Every finding on record at Award Care at Sarasota

Based on interviews, review of facility policy, and clinical record review, the facility failed to immediately inform the resident representative when there was a significant change in the resident's physical status and decision to transfer the resident to the hospital for 1 (Resident #1) of 3 residents sampled.The findings included:Review of facility policy and procedure N-105 effective [DATE], revised [DATE], Notification of Change in Condition revealed Policy: The center to promptly notify the Patient/Resident, the attending physician, and the Resident Representative when there is a change in the status or condition. Procedure: The nurse to notify the attending physician and Resident Representative when there is a(n): Accident, Significant change in the patient/resident's physical, mental, or psychosocial status, Need to alter treatment significantly due to but not limited: Adverse consequences, Acute condition, Exacerbation of chronic condition, A transfer or discharge of the Patient/Resident from the Center. In the event of an emergency situation, 911 to be called and the attending physician and the Resident Representative to be notified as soon as possible . Document the notification in the medical record.A review of the clinical record revealed Resident #1 was admitted to the facility on [DATE] with diagnoses of surgical aftercare following surgery on the digestive system, disruption or dehiscence of closure of internal operation (surgical) wound (a surgical incision unexpectedly breaks open during the healing process), presence of cardiac and vascular implant and graft (a history of heart and blood vessel surgery), and presence of aortocoronary bypass graft (a history of heart blood vessel surgery).Review of the Quarterly Minimum Data Set (MDS) (standardized assessment tool that measures health status in nursing home residents) dated [DATE] revealed Resident #1 had normal cognitive functioning. He required supervision or touching assistance for transfers, sit-to-stand, and walking up to 50 feet.Review of the clinical record for Resident #1 revealed a Progress Note [DATE] at 9:30 p.m. documented Resident #1 complained of not feeling well, patient stated that he hasn't felt well in a couple of days now and keeps having bowel movements. He said he didn't even feel well enough to go out to smoke his cigarettes today. The progress note documented Staff B Licensed Practical Nurse (LPN) went to her medication cart to check his orders for anything for GI (Gastointestinal) upset and moments after a Certified Nursing Assistant (CNA) alerted her to go to him quickly. Upon entering the patient's room he was seen sitting on the toilet hunched over and was being held up by the other CNA. Staff B LPN called a Code Blue (emergency situation), called 911 and Resident #1 was transferred to the hospital.Review of the clinical record for Resident #1 revealed a Change in Condition assessment dated [DATE] at 12:22 a.m. The Change in Condition documented in the evaluation was Unresponsiveness. The Change in Condition Assessment did not document the family representative was notified. This section was left blank.Review of the clinical record for Resident #1 revealed a Transfer Assessment was initiated on [DATE], but it was blank.Review of the clinical record revealed there was no documentation that Resident #1's representative was notified of his change in condition or transfer.On [DATE] at 3:07 p.m. in an interview, the DON (Director of Nursing) said she called the hospital on [DATE] around 5:30 or 6:00 a.m. for an update on Resident #1. She said she heard the resident had multiple cardiac events overnight and was alive. She said after she received that update, early in the morning on [DATE] the nephew of Resident #1 (the resident's representative) called to ask what had happened at the facility. She said the resident's representative told her the hospital had called him in the middle of the night to inform him that the resident was in the Emergency Room. She said she told Resident #1's representative that an aide had answered the resident's call light and he was not looking good. She said she told him the aide got the nurse and EMS was called. She said she told him it seemed like a vaso-vagal event (fainting due to nerve stimulation).The DON said the Change in Condition Assessment in Resident #1's clinical record does not indicate that the Emergency Contact was notified. She said best practice is that the facility notify the family or Emergency Contact of a change in condition. She said she thought that maybe the Staff A LPN Unit Manager's signature on the Agency for Healthcare Administration (AHCA) form indicated that she had informed the resident's representative of the change in condition and transfer.On [DATE] at 3:54 p.m. in an interview, Staff A LPN Unit Manager said she came to work at the facility in the morning on [DATE]. She said at approximately 9:00 a.m. she spoke to Resident #1's representative and let him know the resident was coded (had cardiopulmonary resuscitation, also known as CPR) and sent to the hospital. She said she did not document after speaking to the resident representative on [DATE].

Based on interviews, record review, and review of facility policies, the facility failed to report an allegation of neglect that resulted in death within the specified required timeframe for one resident (Resident #1) reviewed.The findings included:Review of facility policy N-1265 effective 11/30/2014, revised 11/16/2022 Abuse, Neglect, Exploitation & Misappropriation revealed Once an allegation of abuse is reported, the Executive Director, as the abuse coordinator, is responsible for ensuring that reporting is completed timely and appropriately to appropriate officials in accordance with Federal and State regulations.Review of facility investigation revealed on 12/26/25 at approximately 8:03 p.m. in a phone conversation with the Director of Nursing (DON) and the Administrator Resident #1's representative stated he felt Resident #1 should have been transferred to the hospital sooner. The investigation documented that the Administrator became aware of the situation on 12/26/25 at 8:03 p.m. The report of this allegation of neglect was submitted to the Agency on 12/27/25 at 3:29 p.m.On 1/14/26 at 3:07p.m. in an interview, the DON said that Resident #1 was transferred to the hospital on [DATE]. She said she spoke to the resident's representative the morning of 12/26/25 and he informed her that the resident had passed away. She said later in the day the representative was asking more questions about what happened at the facility before Resident #1 was sent to the hospital. She included the Administrator on a 3-way phone call with the representative on 12/26/25 and the representative said he thought they should have sent the resident to the hospital sooner. The DON said she felt it was an allegation of neglect. She acknowledged that the allegation was not reported to the Agency until 12/27/25 at 3:29 p.m. She said the delay may have been because she and the Administrator were trying to gather more information. She said they were trying to see if there was anything they'd have to add to the report before they submitted it.

Based on resident and staff interviews and record review the facility failed to ensure 1, (Resident #1), of 3 residents reviewed for accidents was not burned by hot coffee. The facility had not provided the required staff education and equipment to ensure the reheating of residents' food or beverages were served at an appropriate safe temperature.The findings included:On 12/1/25 a review of an adverse incident report revealed upon completion, Resident #1 had spilled hot coffee on his lap on 9/23/25 causing a blister to the right upper thigh area.On 12/1/25 a review of Resident #1's medical record revealed he was admitted to the facility on [DATE] with diagnoses of hemiplegia and hemiparesis following a cerebral infarction, muscle wasting and atrophy.A nursing progress note dated 9/24/25 at 6:43 p.m., stated the writer was informed by CNA (Certified Nursing Assistant), Staff A, Resident #1 had spilled coffee on his lap. Upon assessment of the skin, the writer noted one small, blistered area on the upper right thigh near his groin, the skin is not intact, and the dermal layer is absent on the upper thigh. The resident did not complain of pain and the primary care physician and family were notified. Wound care to follow up on 9/25/25.An ARNP (Advance Registered Nurse Practitioner) wrote on 9/27/25 at 1:10 p.m. The patient is seen today for a follow-up on the burn area on his right thigh that happened on 9/25/25 after he accidently spilled coffee on it.Silvadene cream was applied to the affected area, pending the Wound Care team to evaluate the site. Advised to keep the area clean and dry. Monitor for secondary skin infection, such as increasing erythema, discharge, pain, swelling and fever.On 10/9/25 a Wound Assessment Report noted a right thigh 1st degree burn with partial thickness measuring 7.0 cm (centimeters) by 2.50 cm with a depth of 0.1 cm. Facility to cleanse the area with normal saline daily and as needed, apply Silver Sulfadiazine 1% cream and leave open to air.On 12/1/25 at around 11:50 a.m., in an interview with Resident #1, he said on 9/23/25, he had returned to his room and went to his room door to ask someone to reheat his coffee. He saw the DPO in the hallway and he asked him to reheat his coffee. The DPO went to the nurses' station and came back with his reheated coffee. He then asked Staff A for some sugar, and when she handed him the sugar, he spilled his coffee on his lap causing the burn to his upper right thigh area. He said the area is now healed and he did not feel any pain at the time of the incident.Review of the facility's Re-heating Resident Food and Beverages policy D-306 with an effective date 11/30/2024, stated this policy is to reduce the risk of resident burns related to hot beverages, liquids and food, and to provide guidance on re-heating resident food and/or liquids. Staff members are to reheat residents' food and or liquids in the microwave to the temperatures that are safe and palatable for residents.Under the procedure section it states . The staff member is to use the dial thermometer provided to ensure a maximum temperature of the item is not greater than 140 degrees at the time of service.On 12/2/25 at 9:15 a.m., CNA Staff A said she was hired 7/1/25. She said on 9/23/25 when she handed Resident #1 the sugar for his coffee, he accidentally spilled it onto his lap. She said she was unaware the coffee had burned Resident #1's upper right thigh until he told her on 9/24/25, and that is when she told the nurse. She said several weeks later she had learned that someone had reheated Resident #1's coffee prior to him spilling it on his lap. She said the facility did education with all the staff about the facility's Re-heating Resident Food and Beverages policy and now the policy is posted by the microwave machine along with a thermometer to check the food or beverage prior to giving the reheated food/beverage to the resident. She said prior to facility wide in-service about the Re-heating Resident Food and Beverages policy she was unaware they were required to check the food or beverage temperature prior to handing a resident reheated food or beverage.On 12/2/25 at 9:40 a.m., the DPO said he had been working at the facility for 1.5 years. He said on 9/23/25 he was walking down the hallway when Resident #1 asked him to reheat his coffee. He said he brought the coffee to microwave, pressed the start button once, reheated Resident #1's coffee, gave Resident #1 the reheated coffee and left the area. He said it was not until several weeks later, when the Executive Director (ED) asked him if he had reheated Resident #1's coffee on 9/23/25 that he learned Resident #1 spilled the coffee in his lap causing a burn to his upper thigh area. He said the ED conducted a 1:1 education with him related to the facility's Re-heating Resident Food and Beverages policy. He said until he received the 1:1 education with the ED on 10/30/25, he was unaware of the facility Re-heating Resident Food and Beverages policy. He said the policy is now posted next to all the microwaves in the facility along with a thermometer to check the reheated food or beverage to ensure it is below 140 degrees before giving it to the resident.On 12/2/25 at approximately 11:00 a.m., the Director of Nursing (DON) and the ED confirmed the facility's Re-heating Resident Food and Beverages policy stated when a facility staff reheats a resident's food or beverage, they are required to check the temperature to ensure it is below 140 degrees. They confirmed some of the facility staff were unaware of reheating food and beverage policy so they conducted a facility wide education with all staff and posted the Re-heating Resident Food and Beverages policy and a thermometer at each microwave in the facility to ensure staff knew the policy and had the required equipment to ensure the food or beverage is reheated and served to the resident at an appropriate temperature as noted in their policy.

Based on staff interviews and record reviews, the facility failed to ensure 1, (Resident #2), of 3 residents with admitting facility orders for an antibiotic medication were clarified by the residents' primary care physician The findings included:Review of the facility's Medication Reconciliation policy #N-1590, with an effective date of 12/17/24, stated the medication reconciliation is the process of ensuring accurate and complete medication list during a transition in care. The medication reconciliation occurs during admission/re-admission and discharge. The policy noted to review and compare medications from the most recent hospital stay, home or prior living establishment and prior stay in the facility; review medication dosage, frequency, and stop date; review all discrepancies with the physician and document findings on the Medication Reconciliation in the resident's medical record.Review of Resident #2's medical record revealed she was admitted to the facility on [DATE] with diagnoses that included Septic Arterial Embolism, Bacteremia, and Methicillin Susceptible Staphylococcus Aureus Infection.A medication error form dated 8/15/25 at 11:00 a.m. stated Resident #2 had missed doses of IV ABT (Intravenous Antibiotic Therapy) on 8/14/25 at 6:00 p.m. and 10:00 p.m., and on 8/15/25 at 2:00 a.m., 6:00 a.m., and 2:00 p.m. The doctor was made aware and IV ABT ordered and verified they were on the way from the pharmacy. Infectious disease specialist was notified and informed the resident had missed doses. The infectious disease specialist gave the okay to start the IV ABT upon arrival.Review of the facility incident report and investigation noted Resident #2 was admitted to the facility on [DATE] with admitting physician orders. On 8/15/25 the nursing staff identified Resident #2 had not received prescribed IV ABT of Oxacillin 2 grams every 4 hours that were ordered on admission. The nursing staff identified the missed doses and the IV ABT medication was ordered from pharmacy and arrived on 8/15/25 and administered as per the physician orders. The facility investigation noted Resident #2 had missed 5 doses of the IV ABT. Resident #2's admitting nurse, Staff C, said the Unit Manager was responsible for the admission and order transcription. Review of the Discharge Reconciliation Document noted the Unit Manager Staff B had placed a question mark next to the Oxacillin order on the hospital medication Discharge Reconciliation Document indicating the medication needed to be clarified by the physician.On 12/2/25 at approximately 2:15 p.m., the Director of Nursing (DON) and the Executive Director (ED) confirmed Resident #2 had missed 5 doses of Oxacillin 2 grams IV ABT when she was admitted to the facility on [DATE]. The DON said every morning she reviewed all new admissions to the facility from the prior day, and she noted a question mark next to the Oxacillin order on Resident #2's Discharge Reconciliation Document from the hospital. The DON said when she reviewed Resident #2's MAR (Medication Administration Record), she noted the Oxacillin was not listed as administered. She then investigated and determined the Unit Manager had not clarified the Oxacillin medication listed on the discharge reconciliation form as required. This caused the medication not to be ordered and administered. She notified the primary care physician and the hospital infectious disease specialist and received the required clarification orders which she sent to pharmacy. The medication arrived that afternoon and was administered at that time.On 12/3/25 at around 10:00 a.m., Staff C confirmed she was Resident #2's nurse when she arrived at the facility. She said because she was busy, the Unit Manager said she would complete Resident #2's admitting paperwork. She said when she was done with her work, she assisted the Unit Manager to complete Resident #2's admission paperwork, and she noted the Oxacillin medication on the discharge orders did not have a dose, frequency or route. They tried to text the primary care physician for clarification order for the Oxacillin, but he did not text her back or call. She said the Unit Manager told her to go home and she would get the clarification order for the Oxacillin. She said she was unaware the Oxacillin was not clarified by the Unit Manager as required until the DON called her to ask why they had not clarified the Oxacillin medication order during Resident #2's admission to the facility on 8/14/25.

Based on review of the clinical record, review of facility policy and procedures, and resident and staff interviews, the facility failed to protect residents from misappropriation of resident property when controlled medications were unaccounted for 1(Resident #45). On 2/13/24 it was reported Resident #45's Hydrocodone-Acetaminophen 5 milligrams (mg)-325 mg, 75 tablets were unaccounted for. The facility failed to account for all controlled medications to prevent loss or diversion. On 8/5/24 controlled medications were signed out on the narcotic declining drug inventory sheet as administered for 3(Resident #12, # 42, and #27) who were alert and oriented and reported they had not received the medications that were documented. On 10/2/24 Resident #63 reported he received a medication that was not his Oxycodone- Acetaminophen 10 mg-325 mg and had not requested the as needed medication from the nurse who documented it was administered. The findings included: The facility policy N-1265 Abuse, Neglect, Exploitation and Misappropriation documented It is inherent in the nature and dignity of each resident at the center that he or she be afforded basic human rights, including the right to be free from abuse, neglect, mistreatment, exploitation and or misappropriation of property. The management of the facility recognizes these rights and hereby establishes the following statements, policies, and procedures to protect these rights and to establish a disciplinary policy which results in the fair and timely treatment of occurrences of resident abuse. Misappropriation of resident property is the deliberate misplacement, exploitation, or wrongful, temporary, permanent use of a residence belongings or money without the residents consent. Employee misappropriation includes but is not limited to: diversion of residents medication(s) including but not limited to controlled substances for staff use or personal gain. The facility policy N-861 Acceptance of Controlled Drugs documented, Controlled drugs will be delivered to the facility by the pharmacy in a sealed, tamper proof container. One nurse will sign for the container on the pharmacy delivery sheet. The container will remain sealed until a second nurse is available to open and validate the contents. 2 nurses will open the controlled drug container and reconcile the controlled drugs including but not limited to: correct medication, dosage, amounts. Controlled medications are then placed into the medication carts by the nurses. If discrepancies are found during reconciliation notify the pharmacy and the director of nursing. Discrepancies may include but are not limited to: missing controlled drugs incorrect quantities, damaged containers or seals, tote is open or there is evidence of tampering. 1. Review of the facility investigation documented on 2/13/24 Resident #45's Hydrocodone-Acetaminophen 5 milligrams (mg)-325 mg, 75 tablets were unaccounted for. Licensed Practical Nurse (LPN) Staff E attempted to administer Hydrocodone-Acetaminophen 5 mg-325 mg to Resident #45, but was not able to locate the medication in the medication cart. Staff E contacted the pharmacy to order the medication and was notified of a delivery of 75 tablets on 2/6/23. The medication was signed as received on the pharmacy manifest on 2/6/24 by LPN Staff L. Staff E notified Unit Manager LPN Staff M and a search of the facilities five medication carts and two medication rooms was conducted. Staff M contacted the pharmacy to confirm the medication was delivered to the facility. The Hydrocodone-Acetaminophen 5 mg-325 mg, 75 tablets were not located. The advanced practice registered nurse (APRN) was contacted for a new order for the missing medication. The facility did not substantiate the investigation due to the allegation was refuted by evidence collected during the investigation. Based on staff and resident interview and full house audit on current residents receiving narcotics ensured no other narcotic medication were misplaced. The facility investigation was inconclusive. Review of the witness statement written by LPN Staff L with a date of 2/14/24 documented I gave the med's to assigned on that cart. I cannot remember anything after that. Review of the phone interview witness statement dated 2/19/24 received by the Regional Nurse Consultant for LPN Staff P documented, She thinks she remembers receiving narcotics from Staff L but cannot verify or remember if anything was for Resident #45. Review of the Pharmacy delivery form documented 75 Oxycodone 10 mg tabs were delivered and signed for by LPN Staff L. On 12/11/24 at 9:30 a.m., the Director of Nursing (DON) said resident interviews were conducted on LPN Staff L's assignment and no other residents receiving pain medications had any issues. Staff L is no longer employed with us. Staff P was the nurse Staff L said she gave the medications to, and she is no longer here either. The DON said the process when the pharmacy delivers medications to the facility a nurse signs electronically, that the medications were received. The pharmacy keeps the record, but a copy is in our electronic dashboard system. We did notify the pharmacy the Hydrocodone was missing and they will follow up. The investigation is a facility thing. I think we found the medication but there is no documentation it was found. We never had to replace it because we found it in the pharmacy bag that is returned to the pharmacy. We searched the medication rooms and did not find the medication until later. The DON confirmed there was no documentation stating the facility had located the medication. The DON said we interviewed all the residents when the medication was not discovered, and we closed the investigation out. She said the root cause of the missing 75 tablets of Hydrocodone/Acetaminophen 5/325 was the nurses were not having a witness when they sign the narcotics in and out, so we implemented that they need to have a second nurse witness. Education was provided with the nurses on the policy of having 2 nurses sign for the medications. Review of the facilities resident interview sheets consisted of the residents name and the question are you receiving your pain medication? circle yes/no. No dates, no time and no signatures were on the facility audits. Review of the education in-service provided on 2/14/23 by the Unit Manager LPN Staff M, specified 2 nurses will sign all narcotic sheets when received from pharmacy and before entering the sheet into the narcotic binder. Nine nurses including the presenter signed the attendance sheet. LPN Staff M signed for nine nurses who were provided with a phone call regarding the policy. On 12/11/24 at 1:46 p.m., Resident #45 said she was informed by the facility staff her pain medication was missing. She said she had pain in her back, and they did not have her medication that evening. She said she was informed that if she wanted a refill, she would have to pay for the medication. Resident #45 said that is not my problem, they need to find out who took my medications, the nurse is the one with the keys not me. I can't unlock the cart. On 12/11/24 at 2:19 p.m., LPN Staff M showed the plastic bag the medications go into for return to the pharmacy. She said the pharmacy delivers medications daily and collects the go back bags. 2. On 12/9/24 at 11:50 a.m., RN Staff J, he said was working on 8/6/24 and when I came in and counted the cart with LPN Staff I, and the count was good. I noted residents who don't ask for controlled medications had received them. Resident #12 never complains of pain and I saw that Tramadol 50 mg was signed off on the declining controlled drug count sheet and one hour later a Hydrocodone/Acetaminophen 5/325 mg was signed off as well. Both medications were scheduled every 4 hours as needed and Resident #12 received the 2 medications 1 hour apart. I asked the resident, and he said he never requested a pain pill. Resident #27 had two Oxycodone 20 mg tablets removed from the medication card but only one tablet was signed out. Resident #42 had one Ativan 0.5 mg removed from a full card of 25 tablets. Resident #42 has never used the medication, he never asks for it. I looked at the count sheets and I thought something was suspicious because I asked the residents, and they all said they did not receive the medications. I went to the DON with my concerns, and we conducted an audit of all the medication carts to make sure the controlled medication count sheets were accurate. We interviewed the residents, and they said they never requested the medications and did not receive them. On 12/9/24 at 2:00 p.m., Resident #12 he said he remembers the nurse who said she gave me Tramadol and Hydrocodone. She said I asked for the pills and I never asked for the medication, and she never gave me anything. I didn't get any medications that night. Resident #12 said the nurse tried to say she gave them to him but he did not receive them. He said They sign it out and say they give it but they don't. It is our word against the nurses. 3. On 8/5/24 at 9:04 p.m., LPN Staff I documented she administered one Oxycodone 20 mg tablet to Resident #27. The facility reviewed the declining narcotic count sheet and a new card of 25 pills showed 2 tablets were removed, leaving a total of 23 pills left in the card. The facility was not able to locate the missing Oxycodone 20 mg. 4. On 8/5/24 at 00:00 LPN Staff I documented she administered one Ativan 0.5 mg (medication used to treat anxiety or agitation) to Resident #42. The medication was scheduled as needed. Review of the declining controlled medication count sheet revealed the pharmacy delivered 25 tablets on 6/29/24. The facility verified the medication was removed from the medication card and declining narcotic count sheet had been filled out correctly but the resident said he did not ask for the medication or receive it. On 12/10/24 at 10:53 a.m., Resident #42 said I know I have not ever requested an Ativan from any nurse here. That night, I don't remember the exact date, but the nurse said she gave me an Ativan and I asked for it, but she never gave me anything. I think maybe she took it or gave it to someone else but not me. The resident said RN Staff J had asked him if he requested and received the Ativan, and I told him I did not get an Ativan from the nurse. On 12/11/24 at 8:30 a.m., the DON said she investigated the event of 8/5/24 with the medications for Residents #12, #27 and #42. She said it was the night shift nurse, Staff J who found the discrepancies with medications which were signed out for residents who do not usually receive them. The DON said, with Resident #12, Staff I had signed the declining narcotic count sheet for a Tramadol 50 mg at 9:00 p.m., and an hour later at 10:00 p.m., a Oxycodone/325 was signed out. Staff J said the resident never asks for the medications and asked him if he had received them. The resident said he had not received them and did not ask for them. The DON said, we checked the count sheet, and the Tramadol and Oxycodone were signed out. I interviewed LPN Staff I and she said she gave it because Resident #12 had asked for it. I interviewed Resident #12 and he said he did not receive the medications, and did not ask for them. He has the capacity to know if he received the medications or not. The DON said, Resident #27 had an unopened card of Oxycodone 20 mg tablets. There were 25 tablets. Staff I gave 1 tablet but, 23 tablets were left indicating Staff I gave 2 pills. She said she only gave one. I interviewed the resident but she could not recall how many pills she received that night. The declining narcotic control count sheet indicated 23 tablets remained. Resident #42 had Ativan .5 mg ordered as need, and one tablet was signed out at 00:00 by Staff I on 8/6/24. Staff J said the resident had never asked for an Ativan before and asked the resident and he said he did not request it or receive it. The DON said, with these three residents identified, we interviewed the nurse and realized she had made multiple medication errors that night. I was not able to determine if she took the medications or gave them to other residents or to the right residents. Staff I said, she had a horrible night with family issues and said she probably should have called off. She said she kept leaving the unit to cry and was upset. Staff I said she gave the medications to Resident #12, #27 and #42. After the investigation I was not able to identify what happened. Staff I did not come in for her scheduled interview and did not show up for her scheduled shift. I attempted to contact her multiple times but she did not return my calls. The DON said the root cause was inconclusive. The facility was not able to substantiate medication diversion. 5. Review of the facility investigation revealed on 10/2/24 at 6:30 a.m., Resident #63 reported a potential discrepancy in his medication administration to the facility nurse, LPN Staff S. He reported he received 3 pills in the medication cup, including his scheduled levothyroxine and Gabapentin. The third pill was marked with a G and numbers, and did not match the appearance of his prescribed as needed Hydrocodone-Acetaminophen 10/325 mg. He suspected the pill was not his prescribed pain medication. Resident #63 reported to the DON and the Social Service Director, that LPN Staff N entered his room and stated she had his morning medications and a pain medication. The resident said he did not request the as needed pain medication. Resident #63 said the Nurse handed him the cup and left the room. The facility investigation was documented as inconclusive. On 12 /9/24 at 12:30 p.m., during an interview, Resident #63 said on 10/2/24, I remember that day very well. LPN Staff N brought me 3 pills in a cup. I identified 2 of them, they were correct. The third one she said was my pain pill. I know I get Hydrocodone 10/325 and the pill has an M on it with some numbers. She gave me a round pill with the letter G on. My pain medication is not round it is long and white. I keep up with my medications, you have to so when things like this happen you are aware. The DON said it was a Tylenol pill that she gave me, I don't know what it was but I refused to take it. There was no Hydrocodone given to me that night. I filed a grievance regarding the incident. I know my medications; you have to be able to look at your pills and know what you are getting. You have to be your own advocate. Review of the medication administration record for October 2024 documented at 10:20 p.m., on 10/2/24 the nurse signed the Hydrocodone-Acetaminophen 10/325 mg was administered to Resident #63. On 12/9/24 at 12:00 p.m., review of Resident #63's pain medication with LPN Staff R. The Hydrocodone-Acetaminophen 10/325 did have the letter M 367 inscribed on the tablet. On 12/11/24 at 08:30 a.m., during an interview, the DON said on 10/2/24 Resident #63 reported to the nurse he received a medication with the letter G on the round tablet. He did have an order for Gabapentin and levothyroxine that he takes at 6:00 a.m. He said the nurse gave him a cup with three pills and said one was a pain pill but he never asked for a pain pill. We did a pain scale and reviewed his medication. He described the pill and one of the nurses determined it was a Mucinex tablet. One of the nurses knew what the Mucinex tablets we have in stock look like and that is what he described. He did not have an order for Mucinex. I don't know if he received the medication it was inconclusive to me. I did not know if the resident took the medication or the nurse did. The DON said she did not do education with the staff as it was an isolated situation. On 12/12/24 at 9:28 a.m., The Quality Assurance Performance Improvement (QAPI) binder was reviewed with the Administrator, and the DON. There was no documentation in the binder of anything discussed in the monthly QAPI meetings. There was no documentation for February and March 2024 regarding the missing tablets of Hydrocodone/Acetaminophen 5/325 75 for Resident #45, and no plan of correction. The DON said we did not bring it to QAPI because we found the medication later but we have no documentation the medication was found. I educated the staff on the 2 person system for checking in medications received from the pharmacy and when removing narcotics from the cart. There were no QAPI notes regarding the reportable event of 8/6/24 with missing narcotics for Residents #12, #27 and #42. The Administrator said he did not know about the missing Hydrocodone/Acetaminophen 5/325 75 for Resident #45 because he was hired in March 2024. There was no QAPI discussion for the 10/2/24 reported incident of Resident #63 receiving a Mucinex tablet in place of the Oxycodone 10/325 mg tablet. I knew about that, he received a Mucinex tablet and not the pain medication. He said, I am not a nurse so I don't know about medications, I leave that for the DON to handle. The Administrator said he kept typed notes in the electronic record for the QAPI meetings because his handwriting was not good but he was not able to find any QAPI notes for the medication diversion. He said the DON handled the QAPI for the reported event on 8/6/24. It was a newly hired nurse, and we reported it. He confirmed there was no documentation of the incident discussed in QAPI. The Administrator said he reported it to the State agency, that is it. The Administrator said we discovered it was newly hired nurses who made medication mistakes so the DON and I are interviewing the new hires and we are more intuitive. If we get a bad feeling about the person or something does not feel right, we don't hire them. On 12/12/24 at 10:20 a.m., the DON she said everything with the medications was traced back to newly hired nurses not our nurses. I did education and I believe it was effective, but I understand there is no documentation of the outcome. It was not taken to QAPI because it was not our nurses who were making the mistakes so there was not anything we could have done for that. I don't see how we could have. We found the missing medications for Resident #45 but we did not document it when they were found. The incident on 8/5/24 occurred because Staff I was a new nurse. We completed assessments of the residents. The DON confirmed the declining narcotic sheets for Resident #27, #12 had the dates crossed out and another date written over it. The DON said that was another error Staff I made that evening. On 12/12/24 at 5:01 p.m., in a telephone interview, the Pharmacy Consultant said he is at the facility monthly and reviews the resident charts and medications and makes recommendations. He said he was not made aware of the missing 75 Oxycodone 5/325 tablets for Resident #45. He said this is the first time I'm hearing about it. I did not know. The Pharmacy Consultant was informed of the event on 8/5/24 of controlled medications signed out to Resident #12, #27 and on 8/6/24 signed out for Resident #42 who reported they had not received the medications. He said Oh gosh I did not know, no one mentioned any of this to me. The Consultant said he was not aware of Resident #63's concern with his pain medication and confirmed the Hydrocodone 10/325 mg did have the letter M and numbers on the tablet. He said I did not know about any of this. If needed I could have worked with the facility to make suggestions on how to prevent the problems. If needed I would have been in QAPI.

Based on staff interviews, and review of the facility policy and procedures, the facility failed to implement a system to account for periodic reconciliation and disposition of all controlled substances. The findings included: The facility Policy N-864 Control Drug Reconciliation Random Audit documented The facility in coordination with the licensed pharmacist provides for: A system of medication records that enables periodic accurate reconciliation and accounting for controlled medications. Prompt identification of loss or potential diversion of controlled substances and determination of the extent of the loss or potential diversion of controlled medications. On 12/11/24 at 10:15 a.m., during an interview, the Director of Nursing (DON) said the process for narcotic medications was to have two nurses' sign when narcotics are received and two nurses sign when the medication is discontinued or the medication card is empty. The DON said she collects the discontinued medications from the medication carts weekly, the nurse and I sign the declining count sheet and then I place the medications in a double locked drawer here. The DON said the pharmacist and I destroy the medications once a month. The DON said she was not able to reconcile the controlled medications currently stored in the locked drawer. She said I would have to open the drawer, pull the count sheets and look at the medication cards to tell you that. The DON confirmed she had no process in place to provide an accurate accounting of the medications kept in a locked drawer in her office.

Based on review of the clinical record, review of facility policies and procedures, and resident and staff interviews, the facility failed to ensure accuracy of medication administration for 17(Residents #122, #222, #70, #41, #97, #13, #92, #10, #61, #8, #46, #67, #74, #12, #27, #63 and #42) of 17 residents reviewed for significant medication errors. The findings included: The facility policy N-861 Acceptance of Controlled Drugs documented, Controlled drugs will be delivered to the facility by the pharmacy in a sealed, tamper proof container. One nurse will sign for the container on the pharmacy delivery sheet. The container will remain sealed until a second nurse is available to open and validate the contents. 2 nurses will open the controlled drug container and reconcile the controlled drugs including but not limited to: correct medication, dosage, amounts. Controlled medications are then placed into the medication carts by the nurses. If discrepancies are found during reconciliation, notify the pharmacy and the director of nursing. Discrepancies may include but are not limited to: missing controlled drugs incorrect quantities, damaged containers or seals, tote is open or there is evidence of tampering. 1. On 12/9/24 at 11:50 a.m., during an interview, Registered Nurse (RN) Staff J, said he was working on 8/6/24. He said, when I came in and counted the cart with LPN Staff I, the count was good. I noted residents who never request controlled medications had received them. Resident #12 never complained of pain and I saw that Tramadol 50 mg was signed off on the declining controlled drug count sheet. One hour later a Hydrocodone/Acetaminophen 5/325 mg was signed off as well. Both medications were scheduled every 4 hours as needed and Resident #12 received the 2 medications, 1 hour apart. I asked the resident, and he said he never requested a pain pill. Resident #27 had two Oxycodone 20 mg tablets removed from the medication card but only one tablet was signed out. Resident #42 had one Ativan 0.5 mg removed from a full card of 25 tablets. Resident #42 has never used the medication, he never asks for it. I looked at the count sheets and I thought something was suspicious because I asked the residents, and they all said they did not receive the medications. I went to the DON with my concerns, and we conducted an audit of all the medication carts to make sure the controlled medication count sheets were accurate. We interviewed the residents, and they said they never requested the medications and did not receive them. 2. On 12/9/24 at 2:00 p.m., during an interview, Resident #12 he said he remembers the nurse who said she gave me Tramadol and Hydrocodone. She said I asked for the pills and I never asked for the medication, and she never gave me anything. I didn't get any medications that night. Resident #12 said the nurse tried to say she gave them to him but he did not receive them. He said They sign it out and say they give it but they don't. It is our word against the nurses. 3. On 8/5/24 at 9:04 p.m., LPN Staff I documented she administered one Oxycodone 20 mg tablet to Resident #27. The facility reviewed the declining narcotic count sheet and a new card of 25 pills showed 2 tablets were removed, leaving a total of 23 pills left in the card. The facility was not able to locate the missing Oxycodone 20 mg. 4. On 8/6/24 at 00:00 LPN Staff I documented she administered one Ativan 0.5 mg (medication used to treat anxiety or agitation) to Resident #42. The medication was scheduled as needed. Review of the declining controlled medication count sheet revealed the pharmacy delivered 25 tablets on 6/29/24. The facility verified the medication was removed from the medication card and the declining narcotic count sheet had been filled out correctly but the resident said he did not ask for the medication or receive it. On 12/10/24 at 10:53 a.m., during an interview, Resident #42 said I know I have not ever requested an Ativan from any nurse here. That night, I don't remember the exact date, but the nurse said she gave me an Ativan and I asked for it, but she never gave me anything. I think maybe she took it or gave it to someone else but not me. The resident said RN Staff J had asked him if he requested and received the Ativan, and I told him I did not get an Ativan from the nurse. On 12/11/24 at 8:30 a.m., the DON said she investigated the event of 8/5/24 with the medications for Residents #12, #27 and #42. She said it was the night shift nurse, Staff J who found the discrepancies with medications signed out for residents who do not usually receive them. Regarding Resident #12, The DON said Staff J saw he had a Tramadol 50 mg at 9:00 p.m., and an hour later at 10:00 p.m., a Oxycodone/325 was signed out. Staff J said the resident never asks for the medications and asked him if he had received them. The resident said he had not received them and did not ask for them. We checked the count sheet, and the Tramadol and Oxycodone were signed out. I interviewed LPN Staff I and she said she gave it because Resident #12 had asked for it. I interviewed Resident #12 and he said he did not receive the medications, and did not ask for them. He has the capacity to know if he received the medications or not. With Resident #27 she had an unopened card of 25 Oxycodone 20 mg tablets. The nurse gave 1 tablet but 23 tablets were left indicating Staff I gave 2 pills but she said she only gave one. I interviewed the resident but she could not recall how many pills she received that night. Resident #42 had Ativan 0.5 mg as need and one tablet was signed out at 00:00 by Staff I. Staff J said the resident had never asked for an Ativan before and asked the resident and he said he did not request it or receive it. With Residents #12, #27 and #42 we identified the errors. When we interviewed the nurse we realized she had made multiple medication errors that night. I was not able to determine if she took the medications or gave them to other residents or to the right residents. She said she had a horrible night with family issues and said she probably should have called off. She said she kept leaving the unit to cry and was upset. Staff I said she gave the medications to Resident #12, #27 and #42. After the investigation I was not able to identify what happened. All the residents on her assignment had medication errors and they did not receive their scheduled medications. LPN Staff I signed the medications as administered for all scheduled medications for the residents on her assignment. She said she gave the medications to Residents #122, # 222, #70, #41, #97, #13, #92, #10, #61, #8, #46, #67, and #74 and signed the Medication Administration Record (MAR). We interviewed the residents who were alert and they said they did not receive any medication from the nurse. The Mars were signed on 8/5/24 for Residents #122, #222, #70, #41, #97, #13, #92, #10, #61, #8, #46, #67, and #74 that the medications were administered, but the residents denied receiving any medications. 5. Review of the facility investigation revealed on 10/2/24 at 6:30 a.m., Resident #63 reported a potential discrepancy in his medication administration to the facility nurse LPN Staff S. He reported he received 3 pills in a medication cup, including his scheduled levothyroxine and Gabapentin. The third pill was marked with a G and numbers and did not match the appearance of his prescribed as needed Hydrocodone-Acetaminophen 10/325 mg. He suspected the pill was not his prescribed pain medication. Resident #63 reported to DON and Social Service Director, that LPN Staff N entered his room and stated she had his morning medications and a pain medication. The resident said he did not request the as needed pain medication. Resident #63 said the Nurse handed him the cup and left the room. Facility investigation was documented as inconclusive. On 12 /9/24 at 12:30 p.m., in an interview, Resident #63 said on 10/2/24, I remember that day very well. LPN Staff N brought me 3 pills in a cup. I identified 2 of them, they were correct. The third one she said was my pain pill. I know I get Hydrocodone 10/325 and the pill has an M on it with some numbers. She gave me a round pill with the letter G on. My pain medication is not round it is long and white. I keep up with my medications, you have to so when things like this happen you are aware. The DON said it was a Tylenol pill that she gave me, I don't know what it was but I refused to take it. There was no Hydrocodone given to me that night. I filed a grievance regarding the incident. I know my medications; you have to be able to look at your pills and know what you are getting. You have to be your own advocate. Review of the medication administration record for October 2024 documented at 10:20 p.m., on 10/2/24 the nurse signed the Hydrocodone-Acetaminophen 10/325 mg was administered to Resident #63. On 12/9/24 at 12:00 p.m., review of Resident #63's pain medication with LPN Staff R. The Hydrocodone-Acetaminophen 10/325 did have the letter M 367 inscribed on the tablet. On 12/11/24 at 8:30 a.m., during an interview, the DON said on 10/2/24 Resident #63 reported to the nurse he received a medication with the letter G on the round tablet. He did have an order for Gabapentin and levothyroxine that he takes at 6:00 a.m. He said the nurse gave him a cup with three pills, and said one was a pain pill but he never asked for a pain pill. We obtained a pain scale and reviewed his medication. He described the pill and one of the nurses determined it was a Mucinex tablet. One of the nurses knew what the Mucinex tablets we have in stock look like and that is what he described. He did not have an order for Mucinex. I don't know if he received the medication it was inconclusive to me. I did not know if the resident took the medication or the nurse did. The DON said she did not do education with the staff as it was an isolated situation.

Based on observations, interviews, and record review the facility failed to provide appropriate housekeeping services to ensure the facility remained in good repair, and ensure facility staff were aware of how to report needed repairs to the maintenance staff. The findings included: 1. On 12/09/24 at 10:52 a.m., a large brown stain was observed on the carpet in the living room area adjacent to room [ROOM NUMBER]. There was a tear in the carpet noted with carpet material being frayed and sticking up above the carpet. The area of carpet torn was approximately 2 to 3 inches wide. On 12/11/24 at 3:17 p.m., during an interview, the Housekeeping Director said the stain in the 507-living area pod was caused by the air conditioner leaking. The Housekeeping Director said he had talked to maintenance about replacing the carpet. On 12/11/24 at 3:21 p.m., during an interview, the Maintenance Director said his plan is to replace all the carpets with hardwood flooring. The Maintenance Director said he has a hard time getting the approval to do the work. 2. On 12/10/24 at 9:43 a.m., an observation of room [ROOM NUMBER] showed the light behind the bed was not working. There was a vanity over a dresser in front of the room in which one of the four light bulbs were not working. Resident #104 said the light over her bed had not been working since she moved into the room [ROOM NUMBER] months ago. On 12/11/24 at 11:05 a.m., during an interview, the Maintenance Director was asked how staff report needed repairs to maintenance. The Maintenance Director said as of about three weeks ago the facility had switched to using Tells to communicate repairs electronically. He said he did not know if staff had been in-serviced on using the Tells system. On 12/12/24 at 10:03 a.m., during an interview Certified Nursing Assistant, Staff D, said she would use the maintenance book at the nurse's station to communicate to maintenance a repair was needed. On 12/12/24 at 10:10 a.m., during an interview Registered Nurse, Staff E said she would document the repair needed in the maintenance book at the nurse's station. On 12/12/24 at 10:15 a.m., during an interview Registered Nurse, Staff F said she would notify maintenance by documenting in the maintenance book at the nurse's station. 41155 On 12/9/24 at 9:15 a.m., during initial observations of the 400 hall on the South Unit, the following was noted: 3. room [ROOM NUMBER] the top to the toilet tank was missing. There was a wash basin on the floor with a roll of toilet paper, in it. 4. room [ROOM NUMBER] there was a plunger on the floor next to the toilet and a wash basin on the floor. 5. room [ROOM NUMBER] there was a wash basin on the floor under the sink. There were three bottles of personal care liquids and an adult brief on the sink in a shared bathroom. 6. room [ROOM NUMBER] there was a wash basin on the floor under the sink in a shared bathroom. 7. room [ROOM NUMBER] there were 2 urinals hanging from the trash can. There was peeling paper, exposing the dry wall next to the head of the bed. 8. room [ROOM NUMBER] there was a urinal with urine in it hanging inside of the trash can. There was oxygen tubing lying across the trash can. On 12/9/24 at 10:00 a.m., during an interview, Certified Nursing Assistant Staff O said he did not know why the urinal was in the garbage and said he thought the resident liked having it there. Photographic evidence obtained.

Based on interview and record review, the facility failed to formulate a comprehensive resident-centered care plan that included the services required to ensure proper functioning and maintenance including monitoring, testing, and ways to identify potential problems or complications for 2 (Residents #9, and #22) of 2 reviewed in the facility who had implanted cardiac pacemakers. The findings included: Review of the Policy for Pacemaker, monitoring of Resident, revised 9/5/17, nursing services will coordinate and assist with pacemaker checks for residents with pacemakers. The procedures included identifying residents with pacemakers and obtaining an order from the physician for routine scheduled pacemaker checks based on manufacturer or physician's order or recommendation. Document in the medical chart. Review of the Policy for Plans of Care revised 9/25/17: The procedures included developing a comprehensive plan of care including measurable objectives and timetables to meet the resident's medical needs that are identified in the comprehensive assessment. The interdisciplinary team shall ensure the plan of care addresses any resident needs and that the plan is oriented toward attaining or maintaining the highest physical, mental and psychosocial well-being. The person-centered care plan may include but is not limited to the following: Services to attain or maintain the highest practicable physical, mental, and psychosocial well-being as required by state and federal regulatory requirements; and individualized interventions that honor the resident's preferences and promote achievement of the resident's goals. Review of the Hospital Cardiology Consult Note for Resident #9 dated 8/4/24 revealed Resident #9 was an [AGE] year-old with a history of atrial fibrillation, prior pacemaker implantation, and non-sustained ventricular tachycardia (fast heart rate). If stable, the plan included conservative management. Resident #9 was discharged from the hospital and admitted to the facility on [DATE]. The quarterly resident assessment completed by the facility on 11/13/24 revealed diagnoses including hypertension and hyperlipidemia, renal (kidney) insufficiency, diabetes, and hemiplegia or hemiparesis (paralysis on one side of the body). There was no diagnoses listed for atrial fibrillation or presence of cardiac pacemaker in the resident assessment. Review of the physician's order summary for Resident #9 revealed there was the presence of a cardiac pacemaker. There were no instructions or orders for the care of the device. Review of the comprehensive care plan for Resident #9 initiated on 8/22/24 revealed the resident wished to remain in the facility for long-term care. The interventions included to encourage the resident to discuss feelings and concerns .; establish a pre-discharge plan .; and evaluate and discuss with the resident or the representative the prognosis for independent or assisted living; identify, discuss and address limitations, risks, benefits, and needs for maximum independence. There were no interventions in the care plan for maintaining the proper functioning of the cardiac pacemaker. Review of Resident #9's nutrition care plan revealed the resident was at risk of malnutrition related to the presence of the pacemaker. The interventions included did not specify instructions to ensure the proper care of the pacemaker. Review of Resident #9's care plan for advanced directives initiated on 8/22/24 revealed the resident did not want cardiopulmonary resuscitation and maintained a Do Not Resuscitate (DNR) status at the facility. The care plan interventions for the DNR status did not include any interventions for the cardiac pacemaker. Review of Resident #9's care plan for terminal prognosis initiated on 12/9/24 revealed comfort, dignity, and autonomy will be maintained at the highest level through the review dated. Interventions included working cooperatively with the hospice team to ensure physical needs are met. There were no interventions or instructions regarding the cardiac pacemaker. On 12/9/24 at 11:31 a.m., Resident #9 was observed in the bedroom. The resident's room did not contain a remote cardiac monitoring device for the pacemaker that would send signals to the doctor's office for monitoring the resident's heart rate. On 12/9/24 at 1:37 p.m., during an interview with Resident #9's health care surrogate, she said the pacemaker was checked in the hospital. She said before that, the resident had not been to the cardiologist in about 2 years. She said she attends the care plan meetings, but the facility has not mentioned any pacemaker checks or cardiology appointments scheduled for Resident #9. She said she does not know anything about the current care or plan for the pacemaker. 12/12/24 9:31 a.m., during an interview with Licensed Practical Nurse (LPN) Staff Q, she said she worked at the facility since March 2024. She said she works on different units in the facility and had taken care of Resident #9 in the past. She said she was not aware of any residents in the facility with pacemakers and usually does not deal with pacemakers. She said she would check the vital signs frequently if the resident had a pacemaker. On 12/12/24 at 9:41 a.m., during an interview with the Minimum Data Set (MDS) Coordinator, she said she is part of the interdisciplinary team and attends the morning meetings with the team. She said the 24-hour report is discussed as well as new orders and she makes sure care planning interventions are initiated when necessary. She verified the pacemaker diagnosis on the physician's order summary. She said there should be a care plan for the cardiac pacemaker. She looked through the resident's electronic and paper medical chart and said there was no care plan or order for routine checks. She said there should be a care plan and that she would add one. On 12/12/24 at 10:17 a.m., during an interview with the Director of Nursing (DON), she said she would expect to see physician's orders for cardiology follow-up and order from the physician for heart rate range, trouble shooting and maintenance. She said she could not find any information other than that listed in the hospital record. The resident does not have a care plan for maintenance of the device. Review of the medical record for Resident #22 revealed and admission to the facility on [DATE]. The annual comprehensive assessment dated [DATE] revealed diagnoses of atrial fibrillation (irregular heartbeat), coronary artery disease, hypertension, and hyperlipidemia. The diagnoses did not include the presence of a cardiac pacemaker. Resident #22's physician order summary revealed the diagnosis of presence of cardiac pacemaker. There were no orders for checking or maintaining the device. Review of the care plans for Resident #22 revealed ones for congestive heart failure, fluid overload related to heart failure, and anticoagulant therapy related to atrial fibrillation and coronary artery disease. None of the care plans had instructions for how the facility was providing care and services for the resident's pacemaker. On 12/12/24 at 10:45 a.m., during an interview, the MDS coordinator confirmed Resident #22 medical record at the facility did not include a care plan for maintenance of the resident's implanted cardiac pacemaker. .

Based on observation, staff and resident interviews and review of facility policies and procedures, the facility failed to ensure 1(Resident #21) of 1 resident reviewed had a wheelchair in good working repair and was safe for resident use. The findings included: The facility policy Wheelchair (w/c) Repair-Electric Wheelchairs documented, Each resident requiring the use of a w/c will be provided the appropriate chair to maintain their highest level of functioning. All chairs will be maintained in a safe operating condition. When identified that the w/c is in need of repair, the staff will notify rehab to obtain a replacement w/c while the chair is being repaired. Preventive maintenance of each w/c should be done on a regular basis and the Director of Environmental Services should keep a log of this. On 12/10/24 at 12:59 p.m., Resident #21 was observed in his w/c, and said he needed a new w/c because his required repair. The resident got up from the w/c and it was observed to have a broken back support that did not provide the necessary support. The arm rests were frayed and covered in black tape. The seat was torn, frayed and tattered. He said he had requested a new w/c multiple times and has not received one. Resident #21 said he felt the w/c was dangerous and not safe. He said he was worried he could fall backwards due to the lack of support with the w/c. On 12/10/24 at 4:47 p.m., during an interview, the Regional Nurse Consultant (RNC) said she and the Director of Nursing did assess the residents w/c. The RNC said they were not aware of the condition of the resident's w/c, and would order him a new w/c. On 12/11/24 at 10:52 a.m., during an interview, the Maintenance Director (MD) said he is notified of things in need of repair in the facility electronic Tell's system. He said the staff are to report repairs using the Tell's system. The MD said there was no log at this time where staff can write their concerns for maintenance. The MD said the process for broken w/c's was to take it to the therapy department and they would determine if the w/c was able to be repaired or needed to be replaced. He said Resident #21 had reported to him for days that he needed a new w/c, and I told him to go to therapy, there was no way that chair could be fixed. On 12/11/24 at 11:55 a.m., during an interview, the Maintenance Director said, he inspected Resident #21's w/c and went to therapy to obtain a new w/c. The MD said he threw the old w/c in the garbage because there was no way to repair the w/c so he replaced it. Photographic evidence obtained.

Based on observation, interview and record review the facility failed to ensure an effective pest control program to prevent flying insects and roaches within the facility. The findings Included: Resident #104 is a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #104's quarterly MDS dated [DATE] shows a BIMS score of 15 which shows no cognitive deficits. On 12/10/24 at 9:43 a.m. Observation's in Resident #104's room noted small insects were flying around the resident's bed in room [ROOM NUMBER]. Resident #104 said she had seen the flying insects in her room for at least two weeks. Resident #104 said she has roaches coming in her room from around the air conditioner. Resident #78 is a [AGE] year-old male who was admitted to the facility on [DATE]. The Annual Minimum Data Set (MDS) dated [DATE] shows Resident #78 had a Brief Mental Interview Status (BIMS) score of 13 which shows his cognition to be intact. On 12/10/24 at 11:35 a.m., during an interview, Resident #78 said he sees roaches in his room at times. Small flying insects were observed flying around the resident's bed in room [ROOM NUMBER]. Resident said he had seen the flying insects around his trash can in his room near his bed for the last year. On 12/11/24 at 11:05 a.m., during an interview, the Director of Maintenance said it was an ongoing battle to keep pests out of the building. He said the sleeves around the air conditioner units in the rooms have been stripped out and it leaves openings in the rooms for insects to get in the building. On 12/12/24 at 11:00 a.m., the Director of Maintenance only could provide documentation of the pest control company's report of treatment for November of 2024. Documentation had been requested for the last three months. There was no documentation on the November report to show the pest control company was treating flying insects in resident's rooms. On 12/12/24 at 1:00 p.m., the pest control logbook at the nurse's station on the 600 hallway showed the last time the pest control company was at the facility was on 12/9/24. rooms [ROOM NUMBERS] were not listed in the logbook to be treated for pests.

Based on observations, review of facility policies and procedures and staff interviews, the facility failed to ensure medications were stored in a safe and secure manner within the facility, including medication carts and resident rooms. The findings included: The facility policy N-853 Medication- Oral Administration of, documented Prepare medication for one resident at a time . Do not use the resident room or bed number as a resident identifier as these may change. Document the administration and acceptance or decline of all medications administered. 1. On 12/9/24 at 9:05 a.m., during an observation of the North medication Cart #2 with Licensed Practical Nurse Staff H, in the top drawer of the cart were three clear, plastic medication cups with unidentified pills. One medication cup had crushed medications in apple sauce. Two other medication cups were stacked on top of each other. The LPN removed the top pill cup with 6 unidentified pills. The bottom pill cup had 7 unidentified pills. The medication cups had room numbers on each cup of medications. The LPN said the residents were not in their rooms so I put the medications in the drawer so I could administer them later. Photographic evidence obtained. 2. On 12/9/24 at 10:36 a.m., Resident #59 was observed with a medication cup containing 1 whole white pill and a half of a white pill in a medication cup on his bedside table. There was an unidentified and unlabeled inhaler with the unidentified pills. Photographic evidence obtained. On 12/10/24 at 11:10 a.m., Resident #59 was noted to have his top nightstand drawer open and 3 medications were observed stored in the drawer: one Symbicort inhaler160/4.5. Fluticasone Propionate nasal spray, 50 micrograms per spray. A bottle of Besivance antibiotic eye drops. Photographic evidence obtained. Review of the clinical record revealed Resident #59 did not have an order to self administer the medications.

Based on observation, interview, an record review, the facility failed to post nursing staff two consecutive days and failed to post accurate numbers of nursing staff on two additional days. The findings Included: On 12/9/24 at 9:10 a.m., the federal posting was observed in the lobby of the facility. The last posted date noted was 12/6/24. Review of the federal postings for 11/16/24, and 11/17/24 showed on both dates there were 13 Certified Nursing Assistants (CNA) listed as working on the morning, and the evening shifts. Review of the two-week staffing hours provided by the facility showed on 11/16/24 there were 12 CNA's working on both the morning and evening shift. On 11/17/24 there were 12 CNA's working on the morning shift, and 11 working on the evening shift. On 12/11/24 at 9:50 a.m., during an interview, the Staffing Coordinator said it was the responsibility of the weekend supervisor to update the federal postings on the weekends because she did not work on the weekends.

Based on observation, interview, and record review the facility failed to ensure one (Resident #104) urinary catheter was secured to allow a free flow of urine to the catheter bag and prevent movement and pulling of the catheter line. Consistent pressure and pulling on the catheter line has a potential to cause irritation to the urethra and contribute to increased urinary tract infections. The findings included: According to the Center for Disease Control 2009 Catheter-Associated Urinary Tract Infections (CAUTI) Prevention Guideline it is strongly recommended to properly secure urinary catheters after insertion to prevent movement and urethral traction [pressure, or pulling]. Resident #104 is a [AGE] year-old female admitted to the facility on [DATE] with a history of Spinal Cord Compression, Intervertebral Disc Degeneration, Neuromuscular Dysfunction of the Bladder, Major Depressive Disorder, Anxiety Disorder Severe Protein Malnutrition, and Constipation. The Quarterly Minimum Data Set, dated dated dated [DATE], Section C shows a Brief Mental Interview Status (BIMS) of 15 which shows no cognitive deficits. Section H shows Resident #104 has an indwelling urinary catheter. Resident #104 is care planned for an indwelling urinary catheter related to a Neurogenic Bladder. The goal is for the resident to be free from catheter related trauma through the review date of 1/11/25. The intervention listed did not include to secure the catheter to prevent movement and pulling. The Kardex (communication tool used to communicate to aide's resident's daily needs) did not list catheter care or securing the catheter to the resident's leg. On 12/10/24 at 9:46 a.m., Resident #104's catheter line was observed to be unsecured to the resident. Resident #104 said she has not had a catheter strap attached to her to secure the catheter all week. On 12/12/24 at 10:40 a.m., the urinary catheter was observed not secured to the resident's leg. Resident #104 verified staff had not attempted to place catheter strap to secure the catheter line. On 12/12/24 at 10:55 a.m., during an interview, Registered Nurse, Staff E said catheter straps were available to secure catheter lines of resident's with urinary catheters. RN Staff E said she was not aware Resident #104 did not have a catheter strap in place. On 12/12/24 at 11:00 a.m., during an interview the Central Supply Aide verified catheter straps were available for residents with catheters.

Based on observation, review of clinical records and resident and staff interviews, the facility failed to assist in making an appointment with a practitioner specializing in the treatment of vision impairments and failed to ensure the resident's glasses were in good repair for 1(Resident #95) of 1 resident reviewed for vision loss. The findings included: Review of the clinical record revealed resident #95 had diagnoses including morbid obesity, type 2 diabetes and acute vision changes. On 12/10/24 at 10:24 a.m., Resident #95 was observed with broken glasses that were taped together on both sides of the arms to the frame. Resident #95 said he has requested to see the eye doctor multiple times, but is told he needs to wait because his insurance does not cover it. Resident #95 said I can only tape them so much before they break completely. I don't see why it is so hard to get an appointment. I was sent to the hospital on 11/27/24 because the pain in my left eye was so bad, and they sent me back here. I can't see well out of my left eye, and I don't see well out of the right eye, just shadows. Review of the physician orders revealed a standing order for Optometry/ophthalmology as needed. The clinical record showed on 11/27/24 Resident #95 was sent to the local emergency department for evaluation of the left eye visual disturbance. The discharge summary dated 11/30/24 documented the resident would require additional ophthalmologic workups. High suspect of patient's visual changes would either be related to hypertensive retinopathy or diabetic retinopathy. Pt appears to have poor insight in regards to his overall health and social situation. Pt has the belief that all of his medical symptoms should be completely resolved and or treated by the time he leaves the hospital. Pt notes good improvement of the vision along his left eye and along with improved visual acuity of the right eye. Recommend ophthalmology evaluation when possible given weekend holiday, it is possible that care may be faster on a outpatient basis. The discharge summary instructed to follow up with ophthalmology to schedule appointment. Review of the clinical record showed no documentation the resident had been seen by the ophthalmologist and no documentation the follow up appointment had been arranged. On 12/11/24 at 8:45 a.m., during an interview the Social Service Director (SSD) said it was difficult to find a physician to accept Resident #95's medical insurance. The SSD said the facility did have an eye doctor who will see residents at the facility, and he was responsible for scheduling the in house appointments with the eye doctor. The SSD said he knew the residents' eyeglasses were broken and new ones were coming in the mail. The eye doctor sends the eyeglasses by mail and will e-mail me a copy of the visit with the resident. The SSD said he would contact the eye doctor to see when Resident #95's glasses would arrive. Review of the SSD progress note with a date of 12/11/24 at 9:11 a.m., documented SS emailed the eye doctor to follow up on glasses of when going to be delivered. On 12/11/24 at 11:21 a.m., during an interview the SSD said he was not able to locate any information regarding new glasses for the resident. I emailed the eye doctor and I'm waiting to hear back. The nurses are helping to make appointments, but he does not have the follow up appointment scheduled right now. He was sent to the hospital recently and they said his eyes were fine there was nothing wrong with his eyes. The SSD said the Director of Nursing (DON) would schedule the follow up appointment with the ophthalmologist. On 12/11/24 at 11:35 a.m., during an interview an interview the DON said the resident reported a problem with his vision and he wanted to go to the eye specialist. When we contacted the eye doctor the resident no longer had insurance and could not be seen. The resident had recently changed his insurance to a different company, and it did not include a vision program. I spoke to the resident and I let him know what was going on with the appointment and the resident said he did have a vision plan with the new insurance and he would look for the card. I told him I would schedule the appointment if he could find his insurance card. He said he wanted to go to theER on [DATE], he said he could not locate the insurance cards. I told him the facility would pay for the appointment and at that time he said he did not want to wait, and he wanted to go to the emergency room (ER). I tried to educate him that the ER was for emergencies, and he might not get the care he is seeking (an eye specialist) but he insisted to go so we had to send him. Since he returned, we are trying to schedule an appointment for him and I believe the nurse is working on it. As for the glasses, I was not aware they were taped on both sides. The SSD is the one who handles routine eye visits and appointments for eyeglasses.

Based on interview and record review, the facility failed to ensure a Pre-Admission Screening and Record Review (PASARR) Level I and Level II were conducted prior to admission to the facility for 1 resident diagnosed with serious mental illness (#79) of 2 residents reviewed for PASARR. The findings included: Review of Resident #79's medical record revealed original admission to the facility on [DATE]. The physician's orders dated 9/2/22 included psychiatry and psychology (consultations) as needed. The psychiatric diagnoses present on admission included: major depressive disorder, recurrent, mild on 9/1/22; psychophysiologic insomnia on 9/1/22. On 1/11/23, the physician ordered that the resident be sent to the emergency room related to altered mental status (AMS) including hallucinations, delusional and combative behaviors. On 1/11/23 the facility added the diagnosis of psychotic disorder with delusions due to known physiological condition. On 1/14/23 the facility added the diagnosis of major depressive disorder, single episode, severe with psychotic features. On 2/27/23 the facility added the diagnosis of anxiety disorder, unspecified. Review of the psychiatric consult note from [area hospital] dated 1/12/23 revealed the resident was hospitalized for behavioral disturbances at the nursing facility. The patient was noted to become emotionally unstable in the emergency room and started yelling with obvious auditory hallucinations. Review of the facility comprehensive assessment dated [DATE] Section A revealed Resident #79 had entered the facility from a general hospital and was not evaluated for PASARR Level II for indications of serious mental illness. Review of Section I of the assessment revealed Resident #79 had diagnoses of anxiety, depression, and psychosis. Review of the physician's orders revealed active orders for the antipsychotic medications Haloperidol 1 milligrams (mg) every 6 hours as needed for agitation, nausea/vomiting, hiccups; Seroquel 50mg every 12 hours as needed for psychosis/paranoia related to psychotic disorder with delusions due to known physiological condition; and Seroquel XR 50mg in the evening. Review of the psychiatrist consultation dated 11/22/24, revealed Resident #79 was seen for a gradual dose reduction (GDR) of psychiatric medications, which is recommended for the age group. The psychiatrist concluded the GDR was not recommended and the resident would become unstable if medications were reduced. Resident #79's diagnoses for consultation included: Psychotic disorder with delusions due to known physiological condition. On 12/10/24 at 9:20 a.m., a review of Resident #79's medical record at the facility including paper chart and electronic health record revealed there was no PASARR Level I screening or PASARR Level II screening for Resident #79. 12/12/24 at 3:25 p.m., during an interview, the Social Services Director (SSD) said he could not locate a PASARR Level I screening in the medical record. He said he thinks the resident has some mental illness. He said before the resident was admitted to the facility, the resident was not receiving any special services for mental illness. The SSD said there is no PASARR Level I in the chart. He said there is no PASARR Level II in the chart. He said he is not qualified to perform the pre-admission screening. He said he looked in the medical record department for any indication a Level I was completed, and he said he did not find one. On 12/12/24 5:33 p.m., during an interview, the Administrator said a PASARR Level I should be in the chart. He said it is the responsibility of the nursing team to make sure the PASARRs are in the chart when the resident is admitted .

Based on record review, staff and resident interviews, review of facility policies, the facility failed to ensure medications were administered as scheduled for 1(Resident #999) of 3 residents reviewed for medication administration. The failure to administer medications accurately places the residents at risk for adverse health consequences, sub-optimal therapy, or pharmacological effects. The findings included: The facility policy Administering Medications (revised 4/19) documented, Medications are administered in a safe and timely manner, and as prescribed . Medications are administered in accordance with prescriber orders, including any required time frames. If a drug is withheld, refused or given at a time other than the scheduled time, the individual administering the medication shall initial and circle the Medication Administration record (MAR) space provided for that drug and dose. Review of the clinical record revealed Resident #999 had an admitted [DATE] with diagnoses including Parkinson's disease and history of falling. The Quarterly Minimum Data Set (standardized assessment tool that measures health status in nursing home residents) with an assessment reference date of 8/26/23 documented Resident #999's cognitive skills for daily decision making were intact. On 9/18/23 at 9:37 a.m., Resident #999 said there are days he does not receive his scheduled Parkinson's medication. The resident said he needs the medication and without it he gets stiff and rigid and has difficulty moving. The record showed a physician order dated 5/16/23 documented Rytary (Carbidopa-Levodopa) oral capsule extended release 23.75-95 milligrams (mg), give 3 capsules by mouth four times a day for Parkinson's. Give before meals. The medication was scheduled for administration at 6:30 a.m., 11:30 a.m., 4:30 p.m., and 10:30 p.m. Review of the Medication Administration Record (MAR) for the month of August 2023, showed no documentation Resident #999 received the scheduled dose of Rytary extended release on 8/13/23, 8/16/23, and 8/23/23 at 6:30 a.m., and on 8/29/23 at 4:30 p.m. The MAR did not document why the medication was omitted. Review of the MAR for the month of September 2023 showed no documentation Resident #999 received the scheduled dose of Rytary extended release on 9/6/23 and 9/7/23 at 6:30 a.m. There was no documentation the medication was administered on 9/17/23 at 4:30 p.m., and 10:30 p.m. The resident's record showed no documentation of why the medication was not administered and no documentation the physician was notified of the missed doses. On 9/18/23 at 1:30 p.m., the Director of Nursing confirmed Resident #999 did not consistently receive the Rytary extended release as ordered by the physician.

Based on observation, record review, and interview, the facility failed to store food in accordance with professional standards for food service safety. The facility also failed to ensure regular cleaning of ice machines to prevent buildup of dust and bio growth. This had the potential to affect all 113 residents who reside in the facility and consume an oral diet. The finding included: The facility policy titled Food Storage stated all time/temperature control for safety (TCS) foods, frozen and refrigerated, will be appropriately stored in accordance with guidelines of the FDA Food Code. All foods will be labeled, dated, and arranged in a manner to prevent cross-contamination. The facility policy titled Snacks revised 9/2017, stated all snacks will be properly stored for time and temperature control, as appropriate. The Food and Drug Administration guide, effective March 2017, stated, Never thaw food at room temperature, such as on the countertop. On 3/20/23 at 9:17 a.m., during the initial kitchen tour, a bag of fish was observed open defrosting on the prep table at room temperature. Dietary Staff person D confirmed food is not to be defrosted at room temperature. Photographic evidence obtained A half-full pitcher of red juice was observed in the walk-in refrigerator. The pitcher was not labeled or dated. Dietary Staff D said the pitcher contained tomato juice and should have been dated. On 3/22/23 at 3:34 p.m., water was observed dripping over large amount of black and grey bio-growth covering the sides and back of the ice maker in the main kitchen. The maintenance director confirmed the observation and said the ice machines are cleaned monthly. He said the ice machine was last cleaned on 3/4/23. Photographic evidence obtained On 3/22/23 at 3:38 p.m., A snack tray containing pudding and peanut butter and jelly sandwiches was observed sitting on the counter of the north hall pantry. The maintenance director commented the room air temperature was about 80 degrees. Photographic evidence obtained On 3/22/23 at 4:10 p.m., The regional food service director said the snack tray with the pudding was delivered to the north nursing station just before 2:00 p.m. He said the pudding needed to be refrigerated. Nursing should have served the pudding to the residents or put the pudding in the refrigerator. On 3/22/23 at 3:39 p.m., the north hall ice maker was observed with the maintenance director. The Ice in the bin was discolored, and a black object was noted in the ice. The Maintenance director said he did not know what the object was. The internal wires were covered with dust; the internal components had a large amount of corrosion and debris. Photographic evidence obtained On 3/23/23 at 3:58 p.m., The Director of Nursing stated, We pass snacks at 10:00 a.m. and 2:00 p.m. The minimal expectation is for the certified nursing assistant to take the snacks and pass them out immediately. The snacks should not sit in the pantry for one to two hours.

Based on observation, review of facility policy, and procedures, resident and staff interviews, the facility failed to ensure menus were developed and prepared to meet resident choices, and nutritional needs. The facility failed to identify and document resident preferences and respond to them. The findings included: Facility policy JCSG Policy 005, revised 9/2017, titled Dining and Food Preferences, was obtained. The policy stated individual dining, food, and beverage preferences are identified for all residents/patients. The Dining Services Director or designee will interview the resident or representative to complete a food preference interview. The purpose of identifying individual preferences is for dining location, meal times, including meal times outside of the routine schedule, and food and beverage preferences. The food preference interview will be entered into the medical record. The Registered Dietitian or other clinically qualified nutrition professional will review and, after consultation with the resident, will enter information pertinent to the individual meal plan into the plan of care. The individual tray ticket will identify all food items appropriate for the resident based on diet order, allergies, intolerances, and preferences. On 3/21/23 at 11:26 a.m., during a group interview, Residents #39, #54, #6, #23, #18, #40, #14, #60, #57, and #1 said the dietary staff would leave a tray of snacks at each nursing station prior to closing the kitchen each day to be given to the diabetic residents at night. The residents said when they asked the night shift staff the facility only provided snacks for diabetic residents at night. They said there was no snack available at night for non-diabetics. The night shift staff told them they could only have left over snacks from the diabetic snacks. Review of the food committee meeting minutes from September 2022 through February 2023 showed residents repeatedly reported concerns about food quality, temperature, and lack of choices. Comments included, Residents hoped to see more choices of protein, more variety, and sandwiches at night, We are tired of pork and turkey, the sausage needed to be cooked more, we want yogurt added to the menu, the toast is served hard, the food is served cold, and the chicken is dry, we want bananas. During the February meeting, the residents again complained of cold food and the trays sitting in the hallway waiting to be passed for a long time. The resident council meeting on 2/1/23 noted a food committee meeting was scheduled for residents, who stated they have numerous concerns. The resident council meeting on 3/1/23 noted a dietary staff stopped briefly for an introduction and informed the council that he was addressing food and dietary concerns. On 3/21/23 at 1:15 p.m., the Registered Dietitian (RD) stated she reviewed and approved the facility menus on 1/31/23. She stated the menus are prepared by corporate, and she would prefer to see more protein and fresh items. She stated 100% pure fruit juice is offered at each meal and is counted as the fruit option. She confirmed no low-sugar or sugar-free juices or snacks for the diabetic residents were available. On 3/22/23 at 12:00 p.m., the delivery of lunch trays pass on the 100 hall was observed with the Dietary Manager. Lemonade was served to all residents. The dietary manager stated the beverage preferences were listed on the meal ticket. Review of random meal tickets with the manager confirmed no beverage preferences were listed, and no residents on the 100 hall were offered a choice of beverage. On 3/22/23 at 2:10 p.m., a follow-up interview was conducted with the dietary manager and the regional district food manager. The dietary manager stated she had been in this position for a week. She reviewed the dietary committee minutes yesterday. The menu comes from corporate, and she does not have any control over that. Yogurt is available if residents ask for it. She said she did not have documentation of meetings with residents or their preferences. She said they generally don't get fruit. Residents can pick an alternative before the meal cut off time. The regional manager confirmed salad was not available as an alternate. Alternates were only available for lunch and dinner, not breakfast. He agreed the juices as currently served are not 100% pure juice and are not an equal substitution for a fruit serving. On 3/23/23 at 10:10 a.m., Certified Nursing Assistant (CNA) Staff K, she said the kitchen staff delivered a snack tray to each nursing station before closing the kitchen for the night. The snack trays contained snacks for diabetic residents and a few extra snacks on the tray. She said there were never enough snacks to give to all the residents who requested a snack before the dietary staff left. On 3/23/23 at 11:07 a.m., the RD stated one fruit serving would be the equivalent of eight ounces of 100% juice, and there were 30 diabetic residents in the building. The regional food service director present during the interview stated juice is offered at all three meals. He confirmed if residents requested juice, they were served juice in a 6-ounce cup that was half full, providing 3 ounces of juice, which is less than half of a fruit serving. Residents were unaware they needed to request juice or that it was available. The RD confirmed all residents were getting the same juice with sugar without regard to diet orders. The RD stated that diabetic residents should only have sugar-free juices, which she had not seen here. The juice was approved as a fruit serving. Residents should be offered choices of beverage. The RD confirmed only lemonade (not sugar-free) was available on the beverage cart on the north hall. The RD stated there were not enough beverages on the cart to serve all the residents. On 3/23/23 at 10:18 a.m., Resident #1 stated, no one has met with me regarding food choices or preferences. I would really like it if someone did. I like fruit and salad. We hardly ever get fruit. They only have vinegar and oil dressing. The old dining manager would make sure we had French dressing. I liked that a lot. On 3/23/23 at 10:28 a.m., Licensed Practical Nurse (LPN), Staff A, stated many residents have said there is not enough food, and they don't like the food. All she can do is pass it on to the dietary manager. On 3/23/23 at 12:12 p.m., The 500-hall meal delivery was observed. Each resident received lemonade and coffee. The residents were not offered a choice of beverage. On 3/23/23 at 2:14 p.m., the administrator stated he was aware of the resident food concerns and was trying to address them. On 3/23/23 at 3:58 p.m., the Director of Nursing (DON) stated the facility should be offering sugar-free pudding and a good protein snack at night. Sugar-free snacks should be available to those that have diabetes. Diabetic residents should not drink juice, period. We give snacks at 10:00 a.m. and 2:00 p.m., and a bedtime snack is provided. Snacks should be offered to everyone. The minimum expectation is for the CNA to take the snacks and pass them out immediately when they arrive on the unit.

Based on observations, interviews, and record review the facility failed to implement an individualized in room activity program to support the physical, mental, and psychosocial well-being of 1 (Resident #45) of 21 residents dependent on staff to meet their needs. The findings included: Clinical record review revealed Resident #45's most recent admission to the facility was 1/19/21 with a history of Traumatic Brain injury, Hypertension, and severe Dementia. The resident was aphasic (unable to speak) and dependent on staff for mobility, toileting, and personal care. Resident #45 has contractures (deformity and rigidity) of all extremities. Resident #45's activity care plan dated 5/21/19 noted the resident was dependent on staff in meeting emotional, intellectual, and social needs related to daily leisure as evidenced by cognitive deficits. The care plan noted the resident needed bedside/in-room visits and activities if unable to attend out of room events. On 3/20/23 at 11:11 a.m., and 3:40 p.m., 3/21/23 at 9:35 a.m., and 4:10 p.m., Resident #45 was observed in bed. The resident was aphasic and not responsive to verbal stimuli. The television was not on and there was no radio in the resident's room. On 3/22/23 at 9:30 a.m. the Activities Director verified Resident #45 did not get out of bed very often. She said the resident's wife visits several times a week. The Activities Director verified Resident #45 was care planed for in room visits and they should be documented in an electronic progress notes. After reviewing the electronic clinical record with the Activities Director, she verified the last documented one-to-one activity for Resident #45 was dated 10/21/22. On 3/22/23 at 10:33 a.m., Resident #45's wife said she has not seen any staff members providing one-to-one activities with her husband. She said her husband was a minister and he loved gospel music. On 3/22/23 at 11:15 a.m., the Regional Nurse Consultant provided a list of 21 residents which she said were dependent on staff for one-to-one activities. She said she could not locate documentation of one-to-one visits for the 21 residents listed.

Based on observation, review of the facility's abuse and neglect policy and procedure, record review, and staff interview, the facility failed to protect one (Resident #19) of one sampled vulnerable resident with dementia from neglect by failing to provide supervision, to ensure the necessary care and services were provided. The findings included: The facility policy N-1265, Abuse, Neglect, Exploitation and Misappropriation (revised 11/28/17) specified, It is inherent in the nature and dignity of each resident at the center that he/she be afforded basic human rights, including the right to be free from abuse, neglect, mistreatment and exploitation .neglect is the failure of the center, it's employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. A review of the clinical record for Resident #19 documented a care plan indicating Resident #19 had an Activities of Daily Living (ADL) self-care performance deficit due to confusion and dementia. The care plan interventions noted Resident #19 required extensive assistance of 1 for bathing, dressing, and toileting. The care plan also documented Resident #19 had alteration in communication related to severe dementia, confusion/delusions and his needs must be anticipated by staff. On 8/10/21 at 9:41 a.m., Resident #19 was observed in his room standing next to his bed eating breakfast with his fingers. The linen on the bed was soaked with urine and the room had a pungent odor of urine. Resident #19 had a hospital gown tied around his neck and hanging down his chest. The incontinent brief was overly saturated with urine and feces and was pulling down to the resident's knees. Resident #19's fingernails extended approximately ½ inch from the base with dark brown substance underneath. He had facial hair growth of approximately three days. He was not able to answer questions. On 8/10/21 at 12:35 p.m., in a second observation Resident #19 was observed lying face down across the head of the bed with his toes touching the floor. The resident was not dressed, he was shivering, and the incontinent brief remained oversaturated with urine and feces. The overbed table had capsized into the bed and Resident #19 was holding onto it with the left hand. The meal tray was in the bed with the dishware, utensils and breakfast food items scattered in the bed. The bed linen was soaking wet and soiled. The room remained with a strong smell of urine. The surveyor turned on the call light and called for assistance from the doorway. No staff was observed in the 4 hallways to assist Resident #19. On 8/10/21 at 12:50 p.m., staff had not responded to the call light and surveyor's calls for assistance for the resident. Resident #19's room was directly across from the nurses' station. Licensed Practical Nurse (LPN) Staff R was observed at the nurses' station. Resident #19's call light remained on and was clearly visible and audible at the nurse's station. LPN Staff R did not respond to the call light or the surveyor's request for immediate assistance for Resident #19. Upon request for assistance, LPN Staff R said she would find a Certified Nursing Assistant (CNA) to help but they were currently busy delivering lunch meal trays to the residents and walked away. LPN Staff R did not go in the room to evaluate Resident #19 and did not send a CNA for help despite the request for assistance. On 8/10/21 at 12:55 p.m., the North Wing Unit Manager LPN Staff I donned personal protective equipment (PPE) and entered Resident #19's room. Staff I left the room and called out for help. Resident #19 remained face down across the head of the bed and shivering. On 8/10/21 at 12:58 p.m. Staff I activated the emergency call signal and stayed with Resident #19. On 8/10/21 at 1:00 p.m., LPN Staff I instructed LPN Staff R to assist her. They pulled up the resident from the bed and placed him in a wheelchair. A large area of red discoloration was observed across the resident's chest. Resident #19 was still shaking, complained he was cold, and said his chest was hurting. On 8/10/21 at 1:05 p.m., CNA Staff K removed the wet linen. The mattress remained visibly wet. CNA Staff K placed clean linen on the wet mattress and assisted Resident #19 back to bed. On 8/10/21 at 1:15 p.m., in an interview CNA Staff K said she usually worked as an activity's assistant and was assigned to screen visitors that day at the rear entrance of the facility. She said on 8/10/21 at 10:00 a.m., she was pulled to work as a CNA on the South Unit but did not realize Resident #19 was assigned to her. CNA Staff K said she looked at the board, missed Resident #19's room and did not provide care to the resident until she was called to the room at 1:05 p.m. CNA Staff K said the night shift CNA had already left and she did not get report on her assigned residents. On 8/10/21 at 1:30 p.m., in an interview, LPN Staff R said she administered medications to Resident #19 at approximately 9:30 a.m. and did not check on him again. LPN Staff R said she was from an agency, did not know Resident #19 and walked away from the interview. On 8/11/21 at 10:00 a.m., a review of the physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . It involved his bedside table; he may have fallen on the floor on his right side. When I saw him, he was on the bed on his right side. Nurse is concerned of Patient's positioning and cough. Patient denies pain. Pt [patient] does have dementia. The Physician ordered a chest x-ray and to continue to monitor the resident. On 8/11/21 at 3:43 p.m., in an interview, the Director of Nursing reviewed the clinical record and confirmed there was no documentation Resident #19 received CNA care on 8/9/21 after 11:59 p.m., through 8/10/21 until 1:05 p.m. She verified the lack of oversight on the unit with agency nurse assigned to the resident.

Based on observation, record review, staff and resident interviews, the facility failed to provide the necessary care and services to maintain grooming and personal hygiene for 3 (Resident #19, #42 and #63) of 17 sampled residents. The findings included: 1. A review of the clinical record for Resident #19 documented a care plan indicating Resident #19 had an Activities of Daily Living (ADL) self-care performance deficit due to confusion and dementia. The care plan interventions noted Resident #19 required extensive assistance of 1 for bathing, dressing, and toileting. The care plan also documented Resident #19 had alteration in communication related to severe dementia, confusion/delusions and his needs must be anticipated by staff. On 8/10/21 at 9:41 a.m., Resident #19 was observed in his room standing next to his bed eating breakfast with his fingers. The linen on the bed was soaked with urine and the room had a pungent odor of urine. Resident #19 had a hospital gown tied around his neck and hanging down his chest. The incontinent brief was overly saturated with urine and feces and was pulling down to the resident's knees. Resident #19's fingernails extended approximately ½ inch from the base with dark brown substance underneath. He had facial hair growth of approximately three days. He was not able to answer questions. On 8/10/21 at 12:35 p.m., in a second observation Resident #19 was observed lying face down across the head of the bed with his toes touching the floor. The resident was not dressed, he was shivering, and the incontinent brief remained oversaturated with urine and feces. The overbed table had capsized into the bed and Resident #19 was holding onto it with the left hand. The meal tray was in the bed with the dishware, utensils and breakfast food items scattered in the bed. The bed linen was soaking wet and soiled. The room remained with a strong smell of urine. The surveyor turned on the call light and called for assistance from the doorway. No staff was observed in the 4 hallways to assist Resident #19. On 8/10/21 at 12:50 p.m., staff had not responded to the call light and surveyor's calls for assistance for the resident. Resident #19's room was directly across from the nurses' station. Licensed Practical Nurse (LPN) Staff R was observed at the nurses' station. Resident #19's call light remained on and was clearly visible and audible at the nurse's station. LPN Staff R did not respond to the call light or the surveyor's request for immediate assistance for Resident #19. LPN Staff R said she would find a Certified Nursing Assistant (CNA) to help but they were currently busy delivering lunch meal trays to the residents and walked away. LPN Staff R did not go in the room to evaluate Resident #19 and did not send a CNA for help despite repeated requests for assistance. On 8/10/21 at 12:55 p.m., the North Wing Unit Manager LPN Staff I donned personal protective equipment (PPE) and entered Resident #19's room. Staff I left the room and called out for help. Resident #19 remained face down across the head of the bed and shivering. On 8/10/21 at 12:58 p.m. Staff I activated the emergency call signal and stayed with Resident #19. On 8/10/21 at 1:00 p.m., LPN Staff I instructed LPN Staff R to assist her. They pulled up the resident from the bed and placed him in a wheelchair. A large area of red discoloration was observed across the resident's chest. Resident #19 was still shaking, complained he was cold, and said his chest was hurting. On 8/10/21 at 1:05 p.m., CNA Staff K removed the wet linen. The mattress remained visibly wet. CNA Staff K placed clean linen on the wet mattress and assisted Resident #19 back to bed. On 8/10/21 at 1:15 p.m., in an interview CNA Staff K said she usually worked as an activity's assistant and was assigned to screen visitors that day at the rear entrance of the facility. She said on 8/10/21 at 10:00 a.m., she was pulled to work as a CNA on the South Unit but did not realize Resident #19 was assigned to her. CNA Staff K said she looked at the board, missed Resident #19's room and did not provide care to the resident until she was called to the room at 1:05 p.m. CNA Staff K said the night shift CNA had already left and she did not get report on her assigned residents. On 8/10/21 at 1:30 p.m., in an interview, LPN Staff R said she administered medications to Resident #19 at approximately 9:30 a.m. and did not check on him again. LPN Staff R said she was from an agency, did not know Resident #19 and walked away from the interview. On 8/11/21 at 10:00 a.m., a review of the physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . It involved his bedside table; he may have fallen on the floor on his right side. When I saw him, he was on the bed on his right side. Nurse is concerned of Patient's positioning and cough. Patient denies pain. Pt [patient] does have dementia. The Physician ordered a chest x-ray and to continue to monitor the resident. On 8/11/21 at 3:43 p.m., in an interview, the Director of Nursing reviewed the clinical record and confirmed there was no documentation Resident #19 received CNA care on 8/9/21 after 11:59 p.m., through 8/10/21 until 1:05 p.m. She verified the lack of oversight on the unit with agency nurse assigned to the resident. 2. A review of the clinical record for Resident #42 documented diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The clinical record showed a care plan that specified the resident required extensive assistance with his activities of daily living (ADL) care. On 8/9/21 at 12:02 p.m., Resident #42 was observed in bed with two urinals hanging above his head from the trapeze bar (used to help a person reposition in bed). One urinal was approximately halfway filled with urine. Resident #42 said no one would come to empty them when he put the call light on. Resident #42 said he would wait over 30 minutes to an hour for assistance and was concerned the urinal would fall and urine would spill on his head. Resident #42 said he always placed the urinals on the trapeze bar so he could reach them. On 8/10/21 at 10:34 a.m., in an interview Resident #42 said his roommate had a different Certified Nursing Assistant (CNA) assigned to his care. Resident #42 said when his roommate's CNA was in the room helping his roommate, he asked to empty the urinal, but the CNA refused. Resident #42 said the roommate's CNAs told him they were not assigned to his care and instructed him to put his call light on. The resident said he put call light on, and no one would come. Resident #42 said his main concern was, the staff did not help him when they were in the room to assist his roommate. On 8/10/21 at 10:40 a.m., in an interview, CNA Staff L said, what he is saying is true, I've seen it with my own eyes. If (Resident # 42) asked the roommate's CNA for assistance with something, they tell him, I don't have you and walk out. Staff L said she had worked at the facility a long time and that was what the other CNAs did. Staff L said when she was assigned the split assignment, and Resident #42 needed something she would do it for him. Staff L said many of the agency CNAs just walked right out of the room, they didn't want to mess with him if they were not assigned to him. On 8/11/21 at 9:59 a.m., in an interview the South Unit Manager LPN Staff T said she split the room to even out the CNA assignments. Staff T said she was not aware of a problem with the split room assignment. Staff T said Resident #42 would make up stories and it was in his care plan that he had that behavior. 3. On 8/10/21 at 11:39 a.m., in an interview, Resident #63 said she wished she could get a bed bath and have her hair washed. She said she could not remember the last time her hair was washed. She said she had even asked for a good bed bath, but they did not give her one. Resident #63 denied receiving showers since she did not get out of bed. On 8/10/21 at 11:40 a.m., observed Resident #63 laying in her bed with her head slightly elevated. Her hair was pulled up on top her head, looked stringy and unkempt. The Resident was alert, she was dressed in hospital gown and covered with a sheet. A review of Resident #63's medical record, showed the resident was scheduled for bathing or showering twice a week on Tuesday and Friday. The Certified Nursing Assistant (CNA) Kardex (area where care need is described), recorded the resident preferred bed baths and required assist of 1 staff member for the task. Review of Resident #63's documented bathing schedule recorded in the prior 28 days the resident received 2 bed baths (7/29/21 and 8/3/21) and a shower on 8/7/21 and 8/8/21. On 8/11/21 at 10:50 a.m., in interview, the LPN South Unit Manager Staff T said she reviewed the CNA documentation for the prior 28 days and verified the lack of documentation Resident #63 received a shower or bed bath as scheduled twice a week. LPN Staff T said the resident did not like showers so she should have received bed baths which would include washing her hair.

Based on record review, observation, and staff interviews, the facility failed to accurately assess and plan care for 2 (Resident #6, and #3) of 3 residents reviewed for pressure ulcer. The facility failed to provide interventions to prevent the development and then worsening of a pressure injury for Resident #6. The facility did not alter the plan of care to include more frequent repositioning or off-loading the area when the pressure injury developed and then worsened for Resident #3. The lack of aggressive interventions for a resident at risk, resulted in Resident #6 developing a full thickness stage III pressure ulcer, and unstageable pressure ulcer for Resident #3. The findings included: Current standard of practice for pressure ulcer assessments were outlined in the National Pressure Ulcer Advisory Panel (NPUAP) . The NPUAP defines pressure injury as localized injury to the skin and/or underlying tissue, usually over a bony prominence as a result of pressure. A stage I pressure injury is intact skin with non blanchable redness (blanchable skin becomes lighter before resuming its natural color) of a localized area usually over a bony prominence. A stage II pressure injury is partial loss of dermis, presents as shallow open ulcer with red/pink wound bed. Granulation tissue, slough, and eschar (dead tissue) are not present. A stage III is a full thickness skin loss and granulation tissue is often present. Slough and/or eschar may be present in the wound. Under assessment; use a structured risk assessment such as the Braden Scale to identify individuals at risk for pressure injury and develop a plan of care based on the areas of risk identified. Under prevention and treatment; avoid positioning the individual on body areas with pressure injury; consider more frequent repositioning and replacing the mattress for more effective pressure redistribution for an individual who fails to heal or demonstrates ulcer deterioration and/or is at high risk for additional pressure ulcers; offloading and pressure redistribution may allow re-perfusion (restore blood flow) to injured tissue. (source https://www.npuap.org/resources/educational-and-clinical-resources/npuap-pressure-injury-stages/) The facility's policy WC-100, Clinical Guideline Skin & Wound (effective 4/1/17) was to provide a system for identifying skin at risk, implementing individual interventions including evaluation and monitoring as indicated to promote skin health, healing and decrease worsening of/prevention of pressure injury. The Licensed Nurse is to complete a skin evaluation weekly and document in the medical record. Develop individualized goals and interventions and document on the care plan and the Certified Nursing Assistant (CNA) Kardex. 1. Resident #6's clinical record revealed an admission nursing note on 1/24/19 completed by Licensed Practical Nurse (LPN) Staff E noting the resident has non-blanchable mushy area on her right heel that was 3.25 centimeters (cm) by 2.0 cm. admission orders [REDACTED]. There was no documentation of the Prevalon boots being applied. On 1/25/19, the facility's wound care nurse Registered Nurse (RN) Staff G again noted the resident had mushy heels. There was no assessment of any pressure injury being present. An admission Minimum Data Set (MDS) assessment was completed on 1/31/19. The MDS indicated the resident had no unhealed pressure injury but was at risk for the development of them. The resident needed the extensive assistance of 2 staff members for bed mobility. On 2/14/19, the wound care physician documented Resident #6 had a stage III pressure wound on the right heel measuring 3.0 cm by 2.5 cm with a depth of 0.2 cm. On 2/15/19, the physician ordered an EZ Boot (for heel pressure relief) be worn in bed and chair to off-load the wound. On 3/5/19 at 11:27 a.m., Resident #6's right heel was observed with RN Staff A. A healing stage III pressure injury was noted to the resident's right heel. Resident #6 had been wearing socks and sneakers. There was no EZ Boot or Prevalon Boot observed in the resident's room. On 3/5/18 at 9:26 a.m., Resident #6 was again observed wearing socks and sneakers. Certified Nursing Assistant (CNA) Staff F was present and said there was nothing special to be applied to Resident #6's foot and got her information from the CNA Kardex. Resident #6's comprehensive care plan was reviewed. The care plan was dated 2/6/19 and under the problem of skin integrity, an update on 2/15/19 indicated the presence of a right heel wound. The intervention of an EZ Boot in bed and chair was added on 2/18/19. The CNA Kardex under skin protection, did not identify any skin issues or that the resident was to have an EZ Boot on. On 3/5/19 at 10:38 a.m., the wound care physician said Resident #6's right heel had a stage III pressure injury and when she first evaluated wound, she told them to get an EZ Boot to float the heel when up and off-load the heels when in bed. The physician said last she visited the resident last week she did not see any boot to relieve pressure on her heels and needed to wear them when she is in the chair. On 3/5/19 at 11:30 a.m., LPN Staff B confirmed there were no care plan interventions in place to relieve pressure to Resident #6's heel prior to the development of a stage III pressure ulcer. Staff B confirmed the CNA Kardex did not identify any interventions for CNA staff to use to relieve pressure to the resident's heel. 2. Resident #3's clinical record revealed an admission an MDS assessment was completed on 1/28/19. The MDS indicated the resident had unhealed pressure injury and was dependent on the assistance of 2 staff members for bed mobility. On 1/30/19, the wound care physician noted on her initial evaluation, the resident had an unstageable pressure injury to her right ear, 1.0 cm by 0.6 cm in size, and unable to determine depth due to necrosis (dead tissue). On 3/4/19 at 11:24 a.m., Resident #3 was observed lying on her right side. RN Staff A was present and positioned the resident onto her left side. A moderate amount of blood tinged drainage was noted on the pillowcase. Staff A removed the dressing to the resident's right ear and a pressure injury was noted on the inner ear lobe. The area had slough (a layer of dead tissue) present in the wound bed, was unstageable, and 1.25 cm by 1.9 cm in size. RN Staff A confirmed the resident had a regular pillow and a folded bath blanket underneath the pillow creating a firm surface. At 12:30 p.m., RN Staff A said the area on the Resident #3's right ear was acquired after admission and identified on 1/30/19 by the wound care physician. On 3/4/19 at 1:22 p.m., Resident #3 was observed lying in bed with her head turned to the right side. CNA Staff D was present and said the resident preferred her head on the right side. Staff D moved the residents head and a moderate amount of blood tinged drainage was noted on the pillowcase. CNA Staff D said she had already changed it earlier. On 3/4/19 at 3:36 p.m., Resident #3 was observed lying on her left side with her head turned to right and her ear in contact with the pillow. On 3/5/19 at 10:38 a.m., the wound care physician said when she saw Resident #3 on 1/30/19, she noted a shearing injury on the resident's right ear. The area deteriorated and was now an unstageable full thickness pressure injury. The physician said she did talk to staff about keeping the resident off her right side and to position her to offload the pressure to her ear. Resident #3's comprehensive care plan dated 1/30/19 was reviewed and under the problem of skin integrity, indicated the resident had an acquired right ear wound. There were no interventions to relieve pressure to the right ear noted on the resident's care plan. The CNA Kardex for Resident #3 did not note the resident should be positioned off her right side. On 3/5/19 at 11:30 a.m., LPN Staff B confirmed Resident #3's care plan and CNA Kardex did not have any interventions for staff to use to relieve the pressure to the area on the right ear.

Based on observation, record review, interview and review of wound policies and procedures, the facility failed to appropriately assess, care plan and implement effective treatment for 7 (Resident #78, #202, #199, #35, #197, #160 and #32) of 25 residents in order to ensure they maintained or attained their highest practicable well being. This failure contributed to the development of avoidable pressure sores to Resident #78, #202, and #35; contributed to increased excruciating pain related to a hernia the facility was unaware of and failed to monitor for Resident #197 and increased the potential for decline in physical well-being for Resident #32, #199, and #160. The findings include: 1. Clinical record review on 4/02/14 included documentation Resident #78 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Record review of physician's orders [REDACTED]." On 2/01/14, physician's orders [REDACTED].=shortness of breath." Review of the nursing readmission assessment, dated 2/06/14, documents an "open area to the right posterior upper ear related to (r/t) oxygen tubing and left ear posterior is reddened." Review of the physician's orders [REDACTED]. Apply triple antibiotic (TAO) behind both ears every (q) day." Review of the weekly skin assessments for March 2014 documents "broken skin behind bilateral ears" on 3/04/14. On 3/10/14, the weekly skin integrity review form documents a 1 centimeter (cm) x .5 cm x 1 cm depth wound to the inside portion of the upper right ear related to the oxygen tubing; there was no assessment of the resident's left ear. On the 3/11/14 skin assessment, the nurse documents skin condition as "other"; the nurse failed to assess and document what "other" meant. Review of the Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) of 3/09/14, documented Resident #78 with a Brief Interview for Mental Status (BIMS) of "12." The resident requires set up help only for personal hygiene. The resident was identified at risk of developing a pressure ulcer; there were no pressure ulcers identified on this assessment. Documentation dated 3/18/14 on the "weekly skin integrity review" form indicated Resident #78 had a partial open area behind the right ear. There was no assessment to determine whether the "broken skin" identified to the resident's left ear on the 3/04/14 skin assessment remained or whether it had resolved. On 3/18/14, a "Guidelines for Unavoidable Wounds" form was completed for Resident #78. This form documents clinical conditions that are primary risk factors for developing pressure ulcers which include, but are not limited to: "immobility, chronic bowel and/or urine incontinence, [MEDICAL CONDITION] or other perfusion disorder." The risk factors the facility listed which included "immobility and chronic bowel and/or urine incontinence" do not support how it would contribute to the resident developing a pressure sore behind the right ear. The following interventions were documented by the facility prior to the development of the open area(s) included: weekly skin assessments; padding to tubing, splints, braces and administer treatments as ordered. The facility failed to accurately assess the contributing factors which might lead to the development of pressure sores behind the resident's ear. Review of the pressure ulcer record documentation, dated 3/18/14, for the "right ear" indicates an unstageable pressure sore measuring 1 x 0.5 x 0.2 cm. The wound bed is slough, color is yellow, wound edges firm/no redness; with small amount of serosanquinous drainage and the periwound was with redness. Review of the physician's orders [REDACTED]." Review of the March 2014 treatment administration record (TAR) documents the treatment was provided to the right ear except for the 7:00 a.m. to 7:00 p.m. shift on 3/30/14. Review of the pressure ulcer record documentation, dated 3/24/14 indicates a Stage III pressure sore to the right ear measuring 1 x 0.2 x 0.1 cm with [MEDICATION NAME] pink wound bed, wound edges with redness, and a small amount of serosanquinous drainage. Documentation in the " Unavoidable Pressure Sore physician progress notes [REDACTED]. The results of my findings are: " was left blank. The physician ' s progress note, dated 3/26/14, did not document the results of his findings. The area was blank. The "weekly skin integrity review", dated 4/01/14, documents an open area to the resident's right ear. The "pressure ulcer record" dated 4/01/14, documents Resident #78 with an "unstaged" wound to the right ear measuring 0.7 x 0.2 x 0.1 cm. During an observation on 4/01/14 at 8:30 a.m., Resident #78 was in his room and in bed. Oxygen tubing was observed in his nares, the pair of openings of the nose or nasal cavity, and a gray cushion was observed covering the tubing over his right ear; there was nothing in his left ear. Resident #78 stated he was having a hard time getting the cushion to stay on his right ear and when he asked certain aides to help him, they would say they would and would not return to his room. During an observation of Resident #78, on 4/01/14 at 4:30 p.m., he was in his room, sitting in bed with his head down and eyes closed. A gray cushion was observed over the tubing over his right ear, there was no cushion over his left ear. The facility failed to consistently assess and implement preventative measures, which were cushions to oxygen tubing to relieve pressure, to prevent the development and or worsening of pressure sores to Resident #78's ears. Observation of the resident on 4/02/14 at 8:40 a.m., revealed Resident #78 in his room, seated in his wheelchair and Staff Nurse "N", a Registered Nurse (RN), was in the resident's room assisting him with his medications. The resident was observed to have a gray cushion over the tubing placed over his right ear; there was no cushion over the left ear. The RN validated there was no cushion over Resident #78's left ear. The resident stated he had a hard time keeping the cushion over the right ear and when asked if staff were helping him, he indicated some staff help him and some staff do not. Record review on 4/02/14 documented physician's orders [REDACTED]. Cleanse rt (right) ear with ns (normal saline), pat dry, apply Ca+alg (calcium alginate), activate with several drops of ns (normal saline), cover with DCD (dry clean dressing) dly (daily) and prn (as needed)." Observation during wound care on 4/02/14 at 11:10 a.m. of Staff N gathering supplies which included 2 packs of gauze, 4 tubes of normal saline, 2 bordered dressings, 2 packs of triple antibiotic ointment and a package of ear cushions. After gathering the supplies, he entered Resident #78's room. It was determined the resident was not in his room and Staff N exited the room indicating he would have to go find the resident. During an observation on 4/2/14, at 11:30 a.m., Resident #78 was in his room seated in his wheelchair. Oxygen tubing was observed in his nares and there were no cushions over the tubing that was resting on top of the resident's ears. Staff N assisted the resident out of his wheelchair to the side of the bed in order to perform wound care. On a bedside table next to the resident's bed observed the following wound care supplies: Two small packages of triple antibiotic ointment, gauze dressing, two small border dressings and 4 small plastic tubes of normal saline as well as non-sterile gloves. The supplies were resting on top of paper towels lining the left side of the bedside table. There was no calcium alginate included in the wound care supplies. An open and empty red bag was observed resting on top of a paper towel at the bottom of Resident #78's bed. After appropriately washing his hands, Staff N donned a pair of non-sterile gloves. He removed the resident's oxygen tubing away from his nares. Resident #78 stated when he came into the facility, he "did not have these areas and what happened was when he wore the tubing and would rub his head back and forth it would rub his ears." Resident #78 stated he "...let the staff know it was sore and they (tubing) were rubbing and they put some salve on it and not every day, they did not change it every day, they changed it maybe twice." Staff N washed his hands appropriately and donned a pair of gloves. He then walked back over to the resident and removed the dressing from the top portion of the back of the resident's right ear exposing a reddish pink area with a small amount of crusted yellow skin. Staff N verified the same appearance of the wound. Staff N was asked to look at the left ear. Using the same gloved hands, he removed the hearing aid and then oxygen tubing to Resident #78's left ear exposing a small open area, size of a small pea, with a reddened wound periphery and yellow wound base. The nurse removed his gloves, washed his hands, and donned another pair of gloves. He opened the bordered gauze, and then removed his gloves stating he forgot to date the gauze. Resident #78 confirmed he observed the open area to his left ear this a.m. He stated he told staff earlier in the evening yesterday, but, no one came to help him. He told staff yesterday his ear was hurting and then stated "They were busier than a one arm paper hanger and that is depending on what staff they have." He stated he believed it starting happening two days ago and believed the area opened up yesterday evening. The resident stated "when the staff do talk to you, you know it ' s because they talk back at you." Resident #78 stated "They are not joking and figured the other ear would open up, just did not know when." The resident stated the Director of Clinical Services (DCS) put a box of ear cushions in his top drawer last week and said, "Some of the nurses, not all, the ones that give you the medications, might help put the cushions on my ears." The aides say they would come back and help (him) with them but do not." When asked which shift, he stated, "The aides in the evening." He stated the nurses would put the two "sleeves" (meaning cushions) on his ears, but not always. Staff N asked him if his ears hurt and the resident answered "Yes" and pointed from the tips of his ears toward his temples. Resident #78 stated when he moves his ear (pointing to the left), it hurts. He stated "I told the nurses the "sleeves" would just fall right off. When my ears hurt, you know it." Staff N confirmed the new open area to the left ear. Staff N and Resident #78 looked inside the drawers of the resident's nightstand and could not locate ear cushions. Staff N then opened the tubes of normal saline and placed them back onto the prep area. He then walked over to the resident with one of the saline tubes and gauze, squirted the normal saline onto the gauze and cleansed the right ear. He tossed the gauze into the red bag. He cleansed the same area in the same fashion and tossed the gauze into the red bag. Then with the same gloved hands, he opened a gauze packet, removed the gauze and walked over to the resident and patted the right ear dry. He then opened a small packet of triple antibiotic ointment and pulled the tip of the resident's right ear down. While doing this, Staff N was questioned as to what he was about to apply to the wound to the resident's right ear and still holding the packet in the air, validated it was triple antibiotic ointment and placed a small amount of ointment on top of the right ear wound. He then walked back over to the bedside table, picked up the dated border dressing and placed it on top of the right ear wound. He then removed his gloves, washed his hands, donned a pair of non-sterile gloves, cleansed the wound to the left ear with normal saline and informed Resident #78 he would place a dry dressing on top (of the wound) until he got a treatment order from the physician. After placing the border gauze on the top inside area of the resident's left ear, he removed his gloves, gathered his supplies and stated he was going to call for a treatment order for the resident's left ear. Review of the March 2014 and April 2014 treatment records revealed there was no documentation to support staff were ensuring ear cushions were being provided to Resident #78 in an effort to prevent skin breakdown due to the pressure of the oxygen tubing resting against his ears. The Staff N failed to follow the physician's orders [REDACTED]. Review of the April 2014 treatment record revealed Staff N documented he applied skin prep to the left ear; this was not observed during wound care. Staff N failed to assess the newly developed pressure sore to the left ear. During an interview on 4/02/14 at 11:50 a.m., the DCS, Administrator (ADM) and Assistant Director of Clinical Services (ADCS) reported they were not aware of the pressure sore to Resident #78's left ear. The DCS stated the resident is supposed to wear ear cushions to the tops his ears and she got him a box of them and placed them in his top drawer. She stated just yesterday afternoon she checked on the resident and placed ear cushions on him as he was not wearing them; she confirmed she did not check behind the resident's ears to determine if there were any new areas of skin breakdown. The DCS stated the resident was observed to constantly pull down on his oxygen tubing and she would constantly remind him to refrain from doing so. When asked if the facility attempted any other interventions, such as a mask or different types of tubing, etc., the ADM stated he asked the doctor if Resident #78 could wear a mask which then he would have two straps around his head rather than tubes resting on top of his ears and the doctor did not seem to think that was an option. There was no indication as to why this did not seem to be an option. The ADM confirmed they did not try a mask with a different set up for oxygen. During an observation on 4/03/14 at 9:00 a.m., Resident #78 was in his room, in a wheelchair attempting to wheel himself out of his bathroom. A dressing was observed to his left ear; there was no dressing to his right ear. There was no evidence of cushions on either side of his ears. Resident #78 stated no one helped him put them on this morning when they got him dressed. At 9:30 a.m., the resident remained without pressure relieving cushions to either side of his ears and no dressing to his right ear. The resident stated he had no cushions to place on the top of his ears and stated the dressing to the right ear must have fallen off. Review of the facility's policies and procedures for assessment and documentation of wounds includes the following: "Policy: Skin assessment for all admissions and residents identified at risk or with acute pressure area. To identify potential risk factors in the development of pressure ulcers and/or appropriateness of currently prescribed interventions/appliances and documentation of wound statistics of active pressure ulcers...Accurate assessment and documentation of wounds and wound status is vitally important in management of wounds regardless of the etiology. Precise documentation provides the following: Communications...to other caregivers and members of the healthcare team, such as Physicians, therapists, nurses or anyone reading the resident's medical record needing information on the history of the wound. Information is essential for continuity of care...Procedure: Location-location of pressure ulcer (s) should be documented according to the bony prominence involved...other wounds should be documented using as detailed terminology as possible...Size-accurate measurements of a wound are essential in assessing progress in wound healing...All ADMISSIONS:-...data collected will be used to determine needed interventions/appliances, which will be submitted to the attending physician for approval...RESIDENTS WITH ACTIVE PRESSURE SORES-...every resident with active pressure sores will have a Pressure Sore Progress documented weekly to determine any changes in potential risk factors, effectiveness/appropriateness of current interventions/appliances, recommendations to the physician for changes in the plan of treatment and complete documentation of current wound statistics..." The facility failed to assess for appropriate interventions to alleviate or minimalize the risk for pressure ulcer development to Resident #78's left ear. When the broken areas were identified to the areas behind both of the resident's ears, staff failed to consistently and comprehensively assess the skin breakdown. Resident #78 complained to staff about his ears hurting him, including his concern about the left ear developing a pressure sore. The facility failed to assess for and intervene regarding the areas the resident expressed concern. The DCS acknowledged the failure of the staff to ensure Resident #78 was consistently wearing the ear cushions and failed to assess the areas behind the resident's ears for skin breakdown. The interdisciplinary team failed to assess the ongoing risks/potential for pressure ulcer development to the resident's left ear which ultimately contributed to an area they were unaware of until the surveyor's interviews were conducted. 2. During an observation and interview on 3/31/14 at 3:40 p.m., Resident #199 was in her room sitting upright in a wheelchair. She stated she was admitted to the facility after being hospitalized for [REDACTED]." She stated she had " MS " ([MEDICAL CONDITION]) and a urinary tract infection [MEDICAL CONDITION] while at the hospital. She stated they were treating her for "sores" on her bottom. During an observation on 4/01/14 at 10:30 a.m., in the presence of the Director of Clinical Services (DCS), Resident #199 was in her room and in bed. The resident was assisted to a left side-lying position. Multiple healed wounds were observed to her bilateral buttocks. The upper left buttock presented with a small reddish brown abraded area at the base of a recently healed pressure sore and was the size of a pea. The upper right buttock presented in the same fashion and a small reddish brown abraded area, size of a small pencil eraser, was observed. Remnants of barrier cream were observed covering the area and the DCS rubbed the areas identified and stated she saw nothing on the resident's buttocks. She stated she was not informed the resident had a recent history of pressure sores to the areas; only observed a Suspected Deep Tissue Injury (SDI) to the resident's right lateral heel. Observation of the right lateral heel failed to reveal any evidence of skin breakdown. Review of Resident #199's record on 4/01/14, documented an admission to the facility on [DATE]. Review of the hospital History and Physical (H and P) dated 3/18/14, documents Resident #199 with decubitus ulcers on the buttocks, recurrent urinary tract infections [MEDICAL CONDITION], an indwelling Foley catheter, [MEDICAL CONDITION], recurrent [MEDICAL CONDITION] under breast and in the groin. Review of the hospital consult dated 3/19/14, and timed 07:18 documents the resident with a "sacral decubitus" and the physician documents "...I would request the wound care team to take a look at that (sacral decubitus)." Under the "Objective" section of the consult, the physician documents "Buttocks: Sacral area, the patient does have a decubitus ulcer, I requested wound care nurse to evaluate this today. This has been chronic..." Under "Plan" the physician documents "The patient does have decubitus ulcer, and we will request the wound care team see her regarding treatment." Review of the infectious disease consultation, dated 3/19/14 at 16:57, the physician's assistant (PA-C) documents "Decubitus ulcerations, currently stable, under the care of home health nurses." She then documents "Buttocks did not reveal sacral decubitus, per nurse, the wound is stable and chronic." On 3/19/14 at 16:02 and authored by the [MEDICATION NAME][MEDICATION NAME] (ET)/skin clinician documentation indicated the "patient has a healed pink ulcer to sacral coccygeal area. Encouraged nurses to turn more frequently, use dry flo pads, zinc and if diaper necessary while in bed do not close tabs on diaper." Review of the facility's attending physician's progress notes, dated 3/20/14, includes the following documented admission [DIAGNOSES REDACTED]." Resident #199's physician diagnosed her with a decubitus ulcer to her buttocks on admission to the facility. Review of the facility's "nursing " admission data collection form documents Resident #199 with an "excoriated red area" to the resident's sacral-coccygeal area. On the back of this admission assessment, the nurse documents the resident's coccyx area as intact with redness noted. This assessment conflicts with the physician's assessment, dated 3/20/14, same admitted , for "buttocks decub ulcer" . There was no accurate assessment with regard to determining the size, stage or appearance of the decubitus ulcers as identified by the admitting physician. There was no treatment ordered for the "buttocks decub ulcer" as identified by the attending physician or the conflicting assessment of "redness/excoriation" by the nurse. Review of the weekly skin integrity review sheet, dated 3/21/14, documents redness to Resident #199's bilateral groins and 3+ [MEDICAL CONDITION] to the bilateral toes. There was no pressure ulcer assessment of Resident #199's buttocks as a result of the attending physician's note documented on 3/20/14 for decubitus ulcer, which was Resident #199 ' s admitted to the facility. An interim plan of care, dated 3/20/14 documents the resident with "pressure sores/skin care" with the goal to prevent /heal pressure sores/skin breakdown. Approaches included immediately report any redness or skin breakdown to charge nurse, turn every 2 hours and as needed (prn). There was no indication or documentation the reddened areas were "immediately" reported to the charge nurse. The weekly skin integrity review form, dated 3/26/14, documents "no new skin issues." Eight days after Resident #199 was admitted , the readmission assessment was amended on 3/28/14 for the following information: "...resident with a pressure area, nonblanchable to the inner left ankle. This area was then crossed out and the right lateral ankle was "x'd" with the date of 3/28/14. Nurse's notes dated 3/28/14 at 11:30 a.m., document "...in to interview resident. Skin check on bilateral heels noted. Nonblanchable area right lateral heel. Tx ordered. Heels offloaded in w/c. Shoe removed from right foot. Fax to MD pat (patient) aware of keep off loaded." There was no assessment regarding the areas identified by the physician related to "buttocks decub ulcer." Review of the comprehensive Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) of 3/27/14 documented Resident #199 with a Brief Interview for Mental Status (BIMS) of "13." The BIMS is a screening assessment of the resident's cognitive ability. The score ranges between 0-15. A high score reflects a higher level of cognitive functioning of the resident. The resident is totally dependent on 2 staff for bed mobility and transfers. She requires extensive assist for personal hygiene and is totally dependent on staff for bathing. Range of motion is impaired to her upper and lower extremities. She has a Foley catheter in place and is always incontinent of bowel. Resident #199 was assessed as having a Stage 1 or higher pressure ulcer and this assessment documents the resident was admitted with an unstageable deep tissue pressure sore. Interventions include pressure reducing devices for chair, for bed and pressure ulcer care. Review of the "Pressure Sore CAT" documents Resident #199 was admitted with a deep tissue injury (DTI) to her right (rt) heel. This is inaccurate as Resident #199 was not admitted with a DTI to her right heels as evidenced by documentation of the development of this area 8 days after admission. (Completing the MDS identifies CATs-Care Area Triggers, which indicate caregiving needs and problems. CATs serve as the link between data and further assessment.) There was no further assessment of the decubs to the buttocks as identified by the physician on his admission assessment dated [DATE]. During an interview on 3/31/14 at 10:30 a.m. related to the lack of assessment and follow up of the decubitus ulcer identified to the resident's buttocks by the physician, the Minimum Data Set (MDS) Coordinator looked puzzled. She confirmed she was not aware of the buttocks decub ulcer identified by the physician. The MDS Coordinator stated she and the DCS went down to look at Resident #199 after she was admitted and confirmed they did not go and assess the resident until 3/28/14, 8 days after the resident was admitted . The MDS Coordinator stated the DCS determined Resident #199 had a SDI to the right lateral ankle, and did not assess the buttocks. When asked where the documentation was regarding the assessment of the right lateral ankle, she stated "I do not know. I thought she documented it." After interviews, the DCS approached the nurses' station and confirmed she did an assessment of the resident's right lateral ankle, but failed to document the findings of her assessment. She then amended the nursing notes. Documentation on 3/31/14 by the DCS included: "Late entry for 3/28/14, checked skin area on (resident). Rt. lateral heel- the area is a suspected deep tissue injury measures 2.3 x .4 x .0 area which is deep red." She was not aware the physician identified a decubitus ulcer to the buttocks 11 days earlier. She stated because she was not aware, there would be no assessment. The DCS confirmed there was no additional assessment of Resident #199's coccyx or buttocks after her admission assessment. During observation on 4/01/2014 at 3:48 p.m., of wound care in the presence of the wound care physician (WCP) and the "North" unit manager (UM) revealed the failure of the physician to wash her hands prior to donning gloves. The UM washed her hands and donned a pair of gloves. The WCP assessed Resident #199's lung sounds, then the carotid arteries. The resident complained of breast pain and the WCP palpated each of the resident's breasts. Still with the same gloved hands, the WCP walked over to a bag of supplies and retrieved a "Doppler machine." A Doppler is a device which is able to detect pulses in the resident's feet. She then applied ultrasound ointment to the tops of the resident's feet and listened for pulses. The WCP wiped the bottom of the Doppler off and placed it back into her supply bag. Still using the same gloved hands, the WCP lifted up and checked the resident's heels. The WCP was preparing to leave the room without examining the resident's buttocks. The WCP was asked if she was going to assess the resident's buttocks. The WCP stated she was not notified to check the resident's buttocks, only her heels. The UM stated barrier cream has been applied to the resident's buttocks by the Certified Nursing Assistants (CNAs) since admission. The UM stated "The resident never had anything on her buttocks." In front of Resident #199, the UM stated "Dr. (name) is crazy. He does not know what he is talking about." The WCP then removed her gloves. She did not wash her hands, then donned another pair of gloves and assessed Resident #199's buttocks. The WCP indicated the resident has healing areas to buttocks, now with 100% [MEDICATION NAME]. Never having seen the resident while in the hospital, the WCP stated she did not agree with the assessment of pressure sores to the resident's buttocks previously identified by the hospital physician, hospital physician's assistant (PA), hospital enteral nurse or the resident's current attending physician's findings related to history of pressure ulcer and decubitus ulcers on residents buttocks. During an interview on 4/01/2014 at 3:48 p.m., the WCP confirmed she was looking at the resident's healing areas 11 days after her admission. Review of the WCP's documentation, dated 4/01/14, includes: "...no ulcers or pressure sores identified in heels or sacrum...old healed MASD (Moisture Associated Skin Damage) in sacral-coccygeal area (bilateral buttocks)...Plan: Zinc oxide to apply in sacral area every 8 hours and prn...." During an interview on 4/01/2014 at 4:15 p.m., the primary Licensed Practical Nurse (LPN), Staff O, stated the wound care doctor ordered the zinc oxide because of the "little bit" of excoriation remaining on the resident's buttocks. The facility failed to comprehensively assess the areas of "decubitus ulcers" to Resident #199's buttocks identified by the primary physician upon admission. It was not until 8 days after she was admitted did the facility assess the resident with a SDI to her right lateral heel. The MDS assessment was inaccurate due to the facility ' s failure to comprehensively assess the resident. The MDS assessment documented Resident #199 was admitted with a deep tissue pressure sore to her right lateral ankle which was inaccurate as this was not identified until 8 days after the resident was admitted to the facility. Due to the failure to comprehensively assess the resident's skin, the MDS assessment failed to reflect the decubitus ulcer on the resident's buttocks as identified by the primary physician. The WCP identified "healing areas" to the resident's buttocks; as a result of not being promptly alerted by the nursing staff to assess the areas on the resident's skin, she was unable to accurately identify what the resident had been admitted with to her bilateral buttocks. The failure to promptly and comprehensively assess wounds on Resident #199 may have increased the risk for the wounds that were identified to become worse. 3. Resident #160 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. During an observation on 04/01/13 at 12:45 p.m., Resident #160 was in the dining room eating his lunch. Resident #160 was seated in a wheel chair, at his assigned table eating his lunch. Observation of the resident legs and feet revealed he had non- skid socks on both feet, the socks were observed over a bandage left heel. Resident #160 did not have Uno Boots on either foot. During an interview on 4/3/14 at 3:20 p.m,. Resident #160 was observed up in a wheelchair at the nurses' station. The resident is alert and communicative. He is clean, well groomed, and appropriately dressed. The resident is wearing red slip proof socks over a bandaged left heel. His feet are resting on foot rests. Resident #160 stated he goes out of the facility for wound treatment. He said the wound on his heel is getting better. Resident #160 states he receives assistance from the nursing staff. Review of the Physician treatment orders dated 4/01/14 reads as follows; Uno Boots bilateral 7:00 a.m. to 7:00 p.m. Review of Resident #160 comprehensive care plan updated on 3/13/14 and (amended date not documented) reads as follows: "Pressure Ulcer location; Stage II Left lateral heel. The section Titled Interventions/Approaches indicates that resident is to have Provolone Boot Bilateral heels. The care plan failed to identify when the boots are to be plac

Based on observation, interview, record review and review of assessment and documentation of wounds, the facility failed to conduct initial and periodical comprehensive assessments for 6 (Resident #35, #199, #78, #197, #202 and #160) of 8 residents identified by the facility with pressure ulcers/sore, including Resident #35 and #78 developing avoidable pressure ulcers. A comprehensive assessment is a tool used by the facility to determine the resident's needs and is used to help develop interventions to address all care needs for the residents. The findings include: 1. Clinical record review on 4/02/14 included documentation Resident #78 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Record review of physician's orders [REDACTED]." On 2/01/14, physician's orders [REDACTED].=shortness of breath." Review of the nursing readmission assessment, dated 2/06/14, documents an "open area to the right posterior upper ear related to (r/t) oxygen tubing and left ear posterior is reddened." Review of the physician's orders [REDACTED]. Apply triple antibiotic (TAO) behind both ears every (q) day." Review of the weekly skin assessments for March 2014 documents "broken skin behind bilateral ears" on 3/04/14. On 3/10/14, the weekly skin integrity review form documents a 1 centimeter (cm) x .5 cm x 1 cm depth wound to the inside portion of the upper right ear related to the oxygen tubing; there was no assessment of the resident's left ear. On the 3/11/14 skin assessment, the nurse documents skin condition as "other"; the nurse failed to assess and document what "other" meant. Review of the Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) of 3/09/14, documented Resident #78 with a Brief Interview for Mental Status (BIMS) of "12." The resident requires set up help only for personal hygiene. The resident was identified at risk of developing a pressure ulcer; there were no pressure ulcers identified on this assessment. Documentation dated 3/18/14 on the "weekly skin integrity review" form indicated Resident #78 had a partial open area behind the right ear. There was no assessment to determine whether the "broken skin" identified to the resident's left ear on the 3/04/14 skin assessment remained or whether it had resolved. On 3/18/14, a "Guidelines for Unavoidable Wounds" form was completed for Resident #78. This form documents clinical conditions that are primary risk factors for developing pressure ulcers which include, but are not limited to: "immobility, chronic bowel and/or urine incontinence, [MEDICAL CONDITION] or other perfusion disorder." The risk factors the facility listed which included "immobility and chronic bowel and/or urine incontinence" do not support how it would contribute to the resident developing a pressure sore behind the right ear. The following interventions were documented by the facility prior to the development of the open area(s) included: weekly skin assessments; padding to tubing, splints, braces and administer treatments as ordered. The facility failed to accurately assess the contributing factors which might lead to the development of pressure sores behind the resident's ear. Review of the pressure ulcer record documentation, dated 3/18/14, for the "right ear" indicates an unstageable pressure sore measuring 1 x 0.5 x 0.2 cm. The wound bed is slough, color is yellow, wound edges firm/no redness; with small amount of serosanquinous drainage and the periwound was with redness. Review of the physician's orders [REDACTED]." Review of the March 2014 treatment administration record (TAR) documents the treatment was provided to the right ear except for the 7:00 a.m. to 7:00 p.m. shift on 3/30/14. Review of the pressure ulcer record documentation, dated 3/24/14 indicates a Stage III pressure sore to the right ear measuring 1 x 0.2 x 0.1 cm with [MEDICATION NAME] pink wound bed, wound edges with redness, and a small amount of serosanquinous drainage. Documentation in the "Unavoidable Pressure Sore physician progress notes [REDACTED]. The results of my findings are: " was left blank. The physician's progress note, dated 3/26/14, did not document the results of his findings. The area was blank. The "weekly skin integrity review", dated 4/01/14, documents an open area to the resident's right ear. The "pressure ulcer record" dated 4/01/14, documents Resident #78 with an "unstaged" wound to the right ear measuring 0.7 x 0.2 x 0.1 cm. During an observation on 4/01/14 at 8:30 a.m., Resident #78 was in his room and in bed. Oxygen tubing was observed in his nares, the pair of openings of the nose or nasal cavity, and a gray cushion was observed covering the tubing over his right ear; there was nothing in his left ear. Resident #78 stated he was having a hard time getting the cushion to stay on his right ear and when he asked certain aides to help him, they would say they would and would not return to his room. During an observation of Resident #78, on 4/01/14 at 4:30 p.m., he was in his room, sitting in bed with his head down and eyes closed. A gray cushion was observed over the tubing over his right ear, there was no cushion over his left ear. The facility failed to consistently assess and implement preventative measures, which were cushions to oxygen tubing to relieve pressure, to prevent the development and or worsening of pressure sores to Resident #78's ears. Observation of the resident on 4/02/14 at 8:40 a.m., revealed Resident #78 in his room, seated in his wheelchair and Staff Nurse "N", a Registered Nurse (RN), was in the resident's room assisting him with his medications. The resident was observed to have a gray cushion over the tubing placed over his right ear; there was no cushion over the left ear. The RN validated there was no cushion over Resident #78's left ear. The resident stated he had a hard time keeping the cushion over the right ear and when asked if staff were helping him, he indicated some staff help him and some staff do not. Record review on 4/02/14 documented physician's orders [REDACTED]. Cleanse rt (right) ear with ns (normal saline), pat dry, apply Ca+alg (calcium alginate), activate with several drops of ns (normal saline), cover with DCD (dry clean dressing) dly (daily) and prn (as needed)." Observation during wound care on 4/02/14 at 11:10 a.m. of Staff N gathering supplies which included 2 packs of gauze, 4 tubes of normal saline, 2 bordered dressings, 2 packs of triple antibiotic ointment and a package of ear cushions. After gathering the supplies, he entered Resident #78's room. It was determined the resident was not in his room and Staff N exited the room indicating he would have to go find the resident. During an observation on 4/2/14, at 11:30 a.m., Resident #78 was in his room seated in his wheelchair. Oxygen tubing was observed in his nares and there were no cushions over the tubing that was resting on top of the resident's ears. Staff N assisted the resident out of his wheelchair to the side of the bed in order to perform wound care. On a bedside table next to the resident's bed observed the following wound care supplies: Two small packages of triple antibiotic ointment, gauze dressing, two small border dressings and 4 small plastic tubes of normal saline as well as non-sterile gloves. The supplies were resting on top of paper towels lining the left side of the bedside table. There was no calcium alginate included in the wound care supplies. An open and empty red bag was observed resting on top of a paper towel at the bottom of Resident #78's bed. After appropriately washing his hands, Staff N donned a pair of non-sterile gloves. He removed the resident's oxygen tubing away from his nares. Resident #78 stated when he came into the facility, he "did not have these areas and what happened was when he wore the tubing and would rub his head back and forth it would rub his ears." Resident #78 stated he "...let the staff know it was sore and they (tubing) were rubbing and they put some salve on it and not every day, they did not change it every day, they changed it maybe twice." Staff N washed his hands appropriately and donned a pair of gloves. He then walked back over to the resident and removed the dressing from the top portion of the back of the resident's right ear exposing a reddish pink area with a small amount of crusted yellow skin. Staff N verified the same appearance of the wound. Staff N was asked to look at the left ear. Using the same gloved hands, he removed the hearing aid and then oxygen tubing to Resident #78's left ear exposing a small open area, size of a small pea, with a reddened wound periphery and yellow wound base. The nurse removed his gloves, washed his hands, and donned another pair of gloves. He opened the bordered gauze, and then removed his gloves stating he forgot to date the gauze. Resident #78 confirmed he observed the open area to his left ear this a.m. He stated he told staff earlier in the evening yesterday, but, no one came to help him. He told staff yesterday his ear was hurting and then stated "They were busier than a one arm paper hanger and that is depending on what staff they have." He stated he believed it starting happening two days ago and believed the area opened up yesterday evening. The resident stated "when the staff do talk to you, you know it ' s because they talk back at you." Resident #78 stated "They are not joking and figured the other ear would open up, just did not know when." The resident stated the Director of Clinical Services (DCS) put a box of ear cushions in his top drawer last week and said, "Some of the nurses, not all, the ones that give you the medications, might help put the cushions on my ears." The aides say they would come back and help (him) with them but do not." When asked which shift, he stated, "The aides in the evening." He stated the nurses would put the two "sleeves" (meaning cushions) on his ears, but not always. Staff N asked him if his ears hurt and the resident answered "Yes" and pointed from the tips of his ears toward his temples. Resident #78 stated when he moves his ear (pointing to the left), it hurts. He stated "I told the nurses the "sleeves" would just fall right off. When my ears hurt, you know it." Staff N confirmed the new open area to the left ear. Staff N and Resident #78 looked inside the drawers of the resident's nightstand and could not locate ear cushions. Staff N then opened the tubes of normal saline and placed them back onto the prep area. He then walked over to the resident with one of the saline tubes and gauze, squirted the normal saline onto the gauze and cleansed the right ear. He tossed the gauze into the red bag. He cleansed the same area in the same fashion and tossed the gauze into the red bag. Then with the same gloved hands, he opened a gauze packet, removed the gauze and walked over to the resident and patted the right ear dry. He then opened a small packet of triple antibiotic ointment and pulled the tip of the resident's right ear down. While doing this, Staff N was questioned as to what he was about to apply to the wound to the resident's right ear and still holding the packet in the air, validated it was triple antibiotic ointment and placed a small amount of ointment on top of the right ear wound. He then walked back over to the bedside table, picked up the dated border dressing and placed it on top of the right ear wound. He then removed his gloves, washed his hands, donned a pair of non-sterile gloves, cleansed the wound to the left ear with normal saline and informed Resident #78 he would place a dry dressing on top (of the wound) until he got a treatment order from the physician. After placing the border gauze on the top inside area of the resident's left ear, he removed his gloves, gathered his supplies and stated he was going to call for a treatment order for the resident's left ear. Review of the March 2014 and April 2014 treatment records revealed there was no documentation to support staff were ensuring ear cushions were being provided to Resident #78 in an effort to prevent skin breakdown due to the pressure of the oxygen tubing resting against his ears. The Staff N failed to follow the physician's orders [REDACTED]. Review of the April 2014 treatment record revealed Staff N documented he applied skin prep to the left ear; this was not observed during wound care. Staff N failed to assess the newly developed pressure sore to the left ear. During an interview on 4/02/14 at 11:50 a.m., the DCS, Administrator (ADM) and Assistant Director of Clinical Services (ADCS) reported they were not aware of the pressure sore to Resident #78's left ear. The DCS stated the resident is supposed to wear ear cushions to the tops his ears and she got him a box of them and placed them in his top drawer. She stated just yesterday afternoon she checked on the resident and placed ear cushions on him as he was not wearing them; she confirmed she did not check behind the resident's ears to determine if there were any new areas of skin breakdown. The DCS stated the resident was observed to constantly pull down on his oxygen tubing and she would constantly remind him to refrain from doing so. When asked if the facility attempted any other interventions, such as a mask or different types of tubing, etc., the ADM stated he asked the doctor if Resident #78 could wear a mask which then he would have two straps around his head rather than tubes resting on top of his ears and the doctor did not seem to think that was an option. There was no indication as to why this did not seem to be an option. The ADM confirmed they did not try a mask with a different set up for oxygen. During an observation on 4/03/14 at 9:00 a.m., Resident #78 was in his room, in a wheelchair attempting to wheel himself out of his bathroom. A dressing was observed to his left ear; there was no dressing to his right ear. There was no evidence of cushions on either side of his ears. Resident #78 stated no one helped him put them on this morning when they got him dressed. At 9:30 a.m., the resident remained without pressure relieving cushions to either side of his ears and no dressing to his right ear. The resident stated he had no cushions to place on the top of his ears and stated the dressing to the right ear must have fallen off. The facility failed to assess for appropriate interventions to alleviate or minimalize the risk for pressure ulcer development to Resident #78's left ear. Once they did identify broken areas to the areas behind both of the resident's ears, they failed to consistently and comprehensively assess the skin breakdown. The resident complained to staff about his ears hurting him, including his concern about the left ear developing a pressure sore. The facility failed to assess for and intervene regarding the areas the resident was concerned about. The DCS acknowledged the failure of the resident to be able to consistently wear the cushions and failed to assess the areas behind the resident's ears for skin breakdown. The interdisciplinary team failed to assess the ongoing risks/potential for pressure ulcer development to Resident #78's left ear which ultimately contributed to an area they were unaware of until surveyor intervention. 2. During an observation and interview on 3/31/14 at 3:40 p.m., Resident #199 was in her room sitting upright in a wheelchair. She stated she was admitted to the facility after being hospitalized for [REDACTED]." She stated she had " MS " ([MEDICAL CONDITION]) and a urinary tract infection [MEDICAL CONDITION] while at the hospital. She stated they were treating her for "sores" on her bottom. During an observation on 4/01/14 at 10:30 a.m., in the presence of the Director of Clinical Services (DCS), Resident #199 was in her room and in bed. The resident was assisted to a left side-lying position. Multiple healed wounds were observed to her bilateral buttocks. The upper left buttock presented with a small reddish brown abraded area at the base of a recently healed pressure sore and was the size of a pea. The upper right buttock presented in the same fashion and a small reddish brown abraded area, size of a small pencil eraser, was observed. Remnants of barrier cream were observed covering the area and the DCS rubbed the areas identified and stated she saw nothing on the resident's buttocks. She stated she was not informed the resident had a recent history of pressure sores to the areas; only observed a Suspected Deep Tissue Injury (SDI) to the resident's right lateral heel. Observation of the right lateral heel failed to reveal any evidence of skin breakdown. Review of Resident #199's record on 4/01/14, documented an admission to the facility on [DATE]. Review of the hospital History and Physical (H and P) dated 3/18/14, documents Resident #199 with decubitus ulcers on the buttocks, recurrent urinary tract infections [MEDICAL CONDITION], an indwelling Foley catheter, [MEDICAL CONDITION], recurrent [MEDICAL CONDITION] under breast and in the groin. Review of the hospital consult dated 3/19/14, and timed 07:18 documents the resident with a "sacral decubitus" and the physician documents "...I would request the wound care team to take a look at that (sacral decubitus)." Under the "Objective" section of the consult, the physician documents "Buttocks: Sacral area, the patient does have a decubitus ulcer, I requested wound care nurse to evaluate this today. This has been chronic..." Under "Plan" the physician documents "The patient does have decubitus ulcer, and we will request the wound care team see her regarding treatment." Review of the infectious disease consultation, dated 3/19/14 at 16:57, the physician's assistant (PA-C) documents "Decubitus ulcerations, currently stable, under the care of home health nurses." She then documents "Buttocks did not reveal sacral decubitus, per nurse, the wound is stable and chronic." On 3/19/14 at 16:02 and authored by the [MEDICATION NAME][MEDICATION NAME] (ET)/skin clinician documentation indicated the "patient has a healed pink ulcer to sacral coccygeal area. Encouraged nurses to turn more frequently, use dry flo pads, zinc and if diaper necessary while in bed do not close tabs on diaper." Review of the facility's attending physician's progress notes, dated 3/20/14, includes the following documented admission [DIAGNOSES REDACTED]." Resident #199's physician diagnosed her with a decubitus ulcer to her buttocks on admission to the facility. Review of the facility's "nursing" admission data collection form documents Resident #199 with an "excoriated red area" to the resident's sacral-coccygeal area. On the back of this admission assessment, the nurse documents the resident's coccyx area as intact with redness noted. This assessment conflicts with the physician's assessment, dated 3/20/14, same admitted , for "buttocks decub ulcer". There was no accurate assessment with regard to determining the size, stage or appearance of the decubitus ulcers as identified by the admitting physician. There was no treatment ordered for the "buttocks decub ulcer" as identified by the attending physician or the conflicting assessment of "redness/excoriation" by the nurse. Review of the weekly skin integrity review sheet, dated 3/21/14, documents redness to Resident #199's bilateral groins and 3+ [MEDICAL CONDITION] to the bilateral toes. There was no pressure ulcer assessment of Resident #199's buttocks as a result of the attending physician's note documented on 3/20/14 for decubitus ulcer, which was Resident #199 ' s admitted to the facility. An interim plan of care, dated 3/20/14 documents the resident with "pressure sores/skin care" with the goal to prevent /heal pressure sores/skin breakdown. Approaches included immediately report any redness or skin breakdown to charge nurse, turn every 2 hours and as needed (prn). There was no indication or documentation the reddened areas were "immediately" reported to the charge nurse. The weekly skin integrity review form, dated 3/26/14, documents "no new skin issues." Eight days after Resident #199 was admitted , the readmission assessment was amended on 3/28/14 for the following information: "...resident with a pressure area, nonblanchable to the inner left ankle. This area was then crossed out and the right lateral ankle was "x'd" with the date of 3/28/14. Nurse's notes dated 3/28/14 at 11:30 a.m., document "...in to interview resident. Skin check on bilateral heels noted. Nonblanchable area right lateral heel. Tx ordered. Heels offloaded in w/c. Shoe removed from right foot. Fax to MD pat (patient) aware of keep off loaded." There was no assessment regarding the areas identified by the physician related to "buttocks decub ulcer." Review of the comprehensive Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) of 3/27/14 documented Resident #199 with a Brief Interview for Mental Status (BIMS) of "13." The BIMS is a screening assessment of the resident's cognitive ability. The score ranges between 0-15. A high score reflects a higher level of cognitive functioning of the resident. The resident is totally dependent on 2 staff for bed mobility and transfers. She requires extensive assist for personal hygiene and is totally dependent on staff for bathing. Range of motion is impaired to her upper and lower extremities. She has a Foley catheter in place and is always incontinent of bowel. Resident #199 was assessed as having a Stage 1 or higher pressure ulcer and this assessment documents the resident was admitted with an unstageable deep tissue pressure sore. Interventions include pressure reducing devices for chair, for bed and pressure ulcer care. Review of the "Pressure Sore CAT" documents Resident #199 was admitted with a deep tissue injury (DTI) to her right (rt) heel. This is inaccurate as Resident #199 was not admitted with a DTI to her right heels as evidenced by documentation of the development of this area 8 days after admission. (Completing the MDS identifies CATs-Care Area Triggers, which indicate caregiving needs and problems. CATs serve as the link between data and further assessment.) There was no further assessment of the decubs to the buttocks as identified by the physician on his admission assessment dated [DATE]. During an interview on 3/31/14 at 10:30 a.m. related to the lack of assessment and follow up of the decubitus ulcer identified to the resident's buttocks by the physician, the Minimum Data Set (MDS) Coordinator looked puzzled. She confirmed she was not aware of the buttocks decub ulcer identified by the physician. The MDS Coordinator stated she and the DCS went down to look at Resident #199 after she was admitted and confirmed they did not go and assess the resident until 3/28/14, 8 days after the resident was admitted . The MDS Coordinator stated the DCS determined Resident #199 had a SDI to the right lateral ankle, and did not assess the buttocks. When asked where the documentation was regarding the assessment of the right lateral ankle, she stated "I do not know. I thought she documented it." After interviews, the DCS approached the nurses' station and confirmed she did an assessment of the resident's right lateral ankle, but failed to document the findings of her assessment. She then amended the nursing notes. Documentation on 3/31/14 by the DCS included: "Late entry for 3/28/14, checked skin area on (resident). Rt. lateral heel- the area is a suspected deep tissue injury measures 2.3 x .4 x .0 area which is deep red." She was not aware the physician identified a decubitus ulcer to the buttocks 11 days earlier. She stated because she was not aware, there would be no assessment. The DCS confirmed there was no additional assessment of Resident #199's coccyx or buttocks after her admission assessment. During observation on 4/01/2014 at 3:48 p.m., of wound care in the presence of the wound care physician (WCP) and the "North" unit manager (UM) revealed the failure of the physician to wash her hands prior to donning gloves. The UM washed her hands and donned a pair of gloves. The WCP assessed Resident #199's lung sounds, then the carotid arteries. The resident complained of breast pain and the WCP palpated each of the resident's breasts. Still with the same gloved hands, the WCP walked over to a bag of supplies and retrieved a "Doppler machine." A Doppler is a device which is able to detect pulses in the resident's feet. She then applied ultrasound ointment to the tops of the resident's feet and listened for pulses. The WCP wiped the bottom of the Doppler off and placed it back into her supply bag. Still using the same gloved hands, the WCP lifted up and checked the resident's heels. The WCP was preparing to leave the room without examining the resident's buttocks. The WCP was asked if she was going to assess the resident's buttocks. The WCP stated she was not notified to check the resident's buttocks, only her heels. The UM stated barrier cream has been applied to the resident's buttocks by the Certified Nursing Assistants (CNAs) since admission. The UM stated "The resident never had anything on her buttocks." In front of Resident #199, the UM stated "Dr. (name) is crazy. He does not know what he is talking about." The WCP then removed her gloves. She did not wash her hands, then donned another pair of gloves and assessed Resident #199's buttocks. The WCP indicated the resident has healing areas to buttocks, now with 100% [MEDICATION NAME]. Never having seen the resident while in the hospital, the WCP stated she did not agree with the assessment of pressure sores to the resident's buttocks previously identified by the hospital physician, hospital physician's assistant (PA), hospital enteral nurse or the resident's current attending physician's findings related to history of pressure ulcer and decubitus ulcers on residents buttocks. During an interview on 4/01/2014 at 3:48 p.m., the WCP confirmed she was looking at the resident's healing areas 11 days after her admission. Review of the WCP's documentation, dated 4/01/14, includes: "...no ulcers or pressure sores identified in heels or sacrum...old healed MASD (Moisture Associated Skin Damage) in sacral-coccygeal area (bilateral buttocks)...Plan: Zinc oxide to apply in sacral area every 8 hours and prn...." During an interview on 4/01/2014 at 4:15 p.m., the primary Licensed Practical Nurse (LPN), Staff O, stated the wound care doctor ordered the zinc oxide because of the "little bit" of excoriation remaining on the resident's buttocks. The facility failed to comprehensively assess the areas of "decubitus ulcers" to Resident #199's buttocks identified by the primary physician upon admission. It was not until 8 days after she was admitted did the facility assess the resident with a SDI to her right lateral heel. The MDS assessment was inaccurate due to the facility ' s failure to comprehensively assess the resident. The MDS assessment documented Resident #199 was admitted with a deep tissue pressure sore to her right lateral ankle which was inaccurate as this was not identified until 8 days after the resident was admitted to the facility. Due to the failure to comprehensively assess the resident's skin, the MDS assessment failed to reflect the decubitus ulcer on the resident's buttocks as identified by the primary physician. The WCP identified "healing areas" to the resident's buttocks; as a result of not being promptly alerted by the nursing staff to assess the areas on the resident's skin, she was unable to accurately identify what the resident had been admitted with to her bilateral buttocks. The failure to promptly and comprehensively assess wounds on Resident #199 may have increased the risk for the wounds that were identified to become worse. 3. Resident #160 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. Review of the clinical record indicated Resident #160 received wound care at an outside wound center. Review of the clinical record including a Pressure Ulcer Assessment form documented weekly on Resident #160 was reviewed, with the following findings. Left Heel: ? assessment dated [DATE] Present on admission left lateral Heel l 1.5 Depth 0 Granulated Red, small drainage no order signed by nurse the nurse. ? 9/30 assessment Stage II left heel Length 1.3 depth 1.2 Granulated, Red, wound edge firm, small Grain age Serous, no odor, intact signed by same nurse. Showed improvement. ? 11/07/13 assessment Stage II Length 3 width .2 depth .1 Granulated firm edge Small Serous no order Pink Intact signed by nurse ? 11/07/13 Stage II Length 1.5 width 1.7 Depth 2 Granulation Red Firm edge intact same nurses. ? 1/07/14 Stage II Length 1.7 width 1.8 depth 0.1 signed by nurse ? 1/14/14 Stage II 2/width 2.2 depth 0.1 Signed same nurse ? 1/21/14 same as week before ? 1/28/14 Stage II 1.8 width 1.4 Depth 0.1 signed by same nurse ? 2/03/14 same as above ? 2/10/14 Stage II Length 1.6 width 1.4 depth 1 signed by same nurse ? 2/18/14 Stage II same as above signed by same nurse ? 2/20 /14 Stage II 1.4 width 2 depth 0 .1 signed by same nurse ? 3/14/14 Stage II 1.4 width 1.4 depths 0.1 signed by same nurse. ? 3/23/14 Stage II Length 4.0 width 3.8 Depth 0.1 wound Bed slough Wound Edges firm and redness Drainage small Type SerosanguinousColor pink. ? 3/25/14 Stage II Length 5 width 3, Depth 0 wound Bed slough, color black, drainage small, type Serosanguinous, order present color pink/red signed by the nurse. Progress note from The Wound Care Center dated 04/04/14: "Wound #09 left, Medial Heel is a Necrotic tissue (unstageable) Pressure Ulcer and has received a status of Not Healed. Subsequent wound encounter measurements are 3.6 cm x 4.5 cm width x 0.6 cm depth, with an area of 16.2 sq cm and a volume of 9.72 cubic cm. There is moderate amount of yellow drainage noted which has no odor. The patient reports a wound pain of level 0. The wound margin is thickened. Wound bed is 26-50% moist black Escher, 26-50% adherent yellow slough, 51-75% Pink granulation. The wound is deteriorating. The Peri-wound skin moisture is normal. The Peri-wound skin exhibited; [MEDICAL CONDITION], Callus. The Peri-wound skin did not exhibit; [DIAGNOSES REDACTED]. The temperature of the Peri-wound skin is with in normal level. Peri-wound skin does not exhibit signs or systems of infection. As above; Left heel is malodorous and infected with necrotic tissue that needs debridement." During an interview on 04/04/14 at 11:30 a.m., the acting Director of Nursing / DIrector of Clinical Services (DON/DCS), from another facility, reviewed the skin assessments the facility had documented and compared them with the progress notes from the wound care center. The Acting DON/DCS validated the facility's assessments were not correct. The DON reviewed the skin assessment for Resident #160's wound, and compared it to the weekly wound care meeting, a Quality Improvement (QA) document, demonstrated the resident wound care assessments were not accurate. During an interview on 04/04/14 at 11:30 a.m., with the Acting DON/DC

Based on observation, record review, interviews, and review of facility wound care protocols; the facility failed to prevent the development of pressure sores for Resident #1 and failed to follow proper infection control techniques during the treatment for [REDACTED].#3. This impacted 2 (Residents #1 and #3) of 3 residents reviewed for pressure sores. The facility failed to establish an interdisciplinary approach, to include the physician, and involve the legal representative and Resident #1, with a known history of refusing care, in the development of a plan of care or strategy in an effort to ensure he was compliant with comprehensive skin assessments. This failure contributed to the lack of a comprehensive skin assessment of the resident's entire skin surface for one month. The facility failed to ensure the physician or registered nurse examined Resident #1 after the identification of impaired skin integrity to his "buttocks" and pus to his "penis" in order to establish an effective treatment plan for the identified areas. These failures contributed to the development of 2 Stage II pressure sores to the resident's coccyx, deep tissue injury to his left heel and left posterior thigh, Stage II pressure sore to his penis and dark, nonblanchable areas to the toes on his feet. The findings include: 1. Closed record review on 3/20/14 documents Resident #1 was admitted to the facility on [DATE], was discharged and readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The resident was deemed incapacitated and his daughter is responsible for making his healthcare decisions. Review of the weekly skin integrity reviews for Resident #1 completed by the nurses documented: 1/03/14-"refused" (resident refused the assessment). 1/10/2014-documentation by the nurse: "no new skin impairment is noted, tx in progress" (the italicized writing underneath this area documents, "if any skin condition present, proceed to skin condition record for each site identified") There was no accompanying skin condition record provided. 1/17/2014-"refused" 1/24/2014-documentation by the nurse: "no new skin impairment is noted, Treatments (tx) in progress." There was no accompanying skin condition record provided. 2/07/2014-documentation by the nurse: "no new skin impairments" 2/28/2014-"refused" 3/07/2014-"refused" There was no documentation to support any reattempts by the facility to reapproach Resident #1 at a different date or time when he refused his skin assessments. There was no documentation to support the facility's attempt to work with the resident and develop a plan with the resident/legal representative as to when he would prefer his skin assessments to be completed in an effort to assist the resident to comply with his assessments. Review of the "Admission/Readmission Data Collection" form, dated 2/14/14, documents Resident #1 is independent in bed mobility and requires supervision with transfers. The resident is "occasionally" incontinent of bowel and bladder. The facility used the Braden Scale for predicting Resident #1's pressure sore risk and documented a total score of "16" which reflects the resident is "at risk" for developing pressure sores. The nurse who completed the assessment documented the "Resident refused assessment per readmission documentation. Several attempts noted without success..." Review of the 14 day Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) of 2/28/14, documents Resident #1 had a Brief Interview for Mental Status (BIMS) of "9." The BIMS is a screening assessment of the resident's cognitive ability. The score ranges between 0-15. A high score reflects a higher level of cognitive functioning of the resident. The MDS noted Resident #1 is extensive to totally dependent on staff for Activities of Daily Living (ADLs) except for eating. His balance is not steady and he is only able to stabilize with staff assistance. He has no impairment to upper and lower extremities. The resident is assessed as "always" is incontinent of bowel and bladder; this is a decline compared to the nurse's assessment on the admission/readmission data collection form of 2/14/14. Pertinent [DIAGNOSES REDACTED]. Resident #1 was considered at risk for developing a pressure ulcer. There were no current pressure ulcers present; no pressure ulcers on the prior assessment; no venous or arterial ulcers. Under "skin/ulcer treatment," interventions include pressure reducing device for chair, for bed and applications of ointments/medications. Review of the plans of care provided by the Director of Clinical Services (DCS) were dated 6/05/13. Included in the documentation was an identified problem of Resident #1's "Risk for skin breakdown related to decreased mobility, cognitive status and incontinent of B & B (bowel and bladder)." The goal for this problem: "Will have no breakdown in next 90 days." A second plan of care undated and entitled, "Occasionally incontinence of bowel and bladder, mixed incontinence related to impaired mobility and cognitive impairment" included a goal of "Resident's skin breakdown will be minimized by interventions." Review of the nursing notes documented by the Licensed Practical Nurse (LPN) and dated 3/06/14 at 2020 include: "Notified daughter of redness noted to buttocks and new order started. Will continue to monitor. Daughter (name) is aware..." There was no additional assessment of the area of "redness" identified on the "buttocks" to include the cause of the redness, specific anatomical location of the redness (upper, lower medial buttocks, right vs. left vs. both) or a detailed description of the integrity of the tissue. Physician's orders, dated 3/06/14, includes zinc oxide mixed with [MEDICATION NAME] powder every (q) shift and as needed (prn) to the buttocks until resolved. There was no documentation to support the physician examined the identified areas of "redness noted to buttocks" by the LPN. Nurse's notes on 3/07/14 at 2200 document: "Resident refusing skin assessment...." There was no documentation to support any additional comprehensive skin assessments were conducted since 2/07/14 (one month). Review of the MDS with an ARD of 3/07/14, documents Resident #1 with an improved BIMS score of "11." The resident is extensive assist with bed mobility and totally dependent on staff for transfers. There is no toileting program being used. Under "Skin Conditions" the resident is coded as having "no" pressure sores, rather "MASD-Moisture Associated Skin Damage." There was no change in facility interventions documented on this assessment compared to the last MDS assessment of 2/28/14. This skin section was completed by the LPN. There was no assessment or examination conducted by the Registered Nurse (RN) or the physician to support the LPN's findings and validate whether Resident #1 had "MASD" or a "pressure sore" or "both." The care plans remained the same and there was no update to the plans of care related to the LPN's finding of redness to the buttocks or "MASD" as documented on the MDS. There were no plans of care developed related to the resident refusing skin assessments. Review of the "Non-pressure skin condition record" completed by the LPN, dated 3/10/14, documents a "MASA (Moisture Associated Skin Abrasion)" to the resident's left posterior thigh measuring .3 x 9.5 with no depth, no drainage noted and periwound area "intact." She documents a "MASD" to the resident's right buttock measuring 1.3 x .7 with no depth, no drainage and periwound is "intact." The nurse documents a "MASD" to the left buttock having the "same" measurements and wound description as the right buttock. The LPN's documentation lacked a detailed description of the integrity of the compromised areas on the resident's buttocks and posterior left thigh in order to show how she determined a "MASD" and "MASA" was present. The daily skilled nurse's notes completed by the same LPN, dated 3/11/14 and timed 0700 documents: "Incontinent of extra large bowel movement (BM), preventative skin care provided. Skin assess. Reveals left buttock 1.3 x .7 red, right buttock .5 x .7 red, left calf red, left posterior thigh .3 x 9.5 red area. Treatments (tx) order obtained and initiated. Small amount of pus noted on foreskin of penis. Condom cath applied, resident removed after 30 minutes ...appetite poor, nutritional intake encouraged..." There was no change in the treatment from the 3/06/14 physician's orders for zinc oxide mixed with [MEDICATION NAME] powder. There was no indication the physician was made aware of the areas, to include the new area on the posterior left thigh, identified by the LPN on 3/11/14. There was no indication the physician was made aware of the "pus" on the resident's penis once identified at 0700. There was no physician's order to place the condom catheter on the resident or a proper indication for its use. A condom catheter is a male urinary incontinence device consisting of a flexible sheath that fits over the penis just like a condom. The condom part is then attached to a tube that drains the urine into a urinary bag. On occasion, the adhesive used to attach the condom catheter may cause irritation to the shaft of the penis. If not properly applied, the risk of developing a pressure ulcer to the penis may occur. There was no order to treat the new area identified as "MASA" to the resident's posterior left thigh. Review of the March 2014 treatment sheets documents the failure of the nurses to administer treatment to Resident #1's buttocks on 3/07/14 (2 doses), 3/08/14 (1 dose), 3/09/14 (2 doses) and 3/11/14 (1 dose) for a total of 6 out of 10 missed doses. When the treatment was provided, the nurses failed to document the condition of the wounds they were treating. Review of the 3/12/14 nurses notes at 10:30 documents Resident #1 was transported to the emergency room (ER) for a fracture to his femur and subsequently admitted . Review of the skin assessment completed by the ER nurse, who is a Registered Nurse (RN), documents the following: "...Patient has multiple area of skin breakdown and unstageable wounds...coccyx red and blanchable with 2 open areas noted...patient has a deep tissue injury to back of left thigh and left heel...both are nonblanchable...scattered areas of circular dark nonblanchable areas to toes on right and left foot and right ring (finger)...left knee [MEDICAL CONDITION] noted with [MEDICATION NAME] on knee, slight ecchymosis noted to left knee...patient has wound noted to penis with a noted odor and discharge coming from penis (not wound)...patient was given a sage bath and [MEDICATION NAME] skin care products...heels offloaded from bed..." The RN documents the following pressure ulcer assessments: *left heel-1 cm x 1 cm in diameter; Stage: deep tissue injury (discolored intact skin or blood-filled blister); appearance-Black/Eschar; surrounding skin: intact; drainage type: none; wound healed: no *left posterior thigh-1 cm x 0.5 cm linear wound; Stage: deep tissue injury (discolored intact skin or blood-filled blister); appearance-persistent redness; non blanchable; surrounding skin: intact; drainage type: none; wound healed: no. *coccyx (#1)-1 cm x 1 cm x 0 cm; Stage: Stage II (partial thickness loss of dermis); appearance-persistent redness; surrounding skin: [DIAGNOSES REDACTED]; no drainage; wound healed: no *coccyx (#2)-1 cm x 1 cm x 0 cm; Stage: Stage II (partial thickness loss of dermis); appearance-persistent redness; surrounding skin: [DIAGNOSES REDACTED]; no drainage; wound healed: no *penis-1 cm x 1 cm; Stage: Stage II (partial thickness loss of dermis); appearance-persistent redness; surrounding skin: intact. The hospital RN documented findings of pressure sores and deep tissue injury differing from the facility's documentation by the LPN of "MASD" and "MASA." The facility failed to ensure the RN or physician examined the areas identified by the LPN. During an interview on 3/19/14 at 9:10 a.m., the resident's daughter stated she took pictures of her father's pressure sores when he arrived to the hospital as she had no idea his wounds were that severe. She stated she was told he had "redness" to her father's buttocks back on the 6th of the month (March), but no one ever said anything about the wounds getting worse. No one told her about the pus coming from his penis. An interview was conducted with the unit manager of the South unit, where Resident #1 originally resided, Director of Clinical Services (DCS) and Administrator on 3/20/14 at 10:30 a.m. They were unaware of the conflicting documentation between their facility nurses regarding the condition of Resident #1's buttocks and left posterior thigh compared to the condition of the wounds assessed by the RN when Resident #1 arrived to the emergency room . They confirmed Resident #1's last comprehensive skin assessment was conducted on 2/07/14, a month earlier. The DCS confirmed neither a RN or physician observed the areas identified by the LPN. No one could confirm why there was a failure to attempt to develop a plan or strategy in conjunction with Resident #1 and/or Resident #1's daughter in order to assist the resident in agreeing to having weekly skin assessments. There was no documentation to support attempts at going at different times, another day, in an effort to comprehensively look at his skin. The facility was not acutely aware of the severity of the wounds on Resident #1. When asked about the pus coming from the resident's penis, the Unit Manager (UM) stated she had told the Advance Registered Nurse Practitioner (ARNP) about it, but, she did not see Resident #1. When asked why she placed a condom catheter on Resident #1, she stated "He was incontinent." She confirmed she did not get an order from the physician for the condom catheter and stated she did not think she needed to because it was not an invasive procedure. There was no indication she was aware of the risks including irritation, pressure sore, or infection after placing a condom catheter on a resident's penis that was already excreting pus. The facility's nurse consultant entered the room with a "Priority Alert Action Plan", dated 3/07/14. The plan indicated the facility had 5 residents with in house acquired pressure ulcers, heels and or buttocks. The plan documented a 100% skin sweep of current residents was completed on 3/13/14, after Resident #1 was discharged ; the target date was set for 3/10/14, 3 days earlier. With the facility's acknowledged recognition of in house acquired pressure sores, neither the RN or physician immediately assessed the condition of Resident #1's wounds. Review of this action plan included a target date for educating nurses regarding how to properly complete a skin check and was set for 3/21/14. The unit managers and the DCS were to conduct wound rounds with the wound care MD weekly and complete skin grids to be completed 3/10/14; this remained incomplete as under the status for completion, the date of "3/20" is documented. They were questioned about the "MASD" and "MASA" documented by the LPN on the "Non-Pressure Skin Condition Record." The DCS offered literature they use entitled, "Assessing risk of pressure-and moisture-related problems in long-term care patients May/June 2013, Volume 2, Number 3, Wound Care Advisor." Review of this documentation includes the following: Page 1, "...This article uses moisture-associated skin damage because it encompasses many causes of skin breakdown related to moisture. Regardless of what we call the condition, we must do everything possible to prevent this painful and costly problem. SKIN ASSESSMENT: Start with an overall assessment of the patient's skin. (The facility failed to conduct an overall assessment of Resident #1's skin.) Consider the texture and note dryness, flaking, redness,[MEDICAL CONDITION], macerated areas, excoriation, denudement, and other color changes. ..ASSESSING MASD risk: A patient's risk of MASD can be assessed in several ways...The Norton and Braden subscales should drive your plan for preventing skin breakdown related to moisture or pressure. (There was no documentation provided by the facility they used either the Norton or Braden scale.) The cause of breakdown (moisture, pressure, or shear/friction) must be identified, because treatment varies with the cause. Both the Norton and Braden scales capture activity, mobility and moisture scores ...EXAMINATION OF THE SKIN: It is often difficult even for an "expert" to distinguish between moisture associated skin damage and a Stage I or II pressure ulcer. Both conditions usually occur over the buttocks in very ill patients. Consequently it is necessary to correctly identify the causative issue or issues to provide appropriate treatment... (The facility failed to ensure the RN or physician examined the resident's identified areas.) Complicating the issue, however, is the fact that it is not uncommon for the incontinent patient to also be unable to effectively shift his/her body weight; thus, pressure-related injury may be occurring to the skin simultaneously. In this case, the damage is mixed etiology and is classified as both moisture damage and a pressure ulcer ...it is proposed that for MASD to occur, another complicating factor is required in addition to mere moisture exposure...TREATMENT: Treatment starts with identification of the moisture source. Test to determine the type of urinary incontinence or if there are underlying causes of fecal incontinence such as [MEDICAL CONDITION] cleansing, a barrier ointment or a no-sting barrier film should be applied ....In some cases, diversion devices such as Foley or condom catheters, or fecal containment devices are used to keep the skin dry. However, use of these devices also has risks, including bladder infection, ulceration of the penis, or anal mucosal erosion ...be sure to monitor for such complications..." (the LPN placed a condom catheter on a penis excreting pus.) The facility identified Resident #1 at risk for pressure sores; and failed to accurately assess, plan for and evaluate the cause of the reddened areas on the resident's buttocks once identified on 3/06/14. The resident was known to be noncompliant with care and despite this knowledge, they failed to get together as an interdisciplinary team, involving the physician, in conjunction with the resident and/or legal representative and develop an agreeable plan of care or strategy as to how they could accommodate the resident in an effort to ensure compliance with his weekly skin assessments. A plan of care had not been established related to his intermittent noncompliance with allowing staff to examine his skin during weekly skin assessments. There was no documentation the facility re-approached the resident at a different time during the day, the following day, etc. in order to obtain an accurate assessment by the RN or physician of his wounds and entire skin surface. There was no documentation the interdisciplinary team discussed the benefit of conducting full skin assessments or risk of developing pressure sores with the resident and legal representative. Therefore, the resident went for one month without a full skin assessment. The LPN documented the resident's impaired skin integrity as "MASD" and "MASA" without consulting an RN or the physician for their clinical expertise. She failed to show the basis of her findings in making this clinical determination as per their wound care literature stipulates. After the identification of redness to the buttocks, then the development of "MASD" vs. "MASA" of the right and left buttocks, left posterior thigh, and pus excreting from the penis, there was no indication the RN or physician examined these areas in order to develop a specific treatment plan to manage the resident's skin issues. This failure contributed to the absence of a root cause analysis as to what exactly was going on with the resident's skin which ultimately contributed to two Stage II pressure ulcers to the resident's coccyx, deep tissue injury to his left posterior thigh, Stage II pressure ulcer to his penis, unstageable pressure area to his left heel (black eschar), and dark, nonblanchable areas to his toes. 2. Observation during wound care on 3/19/14 at 2:45 p.m., revealed Staff "A", who is a Licensed Practical Nurse (LPN), entered Resident #3's and explained the procedure to him. She then entered into the bathroom and washed her hands and donned gloves. She took paper towels and covered the bedside table. She removed her gloves and washed her hands. She then left the room to gather supplies. She re-entered the room and placed supplies on the bedside table. She went into the bathroom and washed her hands. She donned gloves and re-explained the procedure to the resident. The Certified Nursing Assistant (CNA) helped her remove Resident #3's pants and brief. They then rolled the resident over to his right side exposing the wound on his left buttock. She removed the dressing and then removed her gloves. She then donned new ones. Staff "A" then took the saline solution and a 4X4 to cleanse the wound. The employee poured the saline solution onto the wound and then dried the wound by patting and rubbing the wound with the 4X4. Staff "A" then took the silver alginate out of the wrapper and cut it to size. She then activated it with saline and placed it on the resident's wound. She then covered the wound with bordered gauze. Staff "A" failed to wash her hands after removing her gloves used to remove the contaminated dressing and prior to donning a new pair of gloves. During an interview with the Director of Clinical Services (DCS) on 3/20/14 at 1:15 p.m., she was asked what her expectations were for the nurses regarding donning and doffing gloves. She stated she would expect her nurses to remove their gloves after removing a contaminated dressing from the wound, wash their hands and don a new pair prior to applying a clean dressing. Review of the facility's policy and procedure entitled, "Dressing Change" under "procedure" documents the nurse to remove her gloves and wash her hands after handling a contaminated dressing and prior to donning a new pair of gloves to clean the wound. The failure to follow proper hand hygiene and gloving techniques predisposes the wound to cross-contamination of harmful bacteria which may increase the potential for infection.