Every finding on record at Avir at Portland

Based on observation, interview, and record review, the facility failed to ensure residents received necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new pressure ulcers from developing for 1 (Resident #1) of 5 residents reviewed for pressure ulcers.The facility failed to ensure the WCN sanitized the wound care tray adequately on 08/18/2026. The facility failed to ensure the WCN performed hand hygiene on 08/18/2026.The facility failed to ensure the WCN knew the appropriate steps for removing PPE on 08/18/2026.The facility failed to ensure the WCN knew the appropriate technique for cleaning a wound on 08/18/2026.These failures could place residents at risk for cross-contamination, delayed healing, and infection.The findings included:Record review of Resident #1's face sheet, reviewed 08/18/2026, revealed a [AGE] year-old male with an initial admission date of 12/24/2022, and a current admission date of 12/12/2024. Pertinent diagnoses included Diffuse Traumatic Brain Injury (a brain injury in which there was damage to multiple areas of the brain) and Paraplegia (a specific pattern of paralysis which affected the legs).Record review of Resident #1's Quarterly MDS Assessment, dated 08/12/2026, revealed Resident #1 had a BIMS score of 09, which indicated moderately impaired cognition. The MDS noted Resident #1 received applications of nonsurgical dressings and applications of ointments or medications. Record review of Resident #1's Physician Order Summary, revealed an order with a start date of 09/08/2025 for EBP: Practice EBP as indicated when in contact with wound every shift. There was another order, with a start date of 08/15/2026, for wound care to a Stage 2 pressure ulcer (a wound with partial thickness skin loss which did not involve deeper tissues): cleanse with normal saline or wound cleanser, pat dry with gauze, apply Triad (an ointment which was used to help a wound heal) to peri-wound (around the wound), apply collage (part of the wound dressing which promoted wound healing and stimulated new tissue growth) to wound bed, and cover with a bordered dressing three times a week.Record review of Resident #1's Care Plan focus, dated 02/05/2026, revealed EBP: Staff must use gown and gloves during high contact activities. Interventions included staff must use gown and gloves during high-contact activities. Another care plan focus, dated 08/02/2025, revealed Wound Management: Resident #1 had a Stage 2 (pressure injury) to buttocks. Interventions included provide wound care per treatment order. In an observation on 08/18/2026 at 11:30 AM, the WCN, who was also the ICP, was observed to clean the wound care tray with a wipe from a container with a purple top. The WCN turned to the surveyor and stated the purple tops required a 2 minutes set time (a kill time was the time required to let the cleanser work before using the equipment). She then turned around and started adding wound care supplies to the tray without waiting the 2 minutes. After cleaning the tray, setting up supplies, and cleaning her bandage scissors, the WCN removed dirty gloves and donned (to put on) new gloves without performing hand hygiene. The wound care nurse continued to set up tray with ointments and supplies, donned her disposable gown, and placed the tray in Resident #1's room on the bedside table without cleaning the table first. She then performed hand hygiene, donned new gloves, pulled the curtains, then went back into the hall and obtained more supplies out of the wound care cart. She then came back into room and removed Resident #1's dressing with the same gloves. After removing the old dressing, the WCN performed hand hygiene and proceeded to cleanse the wound by sporadically blotting different open areas. She then removed her gloves, performed hand hygiene with ABHS x 7 seconds, donned new gloves, and completed wound care. After completing wound care, the WCN removed gloves, performed hand hygiene x 6 seconds with ABHS, then proceeded to walk into the hallway to remove her gown.Attempted to interview Resident #1 on 08/18/2026 at 11:28 AM but he would say random things and was very difficult to understand. In an interview on 08/18/2026 at 2:23 PM, the WCN, who was also the ICP, stated she realized she had not waited long enough for the tray to be sanitized for setting up her wound care supplies because she was nervous and kept thinking about the next steps in the wound care process. She stated she patted or dabbed the wound to cleanse it because it was an open wound and she was fearful of tearing the skin or causing the wound to bleed. She stated she did not have wound care certification and had not been trained on how to properly clean a wound. She stated she did not realize she had not sanitized between gloving while setting up her tray. The WCN stated hand hygiene should be performed for 20 seconds after removing soiled gloves and before putting on clean gloves. She stated she should not have worn her gloves or gown out of Resident #1's room. In an interview on 08/18/2026 at 3:49 PM, the DON stated hand hygiene should have been performed for 20 seconds every time gloves were removed. She also stated PPE should be removed prior to exiting the resident's room and not worn into the hall. The DON stated not following correct hand hygiene and PPE policies could result in cross-contamination. Record review of the facility's Wound Care Policy, revised June 2026, revealed Preparation: 3. Assemble the equipment and supplies as needed. Steps in the Procedure:. 2. Perform hand hygiene. 7. Clean wound as indicated by Physician's order.Record review of the facility's Hand Hygiene Policy, revised January 2025, revealed Policy: This facility's infection control policies and practices are intended to facilitate maintaining a safe, sanitary, and comfortable environment and to help prevent and manage transmission of diseases and infections. Policy Interpretation and Implementation: 2. All personnel are expected to adhere to hand hygiene policies and practices to help prevent the spread of infection to other personnel, residents, and visitors. Indications for Hand Hygiene: 1. A. Immediately before touching a resident; C. After contact with blood, body fluids, or contaminated surfaces; D. After touching a resident; E. After touching a resident's environment; G. Immediately after glove removal. Applying Alcohol-Based Hand Rubs: 1. Apply generous amount of product to palm of hand and rub hands together. 3. Rub hands together in the same way as if were using soap and water. 4. Allow the sanitizer to dry (this should take around 20 seconds).Record review of the facility's Enhanced Barrier Precautions Policy, revised February 2025, revealed Policy Interpretation and Implementation: 2. EBPs employ targeted gown and glove use in addition to standard precautions during high contact resident care activities.Record review of the CDC: Long-Term Care Facilities (LTCFs): Implementation of Personal Protective Equipment (PPE) Use in Nursing Homes to Prevent Spread of Multidrug-resistant Organisms (MDROs), dated 04/02/2024, revealed Implementation: When implementing Contact Precautions or Enhanced Barrier Precautions, it is critical to ensure that staff have awareness of the facility's expectation about hand hygiene and gown/glove use. Make PPE, including gowns and gloves, available immediately outside of the resident room; . Position a trash can inside the resident room and near the exit for discarding PPE after removal, prior to exit of the room or before providing care for another resident in the same room. 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.html

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 (Resident #1) of 5 residents reviewed for infection control practices. The facility failed to ensure the WCN sanitized the wound care tray adequately on 08/18/2026. The facility failed to ensure the WCN performed hand hygiene on 08/18/2026.The facility failed to ensure the WCN knew the appropriate steps for removing PPE on 08/18/2026.The facility failed to ensure the WCN knew the appropriate technique for cleaning a wound on 08/18/2026.These failures could place residents at risk for cross-contamination and infection. The findings included:Record review of Resident #1's face sheet, reviewed 08/18/2026, revealed a [AGE] year-old male with an initial admission date of 12/24/2022, and a current admission date of 12/12/2024. Pertinent diagnoses included Diffuse Traumatic Brain Injury (a brain injury in which there was damage to multiple areas of the brain) and Paraplegia (a specific pattern of paralysis which affected the legs).Record review of Resident #1's Quarterly MDS Assessment, dated 08/12/2026, revealed Resident #1 had a BIMS score of 09, which indicated moderately impaired cognition. The MDS noted Resident #1 received applications of nonsurgical dressings and applications of ointments or medications. Record review of Resident #1's Physician Order Summary, revealed an order with a start date of 09/08/2025 for EBP: Practice EBP as indicated when in contact with wound every shift. There was another order, with a start date of 08/15/2026, for wound care to a Stage 2 pressure ulcer (a wound with partial thickness skin loss which did not involve deeper tissues): cleanse with normal saline or wound cleanser, pat dry with gauze, apply Triad (an ointment which was used to help a wound heal) to peri-wound (around the wound), apply collage (part of the wound dressing which promoted wound healing and stimulated new tissue growth) to wound bed, and cover with a bordered dressing three times a week.Record review of Resident #1's Care Plan focus, dated 02/05/2026, revealed EBP: Staff must use gown and gloves during high contact activities. Interventions included staff must use gown and gloves during high-contact activities. Another care plan focus, dated 08/02/2025, revealed Wound Management: Resident #1 had a Stage 2 (pressure injury) to buttocks. Interventions included provide wound care per treatment order. In an observation on 08/18/2026 at 11:30 AM, the WCN, who was also the ICP, was observed to clean the wound care tray with a wipe from a container with a purple top. The WCN turned to the surveyor and stated the purple tops required a 2 minutes set time (a kill time was the time required to let the cleanser work before using the equipment). She then turned around and started adding wound care supplies to the tray without waiting the 2 minutes. After cleaning the tray, setting up supplies, and cleaning her bandage scissors, the WCN removed dirty gloves and donned (to put on) new gloves without performing hand hygiene. The wound care nurse continued to set up tray with ointments and supplies, donned her disposable gown, and placed the tray in Resident #1's room on the bedside table without cleaning the table first. She then performed hand hygiene, donned new gloves, pulled the curtains, then went back into the hall and obtained more supplies out of the wound care cart. She then came back into room and removed Resident #1's dressing with the same gloves. After removing the old dressing, the WCN performed hand hygiene and proceeded to cleanse the wound by sporadically blotting different open areas. She then removed her gloves, performed hand hygiene with ABHS x 7 seconds, donned new gloves, and completed wound care. After completing wound care, the WCN removed gloves, performed hand hygiene x 6 seconds with ABHS, then proceeded to walk into the hallway to remove her gown.Attempted to interview Resident #1 on 08/18/2026 at 11:28 AM but he would say random things and was very difficult to understand. In an interview on 08/18/2026 at 2:23 PM, the WCN, who was also the ICP, stated she realized she had not waited long enough for the tray to be sanitized for setting up her wound care supplies because she was nervous and kept thinking about the next steps in the wound care process. She stated she patted or dabbed the wound to cleanse it because it was an open wound and she was fearful of tearing the skin or causing the wound to bleed. She stated she did not have wound care certification and had not been trained on how to properly clean a wound. She stated she did not realize she had not sanitized between gloving while setting up her tray. The WCN stated hand hygiene should be performed for 20 seconds after removing soiled gloves and before putting on clean gloves. She stated she should not have worn her gloves or gown out of Resident #1's room. In an interview on 08/18/2026 at 3:49 PM, the DON stated hand hygiene should have been performed for 20 seconds every time gloves were removed. She also stated PPE should be removed prior to exiting the resident's room and not worn into the hall. The DON stated not following correct hand hygiene and PPE policies could result in cross-contamination. Record review of the facility's Hand Hygiene Policy, revised January 2025, revealed Policy: This facility's infection control policies and practices are intended to facilitate maintaining a safe, sanitary, and comfortable environment and to help prevent and manage transmission of diseases and infections. Policy Interpretation and Implementation: 2. All personnel are expected to adhere to hand hygiene policies and practices to help prevent the spread of infection to other personnel, residents, and visitors. Indications for Hand Hygiene: 1. A. Immediately before touching a resident; C. After contact with blood, body fluids, or contaminated surfaces; D. After touching a resident; E. After touching a resident's environment; G. Immediately after glove removal. Applying Alcohol-Based Hand Rubs: 1. Apply generous amount of product to palm of hand and rub hands together. 3. Rub hands together in the same way as if were using soap and water. 4. Allow the sanitizer to dry (this should take around 20 seconds).Record review of the facility's Enhanced Barrier Precautions Policy, revised February 2025, revealed Policy Interpretation and Implementation: 2. EBPs employ targeted gown and glove use in addition to standard precautions during high contact resident care activities.Record review of the CDC: Long-Term Care Facilities (LTCFs): Implementation of Personal Protective Equipment (PPE) Use in Nursing Homes to Prevent Spread of Multidrug-resistant Organisms (MDROs), dated 04/02/2024, revealed Implementation: When implementing Contact Precautions or Enhanced Barrier Precautions, it is critical to ensure that staff have awareness of the facility's expectation about hand hygiene and gown/glove use. Make PPE, including gowns and gloves, available immediately outside of the resident room; . Position a trash can inside the resident room and near the exit for discarding PPE after removal, prior to exit of the room or before providing care for another resident in the same room. 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.html

Based on interviews and record review, the facility failed to ensure residents received proper treatment and care to maintain mobility and good foot health consistent with professional standards of practice for 1 (Resident #2) of 5 residents reviewed for mobility and foot health.1. The facility failed to ensure CNAs reported Resident #2 needed to be seen by Podiatry to the charge nurses between September of 2025 and August of 2026. 2. The facility failed to ensure Charge nurses reported Resident #2 needed to be seen by Podiatry to the SW between September of 2025 and August of 2026.3. The facility failed to ensure the SW scheduled follow up Podiatry appointments for Resident #2 between September of 2025 and August of 2026.These deficient practices could place residents at risk for complications and conditions related to mobility and foot health.The findings included: Record review of Resident #2's face sheet, reviewed 08/18/2026, revealed a [AGE] year-old male with an initial admission date of 05/18/2022, and a current admission date of 06/04/2025. Pertinent diagnoses included Cerebral Infarction (a type of stroke which occurs when a blood clot blocks a brain artery, leading to a loss of blood flow to a specific area of the brain), Hemiplegia and Hemiparesis (paralysis or partial weakness on one side of the body, usually from a brain or spinal cord disease/injury), and Unspecified Convulsions (seizures). Record review of Resident #2's Significant Change MDS Assessment, dated 06/06/2026, revealed Resident #2's BIMS was not conducted due to Resident #2 was rarely or never understood. The MDS Assessment revealed Resident #2 required partial or moderate assistance with personal hygiene. Record review of Resident #2's Physician Order Summary, reviewed 08/18/2026, revealed an order with a start date of 05/18/2022 for Podiatry (specialized nail and foot care) care PRN (per all Podiatry notes, Resident #2 was seen for at risk foot care and the recommendations were to follow-up every 2-3 months or as needed).Record review of Resident #2's Care Plan, dated 05/18/2022 and revised 03/06/2026, revealed a focus for chronic health conditions and co-morbid conditions which have affected physical function and may further affect quality of life . Interventions included labs as ordered. A care plan focus, initiated 08/14/2026, revealed an ADL self-care performance deficit . Interventions included Personal Hygiene: . Resident #2 needed partial or moderate assist by 1 staff to maintain personal hygiene. Record review of Resident #2's Podiatry Progress Notes, revealed a note for 06/07/2023 and 08/11/2026. The note from 06/07/2023 identified long, moderately thick, discolored nails which required debridement (to thin or reshape thick, deformed, or infected toenails) with a mechanical grinder, and sharp nail nippers. Recommendations were to follow up ever 2-3 months or as needed. The note from 08/11/2026 identified 6-10 nails were treated. Multiple conditions of the feet and nails were identified, to include, Onychomycosis (a toenail fungus), Onychocryptosis (an ingrown toenail), pain to feet and toes, and limited ambulation. In an interview on 08/18/2026 at 11:00 AM, Resident #2's family stated the facility was aware of Resident #2's issues because she had already informed the ombudsman the week prior of the concerns, and the family had taken pictures of Resident #2's feet and legs. She stated this was why Resident #2 was seen by the Podiatrist on 08/11/2026. The family stated they were told by the facility the Podiatrist came every three months to see Resident #2, but the facility had stated Resident #2 would refuse at times to let them take care of his feet. She stated this was not true because Resident #2 had not ever refused to get foot care. She stated she was not aware of how bad his nails had gotten because she was always told they were being taken care of, and she never checked them because she believed the facility was telling her the truth. She stated Resident #2 had a severe brain injury and could not comprehend everything going on with him. In an interview on 08/18/2026 at 3:09 PM, the SW stated before the facility was bought out in October of 2025, the podiatry visits for residents who were seen by podiatry were set up on a routine basis, typically every few months or as needed. She stated since the facility had changed ownership, they no longer wanted to use the same podiatrist they had previously used, so they started with a new podiatry company in May of this year (2026). The SW stated typically the CNAs notified the charge nurses if a resident's nails were bad, and if the charge nurse could not trim them, they would have let the SW know to put in a referral for podiatry. She stated no one had mentioned to her Resident #2 needed a referral to podiatry or she would have set it up. The SW stated since the facility is under new ownership, and had started using a new Podiatrist, the new requirement was the RPs must have given consent before any resident was seen by Podiatry, and if the RP had not given consent, then the resident would not be seen. She stated she sent out reminders on 08/14/2026 to all the RPs of Residents who received routine Podiatry visits notifying them consent was needed prior to treatment. The SW stated the facility had just entered the contract with the new podiatry company in May of 2026. In an interview on 08/18/2026 at 3:49 PM, the DON stated she was still trying to find out if Resident #2 had any podiatry notes between 06/07/2023 and 08/11/2026. She stated the CNAs checked residents' nails every Sunday, and they were supposed to have reported concerns to the charge nurse, who then reported the concerns to the SW. She stated she had not been made aware of any concerns with Resident #2's nails prior to the family and Ombudsman's complaint a couple of weeks ago. The DON stated with the new company, the RPs must have given consent before a resident could have been seen, and if the RP had not given consent, then the resident would not have been seen. In an interview on 08/18/2026 at 4:30 PM, CNA-A stated Resident #2 had refused care sometimes, but he usually let her take care of him. She stated last time she saw his toenails they had gotten really long. She stated she reported his nails to the charge nurse, but she was not sure how long ago it was, maybe a couple of months ago, and she could not remember which nurse she had reported it to. She stated sometimes Resident #2 was showered on the shift she was working, but usually Resident #2's was showered on a different shift, so he was usually already dressed with socks on when she saw him. In an interview on 08/18/2026 at 4:52 PM, LVN-B stated sometimes Resident #2 had bad days and refused care, but usually he was pretty agreeable. She stated she had never seen Resident #2's toenails, and no one had ever reported any issues with his toenails to her. She stated if a CNA had issues with trimming a resident's toenails, they should have reported it to the charge nurse, and if the charge nurse was unable to trim them, the charge nurse would notify the SW for a podiatry referral. LVN-B stated extremely thick, overgrown toenails placed a resident at risk for pain, wounds, and infection. A facility policy addressing nail care and podiatry was requested on 08/18/2026 at 3:30 PM, but the facility did not have a specific policy. Record review of the facility's Protocol Regarding Consents and Visits for Podiatry, Dental, Vision, and Audiology, dated 08/18/2026, revealed 1. The RP will need to sign or verbally state that the resident is able to be treated. 2. The Resident will be placed on their list. 3. The podiatry group (.) will notify social services when the next visit will be made. 4. Social Services will notify department heads and nursing staff of the next visit. 5. Social Services will let staff know of the upcoming visit. 6. During morning and clinical meetings, social services will ask if any residents have issues relating to their feet or toenails. 7. If the resident is not on the list, social services will reach out to [.podiatry group] to understand why that resident was not on the list. 8. Social Services will reach out to the family to let them know that a consent must be completed before services can be rendered. 10. Podiatry visits are done quarterly. If a resident has issues concerning their feet before the next scheduled visit, appointments can be made for a specialist in the community.Record review of the facility's Bath and Bed policy, revised March 2021, revealed Purpose: The purposes of this procedure are to promote cleanliness, provide comfort and to observe the condition of the resident's skin. Legs and Feet: E. Observe the toenails and the skin between the toes for redness and cracking of the skin. Reporting: 2. Notify the supervisor/charge nurse of any new skin issues. 4. Report other information in accordance with facility policy and professional standards of practice.

Based on interviews and record review, the facility failed to obtain laboratory services in accordance with State law for 1 (Resident #2) of 5 residents reviewed for laboratory services.The facility failed to ensure the Charge nurses ordered or followed up on required labs to monitor Resident #2's seizure medications for August 2025, February 2026, and August 2026. These deficient practices affect residents who depend on nursing care and could place residents at risk for harm or a decline in health.The findings included: Record review of Resident #2's face sheet, reviewed 08/18/2026, revealed a [AGE] year-old male with an initial admission date of 05/18/2022, and a current admission date of 06/04/2025. Pertinent diagnoses included Cerebral Infarction (a type of stroke which occurs when a blood clot blocks a brain artery, leading to a loss of blood flow to a specific area of the brain), Hemiplegia and Hemiparesis (paralysis or partial weakness on one side of the body, usually from a brain or spinal cord disease/injury), and Unspecified Convulsions (seizures). Record review of Resident #2's Significant Change MDS Assessment, dated 06/06/2026, revealed Resident #2's BIMS was not conducted due to Resident #2 was rarely or never understood. Record review of Resident #2's Physician Order Summary, reviewed 08/18/2026, revealed an order with a start date of 09/06/2022 for Keppra (a drug used to treat seizures) level every 6 months in September and March.Record review of Resident #2's laboratory results, obtained by the facility from the laboratory, dated 02/26/2025, revealed a Keppra level of 13.6, within range. The lab should have been obtained again for: 08/2025, 02/2026, and 08/2026.Record review of Resident #2's Care Plan, dated 05/18/2022 and revised 03/06/2026, revealed a focus for chronic health conditions and co-morbid conditions which have affected physical function and may further affect quality of life: . poor kidney function, . convulsions. Interventions included labs as ordered. In an interview on 08/18/2026 at 11:00 AM, Resident #2's family stated the facility was aware of Resident #2's issues because she had already informed the ombudsman the week prior of the concerns, and the family had taken pictures of Resident #2's feet and legs. She stated Resident #2 had a severe brain injury and could not comprehend everything going on with him, and she felt like the staff in the facility were not taking care of him. In an interview on 08/18/2026 at 3:49 PM, the DON stated she was still trying to find out if Resident #2 had any missing or pending laboratory results for Keppra levels since 02/26/2025. The DON stated it was the charge nurse's responsibility to place the order for labs to monitor therapeutic drug levels, and if these labs were not monitored, a resident could be out of therapeutic range, and it could have affected their health. She stated Resident #2 had not had any adverse effects or seizures she was aware of. She stated she thought Resident #2 had these labs monitored, and she had reached out to the lab and was still trying to obtain copies of these reports from the lab (ultimately, she was only able to obtain labs that had already been identified).In an interview on 08/18/2026 at 4:52 PM, LVN-B stated sometimes Resident #2 had bad days and refused care, but usually he was pretty agreeable. She was unsure why Resident #2's Keppra levels had not been checked, but she knew they needed to be checked to monitor for therapeutic levels to keep seizure controlled and determine if the medication needed to be adjusted. Record review of the facility's Lab and Diagnostic Test policy, revised November 2018, revealed Procedure: 2. Lab orders will be obtained for drugs that require therapeutic monitoring as ordered by the physician/physician extender. 9. C. Schedule repeat labs if indicated.

Based on interviews and record review, the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment were reported immediately, but not later than two hours after the allegation is made, if the events that cause the allegation involve abuse to the administrator of the facility, for 1 (Resident #1 ) of 6 residents reviewed for abuse/neglect.The facility failed to report an allegation of verbal abuse immediately to the Administrator when CNA B witnessed CNA A using foul language at the bedside within earshot of Resident #1 on [DATE] around 1:00 am. This failure could place all residents at increased risk for potential abuse due to unreported allegations of abuse.The findings were:Record review of Resident #1's face sheet revealed a [AGE] year-old female with an admission date of [DATE] and an original admission date of [DATE]. Diagnoses included respiratory failure, Stage 2 pressure ulcer of the sacrum (lower back), encephalopathy (a change in how the brain functions, including confusion or agitation. It can be temporary, or it could permanently damage the brain. It can be caused by an infection or an underlying condition. Treatment depends on the cause), gastrostomy (a minimally invasive procedure that inserts a feeding tube through the abdominal wall and into the stomach), anemia, diabetes, malnutrition, non-Alzheimer's dementia, depression, high blood pressure, severe chronic kidney disease, difficulty walking, failure to thrive, leukemia (cancer of the blood) in remission, and bone marrow transplant.Record review of Resident #1's quarterly MDS dated [DATE] revealed a BIMS score of 07, indicating severe cognitive impairment. Behaviors included delusions and inattentiveness. She was dependent on staff for personal hygiene, upper and lower body dressing, toileting, positioning, and transfers. Her active diagnosis was medically complex conditions. She was always incontinent of bladder and bowel. She received nutrition by way of a feeding tube and a therapeutic diet.Record review of Resident #1's care plan dated [DATE] revealed a focus that the resident is at risk for psychological distress and potential harm related to an allegation of verbal abuse by facility staff, compounded by cognitive impairment and limited ability to communicate concerns. Date initiated [DATE]. Interventions included 1. Monitor for signs and symptoms of physical injury, emotional distress, fearfulness, withdrawal, agitation, crying, anxiety, or changes in behavior for at least 72 hours and thereafter as indicated. 4. Ensure each resident receives care in a respectful, dignified, and supportive manner by all staff. 5. Report all allegations, suspicions, or observations of abuse, neglect, or mistreatment immediately according to facility policy and state regulations.Focus: Resident #1 has a terminal prognosis related to senile degeneration of the brain and was on hospice. Date initiated [DATE]. Goal: Resident #1's dignity and autonomy will be maintained at the highest level through the review date of [DATE]. Record review of the Provider Investigation Report (PIR) dated [DATE], corporate Termination Request Draft dated [DATE] for CNA A revealed Witness statements alleged that CNA A spoke to residents in a loud, angry, and disrespectful manner during resident care activities. One witness reported observing the employee tell a resident to shut up while providing care. Another witness reported observing the employee yell at a resident and use inappropriate language while in the resident room. Incident occurred during resident care activities on the nursing unit and involved multiple staff witnesses, including CNA B. Impact: Resident dignity and emotional well-being may have been compromised. Conduct is inconsistent with resident rights and expectations for professional caregiving. Policy Violations: Resident Rights - Dignity and Respect, Abuse Prevention Policy, Employee Conduct / Professional Behavior Standards.Observation and interview with Resident #1 on [DATE] at 10:00 am, she said she did not think any staff member had been disrespectful to her. She went on to talk about her childhood, enjoying ice cream, and wishing to speak with her deceased family member. She was lying in bed on her back with her head raised, dressed in clean clothes, and her hair combed. There were no foul odors and her room was neat.In an interview with the DON on [DATE] at 10:10 am, she said between 8:30 & 9:30 am on [DATE], CNA B approached her in her office and alleged verbal abuse by CNA A toward Resident #1 on [DATE] around 1:00 am. The DON said CNA B told her that she was in Resident #1's room heard the alleged verbal abuse by CNA A. She said CNAs A and C were attending to Resident #1, and Resident #1 was trying to pull on her feeding tube. The DON said she had recently (about a week) been investigating CNA A for poor performance (not changing patients) before this incident. The DON said CNA A did not fight the allegation nor admit the allegation when she spoke to her about the allegation of verbal abuse. The DON said CNA A told her she had been overwhelmed lately, but not with work, and did not want to tell her what was going on with her. The DON said CNA A had already left the faciity on [DATE] by the time she arrived at the facility on the morning of [DATE] around 8:00 am, but spoke with CNA A that afternoon. She said CNA A was suspended, then terminated on the 3rd or 4th day after the allegation. She said during a phone call, CNA A told her if she was getting fired, she would just rather not come back, and corporate said that was fine. The DON said she reported the allegation to the ADM, who came to her office immediately.In an interview with CNA B on [DATE] at 11:23 am, she said she had worked with CNA A for about 2-3 months. She said CNA A was always negative. She would speak disrespectfully to residents who could not defend themselves. Things like, Oh, look, you shit the bed or arguing/refusing to take care of one of the residents that had scabies, or within earshot of a resident that had a rash [not scabies]. CNA B said she was in Resident #1's room on [DATE] around 1:00 am, waiting for help with peri care from CNA A, when she heard CNA A call Resident #1 a bitch. She said she told CNA A she can't say things like that, and CNA A just looked at her. She said Resident #1 was messing with her feeding tube. She said CNA A was speaking sternly to Resident #1 to stop messing with it, which she did, turned to her and said loudly, This Bitch won't stop messing with her tube. CNA B said she told a couple of other (unnamed) CNA's and they told her she should report it, but she waited until about 9 or 10 am because she was pondering if she should report it because she knew CNA A's daughter was having a wedding soon, and she knew she was stressed and did not want to jeopardize CNA A's position. CNA B said she ultimately chose to report the allegation of verbal abuse by CNA A in person to the DON at the facility (the same day, [DATE], around 9:00 am) after going home and taking her daughter to school because it was the right thing to do for the residents. She said she spoke with the DON, the ADON, and the ADM. CNA B said she knew better and that she should have called immediately, especially in light of CNA A's past actions. CNA B said she had never been in that position before.In an interview with the ADON on [DATE] at 12:27 pm, she said CNA B reported to her on [DATE] around 10:00 am that CNA A kept redirecting Resident #1 to not mess with her feeding tube then told CNA B, this bitch keeps messing with her g tube in earshot and not in a whisper and CNA B said, it just didn't feel right. The ADON said CNA A told her on the afternoon of [DATE] that she had not heard of anyone being inappropriate, and she had been frustrated that night because two residents were very busy. The ADON said CNA A told her she did not tell anyone she had been frustrated and denied saying anything inappropriate to Resident #1, but did say Resident #1 had kept messing with her g-tube. The ADON said she was present during the corporate and CNA A's meeting, and CNA A told corporate the same thing; Just that she was frustrated and Resident #1 was messing with her g-tube. The ADON said CNA B told her that she told CNA A she can't say that. The ADON said CNA A had been a CNA for about 2 years. The ADON said the next steps were in-services for all staff about reporting allegations immediately, suspending CNA A, getting statements from staff, and conducting safe surveys with the residents. The ADON said, Having an eyewitness and how [CNA A] presented herself negatively in her tone, rude came across as rude, and the residents were not children. Customer service was key and CNA A saying things such as stop doing that to redirect instead of asking if Resident #1 needed anything was unacceptable. The ADON said CNA A asked if she was going to get fired and if so, could it be over the phone. The ADON said CNA A's face said it all, meaning she knew she was caught. In an interview with CNA C on [DATE] at 1:20 pm, she said she had been a CNA for 2 years and worked at the facility after she passed the CNA class. She said she had been trained on abuse and reporting last on [DATE], she thought. She said the training was about speaking up if they heard or saw inappropriate behavior between staff & residents, resident to resident, or staff to staff, and telling the ADM immediately. She said she was not sure about the 2-hour limit. She said she was not at the facility on [DATE].In an interview with CNA D on [DATE] at 1:35 pm, she said she worked at the facility for 2 years after she passed the CNA program. She said she was trained on abuse and reporting two weeks ago. She said she had worked with CNA A before, and she would rather do it herself than ask CNA A to help because of her negative attitude. CNA D said, About a week ago, we were showering a resident who was obese and self-conscious about it. CNA A was holding her nose during his shower and saying things like 'are we done already, ' and it obviously made him feel bad because she could see it in his face, and after she said that he wanted to end his shower. She said she told the nurse and ADON about it. She said CNA A complained about everything except her job-staffing, management, and she was pretty much getting paid for nothing. In an interview with CNA E on [DATE] at 1:49 pm, she said she worked at the facility for 2 years after finishing the CNA classes. She said the last time she was trained on abuse was a month ago during an in-service. She said the in-service covered abuse-see it, hear it, who to call ADM [Abuse coordinator] or nurse immediately. She said she couldn't remember the exact timeframe for reporting. In an interview with the ADM on [DATE] at 3:32 pm, she said she was unaware of CNA A's behavior until this incident, when CNA B spoke about it, then incidentally, when the ADON conducted staff interviews. She said the incident occurred on [DATE] around 1:00 am, but was not reported to her by the DON until [DATE], around 9:00 or 9:15 am, at which time she reported the alleged verbal abuse to the state authority. She said CNA B told her she did not report right away because she was going back and forth in her head about it, and finally decided it was the right thing to do. She said she called the corporate team, who assisted and participated in the investigation and final determination of termination. She said the corporate team participated in the abuse reporting and all staff in-services. She said the frequency of the training was at least monthly, whenever there was an incident, and in the quarterly training modules. She said an ad hoc QAPI (Quality Assessment and Performance Improvement Plan) was done on [DATE].CNA A was unavailable for interview.Record review of CNA A's personnel file revealed she had no previous allegations of abuse or disciplinary action. Her signature was noted on the employee handbook validation page. Record review of the Record of Employee Counseling form dated [DATE] for CNA A revealed Termination due to alleged misconduct based on an internal investigation.Record review of in-service training: [DATE]-Patient/Resident Rights. [DATE]- Abuse, Neglect, and Reporting. [DATE]-Professional courtesy and Customer Service. Record review of the facility employee handbook dated Dec. 2025.You are expected to treat all residents and patients with respect. You are expected to approach customers, clients, residents, patients, and families in a professional, courteous, and efficient manner.Record review of an ad hoc QAPI dated [DATE] under Identified Concerns: Reporting Abuse, Neglect, and Exploitation Timely Abuse Neglect and Exploitation; Education and In-Service have been completed.Record review of the facility policy revised [DATE] titled, Abuse, Neglect, Exploitation and Misappropriation Prevention Program, under 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. Under Policy Interpretation: 1. Protect residents from abuse, neglect, exploitation, or misappropriation of property by anyone, including, but not necessarily limited to: a. facility staff.5. Establish and maintain a culture of compassion and caring for all residents and particularly those with behavioral, cognitive, or emotional problems. 9. Investigate and report any allegations within timeframes required by federal requirements.Record review of the facility policy revised [DATE] titled, Abuse, Neglect, Exploitation or Misappropriation -Reporting and Investigating, Reporting Allegations to the Administrator and Authorities: 1. If resident abuse, neglect, exploitation, misappropriation of resident property, or injury of unknown source is suspected, the suspicion must be reported immediately to the administrator and to other officials according to state law and HHSC (Health and Human Services Commission) reporting guidelines. 3. Immediately is defined as: a. within two hours of an allegation involving abuse or result in serious bodily injury; or b.within 24 hours of an allegation that does not involve abuse or result in serious bodily injury.Record review of the facility policy revised [DATE] titled, Identifying Types of Abuse, under Policy interpretation: 1. Abuse of any kind against residents is strictly prohibited. 4. Abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. c.Abuse includes verbal abuse, sexual abuse, physical abuse, and mental abuse, including abuse facilitated or enabled through the use of technology. Mental and Verbal Abuse: 1. Mental abuse is the use of verbal or non-verbal conduct which causes ( or has the potential to cause) the resident to experience humiliation, intimidation, fear, shame, agitation, or degradation. 2. Verbal abuse may be considered to be a type of mental abuse. Verbal abuse includes the use of verbal, written, or gestured communication, or sounds, to residents within hearing distance, regardless of age, ability to comprehend, or disability. 3. Examples of mental and verbal abuse include, but are not limited to: a. harassing a resident; b. mocking, insulting, ridiculing; c. yelling or hovering over a resident, with the intent to intimidate. Psychosocial Outcomes: 1. Some situations of abuse do not result in an observable physical injury, or the psychosocial effects of abuse may not be immediately apparent. In addition, the alleged victim may not report abuse due to shame, fear, or retaliation. Other residents may not be able to speak due to a medical condition and/or cognitive impairment (e.g., stroke, coma, Alzheimer's disease), cannot recall what has occurred, or may not express outward signs of physical harm, pain, or mental anguish. Neither physical marks on the body nor the ability to respond and/or verbalize is needed to conclude that abuse has occurred.

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 to help prevent the development and transmission of disease and infection for one (Resident #1) of five residents reviewed for infection control, in that:On 05/23/2026, CNA A did not remove her contaminated gloves nor performed hand hygiene after touching multiple surfaces prior to initiating Resident #1's perineal care. Additionally, CNA A failed to perform hand hygiene and gloves changes while performing incontinent care. These failures could place residents at risk for contamination and infection.The findings included:Record review of Resident #1's admission record dated 05/23/2026 revealed, Resident #1 was an [AGE] year-old-female who initially was admitted on [DATE]. Resident #1 was admitted with multiple diagnoses including chronic obstructive pulmonary disease (breathing restriction), chronic atrial fibrillation (heart disease), chronic diastolic (congestive) heart failure (heart failure), and vascular dementia (impaired cognition). Record Review of Resident #1's Quarterly MDS dated [DATE] revealed BIMS of 9 indicating severe cognitive impairment and was dependent on staff for ADLs. Resident #1 was not coded for having any form of infections. Record review of Resident #1's Care Plan date revision on: 03/12/2026 [Resident #1] is at risk for infection or recurrent/chronic infection r/t compromised medical condition: Co-Morbid Disease [Resident #1] will be free from S/S of infections and any complications related to infection through the review date. Administer medication and/or antibiotics as per MD orders Monitor vital signs as indicated. Allergies Albuterol, Docusate [D.O.B.] Report changes in condition to MD as clinically indicated. Review and update immunization record as indicated. Provide education to team members, [Resident #1] and/or visitors regarding infection prevention practices as indicated.During an observation of incontinent care on 05/23/2026 at 11:32AM revealed CNA A washed her hands for 20 seconds using soap and water then proceeded to close the entry door using her foot and hip, then returned to Resident #1's bedside. CNA A closed the curtain with her clean gloved hands, pulled the blankets back, removed the pillows, removed the brief flaps, and rolled Resident #1's brief down with the same gloved hands. CNA A then retrieved clean wipes and cleaned Resident #1's perineal area. After completion of cleaning Resident #1's perineal area, CNA A turned Resident #1 to the left side, removed the soiled brief, then proceeded to clean Resident #1's gluteal area. CNA A then retrieved a clean brief, then attached the clean brief on Resident #1. Throughout the incontinent care CNA A did not change her gloves nor complete any form of hand hygiene. During an interview on 05/23/2026 at 11:46AM CNA A stated she typically did not change gloves after touching the resident's surrounding at it is the Resident #1's personal space however reflecting on the possibility of contracting microorganism, she stated she should have changed her gloves and completed hand hygiene once she touched Resident #1's curtain, blanket, and pillows to promote infection control. CNA A stated that she was unaware that she had to change her gloves and complete hand hygiene when she cleaned Resident #1's perineal area to Resident #1's gluteal area. CNA A stated she could not recall if she was supposed to change gloves when cleaning from the perineal area to the buttocks area, however, would now ensure she performs hand hygiene prior to turning the resident to clean the buttock area. CNA A stated by not completing hand hygiene and gloves changes for the two instances the resident could have contracted germs which could negatively impact the resident. CNA A reiterated she will now ensure she completes hand hygiene according to the CDC recommendations. During an interview on 05/23/2026 at 12:01PM with ADON A and the DON, both stated while reviewing the observation of Resident #1, the facility followed the CDC guidelines regarding when to perform hand hygiene. Both stated CNA A should have removed her gloves and completed hand hygiene after she touched Resident #1's curtain, blanket and pillow, and secondly prior to turning Resident #1 to her side to clean Resident #1's buttock. Both stated by not changing gloves and performing hand hygiene there could be a cross contamination and could negatively affect Resident #1. Both stated they would rectify the issue and commence an impromptu in-service regarding hand hygiene, gloving up, and incontinent care.Record review of the facility Handwashing/Hand Hygiene policy updated 01/2025 revealed, hand hygiene is indicated 1. Immediately before touching a resident, after contact with blood, body fluids, or contaminated surfaces; after touching the resident's environment; before moving from work on a soiled body site to a clean body site on the same resident, and immediately after glove removal.Record review of the CDC guidelines Clinical Safety: Hand Hygiene for Healthcare Workers updated on 02/27/2024 revealed Know when to clean your hands, - Immediately before touching a patient.- Before moving from work on a soiled body site to a clean body site on the same patient- After touching a patient or patient's surroundings- After contact with blood, body fluids, or contaminated surfaces- Immediately after glove removal.

Based on interview and record review, the facility failed to ensure residents were free from significant medication errors for 1 of 5 residents (Resident #1) reviewed for pharmacy services. The facility failed to ensure Resident #1's blood pressures were assessed prior to administering Metoprolol (a medication used to treat high blood pressure) per the prescribed order and blood pressure parameters in February and March of 2026. This failure could have placed residents at risk for complications and jeopardized their health and safety.The findings Included: Record review of Resident #1's face sheet, dated 03/18/2026, revealed a [AGE] year-old female with an admission date of 02/24/2026 and a discharge date of 03/11/2026 at 6:55 PM. Pertinent diagnosis included Essential Primary Hypertension (high blood pressure).Record review of Resident #1's physician orders, started 02/24/2026, revealed an order for Metoprolol 12.5 MG, give one tablet by mouth four times a day for Hypertension. Hold for systolic (the top number which measures the force of the blood against the arterial walls as the heart beats) blood pressure less than 110 or diastolic (the bottom number which measures the force of the blood against the arterial walls while the heart was at rest) blood pressure less than 60.Record review of Resident #1's care plan tab, reviewed 03/18/2026, revealed she had no comprehensive care plan. Record review of Resident #1's March 2026 MAR revealed Metoprolol 12.5 MG, give one tablet by mouth four times a day for Hypertension. Hold for systolic blood pressure less than 110 or diastolic blood pressure less than 60. There were no blood pressures listed in the MAR to coincide (reflect or occur at the same time) with this medication. The times listed for medication administration were 9:00 AM, 12:00 PM, 5:00 PM, and 9:00 PM.Record review of Resident #1's vital signs revealed no blood pressures were taken at times to coincide with the blood pressure medication administration record on the following dates: 02/25/2026 at 12:00 PM, 02/25/2026 at 5:00 PM; 02/26/2026 at 9:00 AM, 02/26/2026 at 5:00 PM; 02/27/2026 at 12:00 PM, 02/27/2026 at 5:00 PM, 02/27/2026 at 9:00 PM; 02/28/2026 at 9:00 AM, 02/28/2026 at 12:00 PM, 02/28/2026 at 5:00 PM, 02/28/2026 at 9:00 PM; 03/01/2026 at 9:00 AM, 03/01/2026 at 12:00 PM, 03/01/2026 at 5:00 PM, 03/01/2026 at 9:00 PM; 03/02/2026 at 12:00 PM, 03/02/2026 at 5:00 PM, 03/02/2026 at 9:00 PM; 03/03/2026 at 12:00 PM, 03/03/2026 at 5:00 PM; 03/04/2026 at 9:00 AM, 03/04/2026 at 12:00 PM, 03/04/2026 at 5:00 PM, 03/04/2026 at 9:00 PM; 03/05/2026 at 9:00 AM, 03/05/2026 at 12:00 PM, 03/05/2026 at 5:00 PM, 03/05/2026 at 9:00 PM; 03/06/2026 at 9:00 AM, 03/06/2026 at 12:00 PM, 03/06/2026 at 5:00 PM, 03/06/2026 at 9:00 PM; 03/07/2026 at 12:00 PM, 03/07/2026 at 5:00 PM, 03/07/2026 at 9:00 PM; 03/08/2026 at 12:00 PM, 03/08/2026 at 5:00 PM; 03/09/2026 at 9:00 AM, 03/09/2026 at 12:00 PM, 03/09/2026 at 5:00 PM, 03/09/2026 at 9:00 PM; 03/10/2026 at 12:00 PM, 03/10/2026 at 5:00 PM, 03/10/2026 at 9:00 PM; and 03/10/2026 at 12:00 PM, 03/10/2026 at 5:00 PM. There was no documentation Resident #1 had and signs or symptoms of negative effects on these days the blood pressure medications was given without first checking the resident's blood pressure. In an interview on 03/19/2026 at 2:55 PM, the NP stated blood pressures should be checked prior to administering blood pressure medications, otherwise, you would not be able to tell if the Resident actually needed the medication. If a blood pressure medication is given outside of parameters, it could affect the resident's health. In an interview on 03/19/2026 at 4:00 PM, the ADON stated nurses should have checked the blood pressures prior to administering the blood pressure medication because it was required, and if blood pressure was already low, the blood pressure medication could have caused the blood pressure to continue to drop, placing the resident's health at risk. She stated the nurses had previously been in-serviced over this topic. In an interview on 03/19/2026 at 6:55 PM, the RNC stated nurses should always check the blood pressure prior to administering the blood pressure medication because if a blood pressure was already low, and the blood pressure medication was administered, the blood pressure could have continued to drop, and the resident's blood pressure could have bottomed out, causing potential health risks for the resident such as dizziness, blurred vision, fainting, or even possibly shock. She stated she could only find a few blood pressures recorded in Resident #1's MAR and vital signs to coincide with the blood pressure medication, and this was because they were being taken for another medication being administered.In an interview on 03/19/2026 at 6:55 PM, the DON stated blood pressures should be assessed prior to administering blood pressure medication or it could have caused the resident to have side effects from the medication, such as blood pressure dropping too low. He stated the RNC could only find the same few blood pressures the nurse surveyor had already pointed out in Resident #1's MAR and vital signs to coincide with the blood pressure medication. He stated the physician had been informed, but the resident was no longer here and there were no negative effects. Record review of the National Institute of Health: National Library of Medicine, dated January 2020, revealed Blood Pressure Assessment in Adults in Clinical Practice and Clinic Based Research: The accurate measurement of blood pressure is essential for the diagnosis and management of hypertension. Statistical Considerations: The diagnosis of hypertension and evaluation of response to treatment require accurate assessment of blood pressure to prevent under or over treatment. https://pmc.ncbi.nlm.nih.gov/articles/PMC6573014/Record Review of the facility's Administering Medications policy, revised April 2019, revealed Policy: Medications are administered in a safe and timely manner, and as prescribed. Policy Interpretation and Implementation: 11. The following information is checked/verified for each resident prior to administering medications: b. Vital signs, if necessary.

Based on interview and record review the facility failed to ensure the comprehensive care plan was developed and implemented for each resident consistent with resident rights to include measurable objectives and timeframes to meet residents medical, nursing, mental, and psychosocial needs identified in the comprehensive assessment for 2 of 5 residents (Resident #1 and Resident #2) reviewed for care plans.The facility failed to develop the comprehensive care plans for Resident #1 and Resident #2.These failures could place residents at risk of receiving improper or inadequate care and services.The findings included:1. Record review of Resident #1's face sheet, dated 03/18/2026, revealed a [AGE] year-old female with an admission date of 02/24/2026 and a discharge date of 03/11/2026 at 6:55 PM. Pertinent diagnosis included Essential Primary Hypertension (high blood pressure).Record review of Resident #1's admission MDS, dated [DATE], revealed a BIMS score of 09, moderately impaired cognition. MDS also revealed assessment signed as completed on 03/04/2026.Record review of Resident #1's care plan tab, reviewed 03/18/2026, revealed Resident #1 had no comprehensive care plan.2. Record review of Resident #2's face sheet, dated 03/19/2026, revealed a [AGE] year-old male with an original admission date of 02/17/2026, a current re-admission date of 03/06/2026. Pertinent diagnosis included Encounter for Surgical Aftercare Following Surgery on the Circulatory System.Record review of Resident #2's care plan tab, reviewed 03/19/2026, revealed Resident #2 had no comprehensive care plan.Record review of Resident #2's BIMS evaluation, dated 02/17/2026, revealed a BIMS score of 15, cognition intact. In an interview on 03/19/2026 at 9:20 AM, the MDS nurse stated if there was not a care plan under the care plan tab, then one was never opened or created. She stated at one point she did mention in the morning meeting a care plan for Resident #1 and Resident #2 needed to be opened because she was not able to create or open a care plan. The MDS nurse stated there was only one RN who other than the DON who could open or create a care plan. The MDS nurse stated once the care plan had been opened, she went in and updated the clinical aspect of the care plan. She stated she typically went by a three-day rule after admission to have comprehensive care plans opened in the chart. In an interview on 03/19/2026 at 12:55 PM, the DON stated care plans were utilized to determine the care and needs of a resident, and any of the IDT could have initiated, opened or created the care plan, but it was closed by the DON, or another RN. The DON stated he could find the baseline care plans for Resident #1 and Resident #2, which he showed to nurse surveyor, but he was unable to find the comprehensive care plans. He was unsure why the comprehensive care plans were not completed, but stated the responsibility ultimately fell back on him to verify care plans had been completed. Record review of the facility's Comprehensive Care Plans policy, revised March 2022, revealed Policy Statement: A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. Policy Interpretation and Implementation: 1. The IDT, in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident. 2. The comprehensive, person-centered care plan is developed within seven days of the completion of the required MDS assessment (Admission, Annual or Significant Change in Status).

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 (Resident #2) of 5 residents reviewed for infection control practices.The facility failed to ensure Resident #2 received wound care consistent with best practices and facility policies and procedures on 03/19/2026, when during wound care with Resident #2, the NP and the WCN incorrectly donned PPE (to don PPE means to put on personal protective equipment) prior to wound care, performed improper hand hygiene during wound care, incorrectly cleansed the wound during wound care, incorrectly performed wound care, incorrectly disposed of contaminated trash and supplies during wound care, and incorrectly cleaned supplies after wound care. These failures could place residents at risk for the wrong PPE being utilized, cross-contamination, and possible infection.The findings included:Record review of Resident #2's face sheet, dated 03/19/2026, revealed a [AGE] year-old male with an original admission date of 02/17/2026, a current admission date of 03/06/2026. Pertinent diagnosis included Encounter for Surgical Aftercare Following Surgery on the Circulatory System.Record review of Resident #2's physician orders, with a start date of 03/09/2026, revealed an order to cleanse right foot surgical site with Dakins solution, rinse with normal saline, pat dry, apply adaptic (sterile, non-adherent wound dressing) to wound bed, apply alginate ag (highly absorbent wound dressing), lightly pack wound bed if needed, cover with ABD pad (highly absorbent wound dressing), wrap with Kerlix (a gauze used to wrap wounds), and secure with tape. Orders also revealed an order for EBP, started 03/09/2026: Practice EBP as indicated when in contact with wound and/or PICC line. Record review of Resident #2's care plan tab in PCC revealed Resident #2 did not have a comprehensive care plan. In an observation on 03/19/2026 at 1:45 PM, it was observed the WCN and the NP had set everything up prior to notifying the surveyor of the wound care. After performing hand hygiene, both the WCN and the NP only donned gloves. The did not don a disposable gown prior to wound care. There was no clean barrier placed between Resident #2's wounds to right foot and dirty sheet the resident was lying on. The NP was noted to lean over the wound, allowing her hair to fall around the wound. The WCN was observed to cleanse the wound inappropriately, cleansing from the outside to the inside (dirtiest to cleanest area of the wound). She then removed the dirty gloves and applied hand sanitizer, but did not rub all areas of her hands until thoroughly dry, and reapplied new, clean gloves. The WCN was noted to apply medicated gel to the wound bed, but when the gel ran down Resident #2's foot, the WCN wiped the unclean, bottom of the foot with gauze and clean gloves, then continued to perform wound care without performing hand hygiene and applying new, clean gloves. The WCN was noted to put some trash from wound care onto her clean barrier on the tray in which she had placed the clean wound care supplies. The WCN was noted to perform hand hygiene and put on clean gloves prior to grabbing the dirty tray and taking it to her treatment cart to clean with sanitizing wipes. The WCN did not have any sanitizing wipes on her cart, so she proceeded to carry the tray throughout the facility until she could find sanitizing wipes to clean the tray. In an interview on 03/19/2026 at 2:55 PM, the NP stated she and the WCN should have put on the appropriate PPE prior to entering Resident #2's room for wound care, to include gloves and a gown. She stated EBP was used to protect the patient and prevent cross-contamination. The NP stated she was leaning over the wound, but she did not think her hair touched the wound. She stated her hair would not stay back, but she should have raised the bed or gotten eye level with the wound instead of leaning her head over the wound. In an interview on 03/19/2026 at 3:05 PM, the WCN stated she should have put on the appropriate PPE, to include a gown, prior to entering Resident #2's room. She stated EBP was used to protect the patient and prevent cross-contamination. She stated she did not typically put a clean barrier between Resident #2's leg/foot and the sheets on the bed because she did not think it was necessary unless the wounds had a lot of drainage and could not be contained. The WCN stated she knew wounds were supposed to be cleaned from the inner to outer so as to not create cross-contamination and re-introduce germs or bacteria back into the wound. She also stated she should have performed hand hygiene and applied clean gloves after wiping the dirty area of the bottom of Resident #2's foot. The WCN also stated after applying alcohol-based hand sanitizer she should have rubbed her hands for at least 20 seconds and until dry prior to putting on new gloves. The WCN stated she usually kept sanitizing wipes on her cart to wipe her equipment down after wound care, but someone must have borrowed them.In an interview on 03/19/2026 at 4:00 PM, the ADON stated EBP was utilized for high contact activities such as wound care, dressing, bathing, transferring, and changing linens. She stated the order for EBP should specify high contact activities and not just wound care. She stated the required PPE to perform wound care for Resident #2 would consist of a gown and gloves if no splash back was expected. The ADON stated nurses should perform hand hygiene between glove changes when going from clean to dirty and back to clean. The ADON stated the wound should be cleansed from the inner to the outer of the wound, cleaning from cleanest area to dirtiest area; otherwise, they could possibly reintroduce bacteria back into the wound. Record review of the facility's Enhanced Barrier Precautions policy, revised February 2025, revealed Policy Statement: Enhanced Barrier Precautions (EBP) refers 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. Policy Interpretation and Implementation: 2. EBPs employ targeted gown and glove use in addition to standard precautions during high contact resident care activities when contact precautions do not otherwise apply. 3. Examples of high contact resident care activity requiring the use of gown and gloves for EBPs include: dressing, bathing/showering, transferring, providing hygiene, changing linens, changing briefs, assisting with toileting, device care or use, wound care.Record review of the facility's Hand Hygiene policy, Revised October 2023, revealed Policy Statement: This facility considers hand hygiene the primary means to prevent the spread of healthcare-associated infections. Policy Interpretation and Implementation: Indications for Hand Hygiene: 1. Hand hygiene is indicated: c. after contact with blood, body fluids, or contaminated surfaces; f. before moving from work on a soiled body site to a clean body site on the same resident. Applying Alcohol-Based Hand Rubs: 2. Cover all surfaces of hands and fingers until hands are dry. 3. Rub hands together for a minimum of 15 seconds.

Based on observations, interviews, and record reviews the facility failed to ensure food was stored, prepared, distributed, and served in accordance with professional standards for food service safety in one of one kitchen reviewed for dietary services. 1. The facility failed to ensure the ice machine was clean. 2. The facility failed to ensure food/ drink items in the reach-in refrigerators and freezers, dry storage area, and kitchen area were properly stored, labeled, and dated. 3. The facility failed to ensure cleaned dishes did not have food or beverage residue in or on them. 4. The facility failed to ensure the floor, dish washing machine, and dirty and clean dish washing tables did not have food residue and other trash on them. 5. The facility failed to ensure the dish machine temperature and sanitizing log was filled out 3 times a day. These failures could place residents who received meals and/or snacks from the kitchen at risk for food contamination and food borne illness. Initial tour and observation of the kitchen on 09/07/25 beginning at 11:01 AM revealed the following: The ice machine had a black colored substance on the inside left side wall near the hinge attachment of the lid. The ice machine lid had a rusty screw/washer on the inside left side hinge attachment of the lid. The ice machine had a rust-colored substance on the inside left side wall near the hinge attachment of the lid. The ice machine had a rust-colored substance on the left hinge attachment of the lid. The ice machine had a black colored substance on the inside of the lid along the back edge. The ice machine had a black colored substance on the inside right-side wall near the hinge attachment of the lid. The ice machine had a stripe of a black colored substance on the left side where the lid closed against the machine. The ice machine had a stripe of a black colored substance on the right side where the lid closed against the machine. A clear empty pitcher on the top of the metal table between the ice machine and microwave had a white colored film covering much of the inside of the pitcher. A tray on top of the metal table in front of the microwave had a spot of a reddish colored substance on it. The tray also had 12 sets of clean silverware individually wrapped in napkins on it. A box on the floor with a watermelon in it on the left side of the reach-in refrigerator. A box on the floor with flour tortillas in it on the right side of the DM's office. Observation of the facility's reach-in refrigerator on 09/07/25 beginning at 11:15 AM revealed the following: A box with Aug. 31st, 2025 written on it with an opened, unsealed plastic overwrap with approximately 4/5 of a block of cream cheese in it. The box was sitting on top of its lid. A partially opened one gallon zipper seal type plastic bag dated 09/06/25 that with Smoked-Sliced turkey breast lunch meat in its original opened plastic wrap which was dated 8/2?????5 (Date was unreadable). An opened unlabeled/undated 5-pound container of sour cream. An opened unlabeled/undated two-gallon zipper seal type plastic bag with another unsealed/unlabeled/undated bag in it that contained shredded cheese. There was also shredded cheese loose in the two-gallon bag. 2 unlabeled/undated two-gallon zipper seal type bags containing sandwiches. Observation of the facility's dry storage area on 09/07/25 beginning at 11:21 AM revealed the following: An opened/unsealed plastic bag dated 08/25/25 with cereal in it. An open two-gallon zipper seal type plastic bag dated 8/12 with an opened/unsealed bag of graham cracker crumbs in it. An approximately 10-gallon white plastic round container with an unsecured and partially opened snap on lid with sugar in it. The sugar had an approximately 4 inch long by 1/4-inch-thick chunk of a beige colored substance in it. An approximately 10-gallon white plastic round container with an unsecured and partially opened snap on lid with flour in it. Observation of the facility's reach-in freezer on 09/07/25 beginning at 11:27 AM revealed the following: An open cardboard box dated 08/29/25 with an open/unsealed bag with frozen peanut butter cookies in it. An opened, unsealed bag of onion rings in the original bag dated 09/05/25. An opened, unsealed/unlabeled/undated bag with an unknown breaded meat product in it. Observation of the facility's dishwashing area on 09/07/25 beginning at 11:41 AM revealed the following: On a rack above the dishwashing sink area, a silver #26 frying pan with the adhesive layer from a sticker still on the cooking surface was hanging on a hook. There was also an intact sticker on the bottom of the frying pan. On a rack above the dishwashing sink area, a fine mesh strainer with brown/black colored mesh and a ring of a thick, black substance around the top rim was hanging on a hook. Observation of a 4-shelf rack of clean dishes on 09/07/25 beginning at 11:46 AM revealed the following: 1 large dark blue bowl with flecks and chunks of a white substance on the inside and outside of it. 20 of 51 maroon bowls with a cream of wheat like substance on the inside and/or outside of them. 51 of 51 maroon bowls with flecks, spots, and/or chunks of a white substance on the inside and/or outside of them. 1 of 8 green bowls which appeared unwashed with a large amount of a thick yellowish substance in streaks on the bottom and sides of it. 1 of 8 green bowls with a reddish filmy substance on the outside of it. 8 of 8 green bowls with flecks, spots, and/or chunks of a white substance on the inside and/or outside of them. 1 of 1 beige bowl with a brownish filmy substance on the inside of it. 18 of 18 small blue bowls with flecks, spots, and/or chunks of a white substance on the inside and/or outside of them. 3 of 18 small blue bowls with a cream of wheat like substance on the inside and/or outside of them. 1 of 18 small blue bowls with a yellowish substance on the inside and outside of it. 23 of 23 maroon cups with flecks, spots, and/or chunks of a white substance on the inside and/or outside of them. 2 of 23 maroon cups with a cream of wheat like substance on the inside and/or outside of them. 3 of 3 blue cups with flecks, spots, and/or chunks of a white substance on the inside and/or outside of them. 1 of 5 grey cups with a cream of wheat like substance on the inside and/or outside of it. 1 of 5 grey cups that was very discolored on the inside with a brownish colored stain. 1 of 1 clear cup with flecks, spots, and/or chunks of a white substance on the inside and/or outside of it. 7 of 7 large porcelain plates with multiple different colored flecks and/or spots on the front and back of them. 11 of 21 small porcelain plates with multiple different colored flecks and/or spots on the front and back of them. 1 of 21 small porcelain plates with 2 chips out of the front edge of it. Observation of the automatic dish washing machine on 09/07/25 beginning at 12:59 PM revealed the following: Limescale build up on top, bottom, right, and left outside and inside edges of both doors. Limescale build up on the front, back, left, and right bottom edge of the inside of the dish washing machine. Limescale build up on the bottom of the dish washing machine. Food chunks including what appeared to be corn, green beans, carrots, and various other food products and a pink sugar replacement package covering approximately 1/3 of the drain pan underneath the dish washing machine. Food particles and trash-including salt and pepper packets, on the floor and in the holes of the black non-slip rubber mats in the dish washing area. A cup on the floor under the dirty side table of the dish washing machine. Food chunks and a wet pepper packet on the surface of the clean side table of the dish washing machine. Food chunks on the bottom of the first of 2 dish washing machine dish trays on the clean side table of the dish washing machine. A wet salt packet on the top of the second of 2 dish washing machine dish trays on the clean side table of the dish washing machine. During an interview on 09/07/25 at 12:05 PM, DA A stated the dishes on the 4-shelf rack in the dish washing area were clean dishes that had been run through the dish washer. DA A walked away before any more questions were asked. During an interview on 09/07/25 at 12:10 PM, the [NAME] stated the dishes on the 4-shelf rack in the dish washing area were clean dishes. He stated he would not have put the rack where it was, but his boss's boss wanted it there. Record review of the Dish Machine Temperatures and Sanitizing Log on 09/07/25 at 1:00 PM reflected the following: On 09/05/25 and 09/06/25, the PM wash temp, final rinse temp, and sanitizer PPM were not documented. On 09/07/25 the AM wash temp, final rinse temp, and sanitizer PPM and the noon wash temp, final rinse temp, and sanitizer PPM were not documented. During interviews at 1:15 PM on 09/07/25 and 8:29 AM on 09/08/25, the DM stated she was off the day before and, apparently the dietary staff did not do what they were supposed to do when I am not there to tell them. The DM stated the sticky frying pan was new, she did not know why it was sticky, and it had not been used yet. The DM stated the fine mesh strainer with the buildup on it was an old strainer and should have been thrown away since they had a new one already. The DM stated the dishes were not checked when they were removed from the dish washer and put on the clean dish rack like they were supposed to be. She stated if the dishes were dirty, they had to be put through the dish washer again. The DM stated she would run the dishes through again and make sure they were clean before putting them back on the clean dish rack. She further stated there was a cleaning log that was supposed to be followed by the dietary staff, but she was not able to locate it, and the ice machine was wiped down daily and deep cleaned once a month. The DM stated it was everyone's responsibility to label, date, and seal food items before they were put in the refrigerator, freezer, or dry storage and her responsibility to make sure it was done. The DM stated if residents were served food that was not stored properly or were served on dishes that were not cleaned and sanitized properly, it could cause them to get sick. In an interview on 09/08/25 at 8:18 AM, DA B stated she checked the dish washing machine and removed any food debris from the inside of it before she ran dishes through it, and she ran the dishes through it three times before she put them on the clean dish rack. DA B stated if residents were served food on dirty dishes, it could cause food borne illnesses. In an interview on 09/08/25 at 8:26 AM, the dietician stated if food was not labeled and dated, staff would not know how long it was open and when it expired. If food that was not properly stored was served to residents, it could cause them to get sick. The dietician also stated residents could get sick of they ate or drank from dishes that were not cleaned and sanitized correctly which could lead to hospitalization or even death. In an interview on 09/09/25 at 1:13 PM, the DON stated it was important for the kitchen to store food properly so that food did not spoil. He stated it was important for dishes to be thoroughly cleaned and sanitized to prevent food borne illness. Record review of the facility's Food Storage Policy dated 01/2024 and revised on 01/2025 reflected 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. h. Store all items at least 6 above the floor with adequate clearance between goods and ceiling to protect from overhead pipes and other contamination. 2. Refrigerators Date, label and tightly seal all refrigerated foods using clean, nonabsorbent, covered containers that are approved for food storage. 3. Freezers e. Store frozen foods in moisture-proof wrap or containers that are labeled and dated. Record review of the facility's undated General Kitchen Sanitation Policy reflected in part: Policy: The facility recognizes that food-borne illness has the potential to harm elderly and frail residents. All Nutrition & Foodservice employees will maintain clean, sanitary kitchen facilities in accordance with the state and US Food Codes in order to minimize the risk of infection and food borne illness. Procedure: 1. Clean and sanitize all food preparation areas, food contact surfaces, dining facilities, and equipment. After each use, clean and sanitize all tableware, kitchenware, and food-contact surfaces of equipment, except cooking surfaces of equipment and pots and pans that are not used to hold or store food and are used solely for cooking purposes. 6. Clean non-food-contact surfaces of equipment at intervals as necessary to keep them free of dust, dirt, and food particles and otherwise in a clean and sanitary condition. Record review of the facility's undated Mechanical Cleaning and Sanitizing of Utensils and Portable Equipment Policy reflected in part: Policy: The facility will follow the cleaning and sanitizing requirements of the state and US Food Codes for mechanical cleaning in order to ensure that all utensils and equipment are thoroughly cleaned and sanitized to minimize the risk of food hazards. Procedure: 1. Use only an approved dish machine that is properly installed and maintained. Operate the dish machine as instructed in the manufacturer's directions. Schedule and complete regular maintenance inspections. 2. Make sure that the automatic detergent dispenser and/or liquid sanitizer injector is working properly. 3. Rinse or scrape equipment and utensils and, when necessary, soak to remove gross food particles and soil prior to being washed. 4. Place equipment and utensils on racks, trays, or baskets, or on conveyors, so that all food-contact surfaces are exposed to the detergent wash and clean rinse water and the equipment and utensils can freely drain. 5. Empty strainer after each meal. 6. Clear the dish machine at least once each day. 7. If a machine that uses chemicals for sanitizing is in use, follow these guidelines: f. A test kit or other device that accurately measures the parts per million concentration of the solution must be available and used. 8. If a machine that uses hot water for sanitizing is in use, follow these guidelines: c. Temperatures must be monitored and recorded during each wash/rinse cycle.

Based on interview and record review, the facility failed to ensure residents were free from significant medication errors for two (Resident #16 and Resident #34) of six residents reviewed for medication errors in that: 1)Resident #16's blood pressure was not taken to assess if Resident #16 required her blood pressure/pulse altering medications (Midodrine HCl Oral Tablet) for 29 days in the month of August 2025 and 0 days in September 2025 per physician orders. 2) Resident #34's blood pressure was not taken to assess if Resident #34 required her blood pressure/pulse altering medications (Lisinopril 10 mg Oral Tablet) for 6 days in the month of September 2025 and 18 days in the month of August 2025 per physician orders. These failures could place residents who receive blood pressure/pulse altering medications at an increased risk for complications such as decreased blood pressure, decreased pulse, exacerbation of symptoms and disease process, and potential hospitalization. The findings include: 1) Record review of Resident #16's face sheet dated 09/08/25 reflected a [AGE] year-old-female with an original admission date 01/25/25. Diagnoses included epilepsy (brain condition that causes recurring seizures), COPD (lung condition caused by damage to the airways that limit airflow), and type two diabetes (insufficient production of insulin in the body). Record review of Resident #16's physician orders dated 7/26/2025 reflected: Midodrine HCl Oral Tablet 5 MG. Give 1 tablet by mouth every 12 hours as needed for hypotension (low blood pressure). Give if SBP is < 100. Record review of Resident #16's blood pressure log on 09/08/25 from August and September of 2025 revealed blood pressures were recorded only on the following days: 8/15/2025- 134/79 mmHg 08/11/2025- 128/80 mmHg Further review revealed Midodrine HCl Oral Tablet 5 mg was not administered in August and September of 2025. In an interview on 09/08/2025 3:57 PM, LVN E stated Resident #16's blood pressure should have been taken twice a day to assess if she required administration of prn blood pressure medication, Midodrine. LVN E stated she had no reason to why Resident #16's blood pressure was not being taken twice a day. LVN E stated it was important to check Resident #16's blood pressure to assess if resident required the medication per physician orders. LVN E stated by not taking Resident #16's blood pressure, she could have been at risk of experiencing signs and symptoms of low blood pressure such as dizziness or fainting An attempt interview with LVN F via telephone on 09/08/2025 at 4:10 PM was unsuccessful. In an interview on 09/08/2025 at 4:42 PM, the DON stated Resident #16's blood pressure should have been taken twice a day to assess if Midodrine was needed. The DON stated by staff not assessing Resident #16's blood pressure, her condition could have worsened. The DON stated the nurse manager who was assigned to the pharmacy task would have been the one in charge of auditing resident medications. The DON stated that position has not been filled for a few months and ultimately, he was responsible to ensure vitals were being taken and medication was being given. The DON stated there was no answer as to why Resident #16's blood pressure and Midodrine medication was not given as prescribed. In an interview on 09/09/2025 at 9:42 AM, Resident #16 stated once in a while staff checked her blood pressure but not twice a day. In a telephone interview on 09/09/25 at 10:31AM, LVN C stated she did not know why she was not documenting Resident #16's blood pressures. LVN C stated if Resident #16's blood pressure was normal she did not document it. LVN C stated, I don't know how Resident #16's blood pressure would be tracked and trended. LVN C stated there was no reason as to why Resident #16's blood pressure was not getting assessed twice a day. LVN C stated Resident #16 could have passed out and possibly hit the floor if her blood pressure became too low. 2) Record review of Resident #34's face sheet dated 09/08/25 revealed a [AGE] year-old female with an admission date of 04/17/25. Pertinent diagnosis included peripheral vascular disease (a condition that affects the blood vessels outside of the heart, typically in the legs. It occurs when the arteries become narrowed or blocked, reducing blood flow to the lower extremities). Record review of Resident #34's Quarterly MDS assessment dated [DATE] revealed a BIMS score of 11 (moderate impairment). Record review of Resident #34's comprehensive care plan dated 09/08/25 revealed the focus I have Heart Disease. I am at risk for associated cardiac complications such as chest pain, [shortness of breath], fatigue, dizziness, poor endurance/activity intolerance and edema . initiated on 04/21/25 and revised on 07/07/25. Interventions listed for the focus included: Administer my medications as ordered by my physician initiated on 04/21/25. Monitor vital signs as indicated and report abnormal findings to [Medical Director] as indicated initiated on 07/07/25. Record review of Resident #34's order summary revealed an active order for Lisinopril Oral Tablet 10 MG: Give 1 tablet by mouth every 24 hours as needed for [Hypertension] (high blood pressure) Give one tablet [by mouth] [every] day if [blood pressure] is above 140/90 initiated on 04/17/25 and revised on 04/19/25. Record review of Resident #34's blood pressure log on 09/08/25 from August and September of 2025 revealed blood pressures were not recorded on the following days: - 09/07/25, 09/05/25, 09/04/25, 09/03/25, 09/02/25, 09/01/25, 08/31/25, 08/30/25, 08/29/25, 08/27/25, 08/25/25, 08/24/25, 08/23/25, 08/22/25, 08/21/25, 08/19/25, 08/18/25, 08/17/25, 08/16/25, 08/15/25, 08/13/25, 08/12/25, 08/11/25, and 08/09/25 In an interview with LVN H at 7:56 AM on 09/08/25, LVN H stated Resident #34's blood pressure should have been checked at least once daily to determine if Resident #34 needed lisinopril 10 mg. LVN H stated Resident #34 should be given her lisinopril 10 mg oral tablet if her blood pressure was over 140/90 mm/Hg that day. LVN H stated if Resident #34's blood pressure was not checked on a given day, her blood pressure could be elevated, and the staff would not know that she needed her lisinopril 10 mg to lower it. LVN H stated untreated high blood pressure could lead to a stroke in residents. In an interview with the DON on 4:42 PM on 09/08/25, the DON stated according to the order, Resident #34's blood pressure should have been taken at least once per day to assess if lisinopril was needed. The DON stated by staff not assessing Resident #34's blood pressure, her condition could have worsened. The DON stated the nurse manager who was assigned to the pharmacy task would have been the one in charge of auditing resident medications. The DON stated that position has not been filled for a few months and ultimately, he was responsible to ensure vitals were being taken and medication was being given. The DON stated there was no answer as to why Resident #34's blood pressure and lisinopril medication was not given as prescribed. In an interview with Resident #34 at 10:18 AM on 09/09/25, Resident #34 stated she always received her medications on time. Resident #34 stated they measured her blood pressure most days. Resident #34 stated she had not experienced any symptoms of high blood pressure such as chest pain or dizziness, but she did get headaches. Resident #34 stated she has had headaches all her life so she did not think it was related to high blood pressure. Record review of facility's policy Medication Administration dated March 2019 and revised in January 2024 reflected: Compliance Guidelines: Resident medications are administered in accurate, safe, timely, and sanitary manner. RESPONSIBLE DISCIPLINES 5. If applicable and/or prescribed, take vital signs or tests prior to administration of the dose (e.g., pulse with digitalis). 6. Administer medications as ordered by the physician. Routine medications shall be according to the established medication administration schedule for the community. Non-Time Sensitive Medications/Treatments Liberalized time ranges are tasks related assignments. The licensed nurse should assign non-time sensitive medications/treatments to the appropriate liberalized time range and appropriate medication or treatment administration record in order to coordinate and facilitate administration.

Based on observations, interviews, and record reviews the facility failed to maintain medical records on each resident that were accurately documented for one (Resident #49) of four residents reviewed for medical records. The facility failed to ensure LVN C did not document care that was not provided on 09/01/25. This failure could affect residents whose records were maintained by the facility and could place them at risk for errors in care and treatment. Record review of Resident #49's admission record reflected a [AGE] year-old male originally admitted to the facility on [DATE] with most recent admission on [DATE]. His pertinent diagnoses included malignant neoplasm (cancerous tumor) of the prostate, obstructive and reflux uropathy (urine flow is blocked and causes urine to back up into the kidneys causing kidney damage), urostomy with suprapubic urinary catheter (an opening in the abdomen that connects to the urinary tract to allow urine to drain into a catheter and urinary collection bag), and difficulty walking. Record review of Resident #49's quarterly MDS dated [DATE] reflected a BIMS score of 15 which indicated he had no cognitive impairment. Record review of Resident #49's care plan dated 01/31/25 reflected the focus, I require a catheter for obstructive and reflux uropathy, other artificial openings of the urinary tract, malignant neoplasm of the prostate, placing me at risk for infection, created on 01/31/25. Interventions listed for the focus included: Catheter Care every shift and as indicated initiated 05/20/25. Change catheter per my physician's order initiated 05/20/25. Monitor for s/sx infection initiated on 05/20/25. Record review of Resident #49's order summary report reflected the following orders: Suprapubic catheter dx: prostate cancer, obstructive and reflex uropathy dated 05/20/25. Suprapubic catheter: change monthly on the 15th day of the month 10-6 shift, every night shift dated 05/25/25. Suprapubic catheter: change collection bag Q2WKS and PRN, every night shift every 2 weeks on Monday dated 05/25/25. Suprapubic catheter: change collection bag Q2WKS and PRN, as needed dated 05/25/25. Record review of Resident #49's August 2025 MAR reflected LVN C documented she changed Resident #49's suprapubic catheter collection bag on 08/18/25. Record review of Resident #49's September 2025 MAR reflected LVN C documented she changed Resident #49's suprapubic catheter collection bag on 09/01/25. During an observation on 09/07/2025 at 3:35 PM, Resident #49's urinary catheter bag had the date 08/16/25 written in black marker on the upper left side of the front of the bag. During an interview on 09/07/25 at 3:37 PM, Resident #49 stated he had the suprapubic catheter placed 25 years ago when he was diagnosed with prostate cancer. Resident #49 stated the night nurse changed the catheter and the collection tubing/bag at the same time in August and the collection tubing/bag was not changed in the previous week. Resident #49 denied any signs or symptoms of a urinary tract infection. During an observation on 09/08/25 at 8:32 AM and 4:15 PM, Resident #49's urinary collection bag was dated 08/16/25. During an interview on 09/08/25 at 5:10 PM, LVN G stated, all resident care was to be documented immediately after it was done because if it was not documented right away, you could forget to document it, or another nurse could perform the same care again. LVN G stated it was important to do the care that was charted because it was fraud and false documentation if the care was not done. LVN G stated she was not aware that night shift did not change the urinary catheter collection tubing and bag on 09/01/25. LVN G further stated it was important to change the urinary catheter, tubing, and collection bag when ordered by the physician, so the resident did not develop a UTI or sepsis. During a telephone interview on 09/09/25 at 10:33 AM, LVN C stated the urinary catheter collection bag change was not due until the 15th of the month. When asked why she documented she changed the urinary collection bag on 09/01/25, LVN C stated because she changed it that day. When asked if she dated the urinary catheter bag when she changed it, she stated she did. When LVN C was told the date on the urinary catheter bag was 08/16/25, she stated she must have intended to change it on 09/01/25, but got busy and did not get it done and forgot to strike it out on the MAR. LVN C stated she documented she changed the collection tubing/bag on 08/18/25 because it showed it was due on the MAR and she knew that it had been changed on 08/16/25. During a telephone interview on 09/09/25 at 12:54 PM, LVN D stated she changed Resident #49's suprapubic catheter and the collection tubing/bag on 08/16/25 and changed the collection tubing/bag on 09/09/25. LVN D stated she documented the 08/16/25 suprapubic catheter change on the MAR for 08/15/25 because she changed it after midnight but forgot to document the collection tubing/bag change because it was not showing due yet and she did not think to document it in the as needed area. She stated she documented the collection tubing/bag change on 09/09/25 in the as needed section in the MAR. LVN D stated it was very important to document care immediately after it was done because, If it was not documented, it was not done. LVN D further stated, If care was documented but not done for whatever reason, there was an option in PCC to strike out and explain. She stated if urinary catheter care was documented but was not provided, it could lead to infection and hospitalization. During an interview on 09/09/25 at 1:22 PM, the DON stated nurses should follow the physician orders for when to change residents' urinary catheters and collection tubing/bags and if there was an issue with timing, they needed to contact the physician to modify the orders or tell the DON. The DON stated, It was important to document care provided right after it was done. If care was documented as done but it was not, it would not trigger for the care to be provided and it would stay dirty longer. If the catheter and/or bag were not changed when it was ordered, it could cause infection which could lead to hospitalization. He stated when he first started here approximately 8 months ago, he had a meeting with staff concerning what his expectations were for documentation. The DON stated in-services on urinary catheter care were done at least annually. A copy of the facility's policy on nursing documentation was requested 09/09/25, however the facility stated they did not have a specific policy for it. The below referenced policy was provided. Record review of the facility's Professional Standard of Care Policy dated 02/2017 and updated 01/2024 reflected in part: Compliance Guidelines: The community provides services that meet professional standards of quality and are provided by appropriately qualified persons (e.g., licensed, certified). Compliance with Professional Standard of Care Nursing Practices: a) Licensed nurses should practice within the constraints of applicable state laws and regulations governing their practice and should follow the guidelines contained in the communities' written policies and procedures.

Based on observation and interview, the facility failed to ensure all drugs and biologicals were stored in locked compartments and labeled in accordance with currently accepted professional principles reviewed for medications stored in 1 of 4 medication carts (Nursing cart 1) reviewed for storage. The facility failed to keep nursing cart 1 locked when not in use. The failure could place residents in the facility at risk of drug diversion or misuse of medications leading to harm.Findings included:During an observation at 2:56 PM on 09/08/25, this state surveyor saw the top drawer on nurse cart 1 was slightly open in front of the nurse's station on wing 1. This state surveyor was able to fully open the drawer and gain access to medications with no nurse present. After approximately 45 seconds after the initial observation, RN E approached the medication cart and stated nurse cart 1 was hers. During an interview with RN E at 4:16 PM on 09/08/25, RN E stated the medication cart should be locked when not in use. RN E stated it was important to keep the cart locked so other people did not gain access to medications, ingest them, and have an adverse reaction. RN E stated the DON came around almost daily to remind nurses to keep their medication carts locked. During an interview with the DON at 4:48 PM on 09/08/25, the DON stated nurses should ensure their medication carts were locked when not in use. The DON stated it was important to keep medication carts secure because there were medications in there that anyone could gain access to and take. Record review of the facility policy titled Medication Cart Use & Storage, dated January 2023, revealed the following: The medication cart and its storage bins should be kept closed, secured and/or in the line of sight when not in use.

Based on observation and interview the facility failed to ensure the resident's right to privacy for 1 (Resident #11) of 6 residents reviewed for dignity in that:The WCN did not provide privacy for Resident #11 while performing his wound care. This failure could cause residents to feel uncomfortable, disrespected, and possibly a loss of dignity due to a lack of privacy. Findings included: Record review of Resident #11's face sheet dated 09/08/25 reflected a [AGE] year-old-male with an original admission date of 08/31/24. Diagnoses included heart disease, type two diabetes (insufficient insulin production in the body), chronic kidney disease, and COPD (lung condition caused by damage to the airways that limit airflow). During an observation on 09/07/2025 at 4:19 PM, the WCN did not provide privacy by leaving Resident #11's room door open while performing his wound care. Other residents, staff, and visitors passing by Resident #11's room were able to see his wound care being performed. In an interview on 09/07/2025 at 4:34 PM, the WCN stated it was important to provide privacy during Resident #11's wound care to maintain his dignity and respect. The WCN stated by not providing privacy, Resident #11 could feel shameful, sad, depressed or less than, by making him feel like he was not important. The WCN stated she did not realize she did not close Resident #11's door. In an interview on 09/08/2025 at 12:15 PM, the DON stated the WCN should have provided privacy to Resident #11 during his wound care to ensure his dignity and respect. The DON stated wound care should be confidential and by not providing privacy, it could make Resident #11 feel violated. Record review of facility's Statement of Resident Rights dated February 2017 and date revised in 2025 reflected: Compliance Guidelines: The facility should educate, encourage, and honor the rights of those we serve. Further, the facility should assist a resident/patient to fully exercise their rights applicable. Residents/Patients do not give up their rights when entering a [NAME] Community. Resident/Patient Rights Include: 4. Be treated with courtesy, consideration and respect; 6. To privacy, including privacy during visits and telephone calls;

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 #11) of 6 residents reviewed for infection control practices.1) The WCN did not perform hand hygiene after removing gloves before, during, and after performing Resident #11's wound care. This failure could place residents that require wound care at risk for healthcare associated cross-contamination and infections. Findings include: Record review of Resident #11's face sheet dated 09/08/25 reflected a [AGE] year-old-male with an original admission date of 08/31/24. Diagnoses included heart disease, type two diabetes (insufficient insulin production in the body), chronic kidney disease, and COPD (lung condition caused by damage to the airways that limit airflow). Record review of Resident #11's care plan revised on 08/08/25 reflected: Resident #11 was at risk for infection or recurrent/chronic infection r/t compromised medical condition. Resident #11 had actual MRSA to LBKA site. Interventions included: Resident #11 would be free from S/S of infections and any complications related to infection through the review date. Enhanced Barrier Precautions practices as clinically indicated. Educate Resident #11 about hand hygiene efforts and avoid coughing or sneezing directly into hands. Provide tissues and supplies as needed. Provide education to team members, resident and/or visitors regarding infection prevention practices as indicated. Record review of Resident #11's Significant Change MDS dated [DATE] reflected a BIM score of 7 (cognition moderately impaired) skin conditions of surgical wounds, surgical wound care, and nutrition or hydration intervention to manage skin problems. Record review of Resident #11's physician orders reflected the following: RBKA, cleanse with normal saline, dry with 4x4 gauze and pack with 1/4in Dakin's (antiseptic solution used to treat wounds) moistened plain packing, cover with dry dressing daily until resolved. Dated 7/18/2025. LBKA, surgical wound, cleanse with normal saline, pat dry with 4 by 4 gauze, apply Santyl (enzyme used to promote healing of skin ulcers, wounds, and burns) to wound bed, cover wound bed with hydrofera blue (antibacterial wound dressing), cover with dry dressing one time a day. Dated 7/4/2025. During an observation on 09/07/2025 at 4:09 PM, the WCN did not perform hand hygiene after removing gloves while preparing and setting up supplies for Resident #11's wound care. During an observation on 09/07/2025 at 4:11 PM, the WCN did not perform hand hygiene after removing gloves prior to beginning Resident #11's wound care. During an observation on 09/07/2025 at 4:24 PM, the WCN did not perform hand hygiene after removing gloves after cleansing Resident #11's wound. During an observation on 09/07/2025 at 4:25 PM, the WCN did not perform hand hygiene after removing gloves after pat drying Resident #11's wound. During an observation on 09/07/2025 at 4:27 PM, the WCN did not perform hand hygiene after removing gloves after completing Resident #11's wound care. In an interview on 09/07/2025 at 4:27 PM, the WCN stated hands need to be cleaned or washed after removing gloves to prevent cross contamination. The WCN stated Resident #11's wound could be introduced to bacteria that was not previously there causing the wound to deteriorate or worsen. The WCN stated she was thinking of all the other steps she had to perform during Resident #11's wound care and just did not realize she was not performing hand hygiene in between glove changes. In an interview on 09/08/2025 at 12:15 PM, the DON stated it was important staff performed hand hygiene after glove removal to avoid possible cross contamination. The DON stated Resident #11's wound could worsen if introduced to bacteria. Record review of the facility's Handwashing/Hand Hygiene policy dated January 2023 reflected: Guideline This facility considers hand hygiene the primary means to prevent the spread of infection. 7. Use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap (antimicrobial or non-antimicrobial) and water for situations such as this (including but not limited to): Before handling clean or soiled dressings, gauze pads, etc.; Before moving from a contaminated/soiled to clean care of procedures; After handling used dressings, contaminated equipment, etc.; Before glove changes/After removing gloves;

Based on observations, interviews, and record reviews the facility failed to ensure residents received appropriate treatment and services to prevent urinary tract infections to the extent possible for one (Resident #49) of three residents reviewed for urinary catheters. The facility failed to ensure LVN C changed Resident #49's urinary catheter drainage bag on 09/01/25 per the physician's order. This failure places residents with urinary catheters at risk for urinary tract infections. Record review of Resident #49's admission record reflected a [AGE] year-old male originally admitted to the facility on [DATE] with most recent admission on [DATE]. His pertinent diagnoses included malignant neoplasm (cancerous tumor) of the prostate, obstructive and reflux uropathy (urine flow is blocked and causes urine to back up into the kidneys causing kidney damage), urostomy with suprapubic urinary catheter (an opening in the abdomen that connects to the urinary tract to allow urine to drain into a catheter and urinary collection bag), and difficulty walking. Record review of Resident #49's quarterly MDS dated [DATE] reflected a BIMS score of 15 which indicated he had no cognitive impairment. Record review of Resident #49's care plan dated 01/31/25 reflected the focus, I require a catheter for obstructive and reflux uropathy, other artificial openings of the urinary tract, malignant neoplasm of the prostate, placing me at risk for infection, created on 01/31/25. Interventions listed for the focus included: Catheter Care every shift and as indicated initiated 05/20/25. Change catheter per my physician's order initiated 05/20/25. Monitor for s/sx infection initiated on 05/20/25. Record review of Resident #49's order summary report reflected the following orders: Suprapubic catheter dx: prostate cancer, obstructive and reflex uropathy dated 05/20/25. Suprapubic catheter: change monthly on the 15th day of the month 10-6 shift, every night shift dated 05/25/25. Suprapubic catheter: change collection bag Q2WKS and PRN, every night shift every 2 weeks on Monday dated 05/25/25. Suprapubic catheter: change collection bag Q2WKS and PRN, as needed dated 05/25/25. During an observation on 09/07/2025 at 3:35 PM, Resident #49's urinary catheter bag had the date 08/16/25 written in black marker on the upper left side of the front of the bag. During an interview on 09/07/25 at 3:37 PM, Resident #49 stated he had the suprapubic catheter placed 25 years ago when he was diagnosed with prostate cancer. Resident #49 stated the night nurse changed the catheter and the collection tubing/bag at the same time in August and the collection tubing/bag was not changed in the previous week. Resident #49 denied any signs or symptoms of a urinary tract infection. During an observation on 09/08/25 at 8:32 AM and 4:15 PM, Resident #49's urinary collection bag was dated 08/16/25. During an interview on 09/08/25 at 5:10 PM, LVN G stated, all resident care was to be documented immediately after it was done because if it was not documented right away, you could forget to document it, or another nurse could perform the same care again. LVN G stated it was important to do the care that was charted because it was fraud and false documentation if the care was not done. LVN G stated she was not aware that night shift did not change the urinary catheter collection tubing and bag on 09/01/25. LVN G further stated it was important to change the urinary catheter, tubing, and collection bag when ordered by the physician, so the resident did not develop a UTI or sepsis. During a telephone interview on 09/09/25 at 10:33 AM, LVN C stated the urinary catheter collection bag change was not due until 09/15. When asked why she documented she changed the urinary collection bag on 09/01/25, LVN C stated because she changed it that day. When asked if she dated the urinary catheter bag when she changed it, she stated she did. When LVN C was told the date on the urinary catheter bag was 08/16/25, she stated she must have intended to change it but got busy and did not get it done and forgot to strike it out on the MAR. LVN C stated she documented she changed the collection tubing/bag on 08/18/25 because it showed it was due on the MAR and she knew that it had been changed on 08/16/25. During a telephone interview on 09/09/25 at 12:54 PM, LVN D stated she changed Resident #49's suprapubic catheter and the collection tubing/bag on 08/16/25 and changed the collection tubing/bag on 09/09/25. LVN D stated she documented the 08/16/25 suprapubic catheter change on the MAR for 08/15/25 because she changed it after midnight but forgot to document the collection tubing/bag change because it was not showing due yet and she did not think to document it in the as needed area. She stated she documented the collection tubing/bag change on 09/09/25 in the as needed section in the MAR. LVN D stated it was very important to document care immediately after it was done because, If it was not documented, it was not done. LVN D further stated, If care was documented but not done for whatever reason, there was an option in PCC to strike out and explain. She stated if urinary catheter care was documented but was not provided, it could lead to infection and hospitalization. During an interview on 09/09/25 at 1:22 PM, the DON stated nurses should follow the physician orders for when to change residents' urinary catheters and collection tubing/bags and if there was an issue with timing, they needed to contact the physician to modify the orders or tell the DON. The DON stated, It was important to document care provided right after it was done. If care was documented as done but it was not, it would not trigger for the care to be provided and it would stay dirty longer. If the catheter and/or bag were not changed when it was ordered, it could cause infection which could lead to hospitalization. He stated when he first started here approximately 8 months ago, he had a meeting with staff concerning what his expectations were for documentation. The DON stated in-services on urinary catheter care were done at least annually. A copy of the facility's policy/procedure for urinary catheters and or urinary catheter care was requested on 09/08/25 and 09/09/25, however the facility stated they did not have one. Record review of the facility's Professional Standard of Care Policy dated 02/2017 and updated 01/2024 reflected in part: Compliance Guidelines: The community provides services that meet professional standards of quality and are provided by appropriately qualified persons (e.g., licensed, certified). Compliance with Professional Standard of Care Nursing Practices: a) Licensed nurses should practice within the constraints of applicable state laws and regulations governing their practice and should follow the guidelines contained in the communities' written policies and procedures.

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 2 of 3 (Resident #1 and Resident #2) residents reviewed for respiratory care.The facility failed to obtain/verify physician's orders to administer oxygen at 3 LPM for Resident #1 from 06/02/25 to 06/23/25 and oxygen at 2 LPM for Resident #2 from 06/19/25 to 07/01/25.This deficient practice could place residents who receive respiratory care at an increased risk of developing respiratory complications and a decreased quality of care. The findings included: Record review of Resident #1's face sheet dated 07/01/25 reflected the resident was a [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses that included: encounter for orthopedic aftercare, chronic obstructive pulmonary disease (lung disease), chronic respiratory failure with hypoxia (low oxygen levels), dependence on supplemental oxygen, muscle wasting and atrophy, depression, and anxiety disorder. Resident #1 was discharged on 06/23/25. Record review of Resident #1's MDS assessment dated [DATE] reflected Resident #1 had a BIMS score of 12, indicating moderate cognitive impairment. Resident #1 was noted to be on oxygen.Record review of Resident #1's care plan dated 07/01/25 reflected [Resident #1] was at risk for experiencing shortness of breath related to COPD and chronic respiratory failure. Interventions included: provide oxygen as ordered/recommended by my physician. Date initiated: 06/03/25. Record review of Resident #1's order summary dated 07/01/25 reflected O2 Filter - Check, Clean and/or replace filter every week, every night shift, every Sunday. Start date: 06/08/25. No other order noted for O2/oxygen. Record review of Resident #1's MAR dated June 2025 reflected no orders for the O2's flow rate of delivery. Only order noted for O2/oxygen was O2 Filter - Check, Clean and/or replace filter every week, every night shift, every Sunday which was completed. Record review of Resident #2's face sheet dated 07/01/25 reflected the resident was an [AGE] year-old male who was last admitted to the facility on [DATE] with diagnoses that included: cellulitis (bacterial infection of the skin and the tissue beneath the skin) of right lower limb, chronic obstructive pulmonary disease (lung disease), heart failure, acute and chronic respiratory failure with hypercapnia (excessive carbon dioxide levels in the blood), chronic respiratory failure with hypoxia (low oxygen levels), and muscle wasting and atrophy. Record review of Resident #2's MDS assessment dated [DATE] reflected Resident #2 had a BIMS score of 15, indicating cognitively intact. Resident #2 was noted to be on oxygen. Record review of Resident #2's care plan dated 07/01/25 reflected [Resident #2] was at risk for experiencing shortness of breath related to COPD and acute respiratory failure. Interventions included: provide oxygen as ordered/recommended by my physician. Date initiated: 06/20/25. Record review of Resident #2's order summary dated 07/01/25 reflected O2 sats every shift. Start date: 06/19/25. No other order noted for O2/oxygen. Record review of Resident #2's MAR dated June 2025 reflected no orders for the O2's flow rate of delivery. Only order noted for O2/oxygen was O2 sats every shift which was completed. On 07/01/25 at 12:45 PM, in an interview with Resident #1, he said during his stay at the facility, he received oxygen and never went without it. Resident #1 said he used continuous oxygen at 3 LPM due to his diagnosis of COPD. On 07/01/25 at 1:05 PM, in an interview with Resident #2, he said he used continuous oxygen at 2 LPM. Resident #2 said he had always used oxygen due to his diagnosis of COPD. Resident #2 said the nurses checked on the oxygen machine and changed his tubing. Resident #2 was not aware of any changes to his physician's orders regarding his oxygen needs. Resident #2 said he had no trouble breathing or felt sick during this stay. On 07/01/25 at 1:15 PM, an observation with Resident #2 revealed the oxygen tubing was connected and the oxygen setting was set at 2 LPM. Resident #2 sat in his wheelchair and was not in distress. Oxygen in use sign noted at door. On 07/01/25 at 1:35, in an interview with LVN C, she said she knew if a resident needed O2 because prior to admission the facility received their paperwork which indicated the use of oxygen. LVN C said another way she found out a resident would need O2 was if the office staff placed a concentrator in the room in preparation for the admission or if the resident mentioned it during the admission assessments. LVN C said she did not recall completing the admission for Resident #1. LVN C said she recalled Resident #1 used O2 but did not recall the LPM setting. LVN C said Resident #2 used O2 at 2 LPM and it was continuous. LVN C said Resident #1 and Resident #2 had to have physician's orders for the oxygen administration and the nurses ensured to follow the orders on the MAR. On 07/01/25 at 2:25 PM, in an interview with the ADON, she said the nurses handled the oxygen concentrators and tubing. The ADON said any changes or issues regarding the oxygen machines, the staff knew to report to the nurses. The ADON said the residents had to have orders for the O2 concentration level and O2 use. The ADON said the MAR showed them the order for the LPM rate, to check the tubing, change filter, and check O2 sats. On 07/01/25 at 3:45 PM, in an interview with the DON, he said when residents were admitted , the orders came in their admissions packets, the nurses input the orders in the system, called the doctor to verify orders, and the doctor agreed or changed the medications as they saw needed. The DON said if a medication such as O2 was not part of the admitting orders or once the nurse assessed and noted the resident needed oxygen, then the nurse should have called the doctor to obtain orders. The DON said if a resident used oxygen, then there was physician's orders in place. The DON said Resident #1 had an order to change O2 tubing and check/clean/replace O2 filter every week. The DON said Resident #1 should have had an order for the oxygen and he did not. The DON said as an example, the order should have read O2 at 3LPM via nasal cannula, continuous or as needed. The DON said Resident #2 had the order to check for O2 sats every shift and did not have an order for the oxygen. The DON said he reviewed the MAR for Resident #1 and Resident #2 which had no orders for the O2's LPM. The DON said the LPM was the flow rate of delivery which was different for each resident. The DON said the nurses were in-serviced on the admissions process and changes of condition. The DON said any nurse that noted a resident using oxygen without a physician's order should have called the doctor to obtain clarification or orders. The DON said Resident #1 and Resident #2 had no negative outcomes as a result of lack of orders for the oxygen administration but it was important to have orders in place so that all staff were aware and knew what flow rate of delivery the residents required. The DON said there was potential for harm to the residents depending on if they were contraindicated or maybe allergic, but Resident #1 and Resident #2 were not. The DON said the lack of orders could have resulted in hypoxia or hyperoxia but there were no indications that Resident #1 or Resident #2 were hypoxic (insufficient oxygen) or hyperoxic (excessive oxygen) during their stays. Record review of the facility's policy subject titled, Oxygen Administration, dated revised January 2023, revealed, Compliance Guidelines: A resident receives oxygen therapy when there is an order by a physician. Procedure: 3. Obtain physician orders for oxygen administration. Orders should include the following:a. oxygen source to be used (concentrator, tank)b. method of delivery (cannula, mask)c. flow rate of delivery

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 the facility's only kitchen and two of two resident nutrition rooms reviewed for dietary services in that: 1. The facility failed to ensure that both of the reach- in refrigerators and both of the reach- in freezers had separate thermometers inside and/ or at the front near the door per facility policy. 2. The facility failed to ensure that the dry storage room had a thermometer in it per facility policy. 3. The facility failed to ensure that refrigerator and freezer temperatures were recorded three times per day per facility policy. 4. The facility failed to ensure that food/ drink items in the reach- in refrigerators, dry storage area, kitchen area and the resident nutrition rooms were properly stored, labeled, and dated and were not expired. 5. The facility failed to ensure that dirty eating utensils were not placed on a clean surface. 6. The facility failed to ensure that scoops were not left inside containers and were stored properly. 7. The facility failed to ensure that cleaned dishes did not have food or beverage residue in them. 8. The facility failed to ensure that ceilings and walls in the kitchen area were not in disrepair. 9. The facility failed to ensure the kitchen area was free of bugs. 10. The facility failed to ensure that serving utensils were free of hazards. 11. The facility failed to ensure that appliances and food preparation areas were clean and free of possible contaminates. 12. The facility failed to ensure that dishwasher temperatures were logged daily. These findings could place residents at risk for food contamination and/ or food borne illnesses. Findings included: Observation of the facility's kitchen area on [DATE] beginning at 9:10am revealed the following: There was no thermometer in the front of either reach- in refrigerator. There was no thermometer in the front of either reach- in freezer. There was no thermometer in the dry storage area. The refrigerator and freezer logs dated [DATE] had temperatures recorded two times daily (AM and PM) instead of three times daily. The left reach- in refrigerator had hard boiled eggs in a zip top bag that was not labeled or dated. The left reach- in refrigerator had celery in a bag that was not sealed or dated leaving the celery exposed to air. The left reach- in refrigerator had a dark colored liquid substance spilled on the inside of the bottom of it. The right reach- in refrigerator had an unlabeled/undated zip top bag containing a block of cheese slices that were in a clear plastic wrapper. There was a slice of cheese on top of that wrapper. There was a clear plastic container on top of the cook side prep table that contained sliced jalapenos with no label/date on it. There was an open box of salt that was on the shelf above the cook side prep table. There was a silver unsealed bag containing three coffee pods sitting in an open box on top of the juice machine. There was a five gallon bucket sitting on the floor in front and to the left of the left reach- in refrigerator that was not labeled/dated or closed tightly. The bucket contained dill pickle chips in a greenish/brownish liquid. The manufacturer's label on the container read, Refrigerate after opening. In the dry storage room, there was a five gallon bucket on the floor in front and to the right of the right reach- in freezer that was not labeled or dated. The bucket had a white cystalliine substance scattered on the top of the lid in granules and clumps. There was a clear eighteen quart square container with what appeared to be flour in it that had a label that read lunch meat [DATE] on one side and a label on the other side that read animal something, however the cook picked up the container and peeled off the label before it could be read. The container had a scoop sitting on top of it that was not in a holder. There was a white, approximately seven gallon container on the floor with a label that read flour on the top, but no date. The label was not readily visible due to another container sitting on top of it. There was a non-sharp knife with a purple jelly like substance on the prep table near the microwave and condiment bins. There was a red ,d+[DATE] cup measuring cup inside a clear square container with a blue lid that contained a crystalline substance. The container was not labeled or dated. The container was on the bottom shelf of a 4 shelf storage rack that contained pots, pans, and trays. The storage rack was approximately 3 feet away from the deep fryer. There was a sugar scoop left inside the sugar container. On a rack that contained cleaned dishes, two of seven bowls had dried food particles inside them, one of five clear cups had a greyish and red substance that appeared to be thickened juice in it, one of five blue two handled cups had a live roach on the outside of it, and a roach ran out from under a second blue two handled cup when it was picked up. There were two other live roaches seen on the tray that contained the blue two handled cups. There were five to ten more live roaches observed on the surfaces of prep tables and clean dish areas throughout the kitchen. There were five to ten more live roaches seen on the floor of the kitchen area. In the clean serving utensils area, there was an ice cream type scoop with a blue plastic handle. The plastic on the handle was peeling off in too many areas to count. (Cook A was notified about this on [DATE] at 10:23am. [NAME] A stated it needed to be thrown away.) At 10:39am, the scoop was observed to be sitting in a container of fruit that was to be served for lunch. The water spigot on the side of the coffee pot had a white and brown sticky substance on it. The backsplash area on the dietary aide side of the prep table was splattered with different colored substances that were on the entire backsplash area. There were also three electrical outlets along that backsplash area that did not have outlet protectors on them and had substances on them. The shelf above the dietary aide prep table had five spots of black and white substances on it. The spots were varied in size. There was a white approximately 50 quart cooler on the floor in front of the storage shelves that were to the left of the left reach- in refrigerator. There was a cardboard box of what appeared to be paper plates on the top shelf of the storage rack that was to the left of the left reach-in refrigerator. The top of the box was approximately 6 inches from the ceiling. There were at least 7 cardboard boxes stacked on the floor in the corner to the left of the storage shelves and to the right of another 4 shelf storage rack on the left wall. The left side freezer doors had a black substance all around the edges of the door and on the inside where the door closed. The left side of the left freezer middle shelf had 2 large boxes stacked on top of each other with the boxes touching both the bottom of the shelf and the shelf above. There was no space between the bottom box and the bottom of the shelf. There was no space between the top box and the shelf above. There was no space between the boxes. There was a clump of ice approximately 4 inches long by 1 inch wide on the inside of the left door of the left freezer. There were also smaller clumps of ice on that same door. The right side of the left freezer middle shelf was resting at an angle on top of boxes that were stacked on the bottom shelf. There was no shelf bracket on the right side of the freezer wall to hold the middle shelf straight across. There were multiple spots of different colors of spilled substances on the inside bottom of the left freezer. There was a light brown substance that appeared to be crumbs all over the top of the dishwasher. There was a white hard substance at the bottom edge of the front and both sides of the dishwasher. The dishwasher temperature log was not filled out for [DATE], [DATE], [DATE], or [DATE]. There was a crack in the ceiling above and to the right of the dishwasher that was approximately 2 feet long. Along the crack, there was a large hole that was approximately 6 inches long by 3 inches wide. The plastic panel that covered the front of the divider wall between the left reach- in refrigerator and the storage shelves was coming off. The ceiling in the dry storage room around the air conditioner vent closest to the entry door had water stains around it, had peeling/chipped paint on the corner with a black/brown substance on the peeling/chipped paint area. Both vents in the dry storage area had a black substance on them. There was a thermostat hanging by a wire from a hole in the ceiling that was on the left side of the divider wall between the left reach- in refrigerator and the storage shelves. The thermostat was hanging approximately halfway down the wall and was not affixed to anything. In an interview on [DATE] at 10:00am the DA stated the dishwasher temperature logs were supposed to be filled out daily. The DA stated she was normally the one to fill them out, but she got busy and forgot. She did not clarify whether she forgot to check the temperatures or forgot to document the temperatures. She stated she had worked 2:00pm to 7:00pm on [DATE] and [DATE]. The DA stated it was important to check the temperature of the dishwasher to make sure the dishes were getting clean. The DA was observed filling out the dishwasher temperature log for both the morning and afternoon shifts. When asked about why the afternoon shift should log their own temperature, the DA stated they should do their own so that they knew what the temperature was. When asked about the substance on top of the dishwasher machine, the DA stated it looked like crumbs, but she did not know how or when it got there. The DA stated she deep cleaned at the end of every shift, but that she did not deep clean after her shift on [DATE], however she did try to do it at the end of every shift. The DA stated it was important to make sure that the top of the dishwasher was clean to prevent the dishes from becoming contaminated and making residents sick. In an interview on [DATE] at 10:09am, [NAME] A stated the salt box on the shelf should be closed so that it doesn't get contaminated. [NAME] A was observed closing the box. [NAME] A stated the scoop with the peeling handle needed to be replaced because plastic could get into the food. In reference to the substance at the bottom of the reach- in refrigerator, [NAME] A stated it was probably water or something and that she would clean it up. [NAME] A stated it could cause Salmonella or food could get contaminated if it was not cleaned up. [NAME] A stated the celery should have been covered and dated and that she did not know why it was not done. [NAME] A stated she did not know why the hard boiled eggs were not dated, but she would take care of the celery and the eggs. When asked about the five gallon bucket by the reach- in refrigerator, [NAME] A stated it was probably pickle juice that she needed to throw away. [NAME] A stated that it had been opened for a week. When asked what she thought when she looked inside the bucket, [NAME] A stated the pickle slices didn't look edible. When asked why she thought it looked like that, [NAME] A stated, Because it's been sitting here a while. When asked what the label said, [NAME] A stated she was not aware that it stated to refrigerate after opening. [NAME] A stated it was important to refrigerate things according to the manufacturer's instructions to keep them safe for when it was used again. [NAME] A stated if spoiled food was served, residents could get sick. [NAME] A stated she was going to throw out the bucket and contents. When asked about the backsplash in the dietary aide prep area, [NAME] A stated it should not look like that. [NAME] A stated the dietary aide is responsible for cleaning their area daily. [NAME] A stated if there were food particles or dirt in the electrical outlets it could cause someone to get shocked or cause a fire. In reference to the five gallon bucket in the dry storage area, [NAME] A stated it was pickle juice that needed to be thrown away. [NAME] A stated the scoop that was in the sugar containter did not belong in the container, it belonged in a holder on the side. [NAME] A stated residents could get sick if the sugar got contaminated. In an interview on [DATE] at 10:49am, the DM stated that everyone, cooks, dietary aides, and the manager, were responsible for labeling/dating food and cleaning. In reference to the blue handled scoop, the DM stated it should not be used, however it was found in the container of fruit that was to be served for lunch. The DM took the scoop out of the fruit and threw it into the trash. The DM stated the backsplash in the dietary aide's prep area was the dietary aide's responsibility to clean and it being dirty could cause cross contamination. The DM stated if something had gotten into the outlets and someone plugged something in, it could cause sparks or fire. The DM stated the celery should always be completely closed. The DM stated she did not know what was in the bottom of the reach- in refrigerator and that the cooks and dietary aides were responsible for the refrigerators and freezers. The DM stated she tries to check dates/labels on everything every morning. When asked about the container of jalapenos on the cook's prep table, the DM stated they were from Monday (no date given) and the cook was going to throw them out. When asked about the dishwasher, the DM stated the DA would clean it after lunch. The DM stated, We have to spray it down with Lime Away every other day because of the hard water. We did it on Saturday ([DATE]) because I worked on Saturday. The DM stated the bag containing the coffee pods should have been sealed so nothing got into it. The DM stated the white and brown sticky substance on the water spigot on the side of the coffee maker was probably sugar. The DM stated she felt like pest control just sprayed water because the bugs just stayed around. When asked about the freezer doors, the DM stated it was probably mold due to the humidity and that she would get it cleaned up. The DM stated the five gallon bucket in the dry storage room had been there ,d+[DATE] days and that the cook would throw it out. The DM stated the bucket does not belong there. The DM stated the hole/crack in the dishwasher room ceiling was noted by the RD during QA rounding on [DATE]. Reobservation of the kitchen on [DATE] at 1:35pm revealed the following: The hole in the ceiling above the dishwasher had been patched. The peeling/chipped paint around the vent in the dry storage room had been patched. The reach- in freezer thermometers were located on the rear right side of the top shelf of each freezer. Both thermometers had boxes and food items on top of and around them. They were moved to the front of the top shelf in both freezers. Neither reach- in refrigerator had a thermometer in it. The DM got thermometers from her office and placed them in the refrigerators. The backsplash of the dietary aide prep table was still dirty. The five spots of black and white substances were still on the shelf above the dietary aide prep table. There were cooked French fries in the right side fryer basket of the deep fryer. The deep fryer was turned off. In an interview with the DM on [DATE] at 1:40pm, the DM stated the thermometers were supposed to be at the front so that she could compare the temperature inside to the digital reading outside and so that she would still have the temperature in case the digital one went out. The DM stated if she did not have accurate temperatures, she could possibly serve spoiled foods and it could make the residents sick. When the DM was asked how often the temperatures were supposed to be checked, the RD directed the DM to the food storage policy. The DM also stated that pest control had been there that morning. The DM stated she would check labeling and such every morning and if she was not there, the cooks would do it. The DM stated it was usually the morning cook that did the checks and cleaned things out. When asked about a cleaning schedule, the DM pulled some papers out of a large stack of papers on her desk and stated, I go through at the end of the day, make sure everything is done, then sign off on it. In an interview on [DATE] at 1:52pm, the RD stated she came in once a month to do QA. The RD stated the DM was ultimately responsible for the kitchen area. The RD stated if there were things on the QA marked no, she would go over it with the DM and do in-services with staff if necessary. In an interview on [DATE] at 3:24pm, the MS stated if something needed to be fixed, a request would be put into the electronic maintenance request system. The MS would look at the request, then contact his corporate supervisor. The MS stated the corporate supervisor would say, we'll do this. The MS stated sometimes corporate would send someone to do it, sometimes they would come down to do it, sometimes they would send someone to come help, and sometimes they would tell me to fix it. The MS stated, I just let them know what the problem is and they will send someone to come look at the problem and figure out what needs to be done. There's no specific time frame to fix anything. The MS stated he let corporate know about the kitchen in the middle of June, 2024 and at that time they told him, we'll get it. The MS stated, last night, the corporate guy, (CMI), called and told me not to go home until it was fixed. The MS stated he put some extra braces in it, patched it, textured it, taped it, and painted it. In an interview on [DATE] at 10:18am, the ADM stated once a maintenance request went into the electronic system, it went to the MS who could access the portal on the computer or on his cell phone. The ADM stated the MS was supposed to check the maintenance requests daily.The ADM stated she usually got a report of the maintenance requests weekly. The ADM stated if she saw something on the maintenance request, she would let the MS know that it needed to be done, depending on what the priority is. The ADM stated the MS could fix something without having to get with anyone if it was something that did not require an outside vendor or outside resource. The ADM stated if there was something that required an outside resource, the MS would get with her and she would approve it. When asked about the ceiling in the kitchen, the ADM stated, Basically it comes down to- the MS knew about it, I knew about it, I asked for it to get completed and it never did. The ADM stated that regional was helping to make sure that things got taken care of in a timely manner. ADM stated she did recall a visit from the RMI, but she did not recall when. The ADM stated it was the responsibility of the MS to fix it. The ADM stated the MS may have been waiting on a more permanent fix, however she should have completed a temporary fix in the meantime. The ADM stated, My expectation would be that there would be a temporary fix for something while waiting on a permanent solution if it could not be permanently fixed in the first place. The ADM stated that, on average, the RMI would come in monthly to as needed and in general, most maintenance stuff did not have to go to regional for approval. ADM stated regional and corporate were a resource for the facility to assist in obtaining things that may have been difficult for her to get. In reference to the other issues with the kitchen, the ADM stated, In general, the DM is responsible to ensure that the policies and procedures are adhered to. Record review of facility's Work Order #4373 revealed the work order was created [DATE] by the DM at 10:45am. Updated status on [DATE] at 8:13am by MS Set to be completed Issue was crack in ceiling Notes: The ceiling in the dish room is cracked and has an opening. Location: Kitchen Priority: Medium Record review of facility's Work Order #4430 revealed the work order was created [DATE] by the ADM at 9:15am. Updated status on [DATE] at 8:11am by MS Set to be completed. Issue was kitchen repairs Location: Dry storage and dish room. Due date: [DATE]. Priority: Medium On [DATE] at 10:54am, observation of the [DATE] hall resident nutrition room revealed the following: Three of nineteen 3.25 ounce vanilla pudding snacks that were in a cabinet expired [DATE]. Four of nineteen 3.25 ounce vanilla pudding snacks that were in the same cabinet expired [DATE]. Eight of fourteen 4 ounce thickened apple juice containers in the same cabinet had a light brown sticky substance on the outside. There was one 4 ounce raspberry sherbet cup in the refrigerator that was completely melted and not dated. There was one 4 ounce strawberry ice cream cup in the refrigerator that was completely melted and not dated. There were four of four plastic bags containing two cookies each that were exposed to air and were not dated, They were in a drawer with other snacks. Observation of the [DATE] hall resident nutrition room on [DATE] at 11:26am revealed the following: Two of four mildly thick coffee drink mixes that were in a drawer below the coffee pot expired [DATE].The other two of four mildly thick coffee drink mix in the same drawer expired [DATE]. Two of two moderately thick coffee drink mix in the same drawer expired [DATE]. In an interview on [DATE], RN A stated that MR is responsible for the supplies and dietary is responsible for the snacks in the nutrition room. In an interview on [DATE] at 1:17pm LVN C stated they usually served snacks three times a day. LVN C stated she did check expiration dates on things and if she found something expired, she would throw it away, check for any other expired items, then she would tell dietary about them. LVN C stated it was the responsibility of everyone who got things out of the nutrition room to make sure stuff was not expired or compromised. LVN C went into the nutrition room and threw away all of the expired items, the unsealed cookies, and the apple juices that had a sticky substance on them. LVN C stated if the residents were served expired food items, it could ultimately cause them to get sick. LVN C stated she thought dietary brought the cookies over that were in the nutrition room yesterday. LVN C stated the last in-service on nutrition rooms was four to six weeks ago. LVN C stated she did not remember what the in-service on [DATE] entailed. In an interview on [DATE] at 1:27pm the DM stated nurses were responsible for the pudding because they were for medication pass. The DM stated she would take the pudding to them and put the date on them, but she did not check dates on the stuff that was already there. The DM stated she would set the case of pudding down on the counter and let the nurses know that it was there. The DM stated she did not take the cookies to the nutrition room, she would take them to the nurses' station on a cart, leave the cart there, and go back to get it later. In an interview on [DATE] at 1:54pm, the ADON stated it was everyone's responsibility to check dates- central supply when they were rotating supplies: nurses when they were getting food or drinks for residents, and the DON and ADON when they were doing random checks. The ADON stated if something was expired, they would pull it and check the rest of the stock of that item to make sure no others were expired. The ADON stated dietary brought the things like pudding and jello to the nutrition rooms. The ADON stated dietary, nursing, housekeeping, and supply were all responsible for making sure things weren't expired and that things that were opened were dated and thrown out after three days. The ADON stated if things did not have a date, they were discarded. The ADON stated the kitchen brought the cookies in baggies over to the nutrition rooms and that room temperature snacks should have been given out right away and the extras/leftovers were to be discarded. The ADON stated if they were going to be kept, they needed to be dated and put into a sealed container. The ADON stated if a residents got expired or contaminated items, it could cause stomach issues. The ADON stated she would do another in-service on nutrition rooms. In an interview on [DATE] at 3:08pm, the DON stated MR was the supply person so she would stock the nutrition room with tube feed bottles and supplies. The DON stated dietary was responsible for stocking snack type stuff and they should have been responsible for checking for expired items. The DON stated supply was responsible for making sure the tube feed and supplies were not expired. The DON stated it was everyone's responsibility to check things before they were served or hung to make sure that they were not expired or contaminated. The DON stated that dietary should have been going into the nutrition rooms and rotating/inspecting the food items that were in the refrigerator, freezer, and cabinets/drawers. The DON stated that room temperature snacks and drinks were to be served within four hours. The DON stated if they were not served within four hours, they were to be thrown out. The DON stated if residents ate expired or contaminated items, they could get sick, could get nausea/vomiting/diarrhea which could lead to electrolyte imbalances and that could lead to hospitalization or even death. The DON stated she was not sure when the last in-service was, but that she would get it done on Monday. Record review of the facility's Food Storage Policy number 03.03.003 dated [DATE] reflected in part: Policy: The consultant dietician with 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. 1. Dry storage rooms a. The storage room is well-ventilated with humidity controls to prevent mold growth. b. For maximum shelf life, dry foods are stored at 50 Degrees Fahrenheit. ,d+[DATE] degrees Fahrenheit is adequate for most products. c. A wall thermometer is used to check the temperature of the dry-storage facility regularly. d. To ensure freshness, opened and bulk items are stored in tightly covered containers. All containers are labeled and dated. e. Scoops are used for items stored in bins such as sugar, flour, rice, and other items. Scoops are stored covered in a protected area near the food containers. i. All items are store at least 6 above the floor. 2. Refrigerators a. All refrigerated foods are stored per state and federal guidelines. e. All refrigerated foods are dated, labeled, and tightly sealed . h. A thermometer is placed inside refrigerators near the door where the temperature is warmest. The temperature of all refrigerators is checked using the internal thermometer to make sure the temperature stays at or below 41 degrees Fahrenheit. Temperatures are checked each morning when the kitchen is opened, once during the day and in the evening when the kitchen is closed. 3. Freezers a. All frozen meats .and some dairy products, such as ice cream, are stored in the freezer at 0 degrees Fahrenheit or below to keep them fresh and safe for an extended period of time. d.The freezer is not over-stocked and space is left between items to further improve air circulation. h. A thermometer is placed inside freezers near the door where the temperature is warmest. The temperature of all freezers is checked using the internal thermometer to make sure the temperature stays below 0 degrees Fahrenheit. Temperatures are checked each morning when the kitchen is opened, once during the day, and in the evening when the kitchen is closed. Record review of the Quality Assurance Monitor, Kitchen/Food Service Observation dated [DATE] stated in part: Section 1: Did the Administrator participate in QA rounding? OR were QA results reviewed with the Administrator? Section 2: General Sanitation and Cleanliness Cleaning schedule posted and followed to indicate routine cleaning of equipment. Clean equipment, drawers, shelves, work surfaces . General appearance of kitchen clean: floors, walls, ceilings, vents . Floors, walls, ceilings, molding, and tiles in good repair. All areas free of cracks, holes, and chipped paint. No evidence of pests. If present, is there documentation of pest control service? Section 2 Comments: cracked ceiling in dish room. Section 3: Dishwashing, tableware sanitation and storage Dish Machine logs complete, up to date, and accurate. Trays, dinnerware, cups, and utensils in good condition, free of cracks, chips, and stains and stored properly to prevent contamination. Section 5: Food Storage Refrigerators/Freezers: Refrigerators and freezers are at proper temp; logs complete, internal thermometers present in each cooler/freezer. All other food items covered, labeled, and dated. Coolers and freezers not overstocked to promote air circulation. Shelves, interior fans, gaskets, floors, walls clean and in good repair . Dry Storage: Dry storage temperature is below 85 degrees Fahrenheit, ,d+[DATE] degrees F as best practice, thermometer in use, well ventilated. All food items covered, labeled, and dated. All food 6 off floor, labeled, dated. Bulk items covered, labeled, dated; scoops clean and stored outside of bulk containers (scoops stored in protected areas) Section 6: Meal Service Observation Nourishment room: clean, no out of date foods, temp logs in use. Reviewed by: RD Date: [DATE] Reviewed with DM: *reviewed in person in kitchen with DM.

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 roaches in the kitchen. This failure could put residents at risk for food contamination and/or food borne illnesses. The findings included: Observation of the facility's kitchen on 08/14/24 at 09:10am revealed live roaches on the floor, food preparation surfaces, and clean dishware throughout the kitchen area. Observation revealed the following: On a rack that contained clean dishware, one of five blue two handled cups had a live roach on the outside of it. A roach ran out from under a second blue two handled cup when it was picked up. There were two other live roaches seen on the tray that contained the blue two handled cups. There were five to ten more live roaches observed on the surfaces of prep tables and clean dishware areas throughout the kitchen. There were five to ten more live roaches seen on the floor of the kitchen area. In an interview on 8/14/24 at 10:49am the DM stated she felt like pest control just sprayed water because the bugs just stayed around. The DM stated that the roach problem had gotten worse since the crack/hole in the ceiling of the dish room appeared. The DM stated the facility had been aware of the ceiling since 5/23/24, but it still had not been repaired. In an interview on 8/15/24 at 1:52pm, the RD stated she came in once a month to do QA. The RD stated that on her QA report dated 5/23/24, she put a comment in Section 2 that stated there was a crack in the ceiling in the dish room. The RD stated that she reviews the QA results with the ADM and the DM. In an interview on 8/15/24 at 4:17pm, the ADM stated that the facility was on a twice monthly pest control schedule, but they would come out more often if necessary. When asked how the pest control technician knew where the trouble areas were, the ADM stated that staff was educated to put a maintenance request into the electronic system stating where and what the problem was so the MS could relay that information to the pest control technician. The ADM stated she was aware of the roaches in the kitchen and that the pest control technician had been out earlier in August to treat the kitchen as well as the rest of the facility for them. Record review of facility's Work Order #4373 revealed the work order was created 5/29/24 by the DM at 10:45am. Updated status on 8/15/24 at 8:13am by the MS reflected: Set to be completed ; issue reflected crack in ceiling; and notes reflected: The ceiling in the dish room is cracked and has an opening. Location: Kitchen Priority: Medium. Record review of facility's Work Order #4430 revealed the work order was created 6/25/24 by the ADM at 9:15am. Updated status on 8/15/24 at 8:11am by the MS reflected: set to be completed; The issue reflected: kitchen repairs; and the location reflected Dry storage and dish room. Due date: 6/25/24. Priority: Medium. Record review of the facility's pest control invoices dated 1/3/24 to 8/16/24 revealed: The open conditions section of the pest control invoices indicated the following five conditions were present in sixteen of sixteen pest control invoices reviewed. The invoices revealed that all of the conditions that contributed to pests entering the facility had been present for six months to five years. Interior- Kitchen Condition: Openings at Plumbing/Electrical Action: Seal Created: 4/3/19 Last Inspected: 8/16/24 Interior- Kitchen Condition: Cracks/ Gaps along baseboards Action: Seal/ Repair Created: 4/3/19 Last Inspected: 8/16/24 Interior- Rooms Condition: Food residue under appliance/ machinery/ equipment Action: Cleaning practices need to be improved Created: 7/10/23 Last Inspected: 8/16/24 Interior- Rooms Condition: Cracks/Gaps around foundation Action: Seal gaps to reduce pest access Created: 9/6/23 Last Inspected: 8/16/24 Interior- Kitchen Condition: Door leveler not sealed adequately Action: Seal and repair Created 12/6/23 Last Inspected: 8/16/24

Based on observation, interview and record review, the facility failed to ensure the residents' right to privacy for 2 (Resident #33 and Resident #70) of 19 residents reviewed for privacy. 1) The facility failed to ensure a printed sheet of paper containing Resident #70's laboratory values was secured and out of view from the public at 4:17 PM on 08/15/2024. 2) The facility failed to ensure RN A locked the computer screen that displayed Resident #33's personal medical information while RN A was away from the computer administering medication to Resident #33 at 8:13 AM on 8/16/2024. These failures could allow residents' protected HIPAA information to be shared with individuals who do not have a need or right to know which could place residents at a risk of loss of dignity due to lack of privacy. The findings included: Record review of Resident #70's face sheet reflected a [AGE] year-old male with an initial admitted [DATE] and a current admitted [DATE]. Pertinent diagnoses included Acute Kidney Failure, Paraplegia (paralysis of the legs and lower body), and Type 2 Diabetes (chronic metabolic disease in which the body does not produce enough insulin). Record review of Resident #70's quarterly MDS assessment section C, cognitive patterns, dated 07/20/2024 reflected a BIMS score of 10 (moderate impairment). Record review of Resident #33's face sheet reflected an [AGE] year-old female with an initial admitted [DATE] and a current admitted [DATE]. Pertinent diagnoses included End Stage Renal Disease (kidneys permanently stop functioning and require dialysis or a kidney transplant), Altered Mental Status Unspecified, Type 2 Diabetes, and Legal Blindness. Record review of Resident #33's quarterly MDS assessment section C, cognitive patterns, dated 05/31/2024 revealed no test was performed to determine BIMS scoring. During an observation at 4:17 PM on 8/15/2024 revealed in front of the nurse's station by the 100 and 200 resident halls, a printed sheet of paper was resting face up on a medication cart with no employees maintaining control over it. The sheet of paper contained the lab results for a complete metabolic panel (blood test that measures 14 substances in the blood to provide information about the body's chemical balance and metabolism) for Resident #70. Several residents were in the lobby area within 45 feet of the sheet of paper. This surveyor took a picture of the sheet of paper without any employee behind the nurse's station noticing. The sheet of paper remained face-up and available to anyone in the room for 1 minute before RN A was informed of the situation. In an interview with RN A at 4:18 PM on 08/15/2024, RN A stated that the sheet of paper contained HIPAA protected information. RN A stated that she did not know who put the sheet of paper on the medication cart. RN A stated that anyone walking by could see Resident #70's personal medical information. RN A stated that if Resident #70 found out that the facility was not protecting his health information, he might experience disappointment and embarrassment. During an observation at 8:13 AM on 08/16/2024, revealed RN A administered medications to Resident #33 inside Resident #33's room. RN A had the medication cart against the wall opposite of Resident #33's room with the computer monitor facing Resident #33's room. While RN A stepped inside of Resident #33's room, the monitor on the medication cart was left on, displaying Resident #33's personal medical information. The monitor was left on for approximately 1 minute until RN A exited the room and noticed that she had left the monitor on. In an interview with RN A at 8:14 AM on 8/16/2024, RN A stated that she accidentally left the computer screen on while she was administering medications to Resident #33. RN A stated that she typically locked the screen when she was not actively using the computer during medication administration. RN A stated that the personal medical information displayed on the computer screen was HIPAA protected information. RN A stated that if Resident #33 found out that the facility was not protecting her health information, she might experience disappointment and embarrassment. In an interview with LVN D at 11:11 AM on 08/16/2024, LVN D stated that revealing a resident's protected personal information to individuals who do not have a need or right to access the information could potentially cause the resident mental distress if they were informed of the incident. LVN D stated that leaving a printed-out sheet of paper face-up containing a resident's laboratory values in a public place would constitute a HIPAA violation. LVN D stated that leaving a computer screen unattended with a resident's personal medical information would constitute a HIPAA violation. LVN D stated that if she saw a resident's protected medical information displayed publicly, she would hide it and then inform the nearby nurse. LVN D stated that she had not witnessed any instances of HIPAA information being displayed unnecessarily at this facility. In an interview with CNA E at 11:29 AM on 08/16/2024, CNA E stated that leaving a printed-out sheet of paper face-up containing a resident's laboratory values in a public place would constitute a HIPAA violation. CNA E stated that leaving a computer screen unattended with a resident's personal medical information would constitute a HIPAA violation. CNA E stated that if she noticed any HIPAA protected information displayed unnecessarily, she would hide the information and alert a nearby nurse. CNA E stated that revealing a resident's protected personal information to individuals who do not have a need or right to access the information could potentially cause the resident mental distress if they were informed of the incident. CNA E stated that since she had been working at the facility, she had not witnessed any HIPAA violations. In an interview with the DON on 08/16/24 at 2:50 PM, the DON stated that the computer screen was not supposed to be left on and unattended during med pass. The DON stated that leaving the computer screen on and unattended while displaying a resident's person medical information in a public area was a HIPAA violation. The DON stated that she was already aware of the incident earlier in the day with RN A and had already in-serviced RN A on the topic. The DON stated that leaving a sheet of paper unattended displaying the laboratory results of a resident in a public area was a HIPAA violation. The DON stated that anytime an employee sees a possible HIPAA violation, they should hide the information from view and then inform the DON. In an interview with the ADM on 08/16/2024 at 3:51 PM, the ADM stated that leaving a printed-out sheet of paper face-up containing a resident's laboratory values unattended in a public place would constitute a HIPAA violation. The ADM stated that leaving a computer screen unattended with a resident's personal medical information would constitute a HIPAA violation. The ADM stated that anytime an employee saw a possible HIPAA violation, they should hide the information from view and then inform their supervisor. The ADM stated that anytime a resident's personal medical information was not protected, individuals who do not have a need or right to know may gather the information. Record review of the undated policy titled Statement of Resident Rights revealed that residents have the right to: 8: have facility information about you maintained as confidential

Based on interview and record review, the facility failed to ensure residents were free of significant medication errors for 1 of 1 residents (Resident # 1) reviewed for significant medication errors, in that; The facility administered Resident #1's Clonidine outside of physician ordered parameters which resulted in Resident #1 being transferred to the hospital due to low blood pressure. This failure placed residents at risk for not receiving therapeutic dosages and placed them at risk for a decline in health. The noncompliance was identified as Past Non-Compliance. The facility had corrected the noncompliance before the investigation began. The findings included: Record review of Resident #1's face sheet dated 7/16/24 reflected an [AGE] year-old-female with an original admitted [DATE] and a BIMS of 6. Diagnoses included heart failure, chronic kidney disease, dementia (general decline and cognitive abilities that affects a person's ability to perform everyday activities), and chronic obstructive pulmonary disease (inflammatory lung disease that causes obstructed air flow from the lungs). Record review of Resident #1's physician orders dated 1/13/24 stated: Clonidine hcl oral tablet 0.1 mg to be given by mouth two times a day for HTN if systolic blood pressure is greater than 160 and diastolic blood pressure is greater than 100. Resident #1's medication for Clonidine hcl oral tablet 0.1 mg was discontinued on 5/8/24. Record review of Resident #1's medication administration record dated from 1/13/24 to 5/6/24 reflected medication administration of Clonidine was given outside of parameters a total of 166 times by various staff members on various shifts. Record review of Resident #1's care plan dated 4/2/23 documented Resident #1 had heart disease, high blood pressure, and was at risk for associated cardiac complications such as chest pain, SOB, fatigue, dizziness, poor endurance/activity intolerance and edema. Related to heart failure, hyperlipidemia/High Cholesterol, and hypertension. Interventions included: Administer medications as ordered by physician. Record review of the medication administration record for Resident #1's Clonodine administration dated 5/8/24 reflected a blood pressure of 142/87 when Resident #1's Clonodine was last administered prior to hospitalization . Record review of facility's investigation summary stated on 5/6/24 at 12:00am Resident #1 was noted by staff to appear different. LVN A stated Resident #1 was able to answer questions but not as appropriately as usual. LVN A did not state any other signs and symptoms Resident #1 was displaying. Resident #1 was assessed by LVN A and Resident #1 had a blood pressure of 84/45. Resident #1 The MD ordered Resident #1 to be sent to the hospital for further evaluation. 911 was initiated by staff and Resident #1 was transferred to a local hospital. During an observation/interview on 7/15/24 at 1:00pm Resident #1 was in bed. Resident #1 stated she had been in the hospital recently but stated it was for her stomach and nothing was wrong. Resident #1 stated her blood pressure was usually normal and had not been low lately and could not recall going to the hospital for having low blood pressure. In an interview on 7/16/24 at 10:18am the ADM stated Resident #1 went to the hospital due to something going on with her blood pressure. The ADM stated that all nurses were in-serviced on medication administration and following parameters. The ADM stated the MD was notified upon residents return and Resident #1's order for Clonidine was discontinued. The ADM stated an audit of all high blood pressure medications being given in the facility were audited and that it was discovered Resident #1's medication was being given outside of MD ordered parameters. The facility administration staff began an investigation, and a 4 step plan was implemented immediately. The ADM stated it was important to follow all doctor orders and blood pressure medication parameters as it could have had an adverse affect on residents. The ADM stated the DON was usually in charge of verifying orders and medication admistration was administered as ordered but the DON at the time was no longer employed with the facility. Attempted to contact former DON a total of 3 times beginning on 7/17/24 with no answer. In an interview on 7/16/24 at 10:26pm the Regional Nurse Consultant stated the DON at the time informed her that Resident #1 was going to be sent to the hospital due to low blood pressure around the beginning of May 2024. The Regional Nurse Consultant stated a family member of Resident #1 spoke to staff about concerns with Resident #'1 blood pressure medications after Resident #1 had been hospitalized . The Regional Nurse Consultant stated when staff were reviewing Resident #1's chart, the order for Clonidine was transcribed in a confusing way. The Regional Nurse Consultant stated Resident #1's Clonidine order read; to give twice a day but only if Resident #1's blood pressure was greater than 160/100 but was interpreted as a scheduled medication instead of PRN. The Regional Nurse Consultant stated that was when they realized Resident #1's medication was being given outside of parameters by some nurses. The Regional Nurse Consultant stated Resident #1's blood pressure was always stable. The Regional Nurse Consultant stated the IDT was the team that reviewed medications and were reviewed upon admission and whenever there was an alert on the system for that medication. The Regional Nurse Consultant stated when medications are held, or not given, the system flags those medication for review. The Regional Nurse Consultant stated the system only displayed that specific medication administration time the medication was held and would not show all administrations for that medication. The Regional Nurse Consultant stated that was why the medication errors were missed when Resident #1 was given Clonidine outside of the parameters. In a phone interview on 7/16/24 at 3:46pm, Resident #1's MD stated the medication Clonidine should not be given to Resident #1 if it was not within the parameters as ordered. The Physician stated Resident #1 could have experience light headedness due to a low blood pressure. The physician stated the medication Clonidine should not have had a long-lasting affect and the medication has since been discontinued for Resident #1. In a phone interview on 7/25/24 at 10:16am the Pharmacist stated he would speak with this surveyor with a staff member present and requested the ADM be present. Noted ADM and ADON present during phone interview. The Pharmacist stated Clonidine was a medication given to control high blood pressure and was usually given PRN but could be given scheduled. The Pharmacist stated if Clonidine was ordered to be given at scheduled times, it should have a parameter to when to hold or administer the medication. The Pharmacist stated if the medication Clonidine was given outside of parameters Resident #1 could experience lightheadedness, possible blurred vision but it would have depended on Resident #1's baseline. The Pharmacist stated with a blood pressure of 84/42 it could have been an emergent situation, but would be based on Resident #1's baseline blood pressure. Separate interviews with LVN A, LVN B, LVN C, and LVN D beginning on 7/15/24 revealed they were administering Resident #1's Clonidine medication outside of parameters but stated since the medication was ordered twice a day, they were not clicking on Resident #1's medication order to expand the full order to reveal the parameters and thought the medication was scheduled. LVN A, LVN B, LVN C, and LVN D stated they had one on one training on medication administration and following MD parameters on high blood pressure medications. Through record review and interview of the facility's action plan, prior to entrance on 7/13/24, the facility conducted the following: -5/8/24 Resident #3's physician and RP were notified of medication error. -5/8/24 ADHOC and QAPI completed with Medical Director and a 4-step response plan implemented. -5/8/24 One to one re-education initiated with specific nurses identified working during the time of Clonidine medication administration on following parameters for blood pressure medications. -5/8/24 Initiated re-education for all nurses/new staff related to medication administration, following parameters for blood pressure medications, 5 rights of medication administration, medication reconciliation upon resident's admissions or when receiving a new blood pressure medication ordered by doctor included parameters to know when to administer or hold medications. -5/8/24 Audit of residents in the facility taking blood pressure medications initiated by DON/Designee to ensure blood pressure parameters were being followed and any adverse effects noted. -3 residents were audited randomly 3 times a week for 8 weeks to confirm medication parameters were being followed correctly in MAR. Record review of facility residents audit binder reviewed and initiated on 5/8/24 through 7/14/24 with no concerns identified. -5/8/24 Initiated re-education with staff regarding abuse, neglect, and resident rights. Record review of Medication Administration Policy dated 3/2019 stated: Compliance Guidelines: Resident medications are administered in an accurate, safe, timely, and sanitary manner. 2. Verify the medication label against the medication sheet for accuracy of drug frequency, duration, strength, and route. 6. Administer medications as ordered by the physician. Routine medication shall be administered according to the established medication administration schedule for the community.

Based on interviews and record reviews the facility failed to immediately inform the physician and/or resident/responsible party when there was a need to alter treatment significantly (that is, a need to discontinue an existing form of treatment due to adverse consequences, or to commence a new form of treatment) for one (Resident #1) of five residents reviewed for physician notification of changes. 1.The facility failed to notify the physician of Resident #1's wounds when she was admitted to the facility on [DATE]. 2.The facility did not consult with Resident #1's physician to reconcile Resident #1's hospital discharge wound treatment orders for specific wound care instructions upon admission on 12/16/23. 3.The facility failed to notify the physician upon the discovery of Resident #1's worsening wound on 12/24/23. An immediate jeopardy was identified on 04/09/24. The IJ template was provided to the facility on [DATE] at 3:15 PM. While the IJ was removed on 04/11/24 at 5:15 PM, the facility remained out of compliance at a scope of pattern with a severity of no actual harm with potential for more than minimal harm that is not immediate jeopardy due to the facility's need to monitor and evaluate the effectiveness of the corrective systems. This failure could place residents at risk of not receiving appropriate and timely medical interventions which could result in a decline in resident's condition, the need for hospitalization , or death. The findings included: Record review of Resident #1's admission record dated 12/16/23 revealed a [AGE] year-old female that was admitted /readmitted to the facility on [DATE] and discharged home on 01/20/24. Diagnoses included displaced intertrochanteric fracture of the right femur (fracture of the right thigh bone), left rib fractures due to fall at home, other abnormalities of gait and mobility, muscle wasting and atrophy- multiple sites, history of falling, spinal stenosis with neurogenic claudication (leg pain, heaviness, and/or weakness when walking), chronic obstructive pulmonary disease, and mild protein-calorie malnutrition. Resident #1 lived alone, had fallen at home on a Tuesday, and remained on the floor until Saturday, 4 days later, when she was able to drag herself to another room to reach a phone to call for help. Record review of Resident #1's Comprehensive MDS dated [DATE] revealed resident had a BIMS score of 15, which indicated she was cognitively intact. Record review of Resident #1's hospital discharge orders dated 12/15/23 revealed an order for dressing changes to wounds on Resident #1's left elbow, left hip, left knee, and left foot to be done daily or as needed if soiled and steri-strips (thin adhesive bandages used to close the surgical incision after staples are removed) to right hip to remain in place. Record review of Resident#1's Admission/ Readmission nurse's notes- head to toe skin assessment dated [DATE] at 03:43 PM and signed by LVN A, indicated resident had non pressure skin impairments of skin tear(s) and an incision/ surgical wound. The nurse's notes also indicated a pressure injury on Resident #1's coccyx (tailbone). Comments were Stage 1 to coccyx. Skin tears to bilateral upper extremities (both arms), left hip, left knee, and left foot 5th digit. In a phone interview on 04/03/24 at 01:43 PM, Resident #1's FM stated Resident #1 fell at home, broke her leg, was on the floor for at least 4 days, and had to drag herself from one room to another to get her phone to call for help. FM stated the hospital put a clear dressing on Resident #1's left outer knee wound on 12/16/23 at 5:00 AM. FM stated she arrived to the facility on [DATE] and found the same dressing was still on the wound with the same date of 12/16/23 5:00 AM marked on the dressing. FM stated that when she brought it to the attention of the nurse, she was told that it was just a skin tear. FM stated she informed the nurse that the wound had green pus under the dressing. FM stated that she had the facility contact the DON for her and once she spoke to the DON, the nurse came in a few minutes later to change the dressing. FM stated when the dressing was taken off, the wound looked nasty and almost necrotic and it was absolutely disgusting and that she took a picture of it. In an interview on 04/05/24 at 12:30 PM, LVN A stated that when she got report on Resident #1 from the hospital, they did not tell her anything about any wounds. When asked about the wound to Resident #1's left knee, LVN A stated she documented it as a skin tear. LVN A stated she did not take the dressing off the wound and that she did not know exactly what it looked like. LVN A stated that she did not want to remove the dressing because she did not want to aggravate the skin tear. When asked about the admission order process, LVN A stated she would read the hospital discharge orders, put the orders into the nursing facility system and contact the provider to verify the orders and accept the admission into the system. LVN A stated that she would contact the provider before doing an assessment and if she had found anything unexpected or unusual, she would call the provider back to let them know about it. When asked about the wounds to Resident #1's left side, LVN A stated she did not contact the provider because they do not usually call them about skin tears. LVN A was shown a photo of Resident #1's left knee dressing that was taken on 12/24/23 before it was removed. LVN A described it as a transparent dressing on a person's leg with some kind of absorbable material under it, but that she could not describe the wound because she could not see it underneath the dressing. LVN A stated that she attempted to contact the on-call physician and it must not have been documented because she was waiting on a call back that she never received. LVN A did not state whether she told the next shift that she was waiting on a call back from the physician. In a phone interview on 04/08/24 at 10:50 AM, LVN B stated she was not aware of Resident #1's wounds until a family member called her into the room and told her about it on 12/24/23. LVN B stated the family member had the dressing in their hand and the dressing appeared soiled. LVN B stated the wound had slough and brownish/greenish drainage that could have indicated infection. LVN B stated she attempted to contact the physician but did not receive a call back. She did work the next day and stated she does not recall attempting to follow up with the physician about the wound. LVN B stated she does not recall documenting her attempt to contact the physician. In an interview with ADMIN and ADON on 04/05/24 at 06:37 PM, ADON stated the facility admitting process was: after receiving the resident, review admitting orders, call physician to notify of resident's admission and review and reconcile the admitting orders, assess resident - if any abnormal assessment finding the nurse must notify the physician to retrieve and or modify orders as necessary. The facility's policy on Changes in Resident Condition dated 05/2017 and reviewed/revised January 2023 stated in part: The resident, assigned medical provider, and resident representative or designated family member should be notified when there is a significant change in the resident's physical, mental or psychosocial status or a need to alter treatment significantly ( .a need to commence new treatment) and changes in condition should be communicated from shift to shift in the 24-hour report management system. The policy also stated changes in the resident status that affect the problem(s)/goal(s) or approach(s) on his/her care plan should be documented as revisions and communicated to the interdisciplinary caregivers. Documentation was to be done in the Nursing Progress Notes indicating date, time, and who was notified (physician/resident representative), information communicated, and response and/or orders received. This was determined to be an Immediate Jeopardy (IJ) on 04/09/2024 at 3:15 PM. The administrator was notified. The Administrator was provided with the IJ template on 04/09/2024. The following Plan of Removal was accepted on 04/10/2024 at 5:15 PM and indicated the following: [Facility] Plan of Removal F684 Quality of Care 04/09/24 It is the policy of this community to provide safe and quality nursing/medication administration practices to minimize and/or prevent less than quality of care provided to the residents we serve. 1. Resident A was properly assessed and there were no adverse effects associated with alleged deficient practice. Treatment order obtained on 12/27/23. Resident A discharged home on 01/20/24. 2. 100% skin assessment completed on all residents. Skin assessments updated. Outcome: There were no negative outcomes identified. Date Completed: 04-10-24 3. Education provided to all licensed nurses related to the process for system management to include Administrative nurses (DNS ADNS & WCN) received re-education by the DCO (regional nurse) ensuring that: a. Upon admission, the day of, or the shift the resident is admitted to facility, the admitting nurse will notify the accepting MD/NP of the resident's condition to include any wounds/skin concerns identified. The nurse will then verify the and/or obtain admission orders and treatment orders at that time. In the event the nurse is unable to reach the accepting PCP (MD/NP) then the nurse will call the medical director and document notification attempts within the medical record. The DNS/ADNS/RN supervisor will review admission on the next day to validate that the appropriate treatment orders are noted within the orders of the medical record. o Upon a resident change in condition the assessing or evaluating nurse will notify the MD/NP of the identified change in condition to include newly identified and/or deteriorating wounds. The notification to the medical provider will be promptly, depending on the nature or severity of the identified change in the resident's status. Urgent condition changes may require immediate emergency response, such as notifying and eliciting 911 for emergency care. The nurse will notify the MD/NP immediately but no later than end of the current shift. The nurse will document the notification to the medical provided within the electronic health record, enter any new orders provided. The nurse on duty of the current shift will implement the new orders as prescribed; accordingly, for example, the nurse will administer the initial dose of the medication or treatment as ordered by the MD/NP per their direction to be started immediately or stat, same day, to initiate new order on the next day, upon arrival of new medication or treatment. o Upon the next business day, during the clinical review meeting that takes place M-F, the clinical leadership (DNS/ADNS/DCE) will review admission/re-admission skin assessment/evaluations, changes in conditions, progress notes to ensure that the required documentation is in place within the electronic health record. The DNS/ADNS/DCE is responsible for validating that the notification has been made, new orders (treatment orders) are carried out as prescribed. o Upon the next business day, during the clinical review meeting that takes place M-F, the clinical leadership (DNS/ADNS/DCE) will review changes in conditions, progress notes to ensure that newly identified wounds or deteriorating wounds have been documented within the electronic health record. The DNS/ADNS/DCE is responsible for validating that the appropriate documentation is in place within the E.H.R. Date Completed: 04-10-24 Administrative nurses (DNS ADNS & WCN) received re-education by the DCO (regional nurse) ensuring that documentation within the electronic health record accurately reflects the wound presentation and status to include but not limited to nursing progress notes, skin assessments and the skilled nurse note assessment form within the medical record. Nursing documentation is expected to be completed prior to the end of the nurse's shift. Date Completed: 04-10-24 Administrative nurses (DNS ADNS & WCN) received re-education by the DCO (regional nurse) on the process of administrative nurses notifying the charge nurses at the start of the shift (or as soon as it has been identified that they wound care nurse will not work that day) of their responsibility to administer wound care/treatments and complete assigned skin assessments for that shift in the event the wound care nurse calls off shift and/or if the designated treatment nurse is absent for any reason, licensed nurse will contact DNS/ADNS. The DNS/ADNS will reassign treatments and verify completion at the end of the shift, by instructing the charge nurse to notify the DNS/ADNS should any treatment not be completed upon the end of their shift. Date Completed: 04-10-24 DNS (director of nurses)/designee educated the licensed nurses on ensuring that identified new admission treatment orders are verified with the accepting MD/NP upon admission/readmission, communicating changes in conditions to the medical provider, to include newly identified and/or deteriorating wounds. If PCP/NP does not call back timely to give orders, contact DNS/Medical Director for orders. Thus, ensuring appropriate documentation of the identified wound status and medical provider's wound care orders are noted within the E.H.R accordingly. o Upon admission, the day of, or the shift the resident is admitted to facility, the admitting nurse will notify the accepting MD/NP of the resident's condition to include any wounds/skin concerns identified. The nurse will then verify the and/or obtain admission orders and treatment orders at that time. In the event the nurse is unable to reach the accepting PCP (MD/NP) then the nurse will call the medical director and document notification attempts within the medical record. The DNS/ADNS/RN supervisor will review admission on the next day to validate that the appropriate treatment orders are noted within the orders of the medical record. Date Completed: 04-10-24 DNS (director of nurses)/designee educated the licensed nurses on ensuring that documentation within the electronic health record accurately reflects the wound presentation and status to include but not limited to nursing progress notes, skin assessments and skilled nurses' notes/assessment form. Nursing documentation is expected to be completed prior to the end of the nurse's shift. Skilled nurse note assessment form should be completed daily when the resident is noted as under skilled care and services, progress notes are expected to be completed as indicated or upon exception and the skin assessment is expected to be completed at least weekly. All nursing documentation should be completed prior to the end of the assigned nurse's shift. Date Completed: 04-10-24 DNS (director of nurses)/designee educated the licensed nurses on the process of administrative nurses notifying the charge nurses on shift of their responsibility to administer wound care/treatments and complete assigned skin assessments for that shift in the event the wound care nurse calls off shift and/or if the designated treatment nurse is absent for any reason, licensed nurse will contact DNS/ADNS. DNS/ADNS will reassign treatments and verify completion. The administrative nurses will notify the charge nurses at the start of the shift (or as soon as it has been identified that they wound care nurse will not work that day) of their responsibility to administer wound care/treatments and complete assigned skin assessments for that shift in the event the wound care nurse calls off shift and/or if the designated treatment nurse is absent for any reason, licensed nurse will contact DNS/ADNS. The DNS/ADNS will reassign treatments and verify completion at the end of the shift, by instructing the charge nurse to notify the DNS/ADNS should any treatment not be completed upon the end of their shift. Date Completed: 04-10-24 DNS (director of nursing)/designee will monitor this process to validate appropriate communication and to ensure patient care needs are met. Date Completed: 04-10-24 DNS (director of nurses)/designee educated the licensed nurses on clinical documentation review upon admit/readmit noting pressure injury/skin concerns identified. A full body skin assessment - intentionally assessing the resident head to toe for evidence of any pressure injury or skin concerns. If a newly admitted resident has an intact dressing in place, the nurse will remove the dressing to complete the skin assessment unless otherwise order not to remove the dressing by the MD/NP and in this case the will document the given instructions by the MD/NP and assess the skin around the dressing indicated the presentation of s/s of infection to the tissue surrounding the dressing in place. The nurse will document the instructions and skin assessment findings within the medical record at that time. Date Completed: 04-10-24 DNS (director of nurses)/designee educated the licensed nurses on the Braden Risk Assessment to be completed by the assigned nurse upon admission, significant change of condition and quarterly reviews in addition to routine re-assessment the Braden Risk Assessment will be completed upon identifying a new onset of pressure related skin injury. Date Completed: 04-10-24 DNS (director of nurses)/designee educated the licensed nurses on conducting weekly skin assessments/evaluation shall be completed upon admission/readmit at least every 7 days thereafter and as clinically indicated thereafter. Head to toe skin assessment- consists of conducting a head - to- toe skin assessment to identify actual skin concerns, such as pressure injury or other skin concerns. After completing the assessment, the nurse will document accordingly. PCP and RP notification and follow through with any new orders. Plan of care will be updated. Date Completed:04-10-24 DNS (director of nurses)/designee educated the licensed nurses on completing weekly skin assessment should be conducted by the designated nurse and/or designated wound care nurse and follow up with new communication to PCP and orders accordingly. Signing out for weekly skin assessments on the MAR and signing out the treatments as ordered and administered by licensed nurse . Date Completed: 04-10-24 DNS (director of nurses)/designee educated the licensed nurses on proper documentation of site, staging as indicated, measurement taken and noting wound bed appearance to be completed on the Skin/Wound Module within the E.H.R. Nursing obtaining wound care orders for identified wounds and implementing treatment orders as per MD/NP orders and ensuring that the RP notified. Date Completed: 04-10-24 DNS, ADNS, or Wound Care Nurse will conduct post admission skin assessments within 24 -72 hours post admission/readmit to validate accuracy of documentation of skin condition noting wound type, presentation, appropriate state for pressure ulcer injuries, validation of proper treatment orders is in place and any consultations are made as clinically indicated. Date Completed: 04-10-24 IDT will review and update plan of care at the initial 48-72 baseline care plan, at the time of the comprehensive care plan, not later than day 21, quarterly thereafter, upon significant change and annually in order to ensure appropriate interventions are in place to address the prevention of or minimizing the risks associated with skin injury in relation to the identified resident's clinical complexity and resident care needs. Date Completed: 04-9-24 Adhoc QAPI held with Medical Director on 4-9-24 to review plan of action and plan of removal submitted. The facility will conduct a monthly QAPI meeting going forward with the Medical Director to discuss the status of compliance. Date Completed: 04-9-24 The admitting nurse will review the hospital discharge paperwork, specifically the hospital discharge orders / instructions and the nurse will review this information with the accepting PCP/NP upon being contacted to verify admission/readmission orders. Date Completed:04-10-24 If PCP/NP does not call back timely (within a reasonable amount of time, during the current shift depending on the urgency of the resident's condition) the nurse should contact the Medical Director to report the resident's condition, verify orders or need for orders before the end of the shift. The nurse will document efforts and any new orders obtained within the medical record. Completed: 04/10/24 4. During the daily clinical review meeting held (5-7 days per week) the DNS/Designee will review new admissions/ readmissions and changes in condition (SBARS) r/t skin/wound concerns in order to ensure accuracy and to ensure appropriate follow up interventions are in place. DNS/ADNS will conduct weekly random audits 3x week x 8 weeks of resident's skin assessments and treatments to verify assessment is correct, orders are in place, and care plan is up to date. Findings of audits and system management will be reported to the Administrator and the QAPI committee during the monthly meetings for the next 2 months, identifying system compliance or need for further education and clinical oversight. Verification of the facility's Plan of Removal consisted of the following: Observations of wound care were conducted on 04/11/24 for Resident #30's non pressure injury and Resident #31's two pressure injuries. No issues were noted with wound care. Interviews with licensed staff (included all three shifts) on 04/11/24 included: 10:34 AM - LVN C 10:40 AM - LVN D 10:52 AM - LVN E 11:02 AM - LVN F 11:08 AM - LVN G 11:21 AM - LVN H 11:25 AM - LVN I 11:28 AM - LVN J 2:46 PM - LVN K All staff interviewed stated the resident admission process included receiving the resident, conducting a complete head to toe assessment, reviewing the orders sent with the resident, calling the physician to notify of the admission, reviewing the orders sent with the resident, and reconciling all orders medications. All staff said they would inform the physician of any wounds found during assessment. All staff said all notifications and assessments would be documented in the electronic system immediately after the tasks were complete. All staff said if they call the physician and do not receive a call back within 30 minutes to an hour, they would attempt again, and if still no call back received, they were educated to call their supervisor and the Medical Director. All staff said they were re-educated to check the resident orders if there were any specific orders not to remove any dressings, if no order, they would remove any dressing over wounds and complete the assessment. All staff said they would document the description of the wound to include, the location, size, shape, color, odor, drainage amount and type. All staff said they would document all wounds in the wound assessment document and any physician attempted calls and physician communication in the Resident Progress Notes. All staff said if no Treatment Nurse was available, they would inform ADON/DON and wait for verification as who would be assigned which wound care tasks. All the licensed staff said they were previously trained on basic wound care that included the description of the wound and measurement of the wound however, if the nurse was not a Treatment Nurse or a Registered Nurse they could not stage a pressure ulcer. All staff interviews corroborated and followed the procedures of the facility's Skin and Wound Prevention and Management Policy and Procedure dated 03/14/19. Interviews with unlicensed staff (including all three shifts) on 04/11/24 included: 10:52 AM - NAIT A 10:58 AM - CNA B 11:15 AM - CNA C 3:07 PM - CNA A 3:24 PM - CNA D 3:32 PM - NAIT B 3:36 PM - CNA E All staff interviewed stated they were recently re-in-serviced on repositioning any resident that could not reposition themselves including residents who have wounds. All the staff said they were reminded to document any resident skin abnormalities in the electronic CNA plan of care and to immediately inform the nurse caring for the resident. Each staff said they also have the Stop & Watch system which they would document any change in the resident's condition and immediately inform their charge nurse. Record reviews conducted on 04/11/24 included: -Review of the Facility's recently In-Services included: Skin and Wound System dated 04/04/24, 04/05/24 Nurse Documentation dated 04/05/24 Notification of Changes dated 04/09/24 Skin and Wound Prevention and Management Policy and Procedure dated 03/14/19 -Review of the facility's Resident Wound Line List dated 04/11/24 indicated 20 residents with non-pressure wounds and 16 residents with pressure injury wounds. -Review of the facility's QAPI Agenda/Sign-In Sheet dated 04/09/24 revealed the facility met regarding Skin and Wound System Compliance. The QAPI indicated DNS, ADNS or Wound Care Nurse will conduct post admission skin assessments within 24-72 hours post admission/readmit to validate accuracy of documentation of skin condition noting wound types, presentation, appropriate stage for pressure injuries, validation of proper treatment orders is in place and any consultations are made as clinically indicated, and plan of care updated. -Review of the facility's 100% Skin Assessment Log indicted each resident was provided an updated skin assessment on 04/05/24 and/or 04/06/24. Review of Resident #2's, clinical record/skin assessment revealed skin assessments were completed on 04/05/24 and/or 04/06/24, no concerns identified. Review of the facility's undated Monitoring Tool indicated DNS, ADNS or Wound Care Nurse will conduct post admission skin assessments within 24-72 hours post admission/readmit to validate accuracy of documentation of skin condition noting wound types, presentation, appropriate stage for pressure injuries, validation of proper treatment orders is in place and any consultations are made as clinically indicated, and plan of care updated. Comparison of the Monitoring Tool and the New Admission Log beginning on 04/06/24- 04/10/24 indicted each resident's (Resident #s 27,28,29,30,31,32) Admission Skin Assessment were reviewed and no concerns were noted. The facility was informed the Immediate Jeopardy (IJ) was removed on 04/11/24 at 5:15 PM. The facility remained out of compliance at a scope of pattern with a severity of no actual harm with potential for more than minimal harm that is not immediate jeopardy due to the facility's need to monitor and evaluate the effectiveness of the corrective systems.

Based on record review and interview, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan for one (Resident #1) of five residents reviewed for quality of care. 1. Upon admission on 12/16/23 at 03:43 PM, the facility failed to perform a thorough, comprehensive head to toe assessment and correctly identify, describe, and document the multiple wounds of Resident #1. 2. Provide Resident #1 with wound care to her wounds as indicated in her hospital discharge orders on 12/16/23. Resident #1 did not receive wound care orders until 11 days later on 12/27/23. 3. The facility did not consult with Resident #1's physician to reconcile Resident #1's hospital discharge wound treatment orders for specific wound care instructions upon admission on 12/16/23. 4. The facility failed to perform and document consistent accurate and detailed assessments of Resident #1's wounds to present accurate wound progress and ensure appropriate treatment was developed. 5. The facility failed to address and include objectives, goals, and interventions specific to Resident #1's surgical and other wounds, oxygen therapy, fall risk, or pain that were present upon her admission on 12/16/23. 6. The facility failed to immediately update Resident #1's care plan upon a change in condition, specifically when Resident #1's wounds were found to be worse on 12/24/23. An immediate jeopardy was identified on 04/09/24. The IJ template was provided to the facility on [DATE] at 3:15 PM. While the IJ was removed on 04/11/24 at 5:15 PM, the facility remained out of compliance at a scope of pattern with a severity of no actual harm with potential for more than minimal harm that is not immediate jeopardy due to the facility's need to monitor and evaluate the effectiveness of the corrective systems. This failure could place residents at risk of not receiving appropriate and timely medical interventions which could result in a decline in resident's condition, the need for hospitalization , or death. The findings included: Record review of Resident #1's admission record dated 12/16/23 revealed a [AGE] year-old female that was admitted /readmitted to the facility on [DATE] and discharged home on 01/20/24. Diagnoses included displaced intertrochanteric fracture of the right femur (fracture of the right thigh bone), left rib fractures due to fall at home, other abnormalities of gait and mobility, muscle wasting and atrophy- multiple sites, history of falling, spinal stenosis with neurogenic claudication (leg pain, heaviness, and/or weakness when walking), chronic obstructive pulmonary disease, and mild protein-calorie malnutrition. Resident #1 lived alone, had fallen at home on a Tuesday, and remained on the floor until Saturday, 4 days later, when she was able to drag herself to another room to reach a phone to call for help. Record review of Resident #1's Comprehensive MDS dated [DATE] revealed resident had a BIMS score of 15, which indicated she was cognitively intact. Record review of Resident #1's hospital discharge orders dated 12/15/23 revealed an order for dressing changes to wounds on Resident #1's left elbow, left hip, left knee, and left foot to be done daily or as needed if soiled and steri-strips (thin adhesive bandages used to close the surgical incision after staples are removed) to right hip to remain in place. Record review of Resident #1's Physician's Order Summary Report dated 12/16/23 revealed an entry that stated, the nurse contacted me as the attending and I reviewed the transfer/admission orders no later than the following day of admission by midnight and made the recommended changes as needed for the plan of care, and, As the PCP I have reviewed, acknowledged and approve all active prescribed orders and plan of care during this residents skilled nursing care stay since the last order review. Both orders were verbal orders dated 12/16/23. Record review of Resident #1's Physician Order Summary Report dated December 2023 revealed Resident #1's wound care orders were not transcribed into the facility electronic system until 12/27/24 for any of Resident #1's non-surgical wounds and that Surgical site assessment/care was not ordered on Resident #1's right leg. Record review of Resident #1's Admission/ readmission nurse's notes dated 12/16/23 at 03:43 pm and signed by LVN A revealed Resident #1 had a clinical condition of respiratory disease/condition and the respiratory assessment indicated Resident #1 was receiving oxygen therapy. Resident #1's head to toe skin assessment indicated resident had non pressure skin impairments of skin tear(s) and an incision/ surgical wound. The nurse's notes also indicated a pressure injury on Resident #1's coccyx (tailbone). Comments were Stage 1 to coccyx. Skin tears to bilateral upper extremities (both arms), left hip, left knee, and left foot 5th digit. In the pain section, LVN A documented that Resident #1 had back and right hip pain that was acute (experienced to a severe or intense degree) and frequent, described as aching, stabbing, and sharp and relieved by medication and frequent position change. In the fall risk review section, LVN A documented that Resident #1 had recent falls (one or more between 3 and 12 months ago). LVN A did not document that Resident #1 had one or more falls in the previous 3 months, though the resident was admitted for a fractured leg that occurred as a result from a fall at home one month prior. In the box marked check if the resident is a high risk for falls, the box was checked. Record review of Resident #1's Admission MDS dated [DATE] revealed Resident #1 was not coded for any pressure ulcers or skin tears which was inconsistent with the nursing admission document dated 12/16/23 which revealed Stage 1 to coccyx; skin tear to bilateral upper extremities, left hip, left knee, left foot 5th digit. Resident #1 was coded for surgical wound(s) and surgical wound(s) care. Record review of Resident #1's Daily Skilled Nursing Notes documented the following for the dates indicated: -12/16/23, 12/18/23, 12/21/23, 12/23/23 revealed Section 1.2. Nursing Observation and Assessment, Assess, Monitor, stabilize medical condition s/p acute illness/ event; Wound care and pressure relief/offloading. Skin: Surgical incision. The notes did not include any mention or assessment of any other wound location or description. -12/24/23-12/28/23 and 01/14/24-01/17/24 revealed no wounds indicated. Which is inconsistent with the admission skin assessment dated on 12/16/23. -12/29/23, 12/30/23, 01/18/24, 01/19/24 revealed Dressing clean/dry/intact and Non pressure injury/ulcer. The notes did not include any wound location or description. -01/07/24-01/09/24 indicated Non pressure injury/ ulcer. The notes did not include any wound location or description. -01/10/24 indicated, Non pressure injury/ ulcer and bruising and discoloration on skin. The notes did not include any wound location or detailed wound description. There were no Daily Skilled Nurses notes documented on 12/17/23, 12/19/23, 12/20/23, 12/22/23, 01/11/24- 01/13/24, or 01/15/24. Record review of Resident #1's Physician Order Summary Report dated December 2023 revealed an order that read, Complete the PCC Skin &Wound - Total Body Skin Assessment every day shift every Sat for Skin Integrity that had an order date of 12/16/23 and a start date of 12/23/23. Record review of Resident #1's PCC Skin and Wound- Total Body Skin assessment dated [DATE] at 08:42PM, 01/04/2024 at 09:53AM, 01/12/2024 at 05:03PM, and 01/13/2024 at 08:24AM revealed Resident #1 had good turgor elasticity, normal skin color, warm (normal) temperature, normal moisture, and normal skin condition with no new wounds documented. Record review of Resident #1's Skin and Wound Evaluation dated 01/19/24 at 05:11 PM revealed Resident #1 had a stage 2 pressure injury that was documented as present upon admission but also documented as present for one week. It documented Area as 1.0 cm, Length as 1.8cm, and Width as 0.3cm. The document stated the wound had 40% of wound covered by epithelial cells, 60% wound filled by granulation, and 30% of wound filled by slough. Exudate (drainage) was documented as moderate and seropurulent (clear with pus) and no odor. Edges were documented at rolled with epithelization and surrounding tissue was documented as blanching, dry/flaky, fragile, intact, normal in color, and scarring. The wound was documented as improving. There was, however, no location of this wound documented. Record review of Resident #1's Skin and Wound Evaluation dated 01/19/24 at 5:14 PM revealed Resident #1 had a front Left Lateral Thigh, Proximal (front/side of left thigh, closer to the hip) pressure injury present on admission, that was documented as a Stage 2 (partial-thickness skin loss with exposed dermis). It stated it was unknown how long the wound was present. Area length, and width were left with no actual numerical measurement value. Documented was 100% of wound was covered by epithelial, with 0% slough of wound filled. Documented the wound bed was noted pink or red, no amount of exudate (drainage), but then documented serous (clear) exudate. The surrounding tissue was documented as eczematous (rash), erythema (redness) but also normal in color. This was inconsistent with the admission skin assessment dated [DATE] which documented a stage 1 pressure injury to coccyx and skin tears to both arms, left thigh area, left outer knee area, and left 5th toe. Record review of Resident #1's Skin and Wound Evaluation dated 01/19/24 at 5:18 PM revealed Resident#1 had a front left lateral lower leg, distal (front of the left lower leg toward the outside, closer to the ankle) abscess present on admission. It stated it was unknown how long the wound was present. Documented was 10% of wound was covered by epithelial, with 70% slough of wound filled. Documented area 2.1cm area, 2.1cm length, and 1.3cm wide; Documented was noted bleeding and fibrin, moderate amount of exudate (drainage) seropurulent (clear with pus), with faint odor. Surrounding tissue was blanching, dry/flaky, erythema (redness of skin), fragile (skin at risk for breakdown) and intact. Documented was non-pitting edema extended to less than 4cm around the wound. This was inconsistent with the nursing admission/ readmission assessment dated [DATE] that did not mention a wound or abscess to this area. Record review of Resident #1's Skin and Wound Evaluations dated 01/19/24 revealed there is no documentation of Resident #1's coccyx wound nor the wound on the knee area. Record review of Resident #1's Discharge MDS dated [DATE] was coded for having an unhealed Stage 2 pressure ulcer that was present upon admission/entry. This was inconsistent with the admission skin assessment dated [DATE] which documented a stage 1 pressure injury to coccyx and skin tears to both arms, left thigh area, left outer knee area, and left 5th toe. Resident #1's Physician Order Summary Report dated 01/20/24 revealed Resident may discharge home with home care on 1/20/24 . Cleanse area to left outer knee with ns. pat dry with gauze. Apply Santyl (used to remove damaged tissue) to wound bed and cover with dry dressing daily. Cleanse left hip area with ns and pat dry with gauze. Apply skin prep and cover with dry dressing every other day. In a telephone interview on 04/03/24 at 01:43pm, Resident #1's FM stated Resident #1 fell at home, broke her leg, was on the floor for at least 4 days, and had to drag herself from one room to another to get her phone to call for help. FM stated the hospital put a clear dressing on Resident #1's left outer knee wound on 12/16/23 at 5:00 AM. FM stated she arrived to the facility on [DATE] and found the same dressing was still on the wound with the same date of 12/16/23 5:00 AM marked on the dressing. FM stated that when she brought it to the attention of the nurse, she was told that it was just a skin tear. FM stated she informed the nurse that the wound had green pus under the dressing. FM stated that she had the facility contact the DON for her and once she spoke to the DON, the nurse came in a few minutes later to change the dressing. FM stated when the dressing was taken off, the wound looked nasty and almost necrotic and it was absolutely disgusting and that she took a picture of it. In an interview on 04/05/24 at 12:00 PM, CNA A stated that she had seen the dressing on Resident #1's left knee but could not recall exactly when she saw it. CNA A stated that one of the nurses patched it up and did something to it, but she really did not remember who or when. CNA A stated that the wound on Resident #1's knee had a rotten smell when one of the nurses peeled back the clear dressing, put a gauze over the wound and pulled the same clear dressing back over it. In an interview on 04/05/24 at 12:30 PM, LVN A stated that when she got report on Resident #1 from the hospital, they did not tell her anything about any wounds. When asked about the wound to Resident #1's left knee, LVN A stated she documented it as a skin tear. LVN A stated she did not take the dressing off the wound and that she did not know exactly what it looked like. LVN A stated that she did not want to remove the dressing because she did not want to aggravate the skin tear. When asked about the admission order process, LVN A stated she would read the hospital discharge orders, put the orders into the nursing facility system and contact the provider to verify the orders and accept the admission into the system. LVN A stated that she would contact the provider before doing an assessment and if she had found anything unexpected or unusual, she would call the provider back to let them know about it. When asked about the wounds to Resident #1's left side, LVN A stated she did not contact the provider because they do not usually call them about skin tears. LVN A was shown a photo of Resident #1's left knee dressing that was taken 12/24/23 before it was removed. LVN A described it as a transparent dressing on a person's leg with some kind of absorbable material under it, but that she could not describe the wound because she could not see it underneath the dressing. LVN A stated that she attempted to contact the on-call physician and it must not have been documented because she was waiting on a call back that she never received. LVN A did not state whether she told the next shift that she was waiting on a call back from the physician. In a phone interview on 04/08/24 at 10:50 AM, LVN B stated she was not aware of Resident #1's wounds until a family member called her into the room and told her about it on 12/24/23. LVN B stated the family member had the dressing in their hand and the dressing appeared soiled. LVN B stated the wound had slough and brownish/greenish drainage that could have indicated infection. LVN B stated she attempted to contact the physician but did not receive a call back. She did work the next day and stated she does not recall attempting to follow up with the physician about the wound. LVN B stated she does not recall documenting her attempt to contact the physician. Resident #1's primary care physician was called but was unavailable and was expected to return approximately 04/09/24. In an interview on 04/05/24 at 03:36 PM, MD stated, I can't defend this. The nurse should have assessed the resident, and the physician or nurse practitioner should have assessed the resident. The nurse should have reviewed the hospital discharge orders and let the physician know about the wound care that was indicated and the physician should have also reviewed the hospital discharge records to be sure that all the orders were reconciled. MD stated he was initially contacted this morning (04/05/24) about this incident. MD stated that if any wound is not assessed or treated, if needed, the resident could acquire an infection, become septic requiring immediate care and hospitalization and/or death could occur. In an interview with ADMIN and ADON on 04/05/24 at 06:37 PM, ADON stated the facility admitting process was: after receiving the resident, review admitting orders, call physician to notify of resident's admission and review and reconcile the admitting orders, assess resident - if any abnormal assessment finding the nurse must notify the physician to retrieve and or modify orders as necessary. When the ADON was shown a picture dated 12/24/23 of Resident #1's left knee wound she described it as, It does not look like a skin tear at this point, it has maceration [prolonged or excessive exposure to moisture that results in skin damage and softening] and slough [dead tissue] in the middle. ADMIN stated they had already started their response plan this morning (04/05/24) and had educated all the nurses that were at the facility about assessment and skin/ wound documentation and had educated all of the aides that were at the facility about skin care, what to look for, and to report any wounds or skin issues to the nurse immediately. ADMIN and ADON also stated that they had begun retraining on contacting a provider and documentation of that. ADMIN stated that the facility would be doing education and training with all the staff over the next several days as they came in. Record review of the facility's policy on Skin and Wound Prevention Management dated 03/14/19, revised January 2023, stated in part that each resident would receive the care and services necessary to retain or regain optimal skin integrity. The guideline within the policy stated that a licensed nurse would document the wound presentation or description of skin issues identified within the electronic health record, the licensed nurse should communicate all newly identified skin concerns as well as the status of current wounds or skin concerns to the attending medical provider then document the notifications and any orders provided within the electronic health record. The licensed nurse will continue to monitor the status and progress of the wound until resolved. Should the wound deteriorate, the nurse should notify the provider and IDT of the change in condition and document the wound assessment/evaluation findings, notifications, new orders, and additional interventions. The plan of care should be reviewed and updated accordingly. The DNS/designee will review the skin and wound data to the QAPI committee to identify compliance of system management, analyze for trends. The policy stated that documentation for abnormal skin conditions should be documented within the electronic health record and should include: 1. Type of injury/ulcer 2. Location, shape, ulcer edges, and wound bed 3. Measurements of wound/skin injury 4. Condition of surrounding tissues 5. Determine the etiology of the wound. Record review of the facility's Care Plan Policy dated 02/2017, revised 03/2022 stated in part: The community develops a comprehensive care plan for each resident that includes measurable objectives and timetables to meet a resident's medical, nursing, mental, and psychosocial needs that are identified in the comprehensive assessment. The comprehensive care plan: -is developed within seven days of the completion of the comprehensive assessment; -is prepared by the interdisciplinary team, including the attending physician, a registered nurse with responsibility for the resident, and other appropriate team members in disciplines as determined by the resident's needs. The care plan reflects intermediate steps for each outcome objective if they will enhance the resident's ability to meet his or her objectives. Team members use these objectives to monitor resident progress. The facility's policy on Changes in Resident Condition dated 05/2017 and reviewed/revised January 2023 stated in part: The resident, assigned medical provider, and resident representative or designated family member should be notified when there is a significant change in the resident's physical, mental or psychosocial status or a need to alter treatment significantly ( .a need to commence new treatment) and changes in condition should be communicated from shift to shift in the 24-hour report management system. The policy also stated changes in the resident status that affect the problem(s)/goal(s) or approach(s) on his/her care plan should be documented as revisions and communicated to the interdisciplinary caregivers. Documentation was to be done in the Nursing Progress Notes indicating date, time, and who was notified (physician/resident representative), information communicated, and response and/or orders received. This was determined to be an Immediate Jeopardy (IJ) on 04/09/2024 at 03:15 PM. The administrator was notified. The Administrator was provided with the IJ template on 04/09/2024. The following Plan of Removal was accepted on 04/10/2024 at 5:00 PM and indicated the following: [Facility] Plan of Removal F684 Quality of Care 04/09/24 It is the policy of this community to provide safe and quality nursing/medication administration practices to minimize and/or prevent less than quality of care provided to the residents we serve. 1. Resident A was properly assessed and there were no adverse effects associated with alleged deficient practice. Treatment order obtained on 12/27/23. Resident A discharged home on 01/20/24. 2. 100% skin assessment completed on all residents. Skin assessments updated. Outcome: There were no negative outcomes identified. Date Completed: 04-10-24 3. Education provided to all licensed nurses related to the process for system management to include Administrative nurses (DNS ADNS & WCN) received re-education by the DCO (regional nurse) ensuring that: a. Upon admission, the day of, or the shift the resident is admitted to facility, the admitting nurse will notify the accepting MD/NP of the resident's condition to include any wounds/skin concerns identified. The nurse will then verify the and/or obtain admission orders and treatment orders at that time. In the event the nurse is unable to reach the accepting PCP (MD/NP) then the nurse will call the medical director and document notification attempts within the medical record. The DNS/ADNS/RN supervisor will review admission on the next day to validate that the appropriate treatment orders are noted within the orders of the medical record. o Upon a resident change in condition the assessing or evaluating nurse will notify the MD/NP of the identified change in condition to include newly identified and/or deteriorating wounds. The notification to the medical provider will be promptly, depending on the nature or severity of the identified change in the resident's status. Urgent condition changes may require immediate emergency response, such as notifying and eliciting 911 for emergency care. The nurse will notify the MD/NP immediately but no later than end of the current shift. The nurse will document the notification to the medical provided within the electronic health record, enter any new orders provided. The nurse on duty of the current shift will implement the new orders as prescribed; accordingly, for example, the nurse will administer the initial dose of the medication or treatment as ordered by the MD/NP per their direction to be started immediately or stat, same day, to initiate new order on the next day, upon arrival of new medication or treatment. o Upon the next business day, during the clinical review meeting that takes place M-F, the clinical leadership (DNS/ADNS/DCE) will review admission/re-admission skin assessment/evaluations, changes in conditions, progress notes to ensure that the required documentation is in place within the electronic health record. The DNS/ADNS/DCE is responsible for validating that the notification has been made, new orders (treatment orders) are carried out as prescribed. o Upon the next business day, during the clinical review meeting that takes place M-F, the clinical leadership (DNS/ADNS/DCE) will review changes in conditions, progress notes to ensure that newly identified wounds or deteriorating wounds have been documented within the electronic health record. The DNS/ADNS/DCE is responsible for validating that the appropriate documentation is in place within the E.H.R. Date Completed: 04-10-24 Administrative nurses (DNS ADNS & WCN) received re-education by the DCO (regional nurse) ensuring that documentation within the electronic health record accurately reflects the wound presentation and status to include but not limited to nursing progress notes, skin assessments and the skilled nurse note assessment form within the medical record. Nursing documentation is expected to be completed prior to the end of the nurse's shift. Date Completed: 04-10-24 Administrative nurses (DNS ADNS & WCN) received re-education by the DCO (regional nurse) on the process of administrative nurses notifying the charge nurses at the start of the shift (or as soon as it has been identified that they wound care nurse will not work that day) of their responsibility to administer wound care/treatments and complete assigned skin assessments for that shift in the event the wound care nurse calls off shift and/or if the designated treatment nurse is absent for any reason, licensed nurse will contact DNS/ADNS. The DNS/ADNS will reassign treatments and verify completion at the end of the shift, by instructing the charge nurse to notify the DNS/ADNS should any treatment not be completed upon the end of their shift. Date Completed: 04-10-24 DNS (director of nurses)/designee educated the licensed nurses on ensuring that identified new admission treatment orders are verified with the accepting MD/NP upon admission/readmission, communicating changes in conditions to the medical provider, to include newly identified and/or deteriorating wounds. If PCP/NP does not call back timely to give orders, contact DNS/Medical Director for orders. Thus, ensuring appropriate documentation of the identified wound status and medical provider's wound care orders are noted within the E.H.R accordingly. oUpon admission, the day of, or the shift the resident is admitted to facility, the admitting nurse will notify the accepting MD/NP of the resident's condition to include any wounds/skin concerns identified. The nurse will then verify the and/or obtain admission orders and treatment orders at that time. In the event the nurse is unable to reach the accepting PCP (MD/NP) then the nurse will call the medical director and document notification attempts within the medical record. The DNS/ADNS/RN supervisor will review admission on the next day to validate that the appropriate treatment orders are noted within the orders of the medical record. Date Completed: 04-10-24 DNS (director of nurses)/designee educated the licensed nurses on ensuring that documentation within the electronic health record accurately reflects the wound presentation and status to include but not limited to nursing progress notes, skin assessments and skilled nurses' notes/assessment form. Nursing documentation is expected to be completed prior to the end of the nurse's shift. Skilled nurse note assessment form should be completed daily when the resident is noted as under skilled care and services, progress notes are expected to be completed as indicated or upon exception and the skin assessment is expected to be completed at least weekly. All nursing documentation should be completed prior to the end of the assigned nurse's shift. Date Completed: 04-10-24 DNS (director of nurses)/designee educated the licensed nurses on the process of administrative nurses notifying the charge nurses on shift of their responsibility to administer wound care/treatments and complete assigned skin assessments for that shift in the event the wound care nurse calls off shift and/or if the designated treatment nurse is absent for any reason, licensed nurse will contact DNS/ADNS. DNS/ADNS will reassign treatments and verify completion. The administrative nurses will notify the charge nurses at the start of the shift (or as soon as it has been identified that they wound care nurse will not work that day) of their responsibility to administer wound care/treatments and complete assigned skin assessments for that shift in the event the wound care nurse calls off shift and/or if the designated treatment nurse is absent for any reason, licensed nurse will contact DNS/ADNS. The DNS/ADNS will reassign treatments and verify completion at the end of the shift, by instructing the charge nurse to notify the DNS/ADNS should any treatment not be completed upon the end of their shift. Date Completed: 04-10-24 DNS (director of nursing)/designee will monitor this process to validate appropriate communication and to ensure patient care needs are met. Date Completed: 04-10-24 DNS (director of nurses)/designee educated the licensed nurses on clinical documentation review upon admit/readmit noting pressure injury/skin concerns identified. A full body skin assessment - intentionally assessing the resident head to toe for evidence of any pressure injury or skin concerns. If a newly admitted resident has an intact dressing in place, the nurse will remove the dressing to complete the skin assessment unless otherwise order not to remove the dressing by the MD/NP and in this case the will document the given instructions by the MD/NP and assess the skin around the dressing indicated the presentation of s/s of infection to the tissue surrounding the dressing in place. The nurse will document the instructions and skin assessment findings within the medical record at that time. Date Completed: 04-10-24 DNS (director of nurses)/designee educated the licensed nurses on the Braden Risk Assessment to be completed by the assigned nurse upon admission, significant change of condition and quarterly reviews in addition to routine re-assessment the Braden Risk Assessment will be completed upon identifying a new onset of pressure related skin injury. Date Completed: 04-10-24 DNS (director of nurses)/designee educated the licensed nurses on conducting weekly skin assessments/evaluation shall be completed upon admission/readmit at least every 7 days thereafter and as clinically indicated thereafter. Head to toe skin assessment- consists of conducting a head - to- toe skin assessment to identify actual skin concerns, such as pressure injury or other skin concerns. After completing the assessment, the nurse will document accordingly. PCP and RP notification and follow through with any new orders. Plan of care will be updated. Date Completed:04-10-24 DNS (director of nurses)/designee educated the licensed nurses on completing weekly skin assessment should be conducted by the designated nurse and/or designated wound care nurse and follow up with new communication to PCP and orders accordingly. Signing out for weekly skin assessments on the MAR and signing out the treatments as ordered and administered by licensed nurse. Date Completed: 04-10-24 DNS (director of nurses)/designee educated the licensed nurses on proper documentation of site, staging as indicated, measurement taken and noting wound bed appearance to be completed on the Skin/Wound Module within the E.H.R. Nursing obtaining wound care orders for identified wounds and implementing treatment orders as per MD/NP orders and ensuring that the RP notified. Date Completed: 04-10-24 DNS, ADNS, or Wound Care Nurse will conduct post admission skin assessments within 24 -72 hours post admission/readmit to validate accuracy of documentation of skin condition noting wound type, presentation, appropriate state for pressure ulcer injuries, validation of proper treatment orders is in place and any consultations are made as clinically indicated. Date Completed: 04-10-24 IDT will review and update plan of care at the initial 48-72 baseline care plan, at the time of the comprehensive care plan, not later than day 21, quarterly thereafter, upon significant change and annually in order to ensure appropriate interventions are in place to address the prevention of or minimizing the risks

Based on observation, interview and record review, the facility failed to be administered in a manner that enabled it to use its resources effectively and efficiently to attain or maintain the highest, practicable physical, mental, and psychosocial well-being of each resident for three Residents (R #3, R #6 and R #11) of 19 residents reviewed for assessments. The Administrator failed to: 1) Implement policies and procedures for Resident Rights and Quality of Care. The administrator did not ensure the nursing staff could accurately assess, document, and communicate changes in resident's wound status to residents Physician. 2) Supervise the DON by ensuring a monitoring process was in place for Licensed Nurse competency with wound assessments, documentation and reporting resident's wound status to Physician. The DON failed to: 1) Implement policies and procedures for Resident's Rights and Quality of care by ensuring Licensed Nurse Competency with wound assessments, accuracy of wound documentation, and communication with Physicians with wound changes and obtain treatment orders. 2) Put effective measures into place to ensure staff accurately provided Head to Toe assessments. 3.) Train the nursing staff on accurate wound assessment and documentation process and obtaining physician's orders [REDACTED]. The above failures resulted in an Immediate Jeopardy (IJ) situation on 11/16/17. While the IJ was removed on 11/20/17, the facility remained out of compliance at actual harm with a scope identified as pattern. The facility continued to monitor to ensure continued implementation of their plan of removal. These failures could affect nine residents with pressure ulcers and 80 residents receiving preventative skin care and place them at risk for developing new pressure ulcers or a decline in existing pressure ulcers. The findings included: R #6: R #6's Face Sheet dated 11/06/17 documented an [AGE] year-old female admitted to the facility on [DATE] and re-admitted on [DATE] with the [DIAGNOSES REDACTED]. R #6's Admission Nursing Evaluation dated 10/25/17 (reviewed and copied on 11/13/17) revealed no documentation of pressure ulcers. On 11/15/17, further review of the same assessment revealed a new entry on the assessment documenting Stage III coccyx. There was no other information describing the pressure ulcer. R #6's Nursing Progress Note dated 10/25/17 documented Resident arrived via stretcher from post acute center .Resident has four open areas to coccyx .See wound care record There was no other specific description or measurements in this note regarding the open areas. R #6's Braden Scale dated 10/25/17 documented a score of 11- High risk. R #6's Weekly Skin Integrity Review dated 10/26/17 documented Upon admission coccyx with open areas. R #6's Physician order [REDACTED]. R #6's Altered Skin Integrity Treatment and Progress Record, Side One, dated 10/26/17 documented Stage 3 Coccyx: cleanse with Dakins solution, apply silver alginate measured to wounds, zinc cream to outer borders, cover with choice of dressing bid (twice a day) and prn (as needed) with each incontinent care .drainage: macerated (softening and breaking down of skin resulting from prolonged exposure to moisture), General Appearance: Yellow, Surrounding Skin: Reddened. Side two of this document entitled Altered Skin Integrity Treatment and Progress Record documented 10/31/17: (Length): 9.0 X (Width): 10.0 cm, moderate exudate. The documentation implied an identification and description of one wound versus four seperate wounds. R #6's Altered Skin Integrity Treatment and Progress Record, Side One, dated 10/27/17 documented Stage 3 Coccyx: cleanse with Dakins solution, apply silver alginate measured to wounds, zinc cream to outer borders, cover with choice of dressing bid and prn with each incontinent care .drainage: macerated, General Appearance: Yellow, Surrounding Skin: Reddened. Side two of this document entitled Altered Skin Integrity Treatment and Progress Record did not have an entry such as description or measurements for this date. R #6's Altered Skin Integrity Treatment and Progress Record, Side One, dated 10/28/17 documented Stage 3 Coccyx: cleanse with Dakins solution, apply silver alginate measured to wounds, zinc cream to outer borders, cover with choice of dressing bid and prn with each incontinent care .drainage: macerated, General Appearance: Red, Surrounding Skin: Reddened. Side two of this document entitled Altered Skin Integrity Treatment and Progress Record did not have an entry such as description or measurements for this date. R #6's Altered Skin Integrity Treatment and Progress Record, Side One, dated 10/29/17 documented Stage 3 Coccyx: cleanse with Dakins solution, apply silver alginate measured to wounds, zinc cream to outer borders, cover with choice of dressing bid and prn with each incontinent care .drainage: macerated, General Appearance: Red, Surrounding Skin: Reddened. Side two of this document entitled Altered Skin Integrity Treatment and Progress Record did not have an entry such as description or measurements for this date. R #6's Altered Skin Integrity Treatment and Progress Record, Side One, dated 10/30/17 documented Stage 3 Coccyx: cleanse with Dakins solution, apply silver alginate measured to wounds, zinc cream to outer borders, cover with choice of dressing bid and prn with each incontinent care .drainage: macerated, General Appearance: Red, Surrounding Skin: Reddened. Side two of this document entitled Altered Skin Integrity Treatment and Progress Record did not have an entry such as description or measurements for this date. R #6's Altered Skin Integrity Treatment and Progress Record, Side One, dated 10/31/17 documented Stage 3 Coccyx: cleanse with Dakins solution, apply silver alginate measured to wounds, zinc cream to outer borders, cover with choice of dressing bid and prn with each incontinent care .drainage: macerated, General Appearance: Dry, Surrounding Skin: Reddened. Side two of this document entitled Altered Skin Integrity Treatment and Progress Record documented 10/31/17: 9.0 X 10.0 cm, moderate exudate. Granulation (reddish connective tissue that forms on the surface of a wound when the wound is healing): No, Decreased Size: No, Decreased Depth: No, Decreased Drainage: No. R #6's Admission Minimum Data Set ((MDS) dated [DATE] documented R #6: -had clear speech -had short and long-term memory problem with severely impaired cognitive skills for decision making -required extensive assistance with one or two person physical assist with bed mobility, dressing, and eating. R #6 was totally dependent for transfers and personal hygiene. -had an indwelling urinary catheter and was always incontinent of bowel. -was at risk of developing pressure ulcers, had one Stage 3 pressure ulcer at admit/reentry measuring 8.0 X 9.0 X 0.5 centimeters (cm). Has pressure reducing device for bed and was receiving pressure ulcer care. The MDS section M1200C: Skin/ulcer treat: turning and reposition was unchecked. R #6's Braden Scale dated 11/01/17 documented a score of 11- High risk. R #6's Initial Wound Consultation Report (performed by Nurse Practitioner/Wound Care Specialist) dated 11/01/17 documented Wound: Bilateral Buttocks/Sacrum/Coccyx, Measurements: 8.0 X 9.0 X 0.5 cm, Wound Bed: 90% adherent, slough, 10% scattered granulation. Periwound: slight moisture, intact. Assessment: Stage 3 Pressure Injury. Elevated right heel on pillows. Treatment: Air Mattress, No diapers in bed. Cleanse with NS, pat dry with gauze, sure prep to peri wound, nickel thick Santyl, protective dressing . R #6's Ulcers, Surgical Site Treatment and Progress Record, Side One, dated 11/01/17 documented Stage 3 Coccyx/Sacrum: cleanse with normal saline. Apply Santyl and cover with protective dressing. Change daily drainage: macerated, General Appearance: Yellow, Surrounding Skin: Reddened. Side two of this document entitled Ulcers, Surgical Site Treatment and Progress Record documented Length: 8.0 X Width: 9.0 X Depth: 0.5 cm. Moderate Serous Exudate. Granulation: Yes, Decreased Size: No, Decreased Depth: No, Decreased Drainage: No. The Ulcers, Surgical Site Treatment and Progress Record, Side Two, included NPUAP (National Pressure Ulcer Advisory Panel) Stages For Pressure Ulcers: -Suspected Deep Tissue Injury (DTI): Purple or maroon localized area of discolored intact skin or blood-filled blister. -Stage 1: Intact Skin. Non-blanchable redness. Skin with darker tones may appear blue, purple, warm, boggy, or firm. -Stage 2: 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. -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, gray, green, brown or black) in the wound bed. R #6's Ulcers, Surgical Site Treatment and Progress Record, Side One, dated 11/02/17- 11/06/17 documented Stage 3 Coccyx/Sacrum: cleanse with normal saline. Apply Santyl and cover with protective dressing. Change daily drainage: macerated, General Appearance: Yellow, Surrounding Skin: Reddened. Side Two of this document entitled Ulcers, Surgical Site Treatment and Progress Record did not have any entries for these dates. R #6's Ulcers, Surgical Site Treatment and Progress Record, Side One, dated 11/07/17 documented Stage 3 Coccyx/Sacrum: cleanse with normal saline. Apply Santyl and cover with protective dressing. Change daily drainage: macerated, General Appearance: Yellow, Surrounding Skin: Reddened. Side two of this document entitled Ulcers, Surgical Site Treatment and Progress Record documented Length: 7.5 X Width: 8.5 X Depth: 0.5 cm. Moderate Serous Exudate. 50% Slough, 50% granulation. R #6's Follow-Up Wound Consultation Report (performed by Nurse Practitioner/Wound Care Specialist) dated 11/01/17 documented Wound: Bilateral Buttocks/Sacrum/Coccyx, Measurements: 7.5 X 8.5 X 0.5 cm, Wound Bed: 50% slough, 50% scattered granulation. Periwound: dry, intact, and no moisture. Assessment: Stage 3 Pressure Injury. Treatment: Air Mattress, No diapers in bed. Continue same treatment plan . R #6's Ulcers, Surgical Site Treatment and Progress Record, Side One, dated 11/08/17- 11/13/17 documented Stage 3 Coccyx/Sacrum: cleanse with normal saline. Apply Santyl and cover with protective dressing. Change daily drainage: macerated, General Appearance: Yellow, Surrounding Skin: Reddened. Side Two of this document entitled Altered Ulcers, Surgical Site Treatment and Progress Record did not have any entries for these dates. R #6's Care Plan dated 11/12/17 documented: -is unable to respond to questions and commands verbally due to [MEDICAL CONDITION] (inability to comprehend or formulate language) and is unable to make needs known verbally. -is alert and oriented to self and needs assistance with making needs known due to dementia. -requires extensive to total staff assistance for all ADL's (activities of daily living) . -has pressure ulcer to coccyx and requires use of low air loss mattress and is at risk for further breakdown. Receives sugar free protein and liquid multivitamin with minerals .Approaches: -assist resident with repositioning frequently -assist resident with obtain and utilizing a pressure relieving device -encourage weight shifts while sitting up in chair -develop turning/repositioning plan with resident input -teach risk factors for development of pressure ulcers -needs wound care as ordered by physician -needs weekly evaluation of wound healing -needs a daily observation of skin with routine care -needs full skin evaluation weekly with bath/shower . Observation of R #6 on 11/13/17 at 9:04 a.m., during initial rounds, revealed R #6 layed on a low air loss mattress, in a face up position with her head of the bed slightly elevated. R #6's bed sheets did not cover her left above the knee stump or hip allowing R #6's blue brief to be visible. Observation of R #6 on 11/13/17 at 11:38 a.m. revealed she sat in a wheelchair in her room with her eyes closed. R #6 had enteral feeding infusing via a pump and connected to her gastric tube infusing at 55 milliliters per hour. R #6 had a brief on. R #6 had blue Prevalon boots (boots that offload the heel) on both feet. Certified Nurse Aide (CNA) G entered the room and introduced herself. CNA G said R #6 rarely spoke any words and when she did, most of the words were not understandable. CNA G said R #6 was not able to voice her needs. CNA G said R #6 was transferred out of bed to her wheelchair via a mechanical lift at approximately 10:50 a.m. CNA G said she had to get R #6 out of bed because therapy usually came for her at about 11:15 a.m. Observation of R #6 on 11/13/17 at 11:48 a.m. revealed R #6 was escorted to the therapy room by a therapist. R #6 sat in her wheelchair throughout the therapy session and was not actively involved in therapy. R #6 was provided with passive therapy until 12:40 p.m. At 12:54 p.m. R #6 was escorted to the nurse's station and positioned beside the television, facing the nurse's station. At 1:40 p.m., CNA G and CNA C escorted R #6 to her room and assisted R #6 to bed using a mechanical lift at 1:46 p.m. R #6 sat in her wheelchair without being offloaded or repositioned from approximately 10:50 a.m.-1:46 p.m. Observation of R #6 on 11/14/17 at 8:35 a.m. revealed R #6 layed in bed on a low air loss mattress with her eyes closed. R #6 had a brief on. Observation of R #6 on 11/14/17 at 9:07 a.m. revealed CNAs C and G escorted R #6 to the shower room and onto the shower bed. Visible was R #6's right foot with a black scabbed area on the medial aspect of her right great toe. A foul odor was prevalent as staff began to undress R #6. Staff removed R #6's brief and exposed R #6's perineal area. The foul odor became stronger when staff turned R #6 to her right side. Staff cleaned R #6's buttocks of feces and exposed was a dressing covered in feces and was half uncovering the wound. R #6's sacral open wound was covered with feces and had a foul odor other than the feces odor. CNA G removed R #6's sacral dressing and allowed water to flow over the wounds. R #6 had denuded skin (loss of the epidermis, caused by exposure to urine, feces, body fluids, wound exudate or friction) between R #6's vagina and anus. In addition, R #6 had five separate open areas to bilateral buttocks: 1. Sacrum at 1 o'clock with the wound bed covered with yellow tissue 2. Right Buttock at 4 o'clock with a red wound bed 3. Right Buttock at 5 o'clock with a red wound bed 4. Left Buttock at 7 o'clock with the more than 50% of the wound bed with yellow tissue and some red tissue 5. Left Buttock at 11 o'clock with approximately 90% of the wound bed with yellow tissue and very little red tissue. There was white macerated (softening and breaking down of skin resulting from prolonged exposure to moisture) surrounding R #6's wounds at 1, 4, 7, and 11 o'clock. After the staff washed the feces off of R #6's buttocks, the foul odor continued from the open wounds. Also exposed, as R #6 layed on her right side was her right heel with dark purple/maroon/black discoloration with the top layer of skin peeling off. Interview with CNA G on 11/14/17 at 10:00 a.m. revealed she stated R #6 had the wound on her right foot for a couple of days, I am not sure exactly how many. I don't know if nurses know, I'm assuming they do, they remind us to put her Prevalon boots on. I don't usually see her buttocks, it is usually covered. CNA G stated R #6 used briefs all day every day because she is incontinent, I haven't been told not to put them on her. CNA G said she was going to call the Licensed Vocational Nurse (LVN) B to dress R #6's wounds before they placed the brief on her. On 11/14/17 at 10:30 a.m., LVN B/Treatment Nurse entered the shower room and said she was going to get the supplies needed for R #6's wounds. LVN B explained R #6 was admitted in the facility with a stage 3 pressure ulcer to her sacrum/buttocks. LVN B said the nurse practitioner/wound care specialist started to see her on 11/01/17 and follows-up with R #6 weekly. When asked if R #6's wounds were healing, LVN B said No, they are the same, it hasn't changed much. LVN B clarified that all the wounds had always been separate open areas but they were measured as one wound because the NP/WCS measured them that way. When asked how LVN B monitored each open area, she said I don't, we look at all of them, the whole area, as one existing wound. LVN B said R #6 had four open areas upon admission and did not know which open area was acquired after admission. LVN B said she had always been taught to identify each wound separately but since working with the NP/WCS, she had learned to combine the area if they are all clustered within the same area. LVN B said she had not consulted with the NP/WCS or R #6's primary care physician about combining all of R #6's wounds as one wound versus identifying them as separate wounds, I just went with it. LVN B was asked about R #6's right foot wounds and LVN B asked what wounds? LVN B assessed R #6's right foot and asked CNA C and CNA G if R #6 already had those, both CNAs shook their head up and down, indicating yes. LVN B said These are new, no one told me about them. LVN B said the right heel is a purple/maroon/black deep tissue injury pressure ulcer. It measures 1.0 X 1.7 centimeters. The right medial great toe had necrotic tissue scabbed, it's an unstageable pressure ulcer, it measures 2.5 X 2.0 centimeters. LVN B then applied skin prep (liquid film-forming dressing that, upon application to intact skin, forms a protective film to help reduce friction) to both wounds on R #6's right foot. After LVN B confirmed that R #6's NP/WCS or physician were not aware of the new wounds and of not having treatment orders for the new wound, LVN B stated I know that is what she (NP/WCS) is going to order. LVN B provided treatment to R #6's right heel and right medial great toe without consulting the physician to inform her/him of the new pressure ulcers or receiving treatment orders. R #6's Daily Skilled Nurse's Note dated 11/14/17 documented Resident in shower with staff- called to shower room to apply treatment to coccyx/sacrum area. Area continue with 50% slough and 50% granulation. No changes. Area with light exudate. Will continue treatment of [REDACTED]. Noted during shower two new areas to right foot. Areas to right heel and right medial foot. Right heel with small DTI- no redness or drainage. Right medial right with thin dry necrotic tissue. Tissue loose and peeling. Spoke to Nurse Practitioner/Wound Specialist and received order for skin prep to areas. daily. Bootie in place . R #6's Ulcers, Surgical Site Treatment and Progress Record, Side One, dated 11/14/17 documented Stage 3 Coccyx/Sacrum: cleanse with normal saline. Apply Santyl and cover with protective dressing. Change daily drainage: macerated, General Appearance: Yellow, Surrounding Skin: Reddened. Side two of this document entitled Ulcers, Surgical Site Treatment and Progress Record documented Length: 9.0 X Width: 8.0 X Depth: 0.5 cm. Light Exudate. 50% Slough, 50% granulation. R #6's Physician order [REDACTED]. R #6's Ulcers, Surgical Site Treatment and Progress Record, Side One, dated 11/14/17 documented Discovered 11/14/17: DTI Right Inner Foot Drainage: dry, General Appearance: Black, Surrounding Skin: Normal. Side two of this document entitled Ulcers, Surgical Site Treatment and Progress Record documented Length: 2.5 X Width: 2.0 cm Thin brown necrotic tissue/dry. Granulation: No R #6's Ulcers, Surgical Site Treatment and Progress Record, Side One, dated 11/14/17 documented Discovered 11/14/17: DTI Right Heel Drainage: dry, General Appearance: Black, Surrounding Skin: Pink. Side two of this document entitled Ulcers, Surgical Site Treatment and Progress Record documented Length: 1.0 X Width: 1.7 cm. dry. Granulation: No On 11/15/17 at 11:14 a.m., this surveyor accompanied the NP/WCS, LVN B, and the Director of Nurses (DON) to R #6's room. The NP/WCS explained that she was caring for R #6 in the hospital prior to her being admitted to this facility. The NP/WCS stated R #6 had three or four separate open areas when she was admitted to this facility. The NP/WCS said R #6 did not have any wounds on her right foot when she last saw her on 11/07/17. The NP/WCS removed R #6's brief and dressing to her sacrum/buttocks. The NP/WCS measured R #6's sacrum/buttocks and said out loud 6.8 X 7.0 X 0.8 centimeters 40% slough and 60% granulation tissue. It has massive excoriation from the moisture retained within the brief. This excoriation could have been prevented if the brief was left off, excoriation could cause new pressure injuries or deterioration. Overall the wound is worsening, it has increased in depth as well. When the NP/WCS was asked the rational for measuring the separate open areas as one area versus separate areas, NP/WCS said That's how I do it, it's too much to separate them. The NP/WCS measured R #6's right medial great toe and stated 2.3 X 2.3 centimeters non-blanchable 100% black eschar. The right heel is dark purple/maroon with some black discoloration with surrounding skin red, non-blanchable. We have to keep the heel offloaded. The NP/WCS verified she had given orders on her consultation sheet for R #6 not to wear briefs in bed since she first saw R #6 on 11/01/17. The NP/WCS said she was there to give the orders and it was the facility's responsibility to implement the orders. The NP/WCS stated the resident's condition could deteriorate if her orders were not implemented. R #6's Daily Skilled Nurse's Note dated 11/15/17 documented 11:00 a.m. (NP/WCS) here to eval and order treatments for wounds to coccyx/sacrum/right and left buttocks and right heel and right medial great toe. recommend to use Santyl to cluster of areas of wounds. Will use Santyl only on areas with slough and will separate areas. Noted 5 different in cluster that only three have slough and needs Santyl. 2 areas have all granulation and use [MEDICATION NAME]. Will leave diaper off as ordered. Will cover with ABD as ordered with tape and use zinc barrier paste for excoriated areas. Bootie to right foot on at all times . R #6's Initial Follow-Up Consultation Report (performed by Nurse Practitioner/Wound Care Specialist) dated 11/15/17 at 11:44 a.m. documented Wound: Bilateral Buttocks/Sacrum/Coccyx, Measurements: 6.8 X 7.0 X 0.8 cm, Wound Bed: 40% slough moist, 60% granulation. Periwound: maceration pallor to wound edges, denuded. Assessment: worsening Stage 3 Pressure Injury. Treatment: Air Mattress, tube of zinc given (to facility)- cleanse with NS, pat dry, zinc to excoriated areas nickel thick, Santyl to slough areas. ABD and secure with tape -Right Medial Heel: Measurement: 1.0 X 1.0 cm, Wound Bed: dark black/purple discoloration, Periwound: non-blanchable redness, dry and intact, Assessment: Suspected DTI, Unstageable Pressure Injury, Treatment: Daily Sure prep and offload . -Right Medial Great Toe: Measurements: 2.3 X 2.3 cm, Wound Bed: 100% dry stable eschar, Periwound: dry intact scaly, Assessment: suspected DTI, Unstageable Pressure Injury, Treatment: Daily Sure Prep, offload. R #6's physician's orders [REDACTED]. Interview with the DON on 11/15/17 at 11:33 a.m. revealed she stated nurses were responsible for assessing and documenting what is seen as accurately as possible. The DON said she did not know R #6 had separate open areas and from reviewing LVN B and NP/WCS's documentation It looked like she only had one wound. I can't tell if any of the separate open areas have improved or worsened because of the incorrect documentation. I can't tell when (R #6) developed the additional ulcer on her bottom. The DON said LVN B should have documented the number of open areas, their location, a description and measurement of each area and it's surrounding skin. The DON said she did not agree with the NP/WCS and LVN B's identification and description of the wounds. The DON said LVN B having several years in wound care background should have informed her or/and (R #6's) physician after the NP/WCS treated the ulcers as one ulcer. The DON stated LVN B was responsible for reviewing the NP/WCS's consultation notes and should have implemented the order, including in-servicing the rest of the staff for R #6 not to wear briefs in bed. The DON said she was going to have LVN B re-measure R #6's wounds and document them separately. Interview with LVN B on 11/15/17 at 12:20 p.m. revealed she confirmed she had seen NP/WCS consultation notes and read the order for no briefs. LVN B said she did not in-service staff to implement that order. R #6's Physician order [REDACTED].#1 at 1 o'clock with normal saline (NS), apply santyl and cover with ABD pad. Clean area #2 at 4 o'clock on right buttock with NS, apply [MEDICATION NAME] and cover with ABD pad. Clean area #3 at 5 o'clock on right buttock with NS, apply [MEDICATION NAME] and cover with ABD. Clean area #4 with NS, apply Santyl, cover with ABD pad. Clean area #5 with NS, apply santyl and cover with ABD pad. Change all sites daily. No brief/can keep under, no binding tapes. R #6's Ulcers, Surgical Site Treatment and Progress Record, Side One, dated 11/15/17 documented Discovered 10/25/17: #1- Stage 3 at 1 o'clock Sacrum: Drainage: moist, General Appearance: Yellow, Surrounding Skin: Reddened. Side two of this document entitled Ulcers, Surgical Site Treatment and Progress Record documented Length: 3.0 X Width: 4.0 cm. Granulation 10%, 90% slough. edges macerated, Decreased in Size: No. R #6's Ulcers, Surgical Site Treatment and Progress Record, Side One, dated 11/15/17 documented Discovered 10/25/17: #2- Stage 3 at 4 o'clock Right Buttock: Drainage: moist, General Appearance: Red, Surrounding Skin: Reddened. Side two of this document entitled Ulcers, Surgical Site Treatment and Progress Record documented Length: 0.8 X Width: 1.3 cm. Slight Exudate. Decreased in Size: No. R #6's Ulcers, Surgical Site Treatment and Progress Record, Side One, dated 11/15/17 documented Discovered 10/25/17: #3- Stage 3 at 5 o'clock Right Buttock: Drainage: moist, General Appearance: Red, Surrounding Skin: Reddened. Side two of this document entitled Ulcers, Surgical Site Treatment and Progress Record documented Length: 2.0 X Width: 2.5 cm. 100% granulation. Decreased in Size: No. R #6's Ulcers, Surgical Site Treatment and Progress Record, Side One, dated 11/15/17 documented Discovered 10/25/17: #4- Stage 3 at 7 o'clock Left Buttock: Drainage: moist, General Appearance: Yellow, Surrounding Skin: Reddened. Side two of this document entitled Ulcers, Surgical Site Treatment and Progress Record documented Length: 3.0 X Width: 1.5 cm. Slight Exudate. 60% slough and 40% granulation. Decreased in Size: No. R #6's Ulcers, Surgical Site Treatment and Progress Record, Side One, dated 11/15/17 documented Discovered 10/25/17: #5- Stage 3 at 11 o'clock Left Buttock: Drainage: moist, General Appearance: Yellow, Surrounding Skin: Reddened. Side two of this document entitled Ulcers, Surgical Site Treatment and Progress Record documented Length: 3.0 X Width: 2.0 X Depth: 0.8 cm 90%slough and 10% granulation. Decreased in Size: No. R #6's Daily Skilled Nurse's Note dated 11/16/17 documented 7:30 a.m.- spoke with (NP/WCS) concerning areas to right buttock #2 and #3, areas with granulation, no slough. Explained talked to (Admitting Doctor's Nurse Practitioner) concerning change from one cluster to five areas. These two areas would treat with [MEDICATION NAME]. NP/WCS gave orders for alginate silver, discontinue ABD pad due to will not stay on areas, will start protective adhesive pad/cover. Continue to cover area daily and prn . R #6's Physician order [REDACTED].#2 and #3 with NS and apply alginate cover with protective ABD pad and adhesive dressing, change daily and prn. D/C (discontinue) [MEDICATION NAME] to areas #2 and #3 on right buttocks. R #6's proceeding physician's orders [REDACTED]. Interview with R #6's Primary Care Physician (PCP) on 11/16/17 at 9:04 a.m. revealed he was informed by the DON the surveyors concern regarding R #6's documentation and identification of pressure ulcers. The PCP said I totally agree with you- standards are that each wound should be identified, described, and documented separately because not all wounds may require the same treatment as in (R #6's) case. The PCP said it did not matter how many wounds there were, they should be separately distinguished. The PCP said due to inaccurate assessment and documentation, there was no way of distinguishing whether R #6's wounds have improved or deteriorated. The PCP was made aware that R #6 initially was admitted to the facility with four open areas to her buttocks and now she had five plus two new wounds on her right foot. The PCP said it sounds like (R #6) is developing more. The PCP said he was not aware that R #6 had more than one wound because of the incorrect documentation he was reading, although he should have been made aware. R #11: Review of R #11's Face Sheet revealed she was originally admitted to the facility on [DATE] and readmitted on [DATE] after hospitalization for acute [MEDICAL CONDITION]. R#11's [DIAGNOSES REDACTED]. R#11 was [AGE] years old. Review of R#11's annual Minimum Data Set (MDS) assessment dated [DATE] revealed she was able to understand others and make herself understood, and she had a BIMS (Brief Interview for Mental Status) score of 13 points, indicating she was cognitively intact. R#11 was able to walk in her room, could dress with supervision, and was continent of bowel all of the time and had occasional bladder incontinence. Bathing had not occurred in the previous seven days. R#11 weighed 181 pounds and she had no pressure sores. R#11 had some mood issues and had little interest and little energy two to six days during the assessment period. R#11 had no behavior issues. Review of R#11's Significant Change MDS dated [DATE] revealed R#11 required physical assistance with the help of one person for bed mobility, transfer, and dressing. The bathing activity did not occur in the previous seven days. R#11 was continent of bowel and bladder but required physical assistance with toileting and some help with hygiene. R#11 had a BIMS score of 13 and had behaviors of rejecting care. She had little pleasure in doing things and was sleeping too much. R#11 had a poor appetite and her weight was 141 pounds. The care plan dated 08/11/17 revealed R#11 revealed R#1(TRUNCATED)

Based on observation, interview, and record review. The facility failed to provide services that met professional standards for three (R #6, 11, and R #13) of 13 residents reviewed for standards of care. R #6: LVN B did not implement R #6's physician's order of not wearing briefs while in bed. LVN B did not consistently identify all of R #6's pressure ulcers in their Altered Skin Integrity Treatment and Progress Record or Ulcers, Surgical Site Treatment and Progress Record. LVN B did not consult with R #6's primary care physician after the Nurse Practitioner/Wound Care Specialist identified, staged, and treated R #6's seperate five pressure ulcers as one pressure ulcer. LVN B provided treatment to R #6's right heel and right medial great toe without consulting the physician to inform her/him of the new pressure ulcers or receiving treatment orders. LVN B's identification, description, and documentation of R #6's pressure ulcer was not congruent with the surveyor's observation of R #6's current pressure ulcer status, making it difficult to track the progress of the pressure ulcers. LVN B did not consult with R #6's primary care physician after the Nurse Practitioner/Wound Care Specialist identified, staged, and treated R #6's seperate five pressure ulcers as one pressure ulcer. R #11: LVN B failed to accurately describe and stage R #11's pressure ulcers. LVN B failed to identify R #11's two new unstageable pressure ulcers during her head to toe skin check, until the surveyor's inquiry. LVN B provided treatment to R #11's newly discovered unstageable pressure ulcers without consulting the physician to inform him of the new ulcers or receiving treatment orders. R #13 LVN P did not notify R #13's RP prior to administering a [MEDICAL CONDITION] medication and change in status. LVN P did not write TO after receiving verbal order from Nurse Practitioner, did not document in the MAR indicated [REDACTED]. The above failures resulted in an Immediate Jeopardy (IJ) situation on 11/16/17. While the IJ was removed on 11/20/17, the facility remained out of compliance at actual harm with a scope identified as pattern. The facility continued to monitor to ensure continued implementation of their plan of removal. These failures could affect nine residents with pressure ulcers and 80 residents receiving preventative skin care and place them at risk for developing new pressure ulcers or a decline in existing pressure ulcers; and 50 residents in the facility prescribed [MEDICAL CONDITION] medications at risk for non-consent. The findings included: The Texas Administrative Code, Title 22, Part 11, Chapter 217, Rule 217.11, Standards of Nursing Practice states: 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 clients status including signs and symptoms; (ii) nursing care rendered; .(v) client response(s); and (vi) contacts with other health care team members concerning significant events regarding client's status; .(M) Institute appropriate nursing interventions that might be required to stabilize a client's condition and/or prevent complications; .(O) Implement measures to prevent exposure to infectious pathogens and communicable conditions; . The facility's undated Skin Management System 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 .If the skin is intact, no further action is required. If skin is compromised, proceed to the appropriate form below. A. Pressure Injuries, Venous Ulcers and Arterial Ulcers, and surgical sites will be documented on the Ulcer, Surgical Site Treatment and Progress Record form 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]. a. Assess all residents for pain and act accordingly during treatments. b. All dressings are to be dated and initialed upon completion. c. Keep open lines of communication with physician's, 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 . 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. B. Non-ulcer/surgical skin issues such as skin tears, bruises, rashes, abrasions, burns, etc. will be documented on the Altered Skin Integrity Treatment and Progress Record . 2. Routine weekly checks will be completed on every resident; if skin is intact it will be noted as such. If a new pressure sore is noted, a Ulcer, Surgical Site Treatment and Progress Record form will be started. Notification of Physician and Responsible Party must be documented in the nurses' notes . A. Assignments for skin assessments will be posted on a monthly calendar at the station and initialed when completed. Assignment should be by room number. These assignments are to be monitored and saved by the DON. B. CNA's will note any alteration in skin integrity during routine care on the Skin Care Alert form and turn in/reported to the Charge Nurse responsible for the resident at that time, for their attention . 3. Braden Scale will be completed upon admission, readmission, weekly X3 weeks, change of condition and then quarter thereafter on the Braden Scale form A. Interventions will be noted on the Interim Plan of Care. 4. Refer to Protocol for Pressure Ulcers by AMT (American Medical Technology) for assistance with wound identification, staging and recommended treatments. Contact Physician for treatment recommendation approval 8. Facility DONs are responsible to establish a system to monitor and assure Skin Management System Compliance. Review of the facility policy and procedure titled Documentation Charting Errors and /or Omissions (no date) revealed, Accurate medical records shall be maintained by this facility 2. If it is necessary to change or add information in the resident's medical record, it shall be completed by means of an addendum and signed and dated by the person making such change or addition .3. Late entries in the medical record shall be dated at the time of entry and noted as a 'late entry.' R #6: R #6's Face Sheet dated 11/06/17 documented an [AGE] year-old female admitted to the facility on [DATE] and re-admitted on [DATE] with the [DIAGNOSES REDACTED]. R #6's Admission Nursing Evaluation dated 10/25/17 (reviewed and copied on 11/13/17) revealed no documentation of pressure ulcers. On 11/15/17, further review of the same assessment revealed a new entry on the assessment documenting Stage III coccyx. There was no other information describing the pressure ulcer. R #6's Nursing Progress Note dated 10/25/17 documented Resident arrived via stretcher from post acute center .Resident has four open areas to coccyx .See wound care record There was no other specific description in this note regarding the open areas. R #6's Braden Scale dated 10/25/17 documented a score of 11- High risk. R #6's Weekly Skin Integrity Review dated 10/26/17 documented Upon admission coccyx with open areas. R #6's Physician Orders dated 10/26/17 documented Coccyx/buttocks/sacrum areas cleanse with Dakins solution, apply silver alginate measured to wounds, zinc cream to outer borders, cover with choice of dressing bid (twice a day) and prn (as needed) with each incontinent care. R #6's Altered Skin Integrity Treatment and Progress Record, Side One, dated 10/26/17 documented Stage 3 Coccyx: cleanse with Dakins solution, apply silver alginate measured to wounds, zinc cream to outer borders, cover with choice of dressing bid (twice a day) and prn (as needed) with each incontinent care .drainage: macerated (softening and breaking down of skin resulting from prolonged exposure to moisture), General Appearance: Yellow, Surrounding Skin: Reddened. Side two of this document entitled Altered Skin Integrity Treatment and Progress Record documented 10/31/17: (Length): 9.0 X (Width): 10.0 cm, moderate exudate. The documentation implied an identification and description of one wound versus four seperate wounds. R #6's Altered Skin Integrity Treatment and Progress Record, Side One, dated 10/27/17 documented Stage 3 Coccyx: cleanse with Dakins solution, apply silver alginate measured to wounds, zinc cream to outer borders, cover with choice of dressing bid and prn with each incontinent care .drainage: macerated, General Appearance: Yellow, Surrounding Skin: Reddened. Side two of this document entitled Altered Skin Integrity Treatment and Progress Record did not have an entry for this date. R #6's Altered Skin Integrity Treatment and Progress Record, Side One, dated 10/28/17 documented Stage 3 Coccyx: cleanse with Dakins solution, apply silver alginate measured to wounds, zinc cream to outer borders, cover with choice of dressing bid and prn with each incontinent care .drainage: macerated, General Appearance: Red, Surrounding Skin: Reddened. Side two of this document entitled Altered Skin Integrity Treatment and Progress Record did not have an entry for this date. R #6's Altered Skin Integrity Treatment and Progress Record, Side One, dated 10/29/17 documented Stage 3 Coccyx: cleanse with Dakins solution, apply silver alginate measured to wounds, zinc cream to outer borders, cover with choice of dressing bid and prn with each incontinent care .drainage: macerated, General Appearance: Red, Surrounding Skin: Reddened. Side two of this document entitled Altered Skin Integrity Treatment and Progress Record did not have an entry for this date. R #6's Altered Skin Integrity Treatment and Progress Record, Side One, dated 10/30/17 documented Stage 3 Coccyx: cleanse with Dakins solution, apply silver alginate measured to wounds, zinc cream to outer borders, cover with choice of dressing bid and prn with each incontinent care .drainage: macerated, General Appearance: Red, Surrounding Skin: Reddened. Side two of this document entitled Altered Skin Integrity Treatment and Progress Record did not have an entry for this date. R #6's Altered Skin Integrity Treatment and Progress Record, Side One, dated 10/31/17 documented Stage 3 Coccyx: cleanse with Dakins solution, apply silver alginate measured to wounds, zinc cream to outer borders, cover with choice of dressing bid and prn with each incontinent care .drainage: macerated, General Appearance: Dry, Surrounding Skin: Reddened. Side two of this document entitled Altered Skin Integrity Treatment and Progress Record documented 10/31/17: 9.0 X 10.0 cm, moderate exudate. Granulation (reddish connective tissue that forms on the surface of a wound when the wound is healing): No, Decreased Size: No, Decreased Depth: No, Decreased Drainage: No. R #6's Admission Minimum Data Set ((MDS) dated [DATE] documented R #6: -had clear speech -had short and long-term memory problem with severely impaired cognitive skills for decision making -required extensive assistance with one or two person physical assist with bed mobility, dressing, and eating. R #6 was totally dependent for transfers and personal hygiene. -had an indwelling urinary catheter and was always incontinent of bowel. -was at risk of developing pressure ulcers, had one Stage 3 pressure ulcer at admit/reentry measuring 8.0 X 9.0 X 0.5 centimeters (cm). Has pressure reducing device for bed and was receiving pressure ulcer care. The MDS section M1200C: Skin/ulcer treat: turning and reposition was unchecked. R #6's Braden Scale dated 11/01/17 documented a score of 11- High risk. R #6's Initial Wound Consultation Report (performed by Nurse Practitioner/Wound Care Specialist) dated 11/01/17 documented Wound: Bilateral Buttocks/Sacrum/Coccyx, Measurements: 8.0 X 9.0 X 0.5 cm, Wound Bed: 90% adherent, slough, 10% scattered granulation. Periwound: slight moisture, intact. Assessment: Stage 3 Pressure Injury. Elevated right heel on pillows. Treatment: Air Mattress, No diapers in bed. Cleanse with NS, pat dry with gauze, sure prep to peri wound, nickel thick Santyl, protective dressing . R #6's Ulcers, Surgical Site Treatment and Progress Record, Side One, dated 11/01/17 documented Stage 3 Coccyx/Sacrum: cleanse with normal saline. Apply Santyl and cover with protective dressing. Change daily drainage: macerated, General Appearance: Yellow, Surrounding Skin: Reddened. Side two of this document entitled Ulcers, Surgical Site Treatment and Progress Record documented Length: 8.0 X Width: 9.0 X Depth: 0.5 cm. Moderate Serous Exudate. Granulation: Yes, Decreased Size: No, Decreased Depth: No, Decreased Drainage: No. The Ulcers, Surgical Site Treatment and Progress Record, Side Two, included NPUAP (National Pressure Ulcer Advisory Panel) Stages For Pressure Ulcers: -Suspected Deep Tissue Injury (DTI): Purple or maroon localized area of discolored intact skin or blood-filled blister. -Stage 1: Intact Skin. Non-blanchable redness. Skin with darker tones may appear blue, purple, warm, boggy, or firm. -Stage 2: 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. -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, gray, green, brown or black) in the wound bed. R #6's Ulcers, Surgical Site Treatment and Progress Record, Side One, dated 11/02/17- 11/06/17 documented Stage 3 Coccyx/Sacrum: cleanse with normal saline. Apply Santyl and cover with protective dressing. Change daily drainage: macerated, General Appearance: Yellow, Surrounding Skin: Reddened. Side Two of this document entitled Ulcers, Surgical Site Treatment and Progress Record did not have any entries for these dates. R #6's Ulcers, Surgical Site Treatment and Progress Record, Side One, dated 11/07/17 documented Stage 3 Coccyx/Sacrum: cleanse with normal saline. Apply Santyl and cover with protective dressing. Change daily drainage: macerated, General Appearance: Yellow, Surrounding Skin: Reddened. Side two of this document entitled Ulcers, Surgical Site Treatment and Progress Record documented Length: 7.5 X Width: 8.5 X Depth: 0.5 cm. Moderate Serous Exudate. 50% Slough, 50% granulation. R #6's Follow-Up Wound Consultation Report (performed by Nurse Practitioner/Wound Care Specialist) dated 11/01/17 documented Wound: Bilateral Buttocks/Sacrum/Coccyx, Measurements: 7.5 X 8.5 X 0.5 cm, Wound Bed: 50% slough, 50% scattered granulation. Periwound: dry, intact, and no moisture. Assessment: Stage 3 Pressure Injury. Treatment: Air Mattress, No diapers in bed. Continue same treatment plan . R #6's Ulcers, Surgical Site Treatment and Progress Record, Side One, dated 11/08/17- 11/13/17 documented Stage 3 Coccyx/Sacrum: cleanse with normal saline. Apply Santyl and cover with protective dressing. Change daily drainage: macerated, General Appearance: Yellow, Surrounding Skin: Reddened. Side Two of this document entitled Altered Ulcers, Surgical Site Treatment and Progress Record did not have any entries for these dates. R #6's Care Plan dated 11/12/17 documented: -is unable to respond to questions and commands verbally due to [MEDICAL CONDITION] (inability to comprehend or formulate language) and is unable to make needs known verbally. -is alert and oriented to self and needs assistance with making needs known due to dementia. -requires extensive to total staff assistance for all ADL's (activities of daily living) . -has pressure ulcer to coccyx and requires use of low air loss mattress and is at risk for further breakdown. Receives sugar free protein and liquid multivitamin with minerals .Approaches: -assist resident with repositioning frequently -assist resident with obtain and utilizing a pressure relieving device -encourage weight shifts while sitting up in chair -develop turning/repositioning plan with resident input -teach risk factors for development of pressure ulcers -needs wound care as ordered by physician -needs weekly evaluation of wound healing -needs a daily observation of skin with routine care -needs full skin evaluation weekly with bath/shower . Observation of R #6 on 11/13/17 at 11:38 a.m. revealed she sat in a wheelchair in her room with her eyes closed. R #6 had enteral feeding infusing via a pump and connected to her gastric tube infusing at 55 milliliters per hour. R #6 had a brief on. R #6 had blue Prevalon boots (boots that offload the heel) on both feet. Certified Nurse Aide (CNA) G entered the room and introduced herself. CNA G said R #6 rarely spoke any words and when she did, most of the words were not understandable. CNA G said R #6 was not able to voice her needs. CNA G said R #6 was transferred out of bed to her wheelchair via a mechanical lift at approximately 10:50 a.m. CNA G said she had to get R #6 out of bed because therapy usually came for her at about 11:15 a.m. Observation of R #6 on 11/13/17 at 11:48 a.m. revealed R #6 was escorted to the therapy room by a therapist. R #6 sat in her wheelchair throughout the therapy session and was not actively involved in therapy. R #6 was provided with passive therapy until 12:40 p.m. At 12:54 p.m. R #6 was escorted to the nurse's station and positioned beside the television, facing the nurse's station. At 1:40 p.m., CNA G and CNA C escorted R #6 to her room and assisted R #6 to bed using a mechanical lift at 1:46 p.m. R #6 sat in her wheelchair without being offloaded or repositioned from approximately 10:50 a.m.-1:46 p.m. Observation of R #6 on 11/14/17 at 8:35 a.m. revealed R #6 layed in bed on a low air loss mattress with her eyes closed. R #6 had a brief on. Observation of R #6 on 11/14/17 at 9:07 a.m. revealed CNAs C and G escorted R #6 to the shower room and onto the shower bed. Visible was R #6's right foot with a black scabbed area on the medial aspect of her right great toe. A foul odor was prevalent as staff began to undress R #6. Staff removed R #6's brief and exposed R #6's perineal area. The foul odor became stronger when staff turned R #6 to her right side. Staff cleaned R #6's buttocks of feces and exposed was a dressing covered in feces and was half uncovering the wound. R #6's sacral open wound was covered with feces and had a foul odor other than the feces odor. CNA G removed R #6's sacral dressing and allowed water to flow over the wounds. R #6 had denuded skin (loss of the epidermis, caused by exposure to urine, feces, body fluids, wound exudate or friction) between R #6's vagina and anus. In addition, R #6 had five separate open areas to bilateral buttocks: 1. Sacrum at 1 o'clock with the wound bed covered with yellow tissue 2. Right Buttock at 4 o'clock with a red wound bed 3. Right Buttock at 5 o'clock with a red wound bed 4. Left Buttock at 7 o'clock with the more than 50% of the wound bed with yellow tissue and some red tissue 5. Left Buttock at 11 o'clock with approximately 90% of the wound bed with yellow tissue and very little red tissue. There was white macerated (softening and breaking down of skin resulting from prolonged exposure to moisture) surrounding R #6's wounds at 1, 4, 7, and 11 o'clock. After the staff washed the feces off of R #6's buttocks, the foul odor continued from the open wounds. Also exposed, as R #6 layed on her right side was her right heel with dark purple/maroon/black discoloration with the top layer of skin peeling off. Interview with CNA G on 11/14/17 at 10:00 a.m. revealed she stated R #6 had the wound on her right foot for a couple of days, I am not sure exactly how many. I don't know if nurses know, I'm assuming they do, they remind us to put her Prevalon boots on. I don't usually see her buttocks, it is usually covered. CNA G stated R #6 used briefs all day every day because she is incontinent, I haven't been told not to put them on her. CNA G said she was going to call the Licensed Vocational Nurse (LVN) B to dress R #6's wounds before they placed the brief on her. On 11/14/17 at 10:30 a.m., LVN B/Treatment Nurse entered the shower room and said she was going to get the supplies needed for R #6's wounds. LVN B explained R #6 was admitted in the facility with a stage 3 pressure ulcer to her sacrum/buttocks. LVN B said the nurse practitioner/wound care specialist started to see her on 11/01/17 and follows-up with R #6 weekly. When asked if R #6's wounds were healing, LVN B said No, they are the same, it hasn't changed much. LVN B clarified that all the wounds had always been separate open areas but they were measured as one wound because the NP/WCS measured them that way. When asked how LVN B monitored each open area, she said I don't, we look at all of them, the whole area, as one existing wound. LVN B said R #6 had four open areas upon admission and did not know which open area was acquired after admission. LVN B said she had always been taught to identify each wound separately but since working with the NP/WCS, she had learned to combine the area if they are all clustered within the same area. LVN B said she had not consulted with the NP/WCS or R #6's primary care physician about combining all of R #6's wounds as one wound versus identifying them as separate wounds, I just went with it. LVN B was asked about R #6's right foot wounds and LVN B asked what wounds? LVN B assessed R #6's right foot and asked CNA C and CNA G if R #6 already had those, both CNAs shook their head up and down, indicating yes. LVN B said These are new, no one told me about them. LVN B said the right heel is a purple/maroon/black deep tissue injury pressure ulcer. It measures 1.0 X 1.7 centimeters. The right medial great toe had necrotic tissue scabbed, it's an unstageable pressure ulcer, it measures 2.5 X 2.0 centimeters. LVN B then applied skin prep (liquid film-forming dressing that, upon application to intact skin, forms a protective film to help reduce friction) to both wounds on R #6's right foot. After LVN B confirmed that R #6's NP/WCS or physician were not aware of the new wounds and of not having treatment orders for the new wound, LVN B stated I know that is what she (NP/WCS) is going to order. LVN B provided treatment to R #6's right heel and right medial great toe without consulting the physician to inform her/him of the new pressure ulcers or receiving treatment orders. R #6's Daily Skilled Nurse's Note dated 11/14/17 documented Resident in shower with staff- called to shower room to apply treatment to coccyx/sacrum area. Area continue with 50% slough and 50% granulation. No changes. Area with light exudate. Will continue treatment of [REDACTED]. Noted during shower two new areas to right foot. Areas to right heel and right medial foot. Right heel with small DTI- no redness or drainage. Right medial right with thin dry necrotic tissue. Tissue loose and peeling. Spoke to Nurse Practitioner/Wound Specialist and received order for skin prep to areas. daily. Bootie in place . R #6's Ulcers, Surgical Site Treatment and Progress Record, Side One, dated 11/14/17 documented Stage 3 Coccyx/Sacrum: cleanse with normal saline. Apply Santyl and cover with protective dressing. Change daily drainage: macerated, General Appearance: Yellow, Surrounding Skin: Reddened. Side two of this document entitled Ulcers, Surgical Site Treatment and Progress Record documented Length: 9.0 X Width: 8.0 X Depth: 0.5 cm. Light Exudate. 50% Slough, 50% granulation. R #6's Physician Order dated 11/14/17 documented Apply skin prep to right heel and right distal medial wounds daily. R #6's Ulcers, Surgical Site Treatment and Progress Record, Side One, dated 11/14/17 documented Discovered 11/14/17: DTI Right Inner Foot Drainage: dry, General Appearance: Black, Surrounding Skin: Normal. Side two of this document entitled Ulcers, Surgical Site Treatment and Progress Record documented Length: 2.5 X Width: 2.0 cm Thin brown necrotic tissue/dry. Granulation: No R #6's Ulcers, Surgical Site Treatment and Progress Record, Side One, dated 11/14/17 documented Discovered 11/14/17: DTI Right Heel Drainage: dry, General Appearance: Black, Surrounding Skin: Pink. Side two of this document entitled Ulcers, Surgical Site Treatment and Progress Record documented Length: 1.0 X Width: 1.7 cm. dry. Granulation: No On 11/15/17 at 11:14 a.m., this surveyor accompanied the NP/WCS, LVN B, and the Director of Nurses (DON) to R #6's room. The NP/WCS explained that she was caring for R #6 in the hospital prior to her being admitted to this facility. The NP/WCS stated R #6 had three or four separate open areas when she was admitted to this facility. The NP/WCS said R #6 did not have any wounds on her right foot when she last saw her on 11/07/17. The NP/WCS removed R #6's brief and dressing to her sacrum/buttocks. The NP/WCS measured R #6's sacrum/buttocks and said out loud 6.8 X 7.0 X 0.8 centimeters 40% slough and 60% granulation tissue. It has massive excoriation from the moisture retained within the brief. This excoriation could have been prevented if the brief was left off, excoriation could cause new pressure injuries or deterioration. Overall the wound is worsening, it has increased in depth as well. When the NP/WCS was asked the rational for measuring the separate open areas as one area versus separate areas, NP/WCS said That's how I do it, it's too much to separate them. The NP/WCS measured R #6's right medial great toe and stated 2.3 X 2.3 centimeters non-blanchable 100% black eschar. The right heel is dark purple/maroon with some black discoloration with surrounding skin red, non-blanchable. We have to keep the heel offloaded. The NP/WCS verified she had given orders on her consultation sheet for R #6 not to wear briefs in bed since she first saw R #6 on 11/01/17. The NP/WCS said she was there to give the orders and it was the facility's responsibility to implement the orders. The NP/WCS stated the resident's condition could deteriorate if her orders were not implemented. R #6's Daily Skilled Nurse's Note dated 11/15/17 documented 11:00 a.m. (NP/WCS) here to eval and order treatments for wounds to coccyx/sacrum/right and left buttocks and right heel and right medial great toe. recommend to use Santyl to cluster of areas of wounds. Will use Santyl only on areas with slough and will separate areas. Noted 5 different in cluster that only three have slough and needs Santyl. 2 areas have all granulation and use [MEDICATION NAME]. Will leave diaper off as ordered. Will cover with ABD as ordered with tape and use zinc barrier paste for excoriated areas. Bootie to right foot on at all times . R #6's Initial Follow-Up Consultation Report (performed by Nurse Practitioner/Wound Care Specialist) dated 11/15/17 at 11:44 a.m. documented Wound: Bilateral Buttocks/Sacrum/Coccyx, Measurements: 6.8 X 7.0 X 0.8 cm, Wound Bed: 40% slough moist, 60% granulation. Periwound: maceration pallor to wound edges, denuded. Assessment: worsening Stage 3 Pressure Injury. Treatment: Air Mattress, tube of zinc given (to facility)- cleanse with NS, pat dry, zinc to excoriated areas nickel thick, Santyl to slough areas. ABD and secure with tape -Right Medial Heel: Measurement: 1.0 X 1.0 cm, Wound Bed: dark black/purple discoloration, Periwound: non-blanchable redness, dry and intact, Assessment: Suspected DTI, Unstageable Pressure Injury, Treatment: Daily Sure prep and offload . -Right Medial Great Toe: Measurements: 2.3 X 2.3 cm, Wound Bed: 100% dry stable eschar, Periwound: dry intact scaly, Assessment: suspected DTI, Unstageable Pressure Injury, Treatment: Daily Sure Prep, offload. R #6's Physician's Order dated 11/15/17 documented Apply zinc barrier paste to excoriated areas to buttocks/peri areas bid and after incontinent episodes. Interview with the DON on 11/15/17 at 11:33 a.m. revealed she stated nurses were responsible for assessing and documenting what is seen as accurately as possible. The DON said she did not know R #6 had separate open areas and from reviewing LVN B and NP/WCS's documentation It looked like she only had one wound. I can't tell if any of the separate open areas have improved or worsened because of the incorrect documentation. I can't tell when (R #6) developed the additional ulcer on her bottom. The DON said LVN B should have documented the number of open areas, their location, a description and measurement of each area and it's surrounding skin. The DON said she did not agree with the NP/WCS and LVN B's identification and description of the wounds. The DON said LVN B having several years in wound care background should have informed her or/and (R #6's) physician after the NP/WCS treated the ulcers as one ulcer. The DON stated LVN B was responsible for reviewing the NP/WCS's consultation notes and should have implemented the order, including in-servicing the rest of the staff for R #6 not to wear briefs in bed. The DON said she was going to have LVN B re-measure R #6's wounds and document them separately. Interview with LVN B on 11/15/17 at 12:20 p.m. revealed she confirmed she had seen NP/WCS consultation notes and read the order for no briefs. LVN B said she did not in-service staff to implement that order. R #6's Physician Order dated 11/15/17 documented Cleanse area #1 at 1 o'clock with normal saline (NS), apply santyl and cover with ABD pad. Clean area #2 at 4 o'clock on right buttock with NS, apply [MEDICATION NAME] and cover with ABD pad. Clean area #3 at 5 o'clock on right buttock with NS, apply [MEDICATION NAME] and cover with ABD. Clean area #4 with NS, apply Santyl, cover with ABD pad. Clean area #5 with NS, apply santyl and cover with ABD pad. Change all sites daily. No brief/can keep under, no binding tapes. R #6's Ul (TRUNCATED)

Based on observation, interview, and record review the facility failed to follow the care plan and provide services in accordance with the Physician's Plan of Care (physician's orders [REDACTED].#1 and R #6) 13 residents reviewed for plans of care. 1.) The facility did not implement R #6's physician's orders [REDACTED]. 2.) The facility did not administer R #1 her prescribed pain medication when needed as per physician's orders [REDACTED]. R #1 was not provided with armsleeves as prescribed by her physician. The above failures resulted in an Immediate Jeopardy (IJ) situation on 11/16/17. While the IJ was removed on 11/20/17, the facility remained out of compliance at actual harm with a scope identified as pattern. The facility continued to monitor to ensure continued implementation of their plan of removal. These failures could place nine residents with pressure ulcers and 80 residents identified as receiving preventative skin care, 77 residents who required the assistance of one or two staff with some activity of daily living, and --- at risk for a deterioration of skin integrity and pain control. The findings included: R #6: R #6's Face Sheet dated 11/06/17 documented an [AGE] year-old female admitted to the facility on [DATE] and re-admitted on [DATE] with the [DIAGNOSES REDACTED]. R #6's Admission Nursing Evaluation dated 10/25/17 (reviewed and copied on 11/13/17) revealed no documentation of pressure ulcers. On 11/15/17, further review of the same assessment revealed a new entry on the assessment documenting Stage III coccyx. There was no other information describing the pressure ulcer. R #6's Nursing Progress Note dated 10/25/17 documented Resident arrived via stretcher from post acute center .Resident has four open areas to coccyx .See wound care record There was no other specific description in this note regarding the open areas. R #6's Braden Scale dated 10/25/17 documented a score of 11- High risk. R #6's Weekly Skin Integrity Review dated 10/26/17 documented Upon admission coccyx with open areas. R #6's Physician order [REDACTED]. R #6's Altered Skin Integrity Treatment and Progress Record, Side One, dated 10/31/17 documented Stage 3 Coccyx: cleanse with Dakins solution, apply silver alginate measured to wounds, zinc cream to outer borders, cover with choice of dressing bid and prn with each incontinent care .drainage: macerated, General Appearance: Dry, Surrounding Skin: Reddened. Side two of this document entitled Altered Skin Integrity Treatment and Progress Record documented 10/31/17: 9.0 X 10.0 cm, moderate exudate. Granulation (reddish connective tissue that forms on the surface of a wound when the wound is healing): No, Decreased Size: No, Decreased Depth: No, Decreased Drainage: No. R #6's Admission Minimum Data Set ((MDS) dated [DATE] documented R #6: -had clear speech -had short and long-term memory problem with severely impaired cognitive skills for decision making -required extensive assistance with one or two person physical assist with bed mobility, dressing, and eating. R #6 was totally dependent for transfers and personal hygiene. -had an indwelling urinary catheter and was always incontinent of bowel. -was at risk of developing pressure ulcers, had one Stage 3 pressure ulcer at admit/reentry measuring 8.0 X 9.0 X 0.5 centimeters (cm). Has pressure reducing device for bed and was receiving pressure ulcer care. The MDS section M1200C: Skin/ulcer treat: turning and reposition was unchecked. R #6's Braden Scale dated 11/01/17 documented a score of 11- High risk. R #6's Initial Wound Consultation Report (performed by Nurse Practitioner/Wound Care Specialist) dated 11/01/17 documented Wound: Bilateral Buttocks/Sacrum/Coccyx, Measurements: 8.0 X 9.0 X 0.5 cm, Wound Bed: 90% adherent, slough, 10% scattered granulation. Periwound: slight moisture, intact. Assessment: Stage 3 Pressure Injury. Elevated right heel on pillows. Treatment: Air Mattress, No diapers in bed. Cleanse with NS, pat dry with gauze, sure prep to peri wound, nickel thick Santyl, protective dressing . R #6's Ulcers, Surgical Site Treatment and Progress Record, Side One, dated 11/01/17 documented Stage 3 Coccyx/Sacrum: cleanse with normal saline. Apply Santyl and cover with protective dressing. Change daily drainage: macerated, General Appearance: Yellow, Surrounding Skin: Reddened. Side two of this document entitled Ulcers, Surgical Site Treatment and Progress Record documented Length: 8.0 X Width: 9.0 X Depth: 0.5 cm. Moderate Serous Exudate. Granulation: Yes, Decreased Size: No, Decreased Depth: No, Decreased Drainage: No. The Ulcers, Surgical Site Treatment and Progress Record, Side Two, included NPUAP (National Pressure Ulcer Advisory Panel) Stages For Pressure Ulcers: -Suspected Deep Tissue Injury (DTI): Purple or maroon localized area of discolored intact skin or blood-filled blister. -Stage 1: Intact Skin. Non-blanchable redness. Skin with darker tones may appear blue, purple, warm, boggy, or firm. -Stage 2: 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. -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, gray, green, brown or black) in the wound bed. R #6's Follow-Up Wound Consultation Report (performed by Nurse Practitioner/Wound Care Specialist) dated 11/01/17 documented Wound: Bilateral Buttocks/Sacrum/Coccyx, Measurements: 7.5 X 8.5 X 0.5 cm, Wound Bed: 50% slough, 50% scattered granulation. Periwound: dry, intact, and no moisture. Assessment: Stage 3 Pressure Injury. Treatment: Air Mattress, No diapers in bed. Continue same treatment plan . R #6's Ulcers, Surgical Site Treatment and Progress Record, Side One, dated 11/08/17- 11/13/17 documented Stage 3 Coccyx/Sacrum: cleanse with normal saline. Apply Santyl and cover with protective dressing. Change daily drainage: macerated, General Appearance: Yellow, Surrounding Skin: Reddened. Side Two of this document entitled Altered Ulcers, Surgical Site Treatment and Progress Record did not have any entries for these dates. R #6's Care Plan dated 11/12/17 documented: -is unable to respond to questions and commands verbally due to [MEDICAL CONDITION] (inability to comprehend or formulate language) and is unable to make needs known verbally. -is alert and oriented to self and needs assistance with making needs known due to dementia. -requires extensive to total staff assistance for all ADL's (activities of daily living) . -has pressure ulcer to coccyx and requires use of low air loss mattress and is at risk for further breakdown. Receives sugar free protein and liquid multivitamin with minerals .Approaches: -assist resident with repositioning frequently -assist resident with obtain and utilizing a pressure relieving device -encourage weight shifts while sitting up in chair -develop turning/repositioning plan with resident input -teach risk factors for development of pressure ulcers -needs wound care as ordered by physician -needs weekly evaluation of wound healing -needs a daily observation of skin with routine care -needs full skin evaluation weekly with bath/shower . Observation of R #6 on 11/13/17 at 9:04 a.m., during initial rounds, revealed R #6 layed on a low air loss mattress, in a face up position with her head of the bed slightly elevated. R #6's bed sheets did not cover her left above the knee stump or hip allowing R #6's blue brief to be visible. Observation of R #6 on 11/14/17 at 8:35 a.m. revealed R #6 layed in bed on a low air loss mattress with her eyes closed. R #6 had a brief in use. Observation of R #6 on 11/14/17 at 9:07 a.m. revealed CNAs C and G escorted R #6 to the shower room and onto the shower bed. Visible was R #6's right foot with a black scabbed area on the medial aspect of her right great toe. A foul odor was prevalent as staff began to undress R #6. Staff removed R #6's brief and exposed R #6's perineal area. The foul odor became stronger when staff turned R #6 to her right side. Staff cleaned R #6's buttocks of feces and exposed was a dressing covered in feces and was half uncovering the wound. R #6's sacral open wound was covered with feces and had a foul odor other than the feces odor. CNA G removed R #6's sacral dressing and allowed water to flow over the wounds. R #6 had denuded skin (loss of the epidermis, caused by exposure to urine, feces, body fluids, wound exudate or friction) between R #6's vagina and anus. In addition, R #6 had five separate open areas to bilateral buttocks: 1. Sacrum at 1 o'clock with the wound bed covered with yellow tissue 2. Right Buttock at 4 o'clock with a red wound bed 3. Right Buttock at 5 o'clock with a red wound bed 4. Left Buttock at 7 o'clock with the more than 50% of the wound bed with yellow tissue and some red tissue 5. Left Buttock at 11 o'clock with approximately 90% of the wound bed with yellow tissue and very little red tissue. There was white macerated (softening and breaking down of skin resulting from prolonged exposure to moisture) surrounding R #6's wounds at 1, 4, 7, and 11 o'clock. After the staff washed the feces off of R #6's buttocks, the foul odor continued from the open wounds. Also exposed, as R #6 layed on her right side was her right heel with dark purple/maroon/black discoloration with the top layer of skin peeling off. Both staff concluded the shower, placed a brief and gown on R #6 before transferring her back to bed. Interview with CNA G on 11/14/17 at 10:00 a.m. revealed she stated R #6 had the wound on her right foot for a couple of days, I am not sure exactly how many. I don't know if nurses know, I'm assuming they do, they remind us to put her Prevalon boots on. I don't usually see her buttocks, it is usually covered. CNA G stated R #6 used briefs all day every day because she is incontinent, I haven't been told not to put them on her. CNA G said she was going to call the Licensed Vocational Nurse (LVN) B to dress R #6's wounds before they placed the brief on her. On 11/14/17 at 10:30 a.m., LVN B/Treatment Nurse entered the shower room and said she was going to get the supplies needed for R #6's wounds. LVN B explained R #6 was admitted in the facility with a stage 3 pressure ulcer to her sacrum/buttocks. LVN B said the nurse practitioner/wound care specialist started to see her on 11/01/17 and follows-up with R #6 weekly. When asked if R #6's wounds were healing, LVN B said No, they are the same, it hasn't changed much. LVN B clarified that all the wounds had always been separate open areas but they were measured as one wound because the NP/WCS measured them that way. When asked how LVN B monitored each open area, she said I don't, we look at all of them, the whole area, as one existing wound. LVN B said R #6 had four open areas upon admission and did not know which open area was acquired after admission. LVN B said she had always been taught to identify each wound separately but since working with the NP/WCS, she had learned to combine the area if they are all clustered within the same area. LVN B said she had not consulted with the NP/WCS or R #6's primary care physician about combining all of R #6's wounds as one wound versus identifying them as separate wounds, I just went with it. LVN B was asked about R #6's right foot wounds and LVN B asked what wounds? LVN B assessed R #6's right foot and asked CNA C and CNA G if R #6 already had those, both CNAs shook their head up and down, indicating yes. LVN B said These are new, no one told me about them. LVN B said the right heel is a purple/maroon/black deep tissue injury pressure ulcer. It measures 1.0 X 1.7 centimeters. The right medial great toe had necrotic tissue scabbed, it's an unstageable pressure ulcer, it measures 2.5 X 2.0 centimeters. LVN B then applied skin prep (liquid film-forming dressing that, upon application to intact skin, forms a protective film to help reduce friction) to both wounds on R #6's right foot. After LVN B confirmed that R #6's NP/WCS or physician were not aware of the new wounds and of not having treatment orders for the new wound, LVN B stated I know that is what she (NP/WCS) is going to order. LVN B provided treatment to R #6's right heel and right medial great toe without consulting the physician to inform her/him of the new pressure ulcers or receiving treatment orders. On 11/15/17 at 11:14 a.m., this surveyor accompanied the NP/WCS, LVN B, and the Director of Nurses (DON) to R #6's room. The NP/WCS explained that she was caring for R #6 in the hospital prior to her being admitted to this facility. The NP/WCS stated R #6 had three or four separate open areas when she was admitted to this facility. The NP/WCS said R #6 did not have any wounds on her right foot when she last saw her on 11/07/17. The NP/WCS removed R #6's brief and dressing to her sacrum/buttocks. The NP/WCS measured R #6's sacrum/buttocks and said out loud 6.8 X 7.0 X 0.8 centimeters 40% slough and 60% granulation tissue. It has massive excoriation from the moisture retained within the brief. This excoriation could have been prevented if the brief was left off, excoriation could cause new pressure injuries or deterioration. Overall the wound is worsening, it has increased in depth as well. When the NP/WCS was asked the rational for measuring the separate open areas as one area versus separate areas, NP/WCS said That's how I do it, it's too much to separate them. The NP/WCS measured R #6's right medial great toe and stated 2.3 X 2.3 centimeters non-blanchable 100% black eschar. The right heel is dark purple/maroon with some black discoloration with surrounding skin red, non-blanchable. We have to keep the heel offloaded. The NP/WCS verified she had given orders on her consultation sheet for R #6 not to wear briefs in bed since she first saw R #6 on 11/01/17. The NP/WCS said she was there to give the orders and it was the facility's responsibility to implement the orders. The NP/WCS stated the resident's condition could deteriorate if her orders were not implemented. R #6's Initial Follow-Up Consultation Report (performed by Nurse Practitioner/Wound Care Specialist) dated 11/15/17 at 11:44 a.m. documented Wound: Bilateral Buttocks/Sacrum/Coccyx, Measurements: 6.8 X 7.0 X 0.8 cm, Wound Bed: 40% slough moist, 60% granulation. Periwound: maceration pallor to wound edges, denuded. Assessment: worsening Stage 3 Pressure Injury. Treatment: Air Mattress, tube of zinc given (to facility)- cleanse with NS, pat dry, zinc to excoriated areas nickel thick, Santyl to slough areas. ABD and secure with tape -Right Medial Heel: Measurement: 1.0 X 1.0 cm, Wound Bed: dark black/purple discoloration, Periwound: non-blanchable redness, dry and intact, Assessment: Suspected DTI, Unstageable Pressure Injury, Treatment: Daily Sure prep and offload . -Right Medial Great Toe: Measurements: 2.3 X 2.3 cm, Wound Bed: 100% dry stable eschar, Periwound: dry intact scaly, Assessment: suspected DTI, Unstageable Pressure Injury, Treatment: Daily Sure Prep, offload. Interview with the DON on 11/15/17 at 11:33 a.m. revealed she stated LVN B was responsible for reviewing the NP/WCS's consultation notes and should have implemented the order, including in-servicing the rest of the staff for R #6 not to wear briefs in bed. The DON said she was going to have LVN B re-measure R #6's wounds and document them separately. Interview with LVN B on 11/15/17 at 12:20 p.m. revealed she confirmed she had seen NP/WCS consultation notes and read the order for no briefs. LVN B said she did not in-service staff to implement that order. R #1: Review of R#1's Face Sheet dated 11/13/17 revealed she was admitted to the facility on [DATE] and readmitted on [DATE]. R#1's [DIAGNOSES REDACTED]. R#1 was [AGE] years old. Review of R#1's Minimum Data Set ((MDS) dated [DATE] revealed she had unclear speech and was rarely or never understood, and sometimes understood others if they used simple, direct communication. R#1 had severely impaired cognitive skills, and she had trouble concentrating and showed little interest or pleasure in things. R#1 had no behavior symptoms. R#1 required extensive assistance with the help of two persons with bed mobility and transfer; she did not walk but used a wheelchair with one person assist; required extensive assistance with the help of one person with dressing and toileting; required one person physical assist with eating and personal hygiene; and was totally dependent on the assistance of one person with bathing. R#1 had no range of motion limitations on her upper or lower extremities. R#1 was always incontinent of bowel and bladder. R#1 had a stage one pressure ulcer and a stage three pressure ulcer. Review of R#1's Physician order [REDACTED]. boundaries; 6/27/16 Pain assessment every shift, document level of pain (0-10) and scale used to determine pain level; 10/22/15 [MEDICATION NAME] .5 mg BID at 0600 and 1400 for anxiety disorder; 10/22/15 [MEDICATION NAME] .5 mg TID (three times daily) PRN for anxiety; 04/01/17 [MEDICATION NAME] .5 mg 1/2 tablet TID PRN; 10/22/15 [MEDICATION NAME] 15 mg QHS (at night); and [MEDICATION NAME] 50 mg 1/2 tablet QHS. Review of R#1's Care Plan dated 08/04/17 for skin tears revealed approaches to be Assess for the need of protective devices (i.e., Geri sleeves, Geri-legs, long sleeved shirts, padded side rails, padded wheelchair arms and legs); and Investigate incident to prevent any further incidents. Review of R#1's Care Plan dated 03/13/17 and updated 06/13/17 for pressure ulcers and skin tears due to poor skin integrity and poor mobility revealed approaches to include Armsleeves or long sleeve on at all times. Review of R#1's Care Plan dated 03/13/17 and updated 06/13/17 revealed R#1 had the potential for alterations in comfort related to a history of low back pain and muscle weakness. R#1 had an increased risk for falls and constipation related to the use of [MEDICATION NAME] medications to aid in the managing of pain or discomfort. Approaches included observing for signs and symptoms of pain (i.e., facial grimacing, moans, restlessness, crying, etc.) and notify MD; and Document pain and assess pain using the pain assessment and pain scale; Encourage resident to ask for pain medications when pain first starts; and Resident is prescribed [MEDICATION NAME] ES PRN. Observation of R#1 on initial tour with Licensed Vocational Nurse (LVN) D at 10:30 a.m. on 11/13/17 revealed R#1 in bed. Surveyor observed R#1 had skin tears on her left forearm about five inches long that were partly covered with a dressing. LVN D said R#1 had a stage two pressure ulcer on the right side of her buttocks and R#1 was a fall risk because she tried to stand without assistance, especially at night. LVN D said R#1 required total assistance with Activities of Daily Living (ADLs) and was subject to skin tears because she had fragile skin and tried to get out of bed or out of her wheelchair and bumped her arms often. LVN D said R#1's skin tears on her left forearm were the result of R#1 bumping her arm on the side rail of her bed. Surveyor observed R#1's bed to be against the wall on one side and the 1/2 side rail to be up on the left side of the bed. R#1 had soft boots on both feet and had long sleeves on her arms. R#1 did not respond when spoken to and had her eyes closed. Observation at 9:35 a.m. on 11/14/17 revealed R#1 sitting in her wheelchair in the common area by the nurse's station, with her left arm resting on a a small tray attached to her wheelchair and a soft boot on her right foot. R#1 also had a covering on her left elbow dated 11/14/17. Certified Nursing Assistant (CNA) Y told R#1 it was time to put her to bed for a while and CNA Y obtained the assistance of CNA X and they took R#1 to her room. Surveyor observed CNA Y and CNA X attempt to transfer R#1 to bed, but R#1 did not want to go to bed. CNA Y said R#1 became stiff and fought sometimes when they tried to assist her with ADLs. Surveyor observed that R#1's arms were exposed as she was wearing short sleeves. CNA Y said sometimes R#1 could assist with transfer but sometimes they needed a gait belt to assist her with transfer. As CNA Y started to assist R#1 out of the wheelchair, R#1 was observed to say, Don't clip me. CNA Y asked R#1 if she was in pain, and she said Yeah, and said moving her left arm hurt. CNA Y said R#1 was up more at night and sometimes sat on the side of the bed. CNA Y said R#1 had a fall mat next to her bed because she tried to get out of bed. R#1 continued to resist being transferred and cried out when touched. CNA Y told R#1 they were not going to continue to try to transfer her and took R#1 back to the area near the nurse's station. Observation of R #1 on 11/14/17 at 2:30 p.m. revealed R #1 sat in her wheelchair positioned in front of the television common area of Side 2 of the facility. R #1 had her eyes closed and had a pillow on her right arm rest of her wheelchair where she rested her head on. R #1's arms were visible; R #1 did not have ant protective devices on her arms. CNAs S and C assisted R #1 to the 400 Hall shower room and explained to R #1 the shower procedure. R #1 responded I'm sick, I'm sick repeatedly. CNA C asked R #1 what she felt but R #1 did not respond. Both CNAs assist to transfer R #1 from her wheelchair to the shower chair using a gait belt aound R #1's waist. Immediately after staff raise R #1 off her wheelchair, R #1 screamed Ahhh, ahhh ahhh, I'm hurting, I'm hurting. Both CNAs apologize to R #1 and then continue to undress R #1. As staff raise R #1's arms and legs remove her shirt and pants, R #1 yells out. As CNA C raised the shower head to allow water to run off of R #1's back and body, R #1 screams and said I'm hurting honey, I'm hurting all over. CNA S began to srub R #1's torso with a soapy washcloth when R #1 yelled It huts, it hurts, will you help me. CNA S apologized to R #1 and asked if she was hurting R #1 however, R #1 did not respond. At 2:58 p.m., CNA C retrieved Registered Nurse (RN) T and as RN T approached R #1, R #1 stated It hurts, it hurts, will you help me. R #1 did not respond to RN T asking her where she hurt. Both CNA's gently pat dry R #1's body when R #1 yelled I'm hurting, please help me lady and guards her torso with her arms in a hunched over position. At 3:17 p.m., RN T exited the shower room. At 3:44 p.m. R #1 was escorted to her room and again when transferred to bed, R #1 yelled It hurts, it hurts repeatedly. At 3:58 p.m. both CNAs exited R #1's bedroom and left R #1 laying on her left side in bed. R #1 was not provided with any protective devices on her arms. From 2:30 p.m.- 3:58 p.m., R #1 expressed pain and received no pain relief medication. Interview with CNA S on 11/14/17 at 3:14 p.m. revealed she stated (R #1) normally says she hurts whenever we do anything with her. We tell the nurse but I don't know if she gets any pain medication. Anytime we touch her, she says she hurts but doesn't or can't really describe her pain to us. Review of Incident documentation revealed the following incidents regarding R#1: 07/21/17 at 4:30 p.m.: Was assisting (R#1) to wc (wheelchair) when resident was leaning back and jerked her L (left) arm away causing a ST (skin tear) 1.0 X 1.5 cm. Action taken was staff re-education. No information was given regarding whether bed rails or other restraints were in use. 08/03/17 at 8:00 a.m.: CNA was dressing res (resident) for breakfast and reported to this nurse she felt something wet. Upon assessment 1.0 X 4.5 cm S/T (skin tear) noted to R (right) F/A (forearm). Action taken was blank. Bed rails were not in use. 09/30/17 at 4:30 p.m.: Resident was being transferred to chair by staff when she hit her elbow on the arm of her chair. Action taken was blank. Bed rails were not in use. 11/06/17 at 2:20 p.m.: Staff member observed ST to L forearm once transfer was completed. Staff were re-educated. Restraints and bed rails were not in use. 11/13/17 at 9:00 a.m.: Resident bumped elbow on bed rail causing S/T. Bed rails were present and were up. Staff and resident were re-educated. Review of the November, 2017 and October, 2017 MAR (Medication Administration Record) revealed Acetominophen 500 mg Q Day was given at 6:00 a.m. daily, with the exception that it was not administered on 10/16/17 and 10/29/17. Review of the Nurse MAR for November, 2017 and October, 2017 revealed no administration of [MEDICATION NAME] 500 mg BID PRN for pain, and no administration of [MEDICATION NAME] .5 mg TID PRN or [MEDICATION NAME] .5 mg 1/2 tablet TID PRN, with the exception of [MEDICATION NAME] .5 mg 1/2 tablet at night on 10/18/17. The Nurse MAR indicated [REDACTED]. Review of the Nurse MAR for October, 2017 and November, 2017 revealed a pain assessment was completed each shift on a daily basis in November, 2017 with the exception of the evenings of 11/04/17, 11/05/17 and 11/09/17, and the night of 11/08/17. R#1 had no observable pain according to the MAR. In October, 2017, the Nurse MAR indicated [REDACTED]. There was no evidence that R #1 received pain medication on 11/14/17. On 11/16/17 at 5:40 p.m., the survey team identified Immediate Jeopardy due to the above failures regarding pressure ulcers. On 11/16/17 at 6:20 p.m., the facility Administrator, the DON, and the Director of Clinical Operations were notified that an Immediate Jeopardy situation had been identified due to the above failures. On 11/17/17 at 8:48 p.m., the facility was notified of the acceptance of the final Plan of Removal (POR). The facility's final Plan of Removal documented: On 11/13/17, a standard survey was initiated at (facility). At approximately 6:20 pm, the surveyor provided verbal notification that the survey agency has determined that the conditions at the center constitute immediate jeopardy to resident health and safety. The notification of the alleged immediate jeopardy states as follows: -Accurate description, staging, and documentation of pressure ulcers. -Position notification of when status related to obtaining treatment orders. -Following physician orders [REDACTED]. The following plan of action outlines immediate intervention is employed by the facility to correct any further concerns surrounding the above issue: Education was initiated on 11/15/17 by the Director of Clinical Operations for licensed staff on assessment of pressure ulcers to include: -Measuring of wounds -Staging of wounds -Documentation of assessment of wounds -Notifying physician of one progress -Obtaining treatment orders from physician on wound treatment -Following physician orders [REDACTED]. AMT (American Medical Technology) wound consultant, AMT LVN, reviewed and provided support regarding needed education for pressure ulcers, assessments, staging, and treatment options on 11/17/17 and ongoing. Education will continue each shift until 100% of the staff is educated on the above. Those employees on leave will have their education completed upon arrival for the start of their next scheduled shift to work. Director of Nursing will be responsible to ensure the above noted education is completed. The facility initiated the following: -A 100% skin sweep of the residents in the center to ensure identification and an evaluation of skin alterations residence by licensed nurse that had received education regarding wound assessment measurement and documentation on 11/15/17 and was completed on 11/16/17 -Upon skin sweep completed from 11/15/17- 11/16/17 there were no new pressure ulcers identified. -Upon skins we've completed from 11/15/17 through 11/16/17 there were no pressure ulcers identified that had worsened. -Resident (#11), was identified with abrasion to right side, unstageable area to upper right buttocks, and stage III area to right buttocks during treatment observation with treatment nurse conducted by state surveyors at approximately 3 PM on 11/16/17. Notification to physician and responsible party were made entering the orders were obtained. -Current treatment nurse suspended on 11/16/17 -Review of pressure ulcer documentation for all individuals who currently have pressure ulcers to ensure accurate staging, documentation, and notifications was performed by the Director of Nursing and the Director of Clinical Operations 11/16/17. -The attending physician and responsible party will be notified on the current status of the residents in house with pressure ulcers to get be completed on or before 11/17/17. Ad-hoc QAPI meeting was conducted on 11/16/17 including the administrator, Director of Nursing, Director of Clinical Operations, and Medical Director, saying, to review the immediate jeopardy and the interventions implemented by the facility to correct please except this letter as our plan a removal for the determination of immediate jeopardy verbally issued on 11/16/17. On 11/17/17, the DON provided a revised list of resident's identified with pressure ulcers after the facility completed their skin sweep of all residents. Among the list was R #3. During the monitoring phase of the facility's plan of removal on 11/18/17, the surveyor accompanied LVN F to R #3's room. LVN F said She has a Stage 2 pressure ulcer to her coccyx, discovered in-house on 11/16/17. It measured 2.0 X 1.4 centimeters on 11/16/17. LVN F removed R #3's dressing dated 11/17/17 and exposed an open area with 100% pink/red wound bed. LVN F then measured the wound and said 2.0 X 1.0 centimeters. LVN F removed a dressing dated 11/17/17 at 3 am off of R #3's right inner thigh and exposed an upside down J shaped open reddened area to R #3's right inner thigh underneath R #3's indwelling urinary catheter tubing. LVN F described the wound as an abrasion. LVN F said It looks like it was from the catheter, it appears the shape of the ports of the catheter. LVN F measured the right inner thigh wound stating 2.5 X 1.5 centimeters. Interview with LVN Q on 11/18/17 at 1 (TRUNCATED)

Based on observation, interview, and record review the facility failed to ensure residents who entered the facility without pressure ulcers did not develop pressure ulcers and a resident having pressure ulcers received care and treatment consistent with professional standards of practice to promote healing and prevent further development of skin breakdown or pressure ulcers for three (R #3, R #6, and R #11) of four residents reviewed for pressure ulcers. R #6: -The facility failed to attempt to offload or reposition R #6 off her buttocks for approximately three hours, even after the facility was aware of R #6 having sacrum/coccyx/buttocks pressure ulcers. The facility failed to implement R #6's physician's orders [REDACTED]. The facility failed to accurately describe, document measurements, and stage all of R #6's pressure ulcers upon admission until the surveyor's inquiry. R #6 was admitted with four stage 3 pressure ulcers and developed one other stage 3 and two unstageable pressure ulcers. The facility failed to consistently identify and document all of R #6's pressure ulcers in their Altered Skin Integrity Treatment and Progress Record or Ulcers, Surgical Site Treatment and Progress Record. The facility failed to identify or document R #6's two new right foot unstageable pressure ulcers until the surveyor's inquiry. LVN B provided treatment to R #6's right heel and right medial great toe without consulting the physician to inform her/him of the new pressure ulcers or receiving treatment orders. The facility's identification, description, and documentation of R #6's pressure ulcer did not match R #6's current pressure ulcer status. The facility was identifying and treating R #6's pressure ulcers as one ulcer instead of instead of five seperate pressure ulcers. LVN B did not consult with R #6's primary care physician after the Nurse Practitioner/Wound Care Specialist identified, staged, and treated R #6's seperate five pressure ulcers as one pressure ulcer. R #11: -The facility failed to accurately describe and stage R #11's pressure ulcers that were facility acquired. The facility failed to identify R #11's two new unstageable pressure ulcers until the surveyor's inquiry. LVN B provided treatment to R #11's newly discovered unstageable pressure ulcers without consulting the physician to inform him of the new ulcers or receiving treatment orders. R #3: -R #3 was not offloaded or repositioned for more than two hours. R #3 did not have a pressure ulcer on 11/13/17 however, on 11/16/17 she had developed two Stage 2 pressure ulcers. The above failures resulted in an Immediate Jeopardy (IJ) situation on 11/16/17. While the IJ was removed on 11/20/17, the facility remained out of compliance at actual harm with a scope identified as pattern. The facility continued to monitor to ensure continued implementation of their plan of removal. These failures could affect nine residents with pressure ulcers and 80 residents receiving preventative skin care and place them at risk for developing new pressure ulcers or a decline in existing pressure ulcers. The findings included: R #6: R #6's Face Sheet dated 11/06/17 documented an [AGE] year-old female admitted to the facility on [DATE] and re-admitted on [DATE] with the [DIAGNOSES REDACTED]. R #6's Nursing Progress Note dated 10/25/17 documented Resident arrived via stretcher from post acute center .Resident has four open areas to coccyx .See wound care record There was no other specific description in this note regarding the open areas such as measurements or description of the wound. On 11/14/17 at 11:45 a.m., Licensed Vocational Nurse (LVN) B/Treatment Nurse verified that the Wound Care Record was the Altered Skin Integrity Treatment Progress Record dated 10/26/17. LVN B said there was no record dated 10/25/17. R #6's Admission Nursing Evaluation dated 10/25/17 (reviewed and copied on 11/13/17) revealed no documentation of pressure ulcers. On 11/15/17, further review of the same assessment revealed a new entry on the assessment documenting Stage III coccyx. There was no other information describing the pressure ulcer. R #6's Braden Scale dated 10/25/17 documented a score of 11- High risk. R #6's Weekly Skin Integrity Review dated 10/26/17 documented Upon admission coccyx with open areas. R #6's Physician order [REDACTED]. R #6's Altered Skin Integrity Treatment and Progress Record, Side One, dated 10/26/17 documented Stage 3 Coccyx: cleanse with Dakins solution, apply silver alginate measured to wounds, zinc cream to outer borders, cover with choice of dressing bid (twice a day) and prn (as needed) with each incontinent care .drainage: macerated (softening and breaking down of skin resulting from prolonged exposure to moisture), General Appearance: Yellow, Surrounding Skin: Reddened. Side two of this document entitled Altered Skin Integrity Treatment and Progress Record documented 10/31/17: (Length): 9.0 X (Width): 10.0 cm, moderate exudate. The documentation implied an identification and description of one wound versus four seperate wounds. R #6's Altered Skin Integrity Treatment and Progress Record, Side One, dated 10/27/17 documented Stage 3 Coccyx: cleanse with Dakins solution, apply silver alginate measured to wounds, zinc cream to outer borders, cover with choice of dressing bid and prn with each incontinent care .drainage: macerated, General Appearance: Yellow, Surrounding Skin: Reddened. Side two of this document entitled Altered Skin Integrity Treatment and Progress Record did not have an entry of description and measurement for this date. R #6's Altered Skin Integrity Treatment and Progress Record, Side One, dated 10/28/17 documented Stage 3 Coccyx: cleanse with Dakins solution, apply silver alginate measured to wounds, zinc cream to outer borders, cover with choice of dressing bid and prn with each incontinent care .drainage: macerated, General Appearance: Red, Surrounding Skin: Reddened. Side two of this document entitled Altered Skin Integrity Treatment and Progress Record did not have an entry for this date. R #6's Altered Skin Integrity Treatment and Progress Record, Side One, dated 10/29/17 documented Stage 3 Coccyx: cleanse with Dakins solution, apply silver alginate measured to wounds, zinc cream to outer borders, cover with choice of dressing bid and prn with each incontinent care .drainage: macerated, General Appearance: Red, Surrounding Skin: Reddened. Side two of this document entitled Altered Skin Integrity Treatment and Progress Record did not have an entry for this date. R #6's Altered Skin Integrity Treatment and Progress Record, Side One, dated 10/30/17 documented Stage 3 Coccyx: cleanse with Dakins solution, apply silver alginate measured to wounds, zinc cream to outer borders, cover with choice of dressing bid and prn with each incontinent care .drainage: macerated, General Appearance: Red, Surrounding Skin: Reddened. Side two of this document entitled Altered Skin Integrity Treatment and Progress Record did not have an entry for this date. R #6's Altered Skin Integrity Treatment and Progress Record, Side One, dated 10/31/17 documented Stage 3 Coccyx: cleanse with Dakins solution, apply silver alginate measured to wounds, zinc cream to outer borders, cover with choice of dressing bid and prn with each incontinent care .drainage: macerated, General Appearance: Dry, Surrounding Skin: Reddened. Side two of this document entitled Altered Skin Integrity Treatment and Progress Record documented 10/31/17: 9.0 X 10.0 cm, moderate exudate. Granulation (reddish connective tissue that forms on the surface of a wound when the wound is healing): No, Decreased Size: No, Decreased Depth: No, Decreased Drainage: No. R #6's Admission Minimum Data Set ((MDS) dated [DATE] documented R #6: -had clear speech -had short and long-term memory problem with severely impaired cognitive skills for decision making -required extensive assistance with one or two person physical assist with bed mobility, dressing, and eating. R #6 was totally dependent for transfers and personal hygiene. -had an indwelling urinary catheter and was always incontinent of bowel. -was at risk of developing pressure ulcers, had one Stage 3 pressure ulcer at admit/reentry measuring 8.0 X 9.0 X 0.5 centimeters (cm). Has pressure reducing device for bed and was receiving pressure ulcer care. The MDS section M1200C: Skin/ulcer treat: turning and reposition was unchecked. R #6's Braden Scale dated 11/01/17 documented a score of 11- High risk. R #6's Initial Wound Consultation Report (performed by Nurse Practitioner/Wound Care Specialist) dated 11/01/17 documented Wound: Bilateral Buttocks/Sacrum/Coccyx, Measurements: 8.0 X 9.0 X 0.5 cm, Wound Bed: 90% adherent, slough, 10% scattered granulation. Periwound: slight moisture, intact. Assessment: Stage 3 Pressure Injury. Elevated right heel on pillows. Treatment: Air Mattress, No diapers in bed. Cleanse with NS, pat dry with gauze, sure prep to peri wound, nickel thick Santyl, protective dressing . R #6's Ulcers, Surgical Site Treatment and Progress Record, Side One, dated 11/01/17 documented Stage 3 Coccyx/Sacrum: cleanse with normal saline. Apply Santyl and cover with protective dressing. Change daily drainage: macerated, General Appearance: Yellow, Surrounding Skin: Reddened. Side two of this document entitled Ulcers, Surgical Site Treatment and Progress Record documented Length: 8.0 X Width: 9.0 X Depth: 0.5 cm. Moderate Serous Exudate. Granulation: Yes, Decreased Size: No, Decreased Depth: No, Decreased Drainage: No. The Ulcers, Surgical Site Treatment and Progress Record, Side Two, included NPUAP (National Pressure Ulcer Advisory Panel) Stages For Pressure Ulcers: -Suspected Deep Tissue Injury (DTI): Purple or maroon localized area of discolored intact skin or blood-filled blister. -Stage 1: Intact Skin. Non-blanchable redness. Skin with darker tones may appear blue, purple, warm, boggy, or firm. -Stage 2: 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. -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, gray, green, brown or black) in the wound bed. R #6's Ulcers, Surgical Site Treatment and Progress Record, Side One, dated 11/02/17- 11/06/17 documented Stage 3 Coccyx/Sacrum: cleanse with normal saline. Apply Santyl and cover with protective dressing. Change daily drainage: macerated, General Appearance: Yellow, Surrounding Skin: Reddened. Side Two of this document entitled Ulcers, Surgical Site Treatment and Progress Record did not have any entries for these dates. R #6's Ulcers, Surgical Site Treatment and Progress Record, Side One, dated 11/07/17 documented Stage 3 Coccyx/Sacrum: cleanse with normal saline. Apply Santyl and cover with protective dressing. Change daily drainage: macerated, General Appearance: Yellow, Surrounding Skin: Reddened. Side two of this document entitled Ulcers, Surgical Site Treatment and Progress Record documented Length: 7.5 X Width: 8.5 X Depth: 0.5 cm. Moderate Serous Exudate. 50% Slough, 50% granulation. R #6's Follow-Up Wound Consultation Report (performed by Nurse Practitioner/Wound Care Specialist) dated 11/01/17 documented Wound: Bilateral Buttocks/Sacrum/Coccyx, Measurements: 7.5 X 8.5 X 0.5 cm, Wound Bed: 50% slough, 50% scattered granulation. Periwound: dry, intact, and no moisture. Assessment: Stage 3 Pressure Injury. Treatment: Air Mattress, No diapers in bed. Continue same treatment plan . R #6's Ulcers, Surgical Site Treatment and Progress Record, Side One, dated 11/08/17- 11/13/17 documented Stage 3 Coccyx/Sacrum: cleanse with normal saline. Apply Santyl and cover with protective dressing. Change daily drainage: macerated, General Appearance: Yellow, Surrounding Skin: Reddened. Side Two of this document entitled Altered Ulcers, Surgical Site Treatment and Progress Record did not have any entries for these dates. R #6's Care Plan dated 11/12/17 documented: -is unable to respond to questions and commands verbally due to [MEDICAL CONDITION] (inability to comprehend or formulate language) and is unable to make needs known verbally. -is alert and oriented to self and needs assistance with making needs known due to dementia. -requires extensive to total staff assistance for all ADL's (activities of daily living) . -has pressure ulcer to coccyx and requires use of low air loss mattress and is at risk for further breakdown. Receives sugar free protein and liquid multivitamin with minerals .Approaches: -assist resident with repositioning frequently -assist resident with obtain and utilizing a pressure relieving device -encourage weight shifts while sitting up in chair -develop turning/repositioning plan with resident input -teach risk factors for development of pressure ulcers -needs wound care as ordered by physician -needs weekly evaluation of wound healing -needs a daily observation of skin with routine care -needs full skin evaluation weekly with bath/shower . Observation of R #6 on 11/13/17 at 9:04 a.m., during initial rounds, revealed R #6 laying on a low air loss mattress, in a face up position with her head of the bed slightly elevated. R #6's bed sheets did not cover her left above the knee stump or hip allowing R #6's blue brief to be visible. Observation of R #6 on 11/13/17 at 11:38 a.m. revealed she sat in a wheelchair in her room with her eyes closed. R #6 had enteral feeding infusing via a pump and connected to her gastric tube infusing at 55 milliliters per hour. R #6 had a brief on. R #6 had blue Prevalon boots (boots that offload the heel) on both feet. Certified Nurse Aide (CNA) G entered the room and introduced herself. CNA G said R #6 rarely spoke any words and when she did, most of the words were not understandable. CNA G said R #6 was not able to voice her needs. CNA G said R #6 was transferred out of bed to her wheelchair via a mechanical lift at approximately 10:50 a.m. CNA G said she had to get R #6 out of bed because therapy usually came for her at about 11:15 a.m. Observation of R #6 on 11/13/17 at 11:48 a.m. revealed R #6 was escorted to the therapy room by a therapist. R #6 sat in her wheelchair throughout the therapy session and was not actively involved in therapy. R #6 was provided with passive therapy until 12:40 p.m. At 12:54 p.m. R #6 was escorted to the nurse's station and positioned beside the television, facing the nurse's station. At 1:40 p.m., CNA G and CNA C escorted R #6 to her room and assisted R #6 to bed using a mechanical lift at 1:46 p.m. R #6 sat in her wheelchair without being offloaded or repositioned from approximately 10:50 a.m.-1:46 p.m. Observation of R #6 on 11/14/17 at 8:35 a.m. revealed R #6 layed in bed on a low air loss mattress with her eyes closed. R #6 had a brief on. Observation of R #6 on 11/14/17 at 9:07 a.m. revealed CNAs C and G escorted R #6 to the shower room and onto the shower bed. Visible was R #6's right foot with a black scabbed area on the medial aspect of her right great toe. A foul odor was prevalent as staff began to undress R #6. Staff removed R #6's brief and exposed R #6's perineal area. The foul odor became stronger when staff turned R #6 to her right side. Staff cleaned R #6's buttocks of feces and exposed was a dressing covered in feces and was half uncovering the wound. R #6's sacral open wound was covered with feces and had a foul odor other than the feces odor. CNA G removed R #6's sacral dressing and allowed water to flow over the wounds. R #6 had denuded skin (loss of the epidermis, caused by exposure to urine, feces, body fluids, wound exudate or friction) between R #6's vagina and anus. In addition, R #6 had five separate open areas to bilateral buttocks: 1. Sacrum at 1 o'clock with the wound bed covered with yellow tissue 2. Right Buttock at 4 o'clock with a red wound bed 3. Right Buttock at 5 o'clock with a red wound bed 4. Left Buttock at 7 o'clock with the more than 50% of the wound bed with yellow tissue and some red tissue 5. Left Buttock at 11 o'clock with approximately 90% of the wound bed with yellow tissue and very little red tissue. There was white macerated (softening and breaking down of skin resulting from prolonged exposure to moisture) surrounding R #6's wounds at 1, 4, 7, and 11 o'clock. After the staff washed the feces off of R #6's buttocks, the foul odor continued from the open wounds. Also exposed, as R #6 layed on her right side was her right heel with dark purple/maroon/black discoloration with the top layer of skin peeling off. Interview with CNA G on 11/14/17 at 10:00 a.m. revealed she stated R #6 had the wound on her right foot for a couple of days, I am not sure exactly how many. I don't know if nurses know, I'm assuming they do, they remind us to put her Prevalon boots on. I don't usually see her buttocks, it is usually covered. CNA G stated R #6 used briefs all day every day because she is incontinent, I haven't been told not to put them on her. CNA G said she was going to call the Licensed Vocational Nurse (LVN) B to dress R #6's wounds before they placed the brief on her. On 11/14/17 at 10:30 a.m., LVN B/Treatment Nurse entered the shower room and said she was going to get the supplies needed for R #6's wounds. LVN B explained R #6 was admitted in the facility with a stage 3 pressure ulcer to her sacrum/buttocks. LVN B said the nurse practitioner/wound care specialist started to see her on 11/01/17 and follows-up with R #6 weekly. When asked if R #6's wounds were healing, LVN B said No, they are the same, it hasn't changed much. LVN B clarified that all the wounds had always been separate open areas but they were measured as one wound because the NP/WCS measured them that way. When asked how LVN B monitored each open area, she said I don't, we look at all of them, the whole area, as one existing wound. LVN B said R #6 had four open areas upon admission and did not know which open area was acquired after admission. LVN B said she had always been taught to identify each wound separately but since working with the NP/WCS, she had learned to combine the area if they are all clustered within the same area. LVN B said she had not consulted with the NP/WCS or R #6's primary care physician about combining all of R #6's wounds as one wound versus identifying them as separate wounds, I just went with it. LVN B was asked about R #6's right foot wounds and LVN B asked what wounds? LVN B assessed R #6's right foot and asked CNA C and CNA G if R #6 already had those, both CNAs shook their head up and down, indicating yes. LVN B said These are new, no one told me about them. LVN B said the right heel is a purple/maroon/black deep tissue injury pressure ulcer. It measures 1.0 X 1.7 centimeters. The right medial great toe had necrotic tissue scabbed, it's an unstageable pressure ulcer, it measures 2.5 X 2.0 centimeters. LVN B then applied skin prep (liquid film-forming dressing that, upon application to intact skin, forms a protective film to help reduce friction) to both wounds on R #6's right foot. After LVN B confirmed that R #6's NP/WCS or physician were not aware of the new wounds and of not having treatment orders for the new wound, LVN B stated I know that is what she (NP/WCS) is going to order. LVN B provided treatment to R #6's right heel and right medial great toe without consulting the physician to inform her/him of the new pressure ulcers or receiving treatment orders. R #6's Daily Skilled Nurse's Note dated 11/14/17 documented Resident in shower with staff- called to shower room to apply treatment to coccyx/sacrum area. Area continue with 50% slough and 50% granulation. No changes. Area with light exudate. Will continue treatment of [REDACTED]. Noted during shower two new areas to right foot. Areas to right heel and right medial foot. Right heel with small DTI- no redness or drainage. Right medial right with thin dry necrotic tissue. Tissue loose and peeling. Spoke to Nurse Practitioner/Wound Specialist and received order for skin prep to areas. daily. Bootie in place . R #6's Ulcers, Surgical Site Treatment and Progress Record, Side One, dated 11/14/17 documented Stage 3 Coccyx/Sacrum: cleanse with normal saline. Apply Santyl and cover with protective dressing. Change daily drainage: macerated, General Appearance: Yellow, Surrounding Skin: Reddened. Side two of this document entitled Ulcers, Surgical Site Treatment and Progress Record documented Length: 9.0 X Width: 8.0 X Depth: 0.5 cm. Light Exudate. 50% Slough, 50% granulation. R #6's Physician order [REDACTED]. R #6's Ulcers, Surgical Site Treatment and Progress Record, Side One, dated 11/14/17 documented Discovered 11/14/17: DTI Right Inner Foot Drainage: dry, General Appearance: Black, Surrounding Skin: Normal. Side two of this document entitled Ulcers, Surgical Site Treatment and Progress Record documented Length: 2.5 X Width: 2.0 cm Thin brown necrotic tissue/dry. Granulation: No R #6's Ulcers, Surgical Site Treatment and Progress Record, Side One, dated 11/14/17 documented Discovered 11/14/17: DTI Right Heel Drainage: dry, General Appearance: Black, Surrounding Skin: Pink. Side two of this document entitled Ulcers, Surgical Site Treatment and Progress Record documented Length: 1.0 X Width: 1.7 cm. dry. Granulation: No On 11/15/17 at 11:14 a.m., this surveyor accompanied the NP/WCS, LVN B, and the Director of Nurses (DON) to R #6's room. The NP/WCS explained that she was caring for R #6 in the hospital prior to her being admitted to this facility. The NP/WCS stated R #6 had three or four separate open areas when she was admitted to this facility. The NP/WCS said R #6 did not have any wounds on her right foot when she last saw her on 11/07/17. The NP/WCS removed R #6's brief and dressing to her sacrum/buttocks. The NP/WCS measured R #6's sacrum/buttocks and said out loud 6.8 X 7.0 X 0.8 centimeters 40% slough and 60% granulation tissue. It has massive excoriation from the moisture retained within the brief. This excoriation could have been prevented if the brief was left off, excoriation could cause new pressure injuries or deterioration. Overall the wound is worsening, it has increased in depth as well. When the NP/WCS was asked the rationale for measuring the separate open areas as one area versus separate areas, NP/WCS said That's how I do it, it's too much to separate them. The NP/WCS measured R #6's right medial great toe and stated 2.3 X 2.3 centimeters non-blanchable 100% black eschar. The right heel is dark purple/maroon with some black discoloration with surrounding skin red, non-blanchable. We have to keep the heel offloaded. The NP/WCS verified she had given orders on her consultation sheet for R #6 not to wear briefs in bed since she first saw R #6 on 11/01/17. The NP/WCS said she was there to give the orders and it was the facility's responsibility to implement the orders. The NP/WCS stated the resident's condition could deteriorate if her orders were not implemented. R #6's Daily Skilled Nurse's Note dated 11/15/17 documented 11:00 a.m. (NP/WCS) here to eval and order treatments for wounds to coccyx/sacrum/right and left buttocks and right heel and right medial great toe. recommend to use Santyl to cluster of areas of wounds. Will use Santyl only on areas with slough and will separate areas. Noted 5 different in cluster that only three have slough and needs Santyl. 2 areas have all granulation and use [MEDICATION NAME]. Will leave diaper off as ordered. Will cover with ABD as ordered with tape and use zinc barrier paste for excoriated areas. Bootie to right foot on at all times . R #6's Initial Follow-Up Consultation Report (performed by Nurse Practitioner/Wound Care Specialist) dated 11/15/17 at 11:44 a.m. documented Wound: Bilateral Buttocks/Sacrum/Coccyx, Measurements: 6.8 X 7.0 X 0.8 cm, Wound Bed: 40% slough moist, 60% granulation. Periwound: maceration pallor to wound edges, denuded. Assessment: worsening Stage 3 Pressure Injury. Treatment: Air Mattress, tube of zinc given (to facility)- cleanse with NS, pat dry, zinc to excoriated areas nickel thick, Santyl to slough areas. ABD and secure with tape -Right Medial Heel: Measurement: 1.0 X 1.0 cm, Wound Bed: dark black/purple discoloration, Periwound: non-blanchable redness, dry and intact, Assessment: Suspected DTI, Unstageable Pressure Injury, Treatment: Daily Sure prep and offload . -Right Medial Great Toe: Measurements: 2.3 X 2.3 cm, Wound Bed: 100% dry stable eschar, Periwound: dry intact scaly, Assessment: suspected DTI, Unstageable Pressure Injury, Treatment: Daily Sure Prep, offload. R #6's physician's orders [REDACTED]. Interview with the DON on 11/15/17 at 11:33 a.m. revealed she stated nurses were responsible for assessing and documenting what is seen as accurately as possible. The DON said she did not know R #6 had separate open areas and from reviewing LVN B and NP/WCS's documentation It looked like she only had one wound. I can't tell if any of the separate open areas have improved or worsened because of the incorrect documentation. I can't tell when (R #6) developed the additional ulcer on her bottom. The DON said LVN B should have documented the number of open areas, their location, a description and measurement of each area and it's surrounding skin. The DON said she did not agree with the NP/WCS and LVN B's identification and description of the wounds. The DON said LVN B having several years in wound care background should have informed her or/and (R #6's) physician after the NP/WCS treated the ulcers as one ulcer. The DON stated LVN B was responsible for reviewing the NP/WCS's consultation notes and should have implemented the order, including in-servicing the rest of the staff for R #6 not to wear briefs in bed. The DON said she was going to have LVN B re-measure R #6's wounds and document them separately. Interview with LVN B on 11/15/17 at 12:20 p.m. revealed she confirmed she had seen NP/WCS consultation notes and read the order for no briefs. LVN B said she did not in-service staff to implement that order. R #6's Physician order [REDACTED].#1 at 1 o'clock with normal saline (NS), apply santyl and cover with ABD pad. Clean area #2 at 4 o'clock on right buttock with NS, apply [MEDICATION NAME] and cover with ABD pad. Clean area #3 at 5 o'clock on right buttock with NS, apply [MEDICATION NAME] and cover with ABD. Clean area #4 with NS, apply Santyl, cover with ABD pad. Clean area #5 with NS, apply santyl and cover with ABD pad. Change all sites daily. No brief/can keep under, no binding tapes. R #6's Ulcers, Surgical Site Treatment and Progress Record, Side One, dated 11/15/17 documented Discovered 10/25/17: #1- Stage 3 at 1 o'clock Sacrum: Drainage: moist, General Appearance: Yellow, Surrounding Skin: Reddened. Side two of this document entitled Ulcers, Surgical Site Treatment and Progress Record documented Length: 3.0 X Width: 4.0 cm. Granulation 10%, 90% slough. edges macerated, Decreased in Size: No. R #6's Ulcers, Surgical Site Treatment and Progress Record, Side One, dated 11/15/17 documented Discovered 10/25/17: #2- Stage 3 at 4 o'clock Right Buttock: Drainage: moist, General Appearance: Red, Surrounding Skin: Reddened. Side two of this document entitled Ulcers, Surgical Site Treatment and Progress Record documented Length: 0.8 X Width: 1.3 cm. Slight Exudate. Decreased in Size: No. R #6's Ulcers, Surgical Site Treatment and Progress Record, Side One, dated 11/15/17 documented Discovered 10/25/17: #3- Stage 3 at 5 o'clock Right Buttock: Drainage: moist, General Appearance: Red, Surrounding Skin: Reddened. Side two of this document entitled Ulcers, Surgical Site Treatment and Progress Record documented Length: 2.0 X Width: 2.5 cm. 100% granulation. Decreased in Size: No. R #6's Ulcers, Surgical Site Treatment and Progress Record, Side One, dated 11/15/17 documented Discovered 10/25/17: #4- Stage 3 at 7 o'clock Left Buttock: Drainage: moist, General Appearance: Yellow, Surrounding Skin: Reddened. Side two of this document entitled Ulcers, Surgical Site Treatment and Progress Record documented Length: 3.0 X Width: 1.5 cm. Slight Exudate. 60% slough and 40% granulation. Decreased in Size: No. R #6's Ulcers, Surgical Site Treatment and Progress Record, Side One, dated 11/15/17 documented Discovered 10/25/17: #5- Stage 3 at 11 o'clock Left Buttock: Drainage: moist, General Appearance: Yellow, Surrounding Skin: Reddened. Side two of this document entitled Ulcers, Surgical Site Treatment and Progress Record documented Length: 3.0 X Width: 2.0 X Depth: 0.8 cm 90%slough and 10% granulation. Decreased in Size: No. R #6's Daily Skilled Nurse's Note dated 11/16/17 documented 7:30 a.m.- spoke with (NP/WCS) concerning areas to right buttock #2 and #3, areas with granulation, no slough. Explained talked to (Admitting Doctor's Nurse Practitioner) concerning change from one cluster to five areas. These two areas would treat with [MEDICATION NAME]. NP/WCS gave orders for alginate silver, discontinue ABD pad due to will not stay on areas, will start protective adhesive pad/cover. Continue to cover area daily and prn . R #6's Physician order [REDACTED].#2 and #3 with NS and apply alginate cover with protective ABD pad and adhesive dressing, change daily and prn. D/C (discontinue) [MEDICATION NAME] to areas #2 and #3 on right buttocks. R #6's proceeding physician's orders [REDACTED]. Interview with R #6's Primary Care Physician (PCP) on 11/16/17 at 9:04 a.m. revealed he was informed by the DON the surveyors concern regarding R #6's documentation and identification of pressure ulcers. The PCP said I totally agree with you- standards are that each wound should be identified, described, and documented separately because not all wounds may require the same treatment as in (R #6's) case. The PCP said it did not matter how many wounds there were, they should be separately distinguished. The PCP said due to inaccurate assessment and documentation, there was no way of distinguishing whether R #6's wounds have improved or deteriorated. The PCP was made aware that R #6 initially was admitted to the facility with four open areas to her buttocks and now she had five plus two new wounds on her right foot. The PCP said it sounds like (R #6) is developing more. The PCP said he was not aware that R #6 had more than one wound because of the incorrect documentation he was reading, although he should have been made aware. R #11: Review of R #11's Face Sheet revealed she was originally admitted to the facility on [DATE] and readmitted on [DATE] after hospitalization for acute [MEDICAL CONDITION]. R#11's [DIAGNOSES REDACTED].

Based on observation, interview, and record review, the facility failed to consult with the resident's physician and resident's family member when there was a significant change in the resident's physical, mental, or psychosocial status, for five (R#6, R #11, R #13, R #8, and R #2) of 19 residents reviewed for physician/ family consultation issues: -LVN B provided treatment to R #6's right heel and right medial great toe without consulting the physician to inform her/him of the new pressure ulcers or receiving treatment orders. The facility's identification, description, and documentation of R #6's pressure ulcer did not match R #6's current pressure ulcer status. The facility was identifying and treating R #6's pressure ulcers as one ulcer instead of instead of five seperate pressure ulcers. LVN B did not consult with R #6's primary care physician after the Nurse Practitioner/Wound Care Specialist identified, staged, and treated R #6's seperate five pressure ulcers as one pressure ulcer. -LVN B provided treatment to R #11's newly discovered unstageable pressure ulcers without consulting the physician to inform him of the new pressure ulcers or receiving treatment orders. The above failures resulted in an Immediate Jeopardy (IJ) situation on 11/16/17. While the IJ was removed on 11/20/17, the facility remained out of compliance at actual harm with a scope identified as pattern. The facility continued to monitor to ensure continued implementation of their plan of removal. -R #13's RP was never notified with change of R #13's behavior and was never informed of the administration of [MEDICATION NAME]. (antianxiety) -R #8's RP was never notified or consented for the administration of Nuvigil (Stimulant) -R #2's RP was never notified or consented for the use of [MEDICATION NAME]. (anti-depressant) This failure could affect 80 residents receiving preventative skin care and nine residents with Pressure Ulcers at risk for discomfort and the development of pressure sores and infections and place 50 residents receiving [MEDICAL CONDITION] medications at risk of treatment without consent. The findings were: R #6: R #6's Face Sheet dated 11/06/17 documented an [AGE] year-old female admitted to the facility on [DATE] and re-admitted on [DATE] with the [DIAGNOSES REDACTED]. R #6's Admission Nursing Evaluation dated 10/25/17 (reviewed and copied on 11/13/17) revealed no documentation of pressure ulcers. On 11/15/17, further review of the same assessment revealed a new entry on the assessment documenting Stage III coccyx. There was no other information describing the pressure ulcer. R #6's Nursing Progress Note dated 10/25/17 documented Resident arrived via stretcher from post acute center .Resident has four open areas to coccyx .See wound care record There was no other specific description in this note such as descriptiona and measurements regarding the open areas. R #6's Braden Scale dated 10/25/17 documented a score of 11- High risk. R #6's Weekly Skin Integrity Review dated 10/26/17 documented Upon admission coccyx with open areas. R #6's Physician order [REDACTED]. R #6's Altered Skin Integrity Treatment and Progress Record, Side One, dated 10/26/17 documented Stage 3 Coccyx: cleanse with Dakins solution, apply silver alginate measured to wounds, zinc cream to outer borders, cover with choice of dressing bid (twice a day) and prn (as needed) with each incontinent care .drainage: macerated (softening and breaking down of skin resulting from prolonged exposure to moisture), General Appearance: Yellow, Surrounding Skin: Reddened. Side two of this document entitled Altered Skin Integrity Treatment and Progress Record documented 10/31/17: (Length): 9.0 X (Width): 10.0 cm, moderate exudate. The documentation implied an identification and description of one wound versus four seperate wounds. R #6's Altered Skin Integrity Treatment and Progress Record, Side One, dated 10/27/17 documented Stage 3 Coccyx: cleanse with Dakins solution, apply silver alginate measured to wounds, zinc cream to outer borders, cover with choice of dressing bid and prn with each incontinent care .drainage: macerated, General Appearance: Yellow, Surrounding Skin: Reddened. Side two of this document entitled Altered Skin Integrity Treatment and Progress Record did not have an entry such as description or measurements for this date. R #6's Altered Skin Integrity Treatment and Progress Record, Side One, dated 10/28/17 documented Stage 3 Coccyx: cleanse with Dakins solution, apply silver alginate measured to wounds, zinc cream to outer borders, cover with choice of dressing bid and prn with each incontinent care .drainage: macerated, General Appearance: Red, Surrounding Skin: Reddened. Side two of this document entitled Altered Skin Integrity Treatment and Progress Record did not have an entry for this date. R #6's Altered Skin Integrity Treatment and Progress Record, Side One, dated 10/29/17 documented Stage 3 Coccyx: cleanse with Dakins solution, apply silver alginate measured to wounds, zinc cream to outer borders, cover with choice of dressing bid and prn with each incontinent care .drainage: macerated, General Appearance: Red, Surrounding Skin: Reddened. Side two of this document entitled Altered Skin Integrity Treatment and Progress Record did not have an entry such as description or measurements for this date. R #6's Altered Skin Integrity Treatment and Progress Record, Side One, dated 10/30/17 documented Stage 3 Coccyx: cleanse with Dakins solution, apply silver alginate measured to wounds, zinc cream to outer borders, cover with choice of dressing bid and prn with each incontinent care .drainage: macerated, General Appearance: Red, Surrounding Skin: Reddened. Side two of this document entitled Altered Skin Integrity Treatment and Progress Record did not have an entry such as description or measurements for this date. R #6's Altered Skin Integrity Treatment and Progress Record, Side One, dated 10/31/17 documented Stage 3 Coccyx: cleanse with Dakins solution, apply silver alginate measured to wounds, zinc cream to outer borders, cover with choice of dressing bid and prn with each incontinent care .drainage: macerated, General Appearance: Dry, Surrounding Skin: Reddened. Side two of this document entitled Altered Skin Integrity Treatment and Progress Record documented 10/31/17: 9.0 X 10.0 cm, moderate exudate. Granulation (reddish connective tissue that forms on the surface of a wound when the wound is healing): No, Decreased Size: No, Decreased Depth: No, Decreased Drainage: No. R #6's Admission Minimum Data Set ((MDS) dated [DATE] documented R #6: -had clear speech -had short and long-term memory problem with severely impaired cognitive skills for decision making -required extensive assistance with one or two person physical assist with bed mobility, dressing, and eating. R #6 was totally dependent for transfers and personal hygiene. -had an indwelling urinary catheter and was always incontinent of bowel. -was at risk of developing pressure ulcers, had one Stage 3 pressure ulcer at admit/reentry measuring 8.0 X 9.0 X 0.5 centimeters (cm). Has pressure reducing device for bed and was receiving pressure ulcer care. The MDS section M1200C: Skin/ulcer treat: turning and reposition was unchecked. R #6's Braden Scale dated 11/01/17 documented a score of 11- High risk. R #6's Initial Wound Consultation Report (performed by Nurse Practitioner/Wound Care Specialist) dated 11/01/17 documented Wound: Bilateral Buttocks/Sacrum/Coccyx, Measurements: 8.0 X 9.0 X 0.5 cm, Wound Bed: 90% adherent, slough, 10% scattered granulation. Periwound: slight moisture, intact. Assessment: Stage 3 Pressure Injury. Elevated right heel on pillows. Treatment: Air Mattress, No diapers in bed. Cleanse with NS, pat dry with gauze, sure prep to peri wound, nickel thick Santyl, protective dressing . R #6's Ulcers, Surgical Site Treatment and Progress Record, Side One, dated 11/01/17 documented Stage 3 Coccyx/Sacrum: cleanse with normal saline. Apply Santyl and cover with protective dressing. Change daily drainage: macerated, General Appearance: Yellow, Surrounding Skin: Reddened. Side two of this document entitled Ulcers, Surgical Site Treatment and Progress Record documented Length: 8.0 X Width: 9.0 X Depth: 0.5 cm. Moderate Serous Exudate. Granulation: Yes, Decreased Size: No, Decreased Depth: No, Decreased Drainage: No. The Ulcers, Surgical Site Treatment and Progress Record, Side Two, included NPUAP (National Pressure Ulcer Advisory Panel) Stages For Pressure Ulcers: -Suspected Deep Tissue Injury (DTI): Purple or maroon localized area of discolored intact skin or blood-filled blister. -Stage 1: Intact Skin. Non-blanchable redness. Skin with darker tones may appear blue, purple, warm, boggy, or firm. -Stage 2: 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. -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, gray, green, brown or black) in the wound bed. R #6's Ulcers, Surgical Site Treatment and Progress Record, Side One, dated 11/02/17- 11/06/17 documented Stage 3 Coccyx/Sacrum: cleanse with normal saline. Apply Santyl and cover with protective dressing. Change daily drainage: macerated, General Appearance: Yellow, Surrounding Skin: Reddened. Side Two of this document entitled Ulcers, Surgical Site Treatment and Progress Record did not have any entries for these dates. R #6's Ulcers, Surgical Site Treatment and Progress Record, Side One, dated 11/07/17 documented Stage 3 Coccyx/Sacrum: cleanse with normal saline. Apply Santyl and cover with protective dressing. Change daily drainage: macerated, General Appearance: Yellow, Surrounding Skin: Reddened. Side two of this document entitled Ulcers, Surgical Site Treatment and Progress Record documented Length: 7.5 X Width: 8.5 X Depth: 0.5 cm. Moderate Serous Exudate. 50% Slough, 50% granulation. R #6's Follow-Up Wound Consultation Report (performed by Nurse Practitioner/Wound Care Specialist) dated 11/01/17 documented Wound: Bilateral Buttocks/Sacrum/Coccyx, Measurements: 7.5 X 8.5 X 0.5 cm, Wound Bed: 50% slough, 50% scattered granulation. Periwound: dry, intact, and no moisture. Assessment: Stage 3 Pressure Injury. Treatment: Air Mattress, No diapers in bed. Continue same treatment plan . R #6's Ulcers, Surgical Site Treatment and Progress Record, Side One, dated 11/08/17- 11/13/17 documented Stage 3 Coccyx/Sacrum: cleanse with normal saline. Apply Santyl and cover with protective dressing. Change daily drainage: macerated, General Appearance: Yellow, Surrounding Skin: Reddened. Side Two of this document entitled Altered Ulcers, Surgical Site Treatment and Progress Record did not have any entries for these dates. R #6's Care Plan dated 11/12/17 documented: -is unable to respond to questions and commands verbally due to [MEDICAL CONDITION] (inability to comprehend or formulate language) and is unable to make needs known verbally. -is alert and oriented to self and needs assistance with making needs known due to dementia. -requires extensive to total staff assistance for all ADL's (activities of daily living) . -has pressure ulcer to coccyx and requires use of low air loss mattress and is at risk for further breakdown. Receives sugar free protein and liquid multivitamin with minerals .Approaches: -assist resident with repositioning frequently -assist resident with obtain and utilizing a pressure relieving device -encourage weight shifts while sitting up in chair -develop turning/repositioning plan with resident input -teach risk factors for development of pressure ulcers -needs wound care as ordered by physician -needs weekly evaluation of wound healing -needs a daily observation of skin with routine care -needs full skin evaluation weekly with bath/shower . Observation of R #6 on 11/13/17 at 11:38 a.m. revealed she sat in a wheelchair in her room with her eyes closed. R #6 had enteral feeding infusing via a pump and connected to her gastric tube infusing at 55 milliliters per hour. R #6 had a brief on. R #6 had blue Prevalon boots (boots that offload the heel) on both feet. Certified Nurse Aide (CNA) G entered the room and introduced herself. CNA G said R #6 rarely spoke any words and when she did, most of the words were not understandable. CNA G said R #6 was not able to voice her needs. CNA G said R #6 was transferred out of bed to her wheelchair via a mechanical lift at approximately 10:50 a.m. CNA G said she had to get R #6 out of bed because therapy usually came for her at about 11:15 a.m. Observation of R #6 on 11/13/17 at 11:48 a.m. revealed R #6 was escorted to the therapy room by a therapist. R #6 sat in her wheelchair throughout the therapy session and was not actively involved in therapy. R #6 was provided with passive therapy until 12:40 p.m. At 12:54 p.m. R #6 was escorted to the nurse's station and positioned beside the television, facing the nurse's station. At 1:40 p.m., CNA G and CNA C escorted R #6 to her room and assisted R #6 to bed using a mechanical lift at 1:46 p.m. R #6 sat in her wheelchair without being offloaded or repositioned from approximately 10:50 a.m.-1:46 p.m. Observation of R #6 on 11/14/17 at 8:35 a.m. revealed R #6 layed in bed on a low air loss mattress with her eyes closed. R #6 had a brief on. Observation of R #6 on 11/14/17 at 9:07 a.m. revealed CNAs C and G escorted R #6 to the shower room and onto the shower bed. Visible was R #6's right foot with a black scabbed area on the medial aspect of her right great toe. A foul odor was prevalent as staff began to undress R #6. Staff removed R #6's brief and exposed R #6's perineal area. The foul odor became stronger when staff turned R #6 to her right side. Staff cleaned R #6's buttocks of feces and exposed was a dressing covered in feces and was half uncovering the wound. R #6's sacral open wound was covered with feces and had a foul odor other than the feces odor. CNA G removed R #6's sacral dressing and allowed water to flow over the wounds. R #6 had denuded skin (loss of the epidermis, caused by exposure to urine, feces, body fluids, wound exudate or friction) between R #6's vagina and anus. In addition, R #6 had five separate open areas to bilateral buttocks: 1. Sacrum at 1 o'clock with the wound bed covered with yellow tissue 2. Right Buttock at 4 o'clock with a red wound bed 3. Right Buttock at 5 o'clock with a red wound bed 4. Left Buttock at 7 o'clock with the more than 50% of the wound bed with yellow tissue and some red tissue 5. Left Buttock at 11 o'clock with approximately 90% of the wound bed with yellow tissue and very little red tissue. There was white macerated (softening and breaking down of skin resulting from prolonged exposure to moisture) surrounding R #6's wounds at 1, 4, 7, and 11 o'clock. After the staff washed the feces off of R #6's buttocks, the foul odor continued from the open wounds. Also exposed, as R #6 layed on her right side was her right heel with dark purple/maroon/black discoloration with the top layer of skin peeling off. Interview with CNA G on 11/14/17 at 10:00 a.m. revealed she stated R #6 had the wound on her right foot for a couple of days, I am not sure exactly how many. I don't know if nurses know, I'm assuming they do, they remind us to put her Prevalon boots on. I don't usually see her buttocks, it is usually covered. CNA G stated R #6 used briefs all day every day because she is incontinent, I haven't been told not to put them on her. CNA G said she was going to call the Licensed Vocational Nurse (LVN) B to dress R #6's wounds before they placed the brief on her. On 11/14/17 at 10:30 a.m., LVN B/Treatment Nurse entered the shower room and said she was going to get the supplies needed for R #6's wounds. LVN B explained R #6 was admitted in the facility with a stage 3 pressure ulcer to her sacrum/buttocks. LVN B said the nurse practitioner/wound care specialist started to see her on 11/01/17 and follows-up with R #6 weekly. When asked if R #6's wounds were healing, LVN B said No, they are the same, it hasn't changed much. LVN B clarified that all the wounds had always been separate open areas but they were measured as one wound because the NP/WCS measured them that way. When asked how LVN B monitored each open area, she said I don't, we look at all of them, the whole area, as one existing wound. LVN B said R #6 had four open areas upon admission and did not know which open area was acquired after admission. LVN B said she had always been taught to identify each wound separately but since working with the NP/WCS, she had learned to combine the area if they are all clustered within the same area. LVN B said she had not consulted with the NP/WCS or R #6's primary care physician about combining all of R #6's wounds as one wound versus identifying them as separate wounds, I just went with it. LVN B was asked about R #6's right foot wounds and LVN B asked what wounds? LVN B assessed R #6's right foot and asked CNA C and CNA G if R #6 already had those, both CNAs shook their head up and down, indicating yes. LVN B said These are new, no one told me about them. LVN B said the right heel is a purple/maroon/black deep tissue injury pressure ulcer. It measures 1.0 X 1.7 centimeters. The right medial great toe had necrotic tissue scabbed, it's an unstageable pressure ulcer, it measures 2.5 X 2.0 centimeters. LVN B then applied skin prep (liquid film-forming dressing that, upon application to intact skin, forms a protective film to help reduce friction) to both wounds on R #6's right foot. After LVN B confirmed that R #6's NP/WCS or physician were not aware of the new wounds and of not having treatment orders for the new wound, LVN B stated I know that is what she (NP/WCS) is going to order. LVN B provided treatment to R #6's right heel and right medial great toe without consulting the physician to inform her/him of the new pressure ulcers or receiving treatment orders. R #6's Daily Skilled Nurse's Note dated 11/14/17 documented Resident in shower with staff- called to shower room to apply treatment to coccyx/sacrum area. Area continue with 50% slough and 50% granulation. No changes. Area with light exudate. Will continue treatment of [REDACTED]. Noted during shower two new areas to right foot. Areas to right heel and right medial foot. Right heel with small DTI- no redness or drainage. Right medial right with thin dry necrotic tissue. Tissue loose and peeling. Spoke to Nurse Practitioner/Wound Specialist and received order for skin prep to areas. daily. Bootie in place . R #6's Ulcers, Surgical Site Treatment and Progress Record, Side One, dated 11/14/17 documented Stage 3 Coccyx/Sacrum: cleanse with normal saline. Apply Santyl and cover with protective dressing. Change daily drainage: macerated, General Appearance: Yellow, Surrounding Skin: Reddened. Side two of this document entitled Ulcers, Surgical Site Treatment and Progress Record documented Length: 9.0 X Width: 8.0 X Depth: 0.5 cm. Light Exudate. 50% Slough, 50% granulation. R #6's Physician order [REDACTED]. R #6's Ulcers, Surgical Site Treatment and Progress Record, Side One, dated 11/14/17 documented Discovered 11/14/17: DTI Right Inner Foot Drainage: dry, General Appearance: Black, Surrounding Skin: Normal. Side two of this document entitled Ulcers, Surgical Site Treatment and Progress Record documented Length: 2.5 X Width: 2.0 cm Thin brown necrotic tissue/dry. Granulation: No R #6's Ulcers, Surgical Site Treatment and Progress Record, Side One, dated 11/14/17 documented Discovered 11/14/17: DTI Right Heel Drainage: dry, General Appearance: Black, Surrounding Skin: Pink. Side two of this document entitled Ulcers, Surgical Site Treatment and Progress Record documented Length: 1.0 X Width: 1.7 cm. dry. Granulation: No On 11/15/17 at 11:14 a.m., this surveyor accompanied the NP/WCS, LVN B, and the Director of Nurses (DON) to R #6's room. The NP/WCS explained that she was caring for R #6 in the hospital prior to her being admitted to this facility. The NP/WCS stated R #6 had three or four separate open areas when she was admitted to this facility. The NP/WCS said R #6 did not have any wounds on her right foot when she last saw her on 11/07/17. The NP/WCS removed R #6's brief and dressing to her sacrum/buttocks. The NP/WCS measured R #6's sacrum/buttocks and said out loud 6.8 X 7.0 X 0.8 centimeters 40% slough and 60% granulation tissue. It has massive excoriation from the moisture retained within the brief. This excoriation could have been prevented if the brief was left off, excoriation could cause new pressure injuries or deterioration. Overall the wound is worsening, it has increased in depth as well. When the NP/WCS was asked the rational for measuring the separate open areas as one area versus separate areas, NP/WCS said That's how I do it, it's too much to separate them. The NP/WCS measured R #6's right medial great toe and stated 2.3 X 2.3 centimeters non-blanchable 100% black eschar. The right heel is dark purple/maroon with some black discoloration with surrounding skin red, non-blanchable. We have to keep the heel offloaded. The NP/WCS verified she had given orders on her consultation sheet for R #6 not to wear briefs in bed since she first saw R #6 on 11/01/17. The NP/WCS said she was there to give the orders and it was the facility's responsibility to implement the orders. The NP/WCS stated the resident's condition could deteriorate if her orders were not implemented. R #6's Daily Skilled Nurse's Note dated 11/15/17 documented 11:00 a.m. (NP/WCS) here to eval and order treatments for wounds to coccyx/sacrum/right and left buttocks and right heel and right medial great toe. recommend to use Santyl to cluster of areas of wounds. Will use Santyl only on areas with slough and will separate areas. Noted 5 different in cluster that only three have slough and needs Santyl. 2 areas have all granulation and use [MEDICATION NAME]. Will leave diaper off as ordered. Will cover with ABD as ordered with tape and use zinc barrier paste for excoriated areas. Bootie to right foot on at all times . R #6's Initial Follow-Up Consultation Report (performed by Nurse Practitioner/Wound Care Specialist) dated 11/15/17 at 11:44 a.m. documented Wound: Bilateral Buttocks/Sacrum/Coccyx, Measurements: 6.8 X 7.0 X 0.8 cm, Wound Bed: 40% slough moist, 60% granulation. Periwound: maceration pallor to wound edges, denuded. Assessment: worsening Stage 3 Pressure Injury. Treatment: Air Mattress, tube of zinc given (to facility)- cleanse with NS, pat dry, zinc to excoriated areas nickel thick, Santyl to slough areas. ABD and secure with tape -Right Medial Heel: Measurement: 1.0 X 1.0 cm, Wound Bed: dark black/purple discoloration, Periwound: non-blanchable redness, dry and intact, Assessment: Suspected DTI, Unstageable Pressure Injury, Treatment: Daily Sure prep and offload . -Right Medial Great Toe: Measurements: 2.3 X 2.3 cm, Wound Bed: 100% dry stable eschar, Periwound: dry intact scaly, Assessment: suspected DTI, Unstageable Pressure Injury, Treatment: Daily Sure Prep, offload. R #6's physician's orders [REDACTED]. Interview with the DON on 11/15/17 at 11:33 a.m. revealed she stated nurses were responsible for assessing and documenting what is seen as accurately as possible. The DON said she did not know R #6 had separate open areas and from reviewing LVN B and NP/WCS's documentation It looked like she only had one wound. I can't tell if any of the separate open areas have improved or worsened because of the incorrect documentation. I can't tell when (R #6) developed the additional ulcer on her bottom. The DON said LVN B should have documented the number of open areas, their location, a description and measurement of each area and it's surrounding skin. The DON said she did not agree with the NP/WCS and LVN B's identification and description of the wounds. The DON said LVN B having several years in wound care background should have informed her or/and (R #6's) physician after the NP/WCS treated the ulcers as one ulcer. The DON stated LVN B was responsible for reviewing the NP/WCS's consultation notes and should have implemented the order, including in-servicing the rest of the staff for R #6 not to wear briefs in bed. The DON said she was going to have LVN B re-measure R #6's wounds and document them separately. Interview with LVN B on 11/15/17 at 12:20 p.m. revealed she confirmed she had seen NP/WCS consultation notes and read the order for no briefs. LVN B said she did not in-service staff to implement that order. R #6's Physician order [REDACTED].#1 at 1 o'clock with normal saline (NS), apply santyl and cover with ABD pad. Clean area #2 at 4 o'clock on right buttock with NS, apply [MEDICATION NAME] and cover with ABD pad. Clean area #3 at 5 o'clock on right buttock with NS, apply [MEDICATION NAME] and cover with ABD. Clean area #4 with NS, apply Santyl, cover with ABD pad. Clean area #5 with NS, apply santyl and cover with ABD pad. Change all sites daily. No brief/can keep under, no binding tapes. R #6's Ulcers, Surgical Site Treatment and Progress Record, Side One, dated 11/15/17 documented Discovered 10/25/17: #1- Stage 3 at 1 o'clock Sacrum: Drainage: moist, General Appearance: Yellow, Surrounding Skin: Reddened. Side two of this document entitled Ulcers, Surgical Site Treatment and Progress Record documented Length: 3.0 X Width: 4.0 cm. Granulation 10%, 90% slough. edges macerated, Decreased in Size: No. R #6's Ulcers, Surgical Site Treatment and Progress Record, Side One, dated 11/15/17 documented Discovered 10/25/17: #2- Stage 3 at 4 o'clock Right Buttock: Drainage: moist, General Appearance: Red, Surrounding Skin: Reddened. Side two of this document entitled Ulcers, Surgical Site Treatment and Progress Record documented Length: 0.8 X Width: 1.3 cm. Slight Exudate. Decreased in Size: No. R #6's Ulcers, Surgical Site Treatment and Progress Record, Side One, dated 11/15/17 documented Discovered 10/25/17: #3- Stage 3 at 5 o'clock Right Buttock: Drainage: moist, General Appearance: Red, Surrounding Skin: Reddened. Side two of this document entitled Ulcers, Surgical Site Treatment and Progress Record documented Length: 2.0 X Width: 2.5 cm. 100% granulation. Decreased in Size: No. R #6's Ulcers, Surgical Site Treatment and Progress Record, Side One, dated 11/15/17 documented Discovered 10/25/17: #4- Stage 3 at 7 o'clock Left Buttock: Drainage: moist, General Appearance: Yellow, Surrounding Skin: Reddened. Side two of this document entitled Ulcers, Surgical Site Treatment and Progress Record documented Length: 3.0 X Width: 1.5 cm. Slight Exudate. 60% slough and 40% granulation. Decreased in Size: No. R #6's Ulcers, Surgical Site Treatment and Progress Record, Side One, dated 11/15/17 documented Discovered 10/25/17: #5- Stage 3 at 11 o'clock Left Buttock: Drainage: moist, General Appearance: Yellow, Surrounding Skin: Reddened. Side two of this document entitled Ulcers, Surgical Site Treatment and Progress Record documented Length: 3.0 X Width: 2.0 X Depth: 0.8 cm 90%slough and 10% granulation. Decreased in Size: No. R #6's Daily Skilled Nurse's Note dated 11/16/17 documented 7:30 a.m.- spoke with (NP/WCS) concerning areas to right buttock #2 and #3, areas with granulation, no slough. Explained talked to (Admitting Doctor's Nurse Practitioner) concerning change from one cluster to five areas. These two areas would treat with [MEDICATION NAME]. NP/WCS gave orders for alginate silver, discontinue ABD pad due to will not stay on areas, will start protective adhesive pad/cover. Continue to cover area daily and prn . R #6's Physician order [REDACTED].#2 and #3 with NS and apply alginate cover with protective ABD pad and adhesive dressing, change daily and prn. D/C (discontinue) [MEDICATION NAME] to areas #2 and #3 on right buttocks. R #6's proceeding physician's orders [REDACTED]. Interview with R #6's Primary Care Physician (PCP) on 11/16/17 at 9:04 a.m. revealed he was informed by the DON the surveyors concern regarding R #6's documentation and identification of pressure ulcers. The PCP said I totally agree with you- standards are that each wound should be identified, described, and documented separately because not all wounds may require the same treatment as in (R #6's) case. The PCP said it did not matter how many wounds there were, they should be separately distinguished. The PCP said due to inaccurate assessment and documentation, there was no way of distinguishing whether R #6's wounds have improved or deteriorated. The PCP was made aware that R #6 initially was admitted to the facility with four open areas to her buttocks and now she had five plus two new wounds on her right foot. The PCP said it sounds like (R #6) is developing more. The PCP said he was not aware that R #6 had more than one wound because of the incorrect documentation he was reading, although he should have been made aware. R #11: Review of R #11's Face Sheet revealed she was originally admitted to the facility on [DATE] and readmitted on [DATE] after hospitalization for acute [MEDICAL CONDITION]. R#11's [DIAGNOSES REDACTED]. R#11 was [AGE] years old. Review of R#11's annual Minimum Data Set (MDS) assessment dated [DATE] revealed she was able to understand others and make herself understood, and she had a BIMS (Brief Interview for Mental Status) score of 13 points, indicating she was cognitively intact. R#11 was able to walk in her room, could dress with supervision, and was continent of bowel all of the time and had occasional bladder incontinence. Bathing had not occurred in the previous seven days. R#11 weighed 181 pounds and she had no pressure sores. R#11 had some mood issues and had little interest and little energy two to six days during the assessment period. R#11 had no behavior issues. Review of R#11's Significant Change MDS dated [DATE] revealed R#11 required physical assistance with the help of one person for bed mobility, transfer, and dressing. The bathing activity did not occur in the previous seven days. R#11 was continent of bowel and bladder but required physical assistance with toileting and some help with hygiene. R#11 had a BIMS score of 13 and had behaviors of rejecting care. She had little pleasure in doing things and was sleeping too much. R#11 had a poor appetite and her weight was 141 pounds. The care plan dated 08/11/17 revealed R#11 revealed R#11 was at risk for pressure ulcers related to decreased mobilit(TRUNCATED)

Based on observation, interview, and record review the facility failed to implement their witten policies that prohibit neglect for three (R #3, R #6, and R #11) of four residents reviewed for pressure ulcers and neglect. R #6: -The facility failed to attempt to offload or reposition R #6 off her buttocks for approximately three hours, even after the facility was aware of R #6 having sacrum/coccyx/buttocks pressure ulcers. The facility failed to implement R #6's physician's orders [REDACTED]. The facility failed to accurately describe, document measurements, and stage all of R #6's pressure ulcers upon admission until the surveyor's inquiry. R #6 was admitted with four stage 3 pressure ulcers and developed one other stage 3 and two unstageable pressure ulcers. The facility failed to consistently identify and document all of R #6's pressure ulcers in their Altered Skin Integrity Treatment and Progress Record or Ulcers, Surgical Site Treatment and Progress Record. The facility failed to identify or document R #6's two new right foot unstageable pressure ulcers until the surveyor's inquiry. LVN B provided treatment to R #6's right heel and right medial great toe without consulting the physician to inform her/him of the new pressure ulcers or receiving treatment orders. The facility's identification, description, and documentation of R #6's pressure ulcer did not match R #6's current pressure ulcer status. The facility was identifying and treating R #6's pressure ulcers as one ulcer instead of instead of five seperate pressure ulcers. LVN B did not consult with R #6's primary care physician after the Nurse Practitioner/Wound Care Specialist identified, staged, and treated R #6's seperate five pressure ulcers as one pressure ulcer. R #11: -The facility failed to accurately describe and stage R #11's pressure ulcers that were facility acquired. The facility failed to identify R #11's two new unstageable pressure ulcers until the surveyor's inquiry. LVN B provided treatment to R #11's newly discovered unstageable pressure ulcers without consulting the physician to inform him of the new ulcers or receiving treatment orders. R #3: -R #3 was not offloaded or repositioned for more than two hours. R #3 did not have a pressure ulcer on 11/13/17 however, on 11/16/17 she had developed two Stage 2 pressure ulcers. The above failures resulted in an Immediate Jeopardy (IJ) situation on 11/16/17. While the IJ was removed on 11/20/17, the facility remained out of compliance at actual harm with a scope identified as pattern. The facility continued to monitor to ensure continued implementation of their plan of removal. These failures could affect nine residents with pressure ulcers and 80 residents receiving preventative skin care and place them at risk for developing new pressure ulcers or a decline in existing pressure ulcers. The findings included: The facility's undated Operational Resident Care Policy: Policy to Prohibit the Mistreatment, Neglect, and Abuse of Residents and the Misappropriation of Resident Property- .Each resident has the right to be free from mistreatment, neglect, and misappropriation of property .The facility's purpose is to assure that the facility is doing all that is within their control to prevent occurrences . The facility's undated Pressure Ulcers Policy and Procedure documented The facility will provide care based on each resident's comprehensive assessment to ensure that a resident who enters the facility without pressure ulcers does not develop pressure ulcers unless pressure ulcers are unavoidable due to the predictable patters of the resident's clinical condition or the resident or his/her representative's refusal of care and treatment to prevent pressure ulcers. Care Assessment Worksheets are used to assess causal factors of decline or potential for improvement of pressure ulcers. Aggressive and appropriate preventive measures and care are provided to address a resident's unique risk factors. Based on each resident's comprehensive assessment, appropriate treatment and services are provided to prevent the formation of pressure ulcers. Resident's having pressure ulcers receive necessary treatment and services to promote healing, prevent infection and prevent new pressure ulcers from developing. Residents who have issued advance directives to refuse or without treatment may be at risk for skin breakdown, and the development of pressure ulcers may be unavoidable. Appropriate measures to promote healing and prevent infection will be provided in accordance with the resident's plan of care. The facility's undated Skin Management System 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 .If the skin is intact, no further action is required. If skin is compromised, proceed to the appropriate form below. A. Pressure Injuries, Venous Ulcers and Arterial Ulcers, and surgical sites will be documented on the Ulcer, Surgical Site Treatment and Progress Record form 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 physician's, 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 . 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. B. Non-ulcer/surgical skin issues such as skin tears, bruises, rashes, abrasions, burns, etc. will be documented on the Altered Skin Integrity Treatment and Progress Record . 2. Routine weekly checks will be completed on every resident; if skin is intact it will be noted as such. If a new pressure sore is noted, a Ulcer, Surgical Site Treatment and Progress Record form will be started. Notification of Physician and Responsible Party must be documented in the nurses' notes . A. Interventions will be noted on the Interim Plan of Care. 4. Refer to Protocol for Pressure Ulcers by AMT (American Medical Technology) for assistance with wound identification, staging and recommended treatments. Contact Physician for treatment recommendation approval 8. Facility DONs are responsible to establish a system to monitor and assure Skin Management System Compliance. According to the National Pressure Ulcer Advisory Panel (NPUAP) website (http://www.npuap.org/resources/educational-and-clinical-resources/npuap-pressure-injury-stages/) searched on 11/16/17 revealed Pressure Injury: A pressure injury is localized damage to the skin and underlying soft tissue usually over a bony prominence or related to a medical or other device. The injury can present as intact skin or an open ulcer and may be painful. The injury occurs as a result of intense and/or prolonged pressure or pressure in combination with shear. The tolerance of soft tissue for pressure and shear may also be affected by microclimate, nutrition, perfusion, co-morbidities and condition of the soft tissue. Stage 1 Pressure Injury: Non-blanchable [DIAGNOSES REDACTED] of intact skin Intact skin with a localized area of non-blanchable [DIAGNOSES REDACTED], which may appear differently in darkly pigmented skin. Presence of blanchable [DIAGNOSES REDACTED] or changes in sensation, temperature, or firmness may precede visual changes. Color changes do not include purple or maroon discoloration; these may indicate deep tissue pressure injury. Stage 2 Pressure Injury: Partial-thickness skin loss with exposed dermis Partial-thickness loss of skin with exposed dermis. The wound bed is viable, pink or red, moist, and may also present as an intact or ruptured serum-filled blister. Adipose (fat) is not visible and deeper tissues are not visible. Granulation tissue, slough and eschar are not present. These injuries commonly result from adverse microclimate and shear in the skin over the pelvis and shear in the heel. This stage should not be used to describe moisture associated skin damage (MASD) including incontinence associated [MEDICAL CONDITION] (IAD), intertriginous [MEDICAL CONDITION] (ITD), medical adhesive related skin injury (MARSI), or traumatic wounds (skin tears, burns, abrasions). Stage 3 Pressure Injury: Full-thickness skin loss Full-thickness loss of skin, in which adipose (fat) is visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. Slough and/or eschar may be visible. The depth of tissue damage varies by anatomical location; areas of significant adiposity can develop deep wounds. Undermining and tunneling may occur. Fascia, muscle, tendon, ligament, cartilage and/or bone are not exposed. If slough or eschar obscures the extent of tissue loss this is an Unstageable Pressure Injury. Stage 4 Pressure Injury: Full-thickness skin and tissue loss Full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer. Slough and/or eschar may be visible. Epibole (rolled edges), undermining and/or tunneling often occur. Depth varies by anatomical location. If slough or eschar obscures the extent of tissue loss this is an Unstageable Pressure Injury. Unstageable Pressure Injury: Obscured full-thickness skin and tissue loss Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar. If slough or eschar is removed, a Stage 3 or Stage 4 pressure injury will be revealed. Stable eschar (i.e. dry, adherent, intact without [DIAGNOSES REDACTED] or fluctuance) on the heel or ischemic limb should not be softened or removed. Deep Tissue Pressure Injury: Persistent non-blanchable deep red, maroon or purple discoloration Intact or non-intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration or [MEDICATION NAME] separation revealing a dark wound bed or blood filled blister. Pain and temperature change often precede skin color changes. Discoloration may appear differently in darkly pigmented skin. This injury results from intense and/or prolonged pressure and shear forces at the bone-muscle interface. The wound may evolve rapidly to reveal the actual extent of tissue injury, or may resolve without tissue loss. If necrotic tissue, subcutaneous tissue, granulation tissue, fascia, muscle or other underlying structures are visible, this indicates a full thickness pressure injury (Unstageable, Stage 3 or Stage 4). Do not use DTPI to describe vascular, traumatic, neuropathic, or dermatologic conditions. Additional pressure injury definitions. Medical Device Related Pressure Injury: This describes an etiology. Medical device related pressure injuries result from the use of devices designed and applied for diagnostic or therapeutic purposes. The resultant pressure injury generally conforms to the pattern or shape of the device. The injury should be staged using the staging system R #6: R #6's Face Sheet dated 11/06/17 documented an [AGE] year-old female admitted to the facility on [DATE] and re-admitted on [DATE] with the [DIAGNOSES REDACTED]. R #6's Nursing Progress Note dated 10/25/17 documented Resident arrived via stretcher from post acute center .Resident has four open areas to coccyx .See wound care record There was no other specific description in this note regarding the open areas such as measurements or description of the wound. On 11/14/17 at 11:45 a.m., Licensed Vocational Nurse (LVN) B/Treatment Nurse verified that the Wound Care Record was the Altered Skin Integrity Treatment Progress Record dated 10/26/17. LVN B said there was no record dated 10/25/17. R #6's Admission Nursing Evaluation dated 10/25/17 (reviewed and copied on 11/13/17) revealed no documentation of pressure ulcers. On 11/15/17, further review of the same assessment revealed a new entry on the assessment documenting Stage III coccyx. There was no other information describing the pressure ulcer. R #6's Braden Scale dated 10/25/17 documented a score of 11- High risk. R #6's Weekly Skin Integrity Review dated 10/26/17 documented Upon admission coccyx with open areas. R #6's Physician order [REDACTED]. R #6's Altered Skin Integrity Treatment and Progress Record, Side One, dated 10/26/17 documented Stage 3 Coccyx: cleanse with Dakins solution, apply silver alginate measured to wounds, zinc cream to outer borders, cover with choice of dressing bid (twice a day) and prn (as needed) with each incontinent care .drainage: macerated (softening and breaking down of skin resulting from prolonged exposure to moisture), General Appearance: Yellow, Surrounding Skin: Reddened. Side two of this document entitled Altered Skin Integrity Treatment and Progress Record documented 10/31/17: (Length): 9.0 X (Width): 10.0 cm, moderate exudate. The documentation implied an identification and description of one wound versus four seperate wounds. R #6's Altered Skin Integrity Treatment and Progress Record, Side One, dated 10/27/17 documented Stage 3 Coccyx: cleanse with Dakins solution, apply silver alginate measured to wounds, zinc cream to outer borders, cover with choice of dressing bid and prn with each incontinent care .drainage: macerated, General Appearance: Yellow, Surrounding Skin: Reddened. Side two of this document entitled Altered Skin Integrity Treatment and Progress Record did not have an entry of description and measurement for this date. R #6's Altered Skin Integrity Treatment and Progress Record, Side One, dated 10/28/17 documented Stage 3 Coccyx: cleanse with Dakins solution, apply silver alginate measured to wounds, zinc cream to outer borders, cover with choice of dressing bid and prn with each incontinent care .drainage: macerated, General Appearance: Red, Surrounding Skin: Reddened. Side two of this document entitled Altered Skin Integrity Treatment and Progress Record did not have an entry for this date. R #6's Altered Skin Integrity Treatment and Progress Record, Side One, dated 10/29/17 documented Stage 3 Coccyx: cleanse with Dakins solution, apply silver alginate measured to wounds, zinc cream to outer borders, cover with choice of dressing bid and prn with each incontinent care .drainage: macerated, General Appearance: Red, Surrounding Skin: Reddened. Side two of this document entitled Altered Skin Integrity Treatment and Progress Record did not have an entry for this date. R #6's Altered Skin Integrity Treatment and Progress Record, Side One, dated 10/30/17 documented Stage 3 Coccyx: cleanse with Dakins solution, apply silver alginate measured to wounds, zinc cream to outer borders, cover with choice of dressing bid and prn with each incontinent care .drainage: macerated, General Appearance: Red, Surrounding Skin: Reddened. Side two of this document entitled Altered Skin Integrity Treatment and Progress Record did not have an entry for this date. R #6's Altered Skin Integrity Treatment and Progress Record, Side One, dated 10/31/17 documented Stage 3 Coccyx: cleanse with Dakins solution, apply silver alginate measured to wounds, zinc cream to outer borders, cover with choice of dressing bid and prn with each incontinent care .drainage: macerated, General Appearance: Dry, Surrounding Skin: Reddened. Side two of this document entitled Altered Skin Integrity Treatment and Progress Record documented 10/31/17: 9.0 X 10.0 cm, moderate exudate. Granulation (reddish connective tissue that forms on the surface of a wound when the wound is healing): No, Decreased Size: No, Decreased Depth: No, Decreased Drainage: No. R #6's Admission Minimum Data Set ((MDS) dated [DATE] documented R #6: -had clear speech -had short and long-term memory problem with severely impaired cognitive skills for decision making -required extensive assistance with one or two person physical assist with bed mobility, dressing, and eating. R #6 was totally dependent for transfers and personal hygiene. -had an indwelling urinary catheter and was always incontinent of bowel. -was at risk of developing pressure ulcers, had one Stage 3 pressure ulcer at admit/reentry measuring 8.0 X 9.0 X 0.5 centimeters (cm). Has pressure reducing device for bed and was receiving pressure ulcer care. The MDS section M1200C: Skin/ulcer treat: turning and reposition was unchecked. R #6's Braden Scale dated 11/01/17 documented a score of 11- High risk. R #6's Initial Wound Consultation Report (performed by Nurse Practitioner/Wound Care Specialist) dated 11/01/17 documented Wound: Bilateral Buttocks/Sacrum/Coccyx, Measurements: 8.0 X 9.0 X 0.5 cm, Wound Bed: 90% adherent, slough, 10% scattered granulation. Periwound: slight moisture, intact. Assessment: Stage 3 Pressure Injury. Elevated right heel on pillows. Treatment: Air Mattress, No diapers in bed. Cleanse with NS, pat dry with gauze, sure prep to peri wound, nickel thick Santyl, protective dressing . R #6's Ulcers, Surgical Site Treatment and Progress Record, Side One, dated 11/01/17 documented Stage 3 Coccyx/Sacrum: cleanse with normal saline. Apply Santyl and cover with protective dressing. Change daily drainage: macerated, General Appearance: Yellow, Surrounding Skin: Reddened. Side two of this document entitled Ulcers, Surgical Site Treatment and Progress Record documented Length: 8.0 X Width: 9.0 X Depth: 0.5 cm. Moderate Serous Exudate. Granulation: Yes, Decreased Size: No, Decreased Depth: No, Decreased Drainage: No. The Ulcers, Surgical Site Treatment and Progress Record, Side Two, included NPUAP (National Pressure Ulcer Advisory Panel) Stages For Pressure Ulcers: -Suspected Deep Tissue Injury (DTI): Purple or maroon localized area of discolored intact skin or blood-filled blister. -Stage 1: Intact Skin. Non-blanchable redness. Skin with darker tones may appear blue, purple, warm, boggy, or firm. -Stage 2: 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. -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, gray, green, brown or black) in the wound bed. R #6's Ulcers, Surgical Site Treatment and Progress Record, Side One, dated 11/02/17- 11/06/17 documented Stage 3 Coccyx/Sacrum: cleanse with normal saline. Apply Santyl and cover with protective dressing. Change daily drainage: macerated, General Appearance: Yellow, Surrounding Skin: Reddened. Side Two of this document entitled Ulcers, Surgical Site Treatment and Progress Record did not have any entries for these dates. R #6's Ulcers, Surgical Site Treatment and Progress Record, Side One, dated 11/07/17 documented Stage 3 Coccyx/Sacrum: cleanse with normal saline. Apply Santyl and cover with protective dressing. Change daily drainage: macerated, General Appearance: Yellow, Surrounding Skin: Reddened. Side two of this document entitled Ulcers, Surgical Site Treatment and Progress Record documented Length: 7.5 X Width: 8.5 X Depth: 0.5 cm. Moderate Serous Exudate. 50% Slough, 50% granulation. R #6's Follow-Up Wound Consultation Report (performed by Nurse Practitioner/Wound Care Specialist) dated 11/01/17 documented Wound: Bilateral Buttocks/Sacrum/Coccyx, Measurements: 7.5 X 8.5 X 0.5 cm, Wound Bed: 50% slough, 50% scattered granulation. Periwound: dry, intact, and no moisture. Assessment: Stage 3 Pressure Injury. Treatment: Air Mattress, No diapers in bed. Continue same treatment plan . R #6's Ulcers, Surgical Site Treatment and Progress Record, Side One, dated 11/08/17- 11/13/17 documented Stage 3 Coccyx/Sacrum: cleanse with normal saline. Apply Santyl and cover with protective dressing. Change daily drainage: macerated, General Appearance: Yellow, Surrounding Skin: Reddened. Side Two of this document entitled Altered Ulcers, Surgical Site Treatment and Progress Record did not have any entries for these dates. R #6's Care Plan dated 11/12/17 documented: -is unable to respond to questions and commands verbally due to [MEDICAL CONDITION] (inability to comprehend or formulate language) and is unable to make needs known verbally. -is alert and oriented to self and needs assistance with making needs known due to dementia. -requires extensive to total staff assistance for all ADL's (activities of daily living) . -has pressure ulcer to coccyx and requires use of low air loss mattress and is at risk for further breakdown. Receives sugar free protein and liquid multivitamin with minerals .Approaches: -assist resident with repositioning frequently -assist resident with obtain and utilizing a pressure relieving device -encourage weight shifts while sitting up in chair -develop turning/repositioning plan with resident input -teach risk factors for development of pressure ulcers -needs wound care as ordered by physician -needs weekly evaluation of wound healing -needs a daily observation of skin with routine care -needs full skin evaluation weekly with bath/shower . Observation of R #6 on 11/13/17 at 9:04 a.m., during initial rounds, revealed R #6 laying on a low air loss mattress, in a face up position with her head of the bed slightly elevated. R #6's bed sheets did not cover her left above the knee stump or hip allowing R #6's blue brief to be visible. Observation of R #6 on 11/13/17 at 11:38 a.m. revealed she sat in a wheelchair in her room with her eyes closed. R #6 had enteral feeding infusing via a pump and connected to her gastric tube infusing at 55 milliliters per hour. R #6 had a brief on. R #6 had blue Prevalon boots (boots that offload the heel) on both feet. Certified Nurse Aide (CNA) G entered the room and introduced herself. CNA G said R #6 rarely spoke any words and when she did, most of the words were not understandable. CNA G said R #6 was not able to voice her needs. CNA G said R #6 was transferred out of bed to her wheelchair via a mechanical lift at approximately 10:50 a.m. CNA G said she had to get R #6 out of bed because therapy usually came for her at about 11:15 a.m. Observation of R #6 on 11/13/17 at 11:48 a.m. revealed R #6 was escorted to the therapy room by a therapist. R #6 sat in her wheelchair throughout the therapy session and was not actively involved in therapy. R #6 was provided with passive therapy until 12:40 p.m. At 12:54 p.m. R #6 was escorted to the nurse's station and positioned beside the television, facing the nurse's station. At 1:40 p.m., CNA G and CNA C escorted R #6 to her room and assisted R #6 to bed using a mechanical lift at 1:46 p.m. R #6 sat in her wheelchair without being offloaded or repositioned from approximately 10:50 a.m.-1:46 p.m. Observation of R #6 on 11/14/17 at 8:35 a.m. revealed R #6 layed in bed on a low air loss mattress with her eyes closed. R #6 had a brief on. Observation of R #6 on 11/14/17 at 9:07 a.m. revealed CNAs C and G escorted R #6 to the shower room and onto the shower bed. Visible was R #6's right foot with a black scabbed area on the medial aspect of her right great toe. A foul odor was prevalent as staff began to undress R #6. Staff removed R #6's brief and exposed R #6's perineal area. The foul odor became stronger when staff turned R #6 to her right side. Staff cleaned R #6's buttocks of feces and exposed was a dressing covered in feces and was half uncovering the wound. R #6's sacral open wound was covered with feces and had a foul odor other than the feces odor. CNA G removed R #6's sacral dressing and allowed water to flow over the wounds. R #6 had denuded skin (loss of the epidermis, caused by exposure to urine, feces, body fluids, wound exudate or friction) between R #6's vagina and anus. In addition, R #6 had five separate open areas to bilateral buttocks: 1. Sacrum at 1 o'clock with the wound bed covered with yellow tissue 2. Right Buttock at 4 o'clock with a red wound bed 3. Right Buttock at 5 o'clock with a red wound bed 4. Left Buttock at 7 o'clock with the more than 50% of the wound bed with yellow tissue and some red tissue 5. Left Buttock at 11 o'clock with approximately 90% of the wound bed with yellow tissue and very little red tissue. There was white macerated (softening and breaking down of skin resulting from prolonged exposure to moisture) surrounding R #6's wounds at 1, 4, 7, and 11 o'clock. After the staff washed the feces off of R #6's buttocks, the foul odor continued from the open wounds. Also exposed, as R #6 layed on her right side was her right heel with dark purple/maroon/black discoloration with the top layer of skin peeling off. Interview with CNA G on 11/14/17 at 10:00 a.m. revealed she stated R #6 had the wound on her right foot for a couple of days, I am not sure exactly how many. I don't know if nurses know, I'm assuming they do, they remind us to put her Prevalon boots on. I don't usually see her buttocks, it is usually covered. CNA G stated R #6 used briefs all day every day because she is incontinent, I haven't been told not to put them on her. CNA G said she was going to call the Licensed Vocational Nurse (LVN) B to dress R #6's wounds before they placed the brief on her. On 11/14/17 at 10:30 a.m., LVN B/Treatment Nurse entered the shower room and said she was going to get the supplies needed for R #6's wounds. LVN B explained R #6 was admitted in the facility with a stage 3 pressure ulcer to her sacrum/buttocks. LVN B said the nurse practitioner/wound care specialist started to see her on 11/01/17 and follows-up with R #6 weekly. When asked if R #6's wounds were healing, LVN B said No, they are the same, it hasn't changed much. LVN B clarified that all the wounds had always been separate open areas but they were measured as one wound because the NP/WCS measured them that way. When asked how LVN B monitored each open area, she said I don't, we look at all of them, the whole area, as one existing wound. LVN B said R #6 had four open areas upon admission and did not know which open area was acquired after admission. LVN B said she had always been taught to identify each wound separately but since working with the NP/WCS, she had learned to combine the area if they are all clustered within the same area. LVN B said she had not consulted with the NP/WCS or R #6's primary care physician about combining all of R #6's wounds as one wound versus identifying them as separate wounds, I just went with it. LVN B was asked about R #6's right foot wounds and LVN B asked what wounds? LVN B assessed R #6's right foot and asked CNA C and CNA G if R #6 already had those, both CNAs shook their head up and down, indicating yes. LVN B said These are new, no one told me about them. LVN B said the right heel is a purple/maroon/black deep tissue injury pressure ulcer. It measures 1.0 X 1.7 centimeters. The right medial great toe had necrotic tissue scabbed, it's an unstageable pressure ulcer, it measures 2.5 X 2.0 centimeters. LVN B then applied skin prep (liquid film-forming dressing that, upon application to intact skin, forms a protective film to help reduce friction) to both wounds on R #6's right foot. After LVN B confirmed that R #6's NP/WCS or physician were not aware of the new wounds and of not having treatment orders for the new wound, LVN B stated I know that is what she (NP/WCS) is going to order. LVN B provided treatment to R #6's right heel and right medial great toe without consulting the physician to inform her/him of the new pressure ulcers or receiving treatment orders. R #6's Daily Skilled Nurse's Note dated 11/14/17 documented Resident in shower with staff- called to shower room to apply treatment to coccyx/sacrum area. Area continue with 50% slough and 50% granulation. No changes. Area with light exudate. Will continue treatment of [REDACTED]. Noted during shower two new areas to right foot. Areas to right heel and right medial foot. Right heel with small DTI- no redness or drainage. Right medial right with thin dry necrotic tissue. Tissue loose and peeling. Spoke to Nurse Practitioner/Wound Specialist and received order for skin prep to areas. daily. Bootie in place . R #6's Ulcers, Surgical Site Treatment and Progress Record, Side One, dated 11/14/17 documented Stage 3 Coccyx/Sacrum: cleanse with normal saline. Apply Santyl and cover with protective dressing. Change daily drainage: macerated, General Appearance: Yellow, Surrounding Skin: Reddened. Side two of this document entitled Ulcers, Surgical Site Treatment and Progress Record documented Length: 9.0 X Width: 8.0 X Depth: 0.5 cm. Light Exudate. 50% Slough, 50% granulation. R #6's Physician order [REDACTED]. R #6's Ulcers, Surgical Site Treatment and Progress Record, Side One, dated 11/14/17 documented Discovered 11/14/17: DTI Right Inner Foot Drainage: dry, General Appearance: Black, Surrounding Skin: Normal. Side two of this document entitled Ulcers, Surgical Site Treatment and Progress Record documented Length: 2.5 X Width: 2.0 cm Thin brown necrotic tissue/dry. Granulation: No R #6's Ulcers, Surgical Site Treatment and Progress Record, Side One, dated 11/14/17 documented Discovered 11/14/17: DTI Right Heel Drainage: dry, General Appearance: Black, Surrounding Skin: Pink. Side two of this document entitled Ulcers, Surgical Site Treatment and Progress Record documented Length: 1.0 X Width: 1.7 cm. dry. Granulation: No On 11/15/17 at 11:14 a.m., this surveyor accompanied the NP/WCS, LVN B, and the Director of Nurses (DON) to R #6's room. The NP/WCS explained that she was caring for R #6 in the hospital prior to her being admitted to this facility. The NP/WCS stated R #6 had three or four separate open areas when she was admitted to this facility. The NP/WCS said R #6 did not have any wounds on her right foot when she last saw her on 11/07/17. The NP/WCS removed R #6's brief and dressing to her sacrum/buttocks. The NP/WCS measured R #6's sacrum/buttocks and said out loud 6.8 X 7.0 X 0.8 centimeters 40% slough and 60% granulation tissue. It has massive excoriation from the moisture retained within the brief. This excoriation could have been prevented if the brief was left off, excoriation could cause new pressure injuries or deterioration. Overall the wound is worsening, it has increased in depth as well. When the NP/WCS was asked the rationale for measuring the separate open areas as one area versus separate areas, NP/WCS said That's how I do it, it's too much to separate them. The NP/WCS measured R #6's right medial gr (TRUNCATED)

Based on observation, interview, and record review the facility failed to ensure residents have the right to be free from neglect for three (R #3, R #6, and R #11) of four residents reviewed for pressure ulcers and neglect. R #6: -The facility failed to attempt to offload or reposition R #6 off her buttocks for approximately three hours, even after the facility was aware of R #6 having sacrum/coccyx/buttocks pressure ulcers. The facility failed to implement R #6's physician's orders [REDACTED]. The facility failed to accurately describe, document measurements, and stage all of R #6's pressure ulcers upon admission until the surveyor's inquiry. R #6 was admitted with four stage 3 pressure ulcers and developed one other stage 3 and two unstageable pressure ulcers. The facility failed to consistently identify and document all of R #6's pressure ulcers in their Altered Skin Integrity Treatment and Progress Record or Ulcers, Surgical Site Treatment and Progress Record. The facility failed to identify or document R #6's two new right foot unstageable pressure ulcers until the surveyor's inquiry. LVN B provided treatment to R #6's right heel and right medial great toe without consulting the physician to inform her/him of the new pressure ulcers or receiving treatment orders. The facility's identification, description, and documentation of R #6's pressure ulcer did not match R #6's current pressure ulcer status. The facility was identifying and treating R #6's pressure ulcers as one ulcer instead of instead of five seperate pressure ulcers. LVN B did not consult with R #6's primary care physician after the Nurse Practitioner/Wound Care Specialist identified, staged, and treated R #6's seperate five pressure ulcers as one pressure ulcer. R #11: -The facility failed to accurately describe and stage R #11's pressure ulcers that were facility acquired. The facility failed to identify R #11's two new unstageable pressure ulcers until the surveyor's inquiry. LVN B provided treatment to R #11's newly discovered unstageable pressure ulcers without consulting the physician to inform him of the new ulcers or receiving treatment orders. R #3: -R #3 was not offloaded or repositioned for more than two hours. R #3 did not have a pressure ulcer on 11/13/17 however, on 11/16/17 she had developed two Stage 2 pressure ulcers. The above failures resulted in an Immediate Jeopardy (IJ) situation on 11/16/17. While the IJ was removed on 11/20/17, the facility remained out of compliance at actual harm with a scope identified as pattern. The facility continued to monitor to ensure continued implementation of their plan of removal. These failures could affect nine residents with pressure ulcers and 80 residents receiving preventative skin care and place them at risk for developing new pressure ulcers or a decline in existing pressure ulcers. The findings included: R #6: R #6's Face Sheet dated 11/06/17 documented an [AGE] year-old female admitted to the facility on [DATE] and re-admitted on [DATE] with the [DIAGNOSES REDACTED]. R #6's Nursing Progress Note dated 10/25/17 documented Resident arrived via stretcher from post acute center .Resident has four open areas to coccyx .See wound care record There was no other specific description in this note regarding the open areas such as measurements or description of the wound. On 11/14/17 at 11:45 a.m., Licensed Vocational Nurse (LVN) B/Treatment Nurse verified that the Wound Care Record was the Altered Skin Integrity Treatment Progress Record dated 10/26/17. LVN B said there was no record dated 10/25/17. R #6's Admission Nursing Evaluation dated 10/25/17 (reviewed and copied on 11/13/17) revealed no documentation of pressure ulcers. On 11/15/17, further review of the same assessment revealed a new entry on the assessment documenting Stage III coccyx. There was no other information describing the pressure ulcer. R #6's Braden Scale dated 10/25/17 documented a score of 11- High risk. R #6's Weekly Skin Integrity Review dated 10/26/17 documented Upon admission coccyx with open areas. R #6's Physician order [REDACTED]. R #6's Altered Skin Integrity Treatment and Progress Record, Side One, dated 10/26/17 documented Stage 3 Coccyx: cleanse with Dakins solution, apply silver alginate measured to wounds, zinc cream to outer borders, cover with choice of dressing bid (twice a day) and prn (as needed) with each incontinent care .drainage: macerated (softening and breaking down of skin resulting from prolonged exposure to moisture), General Appearance: Yellow, Surrounding Skin: Reddened. Side two of this document entitled Altered Skin Integrity Treatment and Progress Record documented 10/31/17: (Length): 9.0 X (Width): 10.0 cm, moderate exudate. The documentation implied an identification and description of one wound versus four seperate wounds. R #6's Altered Skin Integrity Treatment and Progress Record, Side One, dated 10/27/17 documented Stage 3 Coccyx: cleanse with Dakins solution, apply silver alginate measured to wounds, zinc cream to outer borders, cover with choice of dressing bid and prn with each incontinent care .drainage: macerated, General Appearance: Yellow, Surrounding Skin: Reddened. Side two of this document entitled Altered Skin Integrity Treatment and Progress Record did not have an entry of description and measurement for this date. R #6's Altered Skin Integrity Treatment and Progress Record, Side One, dated 10/28/17 documented Stage 3 Coccyx: cleanse with Dakins solution, apply silver alginate measured to wounds, zinc cream to outer borders, cover with choice of dressing bid and prn with each incontinent care .drainage: macerated, General Appearance: Red, Surrounding Skin: Reddened. Side two of this document entitled Altered Skin Integrity Treatment and Progress Record did not have an entry for this date. R #6's Altered Skin Integrity Treatment and Progress Record, Side One, dated 10/29/17 documented Stage 3 Coccyx: cleanse with Dakins solution, apply silver alginate measured to wounds, zinc cream to outer borders, cover with choice of dressing bid and prn with each incontinent care .drainage: macerated, General Appearance: Red, Surrounding Skin: Reddened. Side two of this document entitled Altered Skin Integrity Treatment and Progress Record did not have an entry for this date. R #6's Altered Skin Integrity Treatment and Progress Record, Side One, dated 10/30/17 documented Stage 3 Coccyx: cleanse with Dakins solution, apply silver alginate measured to wounds, zinc cream to outer borders, cover with choice of dressing bid and prn with each incontinent care .drainage: macerated, General Appearance: Red, Surrounding Skin: Reddened. Side two of this document entitled Altered Skin Integrity Treatment and Progress Record did not have an entry for this date. R #6's Altered Skin Integrity Treatment and Progress Record, Side One, dated 10/31/17 documented Stage 3 Coccyx: cleanse with Dakins solution, apply silver alginate measured to wounds, zinc cream to outer borders, cover with choice of dressing bid and prn with each incontinent care .drainage: macerated, General Appearance: Dry, Surrounding Skin: Reddened. Side two of this document entitled Altered Skin Integrity Treatment and Progress Record documented 10/31/17: 9.0 X 10.0 cm, moderate exudate. Granulation (reddish connective tissue that forms on the surface of a wound when the wound is healing): No, Decreased Size: No, Decreased Depth: No, Decreased Drainage: No. R #6's Admission Minimum Data Set ((MDS) dated [DATE] documented R #6: -had clear speech -had short and long-term memory problem with severely impaired cognitive skills for decision making -required extensive assistance with one or two person physical assist with bed mobility, dressing, and eating. R #6 was totally dependent for transfers and personal hygiene. -had an indwelling urinary catheter and was always incontinent of bowel. -was at risk of developing pressure ulcers, had one Stage 3 pressure ulcer at admit/reentry measuring 8.0 X 9.0 X 0.5 centimeters (cm). Has pressure reducing device for bed and was receiving pressure ulcer care. The MDS section M1200C: Skin/ulcer treat: turning and reposition was unchecked. R #6's Braden Scale dated 11/01/17 documented a score of 11- High risk. R #6's Initial Wound Consultation Report (performed by Nurse Practitioner/Wound Care Specialist) dated 11/01/17 documented Wound: Bilateral Buttocks/Sacrum/Coccyx, Measurements: 8.0 X 9.0 X 0.5 cm, Wound Bed: 90% adherent, slough, 10% scattered granulation. Periwound: slight moisture, intact. Assessment: Stage 3 Pressure Injury. Elevated right heel on pillows. Treatment: Air Mattress, No diapers in bed. Cleanse with NS, pat dry with gauze, sure prep to peri wound, nickel thick Santyl, protective dressing . R #6's Ulcers, Surgical Site Treatment and Progress Record, Side One, dated 11/01/17 documented Stage 3 Coccyx/Sacrum: cleanse with normal saline. Apply Santyl and cover with protective dressing. Change daily drainage: macerated, General Appearance: Yellow, Surrounding Skin: Reddened. Side two of this document entitled Ulcers, Surgical Site Treatment and Progress Record documented Length: 8.0 X Width: 9.0 X Depth: 0.5 cm. Moderate Serous Exudate. Granulation: Yes, Decreased Size: No, Decreased Depth: No, Decreased Drainage: No. The Ulcers, Surgical Site Treatment and Progress Record, Side Two, included NPUAP (National Pressure Ulcer Advisory Panel) Stages For Pressure Ulcers: -Suspected Deep Tissue Injury (DTI): Purple or maroon localized area of discolored intact skin or blood-filled blister. -Stage 1: Intact Skin. Non-blanchable redness. Skin with darker tones may appear blue, purple, warm, boggy, or firm. -Stage 2: 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. -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, gray, green, brown or black) in the wound bed. R #6's Ulcers, Surgical Site Treatment and Progress Record, Side One, dated 11/02/17- 11/06/17 documented Stage 3 Coccyx/Sacrum: cleanse with normal saline. Apply Santyl and cover with protective dressing. Change daily drainage: macerated, General Appearance: Yellow, Surrounding Skin: Reddened. Side Two of this document entitled Ulcers, Surgical Site Treatment and Progress Record did not have any entries for these dates. R #6's Ulcers, Surgical Site Treatment and Progress Record, Side One, dated 11/07/17 documented Stage 3 Coccyx/Sacrum: cleanse with normal saline. Apply Santyl and cover with protective dressing. Change daily drainage: macerated, General Appearance: Yellow, Surrounding Skin: Reddened. Side two of this document entitled Ulcers, Surgical Site Treatment and Progress Record documented Length: 7.5 X Width: 8.5 X Depth: 0.5 cm. Moderate Serous Exudate. 50% Slough, 50% granulation. R #6's Follow-Up Wound Consultation Report (performed by Nurse Practitioner/Wound Care Specialist) dated 11/01/17 documented Wound: Bilateral Buttocks/Sacrum/Coccyx, Measurements: 7.5 X 8.5 X 0.5 cm, Wound Bed: 50% slough, 50% scattered granulation. Periwound: dry, intact, and no moisture. Assessment: Stage 3 Pressure Injury. Treatment: Air Mattress, No diapers in bed. Continue same treatment plan . R #6's Ulcers, Surgical Site Treatment and Progress Record, Side One, dated 11/08/17- 11/13/17 documented Stage 3 Coccyx/Sacrum: cleanse with normal saline. Apply Santyl and cover with protective dressing. Change daily drainage: macerated, General Appearance: Yellow, Surrounding Skin: Reddened. Side Two of this document entitled Altered Ulcers, Surgical Site Treatment and Progress Record did not have any entries for these dates. R #6's Care Plan dated 11/12/17 documented: -is unable to respond to questions and commands verbally due to [MEDICAL CONDITION] (inability to comprehend or formulate language) and is unable to make needs known verbally. -is alert and oriented to self and needs assistance with making needs known due to dementia. -requires extensive to total staff assistance for all ADL's (activities of daily living) . -has pressure ulcer to coccyx and requires use of low air loss mattress and is at risk for further breakdown. Receives sugar free protein and liquid multivitamin with minerals .Approaches: -assist resident with repositioning frequently -assist resident with obtain and utilizing a pressure relieving device -encourage weight shifts while sitting up in chair -develop turning/repositioning plan with resident input -teach risk factors for development of pressure ulcers -needs wound care as ordered by physician -needs weekly evaluation of wound healing -needs a daily observation of skin with routine care -needs full skin evaluation weekly with bath/shower . Observation of R #6 on 11/13/17 at 9:04 a.m., during initial rounds, revealed R #6 laying on a low air loss mattress, in a face up position with her head of the bed slightly elevated. R #6's bed sheets did not cover her left above the knee stump or hip allowing R #6's blue brief to be visible. Observation of R #6 on 11/13/17 at 11:38 a.m. revealed she sat in a wheelchair in her room with her eyes closed. R #6 had enteral feeding infusing via a pump and connected to her gastric tube infusing at 55 milliliters per hour. R #6 had a brief on. R #6 had blue Prevalon boots (boots that offload the heel) on both feet. Certified Nurse Aide (CNA) G entered the room and introduced herself. CNA G said R #6 rarely spoke any words and when she did, most of the words were not understandable. CNA G said R #6 was not able to voice her needs. CNA G said R #6 was transferred out of bed to her wheelchair via a mechanical lift at approximately 10:50 a.m. CNA G said she had to get R #6 out of bed because therapy usually came for her at about 11:15 a.m. Observation of R #6 on 11/13/17 at 11:48 a.m. revealed R #6 was escorted to the therapy room by a therapist. R #6 sat in her wheelchair throughout the therapy session and was not actively involved in therapy. R #6 was provided with passive therapy until 12:40 p.m. At 12:54 p.m. R #6 was escorted to the nurse's station and positioned beside the television, facing the nurse's station. At 1:40 p.m., CNA G and CNA C escorted R #6 to her room and assisted R #6 to bed using a mechanical lift at 1:46 p.m. R #6 sat in her wheelchair without being offloaded or repositioned from approximately 10:50 a.m.-1:46 p.m. Observation of R #6 on 11/14/17 at 8:35 a.m. revealed R #6 layed in bed on a low air loss mattress with her eyes closed. R #6 had a brief on. Observation of R #6 on 11/14/17 at 9:07 a.m. revealed CNAs C and G escorted R #6 to the shower room and onto the shower bed. Visible was R #6's right foot with a black scabbed area on the medial aspect of her right great toe. A foul odor was prevalent as staff began to undress R #6. Staff removed R #6's brief and exposed R #6's perineal area. The foul odor became stronger when staff turned R #6 to her right side. Staff cleaned R #6's buttocks of feces and exposed was a dressing covered in feces and was half uncovering the wound. R #6's sacral open wound was covered with feces and had a foul odor other than the feces odor. CNA G removed R #6's sacral dressing and allowed water to flow over the wounds. R #6 had denuded skin (loss of the epidermis, caused by exposure to urine, feces, body fluids, wound exudate or friction) between R #6's vagina and anus. In addition, R #6 had five separate open areas to bilateral buttocks: 1. Sacrum at 1 o'clock with the wound bed covered with yellow tissue 2. Right Buttock at 4 o'clock with a red wound bed 3. Right Buttock at 5 o'clock with a red wound bed 4. Left Buttock at 7 o'clock with the more than 50% of the wound bed with yellow tissue and some red tissue 5. Left Buttock at 11 o'clock with approximately 90% of the wound bed with yellow tissue and very little red tissue. There was white macerated (softening and breaking down of skin resulting from prolonged exposure to moisture) surrounding R #6's wounds at 1, 4, 7, and 11 o'clock. After the staff washed the feces off of R #6's buttocks, the foul odor continued from the open wounds. Also exposed, as R #6 layed on her right side was her right heel with dark purple/maroon/black discoloration with the top layer of skin peeling off. Interview with CNA G on 11/14/17 at 10:00 a.m. revealed she stated R #6 had the wound on her right foot for a couple of days, I am not sure exactly how many. I don't know if nurses know, I'm assuming they do, they remind us to put her Prevalon boots on. I don't usually see her buttocks, it is usually covered. CNA G stated R #6 used briefs all day every day because she is incontinent, I haven't been told not to put them on her. CNA G said she was going to call the Licensed Vocational Nurse (LVN) B to dress R #6's wounds before they placed the brief on her. On 11/14/17 at 10:30 a.m., LVN B/Treatment Nurse entered the shower room and said she was going to get the supplies needed for R #6's wounds. LVN B explained R #6 was admitted in the facility with a stage 3 pressure ulcer to her sacrum/buttocks. LVN B said the nurse practitioner/wound care specialist started to see her on 11/01/17 and follows-up with R #6 weekly. When asked if R #6's wounds were healing, LVN B said No, they are the same, it hasn't changed much. LVN B clarified that all the wounds had always been separate open areas but they were measured as one wound because the NP/WCS measured them that way. When asked how LVN B monitored each open area, she said I don't, we look at all of them, the whole area, as one existing wound. LVN B said R #6 had four open areas upon admission and did not know which open area was acquired after admission. LVN B said she had always been taught to identify each wound separately but since working with the NP/WCS, she had learned to combine the area if they are all clustered within the same area. LVN B said she had not consulted with the NP/WCS or R #6's primary care physician about combining all of R #6's wounds as one wound versus identifying them as separate wounds, I just went with it. LVN B was asked about R #6's right foot wounds and LVN B asked what wounds? LVN B assessed R #6's right foot and asked CNA C and CNA G if R #6 already had those, both CNAs shook their head up and down, indicating yes. LVN B said These are new, no one told me about them. LVN B said the right heel is a purple/maroon/black deep tissue injury pressure ulcer. It measures 1.0 X 1.7 centimeters. The right medial great toe had necrotic tissue scabbed, it's an unstageable pressure ulcer, it measures 2.5 X 2.0 centimeters. LVN B then applied skin prep (liquid film-forming dressing that, upon application to intact skin, forms a protective film to help reduce friction) to both wounds on R #6's right foot. After LVN B confirmed that R #6's NP/WCS or physician were not aware of the new wounds and of not having treatment orders for the new wound, LVN B stated I know that is what she (NP/WCS) is going to order. LVN B provided treatment to R #6's right heel and right medial great toe without consulting the physician to inform her/him of the new pressure ulcers or receiving treatment orders. R #6's Daily Skilled Nurse's Note dated 11/14/17 documented Resident in shower with staff- called to shower room to apply treatment to coccyx/sacrum area. Area continue with 50% slough and 50% granulation. No changes. Area with light exudate. Will continue treatment of [REDACTED]. Noted during shower two new areas to right foot. Areas to right heel and right medial foot. Right heel with small DTI- no redness or drainage. Right medial right with thin dry necrotic tissue. Tissue loose and peeling. Spoke to Nurse Practitioner/Wound Specialist and received order for skin prep to areas. daily. Bootie in place . R #6's Ulcers, Surgical Site Treatment and Progress Record, Side One, dated 11/14/17 documented Stage 3 Coccyx/Sacrum: cleanse with normal saline. Apply Santyl and cover with protective dressing. Change daily drainage: macerated, General Appearance: Yellow, Surrounding Skin: Reddened. Side two of this document entitled Ulcers, Surgical Site Treatment and Progress Record documented Length: 9.0 X Width: 8.0 X Depth: 0.5 cm. Light Exudate. 50% Slough, 50% granulation. R #6's Physician order [REDACTED]. R #6's Ulcers, Surgical Site Treatment and Progress Record, Side One, dated 11/14/17 documented Discovered 11/14/17: DTI Right Inner Foot Drainage: dry, General Appearance: Black, Surrounding Skin: Normal. Side two of this document entitled Ulcers, Surgical Site Treatment and Progress Record documented Length: 2.5 X Width: 2.0 cm Thin brown necrotic tissue/dry. Granulation: No R #6's Ulcers, Surgical Site Treatment and Progress Record, Side One, dated 11/14/17 documented Discovered 11/14/17: DTI Right Heel Drainage: dry, General Appearance: Black, Surrounding Skin: Pink. Side two of this document entitled Ulcers, Surgical Site Treatment and Progress Record documented Length: 1.0 X Width: 1.7 cm. dry. Granulation: No On 11/15/17 at 11:14 a.m., this surveyor accompanied the NP/WCS, LVN B, and the Director of Nurses (DON) to R #6's room. The NP/WCS explained that she was caring for R #6 in the hospital prior to her being admitted to this facility. The NP/WCS stated R #6 had three or four separate open areas when she was admitted to this facility. The NP/WCS said R #6 did not have any wounds on her right foot when she last saw her on 11/07/17. The NP/WCS removed R #6's brief and dressing to her sacrum/buttocks. The NP/WCS measured R #6's sacrum/buttocks and said out loud 6.8 X 7.0 X 0.8 centimeters 40% slough and 60% granulation tissue. It has massive excoriation from the moisture retained within the brief. This excoriation could have been prevented if the brief was left off, excoriation could cause new pressure injuries or deterioration. Overall the wound is worsening, it has increased in depth as well. When the NP/WCS was asked the rationale for measuring the separate open areas as one area versus separate areas, NP/WCS said That's how I do it, it's too much to separate them. The NP/WCS measured R #6's right medial great toe and stated 2.3 X 2.3 centimeters non-blanchable 100% black eschar. The right heel is dark purple/maroon with some black discoloration with surrounding skin red, non-blanchable. We have to keep the heel offloaded. The NP/WCS verified she had given orders on her consultation sheet for R #6 not to wear briefs in bed since she first saw R #6 on 11/01/17. The NP/WCS said she was there to give the orders and it was the facility's responsibility to implement the orders. The NP/WCS stated the resident's condition could deteriorate if her orders were not implemented. R #6's Daily Skilled Nurse's Note dated 11/15/17 documented 11:00 a.m. (NP/WCS) here to eval and order treatments for wounds to coccyx/sacrum/right and left buttocks and right heel and right medial great toe. recommend to use Santyl to cluster of areas of wounds. Will use Santyl only on areas with slough and will separate areas. Noted 5 different in cluster that only three have slough and needs Santyl. 2 areas have all granulation and use [MEDICATION NAME]. Will leave diaper off as ordered. Will cover with ABD as ordered with tape and use zinc barrier paste for excoriated areas. Bootie to right foot on at all times . R #6's Initial Follow-Up Consultation Report (performed by Nurse Practitioner/Wound Care Specialist) dated 11/15/17 at 11:44 a.m. documented Wound: Bilateral Buttocks/Sacrum/Coccyx, Measurements: 6.8 X 7.0 X 0.8 cm, Wound Bed: 40% slough moist, 60% granulation. Periwound: maceration pallor to wound edges, denuded. Assessment: worsening Stage 3 Pressure Injury. Treatment: Air Mattress, tube of zinc given (to facility)- cleanse with NS, pat dry, zinc to excoriated areas nickel thick, Santyl to slough areas. ABD and secure with tape -Right Medial Heel: Measurement: 1.0 X 1.0 cm, Wound Bed: dark black/purple discoloration, Periwound: non-blanchable redness, dry and intact, Assessment: Suspected DTI, Unstageable Pressure Injury, Treatment: Daily Sure prep and offload . -Right Medial Great Toe: Measurements: 2.3 X 2.3 cm, Wound Bed: 100% dry stable eschar, Periwound: dry intact scaly, Assessment: suspected DTI, Unstageable Pressure Injury, Treatment: Daily Sure Prep, offload. R #6's physician's orders [REDACTED]. Interview with the DON on 11/15/17 at 11:33 a.m. revealed she stated nurses were responsible for assessing and documenting what is seen as accurately as possible. The DON said she did not know R #6 had separate open areas and from reviewing LVN B and NP/WCS's documentation It looked like she only had one wound. I can't tell if any of the separate open areas have improved or worsened because of the incorrect documentation. I can't tell when (R #6) developed the additional ulcer on her bottom. The DON said LVN B should have documented the number of open areas, their location, a description and measurement of each area and it's surrounding skin. The DON said she did not agree with the NP/WCS and LVN B's identification and description of the wounds. The DON said LVN B having several years in wound care background should have informed her or/and (R #6's) physician after the NP/WCS treated the ulcers as one ulcer. The DON stated LVN B was responsible for reviewing the NP/WCS's consultation notes and should have implemented the order, including in-servicing the rest of the staff for R #6 not to wear briefs in bed. The DON said she was going to have LVN B re-measure R #6's wounds and document them separately. Interview with LVN B on 11/15/17 at 12:20 p.m. revealed she confirmed she had seen NP/WCS consultation notes and read the order for no briefs. LVN B said she did not in-service staff to implement that order. R #6's Physician order [REDACTED].#1 at 1 o'clock with normal saline (NS), apply santyl and cover with ABD pad. Clean area #2 at 4 o'clock on right buttock with NS, apply [MEDICATION NAME] and cover with ABD pad. Clean area #3 at 5 o'clock on right buttock with NS, apply [MEDICATION NAME] and cover with ABD. Clean area #4 with NS, apply Santyl, cover with ABD pad. Clean area #5 with NS, apply santyl and cover with ABD pad. Change all sites daily. No brief/can keep under, no binding tapes. R #6's Ulcers, Surgical Site Treatment and Progress Record, Side One, dated 11/15/17 documented Discovered 10/25/17: #1- Stage 3 at 1 o'clock Sacrum: Drainage: moist, General Appearance: Yellow, Surrounding Skin: Reddened. Side two of this document entitled Ulcers, Surgical Site Treatment and Progress Record documented Length: 3.0 X Width: 4.0 cm. Granulation 10%, 90% slough. edges macerated, Decreased in Size: No. R #6's Ulcers, Surgical Site Treatment and Progress Record, Side One, dated 11/15/17 documented Discovered 10/25/17: #2- Stage 3 at 4 o'clock Right Buttock: Drainage: moist, General Appearance: Red, Surrounding Skin: Reddened. Side two of this document entitled Ulcers, Surgical Site Treatment and Progress Record documented Length: 0.8 X Width: 1.3 cm. Slight Exudate. Decreased in Size: No. R #6's Ulcers, Surgical Site Treatment and Progress Record, Side One, dated 11/15/17 documented Discovered 10/25/17: #3- Stage 3 at 5 o'clock Right Buttock: Drainage: moist, General Appearance: Red, Surrounding Skin: Reddened. Side two of this document entitled Ulcers, Surgical Site Treatment and Progress Record documented Length: 2.0 X Width: 2.5 cm. 100% granulation. Decreased in Size: No. R #6's Ulcers, Surgical Site Treatment and Progress Record, Side One, dated 11/15/17 documented Discovered 10/25/17: #4- Stage 3 at 7 o'clock Left Buttock: Drainage: moist, General Appearance: Yellow, Surrounding Skin: Reddened. Side two of this document entitled Ulcers, Surgical Site Treatment and Progress Record documented Length: 3.0 X Width: 1.5 cm. Slight Exudate. 60% slough and 40% granulation. Decreased in Size: No. R #6's Ulcers, Surgical Site Treatment and Progress Record, Side One, dated 11/15/17 documented Discovered 10/25/17: #5- Stage 3 at 11 o'clock Left Buttock: Drainage: moist, General Appearance: Yellow, Surrounding Skin: Reddened. Side two of this document entitled Ulcers, Surgical Site Treatment and Progress Record documented Length: 3.0 X Width: 2.0 X Depth: 0.8 cm 90%slough and 10% granulation. Decreased in Size: No. R #6's Daily Skilled Nurse's Note dated 11/16/17 documented 7:30 a.m.- spoke with (NP/WCS) concerning areas to right buttock #2 and #3, areas with granulation, no slough. Explained talked to (Admitting Doctor's Nurse Practitioner) concerning change from one cluster to five areas. These two areas would treat with [MEDICATION NAME]. NP/WCS gave orders for alginate silver, discontinue ABD pad due to will not stay on areas, will start protective adhesive pad/cover. Continue to cover area daily and prn . R #6's Physician order [REDACTED].#2 and #3 with NS and apply alginate cover with protective ABD pad and adhesive dressing, change daily and prn. D/C (discontinue) [MEDICATION NAME] to areas #2 and #3 on right buttocks. R #6's proceeding physician's orders [REDACTED]. Interview with R #6's Primary Care Physician (PCP) on 11/16/17 at 9:04 a.m. revealed he was informed by the DON the surveyors concern regarding R #6's documentation and identification of pressure ulcers. The PCP said I totally agree with you- standards are that each wound should be identified, described, and documented separately because not all wounds may require the same treatment as in (R #6's) case. The PCP said it did not matter how many wounds there were, they should be separately distinguished. The PCP said due to inaccurate assessment and documentation, there was no way of distinguishing whether R #6's wounds have improved or deteriorated. The PCP was made aware that R #6 initially was admitted to the facility with four open areas to her buttocks and now she had five plus two new wounds on her right foot. The PCP said it sounds like (R #6) is developing more. The PCP said he was not aware that R #6 had more than one wound because of the incorrect documentation he was reading, although he should have been made aware. R #11: Review of R #11's Face Sheet revealed she was originally admitted to the facility on [DATE] and readmitted on [DATE] after hospitalization for acute [MEDICAL CONDITION]. R#11's [DIAGNOSES REDACTED]. R#11 was [AGE] years old.(TRUNCATED)