Every finding on record at Bayside of Poquoson Health and Rehab

Based on observations and staff interviews the facility staff failed to ensure resident equipment was kept clean for 1 of 12 residents (Resident #7), in the survey sample. The findings included: Resident #7 was originally admitted to the facility 09/17/2021 after an acute care hospital stay. The current diagnoses included advanced dementia, paranoid schizophrenia, and severe protein-calorie malnutrition. The quarterly Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 2/10/25 coded the resident as not having the ability to complete the Brief Interview for Mental Status (BIMS). The staff interview was coded for long and short term memory problems as well as severely impaired daily decision making abilities. The resident's person centered care plan with a revision date of 10/25/24 had a problem which stated I am at risk for falls related to cognitive impairment, poor safety awareness, and psychotropic medication use. The goal stated I will not fall and injure myself through next care plan review. The interventions included two mats left and right side of bed for safety/fall risk. On 3/25/25 at 12:50 PM, Resident #7 was observed in a low bed with bilateral mats. The mat between the resident's bed and the roommate's bed was observed with dark stains on it as well as bread crumbs, debris and shoe prints. The fall mats were also observed on 3/26/25 with dark stains, shoe prints, debris and staff standing on the one between the two beds. On 3/27/25 at approximately 5:30 P.M., a final interview was conducted with the Administrator, Director of Nursing, Assistant Director of Nursing, and [NAME] President of Operations and Corporate Nurse Consultant. The above findings were conveyed to the administrative team. The Director of Nursing stated the mats had been removed and new ones put in place. She also stated that staff had been educated that they were not to be walked on and that the environmental services staff would be paying more attention to the fall mats for all residents with them, for they are to be cleaned and disinfected on a regular schedule and removed when they are no longer in good repair.

Based on observations, family interview, and staff interviews, the facility staff failed to develop person-centerd care plan for a percutaneous endoscopic gastrostomy (PEG) tube for 1 of 12 residents (Resident #8), in the survey sample. The findings included: Resident #8 was originally admitted to the facility 03/03/2023 after an acute care hospital stay. The current diagnoses included vascular dementia and chronic gastric outlet obstruction status post PEG tube placement. The quarterly Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 2/01/25 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 3 out of a possible 15. This indicated Resident #8's cognitive abilities for daily decision making were severely impaired. On 3/25/25 at approximately 12:43 PM during the initial tour an interview was conducted with Resident #8's daughter who was visiting. The daughter lifted the resident's top which revealed a PEG tube. The PEG's external bumper was observed to be position too far from the abdominal skin and the insertion site had leakage and presented with small red and raised irritation. The daughter removed gauze from the closet and wiped the site dry, afterwards she applied a split drain sponges around the insertion site. A review of the resident's person centered care plan failed to have a problem secondary to the PEG tube and a review of the current physician's orders failed to reveal an order for the PEG tube, but here were orders for management of the PEG. The orders included one dated 7/15/24 to cleanse and place a dressing to the PEG tube site every day and an order dated 5/08/24 which stated PEG tube - flush with thirty milliliters of water every eight hours for patency. On 3/27/25 at approximately 5:30 P.M., a final interview was conducted with the Administrator, Director of Nursing, Assistant Director of Nursing, and [NAME] President of Operations and Corporate Nurse Consultant. The above findings were conveyed to the administrative team, and they had no comments and voiced no concerns.

2. The facility staff failed to provide showers to a dependent resident (Resident #6). Resident #6 was originally admitted to the facility 1/9/25 after an acute care hospital stay. The resident's current diagnoses included a stroke resulting in left hemiplegia, spatial neglect of left side, left visual deficit and obstructive sleep apnea. The admission Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 1/15/25 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 11 out of a possible 15. This indicated Resident #6's cognitive abilities for daily decision making were moderately impaired. In section GG0130 (Self-Care) of the 1/15/25 MDS assessment the resident was coded as requiring substantial/maximal assistance with shower/bathe. An interview was conducted with Resident #6 on 3/26/25 at approximately 2:06 PM. The resident stated he was admitted to the facility in early January, and he had received only one shower since his admission. He stated he was told that two showers were scheduled weekly for each resident. The resident further stated he believed if he showered more he would feel better. The resident also stated he was to be shaved on 3/26/25 but he assumed the staff ran out of time because they did not come back to shave him. The resident stated on 3/27/25 at 10:30 AM that CNA #3 stated she would be giving him a shower and shave later on 3/27/25. A review of the Shower/Bathe documentation on the Documentation Survey Reports revealed no showers were provided in January 2025, one was documented on 2/4/25 and one was documented on 2/18/25 with the resident providing all care after he was set-up and the March documentation stated he received showers 3/3/25, 3/6/25, and 3/10/25. The resident identified CNA #6 as the staff member who provided him with the one shower and denied that CNA #5 had provided him with any showers. All shower/bathe entries by CNA #5 were coded the resident was dependent and a shower was provided. On 3/27/25 at approximately 5:30 P.M., a final interview was conducted with the Administrator, Director of Nursing, Assistant Director of Nursing, and [NAME] President of Operations and Corporate Nurse Consultant. The above findings were conveyed to the administrative team and they had no comments and voiced no concerns. Based on observation, resident interview, staff interview, and clinical record review, the facility staff failed to provide hygiene care for dependent residents for 2 of 12 residents (Residents #2 and #6), in the survey sample. The findings included: 1. The facility staff failed to remove unwanted hair from the neck and chin of Resident #2. Resident #2 was originally admitted to the facility 12/11/24 after an acute care hospital stay. The current diagnoses included; end stage renal disease, type 2 diabetes mellitus with hyperglycemia, essential hypertension, and muscle weakness. The quarterly Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 2/18/25 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 14 out of a possible 15. This indicated Resident #2's cognitive abilities for daily decision making were intact. On 3/25/25 at 12:45 PM an interview was conducted with Resident #2. It was observed that Resident # 2's was rubbing her fingers through a large amount of hair on her neck and chin. Resident #2 stated, I wish they would shave this hair off of my neck and chin. Resident #2 also stated, they have never asked me if I want to have this hair shaved off of my neck and chin. On 3/27/25 at 12:05 PM an interview was conducted with Resident #2. It was observed that Resident # 2 still had a large amount of hair on her neck and chin. Resident #2 stated, I wish they would clean me up and shave me. Resident #2 also stated, I feel so dirty and just want them to clean me and shave me. On 3/27/25 at 2:51 PM an interview was conducted with Certified Nursing Assistant (CNA) #1. CNA #1 stated, I saw the hair on her neck and chin. I will be honest with you, I did not ask her if she wanted me to shave her today and I should have. CNA #1 also stated, I should have shaved her today and I will before I leave if you want me too. On 3/27/25 at 6:11 PM an interview was conducted with the Administrator. The Administrator stated, We will be shaving the resident. The Care Plan with an initiated date of 12/23/24 read that Resident #2 has a physical functioning deficit related to: Mobility impairment, Self care impairment. The goal is resident will improve my current level of physical functioning. The intervention for Resident #2 was Personal Hygiene assistance of (dependent) 1 person. In section GG (Functional Abilities) the resident was coded dependent with Personal Hygiene: the ability to maintain personal hygiene, including combing hair, shaving, applying makeup, washing/drying face and hands(excludes baths, showers, and oral hygiene). On 3/27/25 at approximately 8:30 PM, a final interview was conducted with the Administrator, Director of Nursing, Regional Director of Clinical Services, and Regional [NAME] President of Operations. An opportunity was offered to the facility's staff to present additional information. They had no further comments and voiced no concerns regarding the above information.

Based on observations, resident interview, staff interviews, and clinical record review, the facility staff failed to provide required care to prevent complications while utilizing an indwelling catheter for 1 of 12 residents (Resident #4), in the survey sample. The findings included: Resident #4 was originally admitted to the facility 03/01/24 after an acute care hospital stay. The current diagnoses included neurogenic uropathy with urinary retention. The annual Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 03/09/25 coded the resident as not having the ability to complete the Brief Interview for Mental Status (BIMS). The staff interview was coded for long and short term memory problems as well as severely impaired daily decision making abilities. At section H0100 A - the resident was coded for requiring use of an indwelling catheter. A physician order dated 3/6/24 stated Foley Catheter 16 french with a 5 milliliter balloon every shift related to urinary retention. The person centered care plan dated 9/13/24 had a problem which stated I have a Foley catheter 16 french with a 5 milliliter balloon related to a neurogenic uropathy with urinary retention. The goal stated I will not experience an infection until next review. The interventions included Position catheter below bladder, ensure tubing has no kinks, and secure for safety. On 3/25/25 at 1:37 PM Resident #4 was observed in bed with a bedside drainage bag and yellow urine in the tubing. An interview was conducted with Resident #4 regarding the indwelling catheter. The resident pulled back her linens and revealed the upper indwelling catheter tubing. The stat lock (a device to stabilize an indwelling catheter) was observed wrapped around the catheter tubing at the point of the aspiration port. Again on 3/26/25 at 12:49 PM the resident's tubing was observed unstabilized and the stat lock was observed wrapped around the tubing. This information was obtain from the Internet on 3/31/25 - If urinary catheters are not secured appropriately, they can lead to severe trauma of a patient's urethra, potential damage to bladder neck, infection and inflammation, pain and irritation, possible bypassing, accidental dislodging of a catheter and a cleaving (condition whereby the catheter splits the penile or labial tissues). https://pubmed.ncbi.nlm.nih.gov/24335791/ On 3/27/25 at approximately 5:30 P.M., a final interview was conducted with the Administrator, Director of Nursing, Assistant Director of Nursing, and [NAME] President of Operations and Corporate Nurse Consultant. The above findings were conveyed to the administrative team, and the Director of Nursing stated her observation on 3/27/25 also revealed the catheter tubing was unsecured. The Director of Nursing further stated that the stat locks supplied by the facility were not of a good quality and the catheter was likely to become unsecured because of the adhesive on the product, therefore she authorized the central supply personnel to order a different indwelling catheter stabilizer.

Based on observations, resident interview, and clinical record review, the facility staff failed to necessary respiratory care and services for 1 of 12 residents (Resident #6), in the survey sample. The findings included: Resident #6 was originally admitted to the facility 1/9/25 after an acute care hospital stay. The resident's current diagnoses included a stroke resulting in left hemiplegia, spatial neglect of left side, left visual deficit and obstructive sleep apnea. The admission Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 1/15/25 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 11 out of a possible 15. This indicated Resident #6's cognitive abilities for daily decision making were moderately impaired. The physician's order summary had an order dated 1/20/25 for a C-PAP at previous home settings at bedtime for acute and chronic respiratory failure with hypercapnia and as needed. The person centered care plan with a problem dated 1/29/25 which stated alteration in respiratory status due to sleep apnea. The goal read the resident will have adequate gas exchange as evidenced by no adventitious breath sounds, absence of respiratory distress, and absence of shortness of breath thru the next review. The interventions included monitor to ensure the C-PAP mask in place at nighttime/sleeping time. An interview was conducted with Resident #6 on 3/26/25 at approximately 2:06 PM. The resident stated he utilized a C-PAP (a machine which keeps your airways open while you sleep). The resident stated some nights the C-PAP is not applied at all and other times it is misapplied. The resident stated that sometimes the staff applies the C-PAP while he is asleep and he is awaken by water entering his nose or splashing all over him. The resident stated as a result of the water splashing he had to remove the mask because he was no longer capable of draining the tubing and repositioning the C-PAP mask himself. The resident stated that no one asked him why he removed the C-PAP, if they had he would explained that it was not applied appropriately to remain in place, for the water should not have been inside the tubing. On 3/27/25 at approximately 5:30 P.M., a final interview was conducted with the Administrator, Director of Nursing, Assistant Director of Nursing, and [NAME] President of Operations and Corporate Nurse Consultant. The above findings were conveyed to the administrative team and the Corporate Nurse Consultant stated they identified the resident needs to be shaved more often so they can get the good fit of the C-PAP mask.

Based on observations and staff interview the facility staff failed to secure resident medications on 3/27/25. The findings included: On 3/27/25 at approximately 10:47 AM Licensed Practical Nurse (LPN) #2 was observed passing medications on the 200's hall. LPN #2 went from room to room for seven rooms pulling and administering the medications. In between pulling the medication and administering it to the residents the medication cart was left unlocked making the medications accessible to unauthorized individuals. At 11:06 AM the Administrator was observed coming onto the 200's hall with a visiting male and female to visit a resident. The Administrator observed the unattended, unlocked medication cart in the hallway and went over to it and closed the locking mechanisms without saying anything to LPN #2, who was inside a resident's room. When LPN #2 returned to the medication cart, he pulled at a medication drawer but it did not open, he looked around but said nothing. LPN #2 was observed removing the medication cart key from his pocket, unlocked the medication cart and resumed pulling medications for other residents. On 3/27/25 at approximately 4:05 PM LPN #2 was sought for an interview but he was not located. The Director of Nursing stated he was gone for the day. On 3/27/25 at approximately 5:30 P.M., a final interview was conducted with the Administrator, Director of Nursing, Assistant Director of Nursing, and [NAME] President of Operations and Corporate Nurse Consultant. The above findings were conveyed to the administrative team, and they had no comments and voiced no concerns.

Based on family interview, staff interview, clinical record review, and review of facility documents, the facility's staff failed to assess and monitor a surgical wound on a resident's right breast after a breast biopsy was completed; which contributed to the resident becoming septic and hospitalized for 1 of 12 residents (Resident #1), in the survey sample. The findings included: Resident #1 was initially admitted to the facility on [DATE] and discharged on 11/11/24. The resident did not return to the nursing facility. The current diagnoses included major depressive disorder. The admission Minimum Data Set (MDS) assessment, with an assessment reference date (ARD) of 04/21/24, coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 15 out of 15. The care plan dated 4/27/24 read Resident #1 had open areas related to dermatitis of the right buttock and perineum. The goal for Resident #1 is open areas will be free of infection and healing state through the next care plan review on 05/01/2024. The interventions for Resident #1 were: Encourage proper nutrition. If a resident refuses a meal, offer an alternative and provide medication/treatment as ordered by the physician, observe for effectiveness, and use pressure-reducing seats/mattresses as necessary. A general note read: A physician visit was conducted by the facility Physician's Assistant (PA) on 11/11/24, the day of transfer from the nursing facility to the hospital admission. The chief complaint was sepsis. The resident had an elevated temperature and was hypotensive (90/60). Fluids and resuscitation were ordered. Although the provider doubted her sacral ulcer as the cause of her fever. No other source was identified at this time. A wound care consult was ordered. And local wound care was continued. According to medical records and Family Member #1, the resident had a biopsy of her right breast on 10/22/24. A review of a general progress note on 11/11/24 at 9:00 AM., read: Resident alert/verbal/responsive with difficulty understanding mumbling of words, eyes dazed in bed, head of bed up no signs and symptoms (s/s) of aspiration, skin clammy, hot/warm to touch, observed not eating breakfast vital signs (v/s) Temperature=100.7, blood pressure (bp)= 93/46, Pulse =93, Respiration =18, Oxygen 02= 83% with return 1min 94% 02 applied as ordered blood sugar (b/s) 86, lung sounds slightly diminished on left, right side clear, cap refill less than 3 seconds, and within normal limits with active bowel sounds large bowel movement. The progress note dated 11/11/24 at 9:10 AM read: PA in the facility and updated orders given, unable to do Intravenous (IV). At 9:15 AM, the company called, spoke to staff, and requested midline stat confirmation number given at 9:25 AM., Responsible Party (RP) updated per his request wants resident sent to the Emergency Room/ ER/Treatment 9:30 AM., Message left via PA answering machine along with phone number waiting call back. 09:30 AM., 911 called 9:45 AM., Resident left via stretcher going to the hospital. Resident remains alert/verbal/responsive prior to departure, all peri care done Assistant Director of Nursing (ADON)/Unit Manager (UM) updated, at 11:30 AM., RP updated of departure. A review of the hospital records dated 11/11/24 at approximately 2:08 PM., read that the patient expressed concern that she was not getting adequate care and was not feeling safe at the facility. According to the History and Physical (H&P) the patient was diagnosed with Sepsis (mostly due to draining of the right breast). On 3/25/25 at approximately 2:15 PM, an interview was conducted with family member (FM) #1 concerning his loved one. FM #1 said that when his mom came into the hospital, she smelled bad from the infections. He also said that she had had a breast biopsy a few weeks before coming here. On 3/26/25 at approximately 2:50 PM, an interview was conducted with Certified Nursing Assistant (CNA) #1. CNA #1 said that on 11/10/24, before the staff called 911, the resident was seen sleeping a lot. The resident started feeling bad after eating her breakfast. She was nauseated and refused her lunch. CAN#1 said, The next mornings she didn't look herself, she would open her eyes and not speak, she didn't eat breakfast that morning (11/11/24). LPN #3 helped me turn the resident in because she had a foley catheter. While giving her a bath I noticed a small area on her butt cheek. We put a protective cream on it. She would always have a bowel movement when receiving activities of daily living (ADL) care. Other CNAs said she had a milky substance coming from her breast. On 3/27/25 at approximately 3:45 PM, an interview was conducted with the Physician Assistant (PA). The PA said that the right breast drainage had been ongoing for some time. The PA also said that he was not informed the resident had a breast procedure done requiring steri strips. An interview was conducted on 3/27/25 at approximately 4:00 PM with Corporate Staff #2, the DON, and the facility Administrator. The administrator said that Resident #1 had a work-up for a breast mass, intermittent discharge, and an inverted nipple at the diagnostic center on 10/22/24. The Administrator said, We saw no progress notes. We should monitor for s/s of infections. The PA and the Medical Director were contacted via telephone during this interview. The DON said, If they came back with no orders (The Diagnostic Breast Center), you would call the hospital. Corporate Staff #2 asked the PA, Did you see anything? The PA said he wasn't aware at all that the resident had a biopsy until the resident went out to another facility (after hospital admission, the resident was discharged to another facility). The PA was asked what the facility was doing to monitor and care for the resident's right breast. The PA said, That was outpatient. I was not aware of a discharge at that time. On 3/27/25 at approximately 4:25 PM, a document was presented by Corporate Staff #2. Corporate staff #2 said that the document could not be found in the Medical Records under Point Click Care (PCC) a cloud-based electronic health records (EHR) system; it could only be found under Point Click Care Connect (Optimize care collaboration by connecting to a national-level health data network with hospitals, active resident and patient records, to exchange timely clinical data). The PA and staff present said they were not aware of this system until now. Corporate Staff #2 said that the staff would be educated on Point Click Care Connect because they can access it. The surveyors were not able to retrieve any notes or documents as they were not informed of this system until 3/27/25. The retrieved document from Point Click Care Connect was presented to the surveyors by Corporate Staff #2, dated 10/29/24 at 9:45 AM, that read: Called patient and gave negative biopsy results. Patient very happy with the results, patient has no signs of infection around the biopsy site. Steri strips on and precautions reviewed per protocol. Post operative Biopsy results-Unspecified lump in right breast, subareolar. Pathology from right breast twelve o'clock radius subareolar margin demonstrates benign squamous epithelium with focal acute and chronic inflammation, including giant cells, suggestive of ruptured cyst. Findings are benign. At minimum suggest a 3 month follow-up. On 3/27/25, at approximately 4:50 PM, Licensed Practical Nurse (LPN) #3 was interviewed. LPN #3 said that she noticed the discharge coming from the resident's right breast and notified the doctor. The above findings were shared with the Administrator, Corporate Consultant, and Regional [NAME] President of Operations on 3/27/25 at approximately 7:45 p.m. The facility's staff was offered an opportunity to present additional information, but no additional information was provided. Steri-Strips (Butterfly Bandage) Steri-Strips and butterfly bandages are thin, sticky bandages that cover small cuts and some surgical incisions. You apply them across your cut (running in the opposite direction) to help the two sides of your skin stay tightly closed. This helps prevent bacteria from getting in. Seek medical care immediately at the first sign of a wound infection. https://my.clevelandclinic.org/health/treatments/steri-strip-butterfly-bandage Incision & Surgical Wound Care An incision is an opening of your skin after surgery. Your surgeon will close this surgical wound with stitches (sutures), staples or adhesives (Steri-Strips). A dressing goes over the closed incision. You'll need to keep your incision clean to prevent infection. Your healthcare provider will give you instructions to take care of your wound. What is incision and surgical wound care? Incision and surgical wound care are instructions that you follow to prevent infections and help your body heal. You get these instructions after a surgery or procedure where a surgeon or healthcare provider made an incision (entry point) to access the inside of your body. You'll need to clean and protect your incision site until it heals completely. If you notice any pain, swelling, warmth around the site, or fluid oozing out of your wound, visit a healthcare provider, as you may have an infection. Adhesives: Adhesives include special tapes and glues that use their stickiness to hold your skin together. A healthcare provider may choose adhesives to close wounds from needles (percutaneous wounds), pediatric wounds or apply them in addition to deep sutures. Adhesives are painless. A common adhesive tape is Steri-Strips® https://my.clevelandclinic.org/health/treatments/15709-incision-care

Based on observations, family interview, and staff interviews, the facility staff failed to properly care for a percutaneous endoscopic gastrostomy (PEG) tube for 1 of 12 residents (Resident #8), in the survey sample. The findings included: Resident #8 was originally admitted to the facility 03/03/2023 after an acute care hospital stay. The current diagnoses included vascular dementia and chronic gastric outlet obstruction status post PEG tube placement. The quarterly Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 2/01/25 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 3 out of a possible 15. This indicated Resident #8's cognitive abilities for daily decision making were severely impaired. On 3/25/25 at approximately 12:43 PM during the initial tour an interview was conducted with Resident #8's daughter who was visiting. The daughter lifted the resident's top which revealed a PEG tube. The PEG's external bumper was observed to be position too far from the abdominal skin and the insertion site had leakage and presented with small red and raised irritation. The daughter removed gauze from the closet and wiped the site dry, afterwards she applied a split drain sponges around the insertion site. A review of the resident's person centered care plan failed to have a problem secondary to the PEG tube and a review of the current physician's orders failed to reveal an order for the PEG tube, but here were orders for management of the PEG. The orders included one dated 7/15/24 to cleanse and place a dressing to the PEG tube site every day and an order dated 5/08/24 which stated PEG tube - flush with thirty milliliters of water every eight hours for patency. On 3/27/25 at approximately 10:14 AM the resident's PEG site was observed again after the resident lifted her shirt, The area was again very wet and the split drain sponge was disheveled around the tubing. An interview was conducted with Certified Nursing Assistant (CNA) #6 on 3/27/25 at approximately 10:21 AM. CNA #6 stated it was not the CNA's responsibility to clean Resident's #8's PEG site and apply the sponges. CNA #6 stated her role was to let the nurse know if changes were observed or if the PEG appeared to need care. On 3/27/25 at approximately 1:37 PM an interview was conducted with Resident #8's hospice nurse. The hospice nurse stated the residents PEG tube insertion site was irritated because of a fungus and an antifungal had been ordered. On 3/27/25 at approximately 5:30 P.M., a final interview was conducted with the Administrator, Director of Nursing, Assistant Director of Nursing, and [NAME] President of Operations and Corporate Nurse Consultant. The above findings were conveyed to the administrative team. The Director of Nursing stated they had obtained new orders for the residents PEG insertion site.

Based on staff interview, clinical record review, and in the course of a complaint investigation, it was determined that facility staff failed to maintain a complete record for 1 of 12 residents in the survey sample; Resident #1 The findings included: Resident #1 was originally admitted to the facility on [DATE] and discharged on 11/11/24. The current diagnoses included major depressive disorder. The admission Minimum Data Set (MDS) assessment, with an assessment reference date (ARD) of 04/21/24, coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 15 out of 15. The care plan dated 4/27/24 read Resident #1 had open areas related to dermatitis of the right buttock and perineum. The goal for Resident #1 is for open areas to be free of infection and in a healing state through the following care plan review on 05/01/2024. The interventions for Resident #1 were: Encourage proper nutrition. If a resident refuses a meal, offer an alternative and provide medication/treatment as ordered by the physician, observe for effectiveness, and provide pressure-reducing seats/mattresses as necessary. According to medical records and Family Member #1, the resident had a biopsy of her right breast on 10/22/24. An interview was conducted on 3/27/25 at approximately 4:00 PM with Corporate Staff #2, the DON, and the Facility Administrator. The administrator said that Resident #1 had a work-up for a breast mass, intermittent discharge, and an inverted nipple at the diagnostic center on 10/22/24. We saw no progress notes. We should monitor for s/s of infections. The PA and the Medical Director were contacted by telephone during this interview. The DON said that if they came back with no orders (The Diagnostic Breast Center) you would call the hospital). Corporate Staff #2, asked the PA did you see anything. The PA said he wasn't aware at all that the resident had a biopsy until the resident went out to another facility (after hospital admission, the resident was discharged to another facility). The PA was asked what the facility was doing to monitor and care for the resident's right breast. The PA said, That was outpatient. I was not aware of a discharge at that time. On 3/27/25 at approximately 4:25 PM, a document was presented by Corporate Staff #2. Corporate Staff #2 said that the document could not be found in the Medical Records under Point Click Care (PCC) a cloud-based electronic health records (EHR) system; (Optimize care collaboration by connecting to a national-level health data network with hospitals, active resident and patient records, to exchange timely clinical data). The PA and staff present said they were not aware of this system until now. Corporate Staff #2 said that the staff would be educated on Point Click Care Connect because they can access it. The surveyors could not retrieve any notes or documents as they had not been informed of this system until 3/27/25. The retrieved document from Point Click Care Connect was presented to the surveyors by Corporate Staff #2, dated 10/29/24 at 9:45 AM, which read: Called patient and gave negative biopsy results. Patient very happy with the results, patient has no signs of infection around the biopsy site. Steri strips on and precautions reviewed per protocol. Post operative Biopsy results-Unspecified lump in right breast, subareolar. Pathology from right breast twelve o'clock radius subareolar margin demonstrates benign squamous epithelium with focal acute and chronic inflammation, including giant cells, suggestive of ruptured cyst. Findings are benign. At minimum suggest a 3 month follow-up. On 3/27/25 at approximately 7:45 p.m., the above findings were shared with the Administrator, Corporate Consultant and the Regional Vice-President of Operations. An opportunity was offered to the facility's staff to present additional information, but no additional information was provided.

Based on observation staff interviews and a clinical record review, the facility staff failed to establish/provide collaborative care (Hospice) for 3 of 12 residents (Resident #7, 8, and 12), in the survey sample. The findings included: 1. Resident #7 was originally admitted to the facility 09/17/2021 after an acute care hospital stay. The current diagnoses included advanced dementia, paranoid schizophrenia, and severe protein-calorie malnutrition. The quarterly Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 2/10/25 coded the resident as not having the ability to complete the Brief Interview for Mental Status (BIMS). The staff interview was coded for long and short term memory problems as well as severely impaired daily decision making abilities. A physician order dated 2/12/24 stated (name of the hospice agency) to evaluate and treat. A hospice agency document dated 2/14/24 stated the resident elected hospices services 2/14/24. A review of the resident's clinical record failed to reveal collaboration between the facility and the hospice agency in development of a plan of care between the facility and the hospice agency and evidence of the hospice agency's participation in the resident's interdisciplinary care plan meeting. On 3/27/25 at 1:37 PM an interview was conducted with the resident's visiting hospice primary care nurse. The hospice nurse stated she does not participate in the resident care plan meetings at this facility and the facility's staff is not permitted to participate in their biweekly care planning meetings. The hospice nurse further stated she does not combine her care documents and assessments with the facility's documents because hospice documents are kept in a book at the nurse's station. She also stated the facility can call the hospice agency's office and request other documentation they would like. A review of the resident's clinical record revealed some dates the hospice disciplines visited the resident and general forms of what they did such as assessments, case manage, wound care and refill medications, no specifics or details regarding the resident's care was documented. An interview was conducted with the facility's Social Services Director (SSD) on 3/27/25 at approximately 5:20 PM. The SSD stated she had no documentation to support that the hospice agency participated in Resident #7's care plan conferences but she would make sure they were invited and participated going forward. On 3/27/25 at approximately 5:30 P.M., a final interview was conducted with the Administrator, Director of Nursing, Assistant Director of Nursing, and [NAME] President of Operations and Corporate Nurse Consultant. The above findings were conveyed to the administrative team, and they had no comments and voiced no concerns. 2. Resident #8 was originally admitted to the facility 03/03/2023 after an acute care hospital stay. The current diagnoses included vascular dementia and chronic gastric outlet obstruction status post PEG tube placement. The quarterly Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 2/01/25 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 3 out of a possible 15. This indicated Resident #8's cognitive abilities for daily decision making were severely impaired. A physician's order dated 7/19/24 stated to consult (name of the hospice agency) to evaluate related to unspecified intestinal obstruction, unspecified as to partial versus complete obstruction. A document completed by a hospice agency representative on 7/21/24 titled Hospice IDG comprehensive assessment and Plan of Care Update Report revealed the resident was a new admission for hospice services. The resident's record has no order to be admitted for hospice services. Otherwise there is only a progress note of a care plan meeting dated 7/24/24 which stated the resident recently entered hospice services. The participants did not include a representative from the hospice agency. On 3/27/25 at 1:37 PM an interview was conducted with the resident's visiting hospice primary care nurse. The hospice nurse stated she does not participate in the resident care plan meetings at this facility and the facility's staff is not permitted to participate in their biweekly care planning meetings. The hospice nurse further stated she does not combine her care documents and assessments with the facility's documents because hospice documents are kept in a book at the nurse's station. The hospice nurse also stated until recently she did not provide wound measurements to the facility because they were hospice measurements and not for the facility. The hospice nurse stated the facility's staff requested the wound assessment documents therefore they were provided by the hospice office A review of the resident's clinical record revealed some dates the hospice disciplines visited the resident and general forms of what they did such as assessments, case manage, wound care and refill medications, no specifics or details regarding the resident's care was documented. An interview was conducted with the facility's Social Services Director (SSD) on 3/27/25 at approximately 5:20 PM. The SSD stated she had documentation to support the hospice agency participated in Resident #8's care plan conferences on 1/3/24 and 11/6/24, but the hospice agency did not participate in the care plan conferences in between 1/3/24 and 11/6/24 or the most recent care plan conference on 2/5/25. On 3/27/25 at approximately 5:30 P.M., a final interview was conducted with the Administrator, Director of Nursing, Assistant Director of Nursing, and [NAME] President of Operations and Corporate Nurse Consultant. The above findings were conveyed to the administrative team, and they had no comments and voiced no concerns. 3. The facility's staff failed to provide a Hospice Care Plan, nurses notes and other dispositions for Resident #12. Resident #12 was originally admitted to the facility 1/13/23 and readmitted [DATE] after an acute care hospital stay. The resident has never been discharged from the facility. The current diagnoses included; End Stage Renal Disease. The significant Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 1/24/25 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 5 out of a possible 15. This indicated Resident #12 cognitive abilities for daily decision making were severely impaired. The person-centered care plan dated 1/27/25 read Resident #12 is on hospice relating to end of life care. The Goal for Resident #12 Patient will be comfortable and have needs meet. The interventions for Resident #12 were: Evaluate effectiveness of medications/interventions to address comfort and Respect patient and family wishes. In Section O Special Treatments and Programs. K1= Coded resident as receiving Hospice Care. A care plan review note dated 02/05/2025 at 2:31 PM., read: Resident had her care plan meeting. In attendance was the SSD, MDS, and UM. Resident declined to attend. Resident is staying at the facility for LTC and has a code status of DNR. According to the above care plan meeting note. Hospice was not in attendance. On 3/27/25 at 1:37 PM an interview was conducted with the resident's visiting hospice primary care nurse. The hospice nurse stated she does not participate in the resident care plan meetings at this facility and the facility's staff is not permitted to participate in their biweekly care planning meetings. The hospice nurse further stated she does not combine her care documents and assessments with the facility's documents because hospice documents are kept in a book at the nurse's station. She also stated the facility can call the hospice agency's office and request other documentation they would like. An interview was conducted with the facility's Social Services Director (SSD) on 3/27/25 at approximately 5:20 PM. The SSD stated she had no documentation to support that the hospice agency participated in Resident #12's care plan conferences, but she would make sure they were invited and participated going forward. On 3/27/25 at approximately 7:45 p.m., the above findings were shared with the Administrator, Corporate Consultant and the Regional Vice-President of Operations. An opportunity was offered to the facility's staff to present additional information, but no additional information was provided.

Based on staff interviews and review of facility documents, the facility staff failed to ensure that twelve hours of in-service education/training within twelve months was completed by five of five sampled Certified Nurse Aides (CNA) #7, 6, 3, 8 and 9. The findings included: A review of the five CNA training transcripts and education records revealed that they had not completed the mandatory 12- hours of in-service education/training including dementia management and resident abuse prevention training. An interview was conducted with CNA #7 on 8/28/24 at 10:05 AM. CNA #7 stated she did not recall if she had completed twelve hours of in-service training to include working with residents with dementia and resident abuse prevention training. An interview was also conducted with CNA #3 on 8/28/24 at 10:17 AM. CNA #3 stated she could not remember if she had received twelve hours of training within the last year. On 8/28/24 at 11:24 AM, an interview was conducted with the Director of Nursing (DON) regarding CNAs mandatory training. The DON stated that training and education were areas they had not focused a lot of attention on, but there was an ongoing plan for all CNAs to become compliant with mandatory training. On 8/29/24 at approximately 2:00 PM, a final interview was conducted with the Administrator, DON and two Corporate Consultants. They had no comments and voiced no concerns regarding the above findings.

Based on observation and staff interview the facility staff failed to maintain a clean and sanitary food preparation area in accordance with professional standards for food service safety. The findings included; On 8-26-24 at approximately 6:40 PM, the kitchen area of the facility was inspected with the dining services manager. A metal drawer was observed under a long counter where food prep was conducted on the back wall of the kitchen. The drawer did not close under the counter, and was rusty, off of the track, and littered with food debris which could not be removed by simply wiping, as the debris was adhered with a sticky greasy substance. The inspection observations continued in the walk in freezer, dry storage room, and refrigerator. The dry storage food room contained canned goods, pasta, boxed goods, bagged cereals, and pantry storage of shelf stable items. Three large rolling bins of flour, sugar, and rice were observed open, which were dirty with a dried film on them and presumably a white food debris substance in the crevices of the sliding tops. The floor had food debris and a black sticky substances around the base boards and in the corners of the room. Mouse droppings (excrement) were on the floor of the room close to a mouse trap with a dead mouse in it. Behind the main door into the room was a Sticky trap which captures everything crawling across it, and the insect or animal would be trapped in the glue covered top to die as they are unable to escape. The sticky trap was covered in insect and spider carcasses, some of which were dried and dessicated, indicating the trap had been in place for a substantial amount of time. A black mildew substance was found covering the backside of a closet door in the dry storage room, and empty cardboard boxes, a broken shelf, and more food debris on the floor was found within the closet. The Dining Services Manager stated that they would begin to clean the kitchen immediately, and that she had forgotten to ask anyone to take care of the mouse trap, and stated Yes there was a problem with mice I will admit, and so the maintenance director was unaware of the situation. On 8-27-24 the Regional manager and Dining Services Manager were made aware of the issues, and had no further information to provide. On 8-29-24 prior to exit, the same sticky trap full of insects remained as unchanged in it's location behind the door of the dry food storage room, the mouse droppings were gone, however, either the same mouse trap, or an identical one was in the same location also. No further information was provided.

Based on observation and interview, the facility staff failed to implement an effective pest control program affecting dining services and as a result the facility as a whole. The findings included: For the Residents of the facility the facility staff failed to ensure the facility was free of pests to include mice. On 8-26-24 at approximately 6:40 PM, the kitchen area of the facility was inspected with the dining services manager. The inspection observations continued in the dry storage room of the kitchen which contained canned goods, pasta, boxed goods, bagged cereals, and general pantry storage of shelf stable items. Three large rolling bins of flour, sugar, and rice were observed open, which were dirty with a dried film on them and presumably a white food debris substance in the crevices of the sliding tops. The floor had food debris and a black sticky substances around the base boards and in the corners of the room. Mouse droppings (excrement) were on the floor of the room close to a mouse trap with a dead mouse in it. Behind the main door into the room was a Sticky trap which captures everything crawling across it, and the insect or animal would be trapped in the glue covered top to die as they are unable to escape. The sticky trap was covered in insect and spider carcasses, some of which were dried and dessicated, indicating the trap had been in place for a substantial amount of time. A black mildew substance was found covering the backside of a closet door in the dry storage room, and empty cardboard boxes, a broken shelf, and more food debris on the floor was found within the closet. The Dining Services Manager stated that they would begin to clean the kitchen immediately, and that she had forgotten to ask anyone to take care of the mouse trap, and stated Yes there was a problem with mice I will admit, and so the maintenance director was unaware of the situation. On 8-27-24 the Regional manager and Dining Services Manager were made aware of the issues, and had no further information to provide. On 8-29-24 prior to exit, the same sticky trap full of insects remained as unchanged in it's location behind the door of the dry food storage room, the mouse droppings were gone, however, either the same mouse trap, or an identical one was in the same location also. No further information was provided.

Based on observation, interview, clinical record review, and facility documentation, the facility staff failed to ensure a resident's right to a dignified existence and self-determination for 1 Resident (#21) in a survey sample of 35 Residents. The findings included: For Resident #21, the facility staff failed to appropriately dress the resident, supply a top sheet and blanket and respond to his request to wear something other than an incontinent brief. Resident #21 was admitted to the facility on [DATE] with diagnoses that included but were not limited to dysphagia after stroke, Diabetes Type II, dialysis-dependent end-stage renal disease, hypertension, congestive heart failure, lack of coordination, major depressive disorder, muscle weakness (generalized) hemiplegia and hemiparesis following stroke affecting the right dominant side, contracture of the right hand and contracture of the right elbow. Resident #21's most recent MDS (Minimum Data Set), dated 7/7/24, coded Resident #21 as having a BIMS (Brief Interview of Mental Status) score of 15/15, indicating no cognitive impairment. On 8/26/24 at approximately 7:00 p.m., the resident was heard yelling out. Resident #21's door was closed, but he could be heard yelling, Hey! Resident #21 was observed dressed only in an incontinent brief with no top sheet or blanket. He had a right elbow splint and right palm guard in place; the call bell was wrapped around the bed rail on the right side of the bed; however, upon closer look, it was disconnected from the wall. The bed was elevated to the highest position, and the foot of the bed was elevated. Resident #21 said, Hey, are you going to get me some clothes? I don't want to be here like this. I can't get nobody to help me. When asked if he had utilized the call bell, the resident said someone had come in, turned it off, and said they would be back. When asked how long that was, he said, A long time ago. During the above observation, CNA #1 was asked if the bed was the appropriate height, and she stated that it was not the proper height for safety. When asked if the call bell should be on the right side of the bed (the stroke-affected side where the Resident has splints and a palm guard), she stated it was the Resident's choice. Resident #21 was asked where he preferred the call bell, and he said, Over here, indicating the left side of the bed (his unaffected side). When asked if the call bell should ever be left unplugged from the wall, she said it should not, and it was the only way residents could call for assistance. When asked why Resident #21's door was shut, she stated it was the resident's preference. CNA #1 asked Resident #21 how she could help him, and he replied I got no clothes on I want some clothes. Why y'all leave me here like this? CNA #1 responded that it was nighttime, and he was getting ready for bed, to which the Resident responded, I still need something on. CNA#1 was asked why the Resident did not have a top sheet and blanket CNA #1 stated she did not know and would get them. On 8/29/24, during the end-of-day meeting, the Administrator was made aware of the concerns, but no further information was provided.

Based on observations and interviews, the facility staff failed to ensure the survey results book was readily accessible during the initial entrance of the facility. The findings included: On 8/26/24 at approximately 7:05 PM., during the facility entrance of the main lobby a sign was noticed on a table in the main lobby that read Survey Book is kept in the main lobby. No Survey Book was observed. 08/26/24 at approximately, 7:09 PM., an interview was conducted with the administrator concerning the survey book whereabout. The administrator pulled the survey book from a table in his office, saying that he had the survey book since Friday (8/23/24) because he was expecting us to come in at any time to survey the facility. The above findings were shared with the Administrator, The Director of Nursing (DON) and corporate staff on 8/28/24 at approximately 1:30 PM., during the final interview.

Based on observation, interview, and clinical record review, the facility staff failed to provide a clean, comfortable, home-like environment for 3 of the 14 Resident rooms in Hall 100. The findings included: For the Residents who resided in rooms [ROOM NUMBERS], the facility staff failed to make repairs to the walls by the head of the bed, where there were gouges in the drywall from the bed impacting the wall. For the Residents in rooms [ROOM NUMBERS], the facility staff failed to provide linens that were in good repair and without holes or stains. On 8/26/24 at approximately 6:45 p.m. during the initial tour of the facility, the following observations were made: room [ROOM NUMBER] A & B - Deep gouges in the drywall by the head of the bed were observed and had not been repaired. room [ROOM NUMBER] A Bed - Resident asleep and the blanket was noted to have brownish colored stain at foot of bed room [ROOM NUMBER] A Bed - Small hole in bottom sheet and no top sheet on bed. room [ROOM NUMBER] A Bed - Large gouges in drywall near head of bed, hole in bottom sheet and no top sheet or blanket and the resident visibly lying in bed wearing a brief with no blanket or top sheet. On 8/26/24, an interview was conducted with CNA #1, who stated that the resident was ready for bed, which is why he did not have any clothes on. When asked why the Resident did not have a top sheet and blanket, she stated she did not know and would get them. On 8/27/24, an interview was conducted with LPN #1, who stated that repairs are put in for maintenance to complete, but if they are not reported, maintenance cannot do the repairs. When asked if she knew if the gouges in the drywall were reported, she stated that she did not. When asked if holes in the stained sheets and blankets are acceptable for Resident use, she stated that when the beds are made, the CNAs should not be using stained or torn linens; they should let the laundry know so they can remove them. A review of the maintenance logs did not reveal any reports of damaged drywall in rooms. On 8/28/24 during the end of day meeting the Administration was made aware of the findings and no further information was provided.

Based on observation, staff interview, clinical record review and facility documentation review, the facility failed to review and revise the care plan for 2 Residents (Residents #2, and #21) in a survey sample of 35 Residents. The findings included: 1. For Resident #2, the the facility staff failed to document resident specific measurable goals, and failed to derive and implement a behavioral modification care plan for a Resident with documented brain injury and behaviors. Resident #2 was initially admitted to the facility on [DATE], and most recently readmitted on [DATE]. Diagnoses included; hypertension, seizure disorder, dementia, depression, pulmonary embolus, and traumatic brain injury with behaviors, stroke and convulsions/movement disorders/muscle weakness. The most recent Minimum Data Set assessment was a quarterly assessment with an assessment reference date of 7-17-24. He was coded with a Brief Interview of Mental Status score of 15 indicting no cognitive impairment. He required assistance with activities of daily living care. He was unable to walk and self propelled slowly in a manual wheel chair. The Resident was interviewed upon entrance to the facility and found to be non-verbal, with a communication deficit. He was pleasant, welcoming and smiling throughout the exchange. He used a writing pad successfully to communicate, although it was difficult for him to write and hold the pad as he he exhibited weakness in his upper extremities, and a tremor which resulted in involuntary shakiness and scribbled shaky writing, though mostly legible. Resident #2 had current physician's orders for the following; Seroquel 25 milligrams (mg) once per day at 9:00 PM Depakote 250 mg once per day at 9:00 PM Depakote 500 mg once per day at 9:00 PM Aricept 10 mg once per day at 9:00 PM The Resident's care plan was reviewed and revealed Focus statements and interventions as follows; FOCUS: Swung at another Resident after being hit by wheel chair (3-15-2019). Resident continues to have outbursts with other Residents (11-16-2019), (11-18-2019). (name) and his room mate had an angry episode over the doorway being blocked by a wheel chair. Another (female) Resident thought (Resident #2) was her husband and followed and yelled at him. He tried to get away from her. He did not hit her. He had an altercation with another resident over a woman. Resident to Resident verbal altercation (date unknown) (6-17-19?) per interventions in the careplan dates. INTERVENTION: Encourage Resident to not hit other residents, when another Resident is agitated with me remove me from the situation, offer something I like as a diversion 4-17-19. Resident will not talk with the other Resident, and will stay away from the woman in the incident 6-17-19. If I don't like what I'm doing let me choose something else, if I'm upset please redirect the conversation or task. New focuses were not care planned for 2020 through 2023, however interventions were added. Those follow below; please avoid things that make me more anxious 8-16-22. One to one observation 2-27-23. Velcro stop sign across Residents door per his request 5-15-23. Medication review, psyche referral, and one to one observation 8-3-23. two to one staff observation 11-7-23. On 2-27-23 the psychiatric evaluation was completed by a physician and notes from the physician revealed that the Resident did remember the altercations and felt justified in his self preservation. The doctor further documented that the Resident seemed unconcerned that striking out at a demented person was morally wrong, and that the psychotherapeutic techniques used were attempts to alleviate the emotional disturbances, and attempts to reverse or change maladaptive patterns of behavior. The session lasted 23 minutes. There was no behavior management program ever instituted for this Resident. Interventions for the Resident were not defined nor measurable, and not Resident specific. The Psychiatric evaluation entered into the care plan on 8-3-23 was never obtained. FOCUS: Resident to resident (2-15-2024) Resident attempted to yell and point at another resident during bingo (3-20-24) Resident to Resident altercation (4-13-24) Resident to Resident altercation when a wandering female with dementia was in his room. (progress notes 6-18-24). INTERVENTIONS: One on one observation for 5 days 2-16-24. Resident will sit away from other residents during activities 3-20-24. Observe for triggers for physically abusive episodes and intervene at first sign of trigger(s) 4-15-24. No triggers were defined. Redirect resident and remove from area to provide calm 4-15-24. The behaviors follow a pattern of other residents entering his space or blocking his escape. There appears no evaluation of the Resident's behaviors with regard to his specific triggers, and fears. The Resident has known depression and a brain injury, and supervision of other residents with dementia entering his space and or his desire to protect himself, reveals a potential fear for his well being. Progress notes and the care plan document refusing care, refusing therapy, refusing weights being taken, non-compliance with staff, and refusing skin assessments, which is his right, and staff convenience is not a reason for a behavioral care plan. The care plan documents cursing at staff, however, since the Resident only speaks in a whisper or has to write it on a pad of paper, cursing at staff should not impact others around him. There was an addition to the careplan on Focus which stated that this cursing behavior is not his usual. The entire clinical record was reviewed and no documentation was found that a Registered Pharmacist (RPH) had completed the required monthly Medication Regimen Review (MRR) form for Resident #2, who was administered Psychotropic medications with a diagnosis of dementia. The Director of Nursing (DON) was interviewed by surveyors in the conference room and asked to provide the missing documents. The DON stated that she had some in a binder in her office which were not available to staff in her absence. She further stated that she was a new employee who started November of 2023. She went on to state that the MRR reviews had not yet been scanned into the Resident's electronic healthcare clinical record. The binder was reviewed and no MRR records for 2024 could be found for this Resident. No recommendations for gradual dose reductions for Psychotropic medications were made. Further no evaluations nor recommendations regarding a Resident with dementia being administered psychotropic medications were made, and no Laboratory blood tests were recommended by the RPH. On 8-28-24 at 4:00 PM during a meeting with the Administrator and DON they were informed of the failure to adequately care plan the Resident's documented behaviors, and the failure of medication oversight by a Registered Pharmacist for dementia with behaviors while taking psychotropic medications. On 8-29-24 at the time of exit they stated they had no further documents to provide. 40026 2. For Resident #21, the facility staff failed to review and revise the care plan to discontinue fall mats, including a splint and palm guard for right elbow and hand contractures. Resident #21 was admitted to the facility on [DATE] with diagnoses that included but were not limited to dysphagia after stroke, Diabetes Type II, dialysis-dependent end-stage renal disease, hypertension, congestive heart failure, lack of coordination, major depressive disorder, muscle weakness (generalized) hemiplegia and hemiparesis following stroke affecting the right dominant side, contracture of the right hand and contracture of the right elbow. Resident #21's most recent MDS (Minimum Data Set), dated 7/7/24, coded Resident #21 as having a BIMS (Brief Interview of Mental Status) score of 15/15, indicating no cognitive impairment. On 8/26/24, at approximately 7:00 p.m., Resident #21 was observed in bed with an elbow splint to the right elbow and palm guard to the right hand in place. There were no floor mats at the bedside. On 8/27/24, the resident was out to dialysis, and no floor mats were observed in his room. On 8/27/24, a review of the clinical record revealed the following: FOCUS: Falls- [Resident name redacted] is at risk for falls related to poor sense of safety awareness and possible sedation due to use of psychoactive medication. Date Initiated: 09/18/2019 GOAL: [Resident name redacted] risk for falls will be minimized through next review. Date Initiated: 09/18/2019 Revision on: 05/02/2024 Target Date: 07/24/2024 INTERVENTIONS: 3/1/2023- Bilateral floor Mats Date Initiated: 03/01/2023 Assess for pain. Date Initiated: 09/18/2019 Revision on: 09/18/2019 Call light and personal items available and in easy reach. Date Initiated: 09/18/2019 Revision on: 09/18/2019 Keep environment well-lit and free of clutter. Date Initiated: 09/18/2019 Revision on: 09/18/2019 Observe for side effects of Medications. Date Initiated: 09/18/2019 Revision on: 09/18/2019 On 8/27/24 at approximately 11:45 a.m., Other Staff #1 was interviewed. She was asked if she knew whether Resident # 21 had any adaptive equipment. She stated that they were using an elbow splint and palm guard to manage his contractures. When asked about floor mats, she stated that he was not a high fall risk; he could not turn himself, so they did not use them with him. She stated that she thought they used them in the past. On 8/27/24, at approximately 2 p.m., CNA #1 was interviewed. She was asked if Resident #21 used floor mats in his room, and she stated that he did not. On 8/28/24 at approximately 3:00 p.m., an interview was conducted with the DON, who was asked the purpose of the care plan, and she stated that it was to outline all the resident's care needs. When asked when it should be updated, she stated quarterly and with any changes in resident care. When asked if this included discontinuing interventions that were no longer used and updating to add new interventions, she stated that it should. When asked if this should consist of splints, palm guards, and fall mats, she said that it should. On 8/28/24, during the end-of-day meeting, the Administrator was made aware of the findings, and no further information was provided.

Based on resident interview, staff interview, clinical record review, and review of facility documents, The facility staff failed to follow a physician's order to ensure two resident received physician ordered medications for two (2) of 35 residents (Resident #38, #21), in the survey sample. The findings included: 1. Resident #38 was originally admitted to the facility on [DATE] after an acute care hospital stay. The resident has never been discharged from the facility. The current diagnoses included; Essential (Primary) Hypertension. The quarterly revised Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 7/13/24 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 13 out of a possible 15. This indicated Resident #38 cognitive abilities for daily decision making were intact. In sectionGG(Functional Abilities and Goals) the resident was coded as being independent with eating, dependent with personal hygiene, showers/bathing, dressing, and toileting. In Section GG (Mobility) the resident was coded as requiring partial/moderate assistance with toilet transfers. The May 2024 Physician's Order Summary read: Senna S Oral Tablet 8.6-50 MG (Sennosides-Docusate Sodium) Give 2 tablet by mouth every 24 hours as needed for constipation. According to the Medication Administration Record (MAR) Resident #38 received her prescribed Docusate Sodium Capsule 100 MG one time a day for constipation every day at 9:00 AM. According to the August 2024 Medication Administration Record (MAR), no prn Senna was administered. On 08/27/24 at approximately 12:56 PM., during the initial tour Resident #38 said that she has not had a bowel movement in a week. Resident #38 also said that she's had issues with her bowel movements for [AGE] years. A review of Bowel Elimination Report showed that Resident #38 had a large Bowel Movement (BM) on 8/21/24 at 6:51 PM. According to the Bowel Elimination Report, Resident #38 had a medium BM on 8/27/24 at 2:59 PM. A review of the above Bowel elimination report show that Resident #38 had not had a BM in 6 days. On 08/28/24 at approximately 10:43 AM., an interview was conducted with Licensed Practical Nurse (LPN) #4 concerning Resident #38. LPN #4 said that there's usually a dashboard that will alert nursing if a resident hasn't had a Bowel Movement (BM) in 3 days but they did not receive an alert. LPN #4 also said that 3 days of having no BM is the facility cut off time. LPN #4 also mentioned the resident would be given an as needed (prn) medication or if there's no prn order, the physician should be notified. On 08/29/24 at approximately 10:00 AM., an interview was conducted with Certified Nursing Assistant (CNA) #4. CNA #4 said that the facility has a tracking system that will notify nursing if a resident hasn't had a BM in 3 days. CNA #4 also mentioned that she would have alerted the nurse if she was aware that a resident hadn't had a BM in 3 days. The above findings were shared during the Pre-exit, with the Administrator, The Director of Nursing (DON) and corporate staff on 8/29/24 at approximately 1:30 PM., The DON said they (nurses) should have been notified and checked the dashboard and called the physician for an as needed (prn) medication if not available. 40026 2. For Resident #21, the facility staff failed to give the ordered medication, gabapentin. On 8/27/24, a review of the clinical record revealed that Resident #21 had an order that read: Gabapentin Oral Capsule 100 MG - Give 100 mg by mouth one time a day for Neuropathy-Order Date- 08/26/2024 On 8/29/24 at approximately 1 p.m., a review of the EMAR (Electronic Medication Administration Record) revealed that the gabapentin ordered on 8/26/24 was not given on 8/27, 8/28, and 8/29/24. The EMAR was coded as #7, which meant see nurse's notes. The nurse's notes reflected that the medication was unavailable on order from the pharmacy, causing the Resident to miss three doses. A review of the stat box contents revealed that gabapentin was available in the 100 mg capsule form in the stat box. On 8/29/24, an interview was conducted with the ADON, who stated that when nurses get an order, they are to check the stat box for availability if the medication is not in the Residents' drawer. When asked if gabapentin is available in the stat box but nurses write unavailable, what would that signify? She stated that it signified they did not check the stat box. On 8/29/24, during the end-of-day meeting, the Administrator was made aware of the findings, and no further information was provided.

Based on interview, clinical record review and facility documentation the facility staff failed to provide necessary services to maintain good grooming and personal hygiene for 1 Resident in a survey sample of 35 Residents. The findings included: For Resident #21 the facility staff failed to provide 2 showers per week for Resident who is unable to provide self-care. Resident #21 was admitted to the facility on [DATE] with diagnoses that included but were not limited to dysphagia after stroke, Diabetes Type II, dialysis-dependent end-stage renal disease, hypertension, congestive heart failure, lack of coordination, major depressive disorder, muscle weakness (generalized) hemiplegia and hemiparesis following stroke affecting the right dominant side, contracture of the right hand and contracture of the right elbow. Resident #21's most recent MDS (Minimum Data Set), dated 7/7/24, coded Resident #21 as having a BIMS (Brief Interview of Mental Status) score of 15/15, indicating no cognitive impairment. On the morning of 8/28/24, Resident #21 was observed in the room. He had finished his breakfast tray and was still in the room. Resident #21 had a strong body odor present. Resident #21 was asked about his showers he stated that he did not like getting showers late at night. When asked if he sometimes refuses showers, he said yes; if it's late and he is already in bed, he will refuse. When asked if he was offered showers at a different time, he said he was not. Reviewing the bathing schedule revealed that Resident #21's bath days were Mon. and Thurs on the 3-11 shift. A review of the POC (Point of Care) documentation in the electronic health record revealed that Resident #21's baths were coded as follows: 8/01/24 - 01, 1 (01 means Resident is dependent, and 1 means Shower given) at 9:08 pm 8/05/24 - NA at 11:46 p.m. 8/08/24 - 02, 03 (02 means max assist, 03 means bed bath) 5:52 p.m. 8/12/24 - NA at 11:59 p.m. 8/15/24 - 03, 03 (03 means partial or mod assist, and 03 means bed bath) at 4:42 p.m. 8/19/24 - NA at 11:44 p.m. 8/22/24 - 01, 1 (01 means Resident is dependent, and 1 means Shower given) at 7:23 p.m. 8/26/24 - NA at 10:59 p.m. On the afternoon of 8/27/24, an interview was conducted with LPN #1, who was asked how many showers residents receive each week. She stated that Residents are scheduled for two showers a week but can have more if requested. When asked if they could switch shower days and times, she said they could if requested. When asked what should happen when a Resident refuses a shower, she stated they should be offered another time or a bed bath. When asked what NA means in the POC documentation, she said she was unsure. When asked if there is a code for resident refusal in the POC documentation, she stated that RR is resident refused. On 8/29/24, during the end-of-day meeting, the Administrator was made aware of the findings, and no further information was provided.

Based on observation, staff interview, clinical record review, and facility document review, the facility staff failed for two residents (Residents #2, and #49) to ensure pharmacy recommendations were obtained and acted upon, in the survey sample of 35 Residents. The findings included: 1. For Resident #2, the pharmacist recommendations were not obtained, nor acted upon, and not in the clinical record, in the preceding 8 months of 2024. Resident #2 was initially admitted to the facility on [DATE], and most recently readmitted on [DATE]. Diagnoses included; hypertension, seizure disorder, dementia, depression, pulmonary embolus, and traumatic brain injury with behaviors, stroke and convulsions/movement disorders/muscle weakness. The most recent Minimum Data Set assessment was a quarterly assessment with an assessment reference date of 7-17-24. He was coded with a Brief Interview of Mental Status score of 15 indicting no cognitive impairment. He required assistance with activities of daily living care. He was unable to walk and self propelled slowly in a manual wheel chair. The Resident was interviewed upon entrance to the facility and found to be non-verbal, with a communication deficit. He was pleasant, welcoming and smiling throughout the exchange. He used a writing pad successfully to communicate, although it was difficult for him to write and hold the pad as he he exhibited weakness in his upper extremities, and a tremor which resulted in involuntary shakiness and scribbled shaky writing, though mostly legible. Resident #2 had current physician's orders for the following: Seroquel 25 milligrams (mg) once per day at 9:00 PM Depakote 250 mg once per day at 9:00 PM Depakote 500 mg once per day at 9:00 PM Aricept 10 mg once per day at 9:00 PM The Resident's care plan was reviewed and revealed Focus statements and interventions as follows: FOCUS: Swung at another Resident after being hit by wheel chair (3-15-2019). Resident continues to have outbursts with other Residents (11-16-2019), (11-18-2019). (name) and his room mate had an angry episode over the doorway being blocked by a wheel chair. Another (female) Resident thought (Resident #2) was her husband and followed and yelled at him. He tried to get away from her. He did not hit her. He had an altercation with another resident over a woman. Resident to Resident verbal altercation (date unknown) (6-17-19?) per interventions in the careplan dates. INTERVENTION: Encourage Resident to not hit other residents, when another Resident is agitated with me remove me from the situation, offer something I like as a diversion 4-17-19. Resident will not talk with the other Resident, and will stay away from the woman in the incident 6-17-19. If I don't like what I'm doing let me choose something else, if I'm upset please redirect the conversation or task. New focuses were not care planned for 2020 through 2023, however interventions were added. Those follow below: Please avoid things that make me more anxious 8-16-22. One to one observation 2-27-23. Velcro stop sign across Residents door per his request 5-15-23. Medication review, psyche referral, and one to one observation 8-3-23. two to one staff observation 11-7-23. On 2-27-23 the psychiatric evaluation was completed by a physician and notes from the physician revealed that the Resident did remember the altercations and felt justified in his self preservation. The doctor further documented that the Resident seemed unconcerned that striking out at a demented person was morally wrong, and that the psychotherapeutic techniques used were attempts to alleviate the emotional disturbances, and attempts to reverse or change maladaptive patterns of behavior. The session lasted 23 minutes. There was no behavior management program ever instituted for this Resident. Interventions for the Resident were not defined nor measurable, and not Resident specific. The Psychiatric evaluation entered into the care plan on 8-3-23 was never obtained. FOCUS: Resident to resident (2-15-2024) Resident attempted to yell and point at another resident during bingo (3-20-24) Resident to Resident altercation (4-13-24) Resident to Resident altercation when a wandering female with dementia was in his room. (progress notes 6-18-24). INTERVENTIONS: One on one observation for 5 days 2-16-24. Resident will sit away from other residents during activities 3-20-24. Observe for triggers for physically abusive episodes and intervene at first sign of trigger(s) 4-15-24. No triggers were defined. Redirect resident and remove from area to provide calm 4-15-24. The behaviors follow a pattern of other residents entering his space or blocking his escape. There appears no evaluation of the Resident's behaviors with regard to his specific triggers, and fears. The Resident has known depression and a brain injury, and supervision of other residents with dementia entering his space and or his desire to protect himself, reveals a potential fear for his well being. Progress notes and the care plan document refusing care, refusing therapy, refusing weights being taken, non-compliance with staff, and refusing skin assessments, which is his right, and staff convenience is not a reason for a behavioral care plan. The care plan documents cursing at staff, however, since the Resident only speaks in a whisper or has to write it on a pad of paper, cursing at staff should not impact others around him. There was an addition to the careplan on Focus which stated that this cursing behavior is not his usual. The entire clinical record was reviewed and no documentation was found that a Registered Pharmacist (RPH) had completed the required monthly Medication Regimen Review (MRR) form for Resident #2 who was receiving psychotropic medications. The Director of Nursing (DON) was interviewed by surveyors in the conference room and asked to provide the missing documents. The DON stated that she had some in a binder in her office which were not available to staff in her absence. She further stated that she was a new employee who started November of 2023. She went on to state that the MRR reviews had not yet been scanned into the Resident's electronic healthcare clinical record. The binder was reviewed and no MRR records for 2024 could be found for this Resident. No recommendations for gradual dose reductions for Psychotropic medications were made. Further no evaluations nor recommendations regarding a Resident with dementia being administered psychotropic medications were made, and no Laboratory blood tests were recommended. The facility policy was reviewed and stated in the document that the MRR's would be completed at least monthly and placed in the Resident's clinical chart. They would be available in an easily retrievable format to nurses, physician's, and the care planning team within 48 hours of MRR completion for review. The recommendations and findings will be documented and acted upon by the nursing care center and/or physician. On 8-28-24 at 4:00 PM during a meeting with the Administrator and DON they were informed of the missing MRR documents. On 8-29-24 at the time of exit they stated they had no further documents to provide. 40026 2. On 8/27/24 during clinical record review it was discovered that Resident #49 had no record of pharmacy medication regimen review since 4/2023 available in the electronic health record. On 8/27/24 at approximately 4 p.m. the DON was asked about the pharmacy review and recommendations, and she stated they are in a book in my office. The DON then produced the book that contained the pharmacy review and recommendations for 2024. The DON was asked if she was aware of any irregularities noted by the pharmacist during their review and if so, could she show documentation of it being acted on by facility physician. The DON opened the book pulled a pharmacy recommendation out for Resident #49 and showed where it had been signed off by the physician and showed where the order had been changed in the EMAR (Electronic Medication Administration Record) however the document was kept in the book not scanned into the electronic health record. On 8/28/24 during the end of day meeting the Administrator was made aware of the findings and no further information was provided.

Based on observations, staff interviews, facility documentation review and clinical record review the facility staff failed to ensure 3 residents (Resident #43, #17, #7) of 34 residents in the survey sample, received care to prevent pressure ulcers from developing prior to an advanced stage which constitutes harm; facility staff failed to do initial and weekly assessments for 1 of 34 residents in the survey sample, Resident #19 and facility staff failed to provide pressure ulcer care as ordered by the physician for 1 of 34 residents in the survey sample, Resident #346. The findings included: 1. For Resident #43, the facility staff failed to prevent pressure ulcer on the sacrum from developing to an advanced stage which constitutes harm. Resident #43 was initially admitted to the facility on [DATE]. Resident #43 was discharged to the hospital on 04/04/2021 and readmitted to the facility on [DATE]. diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #43's Minimum Data Set (an assessment protocol) with an Assessment Reference Date of 04/12/2021 was not coded with a BIMS (Brief Interview for Mental Status) score. The Minimum Data Set coded Resident #43 as requiring extensive assistance of 1 for eating, extensive assistance of 2 for bed mobility, transfer and toilet use and total dependence of 2 for dressing, personal hygiene and bathing. On 5/04/2021 review of Resident #43's clinical record revealed the following: Review of Progress Notes for Resident #43 revealed General Note dated 5/01/2021 time 19:34 which read as follows: Note Text: This nurse noticed two open areas on Resident #43's bottom. AN open are on the coccyx bone and one on the right butt cheek. Notified MD (Medical Doctor) (Other #2) N. O. (New Order) to apply barrier cream and see wound doctor. This nurse made RP (Responsible Party) aware. Review of Progress Notes for Resident #43 revealed Weekly Skin Review dated 5/3/2021 time 15:17 which read as follows: Weekly Skin Review Info (Information): Sacrum - Pressure: Length = 1.5 cm (Centimeter), Width = 2.5 cm, Depth = 0, - Stage Unstageable Healed? No Drainage? No drainage . No tunneling or undermining. Barrier cream. No complaints/evidence of pain r/t (Related To) pressure area The wound has no change. Unable to evidence any previous Weekly Skin Reviews since Resident #43's readmission to facility on 4/8/2021. Resident #43's Pressure Injury Weekly Measurement (rev) - V 4 dated 5/3/2021 time 15:17 was reviewed and revealed the following: A. Pressure Injury 2b. Location of Pressure Injury Site 53) Sacrum Type Pressure Length 1.5 cm Width 2.5 cm Depth 0 Stage Unstageable. (There is a definition for Unstageable on the form that reads as follows: Full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and /or eschar (tan, brown or black) in the wound bed.) 6. TX. (Treatment) barrier cream. Resident #43's Initial Non - Decubitus Skin Injury Record dated 5/3/2021 time 15:21 was reviewed and revealed the following: A. 1. Date first observed: 5/2/2021 2. Date Physician notified: 5/2/2021 3. Description of site/location r (Right) gluteal 4. Describe type of skin condition popped blister 5. Size in CM (Length x Width x Depth) 2.0 cm x 2.5 cm x 0.1 cm 6. Drainage: No 7. Odor 0 8. Color: red Review of Clinical Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] On 05/05/2021 review of Weekly Skin Integrity Check dated 5/4/2021 time 17:01 for Resident #43 revealed the following: 1. Weekly Skin Integrity Checks 1. Skin clear, no change of condition assessed. 2. New wound/change of condition noted. See skin/Condition Assessment Form, for initial/ongoing documentation of assessed Wound or Skin Condition. 3. Wound/Skin condition Present/No new change of condition. Documentation already established on all existing Wound/Skin Conditions. On 05/05/2021 at approximately 9:00 a.m. requested Resident #43's Treatment Administration Record (TAR) for May 2021? On 05/05/2021 received copy of Treatment Administration Record for May 2021 as requested. Review of the Treatment Administration Record revealed that it was printed on May 5, 2021 at 11:13:35 EDT (Eastern Daylight Time). Review of the Treatment Administration Record did not evidence a treatment order for the resident's buttocks, coccyx or sacrum or for barrier cream. On 05/05/2021 at approximately 12:00 p.m., Resident #43 was observed sitting on Comfort Pro Cushion in wheelchair. An interview was conducted with Licensed Practical Nurse (LPN) #7 on 05/05/2021 at 2:45 p.m. When asked what treatment is being done to Resident #43's sacrum, LPN #7 stated, She gets barrier cream. It's applied 3 times a day and PRN (A Needed). When asked to provide a copy of the order, LPN #7 stated, I noticed today that she didn't have an order but I saw the nurse note and transcribed the order. LPN #7 provided surveyor copy of order dated 05/05/2021. Review of order revealed the following: Order Date: 5/5/2021 12 29 Description: apply barrier cream to sacrum/coccyx until seen by wound MD. Order Summary: apply barrier cream to sacrum/coccyx until seen by wound MD every shift for wound care. On 05/05/2021 at 3:41 p.m., at Resident #43's bedside to observed LPN #7 perform wound care on Resident #43. LPN #7 cleaned overbed table. LPN #7 performed hand hygiene, obtained needed wound care supplies and placed on overbed table. LPN #7 performed hand hygiene and gloved. LPN #7 cleansed open area on right buttock with Peri Care Rinse Free Peri Cleanser and gauze pad. Area noted to be pink in color with some light white coloring in the center. LPN #7 cleansed wound on sacrum with Peri Care Rinse Free Peri Cleanser and gauze pad. Wound on sacrum noted to have gray black necrotic tissue in the center. LPN #7 cleansed area on coccyx with Peri Care Rinse Free Peri Cleanser and gauze pad, unable to determine if area was open. LPN #7 removed her gloves and performed hand hygiene, regloved and applied Derma Cream Skin Protectant Cream to all areas. On 05/06/2021 at 7:51 a.m., review of Treatment Administration Record for May 2021 in Resident #43's clinical record revealed the following: Apply barrier cream to sacrum/coccyx until seen by wound MD every shift for wound care. Order Date 05/05/2021 1229. On 05/06/2021 at 10:00 a.m., an interview was conducted over the telephone with LPN #6. When asked were you the nurse for Resident #43 on 05/01/2021, LPN #6 stated, Yes. LPN #6 stated, The CNA told me that the resident had an area on her coccyx and right butt cheek. I called other #2 and he told me to order barrier cream. When asked did you write the order for barrier cream, LPN #6 stated, I was told by (Nurse Name) LPN #8 that barrier cream order was already in place in the facility and didn't need to write the order. LPN #6 stated, All of the residents get barrier cream applied after each incontinent episode by the CNA's. When asked did the physician give parameters of how often to apply the barrier cream and when to apply the barrier cream, LPN #6 stated, No. When asked do the CNA's document when they apply barrier cream, LPN #6 stated, I don't know how the CNA's document. When asked did you apply barrier cream to Resident #43 that evening, LPN #6 stated, No, I told the CNA's to apply. When asked to explain what the areas looked like on Resident #43, LPN #6 stated, The coccyx had a small scab and the cheek, looked like a blister that popped. On 05/06/2021 at approximately 11:00 a.m., when asked if the facility had any standing orders, Corporate Staff Member #5 stated, I will have to find out and get back to you. On 05/06/2021 at 1:00 p.m., Corporate Staff Member #5 stated, No standing orders in facility. An interview was conducted with Certified Nursing Assistant (CNA) #4 on 05/06/2021 at 2:05 p.m. When asked is Resident #43 incontinent of Bowel and bladder, CNA #4 stated, Yes and she goes to the bathroom. When asked how often do you check her for incontinent episodes, CNA #4 stated, Every 2 hours because she does have dementia. When asked do you apply barrier cream to Resident #43, CNA #4 stated, Yes but I can't say everyone does. An interview was conducted with CNA #3 on 05/06/2021 at 2:25 p.m. When asked if Resident #43 needs assistance with transferring, CNA #3 stated, (Resident Name) can transfer with stand by assist and will transfer on her own at times. When asked if Resident #43 is confused, CNA #3 stated, Yes. When asked is Resident #43 incontinent, CNA #3 stated, Yes, she is incontinent of bowel and bladder. When asked how often you offer to toilet Resident #43, CNA #3 stated, She will let you know when she needs to go to the restroom. When asked do you apply barrier cream to Resident #43, CNA #3 stated, Apply barrier cream to residents after they have incontinent episodes. On 05/06/2021 Resident #43 was seen in the facility by other #7. An interview was conducted with other #7 on 05/06/2021 at 3:25 p.m. When asked what stage is Resident #43's wound on her sacrum, other #7 stated, Unstageable. When asked what the wound on the sacrum due to was, other #7 stated, Pressure. When asked what was the wound on the right buttocks due to, other #7 stated, Friction. When asked what the area on the coccyx due to was, other #7 stated, DTI (Deep Tissue Injury). When asked for wound measurements from today's visit, other #7 stated, Measurements on the right buttocks 2 x 2 x 0.1, sacrum 2 x 1 x 0.2 and coccyx 0.5 x 0.5. Other #7 said that she only makes recommendations and the resident's physician gives the orders. When asked what treatments she was recommending, other #7 stated, Santyl to the sacrum, Skin Prep to the Coccyx and Hydrogel for the right buttocks. Other #7 also said that she would recommend a gel cushion for Resident #43. Other #7 stated, The nurses try to wait for me to stage pressure ulcers. The nurses usually tell me they have an Unstageable. Other #7 stated, R.N.'s (Registered Nurses) can stage. Other #7 stated, I come once a week. On 05/06/2021 copy of facility policy and procedure on pressure ulcers was requested. On 05/06/2021 received copy of Trio Healthcare Policy and Procedure Manuals - Wound Prevention Program. Review of manual revealed the following: SKIN PROGRAM Page 6 - Residents with wounds will have appropriate treatment. On 05/07/2021 requested copy of Wound physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] An interview was conducted with RN #1 on 05/07/2021 at 12:35 p.m. When asked to review Pressure Injury Weekly Measurement note for Resident #43 dated 05/03/2021, RN #1 stated, I was sent to get the measurements on 05/03/2021 by the Director of Nursing (DON) after they viewed the notes from the weekend. When asked to describe what the areas on Resident #43 looked like, RN #1 stated, Right butt cheek looked like a popped blister and I documented it on a Non-Pressure form on 05/03/2021. When asked did you measure an area on the coccyx bone, RN #1 stated, I did not see an area on the coccyx bone, I measured the area on the sacrum. RN #1 stated, I had been asked to measure the area on the sacrum. It was discussed that the progress note from 05/01/2021 identified an area on the coccyx bone but not the sacrum. RN #1 stated, I didn't think anything about it because nurses uses the term sacrum and coccyx and mean the same thing. When asked to describe what the sacrum looked like, RN #1 stated, It looked dry, had some yellow tinge on the left and blackened area was on the right. When asked was the physician made aware of the area on the sacrum, RN #1 stated, Yes, talked to the Nurse Practitioner (Name) (Other #8). When asked did you document that the Nurse Practitioner was made aware, RN #1 stated, No. When asked was an order obtained for the sacrum, RN #1 stated, No, per my understanding the DON and Corporate Nurse were working on getting the Wound Nurse to come out. That was Monday. When asked why you contacted the Nurse Practitioner on Monday if you thought the sacrum wound was the coccyx wound that was in the note, RN #1 stated, Just to follow up and cover the bases. RN #1 stated, I made the Nurse Practitioner aware that the wound was identified as unstageable and made her aware of the order for barrier cream and asked her did she want another treatment order and the Nurse Practitioner said no, that's all right someone will be in to see it tomorrow. When asked did you apply barrier cream to the wounds on Monday, RN #1 stated, I don't know. When asked did you document applying the barrier cream, RN #1 stated, Yes on the TAR. Surveyor provided copy of May 2021 TAR to RN #1 to review. After RN #1 reviewed TAR RN #1 stated, No, it just stated to put dry dressing on staples. When asked did you apply barrier cream to Resident #43 yesterday, Thursday, RN #1 stated, No. I knew you wanted wound measurements and the wound doctor came in. When asked have you seen new orders written for wound care for Resident #43 today, RN #1 stated, No, I have not. On 05/07/2021 at 3:20 p.m. An interview was conducted with CNA #3. When asked how was it communicated to you to apply barrier cream to Resident #43, CNA #3 stated, Already knew to apply barrier cream to residents after incontinent episodes. When asked did you document applying barrier cream to Resident #43, CNA #3 stated, No ma'am. On 05/07/2021 at 3:45 p.m., reviewed concerns with Interim Administrator and Corporate Nurse regarding Resident #43's unstageable wound located on the sacrum and looking at possible harm. Discussed unable to locate treatment orders for wounds identified on 05/01/2021 and no documented evidence that treatment was done. Corporate Nurse stated, They wrote an order and documented treatments. Requested evidence of orders written for 05/01/2021 and documented evidence that treatments were provided. On 05/10/2021 at approximately 10:00 a.m., requested copy of Wound physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . Also requested any new orders obtained for Resident #43's wounds on her sacrum, coccyx and right buttocks. On 05/10/2021 at approximately 11:45 a.m. An interview was conducted with CNA #4. When asked how is it communicated to you to apply barrier cream to Resident #43, CNA #4 stated, We apply barrier cream as precautions, if any body's bottom gets red we put cream on. When asked where do you document that you have applied the barrier cream, CNA #4 stated, Nowhere on the kiosk to document putting on barrier cream. On 05/10/2021 received copy of Wound Physicians Initial Wound Evaluation and Management Summary Dated 5/6/2021. Received new orders written for Resident #43. Review of new orders revealed the following: Order Date: 5/10/2021 1245 Description: Clean wound/DTI to sacrum with normal saline, pat dry. Apply Santyl to wound bed, skin prep surrounding skin. Cover with dry dressing. Order Date: 5/10/2021 1245 Description: Clean right lateral buttock with normal saline, pat dry. Apply Hydrogel to wound bed and cover with dry dressing. Order Date: 5/10/2021 1245 Description: Apply skin prep to DTI over coccyx. The Interim Administrator, Interim Director of Nursing and Corporate Nurse was informed of the findings on 05/10/2021 at approximately 8:30 p.m. at the pre-exit meeting. When asked if they had any further information to provide, Corporate Nurse stated, Order put barrier cream on and continued barrier cream until physician seen her and order changed today. On 05/11/2021 at 12:35 p.m. an interview was conducted by telephone with the Interim Director of Nursing. When asked concerning the wounds identified on 05/01/2021, did the resident have a treatment order for the open areas on the buttocks, sacrum and coccyx, Interim Director of Nursing stated, No specific order, were applying barrier cream. On 05/05/2021 received order to continue barrier cream. When asked do you have evidence that barrier cream was applied, Corporate Nurse stated, In the progress note. When asked was barrier cream an appropriate treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . When asked what your expectations of nurses are when wounds are identified, Interim Director of nursing stated, Assess the wound, obtain measurements and notify the physician for treatment orders. To provide pressure relief to any area of concern, offloading heels, floating heels. The Corporate Nurse stated, We replaced the cushion in her chair with a gel cushion on 05/03 or 05/04. The facility did not present any further information about the finding. 2. For Resident #17, the facility staff failed to provide necessary care and services to prevent a pressure ulcer from developing at an advanced stage which constitutes harm. Resident #17 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #17's most recent MDS (Minimum Data Set) assessment was an annual assessment with an ARD (Assessment reference date) of 12/31/20. Resident #17 was coded as being severely impaired in cognitive function scoring 05 out of possible 15 on the BIMS (Brief Interview for Mental Status) exam. Resident #17 was coded as requiring total dependence on two staff members with bed mobility. Resident #17 was coded in Section M (Skin Conditions) as having (1) one unstageable pressure ulcer* (1). Review of Resident #17's clinical record revealed that the only Braden Scale for Predicting Pressure Ulcer Risk was on 11/27/18. Resident #17 was coded as being at high risk for developing pressure sores scoring a 12.0. Review of Resident #17's clinical record revealed that it was documented that Resident #17 developed MASD (Moisture Associated Skin Damage) to the right buttock starting on 11/3/20 and documented as Resolved on 11/10/20. An order was put into place to: Clean right buttock with soap and water blot dry apply [MEDICATION(S)] and [MEDICATION(S)] every shift. This order was initiated on 10/27/20 and continued even after the MASD was resolved on 11/10/20. There was no evidence that Resident #17 had developed any other skin areas until 12/17/20 when a Stage 3 (2) pressure ulcer was documented as being identified to his right buttock. Review of the Initial Pressure Injury Record dated 12/17/20 documented the following: Date first observed: 12/17/20. Location: right buttock. Stage: 3 Length in CM (centimeters): 2. Width in CM: 2. Depth in CM: 0 (zero) Drainage: none. Odor: none. Granulation. None. Describe current treatment plan: [MEDICAL RECORD OR PHYSICIAN ORDER] . This assessment was documented by a LPN (Licensed Practical Nurse). There was no evidence that an RN (Registered Nurse) had went behind the LPN to reassess the wound. The weekly skin assessment directly prior to 12/17/20 was dated 12/14/20. The following was documented: Wound/Skin Condition Present/No new change of condition. Documentation already established on all existing Wound/Skin Conditions. There was no evidence in the clinical record that after 11/10/20 and directly prior to 12/17/20 an existing wound condition was present. Review of Resident #17's December 2020 TAR (Treatment Administration Record) revealed that staff were applying his [MEDICATION(S)] and [MEDICATION(S)] cream every shift on 12/16/20 through 12/17/20 until the wound was found on 12/17/20 day shift. Further review of Resident #17's December TAR revealed 7 blank spaces on 12/1, 12/2, 12/3, 12/8, 12/9 and 12/15; indicating the cream was not applied on those shifts to Resident #17. Review of Resident #17's pressure ulcer care plan dated 9/27/13 documented the following interventions prior to the development of his documented Stage 3 wound: (Name of Resident #17) is a risk for pressure ulcers due to decreased mobility and obesity and co morbidity diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] .CNA (Certified Nursing Assistant) to observe skin during care/bathing with a report to the nurse of any areas of skin breakdown, bruising or redness Conduct weekly skin inspections .Ensure skin folds are kept clean and dry .provide pressure reduction/relieving mattress .treatments as ordered .Turning and repositioning schedule per assessment . Further review of Resident #17's clinical record revealed a dietary note dated 12/11/20 that documented the following: Review for weight loss, 5.5% . x 30 days, Diet: CCD with recent decreased intake 30% average. supervision needed and now more total dependence in recent days .Recommend to d/c (discontinue) ice cream with lunch and dinner, add Mighty Shake with breakfast and lunch, add vitamin C 500mg BID and [MEDICATION(S)] 220 x 14 days. Review of Resident #17's record revealed these recommendations were implemented on 12/14/20. Further review of Resident #17's clinical record revealed his weight (last recorded weight) prior to the development of the pressure ulcer was on 12/4/20. Resident #17 weighed 232.0 pounds. Review of a physician note dated 12/16/20 revealed an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . There was no evidence that this order was followed up on prior to the resident's hospitalization on [DATE] at 9:45 p.m. Further review of Resident #17's clinical record revealed that he was sent out to the hospital on 12/17/20 at 9:45 p.m. The following nursing note was documented: R (Resident) lethargic, will not close mouth to drink water, starting off to the right. R vitals B/P (blood pressure) 88/43, P (pulse) 56, R (16), T (Temp)-97.1, 02 (Oxygen) Sats 87. R c/o (complaints), sob (short of breath), chest pain. NP (Nurse Practitioner) (Name) notified, new order to send to ER (emergency room ) for eval (evaluation) and treat .Transport arrived at 2145 (9:45 p.m.) to transport resident R . Review of Resident #17's hospital discharge summary dated 12/27/20 documented in part, the following: Per HPI (history and physical): .The patient is not responsive, so all history was obtained from the ED report .The ED was able to get in touch with a worker at the NH (Nursing Home) who states he is normally talkative and interactive, but has not been eating, drinking or interacting for the last several days .Per EMS, they were told he has COVID pneumonia .In the ED he was afebrile .CXR (Chest x-ray) looks clear to my eye .On exam he does have sacral decub (decubitus) ulcers, however they do not appear to be infected at this time .Wound Buttocks .Pre-existing: Yes. Further review of the hospital discharge summary revealed that on 12/27/20 it was documented that Resident #17's buttock wounds had Eschar, open, red; Pink .Drainage .Small Primary discharge Diagnosis: [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #17's clinical record revealed that he was admitted back to the facility on [DATE]. Review of Resident #17's Initial Pressure Injury Record dated 12/28/20 revealed that Resident #17 arrived back to the facility with an unstageable pressure ulcer to his sacrum. The following was documented: Date First Observed: 12/28/20. Location: sacrum. Length in CM: 9. Width in CM 7. Depth in CM 0. Drainage: 0 Odor: none. Granulation: 0 Describe current treatment plan: [MEDICAL RECORD OR PHYSICIAN ORDER] Review of Resident #17's clinical record revealed that the wound care physician had seen the wound on 1/7/21. The following was documented: Pressure .Unstageable Necrosis .9 x 7 x not measurable .Periwound radius: Odor .Exudate: Heavy Serous .Thick adherent black tissue: 100 % (percent). On 5/6/21 at 11:46 a.m., wound care observation was made with OSM #7, the wound care nurse. Resident #17's wound was now a stage 4 pressure ulcer (5) with the following measurements in centimeters: 4.4 x 4 x 1.8. The wound was documented as having No Change on the weekly wound summary and surgical debridement was performed at the bedside to assist with healing. On 5/6/21 at 3:05 p.m., an interview was conducted with the Wound Care Physician, OSM (Other Staff Member) #7. OSM #7 stated she was not following Resident #17's wound until he arrived back from the hospital with an unstageable. When asked if LPNs could stage wounds, OSM #7 stated that typically the RNs (Registered Nurses) staged wounds or staff would make a description of the wound when first found and wait for her to come in to stage. When shown OSM #7 the documented paperwork on 12/17/20 from the LPN regarding Resident #17's wound; OSM #7 stated that a stage three would have depth to it and the nurse documented a zero for depth. OSM #7 also stated that the treatment ordered however was for a wound at a three or higher. OSM #7 stated that [MEDICATION(S)] would be used to debride sloth and the calcium alginate would be used for drainage. OSM #7 also observed that it was documented that there was no drainage to this wound on 12/17/20. OSM #7 stated that the treatment orders wouldn't make sense if the wound was less than a three and if there was no drainage. On 5/7/21 at 9:00 a.m., an interview with conducted with LPN (Licensed Practical Nurse) #7, the nurse who first identified the wound to Resident #17's right buttock on 12/17/20. When asked what she saw upon the initial assessment, LPN #7 stated that she saw A lot of necrotic tissue upon her initial assessment. When asked if LPNs were allowed to stage wounds, LPN #7 stated that LPNs were not allowed to stage wounds, that an RN would have to go behind her and assess the wound as well. When asked why her documentation noted that a Stage 3 pressure was first identified to Resident #17's right buttock, LPN #7 stated she is not sure why she would document that; that she was not allowed to stage wounds. When asked if there was any depth or drainage to the wound when first seen, LPN #7 stated that she could not remember; that she didn't remember measuring the wound. LPN #7 stated that all she knew is that there was A lot of slough observed. When asked who was responsible for applying the [MEDICATION(S)] cream that was ordered prior to the development of the wound, LPN #7 stated that the nurses were responsible. LPN #7 confirmed that she had worked the day before 12/16/20 and signed that she had applied the [MEDICATION(S)] cream the 7-3 shift prior to 12/17/20. When asked if she noticed any skin areas then developing to Resident #17 right buttock, LPN #7 stated that she wouldn't know because there was already cream applied and rather than washing the cream off; she just applied more cream. LPN #7 stated that it wasn't until the next 7-3 shift that she saw the area right after the nursing aides had just cleaned him. LPN #7 stated that was when she realized that this was area was now a pressure area. LPN #7 stated that she made the RN wound care nurse aware but she wasn't sure if the wound care nurse was able to assess him before he left for the hospital. LPN #7 stated that she didn't put the wound care orders in, that she was limited on what she could do because she worked the COVID hall and didn't have access to the nursing station. LPN #7 stated that she believed she had called the family regarding the wound. On 5/7/21 at 9:20 a.m. ASM (Administrative Staff Member) #4, the Regional Director of Clinical Services was made aware for the potential for harm. On 5/10/21 at 11:26 a.m., an interview was conducted with RN #3, the former wound care nurse. RN #3 stated that if a new skin area is identified, the staff are supposed to alert an RN or at the time her as the wound care nurse, so she can go back behind and do an assessment. RN #3 stated that LPNs were not allowed to stage; only able to give a description of the wound. On 5/10/21 at 3:25 p.m., further interview was conducted with RN (Registered Nurse) #3, the former wound care nurse. RN #3 stated that she didn't get the time to reassess Resident #17's wound before he was sent out to the hospital. RN #3 could not recall the specifics of when the wound was found. This writer pointed out that the wound was found on the 7-3 shift on 12/1/20 and that the resident did not go out to the hospital until 9:45 p.m. When asked the timeframe an RN should go behind the LPN to reassess the wound; RN #3 stated as soon as available. On 5/10/21 at 6:41 p.m., an interview was conducted with the Acting DON (Director of Nursing) ASM #2. When asked if LPNs were allowed to stage wounds, ASM #2 stated that they were not. ASM #2 stated that if a CNA or LPN finds a new skin area, the area should be assessed by description and an RN and physician should be made aware to go back and assess. ASM #2 stated that he would then expect nursing staff to obtain orders and to continue to monitor the wound until resolved. On 5/10/21 at 5:59 p.m., ASM (Administrator Staff Member) #1, the Interim Administrator, ASM #2, the Acting DON (Director of Nursing) and ASM #4, the Regional Director of Clinical Services were made aware of the above concerns. No further information was presented prior to exit. Facility policy titled, Skin Program documented in part, the following: Identify residents at risk utilizing Braden scale. Implement Plan of Care interventions for residents identified at risk for Pressure Ulcers. A Licensed Nurse will complete a total body assessment on each resident on admission and weekly. C.N.A. (Certified Nursing Assistant) will observe resident skin condition daily during care and report skin conditions to the Licensed Nurse .All open areas will be identified and document on the appropriate forms- Pressure Ulcer Record/Non-Decubitus skin Condition Record. Resident(s) with wounds will have appropriate treatment. If there is deterioration, or no change in a change in a wound within 2 weeks, the treatment will be changed. Resident(s) with a wound acquired in the facility will be assessed to determine if pressure ulcers are unavoidable .Pressure Ulcer: Stage III First line of treatment .[MEDICATION(S)] agents .Stage III (3) -IV (4) First line of treatment .Calcium Alginate .UTS (Unstageable) First line of treatment Debride agent . *Pressure Ulcer/Injury- A pressure injury is localized damage to the skin and underlying soft tissue usually over a bony prominence or related to a medical or other device. The injury can present as intact skin or an open ulcer and may be painful. The injury occurs as a result of intense and/or prolonged pressure or pressure in combination with shear. The tolerance of soft tissue for pressure and shear may also be affected by microclimate, nutrition, perfusion, co-morbidities and condition of the soft tissue. https://npuap.org/page/PressureInjuryStages. The following below information was obtained from National Pressure Ulcer Advisory Panel website at http://www.npuap.org/pr2.htm (1) Unstageable Pressure Ulcer- Unstageable: Full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed. Further description: Until enough slough and/or eschar is removed to expose the base of the wound, the true depth, and therefore stage, cannot be determined. Stable (dry, adherent, intact without [CONDITION(S)] or fluctuance) eschar on the heels serves as the body's natural (biological) cover and should not be removed (2) Stage 3 -Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle are not exposed. Slough may be present but does not obscure the d [TRUNCATED]

Based on observation, staff interviews, clinical record review and review of the facility's policy, the facility staff failed to ensure the necessary treatment, care and services were provided to prevent development of pressure ulcers for 2 of 24 residents (Resident #24 and #31) that were identified at an advanced stage, resulting in harm. 1. For Resident #24, the staff failed to identify two pressure ulcers prior to being found at an advanced stage resulting in harm. The first wound was found on the left buttocks as an unstageable with a thin layer of eschar (hard black dead tissue) on 07/20/18. The second wound was found on 09/20/18 by the surveyor to the left outer bunion. The wound was found as an unstageable with eschar (hard black dead tissue). 2. The facility staff failed to identify Resident #31 a sacral pressure injury prior to it being found at an advanced stage resulting in harm. The pressure injury was found as a stage 3 pressure injury with 40 percent necrotic tissue. The findings included: 1. Resident #24 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED].*Dow[DIAGNOSES REDACTED], *Autistic disorder and *Muscle weakness. Resident #24's Minimum Data Set (MDS-an assessment protocol) with an Assessment Reference Date of 07/27/18 coded Resident #24 indicating short and long-term memory problems and cognitive skills severely impaired-never/rarely made decisions. In addition, the MDS coded Resident requiring total dependence of two with transfer, total dependence of one with bathing, personal hygiene, toilet use, dressing and extensive assistance of two with bed mobility. The MDS with an ARD of 07/27/18 under section M (Skin Condition - M0100) was coded: Resident has a stage 1 or greater pressure ulcer. Under section (M0150) at risk for developing pressure ulcers was coded yes, under section (M0210) for unhealed pressure ulcers was coded yes, under section (M0300) for having stage 2 (2) pressure ulcer and unstageable (1) pressure ulcer was coded yes. Under section (M0610) for dimension of unhealed stage 3 or 4 pressure ulcers or eschar was to identify the pressure ulcer with the largest surface area (length x width) was measured (4.0 cm x 2.0 cm x 0 cm). Under section (M0700) most severe tissue type for any pressure ulcer was coded 4 for eschar (black, brown, or tan tissue that adheres firmly to the wound bed or ulcer edges, may be shorter or harder that an surrounding skin) and under section (M1200) for skin and treatments was coded for having pressure reducing device for chair and bed, nutrition or hydration intervention to manage skin problems, pressure ulcer care, application of nonsurgical dressings and applications of ointments/medications other than feet and application of dressings to feet (with or without tropical medication). Resident #24's care plan initiated 7/27/17 was reviewed and included: conduct weekly skin inspection, moisture skin with lotion as needed; nutrition and hydration support; provide low air loss mattress; skin care after incontinent episodes and apply barrier cream; treatments as ordered. Resident #24's person-centered comprehensive care plan revised on 7/20/18 documented Resident #24 with actual skin breakdown to left buttocks (*pressure ulcer-stage 3) due to assistance required with bed mobility. The goal: pressure ulcer will heal without complication. Some of the intervention/approaches to manage goal included provide *Pressure air loss mattress, conduct weekly skin inspection and treatment as ordered. *Stage 3 Pressure Injury: Full-thickness skin loss Full-thickness loss of skin, in which adipose (fat) is visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. Slough and/or eschar may be visible. The depth of tissue damage varies by anatomical location; areas of significant adiposity can develop deep wounds. Undermining and tunneling may occur. Fascia, muscle, tendon, ligament, cartilage and/or bone are not exposed. If slough or eschar obscures the extent of tissue loss this is an Unstageable Pressure Injury. (http://www.npuap.org/resources/educational-and-clinical-resources/npuap-pressure-injury-stages/). A Braden Risk Assessment Report was completed on 04/29/18 and on 07/27/18; resident scored a nine indicating very high risk for the development of pressure ulcers. Mobility is completely immobile-does not make even slight change in body or extremity position without assistance. On 09/20/18 at approximately 4:30 p.m., a wound care observation was conducted with License Practical Nurse (LPN) #1. Resident #24 was lying in bed, positioned on her right side lying on an alternating low air loss pressure mattress. LPN #1 to perform wound care with the assistance of Certified Nursing Assistant (CNA) #6. Prior to starting wound care to the Resident #24, LPN #1 washed her hands x 24 seconds then used hand sanitizer and CNA #6 washed her hands x 20 seconds; both donned a new pair of gloves. The LPN repositioned the resident on her right side with the assistance of CNA #6. The CNA pulled the covers off Resident #24 legs. The surveyor observed a wound to residents left bunion without a dressing in place. The surveyor asked, What is the current treatment to the wound to Resident #24's left bunion LPN #1 replied, There is no treatment for [REDACTED]. The review of the clinical nurse's note evidenced an entry dated 09/20/18 at 8:22 p.m., indicated the following: The new wound measured 2.5 cm x 2.2 cm with two small inner areas to left bunion. The superior inner area is gray in color. The inferior inner area is black in color and the surrounding tissue is red. The wound physician was notified with the following new orders obtained: cleanse area with wound cleanser, pat dry, apply skin prep around peri wound, apply santyl to wound bed, cover with foam dressing and change daily and as needed. The review of the clinical nurse's notes evidenced an entry dated 09/21/18 at 3:52 p.m., written by the Director of Nursing (DON) indicated the following: Resident noted with an unstageable are to her left bunion, related to hard eschar to wound - area measured at 2.5 cm x 2.2 cm with wound edges intact. Wound without drainage or order. New order obtained to discontinue Santyl and begin *[MEDICATION NAME] daily. *[MEDICATION NAME] is a topical antiinfective (providone-iodine) (Mosby's Dictionary of Medicine, Nursing and Health Professions 7th Edition). The current treatment as of 09/21/18 read as follow: [MEDICATION NAME] 10% (Providone-Iodine) - apply to left bunion topically every day for wound car. Clean left bunion with wound cleaner, apply *skin prep to peri wound bed, apply [MEDICATION NAME] swab to eschar plate and leave on to air. *Skin prep is a thin liquid film-forming dressing that, upon application to intact skin, forms a protective film to help reduce friction during removal of tapes and films (http://www.smith-nephew.com/professional/products/advanced-wound-management/skin-prep/). A nurse's note dated 07/20/18 at 4:11 p.m., read, in part: Resident noted with an *unstageable area to left buttock measuring 4 cm x 2 cm, wound bed noted with thin layer of eschar. *Unstageable Pressure Injury: Obscured full-thickness skin and tissue loss. Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar. If slough or eschar is removed, a Stage 3 or Stage 4 pressure injury will be revealed. Stable eschar (i.e. dry, adherent, intact without [DIAGNOSES REDACTED] or fluctuance) on the heel or ischemic limb should not be softened or removed (http://www.npuap.org/resources/educational-and-clinical-resources/npuap-pressure-injury-stages/). On 07/20/18, the initial wound care assessment was completed by Director of Nursing (DON). It read, in part: left buttocks with unstageable measuring 4 cm x 2 cm with thin layer of eschar. Wound without drainage or odor. The current treatment plan is as follow: *Santly and *Calcium Alginate. The current treatment as of 08/02/18 read as follows: Apply santyl to wound bed and calcium alginate, cover with foam dressing daily to left buttocks. *Santyl is used to help the healing [MEDICAL CONDITION] ulcers. [MEDICATION NAME] is an enzyme. It works by helping to break up and remove dead skin and tissue. This effect may also help to work better and speed up your body's natural healing process (antibiotics <http://www.webmd.com/cold-and-flu/rm-quiz-antibiotics-myths-facts. *Alginate Dressings are composed of calcium alginate, a gelatinous and water-insoluble substance. When in contact with a wound, the calcium alginate in the dressing reacts with sodium chloride from the wound. This turns the dressing into a [MEDICATION NAME] gel that maintains a moist environment for the wound (www.medicaldepartmentstore.com/Alginate-Dressings-s/286.htm). The resident's wound was being cared for by the wound care specialist, and assessed on a weekly basis from 07/26/18 through 09/13/18. The wound care specialist documented the following: 1. On 09/13/18 - *Stage III to left buttocks, 4.5 cm x 7.0 cm x 0.1 cm with 40% granulation and 60% skin with moderate amount of sero-sanquinous exudate; wound condition - deteriorated. Recommendation: Off-load wound, reposition per facility protocol. 2. On 09/06/18 - Stage III to left buttocks, 3.5 cm x 2.5 cm x 0.1 cm with 10% granulation and 90% skin with moderate amount of sero-sanquinous exudate. *Hypergranulation tissue present within the wound margins; wound progress - no change. Recommendation: Off-load wound, reposition per facility protocol. Procedure: cauterization for hypergranulation tissue. Chemical *cauterization of hypergranulation tissue performed on buttock wound with topical anesthetic to facilitate healing. No complications or bleeding. 3. On 08/30/18 - Stage III to left buttock measuring 3.5 cm x 2.0 cm x 0.1 cm with 10% granulation and 90% skin with moderate amount of sero-sanquinous exudate. Wound condition - improved. Recommendation: Off-load wound, reposition per facility protocol. 4. On 08/16/18 - Stage III to left buttocks measuring 1.5 cm x 3.5 cm x 0.1 cm with 30% granulation and 70% skin with moderate amount of sero-sanquinous exudate. Wound condition - no change. Recommendation: Off-load wound, reposition per facility protocol, and obtained consent for debridement. 5. On 08/09/18 - Stage III to left buttocks measuring 2.5 cm x 0.9 cm x 0.1 cm with 100% granulation with moderate amount of sero-sanquinous exudate. Wound condition - improved. Recommendation: Off-load wound, reposition per facility protocol, obtained consent for debridement. 6. On 08/02/18 - Stage III to left buttocks measuring 6.0 cm x 2.5 cm x 0.2 cm with 100% granulation with moderate amount of sero-sanquinous exudate. Wound condition - improved. Off-load wound, reposition per facility protocol and obtained consent for debridement. Hypergranulation tissue present within the wound margins. Procedure: cauterization for hypergranulation tissue. Chemical cauterization of hypergranulation tissue performed on buttock wound with topical anesthetic to facilitate healing. No complications or bleeding. 7. On 07/26/18 - (Pressure-unstageable due to necrosis) to left buttocks measuring 4.0 cm x 2.0 cm x not measurable cm with light serous. Wound with thick adherent black necrotic tissue (eschar) 80% and thick adherent devitalized necrotic tissue 20%. Hyper-granulation (or overgranulation) is an excess of granulation tissue beyond the amount required to replace the tissue deficit incurred as a result of skin injury or wounding (https://www.ncbi.nlm.nih.gov/pubmed/ 928). Cauterization is the process of burning a part of the body cautery. A cautery is a device or agent used in the coagulation of tissue by heat or caustic substances (Mosby's Dictionary of Medicine, Nursing and Health Professions, 7th Edition). The facility administration was informed of the finding during a briefing on 09/07/18 at approximately 7:10 p.m. The facility did not present any further information about the findings. The surveyor asked the DON, what stage you expect your staff to identify a pressure ulcer, she replied, At a stage 1 but no greater than a stage 2. The facility did not present any further information about the findings. *Dow[DIAGNOSES REDACTED] is a chromosomal condition that is associated with intellectual disability, a characteristic facial appearance, and weak muscle tone ([DIAGNOSES REDACTED]) in infancy. All affected individuals experience cognitive delays, but the intellectual disability is usually mild to moderate (https://ghr.nlm.nih.gov/condition/down-syndrome). *Autistic disorder is a complex neurobehavioral condition that includes impairments in social interaction and developmental language and communication skills combined with rigid, repetitive behaviors (https://www.webmd.com/brain/autism/understanding-autism-basics). *Muscle weakness is reduced strength in one or more muscles (https://medlineplus.gov/ency/article/ 5.htm). *Pressure Injury: A pressure injury is localized damage to the skin and underlying soft tissue usually over a bony prominence or related to a medical or other device. The injury can present as intact skin or an open ulcer and may be painful. The injury occurs as a result of intense and/or prolonged pressure or pressure in combination with shear (http://www.npuap.org/resources/educational-and-clinical-resources/npuap-pressure-injury-stages/). *Low air loss mattress is an alternating pressure mattress systems are designed to heal and prevent bedsores (http://www.medicalairmattress.com/deluxe.html). 2. Resident #31 was originally admitted to the facility 8/6/18 and has never been discharged from the facility. The resident's [DIAGNOSES REDACTED]. The admission Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 8/13/18 coded the resident as not having the ability to complete the Brief Interview for Mental Status (BIMS). The staff interview was coded for long and short term memory problems as well as severely impaired daily decision making abilities. The resident was also coded for highly impaired hearing, no speech and rarely to never having the ability to understand others. Resident #31 was coded as having no mood or behavior problems. In section G (Physical functioning) the resident was coded as requiring total care of 2 people with transfers and toileting, total care of 1 person with locomotion, personal hygiene, and bathing, extensive assistance of 2 people with bed mobility and extensive assistance of 1 person with dressing and eating. In section M (Skin Condition) the resident was coded as having an unstageable pressure injury present and a potential for additional skin problems. The pressure ulcer coded upon admission was to the left heel. The most recent Risk for Pressure Ulcer tool, dated 8/6/18, revealed a score of 10 for Resident #31. This indicated the resident had a risk for pressure ulcer development because of very limited sensory perception, occasionally moist, chairfastness, immobility, dependence upon staff for provision of fluid intake, always incontinent of bladder and bowels, potential problems from friction when turned and repositioned. The facility staff presented only 2 weekly skin integrity checks since admission for Resident #31. They were dated 8/15/18 and 8/29/18. Both skin checks were checked; skin clear, no change of condition assessed. Review of the clinical record revealed a nurses' note dated 9/12/18 at 13:12, It read; called to resident's room by Certified Nurse's Assistant (CNA), resident noted with an open area to her sacrum, wound bed dark red, no odor, no drainage, edges uneven, jagged. Resident currently has zinc oxide to be applied each shift. Responsible party and Physician notified. Will have resident seen by the wound care physician. Clinical documentation revealed the wound care physician assessed Resident #31's sacral pressure injury 9/13/18. The wound care physician 9/13/18, progress note revealed the sacral pressure injury was a stage 3, measuring length 2.7 centimeters by width 2.0 centimeters by depth 0.2 centimeters. The progress note further stated the sacral pressure injury also presented with a moderate amount of sero-sangious drainage, 60 percent granulation tissue and 40 percent necrotic tissue. The wound care physician's progress note stated debridement of the necrotic tissue was recommended. On 9/13/18, the wound care physician ordered Alginate calcium, be applied once daily for 30 days, Santyl ointment, apply once daily for 30 days and a secondary dressing; Foam with silicone, apply once daily for 30 days. A physician's orders [REDACTED]. Clean sacrum with wound cleaner, apply skin prep to peri wound, cover wound bed with Santyl, then apply Alginate calcium, cover with border gauze. Change daily and as needed. The current care plan dated 8/17/18 read; Pressure ulcer actual or at risk due to assistance required in bed mobility, bowel incontinence, [DIAGNOSES REDACTED]. 9/14/18 sacrum pressure ulcer. The goal read; skin will remain intact. The interventions included; Braden scale per facility policy, Conduct weekly skin inspection. Float heels. Pillow prop as ordered. Provide pressure reducing wheelchair cushion. Provide pressure reduction/relieving mattress. Provide thorough skin care after incontinence episodes and apply barrier cream. Treatments as ordered. The facility staff didn't update the care plan with a new goal or interventions after the sacral pressure ulcer was identified and added as a problem. Resident #31's wound care was observed 9/20/18 at approximately 2:15 p.m. Registered Nurse (RN) #1 washed her hands, pulled down Resident #31's pants, removed the old dressing, removed her gloves, applied a new pair of gloves, cleaned up a small amount of stool, removed her gloves, apply another pair of gloves, applied wound cleanser to Resident #31's sacral pressure injury, wiped the pressure injury with 4 by 4 gauze and repeated the wound cleanser, then placed the wound cleanser in the bed, and wiped the pressure injury with 4 by 4 gauze. RN #1 removed her gloves applied another pair of gloves, used her gloved hands to tear the Alginate calcium, applied Santyl ointment (then placed the Santyl tube in the bed,) with cotton tip applicators, applied border gauze, removed her gloves, changed the resident's incontinence brief, pulled her pants up, and repositioned the resident in bed. the dressing wasn't dated or signed. RN #1 cleaned up the used products, discarding everything except the wound cleanser and the Santyl ointment. RN #1 didn't wash her hands or use hand sanitizer during the entire dressing change. An interview was conducted with Registered Nurse (RN) #1, on 9/20/18, directly after wound care for Resident #31 was completed. RN #1 stated she had to be someplace very soon and it was all she could think of. She also stated I will get training on wound care, since she will be assisting the wound care physician when she is in the facility. An interview was conducted on 9/20/18, at approximately 2:50 p.m., with the Director of Nursing. She stated the corporate consultant had identified they had a problem with skin checks not getting done. The Director of Nursing stated in-services were conducted on completing shower sheets by the CNA staff on shower days and the Wound Care Protocol. The Director of Nursing stated it is the facility's expectation for pressure injuries to be identified at an early stage, when the area is red or a stage1, not at a stage 3 or 4. The Director of Nursing also stated the first line of detecting skin impairment should be from direct care observations during daily care and skin checks and skin assessments. The facility's policy titled Pressure Sore Prevention-Quick Look (Revision-1/2017). -Assess skin daily (every shift and prn). Prevention (High Risk) -Interventions for Minimal and Moderate Risk -Place on pressure reducing chair device -Appropriate disciplines to scree - OT/PT -Care Plan to identify interventions -Increase turning and reposition On 9/21/18, at approximately 5:55 p.m., the above findings were shared with the Administrator and Director of Nursing. An opportunity was given for the facility to present additional information but none was provided. The National Pressure Ulcer Advisory Panel (NPUAP) NOTE: Based on current reported data, Stage I PrU likely began 12-24 hours prior Stage II PrU likely began 24 hours prior Stage III - IV PrU likely began at least 72 hours prior sDTI PrU purple tissue without [MEDICATION NAME] loss likely began 48 hours prior (file:///C:/Users/eyz /AppData/Local/Microsoft/Windows/INetCache/IE/NTPQV9PP/UPDATED-3-9-2014-RCA-Template.pdf) Definitions: Pressure Injury: A pressure injury is localized damage to the skin and underlying soft tissue usually over a bony prominence or related to a medical or other device. The injury can present as intact skin or an open ulcer and may be painful. The injury occurs as a result of intense and/or prolonged pressure or pressure in combination with shear. The tolerance of soft tissue for pressure and shear may also be affected by microclimate, nutrition, perfusion, co-morbidities and condition of the soft tissue. Stage 3 Pressure Injury: Full-thickness skin loss Full-thickness loss of skin, in which adipose (fat) is visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. Slough and/or eschar may be visible. The depth of tissue damage varies by anatomical location; areas of significant adiposity can develop deep wounds. Undermining and tunneling may occur. Fascia, muscle, tendon, ligament, cartilage and/or bone are not exposed. If slough or eschar obscures the extent of tissue loss this is an Unstageable Pressure Injury. Debridement=Debridement is the removal of devitalized/necrotic tissue and foreign matter from a wound to improve or facilitate the healing process. Zinc oxide-a protective barrier cream

Based on observation, clinical record review and staff interview, for 2 of 3 residents in the survey sample with pressure areas, facility staff failed to identify, assess and provide treatment for [REDACTED].#3 and failed to provide care in a manner to prevent infection for Resident #2 . The findings included; 1. Resident #3 developed a stage II on her coccyx area and a stage III on her right buttocks. Resident #3 fell [DATE] and fractured her pelvis she was treated surgically at the hospital and returned [DATE] to the facility as non weight bearing and with orders to use a wedge pillow while in bed. A wedge pillow is a triangular shape, with the narrow end at the top and the wide end (base) at the lower legs. Straps hold the legs along the sides and keep the hips in alignment specifically to prevent the legs from being crossed while in bed. Additional [DIAGNOSES REDACTED]. The significant change MDS with an assessment reference date of [DATE], completed when the resident was readmitted from the hospital evidenced a score of 13 of 15 on the interview for mental status and required the extensive assistance of two persons for bed mobility. The resident also was assessed as having pain in the last five days that made it hard to sleep at night and was rated seven on a scale of ,[DATE]. Resident #3 was assessed as at risk for pressure areas but did not currently have pressure areas. Review of the clinical record evidenced the resident was treated for [REDACTED]. Prior to her hospitalization and upon her return the treatment for [REDACTED]. "Cleanse buttocks/perineum with 4-n-1 cleaner, pat dry, apply [MEDICATION NAME] protection." (May keep at bedside) [MEDICATION NAME] is a thick paste that acts as a moisture barrier. This type of treatment can be done by certified nursing assistants or CNAs. On [DATE] this order was changed to include [MEDICATION NAME] ([MEDICATION NAME] - brand name) with the instructions to apply the [MEDICATION NAME] to the rash and then apply the Calazine with both products to be kept at bedside. The application of the [MEDICATION NAME] (as a treatment) would need to be applied by licensed nurses. Review of the [DATE] and [DATE] treatment record evidenced the two products were signed as applied per the physician's orders [REDACTED]. Review of the wound physician's [DATE] notes evidenced, "Stage II pressure ulcer of the medial sacrum 3.1 x 1.1 x 0.1 (L x W x D) surface area 3.41 cm." Etiology was, "pressure", Duration was "> (greater than) 1 days." Site 2 was "pressure wound of the right buttock, stage III", duration > 1 days 1.2 x 0.7 x 0.1 surface area 0.84 cm, light serous exudates with thick adherent devitalized necrotic tissue 100%. The physician surgically removed or debrided the necrotic tissue and noted residual necrosis was present and scored (cut to allow the Santyl to penetrate). Santyl is a chemical agent ordered to remove the remaining necrotic tissue to promote wound healing. "Surgical excisional debridement of subcutaneous tissue." Even though facility staff was documenting daily application of [MEDICATION NAME] and/or [MEDICATION NAME] creams daily in same area as the pressure areas, the resident was not determined to have wounds until seen by the physician. One of the two wound was at an advanced stage, Stage III, and required debridement. Review of the nursing notes since the resident's return from the hospital did not evidence nursing staff identified the areas and there was no documentation of the two areas prior to [DATE]. Further review of the clinical record evidenced that in [DATE] two new pressure area were identified on the pressure tracking sheet. One was a stage II on the resident's coccyx and the second a stage III on the resident's right buttocks. A Stage II pressure area is a particial thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed without slough. Stage II's may also present as an intact or open blister. A Stage III is a full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining or tunneling. Slough is necrotic/avascular tissue in the process of separating from the viable portions of the body and is usually light colored, soft, moist and stringy (at times). Debridement is the removal of devitalized /necrotic tissue and foreign matter from a wound to improve or facilitate the healing process. One method is enzymatic (chemical debridement refers to the topical application of substances such a enzymes to break down devitalized tissue. On [DATE] at 4:30 p.m. a dressing change was observed on Resident #3. The resident was on her left side and held her self in place with the half side rail. The Calazine (which is thick and a light pink color) was visible in the glutaneal fold. The duoderm dressing on the coccyx was loose as was the dressing on the right buttock. LPN # 4 stated she would be replacing both even though the duoderm was scheduled for every third day. The skin in the gluteal fold was bright red (inflamed appearing) and the redness extended out onto the buttocks for over an inch. The resident had a bowel movement and the nurse cleaned her prior to completing the dressing change. The stage II in the coccyx area could not be seen without separating the gluteal fold but the stage III was easily seen and was irregular in shape but approximately the size of a quarter and covered in slough. The area around the ulcer was reddened. On the right buttock was dried peeling skin with two elongated areas that the nurse stated were "scratches." The open area on the left buttock was also identified as a scratch or a "macerated" area. Neither area was identified on the tracking sheet or in the nursing notes. Following the dressing changes LPN #4 applied the [MEDICATION NAME] but did not apply the [MEDICATION NAME] cream and replaced the resident's brief. On [DATE] at 11:20 a..m. LPN#5 was interviewed and requested to show the surveyor the [MEDICATION NAME] cream. LPN #5 first looked in the treatment cart drawer but found only the empty box. The surveyor accompanied LPN #5 to the resident's room where the [MEDICATION NAME] cream was located in the resident's bedside cabinet. The tube of [MEDICATION NAME] was labeled as delivered by the pharmacy on [DATE] and with a refill date not before [DATE]. The tube was noted to almost full, that is not flattened as if repeatedly squeezed three times a day for 8 days.. The surveyor took the [MEDICATION NAME] tube to the Director of Nurses, Administrator and corporate nurse. The DON stated that she would have to investigate the situation before commenting but did stated that it appeared that "very little" had been used. At 1:40 p.m. LPN #5 was again interviewed and stated that on [DATE] she noted that the resident's rash was getting worse and she contacted the attending physician and received the order for the [MEDICATION NAME] cream. LPN #5 also stated that she reported this to the Unit Manager (UM). The UM confirmed this and stated that she placed the resident on the list to be seen by the wound physician the following Monday ([DATE]). The UM stated that she did not at that time or later observe the resident's buttocks. The Assistant Director of Nurses stated that the first time the two areas were seen was with the wound care physician on [DATE]. There had been no reports from the CNAs or the nurses about the development of the two open areas. The DON stated that she believed that her nurses were applying the [MEDICATION NAME] every shift as documented but would question the amount of [MEDICATION NAME] being used. The resident was compromised. Her oral intake was poor and she did refuse care at times but the DON stated she did allow herself to be repositioned. The DON stated the two areas must have developed developed between Sunday night and Monday morning. During an interview on [DATE] at 4:05 p.m. LPN #6, who cared for the resident on Sunday night ([DATE]), stated she "honestly" could not remember anything unusual, "I think we were just putting some cream on her." The CNA (#6) who cared for the resident on Saturday and Sunday was interviewed on the phone and stated she had not noted anything but the rash and had not reported anything to the nurses. A second surveyor observed the resident's rash and pressure areas on [DATE] at 3:40 p.m.. The resident's buttocks were excoriated, a dark purple/deep red and non blanchable around her sacrum. Between the residents legs, groin area and labial folds the skin was also excoriated and a deep purple red. The stage III was an irregular shape and slightly bigger than a quarter. Also identified were the elongated scratches and open area on the left buttock. There was no documentation in the nursing notes or on the pressure tracking sheet regarding the area on the left buttocks or the "scratches." During an interview with the DON later that afternoon she confirmed that there was no additional documentation. 2. a. The facility staff failed to prevent pressure from the wound V.A.C. tubing. Resident #2 was observed laying on the tubing of the Vacuum Assisted Closure (V.A.C.) system directly leading from a Stage IV sacral pressure ulcer. The V.A.C. therapy system is an integrated wound management system to optimize benefits of negative pressure wound therapy. Foam (Black, white, silver) is cut to fit the wound, then covered with an adhesive drape. The open cells of the foam enable equal distribution of negative pressure across the surface of the wound, while tubing transfers accumulated fluids to the V.A.C. canister. The Therapy unit (box) applies negative pressure to the wound bed and can be set on continuous or intermittent therapy, depending on the needs of each patient. The SensaT.R.A.C. over the wound helps to monitor and maintain target pressures and relay signals (includes tubing blockages, missing canister, inactive therapy, low battery, leaks in the seal of the dressing) to the therapy unit. A Stage IV pressure ulcer is a full thickness loss with extensive destruction, tissue necrosis, or damage to muscle, bone, or supporting structures. Undermining and sinus tracts also ay be associated with Stage IV pressure ulcers. Resident #2 was admitted to the nursing facility on [DATE] with [DIAGNOSES REDACTED]. Resident #2 acquired a heel pressure ulcer on [DATE] and a sacral pressure ulcer on [DATE]. The most recent Minimum Data Set (MDS) assessment was an annual dated [DATE] coded Resident #2 on the Brief Interview for Mental Status (BIMS) with a score of 01, which indicated she was severely impaired in memory and cognitive skills for daily decision making. She required extensive assistance from two staff for bed mobility and dressing. She was assessed totally dependent on two staff for transfers, bathing, toilet use, and dependant on one staff for personal hygiene and eating. Resident #2 was coded with an indwelling urinary drainage catheter and always incontinent of bowel. She was assessed with [REDACTED]. She was coded for pressure reducing devices to chair and bed, ulcer care, application of non-surgical dressing, ointments and medications. The revised care plan dated [DATE] identified Resident #2 had a Stage IV pressure area and was at risk for further breakdown. The goal was Resident #2 would remain free of infection and further avoidable pressure areas. Some of the approacheds to be used to accomplish this goal included turning and repositioning schedule per assessment, provide pressure reduction/relieving mattress, skin assessment to be completed per policy and treatments as ordered by the physician to include a wound V.A.C. ([DATE]). Resident #2 had an indwelling urinary catheter to assist in wound healing. The following observations were made of Resident #2: On [DATE] at approximately 2:00 pm, the resident was observed in bed positioned on her right side. She was observed to be small and frail. The V.A.C. therapy unit was sitting on the night stand, located to the right side of the resident. The hard plastic tubing from the V.A.C. canister could be followed directly under the resident's right side hip to the sacral wound. There was no foam bridging protecting the skin. The unit was set on 150 millimeters of mercury (mmHg) negative pressure. Brown/reddish drainage was observed in the tubing and canister. On [DATE] at 9:30 am, the resident was laying on her right side with the tubing position observed unchanged. CNA #5 provided perineum care after a bowel movement at this time and when the resident was turned for care; a prominent red streak was observed where the the resident had been laying on the tubing. On [DATE] at 1:30 pm, pressure ulcer wound care was performed by LPN #1 assisted by the Assistant Director of Nursing (ADON). When the resident was turned off her right side, the red streak was obvious to both licensed staff. They stated the facility was not used to having a resident with a wound V.A.C. to sacral area, but usually had V.A.C.'s on resident's with abdominal dehisced wounds. The ADON stated, "That's why we have the pre-prepared bridge dressing now because she should not have been laying on the pad or the tubing, especially due to her small size and risk for skin injury and breakdown. We ordered it on [DATE], but because of the holiday, it did not come in until today." During an interview with the ADON on [DATE] at 11:10 am, she stated the wound V.A.C. Freedom system she ordered on the [DATE] came with a small Granu (Black)-Foam dressing and did not allow for a bridge from the sacral wound to the front of her body. She also said she needed the White-Foam dressing for the undermining portion of the pressure ulcer. She said, "I have never created a bridge from a sacral wound and I don't know how to do it. I will be checking with the (clinical consultant's name). We could have called the doctor and got orders for wound care until the bridge dressing came in, but we will get the education we need." On [DATE] at 12:00 pm, the company representative for the wound V.A.C. system was called to check the wound V.A.C. system. He stated the black foam needed to create bridges was available and could be called if there was a delay in delivery. He said, "Most products can be ordered overnight, but the resident absolutely should not lay on the T.R.A.C. pad or tubing." The professional clinical guidelines the V.A.C. therapy system indicated a bridge provides the application of the necessary negative pressure wound therapy to those wounds, which because of their anatomical location, require that the SensaT.R.A.C. Pad and tubing be placed at a remote location, such as with sacral wounds, wounds on the foot or wounds requiring off-loading or compression therapy. b. On [DATE] at 1:30 pm, pressure ulcer wound care was performed by LPN #1 assisted by the Assistant Director of Nursing (ADON). LPN #1 failed to prevent the chances of cross contamination by not disinfecting her personal scissors before and after a dressing change; she failed to catch and dispose of irrigating solution; did not clean off the over bed table after dressing procedure and did not ensure reusable supplies were returned clean to the resident's personal treatment equipment drawer. LPN#1 donned with gloves and prepared bedside table with items needed for the dressing change procedure; she asked the ADON to remove the scissors out of left uniform pocket. Without disinfecting the scissors, LPN#1 proceeded to cut the white foam dressing for the tunneling portion of the wound, cut the black foam dressing applied over the entire wound bed and pried loose the old drainage canister. During the dressing change procedure, she intermittently laid the scissors on the white towel, that had been placed on the over bed table, with the wound care supplies. During the wound care, LPN #1 irrigated the wound with a syringe of Dakins solution into the existing diaper and closed up the same diaper at the completion of the wound care and application of the wound V.A.C. Dakin's solution is used to prevent and treat and tissue infections that could result from cuts, scrapes and pressure sores. It is made from bleach that has been diluted and treated to decrease irritation. Chlorine, the active ingredient in Dakin's solution, is a strong antiseptic that kills most forms of bacteria [MEDICAL CONDITION]. Pour, apply or spray onto the injured area. When used on wounds, Dakin's solution can be poured onto the affected area as an irrigation or cleanser. It is also used to wet certain types of wound dressings (e.g., wet to moist dressing) (webmd.com). Prior to leaving the room, the LPN placed the scissors on the over bed table as she replaced the residents water pitcher and cups. The over bed table was not cleaned after completion of wound care. She transferred the scissors from the room and laid them on the top of medication cart, along with the bottle of Dakins solution, 4 x 4's and hand sanitizer, after which she placed these items in the resident's treatment drawer. LPN#1 proceeded to another resident's room and while at the bedside she started to use her scissors to cut a piece of [MEDICATION NAME] gauge and place over a leg wound. She abruptly stopped and commented she had not cleaned her scissors when first removed from her pocket or after Resident #2's dressing procedure. Irrigating solution should be flow through the wound into a collection receptacle and dispose of equipment and soiled supplies. Once the hands are soiled, they should not come in contact with the remaining clean dressings and other supplies. Individual patients should have their own dressing supplies that are protected from contact contaminants. Agency for Health Care Policy and Research (AHCPR) clinical practice guidelines 1994.

Based on observation, staff interview, clinical record review and facility document review the facility staff failed to provide the necessary care and services to promote the healing and prevent infection of pressure ulcers for 2 of 10 active residents in the survey sample (Residents #103 and 104). 1. The facility staff failed to follow the physician orders [REDACTED].#103's right outer heel area (the pressure ulcer stage is unknown due to coverage of wound bed by slough and/or eschar-dead tissue.) 2. The facility staff failed to follow the physician orders [REDACTED].#104. The findings include: 1. Resident #103 a [AGE] year old originally admitted to the facility on [DATE] with a readmission date of [DATE] with [DIAGNOSES REDACTED]. Review of the current MDS (Minimum Data Set) an admission with an assessment reference date of 1/10/12 assessed the resident as having severely impaired cognition. The resident required extensive assistance of 2 staff for bed mobility, is dependent on staff for transfers and bathing. Resident #103 required extensive assistance with dressing, eating and toileting. The resident was incontinent of stool and had an indwelling Foley catheter for bladder management. Under section M. skin conditions the resident was assessed as being at risk for the development of pressure ulcers and was being treated for [REDACTED]. May also present as an intact or open/ruptured blister.) The plan of care (POC) dated 1/16/12 identified the resident was at risk for the pressure ulcers due to assistance required in bed mobility and [DIAGNOSES REDACTED]. On 1/9/12 the resident was identified with "ischemic areas" to the right outer heel and ankle. The goal was the resident would not acquire any avoidable pressure ulcers and the arterial ulcers would heal without complications. Two of the approaches listed were to consult the wound care specialist and provide treatments as ordered. Review of the wound care specialist initial evaluation dated 1/16/12 indicated the resident had an unstageable DTI (deep tissue injury) to the right lateral heel. The etiology was pressure. The wound measured 1.5 cm (centimeters) in length and 2.0 cm in width and was described as blood filled. Duration was greater than 1 day. The treatment was to apply skin prep every shift. On 2/20/12 the wound care specialist evaluation of the right lateral heel was conducted. The wound was described as unstageable (due to necrosis), etiology was pressure. The wound measured 1.0 cm in width x 1.3 cm in length x 0.1 cm in depth. Surface area 1.30 cm 2, exudate-light scab with thick adherent black necrotic tissue 100%. A surgical excisional debridment of the subcutaneous tissue was performed to remove the necrotic tissue and establish the margins of viable tissue. The treatment was to discontinue the skin prep, and apply a [MEDICATION NAME] soaked gauze daily. Review of the treatment administration record (TAR) for February 2012 evidenced a treatment order dated 2/20/12 for the right outer heel. The order was to cleanse the right outer heel with Saf-clens, pat dry with 4 x 4 gauze, apply [MEDICATION NAME] soaked gauze to area and cover with 3.6 x 4 inch Mepore daily and PRN (as needed) until healed. The dressing was scheduled to be changed on the 3pm-11pm shift. On 2/23/12 at 3:30 P.M., the dressing change observation for Resident # 103 was conducted. The licensed practical nurse (LPN#2) removed the pressure relieving boot to the resident's left foot, changed the dressing to the resident's left heel and then put away the supplies. While at the treatment cart the nurse was asked about the dressing change to the right lateral heel. At this time the 3pm-11pm nurse (LPN#1) assigned to care for Resident #103 on 2/21 and 2/22 was standing by the treatment cart and stated, "She (Resident #103) doesn't get a dressing to the right heel, she only get's skin prep." The TAR was reviewed by both the nurses. The TAR evidenced a nurses initial on 2/20/12, 2/21/12, and 2/22/12 indicating the right outer heel dressing was changed according to the physician orders. LPN#1 was asked to read the current treatment order dated 2/20/12. She read it and stated she had initialed the right outer heel dressing was changed on 2/21 and 2/22. She stated she did not apply a dressing to the right outer heel and had only applied skin prep. The nurse failed to read and follow the physician's orders [REDACTED]. LPN#2 and this surveyor went back into the resident's room and assessed the right outer heel. The right pressure relief boot was removed and the outer heel wound did not have a dressing on it. The pressure ulcer wound bed was observed to have a thickened light colored hard tissue covering it with a small amount of light brownish colored tissue to the distal end of the wound. The wound was irregular in shape and approximately 1.0 cm x 1.0 cm. 2. Resident #104 an [AGE] year old admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Slough or eschar-dead tissue may be present on some parts of the wound bed. Often includes undermining and tunneling.) Review of the quarterly MDS (Minimum Data Set) with an assessment reference date of 2/03/12 assessed the resident as dependent on staff for bed mobility, transfers, dressing, eating, toileting, personal hygiene and bathing. Under skin conditions the resident was assessed as having a stage IV pressure ulcer. Review of the plan of care (POC) dated 1/17/11 identified the resident as having a stage IV pressure ulcer. The goal was the pressure ulcer will remain free of infection and the resident would remain free from further avoidable pressure ulcers. One of the interventions to achieve the goals was to apply treatments as ordered. Review of the clinical record evidenced the wound care specialist was consulted for the management of the chronic pressure ulcer. The wound care specialist evaluation dated 2/20/12 indicated the stage IV pressure ulcer measured 1.7 cm x 2.5 cm x 0.5 cm with undermining at 12 o'clock measuring 3.3 cm. The wound had light sero-sanguineous exudate with 100% granulation tissue. There was no maceration observed. The treatment was to continue to clean with Dakins solution, [MEDICATION NAME] blue dressing once a day. Review of the physician orders [REDACTED]. On 2/23/12 at 4:21 P.M., the coccyx pressure dressing change was observed. LPN #2 obtained the needed supplies and placed at the bedside. The dressing was removed and the wound was cleaned, irrigated and packed as ordered. The peri-wound was a darker pinkish color then the surrounding tissue. The nurse then covered the wound with the 4 x 4 [MEDICATION NAME] dressing, and supplies were placed back into the treatment cart. The nurse failed to apply the Zguard protective paste to the peri-wound. Immediately following the dressing change the nurse was interviewed. The failure to apply the Zguard was discussed. She was asked to described the condition of the periwound. The nurses response was, "I did not do perineal care". The surveyor explained to the nurse what the peri-wound was. She stated, "I forgot to apply the protective ointment (Zguard)". Further questioning evidenced the nurse had been applying the Zguard to the skin surrounding the dressing and not the peri-wound as ordered. On 2/23/12 at approximately 5:00 P.M., the dressing change observations for Resident's #103 and #104 was shared with the director of nurses (DON). The DON indicated the nursing staff needed further education.