment also indicated Resident #6 had a dependence on renal dialysis. Record review of Resident #6's comprehensive care plan, dated 03/25/2025, revealed Resident #6 received dialysis on Mondays, Wednesdays, and Fridays with a goal for Resident #6 to have no signs or symptoms of complications from dialysis through the review date. Interventions of this care plan included no blood pressure or venipuncture (blood draws) on extremity with dialysis access site. Record review of Resident #6's progress note, dated 08/19/2025, revealed Resident #6 had a left AV fistula placed (a procedure which connects an artery to a vein **AV - arteriovenous** to allow for a more durable access point for hemodialysis) and was noted to have sutures and Dermabond (a liquid topical skin adhesive) to the area. Record review of Resident #6's physician orders, dated 03/19/2025, revealed an order for Dialysis weekly on Mondays, Wednesdays, and Fridays. Record review of Resident #6's physician orders, after an interview with both the DON and the ADON, revealed there were new orders initiated today (09/03/2025) to include monitor left AV shunt/fistula for bleeding every shift; no blood pressures or venipuncture on extremity with dialysis site; monitor AV shunt/fistula to left arm for thrill (a palpable vibration felt over the fistula) and bruit (a sound produced by turbulent blood flow) every shift In an interview on 09/02/25 at 1:30 PM LVN-A stated to surveyor there was not an order to assess the shunt, but she knew it was supposed to be assessed. LVN-A stated she had assessed the dialysis shunt for thrill and bruit prior to sending to dialysis on Mondays, Wednesdays and Fridays. She stated she did not chart in the assessment in Resident #6's progress notes but charted it on his paperwork which went with him to dialysis. In an interview on 09/02/25 at 1:35 PM, the ADON stated to the surveyor she could not find an order for the nurses to assess the dialysis shunt, but there should have been. She stated Resident #6 had this shunt/fistula placed on the 8/19/25, which was when the order should have been put in. She stated assessing the shunt was a way to monitor it was working properly and had good blood flow. In an interview on 09/02/25 at 1:38 PM, the DON stated to the surveyor she could not find an order for the nurses to assess the dialysis shunt/fistula, but there should have been. She stated Resident #6 had this shunt/fistula placed on the 8/19/25, and the order should have been put in when the resident had the shunt placed. She stated the shunt/fistula needed to be assessed routinely to make sure it was functioning and working properly and not having complications, and she would obtain that order today. Record review of the facility's Physician Orders Policy, dated 02/2025, revealed The purpose is to establish uniform guidelines in the receiving and recording of physician orders to ensure the resident receives the necessary care and services. Physician orders are essential for the comprehensive care of residents.

Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment, and to help prevent the development and transmission of communicable diseases and infections for 1 resident (Resident #89) of 6 residents reviewed for infection control practices.1) The facility failed to ensure the WCN performed hand hygiene after removing gloves prior to performing wound care on Resident #89 and after sanitizing scissors.This failure could place residents at risk for healthcare associated cross-contamination and infections.Findings include:Record review of Resident #89's face sheet, dated 09/04/25, reflected a [AGE] year-old-male with an initial admission date of 06/01/23. Diagnoses included stage 4 (full thickness tissue loss, exposing underlying structures such as muscle, tendon, or bone) pressure ulcer of the sacral (tailbone) region and right ankle, type two diabetes (insufficient insulin production in the body), and high blood pressure. Record review of Resident #89's physician orders reflected:Stage 4 (full thickness skin loss and exposing of underlying tissues, including muscle and bone) pressure sore to sacrum (tailbone) clean with normal saline, pat dry with 4x4 gauze, apply collagen (protein that stimulates new tissue growth) and cover with dry dressing daily and as needed. Dated 09/02/25. Left hallux (big toe) stage 4 pressure sore, Clean with normal saline, pat dry with 4x4 gauze, apply hydrofera blue (antibacterial wound dressing) cut to size of wound bed wrap with kerlix and secure with tape on Monday's, Wednesday's, Friday's, and as needed. Record review of Resident #89's quarterly MDS dated [DATE] reflected a BIM score of 14 (cognition intact). During an observation on 09/03/2025 at 2:44 PM, the WCN took off her gloves after sanitizing scissors and did not perform hand hygiene before putting on new gloves and prior to performing wound care on Resident #89. In an interview on 09/03/2025 at 4:13 PM, the WCN stated she did not sanitize her hands after removing gloves when she cleaned the scissors because she did not have her hand sanitizer where she usually had it and it threw her off. The WCN stated she was nervous and forgot to sanitize her hands or perform hand hygiene after removing her gloves. The WCN stated it was important to perform hand hygiene after taking off gloves to stop the spread of infection and possible cross contamination. The WCN stated if Resident #89's wound came in contact with bacteria; it could get infected. In an interview on 09/03/2025 at 4:51 PM, the DON stated staff should sanitize or wash hands for at least 30 seconds with 20 seconds of friction. The DON stated it was important to wash hands to prevent the spread of infection. The DON stated the facility conducted a lot of in-services on infection control but could not state when the last hands-on in-service was for handwashing. Record review of Handwashing/Hand Hygiene policy not dated reflected:Policy StatementThis facility considers hand hygiene the primary means to prevent the spread of healthcare-associated infections.Indications for Hand Hygieneg. immediately after glove removal

Based on record review and interview, the facility failed to maintain clinical records in accordance with accepted professional standards of practice, that were complete and accurately documented, for one resident (Resident #1) of three residents reviewed for personal inventory log. When Resident #1 was admitted on [DATE], LVN A failed to complete an accurate inventory log for Resident #1's belongings. This failure could jeopardize a resident from having their valuables properly recorded, which in turn could result in a resident's valuables being misplaced and/or not returning home with the correct resident. The findings included: Record review of Resident #1's admission record dated 07/15/2025, revealed Resident #1 was a [AGE] year-old female who was initially admitted on [DATE] and readmitted on [DATE] and later discharged [DATE] to home with hospice. Resident #1's primary stay was for Respite Hospice. Resident #1 had diagnoses of acute diastolic (congestive) heart failure, and type 2 diabetes (sugar irregularity). Record review of Resident #1's Discharge MDS dated [DATE] revealed Resident #1 had a BIMS score of 4 which meant she had severe cognitive impairment and additionally was independent for ADLs. Record review of Resident #1's Care Plan date initiated 06/15/2025 revealed the resident has an ADL self-care performance deficit. Goal: The resident will maintain current level of function through review date. Interventions: BATHING/SHOWERING: Check nail length and trim and clean on bath day and as necessary. Report any changes to the nurse. DRESSING: Assist the resident to choose simple comfortable clothing that enhances the resident's ability to dress self. Record review of the facility provider investigation report date of incident 06/18/2025 revealed On Wednesday 6/18/25 resident [Resident #1] was bathed by [hospice agency] C.N.A. Hospice C.N.A left [facility], later in the day [ADON A] received a phone call from [hospice agency], to inform us that the C.N.A who bathed [Resident #1] verbalized resident [Resident #1]'s gold chain with Crucifix pendant was not on her. [ADON A] and [Social Worker] went to speak to [Resident #1] about the jewelry in question. [Resident #1] verbalized she isn't sure what happened to it. [Social Worker] questioned [Resident #1] if resident recalls anyone taking it off of her or taking it in general. [Resident #1] verbalized No, no one took it off of me. [Social Worker] and [ADON A] looked in the resident room, around [facility] nursing facility and the assisted living side, since resident was noted going over to assisted living area and enjoying spending time there. The jewelry was unable to be located on the day it was noted to be missing. [Resident #1] 's [family member] was informed [facility] nursing staff were unable to locate jewelry, but staff will continue to look for it. At this time there were no allegations of theft and [facility] team members continued to look for jewelry in laundry and throughout the nursing home. During an interview on 07/12/2025 at 3:57PM, LVN A stated she recalled admitting Resident #1 into the facility on [DATE]. LVN A stated she recalled Resident #1 wearing a necklace, alongside a matching purple sweater, pants, and shoe attire. LVN A stated typically when admitting a resident, she would fill out all admission documents which included several types of assessments and a personal inventory log of all belongings. LVN A stated on the day of 06/15/2025 there were multiple residents being admitted and during the commotion of the day, she forgot to complete Resident #1's inventory log. LVN A reiterated she recalled seeing a necklace but could not recall the specific details of what the necklace looked like. LVN A stated although filling out the inventory log was a collaborative effort amongst the clinical staff, all personnel were busy on 06/15/2025 and therefore the inventory log was forgotten. LVN A stated filling out Resident #1's inventory was important, as it aided in ensuring Resident #1's belongings returned with her when she returned home. LVN A stated by not filling out Resident #1's inventory log, it jeopardized accurate monitoring of Resident #1's belongings and furthermore resulted in Resident #1 returning home without her sentimental valuables. LVN A stated she should have filled out Resident #1's inventory log but reiterated that day she had multiple admissions and forgot to complete Resident #1's inventory log. LVN A stated after the incident, she ensured to procedurally conduct the admission process which included filling out residents' inventory log of belongings. During an interview on 07/15/2025 at 5:15PM, the DON stated LVN A should have completed Resident #1's inventory log of personal belongings. The DON stated the importance of filling out an inventory log was to ensure a resident's belongings are itemized and accounted for during the resident's stay. Furthermore, once a resident is discharged the inventory log would ensure that the resident's belongings are all returned accurately. The DON reiterated LVN A should have completed Resident #1's inventory log but was not completed due to LVN A having multiple admissions on 06/15/2025. The DON stated Resident #1's well-being could have been negatively affected as the necklace held sentimental value. The DON stated if LVN A had completed Resident #1's inventory log, potentially, Resident #1's crucifix necklace could have been accurately monitored. The DON stated all clinical nurses were educated on admission requirements upon their hiring orientation. The DON stated the incident regarding Resident #1's crucifix necklace was an isolated event and accident. Record review of the facility's Admissions Checklist (Must be checked off by Documenting Nurse) undated revealed, Inventory Sheet Record review of the facility's Personal Property policy revised August 2022 revealed, 10. The resident's personal belongings and clothing are inventoried and documented upon admission and updated as necessary.

Based on observations, interviews, and record review, the facility failed to ensure that each resident received adequate supervision to prevent accidents for one (Resident #1) of 5 residents reviewed for supervision. The facility failed to ensure Resident #1 received adequate supervision while Resident #1 was unaccounted for approximately 10 minutes from 9:05 PM to 9:15 PM on 12/13/24 before LVN C found Resident #1 alone in the 100-hall shower room on the floor. Resident #1 sustained an injury to his head from the fall and was taken to a local hospital where he was diagnosed with an acute on chronic intracranial subdural hematoma (occurs when a new, acute bleed happens to a pre-existing chronic subdural hematoma, often triggered by even minor trauma. A subdural hematoma is a collection of blood that accumulates between the brain and the innermost layer of the skull). The noncompliance was identified as PNC. The PNC began on 12/13/24 and ended on 12/14/24. The facility had corrected the noncompliance before the investigation began. This failure could place residents requiring supervision at risk for injury and accidents with potential for more than minimal harm. The findings included: Record review of Resident #1's face sheet dated 03/25/25 revealed a [AGE] year-old male with an original admitted [DATE] and a current admitted [DATE]. Pertinent diagnoses included abnormalities of gait and mobility and lack of coordination. Record review of Resident #1's Quarterly MDS assessment dated [DATE] section C, cognitive patterns, revealed a BIMS score of 5 (Severe Impairment). Section GG, functional abilities, revealed no attempt was made for Resident #1 to walk 10 feet due to medical conditions or safety concerns, but Resident #1 was able use his wheelchair to travel 150 feet with partial assistance (helper does less than half the effort). Section J, health conditions, revealed the resident had not had any falls since admission/entry or reentry or the pior assessment, whichever was more recent. Record review of Resident #1's care plan dated 03/24/25 revealed the problem [Resident #1] is at risk for falls and injuries r/t Confusion, Gait/balance problems, Incontinence, and episodes of generalized weakness, poor safety awareness and forgets limitations, does not call for assistance with transfers or use call light, hx of falls initiated on 03/01/23 and revised on 12/16/24. Interventions listed for the problem included: -Orthostatic Blood Pressures [drop in blood pressure that occurs when a person stands up from a sitting or lying position] to be taken when resident gets up in AM and again before he does to bed at night initiated on 12/11/24 and revised on 12/16/24. -9/11/24 Intervention: assessment, neurological checks, encouraged to utilize call bell, medication review, RP and MD notified initiated on 09/11/24. -Anticipate and meet the resident's needs initiated on 03/01/23. -Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance initiated on 03/01/23. -Ensure that the resident is wearing appropriate footwear or non-skid socks during transfers or mobilizing in w/c initiated on 03/01/23. -The resident needs a safe environment with: even floors free from spills and/or clutter; adequate, glare-free light; a working and reachable call light, the bed in low position, personal items within reach initiated on 03/01/23. -Toileting program Q 2HRS to aide in prevention of falls[.] Placed in tasks for aides to assist initiated on 12/26/24. Record review of Resident #1's order summary revealed an active order titled Toileting program Q 2HRS to aide in prevention of falls[.] Placed in tasks for aides to assist initiated on 12/19/24. Record review of the provider investigation report dated 12/20/24 revealed the following report of the incident: It was reported on 12/13/24 around 9:15 pm that [Resident #1] was observed in 100 hall shower room about 10 minutes after being seen by [LVN C] while he was making his way to his room. [Resident #1] scheduled shower on the 2-10 [PM shift] but was not getting a shower at the time. Currently being treated for UTI. Resident self propels in wheelchair and self transfers at times. Requires frequent education on call light and assistance with transferring. [Resident #1] sustained laceration to left ear, unable to determine the severity initially due to bleeding. Sent to [local hospital] ER for evaluation. [Resident #1] is there currently under observation. [Resident #1's] room is two doors down from the shower room and we believe he mistook it for the correct door. Record review of LVN C's progress note dated 12/13/24 at 9:36 PM revealed the following narrative of the incident: [LVN C] observed resident on the floor of 100 hall's common bathroom/shower room laying on his left side with his pants around his ankles, brief intact, no shoes and only wearing socks on. Resident's wheelchair noted beside him facing his back. Resident noted to be alone in 100 hall bathroom. [LVN C] observed blood on the floor of resident's cephalic [head] region. Upon further assessment laceration noted to left ear. Resident stated, I was trying to go to the bathroom. This nurse pulled call light located in bathroom then stood at entrance of 100 hall bathroom doorway and shouted Help for additional assistance. Immediately after [LVN D] and [LVN E] arrived at restroom to assist. [LVN E] initiated 911 call after observing resident's condition. This nurse immediately provided treatment to left ear wound while resident in supine [lying down face upward] position. Dressing noted intact to old skin tear to right and left forearm. During treatment this nurse assessed resident's mental status. Resident noted to be alert and oriented to person, place, and situation. Resident answered questions appropriately. Vitals obtained BP 142/97 HR 76 T 97.4 O2 96% on room air PAIN 0/10. Head to toe assessment completed. Patient continued to deny pain and discomfort to this nurse. EMS arrived at scene at approximately 9:30 PM and took over care. EMS transported resident to [local hospital] ER for further evaluation and treatment. MD notified. DON notified. RP notified. Record review of Resident #1's hospital discharge summary dated 12/18/24 revealed Resident #1 was diagnosed with an acute on chronic intracranial subdural hematoma while at the local hospital after his fall on 12/13/24. Record review of Resident #1's fall risk assessment dated [DATE] revealed Resident #1 was a high risk. During an observation at 8:30 AM on 03/25/25, the shower rooms on the 100, 200, and 300 halls were all locked and secured with a number combination lock. During an observation at 10:55 PM on 03/25/25, the shower rooms on the 100, 200, and 300 halls were all locked and secured with a number combination lock. During an observation of Resident #1's room at 11:00 AM on 03/25/25, Resident #1's room was free from clutter, fall mats were in position by his bedside, his bed was in the low position, and his call light was within reach of his bed. In an interview with Resident #1 at 11:07 AM on 03/25/25, Resident #1 stated he remembered falling in December, 2024. Resident #1 stated he tripped, went down, and hit his face while he was walking. Resident #1 was not able to recall any more details about the fall on 12/13/24. An interview was attempted with LVN C at 3:06 PM on 03/25/25, but LVN C could not be reached so this state surveyor left a message on her voicemail. In an interview with the ADM at 3:59 PM on 03/25/25, the ADM stated he remembered getting a call that the resident fell in the shower room and nobody knew how he got in there. The ADM stated the shower door was supposed to be locked, and that Resident #1 should not have been allowed in the room without an employee present. The ADM stated before Resident #1's fall, they used to have a lock and key mechanism on the shower doors, with the key hanging from a chain by the door. The ADM stated they did not know if Resident #1 used the key to enter the shower room or an employee left the door slightly open on accident. The ADM stated the DOM came up to the facility that evening to change the lock on the 100-hall shower door to a number combination lock. The ADM stated the locks on the shower rooms in the 200 and 300 halls were changed the following day. In an interview with LVN E at 5:50 PM on 03/25/25, LVN E stated he was working the night Resident #1 fell in the 100-hall shower room. LVN E stated both LVN C and LVN D arrived at the resident before him, so LVN C told him to go call 911. LVN E stated after he called 911, he started getting paperwork ready for EMS and waited for them by the door to direct them to Resident #1 as fast as possible. LVN E stated he did not know how Resident #1 got in the shower room, but that the shower rooms were supposed to be locked at all times. In an interview with the DON at 8:57 AM on 03/26/25, the DON stated LVN C notified her that Resident #1 fell in the shower room on the night it occurred. The DON stated she recommended Resident #1 wear a helmet to protect him from future injuries, but the family did not want him to wear it to protect his dignity. The DON stated the shower room doors were always supposed to be locked and Resident #1 was not supposed to be in a shower room without an employee present. The DON stated she did not know how Resident #1 got in the shower room. The DON stated they provided in-services for all staff on ensuring shower room doors were closed and functioning properly at all times, fall prevention, and abuse/neglect. The DON stated they changed the locks on all shower room doors to require a keypad entry instead of just a lock and key. The DON stated Resident #1 had many fall prevention tasks implemented, which included fall mats, keeping his bed in the low position, toileting program to ask him if he needs to go to the bathroom every 2 hours, medication reviews, encouraging Resident #1 to use his call light, keeping his phone and glasses on a bedside table near him, and a camera in his room for his RP to help keep an eye on him. The DON stated it was important for residents to not enter the shower rooms without staff because a resident could fall in the shower room and not be able to call for help. In an interview with the DOT at 9:18 AM on 03/26/25, the DOT stated Resident #1 has not regressed physically due to his fall on 12/13/24. The DOT stated any decline Resident #1 has had since then has been due to his natural disease processes. In an interview with the DOM at 9:33 AM on 03/26/25, the DOM stated he was notified of Resident #1's fall on 12/13/24 the night it happened. The DOM stated he came up that night and replaced the lock on the 100-hall shower door. The DOM stated he would have replaced all three shower door locks at that time, but they only had one replacement lock in the facility. The DOM stated he went out to a local department store on the morning of 12/14/24 and bought two more locks to replace the locks on the 200 and 300-hall shower doors. The DOM stated all three shower rooms had a new lock on them before the afternoon of 12/14/24. The DOM stated the old locks required a key, but the key was hung by a chain next to the door. The DOM stated he checked the shower doors daily for functionality and they never failed during the month of December, 2024. In an interview with LVN D at 2:14 PM on 03/26/25, LVN D stated he worked the night Resident #1 fell in the 100-hall shower room. LVN D stated he heard LVN C call for help, and by the time he got there another staff member had placed a towel on Resident #1's ear to help with the bleeding. LVN D stated he did not remember much about the incident, but that LVN C was the charge nurse at that time, and she provided most of the care that night to Resident #1. LVN D stated he did not know how Resident #1 got in the shower room and that he should not have been in there on his own. This surveyor requested a facility policy from the ADM at 4:00 PM on 03/25/25 regarding proper shower room use and keeping the doors locked, but none was provided. In interviews beginning at 11:28 AM on 03/25/25 with staff from multiple shifts, the DON, DOT, DOM, ADM, LVN D, LVN E, LVN F, LVN H, MA G, CNA I, CNA J, CNA K, CNA L, CNA M, and CNA N were able to identify the proper procedures to follow when responding to a witnessed or unwitnessed fall. All staff understood the importance of keeping the shower doors locked and secured and were familiar with proper abuse and neglect policies and procedures. Record review and verification of the corrective action implemented by the facility beginning on 12/13/24: All staff in-serviced on the following procedures: - Keeping the shower room doors closed at all times, - Ensuring shower room doors function properly, - Fall precautions, - Abuse/Neglect, Verified by observations, record review and interviews with various staff. All shower door locks replaced by 12/14/24 to provide additional security verified by interview with the DOM. Medication review conducted for Resident #1 to help prevent future falls by 12/18/24 verified by record review and interview with the DON. Ordered a soft helmet for Resident #1 to wear throughout the day verified by interview with the DON. Instituted bathroom checks every 2 hours for Resident #1 to limit him trying to perform a self-transfer verified by interviews with the DON and various CNAs. The noncompliance was identified as PNC. The PNC began on 12/13/24 and ended on 12/14/24. The facility had corrected the noncompliance before the investigation began.

Based on interview, and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, documenting, and administering of all drugs and biologicals) to meet the needs of each resident for 3 of 5 residents (Residents #4, #2, and #3) reviewed for pharmacy services. The facility failed to ensure LVN-A signed her MAR when she administered PRN narcotics to Residents #4, #2 and #3. The facility failed to ensure LVN-A wasted her PRN narcotic medications with another licensed nurse. These failures could place residents at risk for not receiving, or receiving more than intended amount of, PRN narcotic medications. Findings included: Record review of Resident #4's face sheet dated 03/26/25 revealed a [AGE] year-old female with an admitted [DATE], and a discharge date of [DATE]. One of her diagnoses included Systemic Inflammatory Response Syndrome (an exaggerated defense response of the body to a harmful stressor, such as infection, trauma, or inflammation, and can cause intense pain). Record review of Resident #4's admission MDS assessment dated [DATE] revealed a BIMS score of 15, indicating intact cognition. Record review of Resident #4's physician orders dated 08/25/24 revealed an order for Hydrocodone-Acetaminophen (a narcotic pain medication) Oral Tablet 5-325 MG for pain. Record review of Resident #4's MAR dated September 2024 revealed no signatures for the whole month of September 2024 for Hydrocodone-Acetaminophen 5-325 MG. Record review of Resident #4's Controlled Substance Administration Record - Hydrocodone/APAP 5-325 MG dated 08/28/24 revealed the starting count was 30 tablets and the ending count was 18 tablets on 09/05/24 with 1 tablet documented as dropped with no witnessed waste on 09/04/24. Record review of Resident #2's face sheet dated 03/26/25 revealed a [AGE] year-old male with an original admitted [DATE], and a current admitted [DATE]. Resident #2 had a diagnosis of Pain Unspecified. Record review of Resident #2's quarterly MDS assessment dated [DATE] revealed a BIMS score of 15, indicating intact cognition. Record review of Resident #2's physician orders started on 08/26/24 revealed an order for Hydrocodone-Acetaminophen 5-325 MG for pain. Record review of Resident #2's MAR dated September 2024 revealed only two signatures for the whole month of September 2024 for Hydrocodone-Acetaminophen 5-325 MG. Record review of Resident #2's Controlled Substance Administration Record - Hydrocodone/APAP 5-325 MG, dated 08/30/24, revealed the starting count was 30 tablets and the ending count was 8 tablets on 09/16/24 with 1 extra tablet pulled but no witnessed waste on 09/01/24. Record review of Resident #3's face sheet dated 03/25/25 revealed an [AGE] year-old male with a current admitted [DATE], and a discharge date of [DATE]. Resident #3 had a diagnosis of Gout (a type of arthritis that includes sudden attacks of severe pain). Record review of Resident #3's quarterly MDS assessment dated [DATE] revealed a BIMS score of 10, indicating moderately impaired cognition. Record review of Resident #3's physician orders started on 08/01/24 revealed an order for Hydrocodone-Acetaminophen 7.5-325 MG for pain. Record review of Resident #3's MAR dated September 2024 revealed no signatures for the whole month of September 2024 for Hydrocodone-Acetaminophen 5-325 MG. Record review of Resident #3's Controlled Substance Administration Record - Hydrocodone/APAP 7.5-325 MG, dated 08/31/24, revealed the starting count was 30 tablets and the ending count was 15 tablets on 09/16/24. Interview with LVN-A attempted, but she no longer worked for the facility, and her phone number was disconnected. Interview with Resident #4 attempted, but she is no longer living at this facility, and she refused to be interviewed by phone. In an interview with the ADON on 03/25/25 at 9:30 AM, she stated she never realized the MAR was not being signed off accordingly because with PRN medications there was really no way to tell if they were signed or any type of alert since they were PRN medications and not scheduled. She denied that there was any sort of check or audit in place during that timeframe in which they were checking the MARs against the narcotic count sheets for signatures or accuracy. She stated she and the DON were trying to be more proactive and aware and follow-up on reviewing the PRN medications at the weekly meetings. She stated this could have been an issue because residents may or may not have been getting any or the appropriate amounts of pain medication, which could ultimately not relieve their pain at all or cause the resident harm if too much pain medication was administered. In an interview with Resident #2 on 3/25/25 at 9:40 AM, he stated he remembered the nurse, and she was always nice to him. He stated he did not use much pain medication, but she was always good about bringing him his medication. In an interview with the DON on 03/25/25 at 9:50 AM, she stated she was not here during this time frame, so she was not sure if any audits were being completed to verify that the MARs were being signed appropriately and checked or verified against the narcotic count logs, or if medications were being wasted appropriately, but she stated she felt like if there were any systems in place to check, this would not have happened, and it should have been noticed or caught by someone. She stated this could have been an issue because if the MARs were not signed appropriately residents may end up getting inappropriate amounts of pain medication, which could ultimately not relieve their pain at all or cause harm if too much pain medication was administered. She stated she was trying to be more proactive and aware and follow-up on reviewing the PRN medications at the weekly meetings. She also stated she and the facility were currently putting a system into place to perform random audits of the MARs of residents with narcotics and compare to the narcotic logs, as well as compare the MARs and logs to resident interviews. In an interview with LVN-B on 3/25/25 at 1:37 PM, she stated she never paid attention to whether things were being signed off on the MARs or narcotic logs by other nurses, and she never paid attention to whether other nurses were wasting medications with or without a witness. She stated they had previously been in-serviced over documentation and passing medications so as to keep the residents safe from harm. In an interview with the pharmacy director on 3/25/25 at 3:18 PM, he stated he did an audit around September 17th or 18th 2024 and sent the report to the interim DON at the time. He stated he provided dispensing information, but no further recommendations since there were no red flags or discrepancies with the areas that were observed during their audit. He stated they did an observational reconciliation to make sure there were not any discrepancies in medication counts. He stated they did not audit to check against MARS or nursing narcotic count logs because that was not something they performed in their audits, but they basically just checked to make sure the count was correct and that nothing seemed off, so their audits would not have noticed or recognized unsigned MARS or unsigned wasted narcotic medications. In an interview with the Administrator on 3/26/25 at 2:30 PM, he stated he did not know what systems or checks were in place during the time frame between August and October to verify that MARs and narcotic logs were being checked for accuracy, but the DON and ADON had been discussing these areas in their weekly meetings in which they review from the previous Friday to the current Friday to look for any red flags with the residents who were on PRN medications. He stated that he did not understand how these things were missed before, and that could have caused harm to the residents if they had been given incorrect or inaccurate dosages of medications. He was unsure if any in-services since September of 2024 had been conducted regarding verification of signing MARS appropriately and wasting narcotics with another licensed nurse. In an interview with the DON on 3/26/25 at 2:35 PM, she stated they had been doing spot checks here and there of MARs and Narcotic logs but not performing any actual audits. She stated during the weekly meetings they review pain, pain medications, and other areas of concern. She also stated she met with the nurses each morning went over any concerns with the residents, but she did not think any in-services since September of 2024 had been conducted regarding verification of signing MARS appropriately and wasting narcotics with another licensed nurse. The DON stated after consulting with her regional nurse, and as of today, she would be putting a system check or audit into place where she would look at three residents with a BIMS of 13 or greater on each hall weekly to ensure they received their PRN pain medication, and that it was signed out appropriately on the narcotic log and MAR. Record review of the Controlled Substance Policy, 2001 Med-Pass revised November 2022, revealed 6. Unless otherwise instructed by the director of nursing services, when a resident refuses a dose (or it was not given), or a resident receives a partial dose (or it was not given) the medication was destroyed and may not be returned to the container. 7. Waste and/or disposal of controlled medication were done in the presence of the nurse and a witness who also signs the disposition sheet. Record review of the Pharmacy Medication Administration Policy (no date listed on policy) revealed 9.4 Following resident medication administration, facility staff should appropriately document medication administration, dispose of unused medication per facility policy, discard used supplies per facility policy, and clean reusable equipment and supplies.

Based on observation, interview and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for one of one kitchen reviewed for dietary services. 1. The facility failed to ensure that food items in the walk- in cooler were labeled and dated. 2. The facility failed to ensure that food items in the walk- in cooler were discarded after the use by date. 3. The facility failed to ensure that food containers in the walk- in cooler were tightly sealed. 4. The facility failed to ensure that items labeled keep frozen were kept in the freezer. 5. The facility failed to ensure that food items in the dry storage area were labeled and dated. 6. The facility failed to ensure that food items were refrigerated after opening per the manufacturer's label. 7. The facility failed to ensure that food items in the dry storage area were closed and/or sealed properly. 8. The facility failed to ensure that food items in the reach in cooler were labeled and dated. 9. The facility failed to ensure that food items in the reach in cooler were not expired. 10. The facility failed to ensure that there were no personal items stored in the reach in cooler. 11. The facility failed to ensure that food items were covered when not being actively prepared or served. 12. The facility failed to record food temperatures for all food at all meals. 13. The facility failed to serve some foods at safe temperatures. These failures could place all residents who consumed food from the kitchen at risk for food borne illness. Findings included: Observation of the facility's walk- in cooler on [DATE] at 08:59am revealed the following: An unknown reddish substance inside a clear, square plastic container with a green lid that had no label on it. An original carton that contained approximately half of a ,d+[DATE] pound block of cream cheese that was stamped, made [DATE] and a shipping type sticker that had [DATE] on it. This carton was sitting on top of another carton of the same type of cream cheese (unused) that was stamped, made on [DATE]. Above that, a date of ,d+[DATE] was written in black marker. The above referenced carton containing approximately half of a ,d+[DATE] pound block of cream cheese had 2 stains of an unknown origin that were beige colored with a clear outer margin that covered approximately ,d+[DATE] of the top of the carton. Corn inside a clear, square plastic container with a green lid that had a label with only ,d+[DATE] on it. An unknown yellowish substance inside a clear, square plastic container with a green lid that had a label with ChNS and ,d+[DATE] on it. An unknown reddish brown substance inside a clear, square plastic container with a red lid that had a label with ,d+[DATE] marked out and ,d+[DATE] on it. Dill relish in its original container that was approximately ,d+[DATE] empty with no date on it. Texas One Step Chili in its original container that had KEEP FROZEN on the lid. 4 cartons of Pasteurized liquid egg product- Whole eggs- with an expiration date of [DATE]. A Ziplock bag that contained what appeared to be half of a green pepper and half of an avocado that was not labeled or dated. A Ziplock bag that contained what appeared to be half of a red onion and half of a tomato that was not labeled or dated. A large, black metal pot that contained an unknown substance with foil over the top that was not tightly sealed nor labeled or dated. The inside walls of the walk- in cooler had black spots of what appeared to be mold or mildew on them. Observation of the facility's dry food storage on [DATE] at 09:10am revealed: Karo corn syrup in its original 1 gallon container that was approximately ,d+[DATE] full with a sticker that read Use First, writing in black marker that read open [DATE] and ,d+[DATE] written in black marker below that. There was a shipping type label on it that read [DATE]. Maraschino cherries in liquid in the original container that had ,d+[DATE] written in black marker on the lid. The container had been opened and was approximately ,d+[DATE] full. The manufacturer label read Refrigerate after opening. A Ziplock bag that contained bacon bits that was only sealed approximately ,d+[DATE] at the top. Teriyaki sauce in the original container that had 7/?? written in black marker on the lid. The container had been opened and was approximately ,d+[DATE] full. The manufacturer label read Refrigerate after opening. A bottle of ketchup that was opened with no date on it. Apple cider vinegar that was in the original container that did not have a date on it. The container had been opened and was approximately ,d+[DATE] full. On the outside of the above referenced vinegar container there were approximately 10 spots of a black crusty substance. Lemon and Pepper Seasoning salt in the original container that was approximately half full with the lid not tightly closed. A black milk type crate on its side with two stacks of tortillas in separate plastic bags sealed with twist ties. Neither bag had a date on it. The milk crate had a label that had corn tortillas [DATE] written in black marker on it. A black milk type crate on its side with 2 stacks of tortillas in separate plastic bags sealed with plastic bread clips. Neither bag had a date on it. There was a label on the inside of the top of the crate that had flour tortilla [DATE] written in black marker on it and another label on the inside of the back of the crate that had tortillas ,d+[DATE] written in black marker on it. Both labels were clearly visible. Coleslaw dressing that was in its original container with a use first sticker and [DATE] written in blue marker on the lid. The container had been opened, however it appeared full. The manufacturer label read Refrigerate after opening. Brown gravy mix in its original plastic bag that was cut open at the top and not sealed shut. ,d+[DATE] was written in black marker on the front of the bag. Brown gravy mix in its original plastic bag that was rolled down and sealed with a label that did not have a date on it. There was no date anywhere else on the bag. Instant mashed potatoes sealed with a label that did not have a date on it. There was no date anywhere else on the bag. 2 bags of unopened sweetened coconut flakes that had Best if used by Mar-,d+[DATE] printed by the manufacturer on the front. A white five gallon bucket with a green lid on it that contained what appeared to be brown sugar. The lid was not on tight and fell off when the bucket was moved. Observation of the facility's reach in cooler on [DATE] at 09:30am revealed: A clear jelly like substance in a square, clear plastic container with a green lid that was not tightly sealed and did not have a label or date on it. A red jelly like substance in a square, clear plastic container with a green lid that did not have a label or date on it. A metal bin that had a label with Ranch [DATE] written in black marker on it. The bin contained 1 prepackaged vanilla pudding and approximately ,d+[DATE] portion cups that had what appeared to be ranch dressing, shredded cheese, and bacon bits in them (in separate portion cups) that had no identifiers or dates on them. A tub of sour cream in its original container that had a label that had opened ,d+[DATE] written in black marker on the top of it. The manufacturer printing on the side of the container read Best if used by [DATE]. A metal bin that had a label with C,Ch ,d+[DATE] written in black marker on it. The bin contained approximately ,d+[DATE] portion cups that had what appeared to be shredded white cheese in them that had no identifiers or dates on them. A brown, plastic grocery store bag that had an opened container of coconut water in it. A white plastic pitcher with a blue lid that contained what appeared to be orange juice that was not labeled or dated. A tray that had snacks [DATE] written in orange marker on a label stuck on it that had 6 portion cups with a yellow pudding like substance in them, 17 portion cups with a white pudding like substance in them and 3 portion cups with a brown pudding like substance in them -none of them were dated; 3 portion cups with what appeared to be fruit salad with ,d+[DATE] written in black marker on the top of them; 1 portion cup with what appeared to be mixed fruit in it with no date on it; 1 portion cup with a yellowish liquid substance in it with no date on it. 3 cups that had red liquid in them with plastic wrap sealing the tops with no dates on them. A tray that had a paper liner on the bottom of it with red stains on it. The paper liner also had a sticker label with PM Drinks ,d+[DATE] written in black marker on the left front of it, a sticker label with [NAME] ,d+[DATE] written in black marker on the front center of it, and a sticker label with Sandwiches written on it in black marker on the right front of it. The left side of the tray had approximately ,d+[DATE] sandwiches in Ziplock bags that had ,d+[DATE] Tuna written in black marker on them; the center of the tray had approximately 15 sandwiches in Ziplock bags that had HC or HL written in black marker on the front of them; the right side of the tray had approximately 10 sandwiches in Ziplock bags that had ,d+[DATE] and possibly Ce written in black marker on the front of them. Observation kitchen on [DATE] at 09:45am revealed ,d+[DATE] capacity muffin tins and ,d+[DATE] capacity muffin tin that had uncooked biscuits in them sitting on top of the steam table. All 4 of the muffin tins were uncovered and a fly landed on the edge of one of the muffin tins. The DM was observed throwing away all the biscuit dough immediately after it was brought to her attention. In an interview on [DATE] at 1:43pm, the DM stated that everything in the refrigerators and dry food storage areas should have been sealed, labeled, and dated. The DM stated things needed to be sealed to prevent contamination. The DM stated that sauces and dressings should be refrigerated after opening per the manufacturer's labels to prevent spoiling or the possibility of bacterial growth. The DM stated that portion cups needed to be dated to make sure the contents did not go bad. The DM stated that most things should be disposed of ,d+[DATE] days after opening and that sandwiches and pudding were only good for 5 days after they were made. The DM stated pureed and cooked food were only good for 3 days. The DM stated she was going to throw away all the unlabeled and undated items that were in the walk in and reach in coolers. The DM stated she was also going to throw away the coconut water that was in the reach in cooler because it belonged to an employee, not the facility. In an interview on [DATE] at 9:33am, the DM stated that everyone was responsible for labeling and dating items and it should be done immediately before putting things into the freezer, refrigerators, or dry storage. The DM stated that she was ultimately responsible for making sure that everything was labeled, and the outdated things were disposed of. The DM stated she would go in every Monday morning to check labels/dates and throw away the things that were beyond their use by date. The DM stated the RD came in every week to make sure that labels were done and such and she had her own checklist that she did. The DM stated she had done an in-service on [DATE] on labeling and that she would be doing an in-service on [DATE] on temperatures and temperature logs. Record review of the facility's Food Storage Policy, Policy Number 03.003, dated [DATE] and revised on [DATE] that was provided by the facility stated in part: Policy: To ensure that all food served by the facility is of good quality and safe for consumption, all food will be stored according to the state, federal, and US Food Codes and HACCP guidelines. Procedure: 1. Dry Storage Rooms d. To ensure freshness, store opened and bulk items in tightly covered containers. All containers must be labeled and dated. g. Use the first-in, first-out (FIFO) rotation method. Date packages and place new items behind existing supplies, so that the older items are used first. 2. Refrigerators d. Date, label, and tightly seal all refrigerated foods using clean, nonabsorbent, covered containers that are approved for food storage. e. Use all leftovers within 72 hours. Discard items that are over 72 hours old. Record review of the facility's Food Storage Policy, Policy Number 03.03.003, dated [DATE] that was attached to the in-service sign in done on [DATE] and provided by the DM stated in part: Policy: The consultant dietician will monitor the storage of foods to ensure that all food served by the facility is of good quality and safe for consumption. All food will be stored according to the state and Federal Food Codes. The following guidelines should be followed. Guidelines: 2. Refrigerators a. All refrigerated foods are stored per state and federal guidelines. e. All refrigerated foods are dated, labeled and tightly sealed, including leftovers, using clean, nonabsorbent, covered containers that are approved for food storage. All leftovers are used within 48 hours. Items that are over 48 hours old are discarded. Section ,d+[DATE] listed recommended maximum storage periods of unopened dry goods. Section ,d+[DATE] listed recommended maximum storage periods of unopened refrigerated items. Section ,d+[DATE] listed recommended maximum storage periods of frozen items. The policies differ on how long leftovers were to be used or discarded. Neither policy had guidance on how long other opened items were usable for whether frozen, refrigerated, or in dry storage. Observation of the kitchen on [DATE] at 10:03am revealed the food temperature log was not filled out or unsafe temperatures were recorded for 27 of 36 days reviewed: [DATE] Dinner: Regular vegetable temperature recorded as 35 by [NAME] A. [DATE] Dinner: Regular vegetable temperature recorded as 35 by [NAME] A. [DATE] Lunch: Milk and Supplement temperature recorded as 170 by [NAME] A. [DATE] Dinner: (filled out but whited out with no temps recorded). [DATE] Dinner: Regular starches temperature recorded as 35 by [NAME] A. [DATE] Dinner: Regular vegetable temperature recorded as 35 by [NAME] A. [DATE] Dinner: Pureed vegetable temperature recorded as 35 by [NAME] A. [DATE] Dinner: Regular vegetable temperature not recorded by [NAME] A. [DATE] Dinner: Blank- No temperatures recorded. [DATE] Dinner: Blank- No temperatures recorded. [DATE] Dinner: Blank- No temperatures recorded. [DATE] Dinner: Temperatures only recorded for soup, milk and supplemental, cold fruit, and hazardous dessert. No other temperatures recorded, and no initials documented. [DATE] Dinner: Blank- No temperatures recorded. [DATE] Dinner: Blank- No temperatures recorded. [DATE] Dinner: Blank- No temperatures recorded. [DATE] Dinner: Blank- No temperatures recorded. [DATE] Dinner: Blank- No temperatures recorded. [DATE] Dinner: Mechanically altered entree temperature recorded as 35 by [NAME] A. [DATE] Dinner: Pureed entree temperature recorded as 35 by [NAME] A. [DATE] Dinner: Regular starches temperature recorded as 35 by [NAME] A. [DATE] Dinner: Puree starches temperature recorded as 35 by [NAME] A. [DATE] Dinner: Regular vegetable temperature recorded as 35 by [NAME] A. [DATE] Dinner: Regular vegetable temperature recorded as 35 by [NAME] A, but [NAME] A's initials were scribbled out. [DATE] Dinner: Blank- No temperatures recorded. [DATE] Dinner: Regular vegetable temperature recorded as 35 by [NAME] A. [DATE] Dinner: Regular vegetable temperature recorded as 35 by [NAME] A. [DATE] Breakfast and Lunch: Blank- No temperatures recorded. [DATE] Breakfast, Lunch, and Dinner: Blank- No temperatures recorded. [DATE] Breakfast, Lunch, and Dinner: Blank- No temperatures recorded. [DATE] Breakfast and Lunch: Blank- No temperatures recorded. [DATE] Breakfast and Lunch: Blank- No temperatures recorded. [DATE] Dinner: Regular vegetable blank- no temperature recorded. [DATE] Breakfast and Lunch: Blank- No temperatures recorded. [DATE] Dinner: Regular vegetable temperature recorded as 35 by [NAME] A. [DATE] Breakfast: Blank- No temperatures recorded. In an interview on [DATE] at 1:00pm, [NAME] C was able to correctly explain and demonstrate the correct procedure for checking the temperatures of food items. [NAME] C was also able to explain the proper food storage and serving temperatures. Neither [NAME] A nor [NAME] B were available for interview. In an interview on [DATE] at 1:30pm, the DM stated they had a new cook (Cook B) who started around [DATE]st. The DM stated that [NAME] B's job performance was sub-par; [NAME] B had some issues with following directions and was not doing the temperature logs. The DM stated [NAME] B was off the schedule now. The DM stated the temperature logs were important so they could make sure food was cooked to the proper temperature to inhibit bacterial growth so residents would not get sick. The DM stated if foods were not at proper temperatures, residents could get sick which could cause dehydration, malnutrition, hospitalization , and even death. The DM stated undercooked foods could cause a facility wide outbreak of Salmonella. In an interview on [DATE] at 9:33am, the DM stated it was the cook's responsibility to fill out the temperature logs and the DM's responsibility to make sure they got done. The DM stated the cooks would typically write the temperatures on a piece of paper and then transfer them into the log, despite being told to write them directly in the book. The DM stated temperatures were done ,d+[DATE] minutes before serving the food. The DM stated they cooks were reminded daily about logging the temperatures and they had monthly in-services on labeling and storage, temperature logs, sanitizing, and other policies and procedures. The DM stated each in-service was on a single topic with quizzes afterward. The DM did not say why the temperature logs were not checked. Record review of the Facility's Nutrition Services in-service dated [DATE] revealed a sheet that stated in part: Recommended Safe Food Temperatures: 165 degrees Fahrenheit . Poultry, ground poultry. Stuffing with poultry. Meat and fish. Microwave cooking and reheating. Reheating leftovers. 155 degrees Fahrenheit . Ground meat and fish 145 degrees Fahrenheit . Meat, fish, and raw shell eggs 135 degrees Fahrenheit . Hot holding of foods -If hot foods are not meeting temperature of 140 degrees Fahrenheit or above - food needs to be reheated at 165 degrees Fahrenheit for 15 seconds until it reached ideal temperature. Temperature Logging When taking food temperatures, please ensure: 5. ALL foods (hot and cold) have temperatures recorded in food temperature log prior to meal service.

Based on observations, interview and record review, the facility failed to ensure residents had the right to reside and receive services in the facility with reasonable accommodation of resident needs and preference for four (Residents #254, #26, #66, #86) of fourteen residents reviewed for call light. The facility failed to ensure Residents #254, #26, #66, #86's call lights were within reach. This failure could place residents at risk of being unable to obtain assistance when needed and help in the event of an emergency. Findings were: 1.Record Review of Resident #254's face sheet dated 7/31/2024 indicated she was a [AGE] year-old female admitted on [DATE] with the diagnoses of Chronic Respiratory Failure, Chronic Obstructive Pulmonary Disease (a chronic lung disease that causes air flow limitation), Encephalopathy (damage or disease that affects the brain), Muscle Weakness, Chronic Kidney Disease Stage 3 (kidneys have mild to moderate damage, and they are less able to filter waste and fluid out of your blood), and Dementia. Record Review of Resident #254's Care Plan revised 7/30/24 revealed Resident #254 was at risk for falls r/t confusion, gait/balance problems. Intervention: Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. Record Review of Resident #254's BIMS assessment dated [DATE] revealed Resident #254's score was 0.0. Resident #254 was severely cognitively impaired. During an observation on 07/29/24 at 09:48 AM Resident #254 was lying in bed, alert, with the push button call light cord wrapped on the right side rail towards the back end of the rail. Resident #254 attempted to find and reach her call light using her left arm. Resident #254 stated she could not reach the call light. During an interview with LVN A on 07/29/24 at 09:05 AM stated that all staff are responsible for placing the call light within resident's reach. She stated it was important for the residents to have call lights within reach so that they can call them for help. The negative outcome was it keeps the resident from falling out of the bed by being able to call for assistance. The resident may not be feeling well and it may take long to have her needs being met if she cannot reach the call light. During an interview with CNA D on 07/29/24 at 09:55 AM, stated she normally checks that the call lights are within the resident's reach every day. She has not done that this morning. She stated when she does her rounds, she checks that the call lights are within reach. During an interview with Residents #254's family member, on 07/29/24 at 10:38 AM, stated he stays and visits with Resident #254 from 9am until around 2pm. Then another family member comes and after that another family member. He stated if the resident needs anything, he will call staff for assistance. During an interview with CNA E on 07/31/24 at 10:00 AM, stated she was responsible for call lights being within resident's reach. She was assigned the first five rooms. She stated some residents tend to mess with the call lights. She tries not to wrap them too much; she prefers to clip them. She stated that Resident #254 usually has family member with her during the day. CNA E stated that the resident should have the call light within reach in case they need something. She rounds every two hours, but she got behind on her rounds today. The negative outcome of the resident not having the call light within reach is that they can be grasping for air, or may need to be changed, and repositioned but they are not able to call them. During an interview with ADON on 07/29/24 at 10:10 AM, stated all staff are responsible for placing the call light within the resident's reach. The negative outcome of resident not having the call light within reach was that a resident can have an emergency or fall. During an interview with DON on 07/31/24 at 4:04 PM, stated nurses, CNAs, and department heads do rounds for quality-of-life. They are responsible for placing the call lights within the resident's reach. He stated there is no negative outcome except customer service. DON stated the facility has no Policy available for call lights on 7/31/24 at 3:30pm. 2. Record review of the admission record for Resident #86 reflected Resident #86 was admitted to the facility on [DATE], was an [AGE] year-old male with diagnoses that included Unspecified Dementia (loss of cognitive functioning that interferes with daily life), other abnormalities of gait and mobility, other lack of coordination, muscle wasting and atrophy, cognitive communication deficit. Record review of Resident #86 Care Plan revised on 05/14/24 noted the resident is at risk for falls r/t impaired balance, cognitive deficits, psychoactive med use, Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance; and the resident needs a safe environment with: (even floors free from spills and/or clutter; adequate, glare-free light; a working and reachable call light, the bed in low position, personal items within reach) Record review of Resident #86's MDS assessment dated [DATE] reflected a BIMS score of 03, indicating severely impaired cognition. Section GG Functional Abilities and Goals stated the resident uses a walker and is independent in sit to stand movement, and setup assistance with walk of 10ft, 50ft and 150ft. Observation on 07/29/24 at 09:15 AM revealed Resident #86 was observed in bed, with the call light clipped on the privacy curtain out of reach of the resident. Observation on 07/31/24 at 10:09 AM revealed Resident #86 lying in bed asleep with the call light clipped to the bedcover within reach of resident. 3. Record review of the admission record for Resident #26 reflected Resident #26 was admitted to the facility on [DATE], was a [AGE] year-old male with diagnoses that included Alzheimer's Disease (progressive brain disorder that causes gradual decline in memory, thinking behavior and social skills), lack of coordination, muscle wasting and atrophy (wasting or thinning of muscle mass. It can be caused by disuse of your muscles or neurogenic conditions), Chronic Obstructive Pulmonary Disorder (a chronic inflammatory lung disease that causes obstructed airflow from the lungs), and Hemiplegia (one-sided paralysis caused by brain, spinal cord or nerve problems) and Hemiparesis (one-sided muscle weakness caused by brain, spinal cord or nerve problems)following cerebral infarct (or stroke, is a brain lesion in which a cluster of brain cells die when they don't get enough blood.) affecting left non-dominant side. Record review of Resident #26's Care Plan revised on 07/29/24 noted the resident is at risk for falls or injuries r/t impaired balance, Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance; and the resident needs a safe environment with: (even floors free from spills and/or clutter; adequate, glare-free light; a working and reachable call light, the bed in low position, personal items within reach) Record review of Resident #26's MDS assessment dated [DATE] reflected a BIMS score of 99, indicating the resident was unable to complete the interview. Section GG Functional Abilities and Goals stated the resident is independent in sit to stand movement and is independent in sit to stand movement, and setup assistance with walk of 10ft, 50ft and 150ft. Observation on 07/29/24 at 09:17 AM revealed Resident #26 was observed in bed, with the call light wrapped down on the left side rail hinge between the rail and mattress, not within reach of the resident. Resident #26 did not respond or answer when asked about call light. Observation on 07/31/24 at 10:10 AM revealed Resident #26 lying in bed with the call light clipped to the bed within reach of resident. 4. Record review of the admission record for Resident #66 reflected Resident #66 was admitted to the facility on [DATE], was a [AGE] year-old female with diagnoses that included Unspecified Dementia (loss of cognitive functioning that interferes with daily life), other abnormalities of gait and mobility, other lack of coordination, muscle wasting and atrophy, cognitive communication deficit and unspecified mood disorder. Record review of Resident #66's Care Plan revised on 04/19/24 noted the resident is at risk for falls r/t gait/balance problems, incontinence, psychoactive med use, Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance; and the resident needs a safe environment with: (even floors free from spills and/or clutter; adequate, glare-free light; a working and reachable call light, the bed in low position, personal items within reach) Record review of Resident #66's MDS assessment dated [DATE] reflected a BIMS score of 03, indicating severely impaired cognition. Section GG Functional Abilities and Goals stated the resident is independent in sit to stand movement and is independent with walk of 10ft, 50ft and 150ft. Observation on 07/29/24 at 09:27 AM revealed Resident #66 was observed in bed, with the call light clipped on the privacy curtain out of reach of the resident. Resident #66 did not respond when attempted to interview, she continued to watch television. Observation on 07/31/24 at 10:07 AM revealed Resident #66 lying in bed with the call light clipped to the bedcover within reach of resident. Interview on 07/31/24 at 10:42 AM LVN F stated call lights should be within reach of residents. If the call light is not within reach, the resident would be unable to ask for help if they need assistance or something such as water, or not feeling well, or they could get out of bed and fall. LVN F sated that CNAs and Nursing staff to include herself and any staff including Administration staff do rounds throughout the day to ensure call lights are within reach during rounds. Interview on 07/30/24 at 10:58 AM CNA D stated that resident call lights should be within reach. CNA D stated that a call light is usually placed on a resident's chest or close to their upper body based on the resident's preference, abilities or functional ability . CNA D stated that if a call light was not within reach of the resident and if a resident was in pain or had an accident staff would not know their needs. CNA D stated that in addition to rounds throughout the shift, she completes a general walk through in the mornings as soon as she comes in and spot checks rooms as well to ensure call lights are within reach. Interview on 07/30/24 at 03:48 PM DON stated that in-services on call lights and rounds are done at least once a month, with the last in-service done in June or end of May 2024. Interview on 07/31/24 at 01:49 PM DON stated that every employee that works with the residents is responsible to ensure that call lights are within reach. DON stated that they do Guardian Angel or Interdisciplinary (IDT) rounds by department heads assigned to specific areas daily before morning meeting, before lunch and at the end of day to check for call light placement and any other issues in the resident rooms. He stated that they had in-serviced all staff over a month ago on call lights and customer service. Record review of the facility policy titled Resident Rights provided by DON when asked for Call light or Call light system policy reflected it does not have information pertaining to call light. On 07/31/24 at 09:17 AM DON stated the facility does not have a policy specific for the call lights or call light system.

Based on observation, interview, and record review, the facility failed to ensure residents had a safe, clean, comfortable, and homelike environment for 1 of 27 residents (Resident #4) reviewed for homelike environment. The facility failed to fix a broken face plate covering an outlet, restore damaged walls, investigate a dark substance on the ceiling, and fix a sharps container that was attached to the wall at a single point allowing it to rotate freely. These failures place residents at risk of experiencing a diminished quality of life potentially leading to psychosocial harm. The findings included: Record review of Resident #4's face sheet dated 07/29/2024 reflected a [AGE] year-old female with an initial admitted [DATE] and a current admitted [DATE]. Pertinent diagnoses included Alzheimer's disease, major depressive disorder with psychotic symptoms and schizoaffective disorder (chronic mental illness causing symptoms of both schizophrenia and a mood disorder at the same time). Record review of Resident #4's MDS assessment section C, cognitive patterns, dated 06/01/2024 reflected a BIMS score of 9 (moderate impairment). In an attempted interview with Resident #4 on 07/29/2024 at 11:07 AM, Resident #4 was not responding to questions. Subsequently, no interview information was obtained. During an observation inside Resident #4's room at 07/30/24 at 8:30 AM, a sharps container was seen hanging on the wall to the left immediately after walking in. The sharps container was attached to the wall by a single point, allowing it to spin freely. Sharps could be heard inside moving around as the container spun. Approximately 24 inches off the ground on the wall an outlet face plate had been cracked and pieces broken off exposing a hole in the wall. Inside the hole a wire could be seen barely protruding out of the hole. On the ceiling of the room closer to the window were dark colored streaks. The streaks were approximately 5 feet long and when combined were approximately 12 inches wide. There were several small holes in the walls. Part of the wall approximately 12 inches below the cracked face plate appeared to be sloughing off. In an interview with CNA C on 07/31/2024 at 2:29 PM, CNA C stated Resident #4's room is not a homelike environment and that she would not want to live in a room with similar amounts of damage. CNA C stated that she was not aware of the damage to the outlet face plate or the general damage to the walls. CNA C stated she did not know what the dark stains were on the ceiling and that she did not know how long they have been there. In an interview with LVN E on 07/31/2024 at 2:42 PM, LVN E stated Resident #4's room looked raggedy. LVN E stated that he did not think the room posed any harm to Resident #4 as long as the exposed wire was not active. LVN E stated he has only been in Resident #4's room [ROOM NUMBER]-3 times before now. LVN E stated the dark stains on the ceiling looked like water damage. In an interview with MS on 07/31/2024 at 2:59 PM, MS stated that, prior to today, the last time he was in Resident #4's room was to fix a plumbing issue in her bathroom a few weeks ago. MS stated that to complete all of the work necessary to fix the walls and outlet face plate was approximately 3 hours not including drying time. MS stated that he would not want to live in a room with the damage that was on the walls. MS stated that the wire barely protruding out of the hole was an old phone line that had been disconnected. MS stated that the wire did not pose any risk of electrocution. MS stated that the only danger in the room was the jagged edges of the broken outlet face plate. MS stated that he was not sure what the dark stains on the ceiling were, but that they looked like water damage. MS stated that he thought the damage to the walls was from furniture moving around. In an interview with the DON on 07/31/2024 at 3:15 PM, the DON stated that he went in Resident #4's room daily. The DON stated that this morning was the first time he had noticed the damage to the outlet face plate. The DON stated that there was a 2nd bed in the room covering that part of the wall that was moved out of the room recently. The DON stated that it was possible that Resident #4 could have hurt herself on the jagged edges of the broken outlet face plate. The DON stated that if he had similar damage in his home then he would have fixed it. The DON stated that they have higher expectations for their facility than what was presented in Resident #4's room. The DON stated that he removed the sharps container from Resident #4's room and placed it in his office in the morning of 07/31/2024. On 07/31/2024 at 4:01 PM, policies were requested from the DON and ADM covering the expectations for a safe, homelike environment but none could be located.

Based on observation, interview and record review, the facility failed to ensure that residents who needed respiratory care were provided such care consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences for 5 of 6 (Resident #12, Resident #7, Resident#254, Resident#396, and Resident #36) residents reviewed for respiratory care. 1. The facility failed to ensure Resident #12 had the required emergency supplies at bedside including a suction machine, supply of suction catheters, sterile gloves and flush solution on 07/30/2024 at 10:08 AM. 2.The facility failed to ensure Resident #7's oxygen tubing was connected to the concentrator and the oxygen was administered at the correct setting of 2 liters per minute on Resident #7's oxygen concentrator was set at 3 liters per minute 7/29/24 at 9:05 AM. 3.The facility failed to ensure Resident #254's had the oxygen sign posted outside his room entrance door on 7/29/24 at 8:40 AM. 4.The facility failed to ensure Resident #254's oxygen was administered at the correct setting of 2 liters per minute on 7/29/24 at 8:40 AM. 5.The facility failed to ensure Resident #396's oxygen was administered at the correct setting of 3 liters per minute on 7/29/24 at 9:30 AM. 6.The facility failed to ensure Resident #36's oxygen was administered at the correct setting of 3 as per physician order and received oxygen at 2.5L/min. This failure places residents who receive respiratory care at an increased risk of danger in a respiratory emergency due to a longer response time and at risk of developing respiratory complications, and a decreased quality of care. The findings included: 1.Record review of Resident #12's face sheet dated 07/30/2024 reflected a [AGE] year-old male with an initial admitted [DATE] and a current admitted [DATE]. Pertinent diagnoses included Chronic Obstructive Pulmonary Disease (chronic inflammatory lung disease that makes it difficult to breathe) and Tracheostomy Status. Record review of Resident #12's annual MDS assessment section C, cognitive patterns, dated 06/04/2024 reflected a BIMS score of 15 (cognition intact). MDS assessment section O, Special Treatments, Procedures and Programs, reflected tracheostomy care has been performed while a resident of the facility within the last 14 days. Record review of Resident #12's order summary report revealed an active order stating Trach care to include changing disposable inner cannula every Tuesday and Saturday (patient will do himself). Inner cannula size #8. Trach tube size 8. Resident does own trach care. Resident #12 had no active orders for emergency respiratory equipment. Record review of Resident #12's care plan dated 06/21/2024 revealed there were no interventions mentioning keeping a suction machine, supply of suction catheters, sterile gloves and flush solution available at bedside in the case of a respiratory emergency. In an interview with Resident #12 on 07/30/2024 at 10:08 AM, Resident #12 stated that he takes care of his own tracheostomy. Resident #12 stated that the nurses assist him sometimes if he needs help. Resident #12 stated that he did not know if there were emergency supplies in his room incase he developed a respiratory emergency. During an observation of Resident #12's room on 07/30/2024 at 10:08 AM, no suction machine, supply of suction catheters, sterile gloves or flush solution could be located. In an interview with CNA B on 07/30/2024 at 3:52 PM, CNA B stated that in a respiratory emergency involving a tracheostomy she would make sure the resident's head was elevated and then go and get the nurse to let them know there was an emergency. Afterwards, CNA B stated she would assist the nurse with whatever they needed in caring for the resident. In an interview with LVN C on 07/30/2024 at 3:55 PM, LVN C stated that in a respiratory emergency involving a tracheostomy she would assess the air way and use a suction as needed to clear the airway. LVN C stated that Resident #12 handles his self-care for the most part. LVN C stated that Resident #12 is a full-code (medical directive that indicates a patient's wish for life saving measures in case of emergency) so she would bring the crash cart (wheeled container carrying medicine and equipment for use in emergency resuscitations) in as needed. LVN C stated she was unable to locate a suction machine, supply of suction catheters, sterile gloves or flush solution inside Resident #12's room. LVN C stated that she would have had to go get the crash cart during a respiratory emergency for Resident #12 to obtain the necessary supplies. LVN C stated that Resident #12 would receive care much quicker if the emergency supplies were by his bedside. LVN C stated that the nurses taking care of Resident #12 would be responsible for making sure the emergency supplies were in the room. During an observation of the crash cart on 7/30/2024 at 4:08 PM, a suction machine, supply of suction catheters, sterile gloves and flush solution were available on the cart. The cart was located at the entrance to the 100 hall, approximately 54 steps away from Resident #12's door. In an interview with the DON on 07/31/2024 at 3:15 PM, the DON stated the purpose of keeping emergency equipment by a resident with a tracheostomy is to provide a quick response time to the resident when they are experiencing a respiratory emergency. The DON stated that a resident could have worse outcomes with the emergency equipment not being in the room because it would take longer before emergency care could begin. The DON stated that it was the DON's responsibility to ensure emergency equipment was available in the room. 2.Record Review of Resident #7's face sheet dated 7/30/2024 indicated she was a [AGE] year old female initially admitted on [DATE], with the diagnoses of Chronic Obstructive Pulmonary disease (a common lung disease causing restrictive airflow and breathing problems), Hypothyroidism (a condition in which the thyroid gland does not produce enough thyroid hormone), Hypertension (a condition in which the force of the blood against the artery walls is too high), Hypomagnesemia (an electrolyte disturbance caused by low levels of magnesium in the blood). Record Review of Resident #7's comprehensive care plan dated 4/29/24 indicated Resident #7 has oxygen therapy related to ineffective gas exchange Diagnoses Chronic Obstructive Pulmonary D isease (lung disease), OXYGEN SETTINGS: OXYGEN at 2 liters per minute via Nasal cannula every shift for to relieve signs and symptoms of hypoxia related to shortness of breath, Date Initiated: 06/01/2022 and Revision on: 04/19/2023. Record Review of Resident #7's significant change Minimum Data Set assessment dated [DATE] indicated she received oxygen therapy while a resident. Record Review of Resident #7's July 2024 physician's orders indicated OXYGEN at 2 liters per minute via Nasal cannula every shift for to relieve signs and symptoms of hypoxia related to shortness of breath. Observation of Resident #7 on 07/29/24 at 9:05 AM revealed her oxygen tubing was not connected to the concentrator. Resident #7's oxygen concentrator was set at 3 liters per minute. LVN A checked oxygen level before and after connecting tubing. LVN A checked Resident #7's oxygen saturation and received a reading of 88%. After LVN A connected the tubing to the oxygen concentrator, Resident #7's oxygen saturation increased to 91%. Observation of Resident #7 on 07/31/24 at 09:44 AM revealed oxygen tubing was connected, oxygen setting was at 2 liters per minute, Resident #7 stated she was doing fine. No respiratory distress noted. 3.Record Review of Resident #254's face sheet dated 7/31/2024 indicated she was a [AGE] year-old female admitted on [DATE] with the diagnosis of Chronic Respiratory Failure, Chronic Obstructive Pulmonary Disease (a chronic lung disease that causes air flow limitation), Encephalopathy (damage or disease that affects the brain), Muscle Weakness, Chronic Kidney Disease Stage 3 (kidneys have mild to moderate damage, and they are less able to filter waste and fluid out of your blood), and Dementia. Record Review of Resident #254's physician's orders dated 7/29/24 indicated O2@2L via nasal cannula continuous. To relieve s/s of Hypoxia r/t Chronic Obstructive Pulmonary Disease. During an observation on 07/29/24 at 08:40 AM, Resident #254 was lying on a bed and had on a nasal cannula with the oxygen concentrator set at 3 liters per minute. Outside of the bedroom entrance door revealed there was not a sign indicating oxygen in use/no smoking. During an interview with LVN A on 07/29/24 at 9:05 AM revealed she was Resident #7's and Resident #254's nurse. She stated she was responsible for checking the oxygen setting on the oxygen concentrator. She stated she usually checked every shift, but she has not checked Resident #7 or Resident #254. She was not aware Resident #7 was not receiving oxygen until told by the surveyor. It is important to check if the tubing was connected to the concentrator because if it was not connected the resident is not receiving oxygen. Resident #7's oxygen setting was at 3 liters per minute and physician order written for 2 liters per minute continuous. LVN A stated a negative outcome can be cyanosis (bluish or grayish color of the skin, nails, lips, or around the eyes), and the resident will not be well oxygenated. LVN A stated that Resident #7's oxygen level was low and that she was going to contact the physician to make them aware about the incident. LVN A stated she cannot recall about respiratory in-service or training. 4.Record Review of Resident #396's face sheet dated 7/31/2024 indicated she was an [AGE] year old female initially admitted on [DATE], with the diagnoses of Chronic Obstructive Pulmonary disease (a common lung disease causing restrictive airflow and breathing problems), unspecified systolic (congestive) heart failure (a specific type of heart failure that occurs in the heart's left ventricle), Paroxysmal atrial fibrillation (an irregular, often rapid heart rate that commonly causes poor blood flow). Record review of Resident #396's comprehensive care plan dated 7/25/24 indicated Resident #396 has oxygen therapy related to The resident has Emphysema/Chronic Obstructive Pulmonary Disease OXYGEN at 3 Liters per minute via NASAL CANNULA CONTINUOUS TO RELIEVE Signs and Symptoms OF HYPOXIA Date Initiated: 07/30/2024 Revision on: 07/30/2024 Record review of Resident #396's July 2024 physician's orders indicated OXYGEN at 3 liters per minute via Nasal cannula every shift continuously for to relieve signs and symptoms of hypoxia related to Chronic Obstructive Pulmonary Disease. During an observation of Resident's #396 on 7/29/24 at 9:30am, her oxygen concentrator setting was at 5 Liters per minute via nasal cannula. During an observation of Resident #396 on 7/31/24 at 10:08am her oxygen concentrator setting was at 2.5 liters per minute via nasal cannula. LVN B verified setting at 2.5 liters per minute and stated that she had just been in resident's room, and it was at the correct setting. At this time LVN B was observed to adjust the concentrator setting at 3 liters per minute. During an interview with LVN B on 7/31/24 at 9:50 AM she stated the nurses are responsible to check oxygen tubing and settings once per shift. She stated she checked them this morning already except for one resident. She makes sure that the tubing was within date, oxygen level was correct and that there was water on concentrator for residents who are on continuous. She reconciled the physician order with the settings. LVN B said the CNAs are their extra eyes and ears so they would tell her if something was wrong with the resident or if the tubing was disconnected. LVN B said in December she had a skill check off on Respiratory care and it included how to use equipment. She said a negative outcome if the setting is low is that a resident can have hypoxia or if too high, LVN B stated the negative outcome will be that residents can be send out to the emergency room for evaluation. Skill check offs for oxygen use were done when she got hired. It was basically showing that they are competent on how to use equipment and check oxygen. LVN B stated the nurses are responsible for the oxygen signage on the outside of the room. If someone does not know the resident, they do not know where to look or how to identify the resident's needs for oxygen and it can cause a fire for example. The oxygen sign was an extra identifier. During an interview with the ADON on 07/29/24 at 10:10 AM she stated that all staff are responsible for placing the oxygen sign outside the room. She stated that Resident #254 was previously on isolation. She was then moved, and the sign did not get moved with her. She stated that all staff are responsible for checking the oxygen when they do their rounds. This includes changing the oxygen tubing. During an interview with the ADON on 7/31/24 at 09:37 AM she stated the nurses are the ones responsible for checking the settings on the concentrators every shift or periodically. The nurses are responsible to put the orders in the system. The negative outcome was over oxygenation or hypoxia, and the last skills check offs were done last December and they are done annually. The ADON said the nurse was responsible to check if tubing is connected appropriately and if a CNA sees it, they have to let the nurse know. If a resident was not receiving the oxygenation the negative outcome can be respiratory distress. During an interview with the DON on 7/31/24 at 4:04 PM he stated the nurses, ADON, staffing educators, and himself are responsible for checking the settings on the concentrators. He stated the managers check oxygen on the hall in the morning before the morning meeting then again at the end of the day. They are checking the tubing, setting, and every week they change filters. DON stated the Tubing is changed on Sundays. Negative outcome of setting not being accurate, not much could happen since a resident can be up to 5 liters per minute and resident can tolerate depending on acuity level . DON stated the facility does skill check offs for oxygen upon hire and annually. 5.Record review of the admission record for Resident #36 reflected Resident #36 was readmitted to the facility on [DATE], was a [AGE] year-old female with diagnoses that included Chronic respiratory failure, Hypercapnia, chronic obstructive pulmonary disease (chronic inflammatory lung disease that causes obstructed airflow from the lungs), iron deficiency anemia(a condition in which blood lacks adequate healthy red blood cells.), sleep apnea(sleep disorder in which breathing repeatedly stops and starts) and other pulmonary embolism without acute cor pulmonale (blood clot that blocks and stops blood flow to an artery in the lung but does not cause sudden enlargement of the right ventricle of the heart) Record review of Resident #36's Care Plan with admitted [DATE] and last revised 03/14/24 stated the resident has congestive heart failure, at risk for activity intolerance, edema, fluid overload, OXYGEN SETTINGS: O2 prn as ordered. The care plan also stated the resident has oxygen therapy r/t CHF, ineffective gas exchange, respiratory illness, OXYGEN @3L/min via NC at HS and PRN at bedtime for the relieve[sic] of s&sx of hypoxia r/t SOB. AND as needed for relive[sic] of sign and symptoms of hypoxia. The care plan also noted that the resident has altered respiratory status/difficulty breathing r/t CHF, OXYGEN SETTINGS: O2 as ordered. Record review of Resident #36's Quarterly MDS assessment dated [DATE] reflected she has a BIMS score of 15, indicating intact cognition. Section O Special Treatments, Procedures, and Programs: Respiratory Treatments has an X on C1 selecting Oxygen Therapy. Record Review of Nurse's Note by LVN F for Resident # 36, dated 07/18/24 stated Resident readmit from [hospital] via [ambulance company] stretcher. Alert x 4. Was admitted pain/SOB and Rt arm pain. Resident states has a Fx Rt arm is wearing a wrapped cast, from voice pain with movement. Has multiple bruising to bi-lat arms/legs abd., yeast under ab and groin area. Remains on routine o2 at 3L per N/C with stats at 98%. Is on 1200 cc flu F/U appt. with cardiologist. Did not receive D/C med list from hospital sent [physician] for now pending fax. Observation on 07/29/24 at 09:04 AM revealed Resident #36 was in bed with oxygen via NC at 2.5L/min. Interview on 07/30/24 at 02:02 PM with Resident #36, she stated that she has always had oxygen on since return from hospital and prior to going to hospital. It was observed that resident# 36 had oxygen via NC at 2.5L/min. Interview on 07/30/24 at 02:02 PM with CNA A, stated she thinks resident #36's oxygen rate is usually at 3L. Interview on 07/30/24 at 02:11 PM with LVN B without reviewing chart stated Resident #36 is on oxygen at 3L via NC. When asked for order LVN B could not find an order for oxygen for Resident #36. Interview on 07/31/24 at 01:46 PM DON stated that they will conduct rounds frequently and in-services on oxygen rates. DON stated they are getting all staff involved to ensure oxygen rates are as ordered. DON stated they assumed it was already at 3 yesterday. This morning it was adjusted to correct rate during morning rounds . DON stated he was working on a plan of correction to in-service nursing staff by DON and designee on random rounds to ensure accuracy of orders being carried out. Record Review of Order Summary and order details on 07/30/24, noted physician order with start date 07/30/24 at 15:41 (3:41pm)Oxygen @ 3 L/pm via NC continuous to relieve s/s of hypoxia r/t COPD was noted in Resident #36's point click care (electronic health record) profile. Observation on 07/30/24 at 03:54 PM revealed Resident #36 observed in bed with oxygen via NC still set at 2.5L/min. Observation on 07/31/24 at 10:18 AM revealed Resident #36 observed in bed with oxygen via NC at 3L/min. Record Review of the facility policy Tracheostomy Care last revised August 2013 stated: A suction machine, supply of suction catheters, exam and sterile gloves, and flush solution, must be available at the bedside at all times. Record review of the facility's Oxygen Administration policy dated October 2010, revealed Purpose: The purpose of this procedure is to provide guidelines for safe oxygen administrations. Preparation: Verify that there is a physician's order for this procedure. Review the physician's orders or facility protocol for oxygen administration. General Guidelines: 1. Oxygen therapy is administered by way of an oxygen mask and nasal cannula. b. The nasal cannula is a tube that is placed approximately one-half inch into the resident's nose. It is held in place by an elastic band placed around the resident's head. Steps in the Procedure: 1.Place an Oxygen in Use sign on the outside of the room entrance door. Close the door. 3.Check the tubing connected to the oxygen cylinder to assure that is free of kinks. Record Review of the facility's oxygen administration policy dated October 2010, reflected Verify that there is a physician's order for this procedure. Review the physician's orders or facility protocol for oxygen administration. 50039 50487

Based on observation and interview the facility failed to provide a safe, functional, sanitary, and comfortable environment for 1 of 3 halls (Hall 200) reviewed for environment. 1) The facility failed to keep the soiled linen utility closet containing dirty linens locked when not in use. 2) The facility failed to keep the oxygen storage room containing empty and full oxygen canisters locked when not in use. 3) the facility failed to keep the central supply storage room containing approximately 40 individual shaving razors locked when not in use. These failures could result in injury for residents who come into contact with sharp implements or hazardous materials. The findings included: During an observation on 07/29/2024 at 10:53 AM, the soiled linen utility closet on hall 200 across from resident room [ROOM NUMBER] was noted to be partially ajar. The sign on the door read Authorized Personnel Only. Inside the room was soiled linens and trash. During an observation on 07/29/2024 at 3:03 PM, the oxygen storage room and central supply storage rooms at the end of hall 200 were unlocked. The signs on the oxygen storage room read Danger Flammable Gas and Danger Gas Cylinder Storage Area. Inside the oxygen storage room were approximately 50 oxygen canisters in racks. Half of them were in the section labeled O2 full and the other half were in the section labeled O2 empty. The door to central supply storage room had a locking mechanism with buttons for input, but the door could be opened without inputting any combination. Inside the central supply storage room were various hygiene supplies, including approximately 40 individual shaving razors in a basket on a shelf. In an interview with CNA C on 07/31/2024 at 2:29 PM, CNA C stated that the locking mechanism on the door to the central supply storage room stopped working about a year ago. CNA C stated that she was not certain if the oxygen room had ever been locked because she had never been in that room. CNA C stated that she had never seen a resident by the storage rooms at the end of hall 200. CNA C stated that she did not think any residents on the 200 hall would grab a razor in the central supply storage room and hurt themselves or others. CNA C stated that she was not sure whether or not the oxygen storage room should be locked, but that the central supply storage room should probably be locked. CNA C stated that it should be the responsibility of whoever stocks the supply rooms to inform the DON or administrator that the doors are unlocked. In an interview with LVN E on 07/31/2024 at 2:42 PM, LVN E stated that the oxygen storage room is usually locked at other facilities he has worked. LVN E stated that it was possible for a resident to go into the central supply storage room, grab a razor, and then hurt themselves or others. LVN E stated that if a resident walked into the central supply storage room and fell it could take a while before anyone would notice that the resident had fallen and injured themselves. In an interview with the DON on 07/31/2024 at 3:15 PM, the DON stated whether or not storage rooms should be locked depends on what is being stored. The DON stated that the soiled linens closet should be secured when not in use. The DON stated that he was fine with the oxygen supply room being unlocked because they are in racks. The DON stated that he was fine with the central supply door being unlocked as long as nothing dangerous was in there. The DON stated that shaving razors do not belong in the central supply storage room at the end of hall 200. The DON stated that there was potential for residents to harm themselves or others with the razors in the room. The DON stated that it was possible, but not likely, that a resident could go into the central supply storage room and fall causing them to injure themselves. On 07/31/2024 at 4:01 PM, a policy was requested from the DON and ADM covering the expectations for a safe, homelike environment but none could be located.

Based on observation, interview, and record review the facility failed to maintain an effective pest control program so that the facility was free of pests in one of one kitchen reviewed for pests. 1. There were multiple live flies and gnats in the kitchen. 2. There were multiple live flies in the dining room. These failures could put residents who consumed food from the kitchen and who ate in the dining room at risk for infection and/or food contamination. The findings included: Observation of the facility's kitchen dry storage area on 07/29/24 at 09:10am revealed 2 flies and approimately 10 gnats that were flying around in the area. Observation of the facility's kitchen food preparation and cooking area on 07/29/24 at 09:45am revealed multiple flies were flying around in the kitchen area and had landed on multiple food preparation surfaces. Observation on 07/29/24 at 11:45am of the facility's dining room revealed multiple flies in the dining room. One resident was noted to have a fly swatter on the dining room table that she was sitting at. In an interview on 07/30/24 at 1:43pm, the DM stated that they had ordered and received an air curtain for the dining room door to help keep the flies and gnats outside and they were waiting on an electrician to fix the electrical issue so that it could be installed. The DM stated the electrician should be out next week. In an interview on 07/31/24 at 10:36am, the ADM stated that the MS was out of the facility to get foggers to spray outside. The ADM stated they would be spraying outside at least weekly during peak seasons to help control the flies. The ADM stated the MS was also looking for fly traps for the kitchen. The ADM stated pest control was contracted for 2 times a month; one time to spray the inside and the next time outside, but that they could call them anytime to come in for additional treatment if needed. The ADM stated that pest control should be coming out today (07/31/24). In an interview on 07/31/24 at 11:24am, MS stated pest control came out 2 times a month and as needed. MS stated pest control had been out on 7/25/24 and 7/20/24. MS stated pest control should be out by about 1:00 pm today and that he was going to discuss how to control the flies in the facility and what recommendations or remedies the pest control company had. Record review of the facility's pest control request log on 7/31/24 at 10:50am revealed 13 entries dated 6/26/24 through 7/29/24. 12 of 13 entries were related to roaches and 1 of 13 entries was related to ants. There were no entries related to flies or gnats for any area of the facility. Record review of the facility's pest control invoices on 7/31/24 at 11:26am revealed the pest control company had been out on 7/20/24 and 7/25/24 and had treated for roaches and ants, but there was no mention of treating for flies inside or outside the facility.

48278 Based on interviews and record review, the facility failed to send a copy of the notice of transfer or discharge and the reasons for the transfer or discharge in writing to the Office of the State Long-Term Care Ombudsman for two (Resident #82 and Resident 93) of two residents reviewed for transfer and discharge. The facility failed to send a transfer or discharge notice in writing to the facility's Ombudsman as soon as practicable when Resident #82 was discharged home on 7/25/24. The facility failed to send a transfer or discharge notice in writing to the facility's Ombudsman as soon as practicable when Resident #93 was discharged to another facility on 5/11/24. This failure could affect residents at the facility by placing them at risk of being discharged and not having access to available advocacy services, discharge/transfer options, and the appeal processes. Findings included: 1. Resident #82 Record Review of Resident #82's face sheet dated 7/31/2024 indicated she was a [AGE] year-old female admitted on [DATE] with the diagnosis of Cellulitis (a deep infection of the skin caused by bacteria), Muscle Wasting and Atrophy, Muscle Weakness, Type 2 Diabetes Mellitus, Essential Hypertension (high blood pressure), and Morbid Obesity (more than 80 to 100 pounds above their ideal body weight). Reviewed discharge summary dated 7/25/24. During an interview on 7/30/24 at 4:10pm with SW, stated that Resident #82's discharge was a planned discharge. The facility got a medical provider notice. She got a signed a NOMNC (a notice that indicates when Medicare coverage is about to end). She stated this medical provider sends them these notices for all WellMed patients. It tells her when the residents last day of therapy will be. This information was provided to Resident #82 and the resident's responsible party. She stated they both received a copy of the medical provider NOMNC, and both were made aware of Resident #82 was going to be discharged on [DATE]. She was not aware that she needed to notify the Ombudsmen. She stated she did not notify Ombudsmen but will from here on out. 2. Resident #93 Record review of Resident #93's face sheet dated 7/30/24 reflected a [AGE] year-old male with an original admitted [DATE]. Diagnoses included cerebral infarction (type of stroke that occurs when a blood vessel that supplies blood to the brain is blocked) and diabetes type two (insufficient insulin production in the body). There was no discharge notice reviewed. In an interview on 07/30/24 at 03:02 PM the SW stated Resident #93 was discharged to another facility due to resident needed to be in a memory care unit since Resident #93 was exit seeking. The SW stated the doctor made the referral for Resident #93 to be discharged to a memory unit. The SW sated a referral was discussed with Resident #93's family and the family agreed to the transfer. The SW stated she was not sure if a written notice was done and provided to Resident #93, Resident #93's responsible party, and local Ombudsman. The SW stated she was responsible for discharge procedures and notifying residents, resident's family, and the local Ombudsman. In an interview on 07/31/24 at 09:30 AM the SW stated she felt the discharge process the facility conducted was appropriate due to Resident #93 was being immediately discharged because the family was in agreeance and the facility spoke with the other facility and they accepted Resident #93. The SW She stated Resident #93 was a certain insurance patient and that insurance company sends them the notices and information about transfers. The SW stated after talking with the facility team, they felt they completed the transfer appropriately. The SW stated with every discharge, the family and resident are aware of the discharge and discharge plan wither through a care plan meeting or through a 30-day discharge notice. The SW stated for Resident #93's transfer to another facility, written notice was not given to Resident #93, Resident #93's family, or the local Ombudsman but they were made aware of the transfer. Record review of the facility's Transfer or Discharge, Facility-Initiated policy dated October 2022, revealed 3. A copy of the notice is sent to the Office of the State Long-Term Care Ombudsman at the same time the notice of transfer or discharge is provided to the resident and representative.

Based on observation, interview and record review, the facility failed to implement their policy and procedure that prohibits neglect for two Residents (R #4 and R #8) of 17 Residents reviewed for neglect. -R#4 was admitted to the facility without a pressure ulcer and developed a pressure ulcer after admission to the facility. The facility did not accurately identify, stage, and document R #4's pressure ulcer, that worsened and was then identified as an unstageable. The facility did not reassess or update R #4's Braden Scale Risk Assessments for predicting pressure ulcers. -R#8 developed a pressure ulcer four months after admission to the facility. The facility did not accurately identify, stage, and document R #8's pressure ulcer, that worsened to a Stage IV with tunneling.The facility did not reassess or update R #8's Braden Scale Risk Assessments for predicting pressure ulcers. -R #4 and R #8's documentation of their Pressure Ulcers contained some ommited information, inconsistent, and contradicting staging and description of their wounds, from document to document. These failures of developing/worsening of pressure ulcers in the facility, correctly identifying/assessing, documenting, and treating pressure ulcers resulted in an Immediate Jeopardy (IJ) situation on 02/25/16. While the IJ was removed on 02/26/16, the facility remained out of compliance at a potential for more than minimal harm with a scope identified as pattern. The facility was continuing to monitor to ensure continued implementation of their plan of removal. This deficient practice could place 16 residents with pressure ulcers and 31 residents receiving preventative skin care at risk of skin breakdown or worsening of pressure ulcers, due to not receiving accurate assessments, care, and services needed to prevent delay in treatment, complications, hospitalization , and neglect from the facility to not provide goods and services necessary to avoid physical harm, mental anguish or mental illness. The findings included: R #4: R #4's Face Sheet dated 02/25/16 documented an [AGE] year-old female admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. R #4's Admission Nursing Evaluation dated 08/20/15 documented General Skin Condition: dry and warm. The form indicated Skin Condition (if checked, further evaluation required per facility policy. Indicate below all body marks such as pressure ulcers, abrasions, bruises, soft heels, moles, skin tears, cancer [MEDICAL CONDITION], oozing, surgical wounds and scars. Indicate location, size, depth (cm (centimeter)) color, and drainage. A circle was drawn on the middle right of the buttocks with area written beside it. There was no detail information documented about the area. R #4's Telephone Physician Order, Treatment Record, and Progress Note dated 09/26/15 revealed R #4's Stage II pressure Ulcer was resolved and treatment was discontinued. R #4's Braden Scale for Predicting Pressure Ulcer Risk Form indicated To be completed upon admission, weekly X3, then quarterly and PRN (as needed). -Evaluation Date: 09/09/15, Total Score: 17; -Evaluation Date: 12/31/15, Total Score: 20; -Evaluation Date: 01/27/16, Total Score: 19; Total Score Key: equal to or less than 9= Very High Risk; 10-12= High Risk; Moderate Risk= 13-14, and At Risk= 15-18. There were no other Braden Assessments in R #4's clinical record. R #4's Care Plans revised 12/31/15 included: -(R #4) has the potential for impaired skin integrity related to periods of incontinence, and end of life. Goal: (R #4) will maintain intact skin through the next review date. (R #4) will have a resolved current wound X 90 days; Current Stage II to coccyx- 02/16/16. Approaches: Check q (every) 2 hours for incontinence and provide cleansing as needed; Turn and reposition q 2 hours; Monitor skin during shower and report abnormalities to MD (Medical Doctor); Wheelchair cushion; Encourage to lay down in bed for pressure relief; Treatment as ordered; Notify physician if treatment not effective. R #4's Quarterly Minimum Data Set ((MDS) dated [DATE] documented R #4: -Had clear speech, made self understood, and understood others- clear comprehension; -Brief Interview of Mental Status (BIMS) score was 8. R #4 could recall after cueing. -Behaviors not exhibited; -Required supervision with one person physical assistance for bed mobility, transfers, dressing, eating, locomotion on and off unit, personal hygiene, and bathing. -Range of Motion: upper extremity- no impairment; lower extremity- no impairment; -Mobility Devices: wheelchair; -Was occasionally (less than 7 episodes of incontinence) incontinent of urine and always incontinent of bowel; -Height: 56 inches. Weight- 82 pounds. No or unknown weight loss or gain; -At risk of developing pressure ulcer: No; No pressure ulcers. R #4's February 2016 Consolidated physician's orders [REDACTED].>- Hospice services as of 08/11/15, Dx: Neoplasm of the bone, [DIAGNOSES REDACTED], and Dementia. R #4's Progress Note dated 02/01/16 documented Called into room per RP (responsible party) states pt (patient) c/o (complains of) pain to buttocks and noted open area to coccyx. Assess approximately 1 cm X 1 cm diameter Stage II to coccyx. N.O. (new order) with treatment with cleanse with NS (Normal Saline) pat dry with gauze. Covered with Duoderm ([MEDICATION NAME] dressing is a wafer type of dressing that contains gel-forming agents in an adhesive compound laminated onto a flexible, water-resistant outer layer). To be changed q 2 days and PRN . R #4's Immediate Needs Care Plan: Pressure Ulcer dated 02/01/16 documented Location: Coccyx. Strength to draw from: Able to communicate needs and able to follow directions. Goals: Ulcers will be healed without complication, Surface area will decrease. Interventions: Wound Status: size of wound: measurements of depth and width, skin color, surrounding skin tissue assessments weekly; Complaints of pain, effectiveness of pain medication per order; Apply dressing per Order; Note old dressing for any signs of exudate. Assess color and amount if present; Be alert to any signs of infection: drainage, odor, redness of surrounding tissue, red streaking up the extremity. Treatment changed 02/02/16 to Xeroform. R #4's February 2016 Ulcers, Surgical Site Treatment and Progress Record- Side One documented Discovered 02/01/16, Diagnosis/Stage: Stage II. Order Date: 02/02/16. Treatment: Coccyx- Cleanse with NS pat dry apply Xeroform cover with foam dressing change QD and PRN. From 02/02/16-02/24/16, the following was documented: -Drainage: M -General Appearance: R -Surrounding Skin: N . According to the Drainage Key on this form M = moist, General Appearance Key: R= red, P = pink, W= white; and Surrounding Skin Key: N = normal. R #4's February 2016 Ulcers, Surgical Site Treatment and Progress Record- Side Two documented NPUAP Stages For Pressure Ulcers: - .Stage 2: Partial thickness loss of dermis presenting as a shallow open ulcer with red pink wound bed, without slough. May also present as an intact or open/ruptured serum-filled blister. - Stage 3: Broken skin, deep tissue involvement. Full thickness wound. -Stage 4: Broken skin through all layers of tissue, including muscle, tendon or bone. Full thickness wound. -Unstageable: Full thickness loss in which the base of the ulcer is covered by slough (yellow, tan, grey, green or brown), and/or eschar (tan, brown or black) in the wound bed. -Partial thickness wound (PTW): Loss of epidermis and partial loss of dermis. -Full thickness Wound (FTW): Tissue destruction extending through the dermis and involving the subcutaneous layer. May involve muscle or bone. Date: 02/02/16 NPUAP Stage: Stage II L (length)= 0.5, W= 0.6 (width), D (depth)= 0.1 The same section of the form documenting Undermining, Tunneling Depth, Process: Yes or No boxes for: Granulation, Decreased Size, Decreased Depth, Decreased Drainage; were blank. R #4's Telephone Orders dated 02/02/16 documented Cleanse Stage II coccyx with NS pat dry apply Xeroform cover with foam dressing, change QD (every day) and PRN. R #4's Weekly Skin Integrity Review Sheet dated 02/03/16 documented Stage II. An X was drawn just above the horizontal gluteal crease. No other documentation was provided of this assessment except for Treatment Nurse/LVN B's signature. R #4's February 2016 Ulcers, Surgical Site Treatment and Progress Record- Side Two documented 02/09/16 NPUAP Stage: (no stage documented), L= 0.5, W= 0.5, D= 0.1 cm. No other documentation or detail was documented. R #4's Weekly Skin Integrity Review Sheet dated 02/10/16 documented Stage II. An X was drawn just above the horizontal gluteal crease. No other documentation was provided of this assessment except for Treatment Nurse/LVN B's signature. R #4's Nurse's Notes dated 02/10/16 (no time documented) documented Stage II coccyx 0.5 X 0.5 X 0.1 cm (centimeter). Wound bed is granulated tissue, scant amount of serous (a thin watery liquid) drainage, wound edges are attached peri-wound is clean, pt denies any pain, continue current treatment as ordered. R #4's Nurse's Notes dated 02/16/16 (no time documented) documented Stage II coccyx 0.8 X 0.8 X 0.1, wound base is granulated tissue, scant amounts of serous drainage, no odor, continue current treatment. R #4's Weekly Skin Integrity Review Sheet dated 02/17/16 had no documentation of the assessment except for Treatment Nurse/LVN B's signature. R #4's February 2016 Ulcers, Surgical Site Treatment and Progress Record- Side Two documented 02/17/16 NPUAP Stage: (no stage documented), L= 0.8, W= 0.8, D= 0.1 cm. No other documentation or detail was documented. R #4's February 2016 Ulcers, Surgical Site Treatment and Progress Record- Side Two documented 02/24/16 NPUAP Stage: Stage II, L= 0.8, W= 0.5, D=0.1 cm and L= 0.8, W= 0.8, D= 0.1 cm. There were two different measurements of the same wound. No other documentation or detail was documented. R #4's Nurse's Notes dated 02/24/16 (no time documented) documented Wound to coccyx 0.8 X 0.8 X 0.1 cm wound base has granulated tissue with area of white to 12 o'clock area, wound has moderate serous drainage, peri-wound has blanchable redness, spoke to (physician) for coordination of care, doctor saw pts wound, doctor stated to continue current orders of Xeroform and wait to change anything until (Wound Care Specialist) next visit, this nurse requested if we could start Santyl with Xeroform, doctor stated no, wait for (Wound Care Specialist), but he started [MEDICATION NAME] (antibiotic) 500 mg (milligrams) BID (twice a day) X 7 days, no s/s (signs/symptoms) of infection however blanchable redness in peri-wound no change in size of wound remains on wheelchair cushion and has a foam preventative matress to the bed. Pt has episodes of incontinence. Incontinent care provided . R #4's Nurse's Notes dated 02/24/16 (no time documented) documented Received new orders from doctor, 1.) low air loss mattress, 2.) Multivitamin QD, 3.) Stress tab with Zinc 1 tablet BID X 10 days, spoke to hospice nurse on changing pt wheelchair cushion, hospice nurse stated they would order a new cushion . On 02/24/16 at 11:00 a.m., review of R #4's Telephone Physician order [REDACTED].#4's Telephone Orders dated 02/02/16 documented Cleanse Stage II coccyx with NS pat dry apply Xeroform cover with foam dressing, change QD and PRN. There was no proceeding order as of this date on the sheet at the time the copy was made. On 02/24/16 at 2:09 p.m., this surveyor accompanied Treatment Nurse/LVN B to R #4's room. As Treatment Nurse/LVN B prepared her supplies for wound care, she stated (R #4) has a Stage II to her coccyx and it is cleaned daily. It last measured 0.8 X 0.8 X 0.1 cm. I cleanse with wound cleanser, place a piece of Xeroform, and cover with Foam dressing. As of yesterday, the wound looked pink with a couple of small spots of white in the center of the wound. There is a little depth. Treatment Nurse/LVN B removed R #4's dressing on her coccyx and this surveyor saw a wound approximately the diameter of a dime with some depth. The wound bed had pink and white with yellow/tan pinpoint specks of tissue in the wound. There was no odor and the old dressing had serous drainage. There was reddness surrounding the wound. The Treatment Nurse/LVN B measured the wound and stated outloud 1 X 1 X 0.1 cm., it looks like it has a little more white today. The Treatment Nurse/LVN B again stated the wound was a Stage II Pressure Ulcer acquired in-house. The Treatment Nurse/LVN B said R #4's physician saw the wound this morning and the physician did not want to change anything until (wound specialist) was told of the wound but he will not be here until next week because he is on vacation. I called the hospice nurse for approval for an air mattress. On 02/24/16 at 2:40 p.m., this surveyor accompanied the Treatment Nurse/LVN B and the Director of Nurses (DON) to view R #4's pressure ulcer. While walking to R #4's room, the DON stated I am not good at staging ulcers. Pressure ulcers are my weak point, the staging is confusing to me. I recognize Stage I and I know a Stage IV involves the bone and muscle. The Stage II and III's is where I have trouble. The DON read outloud the NPUAP Stages For Pressure Ulcers off of R #4's February 2016 Ulcers, Surgical Site Treatment and Progress Record- Side Two. The DON confirmed the facility used the NPUAP Stages for Pressure Ulcers as a reference tool in staging ulcers. The DON looked at R #4's wound and stated I would have to say and agree with the Treatment Nurse that it is a Stage II, because she is more educated in this than I am. I see pink with a couple of white small spots with a small amount of drainage and a little depth. Interview with R #4's Physician on 02/24/16 at 3:38 p.m. revealed Yes, I saw the wound. When I saw her wound this morning, I did not see slough or anything. I am not a wound doctor. I don't know how to stage wounds or the correct treatment for [REDACTED]. I rely on the wound nurse and wound doctor's recommendations because they are more educated on wounds than I am. The nurse said she was going to ask the wound doctor about the wound next week because he is on vacation, or something like that. I'm treating her for infection of the wound, I ordered antibiotics. No, I don't know what infection she has; no culture has been taken. On 02/24/16 at 4:21 p.m., this surveyor accompanied Director of Clinical Operations (DCO) and the Division Clinical Vice President (DVP) to R #4's room to observe R #4's pressure ulcer. The DCO stated outloud I see a clean open wound with white area and some pink in the center of the wound. I agree there is a Stage II there. Interview with R #4's Hospice Registered Nurse (RN) G on 02/24/16 at 4:38 p.m. revealed she had not seen R #4's pressure ulcer since last week. RN G said last week she had seen the wound to be an open rounded wound with slough and some serous drainage. The Treatment Nurse staged it as a Stage II but I don't think it was a Stage II due to the slough. To me, the ulcer was a Stage III, because of the slough and it was getting deeper. The Treatment Nurse told me the specialist was going to see (R #4) next week because he was on vacation this week. RN G said she did not recall seeing an order to consult the wound specialist as of 02/22/16, I assumed (R #4's) physician spoke to the specialist, directly. I went ahead and ordered (R #4) an air mattress today because she is so thin and bony and any pressure could easily worsen her wound, which we see has happened. On 02/25/16 at 10:05 a.m., this surveyor accompanied the Treatment Nurse/LVN B to R #4's room and observed wound care. R #4's wound had more white and yellow tissue in the center of the wound with moderate serous drainage, redness, and maceration (softening and breaking down of skin resulting from prolonged exposure to moisture) surrounding the ulcer.The Treatment Nurse/LVN B (accompanied by the DVP) stated she called R #4's physician and got an order to change the treatment to the ulcer. The Treatment Nurse/LVN B said she had a conference call with the American Medical Technology (AMT) Representative Consultant and all were in agreement (R #4's) ulcer was an unstageable ulcer because we can't see the wound base due to it being covered with white tissue, we all agreed to use Santyl. I told (the physician) the white tissue from yesterday increased and there was redness around the wound bed. I agreed with you yesterday that the wound had worsen but after I spoke to the doctor yesterday morning he did not want to make any changes because he wanted to wait for the specialist recommendations; I just didn't want to undermine his authority. I should have just told you yesterday that it was no longer a Stage II. On 02/25/16 at 11:00 a.m., interview with the DCO, DVP, and the Administrator accompanied the Treatment Nurse/LVN B and the DON to the facility's conference room for an interview. The DON explained the facility no longer had policy and procedures and provided a copy of the facility's Skin Management Systems revised 10/2015 that took the place of the policy and procedure. The DON stated the facility also used the Perry and Potters' Clinical Nursing Skills and Techniques 8th Edition Manual for clinical resources as a reference. The Treatment Nurse/LVN B confirmed R #4 did not have current Braden assessment and should have had one when her pressure ulcer was found on 02/01/16. I forgot to do it. The Treatment Nurse/LVN B reviewed R #4's most recent Ulcers, Surgical Site Treatment and Progress Record and confirmed she documented incorrectly by not documenting there was white and yellow tissue in the wound on 02/23/16 and 02/24/16. At this time the Treatment Nurse/LVN B agreed she should have documented her exact observation of R #4's wound on 02/23/16 and 02/24/16. The Treatment Nurse/LVN B said she did not call R #4's physician on 02/23/16 when she first saw a change (white tissue) in R #4's ulcer. The DON interrupted and said yes there was a change in the ulcer then the Treatment Nurse/LVN B abruptly stood up and walked out of the room. At 1:15 p.m., the interview continued, Treatment Nurse/LVN B said she could not recall R #4's wound having a change or having white tissue in the ulcer on 02/23/16. The Treatment Nurse/LVN B said I know there was white in the wound on 02/24/16 when I first treated it in the morning. No, I did not document it. I do not remember telling you the ulcer changed on 02/23/16. This surveyor read outloud to the Treatment Nurse/LVN B her statement on 02/24/16 at 2:09 p.m. the Treatment Nurse/LVN B said oh, I don't remember that. The DON said If an assessment or documentation is inaccurate, it can effect the wound and maintenance of continuity of care. The DON confirmed each form should be completed to it's entirty, if not document the reason why. On 02/25/16 at 4:50 p.m., this surveyor reviewed R #4's updated Telephone Physician order [REDACTED]. (evaluate) and treat dated 02/19/16. Record Review of the facility's Skin Management System revised 10/2015 documented: 1. A head to toe body evaluation will be completed on every resident upon admission or readmission and weekly thereafter. These evaluations will be documented on the Weekly Skin Integrity Review form or EMR (Electronic Medical Record). If skin is intact, no further action is required. If skin is compromised, proceed to the appropriate form below. A. Pressure Ulcers, Venous Ulcers and Arterial Ulcers, and surgical sites will be documented on the Ulcer, Surgical Site Treatment and Progress Record or EMR. Use one form per wound. Wound progress is to be documented each week with measurements and wound descriptions. Daily treatments are also documented on the same form. I. treatment for [REDACTED]. .c. Keep open lines of communication with physicians, families, and residents regarding status of wounds. d. Responsible Party will be notified at the onset of an identified area as well as with all treatment changes, decline in the status of the area, and when the area is healed. Documentation of the notification is to be in the Nurses Notes in the clinical record or EMR. II. Progress of the identified area, will be documented on the back of the Ulcer, Surgical Site Treatment and Progress Record form at least every 7 days, or less if the wound shows a decline or is healed. The Physician is to be contacted after 14 days if the area has not shown improvement or immediately if it shows a decline. Documentation of the Physician notification is to be in the Nurses Notes in the chart or EMR 2. Routine weekly checks will be completed on every resident; if skin is intact it will be noted as such. If a new pressure ulcer is noted, a Ulcer, Surgical Site Treatment and Progress Record form will be started . B. CNA's (Certified Nurse Aides) will note any alteration in skin integrity during routine care on the Skin Care Alert form or EMR and turn in/reported to the Charge Nurse responsible for the resident at the time, for their attention 3. Braden Scale will be completed upon admission, with change of condition, and quarter on the Braden Scale form or the EMR . 4. Refer to Protocol for Pressure Ulcers by AMT, and/or AMT binder, for assistance with wound identification, staging, and recommended treatments. Contact physician for treatment recommendation approval . 8. Facility DON's are responsible to establish a system to monitor and assure Skin Management System Compliance. The facility's undated Protocol for Pressure Ulcers by AMT form documented: -Stage II Pressure Ulcer: Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough. May also present as an intact or open/ruptured serum-filled blister. Presents as a shiny or dry shallow ulcer without slough or bruising. This stage should not be used to describe skin tears, tape burns, perineal [MEDICAL CONDITION], maceration or excoriation. *Focus on pressure reduction . - Stage III Pressure Ulcer: Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling. Further description: The depth varies by anatomical location. Some locations do not have subcutaneous tissue and these stage III ulcers can be shallow. Bone/tendon is not visible or directly palpable. *Focus on pressure reduction . -Stage IV Pressure Ulcer: Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often include undermining and tunneling. The depth varies by anatomical location. Some locations do not have subcutaneous tissue and these stage IV ulcers can be shallow . R #8: R #8's Face Sheet dated 01/27/16 revealed R #8 was a [AGE] year-old female admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. R #8's Braden Scale for Predicting Pressure Sore Risk dated 06/09/15 documented a total score of 13. *R #8 did not have any other Braden Scale assessments in her closed clinical record. R #8's Admission Nursing Evaluation dated 06/09/15 documented R #8 had an open area to right buttock- 2 in (inch) X 2 in and left buttock less than 1 in X 1 in. R #8's MDS dated [DATE] documented R #8: -Had clear speech, made self understood, and understood others- clear comprehension; -BIMS score was 5. R #8 could not recall. -Behaviors not exhibited; -Required extensive assistance with one or two person physical assistance for bed mobility, dressing, and eating. R #8 was totally dependent with one or two person physical assistance for transfers, locomotion on and off unit, personal hygiene, and bathing; -Range of Motion: upper extremity- no impairment; lower extremity- impairment on one side; -Mobility Devices: wheelchair; -Was always incontinent of urine and bowel; -Height: 63 inches. Weight- 100 pounds. No or unknown weight loss or gain; -At risk of developing pressure ulcer. Resident has Stage 1 or higher pressure ulcer (One Stage 2). One Stage 2 Pressure Ulcer present on admit/reentry. Tissue type of ulcer at most advances stage: [MEDICATION NAME] tissue- new skin growing in superficial ulcer. It can be light pink and shiny . R #8's Telephone Physician order [REDACTED]. Resolved Stage II. R #8's Nurse's Treatment Notes dated 10/03/15 documented 10/03/15 8:45 p.m., Initials: (LVN A's initials), Treatment: Left Ischium (the curved bone forming the base of each half of the pelvis), Reason/Remarks: Stage II to Left Ischium at 0.7 X 0.9 X 0.1 cm with pink moist wound bed and [DIAGNOSES REDACTED] to peri-wound. Initiated tx (treatment). Doctor .notified. *There was no Weekly Skin Integrity Review Sheet or October 2015 Wound Treatment and Progress Record or Ulcers, Surgical Site Treatment and Progress Record that documented the discovery or details of R #8's Left Ischium Stage II Pressure Ulcer found anywhere in R #8's clinical record. R #8's Telephone Physician order [REDACTED]. Secure with clear tape q 2 days and PRN. R #8's Weekly Skin Integrity Review Sheet (side two- signed by Treatment Nurse/LVN B) documented 10/05/15: Skin Condition: Skin Intact. No other documentation was completed in this section of the block. R #8's Telephone Physician order [REDACTED]. Pat dry, apply Duoderm, secure with clear tape q 2 days and PRN. Dx (diagnosis): Stage II left Ischium. R #8's Progress Notes dated 10/10/15 (signed by LVN A) documented Stage II to Left Ischium 0.7 X 0.9 X 0.1 cm with errythema to peri-wound. No tenderness . R #8's October 2015 Ulcers, Surgical Site Treatment and Progress Record- Side One documented Discovery: 10/10/15 Diagnosis: [REDACTED]. 10/10/15: Treatment: Duoderm with clear tape q 2 days and PRN; Hour: Days, Noon, Evenings. -Drainage: M -General Appearance: P -Surrounding Skin: N -Initials: (LVN A's initials) R #8's October 2015 Ulcers, Surgical Site Treatment and Progress Record-Side Two documented: Date: 10/10/15 (signed by LVN A) documented NPUAP Stage: Stage II. L- 0.7, W- 0.9, D- 0.1 cm. Additional documentation: Redness to peri-wound, no tenderness. *The same section of the form provided area for documentation under Undermining, Tunneling Depth, Process: Yes or No boxes for: Granulation, Decreased Size, Decreased Depth, Decreased Drainage; No documentation was completed in these areas of the form. R #8's Weekly Skin Integrity Review Sheet (side two- signed by LVN A) documented 10/10/15: Skin Condition: Other: Stage II left Ischium, Open Area: New. No other documentation was completed in this section of the block. R #8's Immediate Needs Care Plan: Pressure Ulcer(s) dated 10/10/15 documented: Problem/Need related to: Immobility. Resulting in location: Stage II Left Ischium. Strength to draw from: Able to communicate Needs and able to follow directions. Goals: Ulcers will be healed without complication. Interventions: Wound Status: sixe of wound: measurements of depth and width, skin color, surrounding skin tissue assessments weekly; Complaints of pain, effectiveness of pain medication per order .; Apply medicated ointment per order; Apply dressing per Order; Be alert to any signs of infection: drainage, odor, redness of surrounding tissue, red streaking up the extremity. *This form was signed by Treatment Nurse/LVN B. No other input was documented on this document. A separate and additional Pressure Ulcer Care Plan dated 10/10/15 documented Problem: Alteration in skin integrity related to Dementia, decreased mobility, and Chronic Ischemic [MEDICAL CONDITION]. Goal: Stage 2 pressure ulcer will heal within 60 days. Approaches: Educate resident and RP (responsible party), Daily wound care, Assist with turning, rising, repositioning every 2-3 hours and PRN, Limit static sitting to 1 hour at any one time, Support surface for bed: pillows, Support surface for chair: Jois cushion, Dietician consult, Weekly assessment of wound, re-eval interventions q 2 weeks, Update physician on wound progress q 2-3 weeks, Risk assessment on admit, change of condition, and quarterly, Ensure adequate nutrition, Manage urinary and fecal incontinence: Wet/soiled checks q 2 hours, Assist with hygiene: q shift, Check skin condition for intactness, color, sensation, and temperature. If changes occur, call physician, Monitor dressing for signs and symptoms of infection, if present notify physician . R #8's Telephone Physician order [REDACTED]. D/C cleanse Left Ischium with NS and Duoderm . 2. Cleanse Left Ischium with NS, pat dry, apply Xeroform (a sterile, non-adhering primary dressing with 3% Xeroform), secure with dry dressing, change q day and PRN. R #8's Weekly Skin Integrity Review Sheet (side two- signed by Treatment Nurse/LVN B) documented 10/13/15 Skin Condition: Other: Stage II, open area new. No other documentation was completed in this section of the block. R #8's Nurses Notes (signed by Treatment Nurse/LVN B) dated 10/14/15 documented pt (patient) has Stage II to Left Ischium 0.6 X 1.0 X 0.1 cm, wound base is red, serous drainage, no odor, peri-wound is clear, pt has no facial grimaces while wound care being performed . R #8's October 2015 Surgical Site Treatment and Progress Record- Side One documented a subsequent entry (after 10/10/15 entry) dated 10/14/15 (signed by Treatment Nurse/LVN B revealed NPAP Stage: Stage II. L= 0.6, W= 1.0, D= 0.1 cm. Undermining= none. Additional documentation: Peri-wound has redness. Undermining= 0.1 cm. The section of the form under Additional documentation, Tunneling Depth, Process that included Yes or No boxes of: Granulation, Decreased Size, Decreased Depth, Decreased Drainage revealed no documentation was completed in these areas of the form. R #8's Weekly Skin Integrity Review Sheet (side two- signed by LVN A) documented 10/17/15: Skin Condition: Other: Stage II left Ischium. No other documentation was completed in this section of the block. R #8's Weekly Skin Integrity Review Sheet (signed by Treatment Nurse/LVN B) documented 10/20/15 Skin Condition: Other was checked but no information was documented on the line. No other documentation was completed in this section of the block. R #8's Nurses Notes (signed by Treatment Nurse/LVN B) dated 10/23/15 documented pt wound to Left Ischium Stage II has deteriorated wound is Stage III 2.3 X 1.6 X 0.1 cm, wound base is red with areas of white, slough, serous drainage, no odor, peri-wound is clear, no s/s (signs/symptoms) of infection . R #8's Weekly Skin Integrity Review Sheet (side two- signed by Treatment Nurse/LVN B) documented 10/23/15: Skin Condition: Other: Stage II left Ischium. No other documentation was completed in this section of the block. R #8's October 2015 Ulcers, Surgical Site Treatment and Progress Record- Side Two documented a subsequent entry (after 10/14/15 entry) dated 10/23/15 (signed by Treatment Nurse/LVN B revealed NPAP Stage: Stage II. L= 2.3, W= 1.6 cm. No documentation was provided under D. Th

Based on observation, interview and record review, the facility failed to implement their written policy and procedure that prohibits neglect for two Residents (R #4 and R #8) of 17 Residents reviewed for neglect. -R#4 was admitted to the facility without a pressure ulcer and developed a pressure ulcer after admission to the facility. The facility did not accurately identify, stage, and document R #4's pressure ulcer, that worsened and was then identified as an unstageable. The facility did not reassess or update R #4's Braden Scale Risk Assessments for predicting pressure ulcers. -R#8 developed a pressure ulcer four months after admission to the facility. The facility did not accurately identify, stage, and document R #8's pressure ulcer, that worsened to a Stage IV with tunneling.The facility did not reassess or update R #8's Braden Scale Risk Assessments for predicting pressure ulcers. -R #4 and R #8's documentation of their Pressure Ulcers contained some ommited information, inconsistent, and contradicting staging and description of their wounds, from document to document. These failures of developing/worsening of pressure ulcers in the facility, correctly identifying/assessing, documenting, and treating pressure ulcers resulted in an Immediate Jeopardy (IJ) situation on 02/25/16. While the IJ was removed on 02/26/16, the facility remained out of compliance at a potential for more than minimal harm with a scope identified as pattern. The facility was continuing to monitor to ensure continued implementation of their plan of removal. This deficient practice could place 16 residents with pressure ulcers and 31 residents receiving preventative skin care at risk of skin breakdown or worsening of pressure ulcers, due to not receiving accurate assessments, care, and services needed to prevent delay in treatment, complications, hospitalization , and neglect from the facility to not provide goods and services necessary to avoid physical harm, mental anguish or mental illness. The findings included: The facility's Reports of Abuse, Neglect, and Exploitation of Residents of Certain Facilities Chapter 260A.001 documented Neglect means the failure to provide for the goods or services, including medical services, which are necessary to avoid physical or emotional harm or pain or the failure of a caregiver to provide such goods or services . The facility's Abuse Prohibition Policy and Procedure dated 05/01/09 documented Each resident has the right to be free from mistreatment, neglect . According to the facility's undated Treatment Nurse Job Description: Essential Functions: -Must have working knowledge of the basic principles of infection control and wound care . -Provides wound care and assessing for appropriateness of treatment and bandage integrity during time between dressing changes . -Provide weekly documentation; -Complies with facility guidelines for documentation and physician's orders [REDACTED]. -Identifies potential problems/issues and reports to supervisor in a timely manner . -Records vital signs, notes changes, and pursues more-specific investigation as needed. -Assesses for and notifies physician and other appropriate parties of changes in condition . -Supports standards of nursing care through adherence to existing policies and procedures -Uses tactful, appropriate communications in sensitive and emotional situations . Record Review of the facility's Skin Management System revised 10/2015 documented: 1. A head to toe body evaluation will be completed on every resident upon admission or readmission and weekly thereafter. These evaluations will be documented on the Weekly Skin Integrity Review form or EMR (Electronic Medical Record). If skin is intact, no further action is required. If skin is compromised, proceed to the appropriate form below. A. Pressure Ulcers, Venous Ulcers and Arterial Ulcers, and surgical sites will be documented on the Ulcer, Surgical Site Treatment and Progress Record or EMR. Use one form per wound. Wound progress is to be documented each week with measurements and wound descriptions. Daily treatments are also documented on the same form. I. treatment for [REDACTED]. .c. Keep open lines of communication with physicians, families, and residents regarding status of wounds. d. Responsible Party will be notified at the onset of an identified area as well as with all treatment changes, decline in the status of the area, and when the area is healed. Documentation of the notification is to be in the Nurses Notes in the clinical record or EMR. II. Progress of the identified area, will be documented on the back of the Ulcer, Surgical Site Treatment and Progress Record form at least every 7 days, or less if the wound shows a decline or is healed. The Physician is to be contacted after 14 days if the area has not shown improvement or immediately if it shows a decline. Documentation of the Physician notification is to be in the Nurses Notes in the chart or EMR 2. Routine weekly checks will be completed on every resident; if skin is intact it will be noted as such. If a new pressure ulcer is noted, a Ulcer, Surgical Site Treatment and Progress Record form will be started . B. CNA's (Certified Nurse Aides) will note any alteration in skin integrity during routine care on the Skin Care Alert form or EMR and turn in/reported to the Charge Nurse responsible for the resident at the time, for their attention 3. Braden Scale will be completed upon admission, with change of condition, and quarter on the Braden Scale form or the EMR . 4. Refer to Protocol for Pressure Ulcers by AMT, and/or AMT binder, for assistance with wound identification, staging, and recommended treatments. Contact physician for treatment recommendation approval . 8. Facility DON's are responsible to establish a system to monitor and assure Skin Management System Compliance. The facility's undated Protocol for Pressure Ulcers by AMT form documented: -Stage II Pressure Ulcer: Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough. May also present as an intact or open/ruptured serum-filled blister. Presents as a shiny or dry shallow ulcer without slough or bruising. This stage should not be used to describe skin tears, tape burns, perineal [MEDICAL CONDITION], maceration or excoriation. *Focus on pressure reduction . - Stage III Pressure Ulcer: Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling. Further description: The depth varies by anatomical location. Some locations do not have subcutaneous tissue and these stage III ulcers can be shallow. Bone/tendon is not visible or directly palpable. *Focus on pressure reduction . -Stage IV Pressure Ulcer: Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often include undermining and tunneling. The depth varies by anatomical location. Some locations do not have subcutaneous tissue and these stage IV ulcers can be shallow . According to NPUAP's Ostomy Wound Management dated 02/2011 at www.o-wm.com: Long Term Care: -Unavoidable means that the individual developed a pressure ulcer even though the facility had evaluated the individual's clinical condition and pressure ulcer's risk factors; defined and implemented interventions that are consistent with individual needs, goals, and recognized standards of practice; monitored and evaluated the impact of the interventions; and revised the approaches as appropriate. -Avoidable: An avoidable pressure ulcer can develop when the provider did not do one or more of the following: evaluate the individual's clinical condition and pressure ulcer risk factors; define and implement interventions consistent with individual needs, individual goals, and recognized standards of practice; monitor and evaluate the impact of the interventions; or revise the interventions as appropriate . According to the Texas Board of Nursing at www.bon.texas.gov/practice: Documentation: After assessment of the resident is completed and appropriate interventions are taken, documentation of the circumstances and the assessment of the resident in the resident record are a requirement. The rules of the BON establish legal documentation standards, (BON Standards of Nursing Practice, 22 TAC §217.11 (1)(D)). Examples of important documentation elements include: · Description of the discovery of the resident · Any treatment of [REDACTED]. · The findings for each of the assessment elements outlined in the standards · All individuals notified of the resident's status (e.g., 9-1-1, the health care provider, the administrator of the facility, family, etc.) · Any directions that were provided to staff or others during the assessment and/or treatment of [REDACTED].>· The results of any communications. Documentation should be adequate to give a clear picture of the situation and all of the actions that were taken or not taken on behalf of the resident. The LVN accurately reports and documents the assessment information and changes in patient conditions to an appropriate clinical supervisor . The findings included: R #4: R #4's Face Sheet dated 02/25/16 documented an [AGE] year-old female admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. R #4's Admission Nursing Evaluation dated 08/20/15 documented General Skin Condition: dry and warm. The form indicated Skin Condition (if checked, further evaluation required per facility policy. Indicate below all body marks such as pressure ulcers, abrasions, bruises, soft heels, moles, skin tears, cancer [MEDICAL CONDITION], oozing, surgical wounds and scars. Indicate location, size, depth (cm (centimeter)) color, and drainage. A circle was drawn on the middle right of the buttocks with area written beside it. There was no detail information documented about the area. R #4's Telephone Physician Order, Treatment Record, and Progress Note dated 09/26/15 revealed R #4's Stage II pressure Ulcer was resolved and treatment was discontinued. R #4's Braden Scale for Predicting Pressure Ulcer Risk Form indicated To be completed upon admission, weekly X3, then quarterly and PRN (as needed). -Evaluation Date: 09/09/15, Total Score: 17; -Evaluation Date: 12/31/15, Total Score: 20; -Evaluation Date: 01/27/16, Total Score: 19; Total Score Key: equal to or less than 9= Very High Risk; 10-12= High Risk; Moderate Risk= 13-14, and At Risk= 15-18. There were no other Braden Assessments in R #4's clinical record. R #4's Care Plans revised 12/31/15 included: -(R #4) has the potential for impaired skin integrity related to periods of incontinence, and end of life. Goal: (R #4) will maintain intact skin through the next review date. (R #4) will have a resolved current wound X 90 days; Current Stage II to coccyx- 02/16/16. Approaches: Check q (every) 2 hours for incontinence and provide cleansing as needed; Turn and reposition q 2 hours; Monitor skin during shower and report abnormalities to MD (Medical Doctor); Wheelchair cushion; Encourage to lay down in bed for pressure relief; Treatment as ordered; Notify physician if treatment not effective. R #4's Quarterly Minimum Data Set ((MDS) dated [DATE] documented R #4: -Had clear speech, made self understood, and understood others- clear comprehension; -Brief Interview of Mental Status (BIMS) score was 8. R #4 could recall after cueing. -Behaviors not exhibited; -Required supervision with one person physical assistance for bed mobility, transfers, dressing, eating, locomotion on and off unit, personal hygiene, and bathing. -Range of Motion: upper extremity- no impairment; lower extremity- no impairment; -Mobility Devices: wheelchair; -Was occasionally (less than 7 episodes of incontinence) incontinent of urine and always incontinent of bowel; -Height: 56 inches. Weight- 82 pounds. No or unknown weight loss or gain; -At risk of developing pressure ulcer: No; No pressure ulcers. R #4's February 2016 Consolidated physician's orders [REDACTED].>- Hospice services as of 08/11/15, Dx: Neoplasm of the bone, [DIAGNOSES REDACTED], and Dementia. R #4's Progress Note dated 02/01/16 documented Called into room per RP (responsible party) states pt (patient) c/o (complains of) pain to buttocks and noted open area to coccyx. Assess approximately 1 cm X 1 cm diameter Stage II to coccyx. N.O. (new order) with treatment with cleanse with NS (Normal Saline) pat dry with gauze. Covered with Duoderm ([MEDICATION NAME] dressing is a wafer type of dressing that contains gel-forming agents in an adhesive compound laminated onto a flexible, water-resistant outer layer). To be changed q 2 days and PRN . R #4's Immediate Needs Care Plan: Pressure Ulcer dated 02/01/16 documented Location: Coccyx. Strength to draw from: Able to communicate needs and able to follow directions. Goals: Ulcers will be healed without complication, Surface area will decrease. Interventions: Wound Status: size of wound: measurements of depth and width, skin color, surrounding skin tissue assessments weekly; Complaints of pain, effectiveness of pain medication per order; Apply dressing per Order; Note old dressing for any signs of exudate. Assess color and amount if present; Be alert to any signs of infection: drainage, odor, redness of surrounding tissue, red streaking up the extremity. Treatment changed 02/02/16 to Xeroform. R #4's February 2016 Ulcers, Surgical Site Treatment and Progress Record- Side One documented Discovered 02/01/16, Diagnosis/Stage: Stage II. Order Date: 02/02/16. Treatment: Coccyx- Cleanse with NS pat dry apply Xeroform cover with foam dressing change QD and PRN. From 02/02/16-02/24/16, the following was documented: -Drainage: M -General Appearance: R -Surrounding Skin: N . According to the Drainage Key on this form M = moist, General Appearance Key: R= red, P = pink, W= white; and Surrounding Skin Key: N = normal. R #4's February 2016 Ulcers, Surgical Site Treatment and Progress Record- Side Two documented NPUAP Stages For Pressure Ulcers: - .Stage 2: Partial thickness loss of dermis presenting as a shallow open ulcer with red pink wound bed, without slough. May also present as an intact or open/ruptured serum-filled blister. - Stage 3: Broken skin, deep tissue involvement. Full thickness wound. -Stage 4: Broken skin through all layers of tissue, including muscle, tendon or bone. Full thickness wound. -Unstageable: Full thickness loss in which the base of the ulcer is covered by slough (yellow, tan, grey, green or brown), and/or eschar (tan, brown or black) in the wound bed. -Partial thickness wound (PTW): Loss of epidermis and partial loss of dermis. -Full thickness Wound (FTW): Tissue destruction extending through the dermis and involving the subcutaneous layer. May involve muscle or bone. Date: 02/02/16 NPUAP Stage: Stage II L (length)= 0.5, W= 0.6 (width), D (depth)= 0.1 The same section of the form documenting Undermining, Tunneling Depth, Process: Yes or No boxes for: Granulation, Decreased Size, Decreased Depth, Decreased Drainage; were blank. R #4's Telephone Orders dated 02/02/16 documented Cleanse Stage II coccyx with NS pat dry apply Xeroform cover with foam dressing, change QD (every day) and PRN. R #4's Weekly Skin Integrity Review Sheet dated 02/03/16 documented Stage II. An X was drawn just above the horizontal gluteal crease. No other documentation was provided of this assessment except for Treatment Nurse/LVN B's signature. R #4's February 2016 Ulcers, Surgical Site Treatment and Progress Record- Side Two documented 02/09/16 NPUAP Stage: (no stage documented), L= 0.5, W= 0.5, D= 0.1 cm. No other documentation or detail was documented. R #4's Weekly Skin Integrity Review Sheet dated 02/10/16 documented Stage II. An X was drawn just above the horizontal gluteal crease. No other documentation was provided of this assessment except for Treatment Nurse/LVN B's signature. R #4's Nurse's Notes dated 02/10/16 (no time documented) documented Stage II coccyx 0.5 X 0.5 X 0.1 cm (centimeter). Wound bed is granulated tissue, scant amount of serous (a thin watery liquid) drainage, wound edges are attached peri-wound is clean, pt denies any pain, continue current treatment as ordered. R #4's Nurse's Notes dated 02/16/16 (no time documented) documented Stage II coccyx 0.8 X 0.8 X 0.1, wound base is granulated tissue, scant amounts of serous drainage, no odor, continue current treatment. R #4's Weekly Skin Integrity Review Sheet dated 02/17/16 had no documentation of the assessment except for Treatment Nurse/LVN B's signature. R #4's February 2016 Ulcers, Surgical Site Treatment and Progress Record- Side Two documented 02/17/16 NPUAP Stage: (no stage documented), L= 0.8, W= 0.8, D= 0.1 cm. No other documentation or detail was documented. R #4's February 2016 Ulcers, Surgical Site Treatment and Progress Record- Side Two documented 02/24/16 NPUAP Stage: Stage II, L= 0.8, W= 0.5, D=0.1 cm and L= 0.8, W= 0.8, D= 0.1 cm. There were two different measurements of the same wound. No other documentation or detail was documented. R #4's Nurse's Notes dated 02/24/16 (no time documented) documented Wound to coccyx 0.8 X 0.8 X 0.1 cm wound base has granulated tissue with area of white to 12 o'clock area, wound has moderate serous drainage, peri-wound has blanchable redness, spoke to (physician) for coordination of care, doctor saw pts wound, doctor stated to continue current orders of Xeroform and wait to change anything until (Wound Care Specialist) next visit, this nurse requested if we could start Santyl with Xeroform, doctor stated no, wait for (Wound Care Specialist), but he started [MEDICATION NAME] (antibiotic) 500 mg (milligrams) BID (twice a day) X 7 days, no s/s (signs/symptoms) of infection however blanchable redness in peri-wound no change in size of wound remains on wheelchair cushion and has a foam preventative matress to the bed. Pt has episodes of incontinence. Incontinent care provided . R #4's Nurse's Notes dated 02/24/16 (no time documented) documented Received new orders from doctor, 1.) low air loss mattress, 2.) Multivitamin QD, 3.) Stress tab with Zinc 1 tablet BID X 10 days, spoke to hospice nurse on changing pt wheelchair cushion, hospice nurse stated they would order a new cushion . On 02/24/16 at 11:00 a.m., review of R #4's Telephone Physician order [REDACTED].#4's Telephone Orders dated 02/02/16 documented Cleanse Stage II coccyx with NS pat dry apply Xeroform cover with foam dressing, change QD and PRN. There was no proceeding order as of this date on the sheet at the time the copy was made. On 02/24/16 at 2:09 p.m., this surveyor accompanied Treatment Nurse/LVN B to R #4's room. As Treatment Nurse/LVN B prepared her supplies for wound care, she stated (R #4) has a Stage II to her coccyx and it is cleaned daily. It last measured 0.8 X 0.8 X 0.1 cm. I cleanse with wound cleanser, place a piece of Xeroform, and cover with Foam dressing. As of yesterday, the wound looked pink with a couple of small spots of white in the center of the wound. There is a little depth. Treatment Nurse/LVN B removed R #4's dressing on her coccyx and this surveyor saw a wound approximately the diameter of a dime with some depth. The wound bed had pink and white with yellow/tan pinpoint specks of tissue in the wound. There was no odor and the old dressing had serous drainage. There was reddness surrounding the wound. The Treatment Nurse/LVN B measured the wound and stated outloud 1 X 1 X 0.1 cm., it looks like it has a little more white today. The Treatment Nurse/LVN B again stated the wound was a Stage II Pressure Ulcer acquired in-house. The Treatment Nurse/LVN B said R #4's physician saw the wound this morning and the physician did not want to change anything until (wound specialist) was told of the wound but he will not be here until next week because he is on vacation. I called the hospice nurse for approval for an air mattress. On 02/24/16 at 2:40 p.m., this surveyor accompanied the Treatment Nurse/LVN B and the Director of Nurses (DON) to view R #4's pressure ulcer. While walking to R #4's room, the DON stated I am not good at staging ulcers. Pressure ulcers are my weak point, the staging is confusing to me. I recognize Stage I and I know a Stage IV involves the bone and muscle. The Stage II and III's is where I have trouble. The DON read outloud the NPUAP Stages For Pressure Ulcers off of R #4's February 2016 Ulcers, Surgical Site Treatment and Progress Record- Side Two. The DON confirmed the facility used the NPUAP Stages for Pressure Ulcers as a reference tool in staging ulcers. The DON looked at R #4's wound and stated I would have to say and agree with the Treatment Nurse that it is a Stage II, because she is more educated in this than I am. I see pink with a couple of white small spots with a small amount of drainage and a little depth. Interview with R #4's Physician on 02/24/16 at 3:38 p.m. revealed Yes, I saw the wound. When I saw her wound this morning, I did not see slough or anything. I am not a wound doctor. I don't know how to stage wounds or the correct treatment for [REDACTED]. I rely on the wound nurse and wound doctor's recommendations because they are more educated on wounds than I am. The nurse said she was going to ask the wound doctor about the wound next week because he is on vacation, or something like that. I'm treating her for infection of the wound, I ordered antibiotics. No, I don't know what infection she has; no culture has been taken. On 02/24/16 at 4:21 p.m., this surveyor accompanied Director of Clinical Operations (DCO) and the Division Clinical Vice President (DVP) to R #4's room to observe R #4's pressure ulcer. The DCO stated outloud I see a clean open wound with white area and some pink in the center of the wound. I agree there is a Stage II there. Interview with R #4's Hospice Registered Nurse (RN) G on 02/24/16 at 4:38 p.m. revealed she had not seen R #4's pressure ulcer since last week. RN G said last week she had seen the wound to be an open rounded wound with slough and some serous drainage. The Treatment Nurse staged it as a Stage II but I don't think it was a Stage II due to the slough. To me, the ulcer was a Stage III, because of the slough and it was getting deeper. The Treatment Nurse told me the specialist was going to see (R #4) next week because he was on vacation this week. RN G said she did not recall seeing an order to consult the wound specialist as of 02/22/16, I assumed (R #4's) physician spoke to the specialist, directly. I went ahead and ordered (R #4) an air mattress today because she is so thin and bony and any pressure could easily worsen her wound, which we see has happened. On 02/25/16 at 10:05 a.m., this surveyor accompanied the Treatment Nurse/LVN B to R #4's room and observed wound care. R #4's wound had more white and yellow tissue in the center of the wound with moderate serous drainage, redness, and maceration (softening and breaking down of skin resulting from prolonged exposure to moisture) surrounding the ulcer.The Treatment Nurse/LVN B (accompanied by the DVP) stated she called R #4's physician and got an order to change the treatment to the ulcer. The Treatment Nurse/LVN B said she had a conference call with the American Medical Technology (AMT) Representative Consultant and all were in agreement (R #4's) ulcer was an unstageable ulcer because we can't see the wound base due to it being covered with white tissue, we all agreed to use Santyl. I told (the physician) the white tissue from yesterday increased and there was redness around the wound bed. I agreed with you yesterday that the wound had worsen but after I spoke to the doctor yesterday morning he did not want to make any changes because he wanted to wait for the specialist recommendations; I just didn't want to undermine his authority. I should have just told you yesterday that it was no longer a Stage II. On 02/25/16 at 11:00 a.m., interview with the DCO, DVP, and the Administrator accompanied the Treatment Nurse/LVN B and the DON to the facility's conference room for an interview. The DON explained the facility no longer had policy and procedures and provided a copy of the facility's Skin Management Systems revised 10/2015 that took the place of the policy and procedure. The DON stated the facility also used the Perry and Potters' Clinical Nursing Skills and Techniques 8th Edition Manual for clinical resources as a reference. The Treatment Nurse/LVN B confirmed R #4 did not have current Braden assessment and should have had one when her pressure ulcer was found on 02/01/16. I forgot to do it. The Treatment Nurse/LVN B reviewed R #4's most recent Ulcers, Surgical Site Treatment and Progress Record and confirmed she documented incorrectly by not documenting there was white and yellow tissue in the wound on 02/23/16 and 02/24/16. At this time the Treatment Nurse/LVN B agreed she should have documented her exact observation of R #4's wound on 02/23/16 and 02/24/16. The Treatment Nurse/LVN B said she did not call R #4's physician on 02/23/16 when she first saw a change (white tissue) in R #4's ulcer. The DON interrupted and said yes there was a change in the ulcer then the Treatment Nurse/LVN B abruptly stood up and walked out of the room. At 1:15 p.m., the interview continued, Treatment Nurse/LVN B said she could not recall R #4's wound having a change or having white tissue in the ulcer on 02/23/16. The Treatment Nurse/LVN B said I know there was white in the wound on 02/24/16 when I first treated it in the morning. No, I did not document it. I do not remember telling you the ulcer changed on 02/23/16. This surveyor read outloud to the Treatment Nurse/LVN B her statement on 02/24/16 at 2:09 p.m. the Treatment Nurse/LVN B said oh, I don't remember that. The DON said If an assessment or documentation is inaccurate, it can effect the wound and maintenance of continuity of care. The DON confirmed each form should be completed to it's entirty, if not document the reason why. On 02/25/16 at 4:50 p.m., this surveyor reviewed R #4's updated Telephone Physician order [REDACTED]. (evaluate) and treat dated 02/19/16. R #8: R #8's Face Sheet dated 01/27/16 revealed R #8 was a [AGE] year-old female admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. R #8's Braden Scale for Predicting Pressure Sore Risk dated 06/09/15 documented a total score of 13. *R #8 did not have any other Braden Scale assessments in her closed clinical record. R #8's Admission Nursing Evaluation dated 06/09/15 documented R #8 had an open area to right buttock- 2 in (inch) X 2 in and left buttock less than 1 in X 1 in. R #8's MDS dated [DATE] documented R #8: -Had clear speech, made self understood, and understood others- clear comprehension; -BIMS score was 5. R #8 could not recall. -Behaviors not exhibited; -Required extensive assistance with one or two person physical assistance for bed mobility, dressing, and eating. R #8 was totally dependent with one or two person physical assistance for transfers, locomotion on and off unit, personal hygiene, and bathing; -Range of Motion: upper extremity- no impairment; lower extremity- impairment on one side; -Mobility Devices: wheelchair; -Was always incontinent of urine and bowel; -Height: 63 inches. Weight- 100 pounds. No or unknown weight loss or gain; -At risk of developing pressure ulcer. Resident has Stage 1 or higher pressure ulcer (One Stage 2). One Stage 2 Pressure Ulcer present on admit/reentry. Tissue type of ulcer at most advances stage: [MEDICATION NAME] tissue- new skin growing in superficial ulcer. It can be light pink and shiny . R #8's Telephone Physician order [REDACTED]. Resolved Stage II. R #8's Nurse's Treatment Notes dated 10/03/15 documented 10/03/15 8:45 p.m., Initials: (LVN A's initials), Treatment: Left Ischium (the curved bone forming the base of each half of the pelvis), Reason/Remarks: Stage II to Left Ischium at 0.7 X 0.9 X 0.1 cm with pink moist wound bed and [DIAGNOSES REDACTED] to peri-wound. Initiated tx (treatment). Doctor .notified. *There was no Weekly Skin Integrity Review Sheet or October 2015 Wound Treatment and Progress Record or Ulcers, Surgical Site Treatment and Progress Record that documented the discovery or details of R #8's Left Ischium Stage II Pressure Ulcer found anywhere in R #8's clinical record. R #8's Telephone Physician order [REDACTED]. Secure with clear tape q 2 days and PRN. R #8's Weekly Skin Integrity Review Sheet (side two- signed by Treatment Nurse/LVN B) documented 10/05/15: Skin Condition: Skin Intact. No other documentation was completed in this section of the block. R #8's Telephone Physician order [REDACTED]. Pat dry, apply Duoderm, secure with clear tape q 2 days and PRN. Dx (diagnosis): Stage II left Ischium. R #8's Progress Notes dated 10/10/15 (signed by LVN A) documented Stage II to Left Ischium 0.7 X 0.9 X 0.1 cm with errythema to peri-wound. No tenderness . R #8's October 2015 Ulcers, Surgical Site Treatment and Progress Record- Side One documented Discovery: 10/10/15 Diagnosis: [REDACTED]. 10/10/15: Treatment: Duoderm with clear tape q 2 days and PRN; Hour: Days, Noon, Evenings. -Drainage: M -General Appearance: P -Surrounding Skin: N -Initials: (LVN A's initials) R #8's October 2015 Ulcers, Surgical Site Treatment and Progress Record-Side Two documented: Date: 10/10/15 (signed by LVN A) documented NPUAP Stage: Stage II. L- 0.7, W- 0.9, D- 0.1 cm. Additional documentation: Redness to peri-wound, no tenderness. *The same section of the form provided area for documentation under Undermining, Tunneling Depth, Process: Yes or No boxes for: Granulation, Decreased Size, Decreased Depth, Decreased Drainage; No documentation was completed in these areas of the form. R #8's Weekly Skin Integrity Review Sheet (side two- signed by LVN A) documented 10/10/15: Skin Condition: Other: Stage II left Ischium, Open Area: New. No other documentation was completed in this section of the block. R #8's Immediate Needs Care Plan: Pressure Ulcer(s) dated 10/10/15 documented: Problem/Need related to: Immobility. Resulting in location: Stage II Left Ischium. Strength to draw from: Able to communicate Needs and able to follow directions. Goals: Ulcers will be healed without complication. Interventions: Wound Status: sixe of wound: measurements of depth and width, skin color, surrounding skin tissue assessments weekly; Complaints of pain, effectiveness of pain medication per order .; Apply medicated ointment per order; Apply dressing per Order; Be alert to any signs of infection: drainage, odor, redness of surrounding tissue, red streaking up the extremity. *This form was signed by Treatment Nurse/LVN B. No other input was documented on this document. A separate and additional Pressure Ulcer Care Plan dated 10/10/15 documented Problem:

Based on observation, interview, and record review, LVN B failed to provide services that met professional standards of quality for three Residents (R #4, R #8 and R #1) of 19 residents reviewed for quality of care. LVN B did not accurately document R #4 and R#8's Pressure Ulcer assessments. LVN B omitted some information, had inconsistent, and contradicting staging and description of their wounds, from document to document. The facility did not consult with R #1's Physician regarding R #1's urinary catheter care and maintenance when R #1 developed a urinary tract infection [MEDICAL CONDITION]. The facility did not obtain complete Physician order [REDACTED].#1. This deficient practice could place 16 residents with pressure ulcers and 31 residents receiving preventative skin care, at risk of skin breakdown or worsening of pressure ulcers and three residents with foley catheters at risk for complications, due to not receiving accurate assessments, care, and services needed to prevent delay in treatment, complications, hospitalization , and a decreased quality of life. The findings included: Texas Administrative Code, Title 22, Part 11, Chapter 217, Standards of Nursing Practice: 217.11 The Texas Board of Nursing is responsible for regulating the practice of nursing within the State of Texas for Vocational Nurses, Registered Nurses, and Registered Nurses with advanced practice authorization. The standards of practice establish a minimum acceptable level of nursing practice in any setting for each level of nursing licensure or advanced practice authorization. Failure to meet these standards may result in action against the nurse's license even if no actual patient injury resulted. (1) Standards Applicable to All Nurses. All vocational nurses, registered nurses and registered nurses with advanced practice authorization shall: (A) Know and conform to the Texas Nursing Practice Act and the board's rules and regulations as well as all federal, state, or local laws, rules or regulations affecting the nurse's current area of nursing practice; (B) Implement measures to promote a safe environment for clients and others; (C) Know the rationale for and the effects of medications and treatments and shall correctly administer the same; . (D) Accurately and completely report and document: (i) the client's status including signs and symptoms; .(iv) administration of medications and treatments; (v) client response(s); and (vi) contacts with other health care team members concerning significant events regarding client's status; . (N) Clarify any order or treatment regimen that the nurse has reason to believe is inaccurate, non-efficacious or contraindicated by consulting with the appropriate licensed practitioner and notifying the ordering practitioner when the nurse makes the decision not to administer the medication or treatment; . 217.12. Unprofessional Conduct. The unprofessional conduct rules are intended to protect clients and the public from incompetent, unethical, or illegal conduct of licensees. The purpose of these rules is to identify unprofessional or dishonorable behaviors of a nurse which the board believes are likely to deceive, defraud, or injure clients or the public. Actual injury to a client need not be established. These behaviors include but are not limited to: (1) Unsafe Practice - actions or conduct including, but not limited to: (A) Carelessly failing, repeatedly failing, or exhibiting an inability to perform vocational, registered or advanced practice nursing in conformity with the standards of minimum acceptable level of nursing practice set out in Rule 217.11; (B) Carelessly or repeatedly failing to conform to generally accepted nursing standards in applicable practice settings; . (2) Failure of a chief administrative nurse to follow appropriate and recognized standards and guidelines in providing oversight of the nursing organization and nursing services for which the nurse is administratively responsible . (4) Careless or repetitive conduct that may endanger a client's life, health, or safety. Actual injury to a client need not be established The Texas Occupations Code and Statutes Regulating the Practice of Nursing as Amended September 2009 revealed the following: The Texas Board of Nursing is responsible for regulating the practice of nursing within the State of Texas for Vocational Nurses, Registered Nurses, and Registered Nurses with advanced practice authorization. The standards of practice establish a minimum acceptable level of nursing practice in any setting for each level of nursing licensure or advanced practice authorization. Failure to meet these standards may result in action against the nurse's license even if no actual patient injury resulted. (1) Standards Applicable to All Nurses. All vocational nurses, registered nurses and registered nurses with advanced practice authorization shall: (C) Know the rationale for and the effects of medications and treatments and shall correctly administer the same; (D) Accurately and completely report and document; (G) Obtain instruction and supervision as necessary when implementing nursing procedures or practices . (R) Be responsible for one's own continuing competence in nursing practice and individual professional growth; According to the Texas Board of Nursing at www.bon.texas.gov/practice: Documentation: After assessment of the resident is completed and appropriate interventions are taken, documentation of the circumstances and the assessment of the resident in the resident record are a requirement. The rules of the BON establish legal documentation standards, (BON Standards of Nursing Practice, 22 TAC §217.11 (1)(D)). Examples of important documentation elements include: · Description of the discovery of the resident · Any treatment of [REDACTED]. · The findings for each of the assessment elements outlined in the standards · All individuals notified of the resident's status (e.g., 9-1-1, the health care provider, the administrator of the facility, family, etc.) · Any directions that were provided to staff or others during the assessment and/or treatment of [REDACTED].>· The results of any communications. Documentation should be adequate to give a clear picture of the situation and all of the actions that were taken or not taken on behalf of the resident. The LVN accurately reports and documents the assessment information and changes in patient conditions to an appropriate clinical supervisor . According to the facility's undated Treatment Nurse Job Description: Essential Functions: -Must have working knowledge of the basic principles of infection control and wound care . -Provides wound care and assessing for appropriateness of treatment and bandage integrity during time between dressing changes . -Provide weekly documentation; -Complies with facility guidelines for documentation and physician's orders [REDACTED]. -Identifies potential problems/issues and reports to supervisor in a timely manner . -Records vital signs, notes changes, and pursues more-specific investigation as needed. -Assesses for and notifies physician and other appropriate parties of changes in condition . -Supports standards of nursing care through adherence to existing policies and procedures -Uses tactful, appropriate communications in sensitive and emotional situations . According to the facility's Perry and Potters' Clinical Nursing Skills and Techniques 8th Edition Manual, Pressure Ulcers: .6. Assess patient's using wound parameters, and continue ongoing wound assessment per agency policy . a. Wound location: Describe the body site where the wound is located. b. Stage of wound: Describe the extent of tissue destruction. Staging is a way of assessing a pressure ulcer based on depth of tissue destruction. Wounds are documented as unstageable if the wound base is not visible. c. Wound size: Length, width, and depth of the wound are measured per agency protocol .Ulcer size changes as healing progresses; therefore the longer and widest areas of the wound change over time. Measuring the width and length by measuring consistent areas provides a consistent measurement. d. Presence of undermining, sinus tract, or tunnels: Use a sterile cotton-tipped applicator to measure depth and, if needed, a gloved finger to examine the wound edges. Wound depth determines amount of tissue loss. e. Condition of wound bed: Describe the type and percentage of tissue in the wound bed. The approximate percentage of each type of tissue in the wound healing and the choice of dressing. A wound with a high percentage of black tissue requires debridement, yellow tissue or slough tissue may indicate the presence of an infection or colonization, and granulation tissue indicates that a wound is moving towards healing. f. Volume of exudate: Describe the amount, characteristics, odor, and color. g. Condition of periwound skin: Examine the skin for breaks, dryness, and the presence of a rash, swelling, redness, or warmth. Modify assessment based on patient's skin color. Impaired skin condition at the edge of an ulcer indicates progressive tissue damage. Maceration on periwound skin shows a need to alter the choice of wound dressing. h. Wound edges: Gives information regarding [MEDICATION NAME]. chronicity, and etiology . According to Lippincott's Nursing Procedures Sixth Edition 2013, pp 230; Documentation is the process of preparing a complete record of a patient's care and is a vital tool for communication among health care team members. Accurate, detailed charting shows the extent and quality of care that nurses provide the outcomes of that care, and treatment and education that the patient still needs. Thorough, accurate documentation decreases the potential for miscommunication and errors. Review of Perry and Potter Clinical Nursing Skills and Techniques 8th edition in reference for catheter care, there was no mention of obtaining complete orders for catheter care. According to the CDC Guideline for Prevention of Catheter-Associated Urinary Tract Infections 2009 .pg.13 E. Changing indwelling catheters or drainage bags at routine intervals is not recommended. Rather, it is suggested to change catheters and drainage bags based on clinical indications such as infection, obstruction, or when the closed system is compromised. (Category II) . R #4: R #4's Face Sheet dated 02/25/16 documented an [AGE] year-old female admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. R #4's Admission Nursing Evaluation dated 08/20/15 documented General Skin Condition: dry and warm. The form indicated Skin Condition (if checked, further evaluation required per facility policy. Indicate below all body marks such as pressure ulcers, abrasions, bruises, soft heels, moles, skin tears, cancer [MEDICAL CONDITION], oozing, surgical wounds and scars. Indicate location, size, depth (cm (centimeter)) color, and drainage. A circle was drawn on the middle right of the buttocks with area written beside it. There was no detail information documented about the area. R #4's Telephone Physician Order, Treatment Record, and Progress Note dated 09/26/15 revealed R #4's Stage II pressure Ulcer was resolved and treatment was discontinued. R #4's Braden Scale for Predicting Pressure Ulcer Risk Form indicated To be completed upon admission, weekly X3, then quarterly and PRN (as needed). -Evaluation Date: 09/09/15, Total Score: 17; -Evaluation Date: 12/31/15, Total Score: 20; -Evaluation Date: 01/27/16, Total Score: 19; Total Score Key: equal to or less than 9= Very High Risk; 10-12= High Risk; Moderate Risk= 13-14, and At Risk= 15-18. There were no other Braden Assessments in R #4's clinical record. R #4's Care Plans revised 12/31/15 included: -(R #4) has the potential for impaired skin integrity related to periods of incontinence, and end of life. Goal: (R #4) will maintain intact skin through the next review date. (R #4) will have a resolved current wound X 90 days; Current Stage II to coccyx- 02/16/16. Approaches: Check q (every) 2 hours for incontinence and provide cleansing as needed; Turn and reposition q 2 hours; Monitor skin during shower and report abnormalities to MD (Medical Doctor); Wheelchair cushion; Encourage to lay down in bed for pressure relief; Treatment as ordered; Notify physician if treatment not effective. R #4's Quarterly Minimum Data Set ((MDS) dated [DATE] documented R #4: -Had clear speech, made self understood, and understood others- clear comprehension; -Brief Interview of Mental Status (BIMS) score was 8. R #4 could recall after cueing. -Behaviors not exhibited; -Required supervision with one person physical assistance for bed mobility, transfers, dressing, eating, locomotion on and off unit, personal hygiene, and bathing. -Range of Motion: upper extremity- no impairment; lower extremity- no impairment; -Mobility Devices: wheelchair; -Was occasionally (less than 7 episodes of incontinence) incontinent of urine and always incontinent of bowel; -Height: 56 inches. Weight- 82 pounds. No or unknown weight loss or gain; -At risk of developing pressure ulcer: No; No pressure ulcers. R #4's February 2016 Consolidated physician's orders [REDACTED].>- Hospice services as of 08/11/15, Dx: Neoplasm of the bone, [DIAGNOSES REDACTED], and Dementia. R #4's Progress Note dated 02/01/16 documented Called into room per RP (responsible party) states pt (patient) c/o (complains of) pain to buttocks and noted open area to coccyx. Assess approximately 1 cm X 1 cm diameter Stage II to coccyx. N.O. (new order) with treatment with cleanse with NS (Normal Saline) pat dry with gauze. Covered with Duoderm ([MEDICATION NAME] dressing is a wafer type of dressing that contains gel-forming agents in an adhesive compound laminated onto a flexible, water-resistant outer layer). To be changed q 2 days and PRN . R #4's Immediate Needs Care Plan: Pressure Ulcer dated 02/01/16 documented Location: Coccyx. Strength to draw from: Able to communicate needs and able to follow directions. Goals: Ulcers will be healed without complication, Surface area will decrease. Interventions: Wound Status: size of wound: measurements of depth and width, skin color, surrounding skin tissue assessments weekly; Complaints of pain, effectiveness of pain medication per order; Apply dressing per Order; Note old dressing for any signs of exudate. Assess color and amount if present; Be alert to any signs of infection: drainage, odor, redness of surrounding tissue, red streaking up the extremity. Treatment changed 02/02/16 to Xeroform. R #4's February 2016 Ulcers, Surgical Site Treatment and Progress Record- Side One documented Discovered 02/01/16, Diagnosis/Stage: Stage II. Order Date: 02/02/16. Treatment: Coccyx- Cleanse with NS pat dry apply Xeroform cover with foam dressing change QD and PRN. From 02/02/16-02/24/16, the following was documented: -Drainage: M -General Appearance: R -Surrounding Skin: N . According to the Drainage Key on this form M = moist, General Appearance Key: R= red, P = pink, W= white; and Surrounding Skin Key: N = normal. R #4's February 2016 Ulcers, Surgical Site Treatment and Progress Record- Side Two documented NPUAP Stages For Pressure Ulcers: - .Stage 2: Partial thickness loss of dermis presenting as a shallow open ulcer with red pink wound bed, without slough. May also present as an intact or open/ruptured serum-filled blister. - Stage 3: Broken skin, deep tissue involvement. Full thickness wound. -Stage 4: Broken skin through all layers of tissue, including muscle, tendon or bone. Full thickness wound. -Unstageable: Full thickness loss in which the base of the ulcer is covered by slough (yellow, tan, grey, green or brown), and/or eschar (tan, brown or black) in the wound bed. -Partial thickness wound (PTW): Loss of epidermis and partial loss of dermis. -Full thickness Wound (FTW): Tissue destruction extending through the dermis and involving the subcutaneous layer. May involve muscle or bone. Date: 02/02/16 NPUAP Stage: Stage II L (length)= 0.5, W= 0.6 (width), D (depth)= 0.1 The same section of the form documenting Undermining, Tunneling Depth, Process: Yes or No boxes for: Granulation, Decreased Size, Decreased Depth, Decreased Drainage; were blank. R #4's Telephone Orders dated 02/02/16 documented Cleanse Stage II coccyx with NS pat dry apply Xeroform cover with foam dressing, change QD (every day) and PRN. R #4's Weekly Skin Integrity Review Sheet dated 02/03/16 documented Stage II. An X was drawn just above the horizontal gluteal crease. No other documentation was provided of this assessment except for Treatment Nurse/LVN B's signature. R #4's February 2016 Ulcers, Surgical Site Treatment and Progress Record- Side Two documented 02/09/16 NPUAP Stage: (no stage documented), L= 0.5, W= 0.5, D= 0.1 cm. No other documentation or detail was documented. R #4's Weekly Skin Integrity Review Sheet dated 02/10/16 documented Stage II. An X was drawn just above the horizontal gluteal crease. No other documentation was provided of this assessment except for Treatment Nurse/LVN B's signature. R #4's Nurse's Notes dated 02/10/16 (no time documented) documented Stage II coccyx 0.5 X 0.5 X 0.1 cm (centimeter). Wound bed is granulated tissue, scant amount of serous (a thin watery liquid) drainage, wound edges are attached peri-wound is clean, pt denies any pain, continue current treatment as ordered. R #4's Nurse's Notes dated 02/16/16 (no time documented) documented Stage II coccyx 0.8 X 0.8 X 0.1, wound base is granulated tissue, scant amounts of serous drainage, no odor, continue current treatment. R #4's Weekly Skin Integrity Review Sheet dated 02/17/16 had no documentation of the assessment except for Treatment Nurse/LVN B's signature. R #4's February 2016 Ulcers, Surgical Site Treatment and Progress Record- Side Two documented 02/17/16 NPUAP Stage: (no stage documented), L= 0.8, W= 0.8, D= 0.1 cm. No other documentation or detail was documented. R #4's February 2016 Ulcers, Surgical Site Treatment and Progress Record- Side Two documented 02/24/16 NPUAP Stage: Stage II, L= 0.8, W= 0.5, D=0.1 cm and L= 0.8, W= 0.8, D= 0.1 cm. There were two different measurements of the same wound. No other documentation or detail was documented. R #4's Nurse's Notes dated 02/24/16 (no time documented) documented Wound to coccyx 0.8 X 0.8 X 0.1 cm wound base has granulated tissue with area of white to 12 o'clock area, wound has moderate serous drainage, peri-wound has blanchable redness, spoke to (physician) for coordination of care, doctor saw pts wound, doctor stated to continue current orders of Xeroform and wait to change anything until (Wound Care Specialist) next visit, this nurse requested if we could start Santyl with Xeroform, doctor stated no, wait for (Wound Care Specialist), but he started [MEDICATION NAME] (antibiotic) 500 mg (milligrams) BID (twice a day) X 7 days, no s/s (signs/symptoms) of infection however blanchable redness in peri-wound no change in size of wound remains on wheelchair cushion and has a foam preventative matress to the bed. Pt has episodes of incontinence. Incontinent care provided . R #4's Nurse's Notes dated 02/24/16 (no time documented) documented Received new orders from doctor, 1.) low air loss mattress, 2.) Multivitamin QD, 3.) Stress tab with Zinc 1 tablet BID X 10 days, spoke to hospice nurse on changing pt wheelchair cushion, hospice nurse stated they would order a new cushion . On 02/24/16 at 11:00 a.m., review of R #4's Telephone Physician order [REDACTED].#4's Telephone Orders dated 02/02/16 documented Cleanse Stage II coccyx with NS pat dry apply Xeroform cover with foam dressing, change QD and PRN. There was no proceeding order as of this date on the sheet at the time the copy was made. On 02/24/16 at 2:09 p.m., this surveyor accompanied Treatment Nurse/LVN B to R #4's room. As Treatment Nurse/LVN B prepared her supplies for wound care, she stated (R #4) has a Stage II to her coccyx and it is cleaned daily. It last measured 0.8 X 0.8 X 0.1 cm. I cleanse with wound cleanser, place a piece of Xeroform, and cover with Foam dressing. As of yesterday, the wound looked pink with a couple of small spots of white in the center of the wound. There is a little depth. Treatment Nurse/LVN B removed R #4's dressing on her coccyx and this surveyor saw a wound approximately the diameter of a dime with some depth. The wound bed had pink and white with yellow/tan pinpoint specks of tissue in the wound. There was no odor and the old dressing had serous drainage. There was reddness surrounding the wound. The Treatment Nurse/LVN B measured the wound and stated outloud 1 X 1 X 0.1 cm., it looks like it has a little more white today. The Treatment Nurse/LVN B again stated the wound was a Stage II Pressure Ulcer acquired in-house. The Treatment Nurse/LVN B said R #4's physician saw the wound this morning and the physician did not want to change anything until (wound specialist) was told of the wound but he will not be here until next week because he is on vacation. I called the hospice nurse for approval for an air mattress. On 02/24/16 at 2:40 p.m., this surveyor accompanied the Treatment Nurse/LVN B and the Director of Nurses (DON) to view R #4's pressure ulcer. While walking to R #4's room, the DON stated I am not good at staging ulcers. Pressure ulcers are my weak point, the staging is confusing to me. I recognize Stage I and I know a Stage IV involves the bone and muscle. The Stage II and III's is where I have trouble. The DON read outloud the NPUAP Stages For Pressure Ulcers off of R #4's February 2016 Ulcers, Surgical Site Treatment and Progress Record- Side Two. The DON confirmed the facility used the NPUAP Stages for Pressure Ulcers as a reference tool in staging ulcers. The DON looked at R #4's wound and stated I would have to say and agree with the Treatment Nurse that it is a Stage II, because she is more educated in this than I am. I see pink with a couple of white small spots with a small amount of drainage and a little depth. Interview with R #4's Physician on 02/24/16 at 3:38 p.m. revealed Yes, I saw the wound. When I saw her wound this morning, I did not see slough or anything. I am not a wound doctor. I don't know how to stage wounds or the correct treatment for [REDACTED]. I rely on the wound nurse and wound doctor's recommendations because they are more educated on wounds than I am. The nurse said she was going to ask the wound doctor about the wound next week because he is on vacation, or something like that. I'm treating her for infection of the wound, I ordered antibiotics. No, I don't know what infection she has; no culture has been taken. On 02/24/16 at 4:21 p.m., this surveyor accompanied Director of Clinical Operations (DCO) and the Division Clinical Vice President (DVP) to R #4's room to observe R #4's pressure ulcer. The DCO stated outloud I see a clean open wound with white area and some pink in the center of the wound. I agree there is a Stage II there. Interview with R #4's Hospice Registered Nurse (RN) G on 02/24/16 at 4:38 p.m. revealed she had not seen R #4's pressure ulcer since last week. RN G said last week she had seen the wound to be an open rounded wound with slough and some serous drainage. The Treatment Nurse staged it as a Stage II but I don't think it was a Stage II due to the slough. To me, the ulcer was a Stage III, because of the slough and it was getting deeper. The Treatment Nurse told me the specialist was going to see (R #4) next week because he was on vacation this week. RN G said she did not recall seeing an order to consult the wound specialist as of 02/22/16, I assumed (R #4's) physician spoke to the specialist, directly. I went ahead and ordered (R #4) an air mattress today because she is so thin and bony and any pressure could easily worsen her wound, which we see has happened. On 02/25/16 at 10:05 a.m., this surveyor accompanied the Treatment Nurse/LVN B to R #4's room and observed wound care. R #4's wound had more white and yellow tissue in the center of the wound with moderate serous drainage, redness, and maceration (softening and breaking down of skin resulting from prolonged exposure to moisture) surrounding the ulcer.The Treatment Nurse/LVN B (accompanied by the DVP) stated she called R #4's physician and got an order to change the treatment to the ulcer. The Treatment Nurse/LVN B said she had a conference call with the American Medical Technology (AMT) Representative Consultant and all were in agreement (R #4's) ulcer was an unstageable ulcer because we can't see the wound base due to it being covered with white tissue, we all agreed to use Santyl. I told (the physician) the white tissue from yesterday increased and there was redness around the wound bed. I agreed with you yesterday that the wound had worsen but after I spoke to the doctor yesterday morning he did not want to make any changes because he wanted to wait for the specialist recommendations; I just didn't want to undermine his authority. I should have just told you yesterday that it was no longer a Stage II. On 02/25/16 at 11:00 a.m., interview with the DCO, DVP, and the Administrator accompanied the Treatment Nurse/LVN B and the DON to the facility's conference room for an interview. The DON explained the facility no longer had policy and procedures and provided a copy of the facility's Skin Management Systems revised 10/2015 that took the place of the policy and procedure. The DON stated the facility also used the Perry and Potters' Clinical Nursing Skills and Techniques 8th Edition Manual for clinical resources as a reference. The Treatment Nurse/LVN B confirmed R #4 did not have current Braden assessment and should have had one when her pressure ulcer was found on 02/01/16. I forgot to do it. The Treatment Nurse/LVN B reviewed R #4's most recent Ulcers, Surgical Site Treatment and Progress Record and confirmed she documented incorrectly by not documenting there was white and yellow tissue in the wound on 02/23/16 and 02/24/16. At this time the Treatment Nurse/LVN B agreed she should have documented her exact observation of R #4's wound on 02/23/16 and 02/24/16. The Treatment Nurse/LVN B said she did not call R #4's physician on 02/23/16 when she first saw a change (white tissue) in R #4's ulcer. The DON interrupted and said yes there was a change in the ulcer then the Treatment Nurse/LVN B abruptly stood up and walked out of the room. At 1:15 p.m., the interview continued, Treatment Nurse/LVN B said she could not recall R #4's wound having a change or having white tissue in the ulcer on 02/23/16. The Treatment Nurse/LVN B said I know there was white in the wound on 02/24/16 when I first treated it in the morning. No, I did not document it. I do not remember telling you the ulcer changed on 02/23/16. This surveyor read outloud to the Treatment Nurse/LVN B her statement on 02/24/16 at 2:09 p.m. the Treatment Nurse/LVN B said oh, I don't remember that. The DON said If an assessment or documentation is inaccurate, it can effect the wound and maintenance of continuity of care. The DON confirmed each form should be completed to it's entirty, if not document the reason why. On 02/25/16 at 4:50 p.m., this surveyor reviewed R #4's updated Telephone Physician order [REDACTED]. (evaluate) and treat dated 02/19/16. R #8: R #8's Face Sheet dated 01/27/16 revealed R #8 was a [AGE] year-old female admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. R #8's Braden Scale for Predicting Pressure Sore Risk dated 06/09/15 documented a total score of 13. *R #8 did not have any other Braden Scale assessments in her closed clinical record. R #8's Admission Nursing Evaluation dated 06/09/15 documented R #8 had an open area to right buttock- 2 in (inch) X 2 in and left buttock less than 1 in X 1 in. R #8's MDS dated [DATE] documented R #8: -Had clear speech, made self understood, and understood others- clear comprehension; -BIMS score was 5. R #8 could not recall. -Behaviors not exhibited; -Required extensive assistance with one or two person physical assistance for bed mobility, dressing, and eating. R #8 was totally dependent with one or two person physical assistance for transfers, locomotion on and off unit, personal hygiene, and bathing; -Range of Motion: upper extremity- no impairment; lower extremity- impairment on one side; -Mobility Devices: wheelchair; -Was always incontinent of urine and bowel; -Height: 63 inches. Weight- 100 pounds. No or unknown weight loss or gain; -At risk of developing pressure ulcer. Resident has Stage 1 or higher pressure ulcer (One Stage 2). One Stage 2 Pressure Ulcer present on admit/reentry. Tissue type of ulcer at most advances stage: [MEDICATION NAME] tissue- new skin growing in superficial ulcer. It can be light pink and shiny . R #8's Telephone Physician order [REDACTED]. Resolved Stage II. R #8's Nurse's Treatment Notes dated 10/03/15 documented 10/03/15 8:45 p.m., Initials: (LVN A's initials), Treatment: Left Ischium (the curved bone forming the base of each half of the pelvis), Reason/Remarks: Stage II to Left Ischium at 0.7 X 0.9 X 0.1 cm with pink moist wound bed and [DIAGNOSES REDACTED] to peri-wound. Initiated tx (treatment). Doctor .notified. *There was no Weekly Skin Integrity Review Sheet or October 2015 Wound Treatment and Progress Record or Ulcers, Surgical Site Treatment and Progress Record that documented the discovery or details of R #8's Left Ischium Stage II Pressure Ulcer found anywhere in R #8's clinical record. R #8's Telephone Physician order [REDACTED]. Secure with clear tape q 2 days and PRN. R #8's Weekly Skin Integrity Review Sheet (side two- signed by Treatment Nurse/LVN B) documented 10/05/15: Skin Condition: Skin Intact. No other documentation was completed in this section of the block. R #8's Telephone Physician order [REDACTED]. Pat dry, apply Duoderm, secure with clear tape q 2 days and PRN. Dx (diagnosis): Stage II left Ischium. R #8's Progress Notes dated 10/10/15 (signed by LVN A) documented Stage II to Left Ischium 0.7 X 0.9 X 0.1 cm with errythema to peri-wound. No tenderness . R #8's October 2015 Ulcers, Surgical Site Treatment and Progress Record- Side One documented Discovery: 10/10/15 Diagnosis: [REDACTED]. 10/10/15: Treatment: Duoderm with clear tape q 2 days and PRN; Hour: Days, Noon, Evenings. -Drainage: M -General Appearance: P -Surrounding Skin: N -Initials: (LVN A's initials) R #8's October 2015 Ulcers, Surgical Site Treatment and Progress Record-Side Two documented: Date: 10/10/15 (signed by LVN A) documented NPUAP Stage: Stage II. L- 0.7, W- 0.9, D- 0.1 cm. Additional documentation: Redness to peri-wound, no tenderness. The same section of the form provided area for documentation under Undermining, Tunneling Depth, Process: Yes or No boxes for: Granulation, Decreased Size, Decreased Depth, Decreased Drainage; No documentation was completed in these areas of the form. R #8's Weekly Skin Integrity Review Sheet (side two- signed by LVN A) documented 10/10/15: Skin Condition: Other: S

Based on observation, interview, and record review the facility failed to ensure a resident who enters the facility without pressure ulcers does not develop pressure ulcers for two Residents (R#4 and R #8) of seven residents reviewed for pressure ulcers. -R#4 was admitted to the facility without a pressure ulcer and developed a pressure ulcer after admission to the facility. The facility assessed, treated, and documented R #4's pressure ulcer as a stage II, however, R #4's pressure ulcer had worsened to an unstageable. -R#8 developed a pressure ulcer four months after admission to the facility. The facility assessed, treated, and documented R #8's pressure ulcer as a stage III, however, R #8's pressure ulcer worsened to a stage IV with tunneling. -The facility did not reassess or update R #4 and R #8's Braden Scale Risk Assessments for predicting pressure ulcers. -R #4 and R #8's documentation of their Pressure Ulcers contained some omitted information, inconsistent, and contradicting staging and description of their wounds, from document to document. These failures of developing/worsening of pressure ulcers in the facility, correctly identifying/assessing, documenting, and treating pressure ulcers resulted in an Immediate Jeopardy (IJ) situation on 02/25/16. While the IJ was removed on 02/26/16, the facility remained out of compliance at a potential for more than minimal harm with a scope identified as pattern. The facility was continuing to monitor to ensure continued implementation of their plan of removal. This deficient practice could place 16 residents with pressure ulcers and 31 residents receiving preventative skin care at risk of skin breakdown or worsening of pressure ulcers due to not receiving accurate assessments, care, and services needed to prevent delay in treatment, complications, hospitalization , and a decreased quality of life. The findings included: R #4: R #4's Face Sheet dated 02/25/16 documented an [AGE] year-old female admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. R #4's Admission Nursing Evaluation dated 08/20/15 documented General Skin Condition: dry and warm. The form indicated Skin Condition (if checked, further evaluation required per facility policy. Indicate below all body marks such as pressure ulcers, abrasions, bruises, soft heels, moles, skin tears, cancer [MEDICAL CONDITION], oozing, surgical wounds and scars. Indicate location, size, depth (cm (centimeter)) color, and drainage. A circle was drawn on the middle right of the buttocks with area written beside it. There was no detail information documented about the area. R #4's Telephone Physician Order, Treatment Record, and Progress Note dated 09/26/15 revealed R #4's Stage II pressure Ulcer was resolved and treatment was discontinued. R #4's Braden Scale for Predicting Pressure Ulcer Risk Form indicated To be completed upon admission, weekly X3, then quarterly and PRN (as needed). -Evaluation Date: 09/09/15, Total Score: 17; -Evaluation Date: 12/31/15, Total Score: 20; -Evaluation Date: 01/27/16, Total Score: 19; Total Score Key: equal to or less than 9= Very High Risk; 10-12= High Risk; Moderate Risk= 13-14, and At Risk= 15-18. There were no other Braden Assessments in R #4's clinical record. R #4's Care Plans revised 12/31/15 included: -(R #4) has the potential for impaired skin integrity related to periods of incontinence, and end of life. Goal: (R #4) will maintain intact skin through the next review date. (R #4) will have a resolved current wound X 90 days; Current Stage II to coccyx- 02/16/16. Approaches: Check q (every) 2 hours for incontinence and provide cleansing as needed; Turn and reposition q 2 hours; Monitor skin during shower and report abnormalities to MD (Medical Doctor); Wheelchair cushion; Encourage to lay down in bed for pressure relief; Treatment as ordered; Notify physician if treatment not effective. R #4's Quarterly Minimum Data Set ((MDS) dated [DATE] documented R #4: -Had clear speech, made self understood, and understood others- clear comprehension; -Brief Interview of Mental Status (BIMS) score was 8. R #4 could recall after cueing. -Behaviors not exhibited; -Required supervision with one person physical assistance for bed mobility, transfers, dressing, eating, locomotion on and off unit, personal hygiene, and bathing. -Range of Motion: upper extremity- no impairment; lower extremity- no impairment; -Mobility Devices: wheelchair; -Was occasionally (less than 7 episodes of incontinence) incontinent of urine and always incontinent of bowel; -Height: 56 inches. Weight- 82 pounds. No or unknown weight loss or gain; -At risk of developing pressure ulcer: No; No pressure ulcers. R #4's February 2016 Consolidated physician's orders [REDACTED].>- Hospice services as of 08/11/15, Dx: Neoplasm of the bone, [DIAGNOSES REDACTED], and Dementia. R #4's Progress Note dated 02/01/16 documented Called into room per RP (responsible party) states pt (patient) c/o (complains of) pain to buttocks and noted open area to coccyx. Assess approximately 1 cm X 1 cm diameter Stage II to coccyx. N.O. (new order) with treatment with cleanse with NS (Normal Saline) pat dry with gauze. Covered with Duoderm ([MEDICATION NAME] dressing is a wafer type of dressing that contains gel-forming agents in an adhesive compound laminated onto a flexible, water-resistant outer layer). To be changed q 2 days and PRN . R #4's Immediate Needs Care Plan: Pressure Ulcer dated 02/01/16 documented Location: Coccyx. Strength to draw from: Able to communicate needs and able to follow directions. Goals: Ulcers will be healed without complication, Surface area will decrease. Interventions: Wound Status: size of wound: measurements of depth and width, skin color, surrounding skin tissue assessments weekly; Complaints of pain, effectiveness of pain medication per order; Apply dressing per Order; Note old dressing for any signs of exudate. Assess color and amount if present; Be alert to any signs of infection: drainage, odor, redness of surrounding tissue, red streaking up the extremity. Treatment changed 02/02/16 to Xeroform. R #4's February 2016 Ulcers, Surgical Site Treatment and Progress Record- Side One documented Discovered 02/01/16, Diagnosis/Stage: Stage II. Order Date: 02/02/16. Treatment: Coccyx- Cleanse with NS pat dry apply Xeroform cover with foam dressing change QD and PRN. From 02/02/16-02/24/16, the following was documented: -Drainage: M -General Appearance: R -Surrounding Skin: N . According to the Drainage Key on this form M = moist, General Appearance Key: R= red, P = pink, W= white; and Surrounding Skin Key: N = normal. R #4's February 2016 Ulcers, Surgical Site Treatment and Progress Record- Side Two documented NPUAP Stages For Pressure Ulcers: - .Stage 2: Partial thickness loss of dermis presenting as a shallow open ulcer with red pink wound bed, without slough. May also present as an intact or open/ruptured serum-filled blister. - Stage 3: Broken skin, deep tissue involvement. Full thickness wound. -Stage 4: Broken skin through all layers of tissue, including muscle, tendon or bone. Full thickness wound. -Unstageable: Full thickness loss in which the base of the ulcer is covered by slough (yellow, tan, grey, green or brown), and/or eschar (tan, brown or black) in the wound bed. -Partial thickness wound (PTW): Loss of epidermis and partial loss of dermis. -Full thickness Wound (FTW): Tissue destruction extending through the dermis and involving the subcutaneous layer. May involve muscle or bone. Date: 02/02/16 NPUAP Stage: Stage II L (length)= 0.5, W= 0.6 (width), D (depth)= 0.1 The same section of the form documenting Undermining, Tunneling Depth, Process: Yes or No boxes for: Granulation, Decreased Size, Decreased Depth, Decreased Drainage; were blank. R #4's Telephone Orders dated 02/02/16 documented Cleanse Stage II coccyx with NS pat dry apply Xeroform cover with foam dressing, change QD (every day) and PRN. R #4's Weekly Skin Integrity Review Sheet dated 02/03/16 documented Stage II. An X was drawn just above the horizontal gluteal crease. No other documentation was provided of this assessment except for Treatment Nurse/LVN B's signature. R #4's February 2016 Ulcers, Surgical Site Treatment and Progress Record- Side Two documented 02/09/16 NPUAP Stage: (no stage documented), L= 0.5, W= 0.5, D= 0.1 cm. No other documentation or detail was documented. R #4's Weekly Skin Integrity Review Sheet dated 02/10/16 documented Stage II. An X was drawn just above the horizontal gluteal crease. No other documentation was provided of this assessment except for Treatment Nurse/LVN B's signature. R #4's Nurse's Notes dated 02/10/16 (no time documented) documented Stage II coccyx 0.5 X 0.5 X 0.1 cm (centimeter). Wound bed is granulated tissue, scant amount of serous (a thin watery liquid) drainage, wound edges are attached peri-wound is clean, pt denies any pain, continue current treatment as ordered. R #4's Nurse's Notes dated 02/16/16 (no time documented) documented Stage II coccyx 0.8 X 0.8 X 0.1, wound base is granulated tissue, scant amounts of serous drainage, no odor, continue current treatment. R #4's Weekly Skin Integrity Review Sheet dated 02/17/16 had no documentation of the assessment except for Treatment Nurse/LVN B's signature. R #4's February 2016 Ulcers, Surgical Site Treatment and Progress Record- Side Two documented 02/17/16 NPUAP Stage: (no stage documented), L= 0.8, W= 0.8, D= 0.1 cm. No other documentation or detail was documented. R #4's February 2016 Ulcers, Surgical Site Treatment and Progress Record- Side Two documented 02/24/16 NPUAP Stage: Stage II, L= 0.8, W= 0.5, D=0.1 cm and L= 0.8, W= 0.8, D= 0.1 cm. There were two different measurements of the same wound. No other documentation or detail was documented. R #4's Nurse's Notes dated 02/24/16 (no time documented) documented Wound to coccyx 0.8 X 0.8 X 0.1 cm wound base has granulated tissue with area of white to 12 o'clock area, wound has moderate serous drainage, peri-wound has blanchable redness, spoke to (physician) for coordination of care, doctor saw pts wound, doctor stated to continue current orders of Xeroform and wait to change anything until (Wound Care Specialist) next visit, this nurse requested if we could start Santyl with Xeroform, doctor stated no, wait for (Wound Care Specialist), but he started [MEDICATION NAME] (antibiotic) 500 mg (milligrams) BID (twice a day) X 7 days, no s/s (signs/symptoms) of infection however blanchable redness in peri-wound no change in size of wound remains on wheelchair cushion and has a foam preventative matress to the bed. Pt has episodes of incontinence. Incontinent care provided . R #4's Nurse's Notes dated 02/24/16 (no time documented) documented Received new orders from doctor, 1.) low air loss mattress, 2.) Multivitamin QD, 3.) Stress tab with Zinc 1 tablet BID X 10 days, spoke to hospice nurse on changing pt wheelchair cushion, hospice nurse stated they would order a new cushion . On 02/24/16 at 11:00 a.m., review of R #4's Telephone Physician order [REDACTED].#4's Telephone Orders dated 02/02/16 documented Cleanse Stage II coccyx with NS pat dry apply Xeroform cover with foam dressing, change QD and PRN. There was no proceeding order as of this date on the sheet at the time the copy was made. On 02/24/16 at 2:09 p.m., this surveyor accompanied Treatment Nurse/LVN B to R #4's room. As Treatment Nurse/LVN B prepared her supplies for wound care, she stated (R #4) has a Stage II to her coccyx and it is cleaned daily. It last measured 0.8 X 0.8 X 0.1 cm. I cleanse with wound cleanser, place a piece of Xeroform, and cover with Foam dressing. As of yesterday, the wound looked pink with a couple of small spots of white in the center of the wound. There is a little depth. Treatment Nurse/LVN B removed R #4's dressing on her coccyx and this surveyor saw a wound approximately the diameter of a dime with some depth. The wound bed had pink and white with yellow/tan pinpoint specks of tissue in the wound. There was no odor and the old dressing had serous drainage. There was reddness surrounding the wound. The Treatment Nurse/LVN B measured the wound and stated outloud 1 X 1 X 0.1 cm., it looks like it has a little more white today. The Treatment Nurse/LVN B again stated the wound was a Stage II Pressure Ulcer acquired in-house. The Treatment Nurse/LVN B said R #4's physician saw the wound this morning and the physician did not want to change anything until (wound specialist) was told of the wound but he will not be here until next week because he is on vacation. I called the hospice nurse for approval for an air mattress. On 02/24/16 at 2:40 p.m., this surveyor accompanied the Treatment Nurse/LVN B and the Director of Nurses (DON) to view R #4's pressure ulcer. While walking to R #4's room, the DON stated I am not good at staging ulcers. Pressure ulcers are my weak point, the staging is confusing to me. I recognize Stage I and I know a Stage IV involves the bone and muscle. The Stage II and III's is where I have trouble. The DON read outloud the NPUAP Stages For Pressure Ulcers off of R #4's February 2016 Ulcers, Surgical Site Treatment and Progress Record- Side Two. The DON confirmed the facility used the NPUAP Stages for Pressure Ulcers as a reference tool in staging ulcers. The DON looked at R #4's wound and stated I would have to say and agree with the Treatment Nurse that it is a Stage II, because she is more educated in this than I am. I see pink with a couple of white small spots with a small amount of drainage and a little depth. Interview with R #4's Physician on 02/24/16 at 3:38 p.m. revealed Yes, I saw the wound. When I saw her wound this morning, I did not see slough or anything. I am not a wound doctor. I don't know how to stage wounds or the correct treatment for [REDACTED]. I rely on the wound nurse and wound doctor's recommendations because they are more educated on wounds than I am. The nurse said she was going to ask the wound doctor about the wound next week because he is on vacation, or something like that. I'm treating her for infection of the wound, I ordered antibiotics. No, I don't know what infection she has; no culture has been taken. On 02/24/16 at 4:21 p.m., this surveyor accompanied Director of Clinical Operations (DCO) and the Division Clinical Vice President (DVP) to R #4's room to observe R #4's pressure ulcer. The DCO stated outloud I see a clean open wound with white area and some pink in the center of the wound. I agree there is a Stage II there. Interview with R #4's Hospice Registered Nurse (RN) G on 02/24/16 at 4:38 p.m. revealed she had not seen R #4's pressure ulcer since last week. RN G said last week she had seen the wound to be an open rounded wound with slough and some serous drainage. The Treatment Nurse staged it as a Stage II but I don't think it was a Stage II due to the slough. To me, the ulcer was a Stage III, because of the slough and it was getting deeper. The Treatment Nurse told me the specialist was going to see (R #4) next week because he was on vacation this week. RN G said she did not recall seeing an order to consult the wound specialist as of 02/22/16, I assumed (R #4's) physician spoke to the specialist, directly. I went ahead and ordered (R #4) an air mattress today because she is so thin and bony and any pressure could easily worsen her wound, which we see has happened. On 02/25/16 at 10:05 a.m., this surveyor accompanied the Treatment Nurse/LVN B to R #4's room and observed wound care. R #4's wound had more white and yellow tissue in the center of the wound with moderate serous drainage, redness, and maceration (softening and breaking down of skin resulting from prolonged exposure to moisture) surrounding the ulcer.The Treatment Nurse/LVN B (accompanied by the DVP) stated she called R #4's physician and got an order to change the treatment to the ulcer. The Treatment Nurse/LVN B said she had a conference call with the American Medical Technology (AMT) Representative Consultant and all were in agreement (R #4's) ulcer was an unstageable ulcer because we can't see the wound base due to it being covered with white tissue, we all agreed to use Santyl. I told (the physician) the white tissue from yesterday increased and there was redness around the wound bed. I agreed with you yesterday that the wound had worsen but after I spoke to the doctor yesterday morning he did not want to make any changes because he wanted to wait for the specialist recommendations; I just didn't want to undermine his authority. I should have just told you yesterday that it was no longer a Stage II. On 02/25/16 at 11:00 a.m., interview with the DCO, DVP, and the Administrator accompanied the Treatment Nurse/LVN B and the DON to the facility's conference room for an interview. The DON explained the facility no longer had policy and procedures and provided a copy of the facility's Skin Management Systems revised 10/2015 that took the place of the policy and procedure. The DON stated the facility also used the Perry and Potters' Clinical Nursing Skills and Techniques 8th Edition Manual for clinical resources as a reference. The Treatment Nurse/LVN B confirmed R #4 did not have current Braden assessment and should have had one when her pressure ulcer was found on 02/01/16. I forgot to do it. The Treatment Nurse/LVN B reviewed R #4's most recent Ulcers, Surgical Site Treatment and Progress Record and confirmed she documented incorrectly by not documenting there was white and yellow tissue in the wound on 02/23/16 and 02/24/16. At this time the Treatment Nurse/LVN B agreed she should have documented her exact observation of R #4's wound on 02/23/16 and 02/24/16. The Treatment Nurse/LVN B said she did not call R #4's physician on 02/23/16 when she first saw a change (white tissue) in R #4's ulcer. The DON interrupted and said yes there was a change in the ulcer then the Treatment Nurse/LVN B abruptly stood up and walked out of the room. At 1:15 p.m., the interview continued, Treatment Nurse/LVN B said she could not recall R #4's wound having a change or having white tissue in the ulcer on 02/23/16. The Treatment Nurse/LVN B said I know there was white in the wound on 02/24/16 when I first treated it in the morning. No, I did not document it. I do not remember telling you the ulcer changed on 02/23/16. This surveyor read outloud to the Treatment Nurse/LVN B her statement on 02/24/16 at 2:09 p.m. the Treatment Nurse/LVN B said oh, I don't remember that. The DON said If an assessment or documentation is inaccurate, it can effect the wound and maintenance of continuity of care. The DON confirmed each form should be completed to it's entirty, if not document the reason why. On 02/25/16 at 4:50 p.m., this surveyor reviewed R #4's updated Telephone Physician order [REDACTED]. (evaluate) and treat dated 02/19/16. R #8: R #8's Face Sheet dated 01/27/16 revealed R #8 was a [AGE] year-old female admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. R #8's Braden Scale for Predicting Pressure Sore Risk dated 06/09/15 documented a total score of 13. R #8 did not have any other Braden Scale assessments in her closed clinical record. R #8's Admission Nursing Evaluation dated 06/09/15 documented R #8 had an open area to right buttock- 2 in (inch) X 2 in and left buttock less than 1 in X 1 in. R #8's MDS dated [DATE] documented R #8: -Had clear speech, made self understood, and understood others- clear comprehension; -BIMS score was 5. R #8 could not recall. -Behaviors not exhibited; -Required extensive assistance with one or two person physical assistance for bed mobility, dressing, and eating. R #8 was totally dependent with one or two person physical assistance for transfers, locomotion on and off unit, personal hygiene, and bathing; -Range of Motion: upper extremity- no impairment; lower extremity- impairment on one side; -Mobility Devices: wheelchair; -Was always incontinent of urine and bowel; -Height: 63 inches. Weight- 100 pounds. No or unknown weight loss or gain; -At risk of developing pressure ulcer. Resident has Stage 1 or higher pressure ulcer (One Stage 2). One Stage 2 Pressure Ulcer present on admit/reentry. Tissue type of ulcer at most advances stage: [MEDICATION NAME] tissue- new skin growing in superficial ulcer. It can be light pink and shiny . R #8's Telephone Physician order [REDACTED]. Resolved Stage II. R #8's Nurse's Treatment Notes dated 10/03/15 documented 10/03/15 8:45 p.m., Initials: (LVN A's initials), Treatment: Left Ischium (the curved bone forming the base of each half of the pelvis), Reason/Remarks: Stage II to Left Ischium at 0.7 X 0.9 X 0.1 cm with pink moist wound bed and [DIAGNOSES REDACTED] to peri-wound. Initiated tx (treatment). Doctor .notified. There was no Weekly Skin Integrity Review Sheet or October 2015 Wound Treatment and Progress Record or Ulcers, Surgical Site Treatment and Progress Record that documented the discovery or details of R #8's Left Ischium Stage II Pressure Ulcer found anywhere in R #8's clinical record. R #8's Telephone Physician order [REDACTED]. Secure with clear tape q 2 days and PRN. R #8's Weekly Skin Integrity Review Sheet (side two- signed by Treatment Nurse/LVN B) documented 10/05/15: Skin Condition: Skin Intact. No other documentation was completed in this section of the block. R #8's Telephone Physician order [REDACTED]. Pat dry, apply Duoderm, secure with clear tape q 2 days and PRN. Dx (diagnosis): Stage II left Ischium. R #8's Progress Notes dated 10/10/15 (signed by LVN A) documented Stage II to Left Ischium 0.7 X 0.9 X 0.1 cm with errythema to peri-wound. No tenderness . R #8's October 2015 Ulcers, Surgical Site Treatment and Progress Record- Side One documented Discovery: 10/10/15 Diagnosis: [REDACTED]. 10/10/15: Treatment: Duoderm with clear tape q 2 days and PRN; Hour: Days, Noon, Evenings. -Drainage: M -General Appearance: P -Surrounding Skin: N -Initials: (LVN A's initials) R #8's October 2015 Ulcers, Surgical Site Treatment and Progress Record-Side Two documented: Date: 10/10/15 (signed by LVN A) documented NPUAP Stage: Stage II. L- 0.7, W- 0.9, D- 0.1 cm. Additional documentation: Redness to peri-wound, no tenderness. *The same section of the form provided area for documentation under Undermining, Tunneling Depth, Process: Yes or No boxes for: Granulation, Decreased Size, Decreased Depth, Decreased Drainage; No documentation was completed in these areas of the form. R #8's Weekly Skin Integrity Review Sheet (side two- signed by LVN A) documented 10/10/15: Skin Condition: Other: Stage II left Ischium, Open Area: New. No other documentation was completed in this section of the block. R #8's Immediate Needs Care Plan: Pressure Ulcer(s) dated 10/10/15 documented: Problem/Need related to: Immobility. Resulting in location: Stage II Left Ischium. Strength to draw from: Able to communicate Needs and able to follow directions. Goals: Ulcers will be healed without complication. Interventions: Wound Status: sixe of wound: measurements of depth and width, skin color, surrounding skin tissue assessments weekly; Complaints of pain, effectiveness of pain medication per order .; Apply medicated ointment per order; Apply dressing per Order; Be alert to any signs of infection: drainage, odor, redness of surrounding tissue, red streaking up the extremity. This form was signed by Treatment Nurse/LVN B. No other input was documented on this document. A separate and additional Pressure Ulcer Care Plan dated 10/10/15 documented Problem: Alteration in skin integrity related to Dementia, decreased mobility, and Chronic Ischemic [MEDICAL CONDITION]. Goal: Stage 2 pressure ulcer will heal within 60 days. Approaches: Educate resident and RP (responsible party), Daily wound care, Assist with turning, rising, repositioning every 2-3 hours and PRN, Limit static sitting to 1 hour at any one time, Support surface for bed: pillows, Support surface for chair: Jois cushion, Dietician consult, Weekly assessment of wound, re-eval interventions q 2 weeks, Update physician on wound progress q 2-3 weeks, Risk assessment on admit, change of condition, and quarterly, Ensure adequate nutrition, Manage urinary and fecal incontinence: Wet/soiled checks q 2 hours, Assist with hygiene: q shift, Check skin condition for intactness, color, sensation, and temperature. If changes occur, call physician, Monitor dressing for signs and symptoms of infection, if present notify physician . R #8's Telephone Physician order [REDACTED]. D/C cleanse Left Ischium with NS and Duoderm . 2. Cleanse Left Ischium with NS, pat dry, apply Xeroform (a sterile, non-adhering primary dressing with 3% Xeroform), secure with dry dressing, change q day and PRN. R #8's Weekly Skin Integrity Review Sheet (side two- signed by Treatment Nurse/LVN B) documented 10/13/15 Skin Condition: Other: Stage II, open area new. No other documentation was completed in this section of the block. R #8's Nurses Notes (signed by Treatment Nurse/LVN B) dated 10/14/15 documented pt (patient) has Stage II to Left Ischium 0.6 X 1.0 X 0.1 cm, wound base is red, serous drainage, no odor, peri-wound is clear, pt has no facial grimaces while wound care being performed . R #8's October 2015 Surgical Site Treatment and Progress Record- Side One documented a subsequent entry (after 10/10/15 entry) dated 10/14/15 (signed by Treatment Nurse/LVN B revealed NPAP Stage: Stage II. L= 0.6, W= 1.0, D= 0.1 cm. Undermining= none. Additional documentation: Peri-wound has redness. Undermining= 0.1 cm. The section of the form under Additional documentation, Tunneling Depth, Process that included Yes or No boxes of: Granulation, Decreased Size, Decreased Depth, Decreased Drainage revealed no documentation was completed in these areas of the form. R #8's Weekly Skin Integrity Review Sheet (side two- signed by LVN A) documented 10/17/15: Skin Condition: Other: Stage II left Ischium. No other documentation was completed in this section of the block. R #8's Weekly Skin Integrity Review Sheet (signed by Treatment Nurse/LVN B) documented 10/20/15 Skin Condition: Other was checked but no information was documented on the line. No other documentation was completed in this section of the block. R #8's Nurses Notes (signed by Treatment Nurse/LVN B) dated 10/23/15 documented pt wound to Left Ischium Stage II has deteriorated wound is Stage III 2.3 X 1.6 X 0.1 cm, wound base is red with areas of white, slough, serous drainage, no odor, peri-wound is clear, no s/s (signs/symptoms) of infection . R #8's Weekly Skin Integrity Review Sheet (side two- signed by Treatment Nurse/LVN B) documented 10/23/15: Skin Condition: Other: Stage II left Ischium. No other documentation was completed in this section of the block. R #8's October 2015 Ulcers, Surgical Site Treatment and Progress Record- Side Two documented a subsequent entry (after 10/14/15 entry) dated 10/23/15 (signed by Treatment Nurse/LVN B revealed NPAP Stage: Stage II. L= 2.3, W= 1.6 cm. No documentation was provided under D. The section of the form under Depth, Undermining, Tunneling Depth, Additional documentation, Process that included Yes or No boxes of: Granulation, Decreased Size, Decreased Depth, Decreased Drainage revealed no documentation was completed in these areas of the form. R #8's Weekly Skin Integrity Review Sheet (side two- signed by Treatment Nurse/LVN B) had a subsequent entry (after 10/23/15 entry) that did not document the entire date, except for: 27: Skin Condition: Stage II Left Ischium. No other documentation was completed in this section of the block. R #8's Weekly Skin Integrity Review Sheet (side two- signed by Treatment Nurse/LVN B) documented 10/29/15: Skin Condition: Other: Stage II left Ischium. No other documentation was completed in this section of the block. R #8's Nurses Notes (signed by Treatment Nurse/LVN B) dated 10/30/15 documented pt has Stage III to Left Ischium 2.2 X 1.6 cm, wound has no change in last week. Wound base is red with some area of white slough tissue .pt has wheelchair cushion . Side Two of R #8's October 2015 Wound Treatment and Progress Record titled: Ulcers, Surgical Site Treatment and Progress Record documented a subsequent entry (after 10/23/15 entry) dated 10/30/15 (signed by Treatment Nurse/LVN B revealed NPAP Stage: Stage II. L= 2.2, W= 1.6 cm, Additional documentation: Ordered wheelchair cushion. The section of the form under Depth, Undermining, Tunneling Depth, Process that included Yes or No boxes under: Granulation, Decreased Size, Decreased Depth, Decreased Drainage revealed no documentation was completed in these areas of the form. R #8's Telephone Physician order [REDACTED]. Dx: wound. R #8's November 2015 Ulcers, Surgical Site Treatment and Progress Record- Side One documented Discovered: 10/10/15, Diagnosis/Stage: Stage III Left Ischium. Order Date: 10/23/15; Treatment: Cleanse Left Ischium with NS, pat dry, apply Santyl, cover with dry dressing, change daily and PRN; Hour: QD (every day). In the blocks beside Drainage dates from 11/01/15-11/11/15 an M was documented. Beside General Appearance a W/G was documented on 11/01/15, 11/06/15-11/08/15 and W was documented on the rest of the days up to 11/11/15. Beside Sur. Skin an N was documented from dates 11/01/15-11/11/15. According to the key on this document: M= Moist, W= White, G= Green, N= Normal. R #8's Weekly Skin Integrity Review Sheet (side two- signed by Treatment Nurse/LVN B) documented 11/04/15: Skin Intact: Other: Stage IV left Ischium, Open Area: Old. No other documentation was completed in this section of the block. There was no description or measurements of the stage IV Pressure Ulcer anywhere in R #8's entire closed clinical record. R #8's Ulcers, Surgical Site Treatment and Progress Record- Side Two dated 11/06/15 revealed NPUAP Stage- no documentation was provided. L= 2.2, W=1.5 cm. The section of the form under Depth, Undermining, Tunneling Depth, Process that included Yes or No boxes under: Granulation, Decreased Size, Decreased Depth, Decreased Drainage revealed no documentation was completed in these areas of the form. R #8's Nurses Notes (signed by Treatment Nurse/LVN B) dated 11/06/15 documented pt has Stage III to Left Ischium wound has no change 2.2 X 1.6 cm wound base, has 30% slough tissue with 20% red granulated tissue, serous drainage, no odor, peri-wound is clear . R #8's Nurses Notes (signed by Treatment Nurse/LVN B) dated 11/11/15 documented During wound care this nurse observed what may be abscess to pt wound at 3 o'clock, slough tissue has lifted wound is 2.2 X 1.5 X 2.0 wound base is pink with some white areas, peri-wound at 3 o'clock is red with hardness to touch, there is no warmth to touch. pt is not running fever at this time temperature: 98.5. Called NP (Nurse Practitioner) for coordination of care, NP stated to not start antibiotics at this time, to have (physician)

Based on observation, interview, and record review the facility failed to be administered in a manner that enables it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of two Resident (R #4 and R #8) of seven residents reviewed for pressure ulcers. The Administrator failed to develop and implement policies and procedures to ensure residents accurate identification, assessment, and documentation of pressure ulcers were implemented The DON failed to supervise staff to ensure accurate identification, assessment, and documentation of pressure ulcers were implemented. Facility staff did not reassess or update R #4 and R #8's Braden Scale Risk Assessments for predicting pressure ulcers. R #4's facility acquired Stage II pressure ulcer worsened to an unstageable within two days. R #8 was admitted into the hospital due to her facility acquired Stage III pressure ulcer worsening to a stage IV with tunneling. These failures of developing/worsening of pressure ulcers in the facility, correctly identifying/assessing, documenting, and treating pressure ulcers resulted in an Immediate Jeopardy (IJ) situation on 02/25/16. While the IJ was removed on 02/26/16, the facility remained out of compliance at a potential for more than minimal harm with a scope identified as pattern. The facility was continuing to monitor to ensure continued implementation of their plan of removal. The findings included: R #4: R #4's Face Sheet dated 02/25/16 documented an [AGE] year-old female admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. R #4's Admission Nursing Evaluation dated 08/20/15 documented General Skin Condition: dry and warm. The form indicated Skin Condition (if checked, further evaluation required per facility policy. Indicate below all body marks such as pressure ulcers, abrasions, bruises, soft heels, moles, skin tears, cancer [MEDICAL CONDITION], oozing, surgical wounds and scars. Indicate location, size, depth (cm (centimeter)) color, and drainage. A circle was drawn on the middle right of the buttocks with area written beside it. There was no detail information documented about the area. R #4's Telephone Physician Order, Treatment Record, and Progress Note dated 09/26/15 revealed R #4's Stage II pressure Ulcer was resolved and treatment was discontinued. R #4's Braden Scale for Predicting Pressure Ulcer Risk Form indicated To be completed upon admission, weekly X3, then quarterly and PRN (as needed). -Evaluation Date: 09/09/15, Total Score: 17; -Evaluation Date: 12/31/15, Total Score: 20; -Evaluation Date: 01/27/16, Total Score: 19; Total Score Key: equal to or less than 9= Very High Risk; 10-12= High Risk; Moderate Risk= 13-14, and At Risk= 15-18. There were no other Braden Assessments in R #4's clinical record. R #4's Care Plans revised 12/31/15 included: -(R #4) has the potential for impaired skin integrity related to periods of incontinence, and end of life. Goal: (R #4) will maintain intact skin through the next review date. (R #4) will have a resolved current wound X 90 days; Current Stage II to coccyx- 02/16/16. Approaches: Check q (every) 2 hours for incontinence and provide cleansing as needed; Turn and reposition q 2 hours; Monitor skin during shower and report abnormalities to MD (Medical Doctor); Wheelchair cushion; Encourage to lay down in bed for pressure relief; Treatment as ordered; Notify physician if treatment not effective. R #4's Quarterly Minimum Data Set ((MDS) dated [DATE] documented R #4: -Had clear speech, made self understood, and understood others- clear comprehension; -Brief Interview of Mental Status (BIMS) score was 8. R #4 could recall after cueing. -Behaviors not exhibited; -Required supervision with one person physical assistance for bed mobility, transfers, dressing, eating, locomotion on and off unit, personal hygiene, and bathing. -Range of Motion: upper extremity- no impairment; lower extremity- no impairment; -Mobility Devices: wheelchair; -Was occasionally (less than 7 episodes of incontinence) incontinent of urine and always incontinent of bowel; -Height: 56 inches. Weight- 82 pounds. No or unknown weight loss or gain; -At risk of developing pressure ulcer: No; No pressure ulcers. R #4's February 2016 Consolidated physician's orders [REDACTED].>- Hospice services as of 08/11/15, Dx: Neoplasm of the bone, [DIAGNOSES REDACTED], and Dementia. R #4's Progress Note dated 02/01/16 documented Called into room per RP (responsible party) states pt (patient) c/o (complains of) pain to buttocks and noted open area to coccyx. Assess approximately 1 cm X 1 cm diameter Stage II to coccyx. N.O. (new order) with treatment with cleanse with NS (Normal Saline) pat dry with gauze. Covered with Duoderm ([MEDICATION NAME] dressing is a wafer type of dressing that contains gel-forming agents in an adhesive compound laminated onto a flexible, water-resistant outer layer). To be changed q 2 days and PRN . R #4's Immediate Needs Care Plan: Pressure Ulcer dated 02/01/16 documented Location: Coccyx. Strength to draw from: Able to communicate needs and able to follow directions. Goals: Ulcers will be healed without complication, Surface area will decrease. Interventions: Wound Status: size of wound: measurements of depth and width, skin color, surrounding skin tissue assessments weekly; Complaints of pain, effectiveness of pain medication per order; Apply dressing per Order; Note old dressing for any signs of exudate. Assess color and amount if present; Be alert to any signs of infection: drainage, odor, redness of surrounding tissue, red streaking up the extremity. Treatment changed 02/02/16 to Xeroform. R #4's February 2016 Ulcers, Surgical Site Treatment and Progress Record- Side One documented Discovered 02/01/16, Diagnosis/Stage: Stage II. Order Date: 02/02/16. Treatment: Coccyx- Cleanse with NS pat dry apply Xeroform cover with foam dressing change QD and PRN. From 02/02/16-02/24/16, the following was documented: -Drainage: M -General Appearance: R -Surrounding Skin: N . According to the Drainage Key on this form M = moist, General Appearance Key: R= red, P = pink, W= white; and Surrounding Skin Key: N = normal. R #4's February 2016 Ulcers, Surgical Site Treatment and Progress Record- Side Two documented NPUAP Stages For Pressure Ulcers: - .Stage 2: Partial thickness loss of dermis presenting as a shallow open ulcer with red pink wound bed, without slough. May also present as an intact or open/ruptured serum-filled blister. - Stage 3: Broken skin, deep tissue involvement. Full thickness wound. -Stage 4: Broken skin through all layers of tissue, including muscle, tendon or bone. Full thickness wound. -Unstageable: Full thickness loss in which the base of the ulcer is covered by slough (yellow, tan, grey, green or brown), and/or eschar (tan, brown or black) in the wound bed. -Partial thickness wound (PTW): Loss of epidermis and partial loss of dermis. -Full thickness Wound (FTW): Tissue destruction extending through the dermis and involving the subcutaneous layer. May involve muscle or bone. Date: 02/02/16 NPUAP Stage: Stage II L (length)= 0.5, W= 0.6 (width), D (depth)= 0.1 The same section of the form documenting Undermining, Tunneling Depth, Process: Yes or No boxes for: Granulation, Decreased Size, Decreased Depth, Decreased Drainage; were blank. R #4's Telephone Orders dated 02/02/16 documented Cleanse Stage II coccyx with NS pat dry apply Xeroform cover with foam dressing, change QD (every day) and PRN. R #4's Weekly Skin Integrity Review Sheet dated 02/03/16 documented Stage II. An X was drawn just above the horizontal gluteal crease. No other documentation was provided of this assessment except for Treatment Nurse/LVN B's signature. R #4's February 2016 Ulcers, Surgical Site Treatment and Progress Record- Side Two documented 02/09/16 NPUAP Stage: (no stage documented), L= 0.5, W= 0.5, D= 0.1 cm. No other documentation or detail was documented. R #4's Weekly Skin Integrity Review Sheet dated 02/10/16 documented Stage II. An X was drawn just above the horizontal gluteal crease. No other documentation was provided of this assessment except for Treatment Nurse/LVN B's signature. R #4's Nurse's Notes dated 02/10/16 (no time documented) documented Stage II coccyx 0.5 X 0.5 X 0.1 cm (centimeter). Wound bed is granulated tissue, scant amount of serous (a thin watery liquid) drainage, wound edges are attached peri-wound is clean, pt denies any pain, continue current treatment as ordered. R #4's Nurse's Notes dated 02/16/16 (no time documented) documented Stage II coccyx 0.8 X 0.8 X 0.1, wound base is granulated tissue, scant amounts of serous drainage, no odor, continue current treatment. R #4's Weekly Skin Integrity Review Sheet dated 02/17/16 had no documentation of the assessment except for Treatment Nurse/LVN B's signature. R #4's February 2016 Ulcers, Surgical Site Treatment and Progress Record- Side Two documented 02/17/16 NPUAP Stage: (no stage documented), L= 0.8, W= 0.8, D= 0.1 cm. No other documentation or detail was documented. R #4's February 2016 Ulcers, Surgical Site Treatment and Progress Record- Side Two documented 02/24/16 NPUAP Stage: Stage II, L= 0.8, W= 0.5, D=0.1 cm and L= 0.8, W= 0.8, D= 0.1 cm. There were two different measurements of the same wound. No other documentation or detail was documented. R #4's Nurse's Notes dated 02/24/16 (no time documented) documented Wound to coccyx 0.8 X 0.8 X 0.1 cm wound base has granulated tissue with area of white to 12 o'clock area, wound has moderate serous drainage, peri-wound has blanchable redness, spoke to (physician) for coordination of care, doctor saw pts wound, doctor stated to continue current orders of Xeroform and wait to change anything until (Wound Care Specialist) next visit, this nurse requested if we could start Santyl with Xeroform, doctor stated no, wait for (Wound Care Specialist), but he started [MEDICATION NAME] (antibiotic) 500 mg (milligrams) BID (twice a day) X 7 days, no s/s (signs/symptoms) of infection however blanchable redness in peri-wound no change in size of wound remains on wheelchair cushion and has a foam preventative matress to the bed. Pt has episodes of incontinence. Incontinent care provided . R #4's Nurse's Notes dated 02/24/16 (no time documented) documented Received new orders from doctor, 1.) low air loss mattress, 2.) Multivitamin QD, 3.) Stress tab with Zinc 1 tablet BID X 10 days, spoke to hospice nurse on changing pt wheelchair cushion, hospice nurse stated they would order a new cushion . On 02/24/16 at 11:00 a.m., review of R #4's Telephone Physician order [REDACTED].#4's Telephone Orders dated 02/02/16 documented Cleanse Stage II coccyx with NS pat dry apply Xeroform cover with foam dressing, change QD and PRN. There was no proceeding order as of this date on the sheet at the time the copy was made. On 02/24/16 at 2:09 p.m., this surveyor accompanied Treatment Nurse/LVN B to R #4's room. As Treatment Nurse/LVN B prepared her supplies for wound care, she stated (R #4) has a Stage II to her coccyx and it is cleaned daily. It last measured 0.8 X 0.8 X 0.1 cm. I cleanse with wound cleanser, place a piece of Xeroform, and cover with Foam dressing. As of yesterday, the wound looked pink with a couple of small spots of white in the center of the wound. There is a little depth. Treatment Nurse/LVN B removed R #4's dressing on her coccyx and this surveyor saw a wound approximately the diameter of a dime with some depth. The wound bed had pink and white with yellow/tan pinpoint specks of tissue in the wound. There was no odor and the old dressing had serous drainage. There was reddness surrounding the wound. The Treatment Nurse/LVN B measured the wound and stated outloud 1 X 1 X 0.1 cm., it looks like it has a little more white today. The Treatment Nurse/LVN B again stated the wound was a Stage II Pressure Ulcer acquired in-house. The Treatment Nurse/LVN B said R #4's physician saw the wound this morning and the physician did not want to change anything until (wound specialist) was told of the wound but he will not be here until next week because he is on vacation. I called the hospice nurse for approval for an air mattress. On 02/24/16 at 2:40 p.m., this surveyor accompanied the Treatment Nurse/LVN B and the Director of Nurses (DON) to view R #4's pressure ulcer. While walking to R #4's room, the DON stated I am not good at staging ulcers. Pressure ulcers are my weak point, the staging is confusing to me. I recognize Stage I and I know a Stage IV involves the bone and muscle. The Stage II and III's is where I have trouble. The DON read outloud the NPUAP Stages For Pressure Ulcers off of R #4's February 2016 Ulcers, Surgical Site Treatment and Progress Record- Side Two. The DON confirmed the facility used the NPUAP Stages for Pressure Ulcers as a reference tool in staging ulcers. The DON looked at R #4's wound and stated I would have to say and agree with the Treatment Nurse that it is a Stage II, because she is more educated in this than I am. I see pink with a couple of white small spots with a small amount of drainage and a little depth. Interview with R #4's Physician on 02/24/16 at 3:38 p.m. revealed Yes, I saw the wound. When I saw her wound this morning, I did not see slough or anything. I am not a wound doctor. I don't know how to stage wounds or the correct treatment for [REDACTED]. I rely on the wound nurse and wound doctor's recommendations because they are more educated on wounds than I am. The nurse said she was going to ask the wound doctor about the wound next week because he is on vacation, or something like that. I'm treating her for infection of the wound, I ordered antibiotics. No, I don't know what infection she has; no culture has been taken. On 02/24/16 at 4:21 p.m., this surveyor accompanied Director of Clinical Operations (DCO) and the Division Clinical Vice President (DVP) to R #4's room to observe R #4's pressure ulcer. The DCO stated outloud I see a clean open wound with white area and some pink in the center of the wound. I agree there is a Stage II there. Interview with R #4's Hospice Registered Nurse (RN) G on 02/24/16 at 4:38 p.m. revealed she had not seen R #4's pressure ulcer since last week. RN G said last week she had seen the wound to be an open rounded wound with slough and some serous drainage. The Treatment Nurse staged it as a Stage II but I don't think it was a Stage II due to the slough. To me, the ulcer was a Stage III, because of the slough and it was getting deeper. The Treatment Nurse told me the specialist was going to see (R #4) next week because he was on vacation this week. RN G said she did not recall seeing an order to consult the wound specialist as of 02/22/16, I assumed (R #4's) physician spoke to the specialist, directly. I went ahead and ordered (R #4) an air mattress today because she is so thin and bony and any pressure could easily worsen her wound, which we see has happened. On 02/25/16 at 10:05 a.m., this surveyor accompanied the Treatment Nurse/LVN B to R #4's room and observed wound care. R #4's wound had more white and yellow tissue in the center of the wound with moderate serous drainage, redness, and maceration (softening and breaking down of skin resulting from prolonged exposure to moisture) surrounding the ulcer.The Treatment Nurse/LVN B (accompanied by the DVP) stated she called R #4's physician and got an order to change the treatment to the ulcer. The Treatment Nurse/LVN B said she had a conference call with the American Medical Technology (AMT) Representative Consultant and all were in agreement (R #4's) ulcer was an unstageable ulcer because we can't see the wound base due to it being covered with white tissue, we all agreed to use Santyl. I told (the physician) the white tissue from yesterday increased and there was redness around the wound bed. I agreed with you yesterday that the wound had worsen but after I spoke to the doctor yesterday morning he did not want to make any changes because he wanted to wait for the specialist recommendations; I just didn't want to undermine his authority. I should have just told you yesterday that it was no longer a Stage II. On 02/25/16 at 11:00 a.m., interview with the DCO, DVP, and the Administrator accompanied the Treatment Nurse/LVN B and the DON to the facility's conference room for an interview. The DON explained the facility no longer had policy and procedures and provided a copy of the facility's Skin Management Systems revised 10/2015 that took the place of the policy and procedure. The DON stated the facility also used the Perry and Potters' Clinical Nursing Skills and Techniques 8th Edition Manual for clinical resources as a reference. The Treatment Nurse/LVN B confirmed R #4 did not have current Braden assessment and should have had one when her pressure ulcer was found on 02/01/16. I forgot to do it. The Treatment Nurse/LVN B reviewed R #4's most recent Ulcers, Surgical Site Treatment and Progress Record and confirmed she documented incorrectly by not documenting there was white and yellow tissue in the wound on 02/23/16 and 02/24/16. At this time the Treatment Nurse/LVN B agreed she should have documented her exact observation of R #4's wound on 02/23/16 and 02/24/16. The Treatment Nurse/LVN B said she did not call R #4's physician on 02/23/16 when she first saw a change (white tissue) in R #4's ulcer. The DON interrupted and said yes there was a change in the ulcer then the Treatment Nurse/LVN B abruptly stood up and walked out of the room. At 1:15 p.m., the interview continued, Treatment Nurse/LVN B said she could not recall R #4's wound having a change or having white tissue in the ulcer on 02/23/16. The Treatment Nurse/LVN B said I know there was white in the wound on 02/24/16 when I first treated it in the morning. No, I did not document it. I do not remember telling you the ulcer changed on 02/23/16. This surveyor read outloud to the Treatment Nurse/LVN B her statement on 02/24/16 at 2:09 p.m. the Treatment Nurse/LVN B said oh, I don't remember that. The DON said If an assessment or documentation is inaccurate, it can effect the wound and maintenance of continuity of care. The DON confirmed each form should be completed to it's entirty, if not document the reason why. On 02/25/16 at 4:50 p.m., this surveyor reviewed R #4's updated Telephone Physician order [REDACTED]. (evaluate) and treat dated 02/19/16. Record Review of the facility's Skin Management System revised 10/2015 documented: 1. A head to toe body evaluation will be completed on every resident upon admission or readmission and weekly thereafter. These evaluations will be documented on the Weekly Skin Integrity Review form or EMR (Electronic Medical Record). If skin is intact, no further action is required. If skin is compromised, proceed to the appropriate form below. A. Pressure Ulcers, Venous Ulcers and Arterial Ulcers, and surgical sites will be documented on the Ulcer, Surgical Site Treatment and Progress Record or EMR. Use one form per wound. Wound progress is to be documented each week with measurements and wound descriptions. Daily treatments are also documented on the same form. I. treatment for [REDACTED]. .c. Keep open lines of communication with physicians, families, and residents regarding status of wounds. d. Responsible Party will be notified at the onset of an identified area as well as with all treatment changes, decline in the status of the area, and when the area is healed. Documentation of the notification is to be in the Nurses Notes in the clinical record or EMR. II. Progress of the identified area, will be documented on the back of the Ulcer, Surgical Site Treatment and Progress Record form at least every 7 days, or less if the wound shows a decline or is healed. The Physician is to be contacted after 14 days if the area has not shown improvement or immediately if it shows a decline. Documentation of the Physician notification is to be in the Nurses Notes in the chart or EMR 2. Routine weekly checks will be completed on every resident; if skin is intact it will be noted as such. If a new pressure ulcer is noted, a Ulcer, Surgical Site Treatment and Progress Record form will be started . B. CNA's (Certified Nurse Aides) will note any alteration in skin integrity during routine care on the Skin Care Alert form or EMR and turn in/reported to the Charge Nurse responsible for the resident at the time, for their attention 3. Braden Scale will be completed upon admission, with change of condition, and quarter on the Braden Scale form or the EMR . 4. Refer to Protocol for Pressure Ulcers by AMT, and/or AMT binder, for assistance with wound identification, staging, and recommended treatments. Contact physician for treatment recommendation approval . 8. Facility DON's are responsible to establish a system to monitor and assure Skin Management System Compliance. The facility's undated Protocol for Pressure Ulcers by AMT form documented: -Stage II Pressure Ulcer: Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough. May also present as an intact or open/ruptured serum-filled blister. Presents as a shiny or dry shallow ulcer without slough or bruising. This stage should not be used to describe skin tears, tape burns, perineal [MEDICAL CONDITION], maceration or excoriation. *Focus on pressure reduction . - Stage III Pressure Ulcer: Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling. Further description: The depth varies by anatomical location. Some locations do not have subcutaneous tissue and these stage III ulcers can be shallow. Bone/tendon is not visible or directly palpable. *Focus on pressure reduction . -Stage IV Pressure Ulcer: Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often include undermining and tunneling. The depth varies by anatomical location. Some locations do not have subcutaneous tissue and these stage IV ulcers can be shallow . R #8: R #8's Face Sheet dated 01/27/16 revealed R #8 was a [AGE] year-old female admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. R #8's Braden Scale for Predicting Pressure Sore Risk dated 06/09/15 documented a total score of 13. *R #8 did not have any other Braden Scale assessments in her closed clinical record. R #8's Admission Nursing Evaluation dated 06/09/15 documented R #8 had an open area to right buttock- 2 in (inch) X 2 in and left buttock less than 1 in X 1 in. R #8's MDS dated [DATE] documented R #8: -Had clear speech, made self understood, and understood others- clear comprehension; -BIMS score was 5. R #8 could not recall. -Behaviors not exhibited; -Required extensive assistance with one or two person physical assistance for bed mobility, dressing, and eating. R #8 was totally dependent with one or two person physical assistance for transfers, locomotion on and off unit, personal hygiene, and bathing; -Range of Motion: upper extremity- no impairment; lower extremity- impairment on one side; -Mobility Devices: wheelchair; -Was always incontinent of urine and bowel; -Height: 63 inches. Weight- 100 pounds. No or unknown weight loss or gain; -At risk of developing pressure ulcer. Resident has Stage 1 or higher pressure ulcer (One Stage 2). One Stage 2 Pressure Ulcer present on admit/reentry. Tissue type of ulcer at most advances stage: [MEDICATION NAME] tissue- new skin growing in superficial ulcer. It can be light pink and shiny . R #8's Telephone Physician order [REDACTED]. Resolved Stage II. R #8's Nurse's Treatment Notes dated 10/03/15 documented 10/03/15 8:45 p.m., Initials: (LVN A's initials), Treatment: Left Ischium (the curved bone forming the base of each half of the pelvis), Reason/Remarks: Stage II to Left Ischium at 0.7 X 0.9 X 0.1 cm with pink moist wound bed and [DIAGNOSES REDACTED] to peri-wound. Initiated tx (treatment). Doctor .notified. *There was no Weekly Skin Integrity Review Sheet or October 2015 Wound Treatment and Progress Record or Ulcers, Surgical Site Treatment and Progress Record that documented the discovery or details of R #8's Left Ischium Stage II Pressure Ulcer found anywhere in R #8's clinical record. R #8's Telephone Physician order [REDACTED]. Secure with clear tape q 2 days and PRN. R #8's Weekly Skin Integrity Review Sheet (side two- signed by Treatment Nurse/LVN B) documented 10/05/15: Skin Condition: Skin Intact. No other documentation was completed in this section of the block. R #8's Telephone Physician order [REDACTED]. Pat dry, apply Duoderm, secure with clear tape q 2 days and PRN. Dx (diagnosis): Stage II left Ischium. R #8's Progress Notes dated 10/10/15 (signed by LVN A) documented Stage II to Left Ischium 0.7 X 0.9 X 0.1 cm with errythema to peri-wound. No tenderness . R #8's October 2015 Ulcers, Surgical Site Treatment and Progress Record- Side One documented Discovery: 10/10/15 Diagnosis: [REDACTED]. 10/10/15: Treatment: Duoderm with clear tape q 2 days and PRN; Hour: Days, Noon, Evenings. -Drainage: M -General Appearance: P -Surrounding Skin: N -Initials: (LVN A's initials) R #8's October 2015 Ulcers, Surgical Site Treatment and Progress Record-Side Two documented: Date: 10/10/15 (signed by LVN A) documented NPUAP Stage: Stage II. L- 0.7, W- 0.9, D- 0.1 cm. Additional documentation: Redness to peri-wound, no tenderness. The same section of the form provided area for documentation under Undermining, Tunneling Depth, Process: Yes or No boxes for: Granulation, Decreased Size, Decreased Depth, Decreased Drainage; No documentation was completed in these areas of the form. R #8's Weekly Skin Integrity Review Sheet (side two- signed by LVN A) documented 10/10/15: Skin Condition: Other: Stage II left Ischium, Open Area: New. No other documentation was completed in this section of the block. R #8's Immediate Needs Care Plan: Pressure Ulcer(s) dated 10/10/15 documented: Problem/Need related to: Immobility. Resulting in location: Stage II Left Ischium. Strength to draw from: Able to communicate Needs and able to follow directions. Goals: Ulcers will be healed without complication. Interventions: Wound Status: sixe of wound: measurements of depth and width, skin color, surrounding skin tissue assessments weekly; Complaints of pain, effectiveness of pain medication per order .; Apply medicated ointment per order; Apply dressing per Order; Be alert to any signs of infection: drainage, odor, redness of surrounding tissue, red streaking up the extremity. This form was signed by Treatment Nurse/LVN B. No other input was documented on this document. A separate and additional Pressure Ulcer Care Plan dated 10/10/15 documented Problem: Alteration in skin integrity related to Dementia, decreased mobility, and Chronic Ischemic [MEDICAL CONDITION]. Goal: Stage 2 pressure ulcer will heal within 60 days. Approaches: Educate resident and RP (responsible party), Daily wound care, Assist with turning, rising, repositioning every 2-3 hours and PRN, Limit static sitting to 1 hour at any one time, Support surface for bed: pillows, Support surface for chair: Jois cushion, Dietician consult, Weekly assessment of wound, re-eval interventions q 2 weeks, Update physician on wound progress q 2-3 weeks, Risk assessment on admit, change of condition, and quarterly, Ensure adequate nutrition, Manage urinary and fecal incontinence: Wet/soiled checks q 2 hours, Assist with hygiene: q shift, Check skin condition for intactness, color, sensation, and temperature. If changes occur, call physician, Monitor dressing for signs and symptoms of infection, if present notify physician . R #8's Telephone Physician order [REDACTED]. D/C cleanse Left Ischium with NS and Duoderm . 2. Cleanse Left Ischium with NS, pat dry, apply Xeroform (a sterile, non-adhering primary dressing with 3% Xeroform), secure with dry dressing, change q day and PRN. R #8's Weekly Skin Integrity Review Sheet (side two- signed by Treatment Nurse/LVN B) documented 10/13/15 Skin Condition: Other: Stage II, open area new. No other documentation was completed in this section of the block. R #8's Nurses Notes (signed by Treatment Nurse/LVN B) dated 10/14/15 documented pt (patient) has Stage II to Left Ischium 0.6 X 1.0 X 0.1 cm, wound base is red, serous drainage, no odor, peri-wound is clear, pt has no facial grimaces while wound care being performed . R #8's October 2015 Surgical Site Treatment and Progress Record- Side One documented a subsequent entry (after 10/10/15 entry) dated 10/14/15 (signed by Treatment Nurse/LVN B revealed NPAP Stage: Stage II. L= 0.6, W= 1.0, D= 0.1 cm. Undermining= none. Additional documentation: Peri-wound has redness. Undermining= 0.1 cm. The section of the form under Additional documentation, Tunneling Depth, Process that included Yes or No boxes of: Granulation, Decreased Size, Decreased Depth, Decreased Drainage revealed no documentation was completed in these areas of the form. R #8's Weekly Skin Integrity Review Sheet (side two- signed by LVN A) documented 10/17/15: Skin Condition: Other: Stage II left Ischium. No other documentation was completed in this section of the block. R #8's Weekly Skin Integrity Review Sheet (signed by Treatment Nurse/LVN B) documented 10/20/15 Skin Condition: Other was checked but no information was documented on the line. No other documentation was completed in this section of the block. R #8's Nurses Notes (signed by Treatment Nurse/LVN B) dated 10/23/15 documented pt wound to Left Ischium Stage II has deteriorated wound is Stage III 2.3 X 1.6 X 0.1 cm, wound base is red with areas of white, slough, serous drainage, no odor, peri-wound is clear, no s/s (signs/symptoms) of infection . R #8's Weekly Skin Integrity Review Sheet (side two- signed by Treatment Nurse/LVN B) documented 10/23/15: Skin Condition: Other: Stage II left Ischium. No other documentation was completed in this section of the block. R #8's October 2015 Ulcers, Surgical Site Treatment and Progress Record- Side Two documented a subsequent entry (after 10/14/15 entry) dated 10/23/15 (signed by Treatment Nurse/LVN B revealed NPAP Stage: Stage II. L= 2.3, W= 1.6 cm. No documentation was provided under D. The section of the form under Depth, Undermining, Tunneling Depth, Additional documentation, Process that included Yes or No boxes of: Granulation, Decreased Size, Decreased Depth, Decreased Drainage revealed no documentation was completed in these areas of the form. R #8's Weekly Skin Integrity Review Sheet (side two- signed by Treatment Nurse/LVN B) had a subsequent entry (after 10/23/15 entry) that did not document the entire date, except for: 27: Skin Condition: Stage II Left Ischium. No other documentation was completed in this section of

Based on observation, interview, and record review, the facility failed to promote care in a manner that maintained or enhanced each resident's dignity and respect for four Residents (R#2, R#7, R#19 and R #14) out of 19 residents reviewed for Quality of Life. -R#2 reported she felt dirty and embarrassed due to not being shaved or provided oral hygiene. -R#7 reported he felt he smelled; was anxious and his face itched due to not being shaved and showered. -R #14 and R #19 had not recieved oral care. -The facility did not arrange for dental care for R#14 when he said he told facility staff repeatedly that he had difficulty eating due to having few teeth. The facility did not repair his bed or provide a new one for him when R#14 told them the headboard of the bed was lying on the floor behind his bed and was not attached to the bed frame. These failures could affect at least 56 residents whom depend on staff for bathing and personal hygiene and place them at risk of loss of dignity and respect that could lead to depression, low self-esteem, isolation and potential increase of health issues. The findings included: R #2: R #2's Face Sheet dated 01/24/16 documented a [AGE] year-old female admitted to the facility on [DATE] and re-admitted on [DATE] with the [DIAGNOSES REDACTED]. R #2's Quarterly Minimum Data Set ((MDS) dated [DATE] documented R #2: -had unclear (slurred or mumbled words) speech; -made self-understood and understood others; -had a memory problem; -cognitive skills for daily decision making were severely impaired; -had feelings of down or depressed; -had trouble sleeping; -required extensive assistance of one or two person physical assistance for bed mobility, transfers, locomotion on and off unit, dressing, eating, personal hygiene, and bathing; -mobility devices: wheelchair; -range of motion limitations: impairment on both sides of upper and lower extremities; -was always incontinent of urine and bowel; -had feeding tube; -had [MEDICAL CONDITION]; and -received oxygen therapy while a resident. R #2's Care Plan, updated on 01/18/16 indicated R #2 required total staff assistance with personal hygiene and bathing. The goal was that R #2 would maintain a sense of dignity by being clean, dry, odor free and well groomed through the next review date. Some of the approaches listed were to assist, provide shaving, oral care, hair care and nail care per the schedule and as needed. Another approach was to assist with the ADL's as needed. Observation of R #2 on 02/22/16 at 10:18 a.m. revealed she was being fed breakfast by Certified Nurse Aide (CNA) H. R #2's upper gums appeared red, with slight swelling, and a white film surrounding the upper teeth. R #2's chin was hairy approximately half an inch long. At 10:21 a.m., after R #2 finished her breakfast, R #2 asked CNA H if she could brush her teeth. CNA H replied When we give you a bath, we will brush your teeth. R #2 asked when is my bath. CNA H replied later. R #2 tells CNA H she needed a diaper change. CNA H said okay but I changed you before breakfast and then walked out of the room with R #2's food tray. R #2 looked at this surveyor as her eyes got watery. R #2 said no one listens to me. I feel so dirty and embarrassed about how I look; R #2's tears rolled down her cheeks. R #2 said her brief was changed around 7:45 this morning. R #2 pointed to the clock on the wall in front of her as she said it's been over two hours ago. R #2 said she frequently asked staff to brush her teeth but either gets ignored or told later but later never comes. R #2 said she would like her teeth brushed after she woke up and after meals. R #2 constantly moves her tongue around in her mouth trying to get the food particles from in between her teeth. R #2 said she had asked staff multiple times to shave her but was told we can't shave you every time. R #2 said she was tired of asking staff to shave her and she wished she could do everything herself. R #2 lifted her arms to show this surveyor the bundle of hair approximately 1 ½ to 2 inches long under both arms. R #2 removed the sheet off her right leg and presented her hairy leg approximately 2 inches long. R #2 continued to cry and said no girl should look like me. R #2 said it had been several weeks since she had been shaved. At 11:00 a.m., CNA H entered R #2's room and assisted R #2's roommate. As CNA H was walking toward the door, R #2 asked if she could get her brief changed. CNA H cleaned R #2 of incontinent feces. Again R #2 asked CNA H if she could get her teeth brushed. CNA H said It's almost lunch, I have to get residents to the dining room, I will brush them when I give you your bath. R #2 was using her right index finger to pick the food particles off her teeth. CNA H raised R #2's head of bed then R #2 asked CNA H if she could give her a piece of her chocolate candy (a Hershey's candy bar was on her bedside table). CNA H said lunch is coming, we will give it to you after lunch okay; R #2 just stared at the staff and did not reply. R #2 said I bet I won't even get a shave or my teeth brushed later. CNA H said she had not shaved R #2 before. Observation of R #2 on 02/22/16 at 1:10 p.m. revealed CNA H provided R #2 with a complete bed bath and a shave of her chin, armpits, and legs. As CNA H began to shave R #2's right leg, R #2 said Ahhhh and smiled and thanked CNA H. On 02/22/16 at 3:30 p.m., R #2 reported she had not had her teeth brushed. At 3:35 p.m., this surveyor informed the Director of Nurses (DON) and the DON asked CNA I to brush R #2's teeth. CNA I informed R #2 that he was going to brush her teeth. R #2 asked if she could eat some of her chocolate candy (still being a new bar). CNA I said, let me brush your teeth first then I will give you some. R #2 looked at CNA I with a confused look on her face and then grimaced. After CNA I brushed R #2's front teeth for a couple of seconds R #2's gums began to bleed. After only 42 seconds of brushing, CNA I said I'm going to stop because your gums are bleeding quite a bit. R #2 said Are you going to give me some candy. CNA I said You still want some, your going to mess up my work, just kidding. After CNA I gave R #2 a piece of candy, R #2 closed her eyes and said Mmmm. CNA I smiled and said Is that good; R #2 looked at this surveyor and said Excuse my language looked at CNA I and said [***] you, I've been wanting this for two days now. Both CNA I and R #2 began to laugh. Interview with the DON on 02/22/16 at 6:40 p.m. revealed this surveyor explained her observations of R #2. The DON said staff should fulfill her requests. The DON said she offered R #2 to shave her chin a couple of times last week and that R #2 declined. The DON said R #2 had not complained about the care she received. R #7: R #7's Face Sheet dated 08/25/15 indicated R #7 was admitted to the facility on [DATE] and readmitted on [DATE] with the [DIAGNOSES REDACTED]. R #7's Quarterly MDS dated [DATE] indicated he had clear speech; was understood and could understand (clear comprehension). R #7 required extensive assistance by one person for bed mobility, transfers, dressing, toilet use and personal hygiene. The MDS indicated he was totally dependent on one person's physical assistance for bathing. R #7's Care Plan, updated on 01/26/16 indicated R #7 required extensive to total staff assist with personal hygiene and bathing. The goal was that R #7 would maintain a sense of dignity by being clean, dry, odor free and well groomed through the next review date. Some of the approaches listed were to assist, provide shaving, oral care, hair care and nail care per the schedule and as needed. Another approach was to assist with the ADLs as needed. On 02/25/16 at 8:55 a.m. R #7 stated he had not been shaved. R #7 stated not being shaved made him anxious and itchy. R #7's facial hair was visible. R #7 stated he did not remember when he was last shaved and showered. He added he had told staff today and yesterday, but no one had come to shave or shower him. R #7 stated he told nursing staff, but could not name whom he had told. Licensed Vocational Nurse (LVN) E stated on 02/25/16 at 9:00 a.m. that R #7 was shaved every other day, whenever he was showered, and upon request. LVN E stated she would look at the schedule to see when R #7 was scheduled for a shower. R #7 reported on 02/25/16 at 9:10 a.m. that he had not been showered in days, and he felt like he smelled of urine. LVN E stated on 02/25/16 at approximately 9:12 a.m. that an updated list showed R#7 was showered on Tuesdays, Thursdays and Saturdays during the 2:00 p.m. to 10:00 p.m. shift. LVN E added R #7 should be showered on that day, but she could not say what time he would be showered. LVN E indicated there was documentation (shower sheets) of when R #7 was last showered. LVN E stated Medical Records (MR) F would have that documentation. MR F reported according to the last shower sheet, R #7 was showered on 02/22/16. Previous shower sheets indicated R #7 was showered on 02/11/16 and 02/16/16. R #7 was observed on 02/26/16 at 3:30 p.m. sitting in his wheelchair in the dining room, listening to music. R #7 appeared clean and no longer had growth on his face. R #7 reported he had been showered and shaved the day before (02/25/16) at 5:00 p.m. R #19: R #19's Face Sheet dated 11/19/15 documented an [AGE] year-old female admited to the facility on [DATE] with the [DIAGNOSES REDACTED]. R #19's Quarterly Minimum Data Set ((MDS) dated [DATE] documented R #19: -had no speech; -rarely/never made self-understood and rarely/never understood others; -had a memory problem; -cognitive skills for daily decision making were severely impaired (never/rarely made decisions); -required extensive assistance of one or two person physical assistance for bed mobility, transfers, locomotion on and off unit, dressing, eating, personal hygiene, and bathing; -range of motion limitations: impairment on both sides of upper and lower extremities. [MEDICAL CONDITION]; -was always incontinent of urine and bowel; -had feeding tube; and -received oxygen therapy while a resident; [MEDICAL CONDITION]. R #19's Care Plan updated 12/20/16 indicated R #19 required total staff assistance with personal hygiene and bathing. The goal was that R #19 could maintain a sense of dignity by being clean, dry, odor free and well groomed through the next review date. Some of the approaches listed were to assist, provide shaving, oral care, hair care and nail care per the schedule and as needed. Another approach was to assist with the ADL's as needed. Observation of R #19 on 02/26/16 at 1:42 p.m., accompanied by LVN E and the DON, revealed R #19 laid in her bed in a fetal position with her eyes closed. R #19's lips had white mucousy secretions that caused her top and lower lips to stick together. LVN E said she had not provided R #19 with any oral care and she did not know if the CNA had provided any oral care. Interview with CNA H on 02/26/16 at 2:02 p.m. revealed she was responsible for R #19's care. CNA H said she had not provided R #19 any oral care today. CNA H said she was expected to end her shift at 2:00 p.m. but would sponge R #19's mouth and lips before I leave. Interview with the DON on 02/26/16 at 2:03 p.m., revealed residents should recieve oral care at least every shift or PRN (as needed). R #14: Review of R#14's Face Sheet dated 02/22/16 revealed he was admitted to the facility on [DATE]. R#14's [DIAGNOSES REDACTED]. R#14 was [AGE] years old. Review of R#14's Quarterly Minimum Data Set ((MDS) dated [DATE] revealed a BIMS (Brief Interview for Mental Status) score of 11 points, indicating he had moderate cognitive impairment. Review of Physician order [REDACTED].=used to treat [MEDICAL CONDITION] or manic episodes); [MEDICATION NAME] 50 mg 1/2 tab (tablet) PO BID; [MEDICATION NAME] 50 mg PO at HS (night); and [MEDICATION NAME] 50 mg 1/2 tab PO every six hours PRN (as needed) for Major [MEDICAL CONDITION]. (Trazadone=antidepressant) In an interview while on intial tour of the facility on 02/22/16 at 8:10 a.m., R#14 said he needed his teeth fixed and needed a new bed. R#14 showed surveyor his teeth and said he needed four teeth to help him chew. Surveyor observed R#14's headboard was on the ground behind his bed and was not attached to his bed. In an interview on 02/22/16 at 10:30 a.m., R#14 said that he had trouble with his teeth. R#14 opened his mouth and pointed to his lower teeth, showing that the lower front teeth had broken off at the gum line. R#14 then ran his finger over his top gums and said, If I could have at least four teeth I could chew. Surveyor observed that R#14 had only a few teeth on his top gums. R#14 said he had not asked anyone to help him get dentures because he was told insurance would not pay for them and he did not have the money to buy them. R#14 said they won't do anything. R#14 said the food was soft most of the time and then he repeated, If I could have at least four teeth I could chew. Surveyor observed that R#14 started crying at this point and when asked why he was crying, he did not answer. In the interview on 02/22/16 at 10:30 a.m., R#14 said his broken bed was causing him problems because he was tall, 5'11, and his feet hit the footboard of the bed. R#14 said that the nurses pulled him up in bed and he did not need a longer bed, but did need his headboard attached to his bed. R#14 said he had asked for a new bed for a long time but was told they did not have one for him. In an interview on 02/22/16 at 3:10 p.m., accompanied by the Director of Nurses (DON), R#14 showed the DON his bed and the headboard which was on the floor behind his bed and not attached to his bed. The DON asked R#14 if he had told anyone about his bed being broken, and R#14 said he had told the nurses. In an interview on 02/23/16 at 9:30 a.m., the Social Worker (SW) said that R#14 did not usually come to care plan meetings. The SW said that R#14's family had not told her that R#14 needed dental care. The SW said that she sent out a letter annually to all residents and their family members, advising them of ancillary services, including dental services, that were available to residents. The SW looked through R#14's facility record and said she did not have a record of notifying R#14 or his family of ancillary services either in 2015 or 2016. The SW said she did not know whether R#14's insurance would cover dental work but she could try sending a request to the dental company that the nursing facility was contracted with. In an interview on 02/23/16 at 10:05 a.m., accompanied by the SW, R#14 said he couldn't chew well because he had no teeth. R#14 showed the SW his upper and lower gums and said If I get four teeth I can chew. I would feel great with dentures because I can chew. The SW said that R#14 went to a care plan meeting a couple of years ago but has not been to one in a while. The SW said that she would check the texture of R#14's food. In an interview on 02/23/16 at 10:30 a.m., R#14 said his food tasted good but it was hard to chew. R#14 said that he preferred to eat in his room and stayed in his room most of the time. In an interview on 02/24/16 at 10:30 a.m., accompanied by the Director of Clinical Operations (DCO), R#14 said that he wanted his bed fixed because having a headboard helped position him at night. R#14 said that he was tall but could fit in the bed all right. R#14 said that the texture of his food was usually all right but he just needed his teeth fixed. R#14 showed DCO his teeth and repeated I just need four teeth so I can chew. Review of Social Services Progress Notes for 2015 and 2016 revealed no notations regarding dental care for R#14. Review of Care Plan updated 01/20/16 revealed no plans regarding dental care for R#14. Review of facility Admission Agreement (undated) revealed the following: Annual dental exams are available for the residents by the facility-consulting dentist. The dental exam will be performed in the facility. Any corrective dental procedures will be at the expense of the resident. Results of the dental exam will become part of the resident's permanent medical record. The facility's undated Bill of Rights documented The resident has a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside this facility .No resident will be denied appropriate care on the basis of his race, religion, color, national origin, sex, age, handicap .Statement of Resident Rights: You have the right: -to all care necessary for you to have the highest possible level of health; -to be treated with courtesy, consideration, and respect . The facility's Form CMS-672 Resident Census and Conditions of Residents dated 02/22/16 indicated there were 56 residents dependant on one or two staff for bathing and personal hygiene.

Based on observation, interview and record review, the facility failed to provide medically related social services to two Residents (R #2 and R #14), who were in need of dental services. -The facility had not assessed or offered R #2 dental services. -The facility did not arrange for dental care for R#14 even though he said he told facility staff repeatedly that he had difficulty eating due to having few teeth. This failure could affect three residents who had concerns regarding oral health. The findings were: R #2: R #2's Face Sheet dated 01/24/16 documented a [AGE] year-old female admitted to the facility on [DATE] and re-admitted on [DATE] with the [DIAGNOSES REDACTED]. R #2's Quarterly Minimum Data Set ((MDS) dated [DATE] documented R #2: -had unclear (slurred or mumbled words) speech; -made self-understood and understood others; -had a memory problem; -cognitive skills for daily decision making were severely impaired; -had feelings of down or depressed; -had trouble sleeping; -required extensive assistance of one or two person physical assistance for bed mobility, transfers, locomotion on and off unit, dressing, eating, personal hygiene, and bathing; -mobility devices: wheelchair; -range of motion limitations: impairment on both sides of upper and lower extremities; -was always incontinent of urine and bowel; -had feeding tube; -had tracheostomy; and -received oxygen therapy while a resident. R #2's Care Plan, updated on 01/18/16 indicated R #2 required total staff assistance with personal hygiene and bathing. The goal was that R #2 would maintain a sense of dignity by being clean, dry, odor free and well groomed through the next review date. Some of the approaches listed were to assist, provide shaving, oral care, hair care and nail care per the schedule and as needed. Another approach was to assist with the ADL's as needed. *R #2's Care Plan did not include any directive in regards to dental services. Observation of R #2 on 02/2216 at 10:18 a.m. revealed she was being fed breakfast by Certified Nurse Aide (CNA) H. R #2's upper gums appeared red, with slight swelling, and a white film surrounding the upper teeth. At 10:21 a.m., after R #2 finished her breakfast, R #2 asked CNA H if she could brush her teeth. CNA H replied When we give you a bath, we will brush your teeth. R #2 asked when is my bath. CNA H replied later. R #2 looked at this surveyor as her eyes got watery. R #2 said no one listens to me. I feel so dirty and embarrassed about how I look; R #2's tears rolled down her cheeks. R #2 said she frequently asked staff to brush her teeth but either gets ignored or told later but later never comes. R #2 said she would like her teeth brushed after she woke up and after meals. R #2 constantly moves her tongue around in her mouth trying to get the food particles from in between her teeth. R #2 said I bet I won't even get a shave or my teeth brushed later. On 02/22/16 at 3:30 p.m., R #2 reported she had not had her teeth brushed. At 3:35 p.m., this surveyor informed the Director of Nurses (DON) and the DON asked CNA I to brush R #2's teeth. CNA I informed R #2 that he was going to brush her teeth. R #2 asked if she could eat some of her chocolate candy (still being a new bar). CNA I said, let me brush your teeth first then I will give you some. R #2 looked at CNA I with a confused look on her face and then grimaced. After CNA I brushed R #2's front teeth for a couple of seconds R #2's gums began to bleed. After only 42 seconds of brushing, CNA I said I'm going to stop because your gums are bleeding quite a bit. Interview with the DON on 02/22/16 at 6:40 p.m. revealed this surveyor explained her observations of R #2. The DON said staff should fulfill her requests. The DON stated she visited R #2 daily and had not noticed the condition of her teeth. The DON explained the facility had a contract to provide dental services for residents. The DON said she and the Social Worker (SW) were responsible for ensuring residents were provided with ancillary services, if needed. The DON said the SW had a list of residents who would be seen for dental services in the up-coming weeks. The DON said she did not see any form offering dental services in R #2's clinical record. The DON returned and stated R #2 was not on the dental care list but would immediately add her to the list. The DON said R #2 had not complained about the care she received. Review of R#14's Face Sheet dated 02/22/16 revealed he was admitted to the facility on [DATE]. R#14's [DIAGNOSES REDACTED]. R#14 was [AGE] years old. Review of R#14's Quarterly Minimum Data Set ((MDS) dated [DATE] revealed a BIMS (Brief Interview for Mental Status) score of 11 points, indicating he had moderate cognitive impairment. Review of Physician order [REDACTED]. six hours PRN (as needed) for Major Depressive Disorder. In an interview while on intial tour of the facility on 02/22/16 at 8:10 a.m., R#14 said he needed his teeth fixed and needed a new bed. R#14 showed surveyor his teeth and said he needed four teeth to help him chew. Surveyor observed R#14's headboard was on the ground behind his bed and was not attached to his bed. In an interview on 02/22/16 at 10:30 a.m., R#14 said that he had trouble with his teeth. R#14 opened his mouth and pointed to his lower teeth, showing that the lower front teeth had broken off at the gum line. R#14 then ran his finger over his top gums and said, If I could have at least four teeth I could chew. Surveyor observed that R#14 had only a few teeth on his top gums. R#14 said he had not asked anyone to help him get dentures because he was told insurance would not pay for them and he did not have the money to buy them. R#14 said they won't do anything. R#14 said the food was soft most of the time and then he repeated, If I could have at least four teeth I could chew. Surveyor observed that R#14 started crying at this point and when asked why he was crying, he did not answer. In an interview on 02/23/16 at 9:30 a.m., the Social Worker (SW) said that R#14 did not usually come to care plan meetings. The SW said that R#14's family had not told her that R#14 needed dental care. The SW said that she sent out a letter annually to all residents and their family members, advising them of ancillary services, including dental services, that were available to residents. The SW looked through R#14's facility record and said she did not have a record of notifying R#14 or his family of ancillary services either in 2015 or 2016. The SW said she did not know whether R#14's insurance would cover dental work but she could try sending a request to the dental company that the nursing facility was contracted with. In an interview on 02/23/16 at 10:05 a.m., accompanied by the SW, R#14 said he couldn't chew well because he had no teeth. R#14 showed the SW his upper and lower gums and said If I get four teeth I can chew. I would feel great with dentures because I can chew. The SW said that R#14 went to a care plan meeting a couple of years ago but has not been to one in a while. The SW said that she would check the texture of R#14's food. In an interview on 02/23/16 at 10:30 a.m., R#14 said his food tasted good but it was hard to chew. R#14 said that he preferred to eat in his room and stayed in his room most of the time. In an interview on 02/24/16 at 10:30 a.m., accompanied by the Clinical Nurse (CN) Y, R#14 said that the texture of his food was usually all right but he just needed his teeth fixed. R#14 showed CN Y his teeth and repeated I just need four teeth so I can chew. Review of Social Services Progress Notes for 2015 and 2016 revealed no notations regarding dental care for R#14. Review of Care Plan updated 01/20/16 revealed no plans regarding dental care for R#14. Review of facility Admission Agreement (undated) revealed the following: Annual dental exams are available for the residents by the facility-consulting dentist. The dental exam will be performed in the facility. Any corrective dental procedures will be at the expense of the resident. Results of the dental exam will become part of the resident's permanent medical record. According to CMS Form 802 dated 02/22/16, three residents had documented concerns with oral health.

Based on observation, interview and record review, the facility failed to ensure residents who were unable to carry out activities of daily living (bathing, showering, grooming, oral hygiene and incontinent care) received the necessary services for three Residents (R#2, R#7 and R#19) out of 16 residents reviewed who were unable to carry out ADLs (Activities of Daily Living.) -R#2 reported she felt dirty and embarrassed due to not being shaved or provided oral hygiene. -R#7 was not showered or shaved as scheduled and upon his request. -R #19 had not recieved oral care. These failures could affect at least 56 residents whom depend on staff for bathing and personal hygiene and place them at risk of loss of dignity and respect that could lead to depression, low self-esteem, isolation and potential increase of health issues. The findings included: R #2: R #2's Face Sheet dated 01/24/16 documented a [AGE] year-old female admitted to the facility on [DATE] and re-admitted on [DATE] with the [DIAGNOSES REDACTED]. R #2's Quarterly Minimum Data Set ((MDS) dated [DATE] documented R #2: -had unclear (slurred or mumbled words) speech; -made self-understood and understood others; -had a memory problem; -cognitive skills for daily decision making were severely impaired (never/rarely made decisions); -had feelings of down or depressed; -had trouble sleeping; -required extensive assistance of one or two person physical assistance for bed mobility, transfers, locomotion on and off unit, dressing, eating, personal hygiene, and bathing; -mobility devices: wheelchair; -range of motion limitations: impairment on both sides of upper and lower extremities; -was always incontinent of urine and bowel; -had feeding tube; -had [MEDICAL CONDITION]; and -received oxygen therapy while a resident. R #2's Care Plan, updated on 01/18/16 indicated R #2 required total staff assistance with personal hygiene and bathing. The goal was that R #2 would maintain a sense of dignity by being clean, dry, odor free and well groomed through the next review date. Some of the approaches listed were to assist, provide shaving, oral care, hair care and nail care per the schedule and as needed. Another approach was to assist with the ADL's as needed. Observation of R #2 on 02/22/16 at 10:18 a.m. revealed she was being fed breakfast by Certified Nurse Aide (CNA) H. R #2's upper gums appeared red, with slight swelling, and a white film surrounding the upper teeth. R #2's chin was hairy approximately half an inch long. At 10:21 a.m., after R #2 finished her breakfast, R #2 asked CNA H if she could brush her teeth. CNA H replied When we give you a bath, we will brush your teeth. R #2 asked when is my bath. CNA H replied later. R #2 tells CNA H she needed a diaper change. CNA H said okay but I changed you before breakfast and then walked out of the room with R #2 food tray. R #2 looked at this surveyor as her eyes got watery. R #2 said no one listens to me. I feel so dirty and embarrassed about how I look; R #2's tears rolled down her cheeks. R #2 said her brief was changed around 7:45 this morning. R #2 pointed to the clock on the wall in front of her as she said it's been over two hours ago. R #2 said she frequently asked staff to brush her teeth but either gets ignored or told later but later never comes. R #2 said she would like her teeth brushed after she woke up and after meals. R #2 constantly moves her tongue around in her mouth trying to get the food particles from in between her teeth. R #2 said she had asked staff multiple times to shave her but was told we can't shave you every time. R #2 said she was tired of asking staff to shave her and she wished she could do everything herself. R #2 lifted her arms to show this surveyor the bundle of hair approximately 1 ½ to 2 inches long under both arms. R #2 removed the sheet off her right leg and presented her hairy leg approximately 2 inches long. R #2 continued to cry and said no girl should look like me. R #2 said it had been several weeks since she had been shaved. At 11:00 a.m., CNA H entered R #2's room and assisted R #2's roommate. As CNA H was walking toward the door, R #2 asked if she could get her brief changed. CNA H cleaned R #2 of incontinent feces. Again R #2 asked CNA H if she could get her teeth brushed. CNA H said It's almost lunch, I have to get residents to the dining room, I will brush them when I give you your bath. R #2 was using her right index finger to pick the food particles off her teeth. CNA H raised R #2's head of bed then R #2 asked CNA H if she could give her a piece of her chocolate candy (a Hershey's candy bar was on her bedside table). CNA H said lunch is coming, we will give it to you after lunch okay; R #2 just stared at the staff and did not reply. R #2 said I bet I won't even get a shave or my teeth brushed later. CNA H said she had not shaved R #2 before. Observation of R #2 on 02/22/16 at 1:10 p.m. revealed CNA H provided R #2 with a complete bed bath and a shave of her chin, armpits, and legs. As CNA H began to shave R #2's right leg, R #2 said Ahhhh and smiled and thanked CNA H. On 02/22/16 at 3:30 p.m., R #2 reported she had not had her teeth brushed. At 3:35 p.m., this surveyor informed the Director of Nurses (DON) and the DON asked CNA I to brush R #2's teeth. CNA I informed R #2 that he was going to brush her teeth. R #2 asked if she could eat some of her chocolate candy (still being a new bar). CNA I said, let me brush your teeth first then I will give you some. R #2 looked at CNA I with a confused look on her face and then grimaced. After CNA I brushed R #2's front teeth for a couple of seconds R #2's gums began to bleed. After only 42 seconds of brushing, CNA I said I'm going to stop because your gums are bleeding quite a bit. R #2 said Are you going to give me some candy. CNA I said You still want some, your going to mess up my work, just kidding. After CNA I gave R #2 a piece of candy, R #2 closed her eyes and said Mmmm. CNA I smiled and said Is that good; R #2 looked at this surveyor and said Excuse my language looked at CNA I and said [***] you, I've been wanting this for two days now. Both CNA I and R #2 began to laugh. Interview with the DON on 02/22/16 at 6:40 p.m. revealed this surveyor explained her observations of R #2. The DON said staff should fulfill her requests. The DON said she offered R #2 to shave her chin a couple of times last week and that R #2 declined. The DON said R #2 had not complained about the care she received. R #7: R#7's Face Sheet dated 08/25/15 indicated R#2 was admitted to the facility on [DATE] and readmitted on [DATE] with the [DIAGNOSES REDACTED]. R#7's Quarterly Minimum Data Set ((MDS) dated [DATE] indicated he had clear speech; was understood and could understand (clear comprehension.) R#7 required extensive assistance by one person for bed mobility, transfers, dressing, toilet use and personal hygiene. The MDS indicated he was totally dependent on one person's physical assistance for bathing. R#7's Care Plan, updated on 01/26/16 indicated R#7 required extensive to total staff assist with personal hygiene and bathing. The goal was that R#7 would maintain a sense of dignity by being clean, dry, odor free and well groomed through the next review date. Some of the approaches listed were to assist, provide shaving, oral care, hair care and nail care per the schedule and as needed. Another approach was to assist with the ADLs as needed. R#7 stated on 02/25/16 at 8:55 a.m. that he had not been shaved. R#7 stated not being shaved made him anxious and itchy. R#7's facial hair was visible. R#7 stated he did not remember when he was last shaved and showered. He added he had told staff today and yesterday, but no one had come to shave or shower him. R#7 stated he told nursing staff, but could not name whom he had told. Licensed Vocational Nurse (LVN) E stated on 02/25/16 at 9:00 a.m. that R#7 was shaved every other day, whenever he was showered, and upon request. LVN E stated she would look at the schedule to see when R#7 was scheduled for a shower. R#7 reported on 02/25/16 at 9:10 a.m. that he had not been showered in days, and he felt like he smelled of urine. LVN E stated on 02/25/16 at approximately 9:12 a.m. that an updated list showed R#7 was showered on Tuesdays, Thursdays and Saturdays during the 2:00 p.m. to 10:00 p.m. shift. LVN E added R#7 should be showered on that day, but she could not say what time he would be showered. LVN E indicated there was documentation (shower sheets) of when R#7 was last showered. LVN E stated Medical Records (MR) F would have that documentation. MR F reported according to the last shower sheet, R#7 was showered on 02/22/16. Previous shower sheets indicated R#7 was showered on 02/11/16 and 02/16/16. R#7 was observed on 02/26/16 at 3:30 p.m. sitting in his wheelchair in the dining room, listening to music. R#7 appeared clean and no longer had growth on his face. R#7 reported he had been showered and shaved the day before (02/25/16) at 5:00 p.m. R #19: R #19's Face Sheet dated 11/19/15 documented an [AGE] year-old female admited to the facility on [DATE] with the [DIAGNOSES REDACTED]. R #19's Quarterly Minimum Data Set ((MDS) dated [DATE] documented R #19: -had no speech; -rarely/never made self-understood and rarely/never understood others; -had a memory problem; -cognitive skills for daily decision making were severely impaired (never/rarely made decisions); -required extensive assistance of one or two person physical assistance for bed mobility, transfers, locomotion on and off unit, dressing, eating, personal hygiene, and bathing; -range of motion limitations: impairment on both sides of upper and lower extremities. [MEDICAL CONDITION]; -was always incontinent of urine and bowel; -had feeding tube; and -received oxygen therapy while a resident; [MEDICAL CONDITION]. R #19's Care Plan updated 12/20/16 indicated R #19 required total staff assistance with personal hygiene and bathing. The goal was that R #19 could maintain a sense of dignity by being clean, dry, odor free and well groomed through the next review date. Some of the approaches listed were to assist, provide shaving, oral care, hair care and nail care per the schedule and as needed. Another approach was to assist with the ADL's as needed. Observation of R #19 on 02/26/16 at 1:42 p.m., accompanied by LVN J and the DON, revealed R #19 laid in her bed in a fetal position with her eyes closed. R #19's lips had white mucousy secretions that caused her top and lower lips to stick together. LVN J said she had not provided R #19 with any oral care and she did not know if the CNA had provided any oral care. Interview with CNA H on 02/26/16 at 2:02 p.m. revealed she was responsible for R #19's care. CNA H said she had not provided R #19 any oral care today. CNA H said she was expected to end her shift at 2:00 p.m. but would sponge R #19's mouth and lips before I leave. Interview with the DON on 02/26/16 at 2:03 p.m., revealed residents should recieve oral care at least every shift or PRN (as needed). The facility's undated Bill of Rights documented The resident has a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside this facility .No resident will be denied appropriate care on the basis of his race, religion, color, national origin, sex, age, handicap .Statement of Resident Rights: You have the right: -to all care necessary for you to have the highest possible level of health . According to Perry and Potter's Clinical Nursing Skills and Techniques 8th edition Reference Manual page 405, Skill 17-2: Oral hygiene: Maintenance of daily oral hygiene, including brushing, flossing, and rinsing, is essential for the prevention and control of plaque-associated oral diseases. In addition to preventing inflammation and infection, oral hygiene promotes comfort, nutrition, and verbal communication. Brushing cleans the teeth of food particles and excess toothpaste. Offer oral hygiene assistance as required .It is also your responsibility to determine the frequency that patients require oral hygiene. Plan the frequency of care based on the condition of the oral cavity and the patient's level of comfort .Assessment: .7. Determine patient's oral hygiene practices .American Dental Association (ADA) recommends brushing teeth at least twice a day with ADA-accepted [MEDICATION NAME] toothpaste and one-a-day flossng .Regular dental visits (every 6 months) are recommended by the ADA; however, frequency of visits can vary for each patient and should be determined by his or her dentist .Evidence -based protocols for bathing and oral hygiene decrease complications such as infection and skin ulceration .Adequate oral hygiene is important in preventing systemic illnesses . The facility's Form CMS-672 Resident Census and Conditions of Residents dated 02/22/16 indicated there were 56 residents dependant on one or two staff for bathing and personal hygiene.