Every finding on record at Belvoir Woods Health Care Center at the Fairfax

Based on observation, resident interview, and staff interview it was determined that the facility staff failed to post the required State Survey Agency, the State licensure office, and the Office of the State Long-Term Care Ombudsman program information in a place that is accessible to all residents.The findings include:During an observation of the third floor on 3/11/2026 at approximately 9:30 am, the list of names, addresses (mailing and email), and telephone numbers of the State licensure office, and the Office of the State Long-Term Care Ombudsman program information was observed to be posted behind the concierge's desk on the wall, inaccessible to the residents. No other signage with the required information was hung on the third floor.During the Resident Council Meeting on 3/11/2026 at approximately 11:07 am, 10 out of 10 residents were unable to identify where the list of names, addresses (mailing and email), and telephone numbers of the State licensure office, and the Office of the State Long-Term Care Ombudsman program information was located. They were unaware that they had the right to file a complaint with the State licensure office or with the State Long-Term Care Ombudsman.At approximately 11:53 am, after the meeting, the Activities Director (AD) took Residents #18 and #39 to see the Ombudsman Information location. The residents were positioned in their wheelchairs in front of the concierge's desk, and the Activities Director walked over to the information desk, pointed to the sign, and explained its contents. Residents #18 and #39 were unable to see the information on the signage from their position. Concierge #2 stated that the residents are not allowed behind the desk. Concierge #2 also stated the residents must ask for the information and phone numbers if they need it, and during the 5 years of her working for the facility, no one has asked her for it. Concierge #2 stated they keep the door to the dining room behind the desk locked so residents cannot go behind the desk. The AD stated that there is another copy outside her office on the 2nd Floor for Assisted Living.During the end-of-day meeting on 3/13/2026 at approximately 11:30 am, the Director of Nursing (DON), Assistant Director of Nursing (ADON), and Administrator were informed of the above. The administrator stated that the Activity Director hands out cards with the Ombudsman information from time to time, and the Ombudsman does come and do rounds.

Based on resident and staff interviews and a review of clinical records, the facility staff failed review and revise the person-centered care plan for 4 for 38 residents (Resident #7, #10, #11 and #43), in the survey sample.1. The facility staff failed to review and revise Resident #7's care plan to include an election of hospice services with an admission to hospice services on 3/8/26.Resident #7 was initially admitted to the facility on [DATE], after an acute care hospital stay. The residents' current diagnoses included Alzheimer's disease, heart failure, and diabetes. The quarterly Minimum Data Set (MDS) assessment, with an assessment reference date (ARD) of 12/22/2025, coded that the resident completed the Brief Interview for Mental Status (BIMS) and scored 3 out of 15. This indicated that Resident #7's cognitive abilities for daily decision-making were severely impaired. A review of the active care plan, with a target date of 3/26/26, failed to identify a care plan addressing the residents' admission to hospice services. The nurse's notes revealed the clinical staff had been working with the resident's Power-of-Attorney since 2/4/26 because of her decrease in oral intake, episodes of MASD, and an overall decline noted by staff. The resident was admitted to hospice services on 3/8/26. On 3/18/26 at approximately 4:00 PM, the above information was conveyed to the Administrator, the DON, ADON, and two corporate consultants. An opportunity was offered for the Team to provide additional information, but they did not. The facility's team nodded in agreement with the non-compliance. 2. The facility's staff failed to review and revise Resident #10's care plan to include a fall from the bed to the fall mat on 3/13/26, and to develop interventions for episodes of orthostatic hypotension. Resident #10 was admitted to the facility on [DATE] after an acute care hospital stay. The residents' diagnoses included diabetes, high blood pressure with episodes of orthostatic hypotension, and impaired mobility and self-care secondary to Fusion of the lumbar spine. The admission Minimum Data Set (MDS) assessment, with an assessment reference date (ARD) of 1/6/26, coded that the resident completed the Brief Interview for Mental Status (BIMS) and scored 5 out of 15. This indicated that Resident #10's cognitive abilities for daily decision-making were severely impaired. A review of the active care plan with a target date of 6/17/26 failed to reveal a care plan that addressed the resident's fall on 3/13/26, and the resident's care plan failed to address that the resident had a diagnosis of hypertension but experienced episodes of orthostatic hypotension. The nurse's notes revealed the resident experienced an unwitnessed fall on 3/13/26, and on 3/17/26, it was not documented on the care plan. The 3/13/26 fall nurse's note stated that no changes to the care plan were needed. An interview was conducted with the Rehabilitation Director on 3/11/26 at 10:00 AM. The Rehab Director stated the resident was unable to tolerate therapy, was resistant to sitting up on the side of the bed or wheelchair, had episodes of low blood pressure, stated ill-feeling while sitting up, and would vomit. On 3/18/26 at approximately 4:00 PM, the above information was conveyed to the Administrator, the DON, ADON, and two corporate consultants. An opportunity was offered for the Team to provide additional information, but they did not. The facility's team nodded in agreement with the non-compliance. 3. The facility staff failed to review and revise Resident #11's care plan to include intolerance to the use of a hearing aid and dentures.Resident #11 was admitted to the facility on [DATE] after an acute care hospital stay following a new L1 compression fracture and a right 11th rib fracture secondary to a fall. The residents' diagnoses included vascular dementia, mild protein-calorie malnutrition, and a hearing loss. The annual Minimum Data Set (MDS) assessment, with an assessment reference date (ARD) of 2/5/2026, coded that the resident completed the Brief Interview for Mental Status (BIMS) and scored 0 out of 15. This indicated that Resident #11's cognitive abilities for daily decision-making were severely impaired. The MDS assessment at B0200. Hearing has minimal difficulty.A review of the active care plan, with a target date of 5/2/26, failed to document that the resident did not tolerate her dentures and hearing aid. A care plan intervention stated that the resident requires assistance with applying, removing, and cleaning her denture.Over the course of the survey, 3/10/26 through 3/13/26 and 3/16/26 through 3/18/26, the resident was seen without dentures at each visit, and she was observed putting foods she was unable to chew well in the napkins on the tray. It was also observed that the resident was experiencing extreme difficulty communicating with the speaker due to her inability to hear what was said. On 3/17/26 at approximately 11:25 AM, the private duty sitter stated that the resident's son said it was okay for the resident not to wear the dentures and hearing aid because, on multiple occasions, she had removed both appendages and thrown them in the trash can. On 3/17/26 at approximately 2:05 PM, the concern was addressed with the DON. The DON stated that she was unaware of the concern, but the private sitter shared the same information with her, and she would follow up with the resident's son. On 3/18/26 at approximately 4:00 PM, the above information was conveyed to the Administrator, the DON, ADON, and two corporate consultants. An opportunity was offered for the Team to provide additional information, but they did not. The facility's team nodded in agreement with the non-compliance. 4. The facility staff failed to review and revise Resident #43's care plan to reflect that he does not receive hospice services.Resident #43 was admitted to the facility on [DATE] after an acute care hospital stay. The residents' diagnoses include atrial fibrillation, stage 4 chronic kidney disease, and heart failure. The annual Minimum Data Set (MDS) assessment, with an assessment reference date (ARD) of 12/12/2025, coded that the resident completed the Brief Interview for Mental Status (BIMS) and scored 15 out of 15. This indicated that Resident #43's cognitive abilities for daily decision-making were intact. A review of the active care plan, with a target date of 6/5/26, stated that the resident was receiving hospice services for multiple problems. A nutrition note dated 3/10/25 revealed that the resident was discharged from hospice services on 3/4/25. On 3/17/26 at approximately 2:05 PM, the concern was addressed with the DON. The DON stated that the resident was no longer receiving hospice services. On 3/18/26 at approximately 4:00 PM, the above information was conveyed to the Administrator, the DON, ADON, and two corporate consultants. An opportunity was offered for the Team to provide additional information, but they did not. The facility's team nodded in agreement with the non-compliance.

Based on resident and staff interviews and a review of the clinical record, the facility staff failed to provide the necessary activities of daily living (ADLs) for 4 dependent residents (Resident #16, Resident #67, Resident #49 and Resident #45) of the 38 residents in the survey sample. 1.The facility staff failed to provide at least 2 showers a week and to wash the residents' hair since admission. Resident #16 was initially admitted to the facility on [DATE] after an acute care hospital stay. The residents' current diagnoses included repeated falls and unsteadiness on feet. The admission Minimum Data Set (MDS) assessment, with an assessment reference date (ARD) of 03/04/26 was coded that the resident completed the Brief Interview for Mental Status (BIMS) and scored 12 out of 15. This indicated that Resident #16's cognitive abilities for daily decision-making were intact. The resident's personal care plan dated 2/26/26 with a focus on bathing had a Goal specifying resident will gain increased functional ability to be able to complete her own bathing. Some interventions included It is very important to the resident to choose between a tub bath, shower, bed bath, or sponge bath; the resident requires a shower/tub chair for bathing, the resident's shower/tub chair will be kept clean and available as needed and stored when not in use. An interview was conducted with Resident #16 on 03/11/2026 at approximately 12:09 pm. Resident #16 said that the staff was counting on her to ask for showers. The resident mentioned that I thought that I had shower days. The resident also said that she's been taking baths with a basin. The resident also said when she's home, she likes to wash her hair when she takes showers. The resident also said I've been using wash clothes to run through my hair. I told my aide today that I wanted to take a shower. I don't refuse showers I love showers. A review of the Activity of Daily Living (ADL) document for February 2026 revealed that the resident had showers scheduled for Wednesday and Saturdays during the 7:00 am to 3:00 pm shift. The ADL documentation dated 2/28/26 was coded as 01, meaning shower/bathe self. A review of the Activity of Daily Living (ADL) document for March 2026 revealed that the resident had showers scheduled for Wednesday and Saturdays during the 3:00 pm to 11:00 pm shift. The ADL documentation dated 3/07/26 was marked (NA). On 3/13/26 at approximately 11:00 am., during the end of day meeting with the administrator, the Director of Nursing (DON) and Assistant Director of Nursing (ADON) concerning showers. The ADON said that shower preferences are based on what's best for the resident. The ADON also said that Resident #16 was getting showers on Monday and Saturdays from 3:00 pm to 11:00 pm but voiced yesterday that she prefers daytime showers. The ADON also stated that showers were not documented for the resident. 2. The facility staff failed to provide at least 2 showers a week since admission. Resident #67 was initially admitted to the facility on [DATE] due to a right intertrochanteric femur fracture. The residents' current diagnoses included repeated falls and unsteadiness on feet. The admission minimum data set (MDS) assessment with an assessment reference date (ARD) of 3/8/2026 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 15 out of the possible 15. This indicated Resident #67 cognitive abilities for daily decision making were intact. The resident's personal care plan dated 3/2/2026 read that resident requires partial/moderate assistance bathing. In section GG (Functional Abilities and Goals) the resident was coded as requiring required partial/moderate assistance with showering/bathing. During an observation and interview with Resident #67 on 3/12/2026 at approximately 11:02 am Resident #67 stated he went to the shower room and received a shower for the first time this morning since admission. Resident #67 stated It was a very thorough washing, and it made him feel clean and great. Resident reports that his preference is showers. Resident stated staff have not bathed him before today in the shower room or in bed, but he has been able to shave, use a washcloth to wipe himself down and brush his teeth in the bathroom. During an interview on 3/12/2026 at approximately 11:28 am Certified Nursing Assistant (CNA) #6 stated that staff document a shower or a refusal in the computer system in the medical record. CNA #6 states that there is a set schedule for each side of each hallway. Showers/baths are also provided if the family or resident requests a shower/bath or if there is an accident/need for a shower/bath. CNA #6 states the shower schedule is on the board in each of the rooms and staff ask the residents what time they want to get a shower/bath. During an observation and interview on 3/12/2026 at approximately 11:34 am Resident #67's board did not have his shower/bath days listed. Licensed Practical Nurse (LPN) #6 was in the room and states that some residents have them scheduled on the board and others do not but that the schedule is in the CNA computers. LPN #6 confirmed that Resident #67's shower/bath schedule is Monday and Thursdays on the 7:00 am-3:00 pm shift. A review of the Activity of Daily Living (ADL) document for March 2026 revealed that the resident had showers scheduled for Monday and Thursdays on the 7am-3pm shift. The ADL documentation reflected the resident received his first shower/bath on 3/12/26 which was coded as 04, supervision or touching assistance. A review of the Activity of Daily Living (ADL) document for March 2026 revealed that the resident had showers scheduled for Monday and Thursdays on the 3:00 pm to 11:00 pm shift, as needed. The ADL documentation dated 3/03/26 was marked (NA). At the end of day meeting on 3/13/2026 the DON (Director of Nursing), ADON (Assistant Director of Nursing), and Administrator were informed of the above. The DON, ADON, and Administrator were given the opportunity to provide any additional information. No further information or documentation was provided. 3. The facility staff failed to give showers/tub baths to Resident #49. Resident #49 was initially admitted to the facility on [DATE] after an acute care hospital stay. The residents' current diagnoses included Alzheimer's dementia and paroxysmal atrial fibrillation. The admission Minimum Data Set (MDS) assessment, with an assessment reference date (ARD) of 2/25/26, coded that the resident completed the Brief Interview for Mental Status (BIMS) and scored 3 out of 15. This indicated that Resident #49's cognitive abilities for daily decision-making were severely impaired. In section GG0130. Self-Care: the resident was coded as dependent with toileting hygiene, shower/bathe self, and lower body dressing; requires substantial/maximal assistance with eating, upper body dressing, personal hygiene, and putting on/taking off footwear; and partial/moderate assistance with oral hygiene. The resident's person-centered care plan, dated 2/19/26, included a problem titled Bathing. The goal stated is that I will gain increased functional ability to be able to complete my own bathing task through the next review date, 5/15/26. The interventions include requiring substantial/maximal assistance with bathing, and it is very important to the resident to choose between a tub bath, shower, bed bath, or sponge bath. On 3/11/26 at 12:15 PM, Resident #49 was observed in bed with oily flat hair, and her skin was observed to have patches of dry, rough skin on her face. The resident was unable to state whether she was receiving showers/tub baths. On 3/13/26 at 11:45 AM, Resident #49 was observed in bed again. The resident was observed again with oily flat hair, rough skin, and an offensive odor. An interview was conducted with Family Member #2, who was seated in the room. He stated that the resident's hair had not been washed for weeks. He stated that the resident would be admitted to an assisted living facility on 3/17/26 and that he would ensure the resident's hair was washed and that she looked good upon admission to the new facility. A review of the resident's bathing records revealed the resident refused showers/tub baths on 3/4/26 and 3/11/26. On 3/18/26 at approximately 4:00 PM, the above information was conveyed to the Administrator, the DON, ADON, and two corporate consultants. An opportunity was offered for the Team to provide additional information, but they did not. 4. The facility staff failed to educate Resident #45 so she would accept showers. Resident #45 was initially admitted to the facility on [DATE] after an acute care hospital stay. The residents' current diagnoses included severe hyponatremia secondary to SIADH and soft tissue swelling along the dorsum of the wrist. The admission Minimum Data Set (MDS) assessment, with an assessment reference date (ARD) of 2/26/26, coded that the resident completed the Brief Interview for Mental Status (BIMS) and scored 15 out of 15. This indicated that Resident # 45's cognitive abilities for daily decision-making were intact. In section GG0130. Self-Care: the resident required substantial/maximal assistance with shower/bathe self, lower-body dressing, putting on/taking off footwear, and toileting hygiene; partial/moderate assistance with personal hygiene, upper-body dressing, and setup or clean-up assistance with eating and personal hygiene. The resident's person-centered care plan, with a revision date of 2/20/26, included a problem titled Bathing. The goal stated that I will gain increased functional ability to complete the bathing task by the next review date. The interventions included: I require substantial/maximal assistance with bathing, and it is very important to the resident to choose between a tub bath, shower, bed bath, or sponge bath. Resident #45 was observed on 3/10/26 with multiple scabs on her arms and legs. The resident's hair had been washed and set at the beauty shop that day, and the resident stated it was beyond styling at the time of the visit. Resident #45 was dressed in matching slacks and a blouse, but her skin on her arms, legs, and face was observed to be dry and scaly. The resident stated she was not taking showers or tub baths because the hospital staff told her that, while she required dressing, she couldn't immerse in water. The resident further stated that no one at the facility informed her that the bandages could be removed and reapplied for showers and/or tub baths. An interview was conducted with Certified Nursing Assistant (CNA) #5 on 3/12/26 at 11:55 AM. CNA #5 stated that every resident received their shower or tub bath as scheduled. A review of the shower/tub bath documentation for Resident #45 stated that she was receiving showers or tub baths according to her personal schedule. The Director of Nursing (DON) interviewed resident #45 on 3/13/26 at approximately 12:40 PM. The DON stated that the resident informed her she had not received showers or tub baths at the facility because the hospital staff had told her that she could not because she required the bandages. On 3/18/26 at approximately 4:00 PM, the above information was conveyed to the Administrator, the DON, ADON, and two corporate consultants. An opportunity was offered for the Team to provide additional information, but they did not.

Based on a review of the Quality Assurance and Performance Improvement (QAPI) program, the facility staff failed to identify failed systems. The findings included:On 3/18/26 at approximately 11:30 AM, an interview was conducted with the Administrator (ADM) regarding any specific care areas or services the committee had identified as not functioning well, or that had failed. Information comes from data collected from the 5-star report, Resident Council meetings, grievances, families, residents, and the Interdisciplinary Team members. The ADM further stated that falls, pressure ulcers, and a newly developed process related to transcription errors were current systems they had identified and were ongoing. The three areas identified during the survey were not identified by the facility's staff and were not presented to the QAPI team. Throughout the survey conducted 3/10/26 through 3/13/26 and 3/16/26 through 3/18/26, three system failures were identified. They were Activities of Daily Living, specifically showers/tub baths, reviews and revisions of person-centered care plans, and maintaining a safe, clean, comfortable, and homelike environment. Several dependent residents were identified as not receiving showers and/or tub baths. Observations were made of dependent residents with oily hair, scaly skin, and body odor; a few complained of not receiving showers or having their hair washed. A review of showers and/or tub baths was conducted, and the documentation revealed that residents did not receive regular full-body baths, primarily showers or tub baths. Resident person-centered care plans were reviewed for all sampled residents, and a pattern was identified, that they were not reviewed and revised on an ongoing basis as the resident improved or deteriorated. Resident rooms were also identified as a failed system, as many were not safe, clean, comfortable, and/or homelike. There was one room with ongoing heating concerns, and the resident stated they had been cold several nights. Over 15 other rooms had walls that required painting or had torn wallpaper and exposed wallboards. An interview was conducted with the Assistant Engineer (AE) on 3/18/26 at 1:15 PM, during which he acknowledged the problem and outlined what they would do to correct it going forward. On 3/18/26 at approximately 4:00 PM, the above information was conveyed to the Administrator, the DON, ADON, and two corporate consultants. An opportunity was offered for the Team to provide additional information, but they did not.

Based on observation, resident interview, and staff interview it was determined that the facility staff failed to inform the residents of the location for the contact information for the State Survey Agency and the State Long-Term Care Ombudsman program.The findings include:During an observation of the third floor on 3/11/2026 at approximately 9:30 am, the list of names, addresses (mailing and email), and telephone numbers of the State licensure office, and the Office of the State Long-Term Care Ombudsman program information was observed to be posted behind the concierge's desk on the wall, inaccessible to the residents. No other signage with the required information was hung on the third floor.During the Resident Council Meeting on 3/11/2026 at approximately 11:07 am, 10 out of 10 residents were unable to identify where the list of names, addresses (mailing and email), and telephone numbers of the State licensure office, and the Office of the State Long-Term Care Ombudsman program information was located. They were unaware that they had the right to file a complaint with the State licensure office or with the State Long-Term Care Ombudsman.At approximately 11:53 am, after the meeting, the Activities Director (AD) took Residents #18 and Resident #39 to see the location of the Ombudsman Information. Both stated they didn't know the information was posted in that location. Concierge #2 stated that residents must ask for the information and phone numbers if they need them, and during the 5 years she has worked at the facility, no one has asked her for them. The AD stated that there is another copy outside her office on the 2nd Floor for Assisted Living.During the end-of-day meeting on 3/13/2026 at approximately 11:30 am, the Director of Nursing (DON), Assistant Director of Nursing (ADON), and Administrator were informed of the above. The administrator stated that the Activity Director hands out cards with the Ombudsman's information from time to time, and the Ombudsman does rounds.

Based on observation and interviews, the facility staff failed to ensure that two (2) residents (Resident #18 and Resident #5) in the survey sample of 38 residents lived in a comfortable, homelike environment.The findings include: 1. The facility staff failed to ensure the Resident #18 remained comfortable and warm in her room, room [ROOM NUMBER] B. Resident #18 was originally admitted to the facility on [DATE] after an acute care hospital stay and readmitted on [DATE]. The current diagnoses included: Chronic Kidney DS, stage 3B, and Neuralgia and Neuritis, Unspecified. The quarterly Minimum Data Set (MDS) assessment, with an assessment reference date (ARD) of 2/14/26, coded the resident as having completed the Brief Interview for Mental Status (BIMS) and scoring 14 out of a possible 15. This indicated that Resident #18's cognitive abilities for daily decision making were intact. The resident's personal care plan dated 5/08/25 read that the resident would make their own decisions and have no memory loss. A Goal set for the resident was to maintain current memory recall and the ability to make their own self-care decisions. Some resident interventions include allowing the resident to make her own self-care decisions daily, keeping herself informed of current events, and encouraging me to attend activities of her choice. On 03/11/2026 at approximately 11:07 am, a meeting was held with residents and two members of the survey team. Resident #18, who lived in room [ROOM NUMBER]B, said she was experiencing ongoing temperature issues in her room. The resident said that maintenance was informed, but has not fixed the issue. The resident said that her room is cold. A review of the Resident Council Meeting notes revealed that a grievance was on file on 1/08/26 by Resident #18. The grievance document stated that maintenance fixed the issue, with no further complaints. However, the Grievance concerned the common areas rather than specific rooms. On 03/12/2026 at approximately 12:39 pm, an interview was conducted with Resident #16. Upon entering the resident's room, the radiator was heard chirping. The resident stated, Feels on the cold side. The resident was observed still in bed, covered with blankets, and with several blankets/throws on her chair. The resident said it wasn't as cold today as it was last night, but she snuggled up with her extra blankets then. On 03/17/2026 at approximately 12:24 pm, a brief interview was conducted with the resident concerning her room temperature. The resident stated she's very satisfied because someone from maintenance came by the other day to fix it. The resident said, The room feels warm. On 03/17/2026 at approximately 6:56 pm, the resident reported the room being cold. The administrator said the staff will be trained to Turn up the residents' heat. On 03/18/2026 at approximately 10:33 am, an interview was conducted with the Maintenance Engineer (ME). The ME said the unit (Packaged Terminal Air Conditioners/PTAC) must be switched from heat to cold, but he switched it from cold to heat. On 03/18/2026 at approximately 10:38 am, the resident was observed in bed. The resident said she thought she was going to freeze last night because she hadn't had heat in her room since yesterday. The engineer appeared shortly thereafter and was asked to check the room temperature. The ME portable thermometer read 71.9 degrees Fahrenheit (71.9F). The ME also said that the room temperature was 69F on yesterday. On 03/18/26 at approximately 11:27 am, the ME informed the surveyor that he was en route to the resident's room to set up a temporary portable heating unit. On 03/18/2026 at approximately 12:19 pm, a portable heater was observed in the resident's room with the temperature set to 75F. Warm air was circulating in the room set to 75 F. On 3/18/2026, a brief interview was conducted with Certified Nursing Assistant (CNA) #1. CNA #1 said that this morning, the resident mentioned she was cold last night, so she gave her two blankets. On 3/18/2026 at approximately 4:45 pm, a final interview was conducted with the Administrator, Director of Nursing, Assistant Director of Nursing, and two Corporate Consultants. The above findings were discussed with the administrative staff. 2. The facility staff failed to maintain a homelike environment for Resident #5. Resident #5 was initially admitted to the facility on [DATE] after an acute care hospital stay. The residents' current diagnoses included atrial fibrillation and chronic venous insufficiency. The significant change Minimum Data Set (MDS) assessment, with an assessment reference date (ARD) of 2/9/26, coded that the resident completed the Brief Interview for Mental Status (BIMS) and scored 3 out of 15. This indicated that Resident # 5's cognitive abilities for daily decision-making were severely impaired. On 3/13/26 at approximately 12:10 PM, Resident #5 was observed in bed. She stated that she did not feel well but was unable to say exactly what was bothering her. The resident's personal belongings were scattered around the room, on top of the bedside table, in the chair, and on the over-the-bed table. The wall behind the bed had torn wallpaper. The resident was asked whether she was alright with her personal belongings not being put away and with the torn wallpaper beside her bed. Resident #5 stated it was her preference to have her belongings stored and that she would like to have the wall repaired. An interview was conducted with the Assistant Engineer (AE) on 3/18/26 at approximately 1:15 PM. The AE stated that they had identified many rooms that require the accent walls to be repaired, but they had not completed many because the resident would need to move out of the room for the wall repair. The AE stated that the direct care staff was tearing the walls when the beds were moved. The AE stated that, going forward, they would work directly with nursing to ensure the rooms were available for the wall work to be completed. On 3/18/26 at approximately 4:00 PM, the above information was conveyed to the Administrator, the DON, ADON, and two corporate consultants. An opportunity was offered for the Team to provide additional information, and the DON stated that nursing is responsible for ensuring that a resident's personal belongings are stored appropriately.

Based on staff interviews and a review of clinical records, the facility staff failed to accurately transcribe a medication order for 1 of 38 residents (Resident 32) in the survey sample.The findings included: Resident #32 was admitted to the facility on [DATE] after an acute care hospital stay. The residents' current diagnoses included Right 5th finger osteomyelitis/septic arthritis requiring IV therapy, congestive heart failure, and atrial fibrillation. The admission Minimum Data Set (MDS) assessment, with an assessment reference date (ARD) of 3/5/26, coded that the resident completed the Brief Interview for Mental Status (BIMS) and scored 11 out of 15. This indicated that Resident # 32's cognitive abilities for daily decision-making were moderately impaired. Resident #32 was discharged from the hospital and admitted to the facility on [DATE] with an order for Apixaban Oral Tablet 2.5 MG. Give one tablet by mouth twice daily. A new order was written on 3/13/26 at 3:56 PM for Apixaban Oral Tablet 2.5 MG. Give 12.5 mg by mouth twice daily, beginning on 3/14/26. On 3/14/26, a nurse signed off on the administration of 12.5 mg of Apixaban. The physician's progress note dated 3/13/26 at 2:55 PM stated that the resident presented with left leg swelling, minimal difference between the right and left, and some redness, which was new per the resident. The note further stated that the resident had an ultrasound to rule out a blood clot. The results were negative. On 3/17/26 at approximately 11:30 AM, an interview was conducted with the Assistant Director of Nursing (ADON) regarding the change in Resident #32's Apixaban Oral Tablet 2.5 mg from 2.5 mg twice daily to 12.5 mg twice daily. The ADON stated the nurse who transcribed the order mistakenly changed the Apixaban Oral Tablet 2.5 mg dosage twice daily to 12.5 mg twice daily. The ADON stated that the Apixaban Oral Tablet 2.5 mg, give 12.5 mg was signed off as administered on 3/14/26, but the nurse stated she only administered one 2.5 mg tablet because she didn't notice the dosage change equaled 5 tablets instead of one tablet. The ADON also stated they validated that the 4 additional tablets had not been administered based on the tablet count. The ADON stated that an audit of the resident's medications was conducted, and it revealed that the 12.5 mg tablet was for the new order obtained on 3/13/26 for Aldactone (a diuretic), not Apixaban. The ADON concluded that the 12.5 mg of Apixaban was never administered, the order was clarified, and returned to Apixaban Oral Tablet 2.5 mg twice daily. The ADON stated that the problem had been traced to a transcription error and that in-service training related to this error had begun. On 3/18/26 at approximately 4:00 PM, the above information was conveyed to the Administrator, the DON, ADON, and two corporate consultants. An opportunity was offered for the Team to provide additional information, but they did not. Apixaban is also used to prevent stroke and blood clots in patients with certain heart rhythm problem (eg, nonvalvular atrial fibrillation). It is also used to treat or reduce the risk of venous thromboembolism (VTE) after receiving at least 5 days of medicine to treat blood clots. Apixaban is a factor Xa inhibitor, an anticoagulant. It works by decreasing the clotting ability of the blood and helps preventing harmful clots from forming in the blood vessels. (Apixaban (oral route) - Side effects & dosage - Mayo Clinic)

Based on observations, staff interviews, and a review of clinical records, the facility staff failed to provide the necessary care to prevent the development of a sacral stage 3 pressure ulcer in 1 of 38 residents in the survey sample (Resident #7), constituting harm. The findings included: Resident #7 was initially admitted to the facility on [DATE], after an acute care hospital stay. The residents' current diagnoses included Alzheimer's disease, heart failure, and diabetes. The quarterly Minimum Data Set (MDS) assessment, with an assessment reference date (ARD) of 12/22/2025, coded that the resident completed the Brief Interview for Mental Status (BIMS) and scored 3 out of 15. This indicated that Resident #7's cognitive abilities for daily decision-making were severely impaired. In section GG0130. Self-Care: the resident was coded as requiring set-up assistance with eating and oral hygiene; supervision or touch assistance with personal hygiene; substantial/maximal assistance with toileting, showers/bathes, lower body dressing, and putting on and taking off footwear; and partial/moderate assistance with upper body dressing. In section GG0170. Mobility: the resident was coded as requiring substantial/maximal assistance with rolling left and right, sitting to lying, lying to sitting, sitting to standing, chair-to-bed transfers, and transfers to the shower or tub. The person-centered care plan dated 9/14/24, which stated that the resident had a potential for impaired/compromised skin integrity with a need for preventative care related to bilateral lower extremity edema and incontinence. The goal stated the resident would be monitored for compromised skin integrity through the next review date, 6/17/26. The interventions included observing chair/bed-bound resident for redness to pressure areas - buttocks, lower back, shoulders, elbow, hip, and heels. Notify the nurse of any redness. Encourage and assist with turning and positioning. Assist the resident to bed during the day to promote pressure relief and assist with repositioning as needed. The use of a low-air-loss mattress in the bed was added 2/25/26. On 3/11/26 at approximately 3:50 PM, Resident #7 was observed sitting in her wheelchair in her room. She was observed in the room, seated in a wheelchair, at approximately 11:00 AM. On 3/12/26, Resident #7 was observed in bed at approximately 9:15 AM with the breakfast meal before her. She was observed at 11:07 AM out of bed in the wheelchair, with the Certified Nursing Assistant (CNA) #4 propelling her towards the dining room. The resident was again observed at approximately 4:30 PM in her wheelchair in her room. On 3/18/26 at approximately 11:00 AM, Resident #7 was observed in the wheelchair sitting in her room. CNA #4 was observed making the bed. The CNA stated that Resident #7 is out of bed daily before 11:00 AM because her spouse wishes the resident to have lunch in the dining room. A review of the nurse's notes revealed that on 2/4/26 at 2:39 PM, the resident had a weekly skin assessment completed with no skin issues noted. The note further stated that barrier cream was in use on both buttocks as a preventative measure secondary to incontinence. A nurse's note dated 2/11/26 at 10:08 AM stated that the resident received a head-to-toe weekly skin assessment, and moisture-associated skin damage (MASD) was observed on the sacrum. A nurse's note dated 2/18/2026 3:01 PM stated that the weekly skin assessment was completed, and the resident continued with MASD to the sacrum. On 2/22/2026 10:52 PM, a nurse's note stated that the resident had an open wound to the sacrum. The open wound measured 2 centimeters (cm) x 2 centimeters. The open wound was not staged during this assessment; it was cleaned with normal saline and covered. The wound care physician's progress note dated 2/24/26 stated that this was the first visit with the resident, and the etiology of the sacral wound was pressure. The sacral pressure ulcer measured a length of 2.0 cm by a width of 1.5 cm by a depth of 0.2. The pressure ulcer was identified as a stage 3, presented with 100% granulation tissue and moderate serous drainage. The treatment orders were for calcium alginate with honey. The wound care physician stated that, given the resident's overall condition, further decline was anticipated, and the pressure ulcer was unavoidable. The Nurse Practitioner also documented on this date that the resident's wound was viewed as unavoidable due to her bedbound status, limited mobility, poor oral intake, and documented weight loss. The resident was observed with no encouragement or assistance from staff with meals.The wound care physician's progress note dated 3/3/26 stated that the sacral pressure ulcer had decreased in size and measured 1.2 cm by 1.2 cm by 0.2 cm. The treatment remained the same, as well as the offloading and repositioning. On 3/10/26, the sacral pressure ulcer was reassessed by the wound care physician, and again it had decreased in size. It measured 0.8 cm by 0.7 cm by 0.2 cm. The treatment remained the same, and the recommendation was to offload pressure and reposition the resident per the facility's protocol. On 3/17/26, the sacral pressure ulcer was reassessed by the wound care physician. The wound continued to decrease in size. It measured 1.2 cm by 0.4 cm by 0.2 cm. An interview was conducted with the Director of Nursing (DON) on 3/17/26 at approximately 1:00 PM. The DON stated that the wound care physician had reassessed the resident's sacral pressure ulcer, and it was expected to be resolved any day now because it responded well to treatment. The resident's daily observation of remaining in the wheelchair for more than 7 hours was discussed with the DON, and the DON stated that the direct care staff had assured her that they shift the resident's weight when she is seated in the wheelchair. The DON didn't state whether the nursing team had educated the Responsible Party and/or Power of Attorney about the need to offload pressure to promote healing of the ulcer and prevent the development of additional pressure ulcers.On 3/18/26 at approximately 4:00 PM, the above information was conveyed to the Administrator, the DON, ADON, and two corporate consultants. An opportunity was offered for the Team to provide additional information, but they did not. Bedsores are injuries to the skin and the tissue below the skin that are due to pressure on the skin for a long time. Bedsores most often arise on skin that covers bony areas of the body, such as the heels, ankles, hips, and tailbone. The people who are most at risk of bedsores have medical conditions that keep them from changing positions or moving. Or they spend most of their time in a bed or a chair. (Bedsores (pressure ulcers) - Symptoms and causes - Mayo Clinic)

Based on an interview with Family Member #1, staff interviews, and a review of clinical records, the facility staff failed to provide adequate assistance during incontinence care to prevent a fall for 1 of 38 residents in the survey sample (Resident #10). The findings included: Resident #10 was admitted to the facility on [DATE] after an acute care hospital stay. The residents' diagnoses included diabetes, high blood pressure with episodes of orthostatic hypotension, and impaired mobility and self-care secondary to Fusion of the lumbar spine. The admission Minimum Data Set (MDS) assessment, with an assessment reference date (ARD) of 1/6/26, coded that the resident completed the Brief Interview for Mental Status (BIMS) and scored 5 out of 15. This indicated that Resident #10's cognitive abilities for daily decision-making were severely impaired. An interview was conducted with the Rehabilitation Director on 3/11/26 at 10:00 AM. The Rehab Director stated the resident was unable to tolerate therapy, was resistant to sitting up on the side of the bed or wheelchair, had episodes of low blood pressure, reported feeling ill while sitting up, and would vomit. Prior to the 3/6/26 fall, the resident didn't have a resistance problem in the care plan. On 3/13/26 at approximately 11:45 AM, Family Member # 1 stated that the resident had fallen from the bed to the floor, and that staff were working to transfer her back to the bed. A review of the nurse's notes revealed that the resident had experienced a witnessed fall on 3/6/26 at 4:30 AM, while a Certified Nursing Assistant (CNA) was providing incontinence care. The nurse's note further stated that the resident was resisting care, tried to get out of bed, and slid off the bed to the floor. The resident required two staff members to assist her back onto the bed. An interview was conducted with the Director of Nursing (DON) on 3/17/26 at 4:40 PM regarding interventions the CNA should have instituted to prevent the fall on 3/6/26. The DON stated that the CNA should have stopped care when the resident became resistant, reminded the resident that she required assistance getting out of bed, ensured the resident was safe, and later reapproached the resident. On 3/18/26 at approximately 4:00 PM, the above information was conveyed to the Administrator, the DON, ADON, and two corporate consultants. An opportunity was offered for the Team to provide additional information, but they did not.

Based on observation, resident interview, staff interview, and clinical record review, it was determined that the facility staff failed to provide the resident with a bedside urinal upon request from the resident for 1 resident (Resident #67) out of 38 residents in the survey sample.The findings Include:Resident #67 was initially admitted to the facility on [DATE] due to a right intertrochanteric femur fracture. The residents' current diagnoses included repeated falls and unsteadiness on their feet.The admission minimum data set (MDS) assessment, with an assessment reference date (ARD) of 3/8/2026, coded the resident as having completed the Brief Interview for Mental Status (BIMS) and scoring 15 out of the possible 15. This indicated that Resident #67's cognitive abilities for daily decision making were intact.The resident's personal care plan dated 3/2/2026 read that the resident requires partial/moderate assistance with toilet use and the use of incontinent briefs, and is able to make self-care decisions daily.In section GG (Functional Abilities and Goals), the resident was coded as requiring substantial/maximal assistance with bed-to-chair transfers and toilet transfers and partial/moderate assistance with toileting hygiene. In section H (Bladder and Bowel), read that the resident is occasionally incontinent.During an observation on 3/11/2026 at approximately 12:01 pm, Resident #67 asked CNA #8 (Certified Nursing Assistant) to have his urinal at his bedside. CNA #8 stated that he could not have one at his bedside and needed to use the call bell to ask for assistance with using the urinal in the bathroom.Observation of room [ROOM NUMBER]-B on 3/11/2026 at approximately 2:13 pm, there was no urinal at Resident #67's bedside. Resident #67's urinal was in a bag in the bathroom. The resident stated he was not provided with a urinal.During an interview on 3/11/2026 at approximately 2:14 pm, CNA #8 stated that Resident #67 transfers with supervision, and sometimes he needs assistance depending on the day. When asked about the bedside urinal, CNA #8 stated they don't usually provide a bedside urinal due to infection control. They would place the urinal in the bathroom in a bag for the resident to use, and the resident would be educated to use the call light to request assistance with using the urinal.During an interview on 3/11/2026 at approximately 2:24 pm, CNA #6 stated that if a resident is unable to transfer to the urinal independently, they would stay at the resident's bedside upon request to prevent falls. If the resident can walk, then the urinal would be left in a bag in the bathroom.Observation of room [ROOM NUMBER]-B on 3/12/2026 at approximately 10:38 am, there was no urinal at Resident #67's bedside. Resident #67's urinal was in a bag in the bathroom. The resident stated he was not provided with a urinal.During an interview on 3/12/2026 at approximately 10:40 am, LPN #6 (Licensed Practical Nurse) stated that the staff usually have residents who cannot transfer independently to the urinals. The residents are allowed to have them at the bedside. Staff use them to prevent falls, and it is better for residents to have them close by, so they don't impulsively get up. LPN #6 was informed that Resident #67 was requesting a urinal for his bedside.During an interview on 3/12/2026 at approximately 11:02 am, Resident #67 stated that he never received the urinal he was requesting for his bedside and that he sure could have used one.Observation of room [ROOM NUMBER]-B on 3/12/2026 at approximately 1:50 pm, there was no urinal at Resident #67's bedside. Resident #67's urinal was in a bag in the bathroom. The resident stated he was not provided with a urinal.Observation of room [ROOM NUMBER]-B on 3/13/2026 at approximately 9:54 am, there was no urinal at Resident #67's bedside. Resident #67's urinal was in a bag in the bathroom. The resident stated he was not provided with a urinal.During the end-of-day meeting on 3/13/2026 at approximately 11:45 am, the DON (Director of Nursing), ADON (Assistant Director of Nursing), and Administrator were informed of the observations and interviews. The ADON stated that the resident could have a bedside urinal if he was able to use it and that there is no policy regarding bedside urinals. No additional information was provided.

Based on information obtained during the medication administration observation, staff interviews, and a review of facility documents, the facility staff failed to ensure that the medication label was not altered from the pharmacy-printed label. The findings included:On 3/12/26 at 1:00 pm, during the medication administration observations with Licensed Practical Nurse (LPN) #3, the label on the Benzonatate 100 mg capsules medication card was noted to have a handwritten 8 covering the previous hourly instructions for administration, such as 4 hours and 12 hours. A review of the physician's order summary revealed that on 2/19/26, an order was received for Benzonatate 100 mg, 1 capsule by mouth every three hours as needed (PRN) for cough. This order was changed on 2/20/26 to Benzonatate 100 mg every eight hours PRN for cough. On 3/11/26, the order was changed to Benzonatate 100 mg, 1 capsule by mouth three times a day for cough for 5 days. The pharmacy instructions further said to use the PRN medication on hand. On 03/12/26 at 1:00 pm, an interview was conducted with LPN #3 regarding the handwritten 8 covering the previous hourly instructions. LPN #3 stated that the order had been changed from PRN to scheduled doses, and the pharmacy's instructions were for the facility staff to use the on-hand medication until the new medication card was received. On 3/13/26 at 11:30 am, an interview was conducted with the Director of Nursing (DON). The DON stated that the staff nurses' expectations are to follow the policy. A review of the facility's policy titled Medication and Medication Labels 3.7, dated January 2025. In section 6a, the policy stated: If the prescriber's directions for use change or the label is inaccurate, the nurse may place a 'direction change. ' Change of order-check chart' or similar label on the container indicating there is a change in directions for use, taking care not to cover important label information. On 3/18/25 at approximately 4:45 pm, a final interview was conducted with the Administrator, Director of Nursing, Assistant Director of Nursing, [NAME] President of Operations, and the Corporate Nurse Consultant. The above findings were conveyed to the administrative team, who made no comments and voiced no concerns.

Based on staff interviews and a review of the clinical record, the facility staff failed to have a hospice-coordinated plan of care for 1 of 38 residents (Resident #5), in the survey sample. The findings included: Resident #5 was initially admitted to the facility on [DATE] after an acute care hospital stay. The residents' current diagnoses included atrial fibrillation and chronic venous insufficiency.The significant change Minimum Data Set (MDS) assessment, with an assessment reference date (ARD) of 2/9/26, coded that the resident completed the Brief Interview for Mental Status (BIMS) and scored 3 out of 15. This indicated that Resident # 5's cognitive abilities for daily decision-making were severely impaired. An interview was conducted with Certified Nursing Assistant (CNA) #6 on 3/13/26 at approximately 12:20 PM. CNA #6 stated she had never seen a hospice aide provide any services to Resident #5. She further stated that a male nurse was observed visiting the resident approximately twice per week. A care plan problem dated 2/4/26 stated that Resident #5 was admitted to hospice services for end-of-life care related to senile degeneration of the brain. The goal was to receive uninterrupted supportive services through the next review date. The interventions included coordinating all residents' needs, communicating any changes to hospice, and educating the resident, family, responsible party, and caregivers about changing needs and the need for additional hospice services. An interview was conducted with the Director of Nursing (DON) on 3/12/26 at approximately 11:40 AM. The DON stated that the hospice admission paperwork, the care plan, and visit notes were likely in the resident's paper chart. A review of the paper charts resulted in no hospice documents. Therefore, the services the hospice agency would provide, when and how those services would be provided, the communication process, and when or why the nursing facility staff should contact the hospice agency were not available in the facility. On 3/13/26, the hospice documents were provided. They had been faxed to the facility on 3/12/26 at 4:53 PM. The hospice documents stated that the resident was admitted for hospice services on 1/29/26 for senile degeneration of the brain. On 3/18/26 at approximately 4:00 PM, the above information was conveyed to the Administrator, the DON, ADON, and two corporate consultants. An opportunity was offered for the Team to provide additional information, but they did not. The facility's team nodded in agreement with the non-compliance.

Based on information received during the infection control task, and staff interviews, the facility staff failed to document each staff member's COVID-19 information. The findings included:On 3/12/26 at 2:00 pm information for investigation of the staff COVID 19 task was provided by the Human Resource Manager (HRM). The HRM stated that they had no documentation for the employees with longevity, but all new hires initial the Orientation Acknowledgement form that says they were given COVID -19 education. The HRM could not provide the education which was acknowledged by initials for two of two selected new hires. On 3/13/26 at 11:23 am the HR manager provided their Infectious disease COVID-19 preparedness and response plan as the education. Also, the HRM was unable to provide education or documentation that all staff had been offered the COVID-19 vaccine. At 1:00 pm the HRM stated going forward they would institute a new process. The new process would document that all staff received education and would be offered the COVID -19 vaccine. On 3/18/26 at approximately 4:45 pm, a final interview was conducted with the Administrator, Director of Nursing, Assistant Director of Nursing, and two Corporate Consultants. The above findings were conveyed to the administrative team, and the overall Director of the facility stated that going forward they would review the requirements and develop a plan for staff COVID-19 vaccines.

Based on observations, resident interviews, and staff interviews, the facility's staff failed to ensure that the call bell was accessible to one (1) of 38 residents in the survey sample (Resident #72). The findings include: Resident #72 was originally admitted to the facility 3/04/26 and after an acute care hospital stay and readmitted on [DATE]. The current diagnoses included; Wedge compression fracture of fourth lumbar vertebra and Subsequent encounter for fracture with routine healing.The 5-day assessment Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 03/11/26 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 15 out of a possible 15. This indicated Resident #72's cognitive abilities for daily decision making were intact.On 3/12/26 at approximately 10:45 am, an interview was conducted with Resident #72 concerning his care. The resident was observed lying in bed with his head raised slightly to approximately 45 degrees; his call bell was observed on the floor beside his bed. During the interview, the resident was observed drinking water and wasting a small to moderate amount on his shirt. The resident asked if he could get something to wipe off the water from his shirt and chest. The resident was asked to use his Call Bell (CB) for assistance, but said that he couldn't find it. The resident had also mentioned that he had a fall last night, I hit the bell, but no one came. I was trying to pull the curtain and fell on my left side.The call bell timeline was as follows on 3/12/26:At 10:45 am, the call bell observed on the floor beside the resident's bed was not accessible.At 10:55 am, call the bell in the same location.At 11:14 am, Certified Nursing Assistant (CNA) #2 was observed entering the resident's room, picking up his CB, and placing it at the bedside. CNA #2 said that she does resident rounds every 15 minutes.On 3/18/26 at approximately 4:45 pm, a final interview was conducted with the Administrator, Director of Nursing, Assistant Director of Nursing, and two Corporate Consultants. The above findings were discussed with the administrative staff. The administrator said that she had not been made aware of the issue.

Based on staff interview, facility document review and clinical record review, it was determined the facility staff failed to ensure one of 22 residents in the survey sample was free of unnecessary medications, Resident #34 (R34). The findings include: For R34, the facility staff failed to ensure an antidepressant medication was administered for an appropriate diagnosis. On the most recent MDS (minimum data set) assessment, an admission assessment, with an assessment reference date of 12/7/2022, the resident was coded as having both short- and long-term memory difficulties, and being moderately impaired for making daily cognitive decisions. The physician order dated 12/14/2022, documented, Mirtazapine (Remeron) Tablet (used to treat depression) (1) 7.5 MG (milligrams); Give 1 tablet by mouth at bedtime for appetite stimulant. This order was written by the nurse practitioner. The comprehensive care plan dated 12/2/2022 and revised on 12/15/2022, documented in part, Focus: (R34) is at risk for compromised nutritional status and weight loss r/t (related to) cancer, hx (history) of weight loss, therapeutic diet, diabetes, cognitive impairment, Bell's Palsy, Parkinson's, new environment, variable po (oral) intake, malnutrition. 12/15/2022 - significant weight loss 4.3% x (within) 1 week. Dx (diagnosis) Mets CA (metastatic cancer). The Interventions dated, 12/19/2022, documented in part, Remeron started for appetite and mood. Monitor po (oral) intake, report changes in mood or po intake. Pharmacy reviews medication profile monthly. The review of the psychiatrist note dated 12/7/2022, documented a diagnosis of mild cognitive impairment. There was no documentation of a diagnosis of depression. The nurse practitioner was unavailable for interview. An interview was conducted on 1/11/2023 at 11:38 a.m. with ASM (administrative staff member) #3, the medical director. When asked what Remeron is indicated for, ASM #3 stated, depression. When asked if it is prescribed to stimulate appetite, ASM #3 stated, normally the people who have a loss of appetite are depressed, so Remeron is to treat the depression. A side effect of the drug is it increases the appetite so it's side effects benefits the person. The facility policy, Psychotropic Medication Use documented in part, Procedure: 1. Psychotropic medication is prescribed for a diagnosed condition and not being used for convenience or discipline .5. Psychotropic medications to treat behaviors will be used appropriately to address specific underlying medical or psychiatric causes of behavioral symptoms. ASM (administrative staff member) #1, the administrator, and ASM #2, the director of nursing, were made aware of the above findings on 1/11/2023 at 2:30 p.m. No further information was provided prior to exit. (1) This information was obtained from the following website: https://medlineplus.gov/druginfo/meds/a697009.html

Based on observation, staff interview, and facility document review, it was determined the facility staff failed to secure hair in a hair restraint in one of two kitchens in the facility. The findings include: Observation was made on 1/10/2023 at 10:56 a.m. of OSM (other staff member) #1, the food and beverage director, walking through the kitchen. There was a staff member making food on the prep tables where she walked by. OSM #1 did not have any type of hair covering on her head. When asked if she had a hair restraint on, OSM #1 stated she usually wore a cap. When asked if she was supposed to have one on while in the kitchen, OSM #1 stated, yes. The facility policy, Uniforms and Personal Hygiene for Food Service documented in part,, Approved Hair Restraints are hair nets, (facility name) logo baseball caps, solid black or white skull caps, or white toques .Hair is neat and clean, and worn pulled away from the face. An approved hair restraint is worn at all times while preparing or plating food. ASM (administrative staff member) #1, the administrator, and ASM #2, the director of nursing, were made aware of the above findings on 1/11/2023 at 2:30 p.m. No further information was provided prior to ext.

Based on resident interview, staff interview, facility document review and clinical record review, it was determined that the facility staff failed to provide the treatment as ordered by the physician to promote healing of a pressure ulcer for one of 25 residents in the survey sample, (Resident #21). Resident #21 was admitted to the facility on [DATE] with a readmission on 8/3/2021, with an unstageable pressure ulcer (1) on the sacrum/buttocks. The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The findings include: 1. Resident #21 was admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #21's most recent MDS (minimum data set) assessment, a 5 day assessment with an ARD (assessment reference date) of 7/25/2021 coded Resident #21 as scoring a 15 on the BIMS (brief interview for mental status), 15- being cognitively intact for making daily decisions. Section G coded Resident #21 requiring extensive assistance of one person for bed mobility and toileting and two persons for transfers. Section M coded Resident #21 having one unstageable pressure ulcer that was present on admission. On 8/10/2021 at approximately 10:45 a.m., an interview was conducted with Resident #21. Resident #21 stated that the facility staff applied a cream to the sore on their buttocks. Resident #21 stated that the nurses changed the dressing every day and they had seen the wound doctor earlier that morning prior to them getting out of bed. Resident #21's comprehensive care plan dated 8/3/2021 documented in part, I have an unstageable sacral wound. Date Initiated: 08/03/2021. The care plan further documented, The resident has unstageable pressure ulcer and potential for pressure ulcer development r/t (related to) disease process, immobility. Date Initiated: 08/08/2021. Under Interventions it documented in part, Adhere to the resident's treatment plan for the prevention/treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . Administer medications and treatments as ordered and monitor for effectiveness. Date Initiated: 08/08/2021 . The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Order Date: 08/03/2021. Start Date: 08/04/2021 . Under the Scheduling Details of the order it documented in part, Frequency: every day shift, Schedule Type: Everyday; Facility Time Code 0700-1500 (7:00 a.m.-3:00 p.m.); Start on: 8/4/2021 Day 7-3 . The eTAR for Resident #21 dated 8/1/2021-8/31/2021 documented the physician treatment orders as documented above, to the unstageable pressure ulcer and documented it was completed on Day shift (between 7:00 a.m.-3:00 p.m.) each day from 8/4/2021 through 8/10/2021. The eTAR for Resident #21 failed to evidence documentation of the pressure ulcer treatment being completed on the evening shift as ordered by the physician. The progress notes for Resident #21 documented in part, - 7/11/2021 19:33 (7:33 p.m.) Note Text: Resident head to toe status post [MEDICAL RECORD OR PHYSICIAN ORDER] . Buttock area is black. Resident son is aware of skin issues . - 7/16/2021 15:53 (3:52 p.m.) Note Text: Weekly skin assessed, no new skin noted. Antifungal cream to bilateral buttock and groin. Sooth and cool to dry scaly skin to both BUE (bilateral upper extremities) and BLE (bilateral lower extremities). No worsening noted. - 7/19/2021 21:54 (9:54 p.m.) Admission Note . Resident arrived at the facility on the 7/19/2021 at 6:20 pm, on a stretcher accompanied by 2 paramedics and his son .Resident has a stage two pressure ulcer . - 7/21/2021 14:23 (2:23 p.m.) Note Text: Resident head toe second skin check after readmit done 07/20/2021 with the following noted: Unstageable to include bilateral buttocks, dry skin lower extremities, DTI (deep tissue injury) to right heel, Fistula (dialysis access) noted to left arm with RP (responsible party) made aware of skin issues. - 7/22/2021 13:41 (1:41 p.m.) Note Text: At risk meeting held today. Resident reviewed and discussed .Resident admitted from hospital with unstageable pressure injury to sacrum to include bilateral buttocks, DTI (deep tissue injury) to right heel and very dry skin. Resident is noted to be refusing care from noc (night) shift. Treatment in place, currently has low air loss mattress to prevent further skin breakdown . - 8/3/2021 23:44 (11:44 p.m.) Admission Note: .Arrived on 8/3/2021 at 9:35 pm from [Name of Hospital] in the company of transportation team and son alert and oriented x 3 (person, place and time), denies pain. sacral wound . - 8/5/2021 11:50 (11:50 a.m.) At risk meeting held today. Resident reviewed and discussed .At risk for skin breakdown r/t (related to) unstageable pressure injury to sacrum to include bilateral buttocks . The Braden Scale for Predicting Pressure Sore Risk dated 7/8/2021 and 7/19/2021 for Resident #21 documented in part, At Risk . The Skilled Wound Care Communication Log for Daily Rounds for Resident #21 dated 7/27/2021 documented in part, .Location: Sacrum; Etiology: pressure unstag (unstageable); Pre-Op L x W x D (length, width, depth): 6 x 15 x UTD (unable to determine) . The Skilled Wound Care Communication Log for Daily Rounds for Resident #21 dated 8/10/2021 documented in part, Location: Sacrum; Pre-Op L x W x D (length, width, depth): 7 x 10.5 x .3 . The Weekly Wound Evaluation Skilled for Resident #21 dated 7/21/2021 documented in part, . Location: Unstageable include bilateral buttock . admitted . Date Acquired 7/19/ .Unstageable pressure injury .Wound measurements: Length- 10.0 cm (centimeters), Width- 15.5 cm, Depth- 0.0 cm .Wound progress: Undetermined: First Visit . The Weekly Wound Evaluation Skilled for Resident #21 dated 7/28/2021 documented in part, .Seen by wound physician [Name of wound physician] .Location: Sacrum extending to the right buttock .unstageable pressure injury .Wound measurements: Length- 6.0 cm (centimeters), Width- 15.0 cm, Depth- 0.0 cm .Wound progress: Undetermined: First Visit . The Weekly Wound Evaluation Skilled for Resident #21 dated 8/11/2021 documented in part, .Seen by wound physician [Name of wound physician] .Location: Sacrum extending to the bilateral buttock .unstageable pressure injury .Wound measurements: Length- 7.0 cm (centimeters), Width- 10.0 cm, Depth- 0.3 cm .Wound progress: Wound has decreased in size . The Weekly Evaluation for Resident #21 dated 7/12/2021 documented in part, .Skin: New skin concerns identified in the last 7 days- No; Current treatment(s) for wounds or pressure ulcers- Yes; Improvement or change in wound or pressure ulcer based on current treatment- Yes . The Weekly Evaluation for Resident #21 dated 7/26/2021 documented in part, .Skin: New skin concerns identified in the last 7 days- No; Current treatment(s) for wounds or pressure ulcers- Yes; Improvement or change in wound or pressure ulcer based on current treatment- Yes . The Weekly Evaluation for Resident #21 dated 8/9/2021 documented in part, .Skin: New skin concerns identified in the last 7 days- No; Current treatment(s) for wounds or pressure ulcers- Yes; Improvement or change in wound or pressure ulcer based on current treatment- Yes . The Surgical Note for Resident #21 dated 7/27/2021 documented in part, .Wound Location: Sacrum; Etiology: Pressure injury/ulcer- Wound Stage: Unstageable pressure injury .Size: Length (cm) 6.0, Width (cm) 15.0, Depth (cm) UTD, Wound Area (cm2) 90; Wound progress: Undetermined: First Visit. The Surgical Note for Resident #21 dated 8/10/2021 documented in part, Wound Location: Sacrum; Etiology: Pressure injury/ulcer- Wound Stage: Unstageable pressure injury .Size: Length (cm) 7.0, Width (cm) 10.5, Depth (cm) 0.3, Wound Area (cm2) 73.5; Wound progress: Wound has decreased in size . On 8/11/2021 at approximately 12:30 p.m., an interview was conducted with LPN (licensed practical nurse) #6. LPN #6 stated that the wound physician came to the facility on ce a week to see residents. LPN #6 stated that the nurses provided the pressure ulcer care when the wound physician was not in the facility. LPN #6 stated that pressure ulcer treatments were documented as completed on the eTAR (electronic treatment administration record). LPN #6 reviewed the physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Order Date: 08/03/2021. Start Date: 08/04/2021 and stated that the eTAR should reflect the treatment being completed on the day shift and the evening shift. LPN #6 reviewed the eTAR for Resident #21 and stated that there was only documentation of the treatment being completed on the day shift. LPN #6 stated that the treatment was not scheduled on the eTAR for the evening shift so they were not aware that it was to be done twice a day. On 8/11/2021 at approximately 12:55 p.m., an interview was conducted with ASM (administrative staff member) #2, the director of nursing. ASM #2 stated that Resident #21's order for the pressure ulcer treatment to the unstageable to the buttocks was written for day and evening shift and should be completed twice a day. ASM #2 stated that the order audit shows that the order was scheduled to be completed on day shift only and was not being done on the evening shift. ASM #2 stated that unless the order was entered with a schedule of day and evening shift it would not show on the eTAR for the nurses to complete it. ASM #2 stated that they would change the scheduling to reflect the treatment order of day and evening shift. On 8/11/2021 at approximately 1:00 p.m., a request was made to ASM #1, the administrator for the facility policy on pressure ulcer care. The facility policy Skin Care & Pressure Injury Management Program documented in part, .Pressure injuries are a serious concern, especially in compromised residents. Using evidence-based treatments, standards of practice, and the APIE (Assess, Plan, Implement & Evaluate) methodology, this guideline helps the resident interdisciplinary team to: Provide standardized treatment and interventions that promote pressure ulcer healing and prevent infection . On 8/11/2021 at approximately 1:15 p.m., ASM #1, the administrator and ASM #2, the director of nursing were made aware of the concerns. No further information was presented prior to exit. References: 1. Pressure ulcer A pressure sore is an area of the skin that breaks down when something keeps rubbing or pressing against the skin. Pressure sores are grouped by the severity of symptoms. Stage I is the mildest stage. Stage IV is the worst. Stage I: A reddened, painful area on the skin that does not turn white when pressed. This is a sign that a pressure ulcer is forming. The skin may be warm or cool, firm or soft. Stage II: The skin blisters or forms an open sore. The area around the sore may be red and irritated. Stage III: The skin now develops an open, sunken hole called a crater. The tissue below the skin is damaged. You may be able to see body fat in the crater. Stage IV: The pressure ulcer has become so deep that there is damage to the muscle and bone, and sometimes to tendons and joints. This information was obtained from the website: https://medlineplus.gov/ency/patientinstructions/ 0.htm. 2. Diabetes mellitus: A chronic disease in which the body cannot regulate the amount of sugar in the blood. This information was obtained from the website: https://www.nlm.nih.gov/medlineplus/ency/article/ 4.htm. 3. Heart failure: A condition in which the heart is no longer able to pump oxygen-rich blood to the rest of the body efficiently. This causes symptoms to occur throughout the body. This information was obtained from the website: https://medlineplus.gov/ency/article/ 8.htm. 4. End-stage kidney disease: The last stage of chronic kidney disease. This is when your kidneys can no longer support your body's needs. This information was obtained from the website: https://medlineplus.gov/ency/article/ 0.htm.

Based on staff interview, facility document review and clinical record review, it was determined that the facility staff failed to follow professional standards of practice for the administration of medication for one of 25 residents in the survey sample, Resident # 17; and failed to follow professional standard for the provision of pressure ulcer treatment per physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The findings include: 1. The facility staff failed to accurately transcribe the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] # 17. Resident # 17 was admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident # 17's most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 06/23/2021, coded Resident # 17 as scoring a 15 on the brief interview for mental status (BIMS) of a score of 0 - 15, 15 - being cognitively intact for making daily decisions. Resident # 17 was coded as requiring extensive assistance of one staff member for activities of daily living. The physician's telephone order dated 09/25/2020 for Resident # 17 documented, Increase Toporol [[MEDICATION(S)]] to 50mg QD [every day] hold for SBP < [less than] 110 or < 60 pulse. Order received: 9/25/2020. The physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Give 1 [one] tablet by mouth one time a day for [CONDITION(S)] [hypertension]. Hold for SBP [systolic blood pressure] less than 110 and pulse less than 60. Order Date: 9/25/2020. The eMARs [electronic medication administration records] for Resident # 17 dated January 2021 through August 11, 2021 documented in part, [MEDICATION(S)] [MEDICATION(S)] ER Tablet Extended Release 24 Hour 50 MG [milligram]. Give 1 [one] tablet by mouth one time a day for [CONDITION(S)] [hypertension]. Hold for SBP [systolic blood pressure] less than 110 and pulse less than 60. Order Date: 9/25/2020. On 8/10/2021 at approximately 12:10 p.m., an interview was conducted with ASM [administrative staff member] #2, the director of nursing. After reviewing the eMARs dated January 2021 through August 11, 2021, ASM # 2 provided a copy of the physician's telephone order dated 09/25/2020 for Resident # 17. ASM # 2 stated that the orders on the eMARs were not transcribed correctly from the physician's telephone order. On 8/11/2021 at approximately 2:40 p.m., an interview was conducted with ASM (administrative staff member) #2, the director of nursing. ASM #2 stated that nursing staff received telephone orders from the physician and documented them on the telephone order sheet. ASM #2 stated that the nursing staff used the telephone order sheet to transcribe the order into the computer. ASM #2 stated that every night the nurse checked every chart for new telephone orders and compared them to the computer to ensure that they were transcribed correctly. The facility's policy Care Standards documented in part, Policy Statement: It is the policy of the center to provide necessary care and services to assist each resident to attain or maintain his/her highest practicable level of physical, mental and psychosocial wellbeing in accordance with physician orders, a comprehensive assessment and plan of care. Care is documented in the medical record in accordance with State and Federal regulations. On 08/11/2021 at approximately 1:08 p.m. ASM (administrative staff member) # 1, the administrator and ASM # 2, director of nursing, were made aware of the above findings. No further information was provided prior to exit. References: [1] Used alone or in combination with other medications to treat high blood pressure. This information was obtained from the website: https://medlineplus.gov/druginfo/meds/a 4.html. [2] High blood pressure. This information was obtained from the website: https://www.nlm.nih.gov/medlineplus/highbloodpressure.html. [3] The broad, dorsal, upper, and largest of the three principal bones composing either half of the pelvis. This information was obtained from the website: https://www.merriam-webster.com/dictionary/ilium 2. The facility staff failed to accurately transcribe a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #21 was admitted to the facility on [DATE] with a readmission on 8/3/2021, with an unstageable pressure ulcer (1) on the sacrum/buttocks. The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #21 was admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #21's most recent MDS (minimum data set) assessment, a 5 day assessment with an ARD (assessment reference date) of 7/25/2021 coded Resident #21 as scoring a 15 on the BIMS (brief interview for mental status), 15- being cognitively intact for making daily decisions. Section G coded Resident #21 requiring extensive assistance of one person for bed mobility and toileting and two persons for transfers. Section M coded Resident #21 having one unstageable pressure ulcer that was present on admission. Resident #21's comprehensive care plan dated 8/3/2021 documented in part, I have an unstageable sacral wound. Date Initiated: 08/03/2021. The comprehensive care plan further documented, The resident has unstageable pressure ulcer and potential for pressure ulcer development r/t (related to) disease process, immobility. Date Initiated: 08/08/2021. Under Interventions it documented in part, Adhere to the resident's treatment plan for the prevention/treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . Administer medication and treatments as ordered and monitor for effectiveness. Date Initiated: 08/08/2021 . On 8/10/2021 at approximately 10:45 a.m., an interview was conducted with Resident #21. Resident #21 stated that the facility staff applied a cream to the sore on their buttocks. Resident #21 stated that the nurses changed the dressing every day and they had seen the wound doctor earlier that morning prior to them getting out of bed. The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Order Date: 08/03/2021. Start Date: 08/04/2021 . Under the Scheduling Details of the order it documented in part, Frequency: every day shift, Schedule Type: Everyday; Facility Time Code 0700-1500 (7:00 a.m.-3:00 p.m.); Start on: 8/4/2021 Day 7-3 . The eTAR for Resident #21 dated 8/1/2021-8/31/2021 documented the physician treatment orders as documented above, to the unstageable pressure ulcer and documented it was completed on Day shift (between 7:00 a.m.-3:00 p.m.) each day from 8/4/2021 through 8/10/2021. The eTAR for Resident #21 failed to evidence documentation of the pressure ulcer treatment being completed on the evening shift as ordered by the physician. The Surgical Note for Resident #21 dated 7/27/2021 documented in part, .Wound Location: Sacrum; Etiology: Pressure injury/ulcer- Wound Stage: Unstageable pressure injury .Size: Length (cm) 6.0, Width (cm) 15.0, Depth (cm) UTD, Wound Area (cm2) 90; Wound progress: Undetermined: First Visit. The Surgical Note for Resident #21 dated 8/10/2021 documented in part, Wound Location: Sacrum; Etiology: Pressure injury/ulcer- Wound Stage: Unstageable pressure injury .Size: Length (cm) 7.0, Width (cm) 10.5, Depth (cm) 0.3, Wound Area (cm2) 73.5; Wound progress: Wound has decreased in size .His wounds are doing well. We will continue the present treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . The goal will be to resolve his wounds . On 8/11/2021 at approximately 12:30 p.m., an interview was conducted with LPN (licensed practical nurse) #6. LPN #6 stated that the wound physician came to the facility on ce a week to see residents. LPN #6 stated that the nurses provided the pressure ulcer care when the wound physician was not in the facility. LPN #6 stated that pressure ulcer treatments were documented as completed on the eTAR (electronic treatment administration record). LPN #6 reviewed the order for Resident #21 which documented, Cleanse unstageable to include bilateral buttocks with wound cleanser, pat dry, apply soothe and cool mix with [MEDICATION(S)] every day and evening shift and cover with boarder gauze until resolved. Order Date: 08/03/2021. Start Date: 08/04/2021 and stated that the eTAR should reflect the treatment being completed on the day shift and the evening shift. LPN #6 reviewed the eTAR for Resident #21 and stated that there was only documentation of the treatment being completed on the day shift. LPN #6 stated that the treatment was not scheduled on the eTAR for the evening shift so they were not aware that it was to be done twice a day. On 8/11/2021 at approximately 12:55 p.m., an interview was conducted with ASM (administrative staff member) #2, the director of nursing. ASM #2 stated that Resident #21's order for the pressure ulcer treatment to the unstageable to the buttocks was written for day and evening shift and should be completed twice a day. ASM #2 stated that the order audit shows that the order was scheduled to be completed on day shift only and was not being done on the evening shift. ASM #2 stated that unless the order was entered with a schedule of day and evening shift it would not show on the eTAR for the nurses to complete it. ASM #2 stated that they would change the scheduling to reflect the treatment order of day and evening shift. On 8/11/2021 at approximately 2:40 p.m., an interview was conducted with ASM (administrative staff member) #2, the director of nursing. ASM #2 stated that nursing staff received telephone orders from the physician and documented them on the telephone order sheet. ASM #2 stated that the nursing staff used the telephone order sheet to transcribe the order into the computer. ASM #2 stated that every night the nurse checked every chart for new telephone orders and compared them to the computer to ensure that they were transcribed correctly. On 8/11/2021 at approximately 1:00 p.m., a request was made to ASM #1, the administrator for the facility policy on transcribing physician orders. The facility policy Physician/Prescriber Authorization and Communication of Orders to Pharmacy dated 12/01/07 documented in part, .Facility staff should read back verbal orders to Physician/Prescriber or Physician's/Prescriber's agent to ensure accuracy and avoidance of sound alike medications. Facility should ensure that the person receiving a verbal order immediately records it in the resident's chart or electronic order system, including the date and time of the order, the name of Physician/Prescriber, and the signature of the person recording the order. All verbal orders should be recorded by a licensed nurse . On 8/10/2021 at approximately 10:48 a.m., ASM #2 stated that the facility followed Perry & Potter as their nursing standard of practice. According to Basic Nursing, Essentials for Practice, 6th edition (Potter and Perry, 2007, pages 349-360) A medication order is required for you to administer any medication to a patient. Once you receive and process a medication, place the physician's or health care provider's complete order on the appropriate medication form, the MAR. The MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . When transcribing orders, ensure the names of medications, dosages, routes, and times are legible. The nurse checks all orders for accuracy and thoroughness. When orders are transcribed, the same information needs to be checked again by the nurse. It is essential that you verify the accuracy of every medication you give to the patient with the patient's orders. To ensure safe medication administration, be aware of the six rights of medication administration. 1. The right medication 2. The right dose 3. The right patient 4. The right route 5. The right time 6. The right documentation . On 8/11/2021 at approximately 1:15 p.m., ASM #1, the administrator and ASM #2, the director of nursing were made aware of the concerns. No further information was presented prior to exit. References: 1. Pressure ulcer A pressure sore is an area of the skin that breaks down when something keeps rubbing or pressing against the skin. Pressure sores are grouped by the severity of symptoms. Stage I is the mildest stage. Stage IV is the worst. Stage I: A reddened, painful area on the skin that does not turn white when pressed. This is a sign that a pressure ulcer is forming. The skin may be warm or cool, firm or soft. Stage II: The skin blisters or forms an open sore. The area around the sore may be red and irritated. Stage III: The skin now develops an open, sunken hole called a crater. The tissue below the skin is damaged. You may be able to see body fat in the crater. Stage IV: The pressure ulcer has become so deep that there is damage to the muscle and bone, and sometimes to tendons and joints. This information was obtained from the website: https://medlineplus.gov/ency/patientinstructions/ 0.htm. 2. Diabetes mellitus A chronic disease in which the body cannot regulate the amount of sugar in the blood. This information was obtained from the website: https://www.nlm.nih.gov/medlineplus/ency/article/ 4.htm. 3. Heart failure A condition in which the heart is no longer able to pump oxygen-rich blood to the rest of the body efficiently. This causes symptoms to occur throughout the body. This information was obtained from the website: https://medlineplus.gov/ency/article/ 8.htm. 4. End-stage kidney disease The last stage of chronic kidney disease. This is when your kidneys can no longer support your body's needs. This information was obtained from the website: https://medlineplus.gov/ency/article/ 0.htm.

Based on observations, staff interview, facility document review and clinical record review, it was determined that the facility staff failed to implement the comprehensive care plan for the use of fall mats for one of 25 residents in the survey sample, Resident # 17; and for the provision of pressure ulcer treatment per physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The findings include: 1. The facility staff failed to implement Resident # 17's comprehensive care plan for the use of fall mats while in bed. Resident # 17 was admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident # 17's most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 06/23/2021, coded Resident # 17 as scoring a 15 on the brief interview for mental status (BIMS) of a score of 0 - 15, 15 - being cognitively intact for making daily decisions. Resident # 17 was coded as requiring extensive assistance of one staff member for activities of daily living. On 08/10/21 at 8:40 a.m., an observation of Resident # 17 revealed the resident lying in their bed. Further observation revealed one fall mat on the floor to the resident's right side of the bed. Observation of the floor to the resident's left side failed to evidence a fall mat on the floor. Observation of Resident # 17's room revealed another fall mat was observed leaning against the wall at the foot of the bed. On 08/11/21 at 7:40 a.m., an observation of Resident # 17 revealed the resident lying in their bed. Further observation revealed one fall mat on the floor to the resident's right side of the bed. Observation of the floor to the resident's left side failed to evidence a fall mat on the floor. Observation of Resident # 17's room revealed another fall mat was leaning against the wall at the foot of the bed. The care plan for Resident # 17 dated 09/21/2020 documented in part, Focus. The resident has had more than one actual fall with h/o [history of] multiple falls, and is at risk for falls r/t [related to] impaired mobility, debility and multiple fractures to lumbar and sacrum with the use of back brace. Use of Antidepressant with risk for side effects. Halo bar to improve pt. [patient] mobility. Fall on 1/17/21 with no apparent injuries. Date Initiated: 09/21/2020. Under Interventions it documented in part, Floor mat to floor when in bed. Date Initiated: 01/17/2021. On 08/10/2021 at 7:42 a.m., an interview was conducted with Resident # 17. When asked about the placement of the fall mats, Resident # 17 stated that both fall mats were supposed to be down when they are in bed. On 08/11/21 at 750 a.m., an interview and observation of Resident # 17's room was conducted with LPN [licensed practical nurse] # 6. After observing the floor around Resident # 17's bed, LPN #6 was asked about the fall mats. LPN # 6 stated that there was one fall mat on the floor next to Resident # 17's bed. LPN # 6 further stated, There should be two fall mats down, one on each side of the bed. On 08/11/21 at 10:46 a.m., an interview with LPN # 6. LPN #6 reviewed Resident # 17's comprehensive care plan for falls After completing the review, LPN # 6 was asked if the comprehensive care plan was being followed based on the observations above. LPN # 6 stated, Not as it should be. There was only one fall mat down and there should be two. On 08/11/2021 at approximately 1:08 p.m. ASM (administrative staff member) # 1, the administrator and ASM # 2, director of nursing, were made aware of the above findings. No further information was provided prior to exit. References: [1] High blood pressure. This information was obtained from the website: https://www.nlm.nih.gov/medlineplus/highbloodpressure.html. [2] The broad, dorsal, upper, and largest of the three principal bones composing either half of the pelvis. This information was obtained from the website: https://www.merriam-webster.com/dictionary/ilium 2. The facility staff failed to implement the comprehensive care plan for Resident #21 to provide pressure ulcer treatment as ordered. Resident #21 was admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #21's most recent MDS (minimum data set) assessment, a 5 day assessment with an ARD (assessment reference date) of 7/25/2021 coded Resident #21 as scoring a 15 on the BIMS (brief interview for mental status), 15- being cognitively intact for making daily decisions. Section G coded Resident #21 requiring extensive assistance of one person for bed mobility and toileting and two persons for transfers. Section M coded Resident #21 having one unstageable pressure ulcer that was present on admission. Resident #21's comprehensive care plan dated 8/3/2021 documented in part, I have an unstageable sacral wound. Date Initiated: 08/03/2021. The care plan further documented, The resident has unstageable pressure ulcer and potential for pressure ulcer development r/t (related to) disease process, immobility. Date Initiated: 08/08/2021. Under Interventions it documented in part, Adhere to the resident's treatment plan for the prevention/treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . Administer medication and treatments as ordered and monitor for effectiveness. Date Initiated: 08/08/2021 . On 8/10/2021 at approximately 10:45 a.m., an interview was conducted with Resident #21. Resident #21 stated that the facility staff applied a cream to the sore on their buttocks. Resident #21 stated that the nurses changed the dressing every day and they had seen the wound doctor earlier that morning prior to them getting out of bed. The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Order Date: 08/03/2021. Start Date: 08/04/2021 . Under the Scheduling Details of the order it documented in part, Frequency: every day shift, Schedule Type: Everyday; Facility Time Code 0700-1500 (7:00 a.m.-3:00 p.m.); Start on: 8/4/2021 Day 7-3 . The eTAR for Resident #21 dated 8/1/2021-8/31/2021 documented the physician treatment orders as documented above, to the unstageable pressure ulcer and documented it was completed on Day shift (between 7:00 a.m.-3:00 p.m.) each day from 8/4/2021 through 8/10/2021. The eTAR for Resident #21 failed to evidence documentation of the pressure ulcer treatment being completed on the evening shift as ordered by the physician. The Surgical Note for Resident #21 dated 7/27/2021 documented in part, .Wound Location: Sacrum; Etiology: Pressure injury/ulcer- Wound Stage: Unstageable pressure injury .Size: Length (cm [centimeter]) 6.0, Width (cm) 15.0, Depth (cm) UTD [unable to determine], Wound Area (cm2) 90; Wound progress: Undetermined: First Visit. The Surgical Note for Resident #21 dated 8/10/2021 documented in part, Wound Location: Sacrum; Etiology: Pressure injury/ulcer- Wound Stage: Unstageable pressure injury .Size: Length (cm) 7.0, Width (cm) 10.5, Depth (cm) 0.3, Wound Area (cm2) 73.5; Wound progress: Wound has decreased in size .His wounds are doing well. We will continue the present treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . The goal will be to resolve his wounds . On 8/11/2021 at approximately 12:30 p.m., an interview was conducted with LPN (licensed practical nurse) #6. LPN #6 stated that the care plan gave everyone a general idea of the care a resident required. LPN #6 stated that pressure ulcers and skin care were documented on the care plan. LPN #6 stated that pressure ulcer treatments were documented as completed on the eTAR (electronic treatment administration record). LPN #6 reviewed the order for Resident #21 which documented, Cleanse unstageable to include bilateral buttocks with wound cleanser, pat dry, apply soothe and cool mix with [MEDICATION(S)] every day and evening shift and cover with boarder gauze until resolved. Order Date: 08/03/2021. Start Date: 08/04/2021 and stated that the eTAR should reflect the treatment being completed on the day shift and the evening shift. LPN #6 reviewed the eTAR for Resident #21 and stated that there was only documentation of the treatment being completed on the day shift. LPN #6 stated that the treatment was not scheduled on the eTAR for the evening shift so they were not aware that it was to be done twice a day. LPN #6 stated that the care plan was not being implemented if the treatment was not being performed as ordered. On 8/11/2021 at approximately 12:55 p.m., an interview was conducted with ASM (administrative staff member) #2, the director of nursing. ASM #2 stated that Resident #21's order for the pressure ulcer treatment to the unstageable PS on the buttocks was written for day and evening shift and should be completed twice a day. ASM #2 stated that the order audit showed that the order was scheduled to be completed on day shift only and was not being done on the evening shift. ASM #2 stated that unless the order was entered with a schedule of day and evening shift it would not show on the eTAR for the nurses to complete the evening shift treatment. ASM #2 stated that they would change the scheduling to reflect the treatment order of day and evening shift. ASM #2 stated that the care plan was not being implemented for treatments as ordered if staff were not completing the treatment on day and evening shift. On 8/11/2021 at approximately 1:00 p.m., a request was made to ASM #1, the administrator for the facility policy on implementing the care plan. The facility policy Individualized Care Plan dated 2/29/16 documented in part, .The IDT (interdisciplinary team) develops comprehensive care plan addressing the resident's most acute problems. The comprehensive care plan will include: a. Services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being . On 8/10/2021 at approximately 10:48 a.m., ASM (administrative staff member) #2 stated that the facility followed Perry & Potter as their nursing standard of practice. Basic Nursing, Essentials for Practice, 6th edition, (Potter and Perry, 2007, pages 119-127), was a reference for care plans. A nursing care plan is a written guideline for coordinating nursing care, promoting continuity of care and listing outcome criteria to be used in the evaluation of nursing care. The written care plan communicates nursing care priorities to other health care professionals. The care plan also identifies and coordinates resources used to deliver nursing care. A correctly formulated care plan makes it easy to continue care from one nurse to another . On 8/11/2021 at approximately 1:15 p.m., ASM #1, the administrator and ASM #2, the director of nursing were made aware of the concerns. No further information was presented prior to exit. References: 1. Pressure ulcer A pressure sore is an area of the skin that breaks down when something keeps rubbing or pressing against the skin. Pressure sores are grouped by the severity of symptoms. Stage I is the mildest stage. Stage IV is the worst. Stage I: A reddened, painful area on the skin that does not turn white when pressed. This is a sign that a pressure ulcer is forming. The skin may be warm or cool, firm or soft. Stage II: The skin blisters or forms an open sore. The area around the sore may be red and irritated. Stage III: The skin now develops an open, sunken hole called a crater. The tissue below the skin is damaged. You may be able to see body fat in the crater. Stage IV: The pressure ulcer has become so deep that there is damage to the muscle and bone, and sometimes to tendons and joints. This information was obtained from the website: https://medlineplus.gov/ency/patientinstructions/ 0.htm. 2. Diabetes: A chronic disease in which the body cannot regulate the amount of sugar in the blood. This information was obtained from the website: https://www.nlm.nih.gov/medlineplus/ency/article/ 4.htm. 3. Heart failure: A condition in which the heart is no longer able to pump oxygen-rich blood to the rest of the body efficiently. This causes symptoms to occur throughout the body. This information was obtained from the website: https://medlineplus.gov/ency/article/ 8.htm. 4. End-stage kidney disease: The last stage of chronic kidney disease. This is when your kidneys can no longer support your body's needs. This information was obtained from the website: https://medlineplus.gov/ency/article/ 0.htm.

Based on staff interview, resident interview, facility document review and clinical record review, it was determined the facility staff failed to ensure resident rights by accommodating the needs of one of 25 residents in the survey sample, Resident #9. The facility staff failed to ensure accommodation of Resident #9's need for a thick wheelchair cushion. The findings include: Resident #9 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #9's most recent MDS (minimum data set) assessment, a five day Medicare assessment, with an assessment reference date of 6/17/21, coded the resident as scoring 15 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was cognitively intact. MDS Section G- Functional Status: coded the resident as extensive assistance with bed mobility, transfers, dressing, locomotion and supervision for eating, hygiene and bathing. Walking did not occur. A review of MDS Section H- Bowel and Bladder: coded the resident as always incontinent for bowel and as having a foley for bladder. On 8/10/21 at 8:45 AM, during the initial resident observations, Resident #9 was observed in bed. He had a wheelchair with two approximately one-inch cushions in the seat of the wheelchair. Resident #9's wife was in room and Resident #9 and his wife were interviewed at this time. When asked how often he got out of bed, Resident #9 stated, Since I came back from the hospital about one week ago, I get up for physical and occupational therapy. Before I went to the hospital, I had a black thick cushion in the wheelchair and I could tolerate being up in the wheelchair. When I came back from the hospital, someone had taken the black cushion and given me these two smaller yellow ones. I can't sit on those cushions for long period of time because it hurts my coccyx. Resident #9's wife stated, We've asked for the cushion back, and were told someone else needed it. He doesn't get out of bed because he is not comfortable. Resident #9 was hospitalized from 8/1/21 to 8/3/21 with Pneumonia. A review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the comprehensive care plan for Resident #9 dated 8/4/21 and revised 8/7/21, documented in part, FOCUS- The resident is at risk for falls related to left BKA, diabetes mellitus and muscle weakness. INTERVENTIONS-Anticipate and meet the resident's needs daily. Check and ensure that wheelchair, positioning equipment are in use. A review of Resident #9's ADL (activities of daily living) form for August 2021, documented in part, Locomotion on Unit-total dependence with one person physical assist for five of eight days (8/4/21, 8/5/21, 8/6/21, 8/7/21, 8/11/21). Locomotion on Unit-NA documented for three of eight days (8/8/21, 8/9/21, 8/10/21). An interview was conducted on 8/11/21 at 9:10 AM with OSM (other staff member) #2, the occupational therapist assistant. When asked if she had worked with Resident #9, OSM #2 stated, Yes, I used to work with him before he went to the hospital. He was out of bed most days and putting on his pants (sweat like pants) with a little assistance. He had a thick black cushion in his wheelchair. I did not know that it was gone. I have not worked with him since his return from the hospital. I will look for it and if I can't find the cushion, I will order another one from supply. An interview was conducted on 8/11/21 at 9:22 AM with OSM #3, the physical therapist. When asked if she had worked with Resident #9, OSM #3 stated, Yes, I did. He had a black cushion in the wheelchair. I did not realize he did not have it anymore. He should be getting up more, but I don't want him to have a skin breakdown because he doesn't have the right cushion. An interview was conducted on 8/11/21 at 9:43 AM with Resident #9. When asked how often he used to get up into the wheelchair, Resident #9 stated, Yes, I used to get up a lot more when I had the thick black cushion in the wheelchair before I went to the hospital. Now I get up to go to OT and PT because the yellow cushions hurt by coccyx. They told me they only had one black cushion in the building and when I went into the hospital, they took it for another resident. I only got up yesterday for PT/OT in the afternoon. On 8/11/21 at 11:15 AM, OSM #2 was observed bringing a black cushion into Resident #9's room. Resident #9 stated, Yes, that is it! I'm so glad you found it. On 8/11/21 at 1:08 PM, ASM (administrative staff member) #1, the administrator and ASM #2, the director of nursing were informed of the concern. On 8/11/21 at 2:00 PM, Resident #9 was observed out of bed in wheelchair. When asked how he was feeling, Resident #9 stated, It feels good sitting up in this chair with this cushion. I had a cheeseburger for lunch. It is going well. On 8/11/21 at 2:11 PM, an interview was conducted with CNA (certified nursing assistant) #1. When asked what the N/A mean on the ADL sheets, CNA #1 stated, It can mean that the resident is refusing to do the activity. Resident #9 did not want to get up because the chair did not have the correct cushion in it. On 8/11/21 at 3:00 PM, Resident #9 was observed sitting in wheelchair in main lobby area participating with the singing activity and at 4:00 PM was observed participating in the facility cocktail hour. ASM #2 provided the team with the facility policy Care Standards dated 2/29/16, which documented in part, The Director of Nursing directs in accordance with care and services standards of clinical practice. For the purposes of this policy, the Clinical Operations Department follows standards as outlined in the practice/program/procedures and physician orders. Perry & Potter: Clinical Nursing Skills & Procedures. According to Perry & Potter, which documents in part, First complete a thorough patient assessment including individual needs. Ultimately the features of the support surface must match a patient's unique needs. (4) A review of the facility's admission packet, Exhibit 7- Resident Rights (Federal) dated 10/25/2018, which documents in part, The facility shall inform the resident of the right to participate in his or her treatment and shall support the resident in this right. The planning process must: include an assessment of the resident's strengths and needs. No further information was provided prior to exit. References: (1) Barron's Dictionary of Medical Terms for the Non-Medical Reader, 7th edition, Rothenberg and Chapman, page 502. (2) Barron's Dictionary of Medical Terms for the Non-Medical Reader, 7th edition, Rothenberg and Chapman, page 160. (3) Barron's Dictionary of Medical Terms for the Non-Medical Reader, 7th edition, Rothenberg and Chapman, page 29. (4) Perry & Potter Clinical Nursing Skills, 8th edition, Ostendorf, Elsevier Publishers, page 274.

Based on observation, staff interview, facility document review and clinical record review, the facility staff failed to assess, identify, monitor and treat to prevent the development of, and or deterioration of pressure ulcers for five of 14 residents in the survey sample, Residents #3, #9, #6, #2, and #11. 1. For Resident # 3, the facility staff failed to assess and identify, initiate treatment and monitor a pressure ulcer on the heel of the resident's right foot. The resident had a cast removed on 10/04/12 and returned from the doctor's office with a dressing covering the foot and ankle. The dressing was not removed until 10/08/12 and revealed a Stage 4 pressure ulcer. During the survey process the resident did not have her heels elevated off of the bed surface and the right heel was boggy and did not blanch. 2. For Resident # 9, the facility staff failed to follow the plan of care for the prevention of pressure ulcers on the resident's severely contracted hand. 3. For Resident # 6: a. Facility staff failed to ensure physician ordered interventions /treatments were provided from June 2012 through October 2012 per the Residents comprehensive plan of care and as a result Resident # 6 developed a pressure sore that was discovered as unstageable. b. Facility staff failed to monitor and reassess Resident # 6's mid back abrasion per physician orders and as a result, Resident # 6's mid back abrasion declined to a Stage III pressure sore first documented on 12/18/12. c. Facility staff failed to provide wound care to Resident #6 in a manner to prevent infection. During a wound care observation staff placed clean supplies directly on the residents bed and used the same measuring strip to measure two separate wounds. Staff was observed placing the used measuring strip with clean supplies between wound measurements. 4. For Resident # 2 the facility staff failed to ensure monitoring, assessment, analysis, evaluation, revision and implementation of new interventions to promote healing of skin breakdown and failed to ensure that wounds were assessed weekly and one wound (coccyx) that was not assessed weekly had a decline from a stage II to a stage III. 5. For Resident #11, facility staff failed to evaluate pressure ulcer treatment in a timely manner and change treatment to promote healing of the pressure ulcer. Pressure Ulcer Stages Suspected Deep Tissue Injury: Purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue. Further description: Deep tissue injury may be difficult to detect in individuals with dark skin tones. Evolution may include a thin blister over a dark wound bed. The wound may further evolve and become covered by thin eschar. Evolution may be rapid exposing additional layers of tissue even with optimal treatment. Stage I: Intact skin with non-blanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not have visible blanching; its color may differ from the surrounding area. Further description: The area may be painful, firm, soft, warmer or cooler as compared to adjacent tissue. Stage I may be difficult to detect in individuals with dark skin tones. May indicate "at risk" persons (a heralding sign of risk) Stage II: Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough. May also present as an intact or open/ruptured serum-filled blister. Further description: Presents as a shiny or dry shallow ulcer without slough or bruising.* This stage should not be used to describe skin tears, tape burns, perineal [MEDICAL CONDITION], maceration or excoriation. *Bruising indicates suspected deep tissue injury Stage III: Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling. Further description: The depth of a stage III pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput and malleolus do not have subcutaneous tissue and stage III ulcers can be shallow. In contrast, areas of significant adiposity can develop extremely deep stage III pressure ulcers. Bone/tendon is not visible or directly palpable. Stage IV: Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often include undermining and tunneling. Further description: The depth of a stage IV pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput and malleolus do not have subcutaneous tissue and these ulcers can be shallow. Stage IV ulcers can extend into muscle and/or supporting structures (e.g., fascia, tendon or joint capsule) making osteo[DIAGNOSES REDACTED] possible. Exposed bone/tendon is visible or directly palpable. 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 [DIAGNOSES REDACTED] or fluctuance) eschar on the heels serves as "the body's natural (biological) cover" and should not be removed. The staging system was defined by Shea in 1975 and provides a name to the amount of anatomical tissue loss. The original definitions were confusing to many clinicians and lead to inaccurate staging of ulcers associated or due to perineal [MEDICAL CONDITION] and those due to deep tissue injury. For more information, contact npuap.org or [PHONE NUMBER] Copyright: NPUAP 2007 The findings included: 1. For Resident # 3, the facility staff failed to assess and identify, initiate treatment and monitor a pressure ulcer on the heel of the resident's right foot. The resident had a cast removed on 10/04/12 and returned from the doctor's office with a dressing covering the foot and ankle. The dressing was not removed until 10/08/12 and revealed a Stage 4 pressure ulcer. During the survey process the resident did not have her heels elevated off of the bed surface and the right heel was boggy and did not blanch. Resident # 3 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The most recent MDS (minimum data set) assessment, a quarterly assessment, with an assessment reference date of 11/16/12, coded the resident as being severely impaired to make daily cognitive decisions. Resident # 3 was coded as requiring extensive assistance of one staff member for moving to and from lying position, turning side to side, and positions body while in bed. The resident was coded as requiring extensive assistance of two staff members to move between surfaces including to and from bed, chair, wheelchair and standing position. The resident was coded as requiring extensive assistance of one staff member for all other activities of daily living. Resident # 3 was coded as having impairment in range of motion, in one of her lower extremities. The resident was incontinent of both bowel and bladder and was not steady, only able to stabilize with staff assistance for moving on and off the toilet. In section K, the resident was coded as being 60 inches tall and weighing 116 pounds. The resident was coded in Section M - Skin Conditions, as being at risk for developing pressure ulcers and currently having a pressure ulcer. Resident # 3 was coded as having one Stage 4 pressure ulcer; the measurements were 1.2 cm (centimeters) in length, 1.0 cm in width and 0.1 cm in depth. The pressure ulcer tissue type was coded as "slough - a yellow or white tissue that adheres to the ulcer bed in strings or thick clumps, or is mucinous." Resident # 3 was observed on 01/03/13 at 11:24 a.m. lying in bed on her back. The resident's heels and feet were observed resting directly on the surface of the bed. No pillows or devices were in place to elevate the heels off of the surface of the bed. CNA (certified nursing assistant) # 8 was present in the room with the resident. The Resident was observed on 01/03/13 at 2:55 p.m. and at 3:45 p.m. lying in bed on her left side. Resident # 3's heels and feet were observed resting directly on the surface of the bed. No pillows or devices were in place to elevate the heels off of the bed. Review of the clinical record revealed the following documented entries in the nursing notes: - 10/03/12 at 11:25 p.m. "Resident A & O (alert and oriented) to self only .....Cast to RLE (right lower extremity) dry and intact. Able to move right toes; has good capillary refill." - 10/04/12 at 7:00 a.m. "Resident's appt (appointment) due today. Escorted by a private aide ...Resident was in wheelchair in a stable condition; left 3rd floor around 0640 (6:40 a.m.)." - 10/04/12, (with no time but followed the above note), "Resident at appt. All 8 a.m. (medications) not -given. Resident back to community - alert and verbally responsive. Denies any discomfort or pain - ate lunch. Leg has new dressing on the right leg." - 10/04/12 at 11:25 p.m. "Brace to RLE intact, no odor. Able to move right toes, no c/o (complaints) voiced." - 10/05/12 at 11 - 7 (11:00 p.m. to 7:00 a.m.), "(a circle with a line through it indicating, No) c/o pain/discomfort R/T (related to) ? (right) leg in new leg brace, (an arrow pointing upward) on pillow." - 10/05/12 at 14:05 (2:05 p.m.) "Resident seen by (name of doctor). New order to cleanse Stage III pressure ulcer to right thigh posterior and cover with a dressing and change q (every) 3 days." - 10/06/12 at 12:35 a.m. "Brace to RLE intact, able to move ? toes. No [MEDICAL CONDITION] observed, No c/o pain to RLE." - 10/06/12 at 7:00 a.m. "Brace to right leg in place." - 10/06/12 at 2:15 p.m. "Brace in place to right leg." - 10/06/12 at 9:50 p.m., "Brace to right leg intact and in place." - 10/07/12 at 4:35 a.m. "Rt (right) leg brace in place." A nutritional note dated, 10/07/12 documented, "Wt (weight) loss most likely R/T full leg cast removal (brace put on)." Further review revealed a documented, nurses noted dated 10/07/12 at 12:30 p.m., "Brace in place to right leg. Turn and position when in bed, pillow place between knees." A nurses noted dated 10/09/12 at 1:15 a.m., documented, "AM (morning) nurse reported to writer that there is an old dressing wrapped over ? (right) foot up to the ? ankle. Writer further assessed affected ? foot; observed dressing dated 10-4-12, dressing consist of yellow gauze, abdominal pad & kerlix. There is a pressure wound to right heel; length is 1.8 cm X 1.4 cm, depth 0.3 tunneling 0.8 cm @ (at) 12 o'clock. It has yellow wound bed with purulent drainage (without) odor. Updated evening supervisor - obtained tx (treatment) orders from MD (doctor)." The review of the clinical record did not reveal any treatment orders from 10/04/12 until 10/08/12 for the treatment of [REDACTED]. The "Pressure Ulcer Wound Assessment" form documented Resident # 3's heel wound measurements as follows: ? 10/08/12 - Stage IV - heel - right - 1.4 x 1.8 (length/width) - 0.3 depth - tunneling 0.8, no odor - yellow wound bed with purulent drainage. ? 10/09/12 - Stage IV - heel - right - 1.4 x 1.8 (centimeters) (length/width) - 0.3 depths - tunneling 0.8, no odor - yellow wound bed with small purulent drainage. ? 10/16/12 - Stage IV - heel - right - 1.4 x 1.8, 0.8 depth - tunneling 0.8, no odor, yellow wound bed, scant purulent drainage. ? 10/23/12 - Stage IV - heel - right - 1.4 x 1.8, 0.8 depth - tunneling 0.8, no odor, yellow wound bed, scant purulent drainage. ? 10/30/12 - Stage III - heel - right - 1.2 x 1.0, 0.2 depth, no tunneling, no odor, yellow wound bed, scant purulent drainage. ? 11/07/12 - Stage III - heel - right - 1.2 x 1.0, 0.2 depth, no tunneling, no odor, yellow wound bed, scant purulent drainage. ? 11/15/12 - Stage III - heel - right - 1.2 x 1.0, 0.1 depth, no tunneling, no odor, yellow wound bed, no drainage. There were no documented measurements between 11/15/12 and 12/18/12. ? 12/18/12 - Stage IV almost healed - heel - right - 0.5 x 0.3, no depth, no tunneling, no odor, wound bed is scabbed, no drainage. ? 12/24/12 - almost healed - heel - right - 0.3 x 0.2, no depth, no tunneling, no odor, wound bed is scabbed, no drainage. ? 01/02/13 - healed. Review of the physician progress notes [REDACTED]." A progress note dated, 10/05/12, documented, "Asked to evaluate wound s/p (status [REDACTED]. Wound located in posterior thigh, Pt not very cooperative, difficult exam. Pt has Stage 3 pressure ulcer 1.5 x 6.5 x 0.5 with serous drainage. A (assessment) Pressure ulcer stage 3 S/P cast removal." There was no progress note regarding the stage IV pressure area on Resident # 3 ' s right heel and no consultation note from the orthopedic surgeon for 10/04/12 in the clinical record. The section of the clinical record for therapy was reviewed. A "Braden Risk Assessment Scale" revealed an assessment performed by physical therapy that documented the resident with a score of "13/23" on 08/17/12. A score of 13 indicated the resident was considered a moderate risk to develop pressure ulcers. Documented on 10/05/12, the resident's score was a "12/23" indicating the resident was at high risk for developing pressure ulcers. Review of the telephone orders revealed no treatment orders for the "new dressing" noted on the resident's foot on 10/04/12 after the cast removal. A physician order dated, 10/08/12, documented, "Cleanse right heel ulcer with wound cleanser, pat dry, apply Santly* to slough, cover with gauze and wrap with kerlix; change daily." *Santyl Enzyme: topical debridement. Use- Promotes debridement of necrotic tissue in dermal ulcers. (1) A physician order dated, 10/12/12, documented, "Air Mattress for bed sore prevention." A physician order dated, 10/30/12, documented, "1. D/C (discontinue air mattress) to bed sore prevention. 2. Air Mattress to bed (check operation q shift) to assist with pressure ulcer healing. 3. Out of bed in W/C (wheelchair) qd (every day) with pressure reduction cushion. 4. Float heels bilat (bilaterally) while in bed." A physician order dated, 12/12/12, documented, "(A 'B' with a circle around it indicating bilateral) heel float." Review of the "Skilled Nursing Health & Services Update (monthly summary)," documented on 11/12/12, "Skin - Brace right leg, ulcer right heel and posterior thigh." The same form dated 11/19/12, documented, "Skin - skin tear to left lower leg." There was no mention of thigh or heel ulcers. The 11/26/12 form documented, "Skin - skin tear to left lower leg." Nothing was documented regarding right thigh or heel wounds. The form dated, 12/24/12 documented, "Skin - scratches to left shin." There was no mention of the pressure ulcers on the thigh or heel. The interim care plan dated, 08/16/12, was reviewed. The care plan documented under the heading of "Bed Mobility/Transferring/Ambulation/Locomotion & Balance: Resident needs extensive assistance with two person for ADLs due to recent [MEDICAL CONDITION] femur. Keep cast to left leg clean and dry at all times even during showers. Log roll with two assist in bed. Keep hip alignment." Under the heading, "Skin - Noted rash all over body. Skin tear to left lateral shin. Cleanse with wound cleaner, pat dry and apply (name of dressing) and wrap with kling daily until healed." The care plan dated 08/16/12 through 11/15/12, documented, "Bed Mobility/Transferring/Ambulation/Locomotion & Balance: Bed Mobility - Total Dependence of two person assist. Resident needs extensive assistance with two person for ADLs due to recent [MEDICAL CONDITION] femur. Keep cast to left leg clean and dry at all times even during showers. Log roll with two assist in bed. Keep hip alignment." Under the heading of "Skin - rash on back; treatment per order. Monitor for healing. Skin tear to left lateral shin." Under the "Skin section, dated, 10/30/12 - Float heels in bed." The care plan dated 11/28/12 through 02/28/13 documented, "Skin: Generalized rash. Low air loss mattress. Assist to turn and reposition frequently. Float heels while she is in bed. Right heel ulcer: treatment per order. Monitor for pain/infection. Knee immobilizer right leg: monitor for skin impairment around immobilizer." Resident #3's skin was observed on 01/03/13 at 11:24 a.m. accompanied by CNA (certified nursing assistant) # 8. The resident was in the bed, lying on her back. Both feet were resting directly on the surface of the mattress. CNA #8 proceeded to remove Resident # 3's right leg brace. A sock, geri-sleeve and 4x4 gauze were observed on Resident # 3's right heel and leg. The thigh area was clear with no impairment. The right heel was red. At this time a facility nurse was requested to review the wound with the surveyor. CNA # 8 was interviewed regarding how resident skin checks were completed at the facility. CNA # 8 stated, "The nurses are to do the skin checks." On 01/03/13 at approximately 11:26 a.m., LPN (licensed practical nurse) # 1 entered Resident # 3's room for wound observation with this surveyor and was interviewed about Resident # 3's current wound treatment. LPN # 1 stated, "We are just applying [MEDICATION NAME] and putting a 4x4 over it for protection for friction. The resident moves her leg and foot up and down." When asked if the area on her right heel was blanchable, LPN # 1 proceeded to press on the resident's heel with her thumb. The area did not blanch. The print of LPN # 1's thumb was observed remaining indented into Resident # 3's right heel for greater than 5 seconds. When asked to describe the heel, LPN # 1 stated that is was not hard but very soft. LPN # 1 stated, "It is boggy and soft." When asked if the heel should be that soft, LPN # 1 stated, "No, it shouldn't be boggy." An interview was conducted with LPN # 3 on 01/03/13 at 4:45 p.m., regarding when resident skin assessments are to be completed. LPN # 3 stated, "We do them on the shower days. We document on the TAR (treatment administration record). We flip the paper over and write on the back that the skin is clear. If it isn't clear we fill out a form in the skin book for non pressure and pressure wounds." LPN # 3 further stated that three months ago the process was changed. Shower sheets were utilized and skin assessments were documented in the nurse's notes. Now we just document on the reverse of the TAR that the skin is clear or write it's on a skin form." When interviewed about the process followed if a CNA identifies a wound or area of concern, LPN # 3 stated, "We assess the area, notify the doctor and responsible party and get treatment orders." When asked how to care for a resident with a cast or brace, LPN # 3 stated, "We check for circulation and the area around the cast." An interview was conducted with CNA # 4 on 01/03/13 at 4:55 p.m. When asked who is responsible for doing the skin checks, CNA # 4 stated, "The nurses do them but if we see something when we are giving a shower, we are to stop and go get a nurse before finishing the shower." An interview was conducted with the director of nursing (DON) on 01/03/13 at 5:00 p.m. regarding how resident wound measurements are completed at the facility. The DON stated, "The wounds are to be measured weekly." When asked about Resident # 3's missing wound measurements from 11/15/12 through 12/18/12, the DON stated, "That's about the time the wound nurse went out on leave for a medical issue. It fell through the cracks. We had a day supervisor doing them and she quit and now they have been assigned to the evening supervisor. We have a new wound nurse in orientation now." When asked how a resident with a cast or brace is to be cared for, the DON stated, "They should assess the skin around the cast, and check for capillary refill. For a brace, if the brace can be removed, the skin should be checked for skin circulation and [MEDICAL CONDITION]." A copy of Resident # 3's orthopedic surgeons consult report for 10/04/12 was requested. A copy of the facility policy on cast and brace care was requested from the DON. At the end of the day meeting on 01/03/13 at 6:10 p.m. the administrator and director of nursing were made aware of the concern facility staff failed to identify, initiate treatment, and measure wounds for progression of healing; and failed to implement the plan of care to float Resident # 3's heels. On 01/04/13 at 8:15 a.m. the DON stated the facility had an action plan to address wounds but it was still being worked on. The DON stated that they did not have a policy on cast care or brace care. She stated she had asked the therapy department for a policy, as there was none in the nursing policy and procedure manuals. When asked if the facility used any sort of scale, such as the Braden scale, to assess a resident for the risk of pressure ulcers, the DON stated, "We don't use the Braden, we use the resident admission assessment and then on the monthly nursing summary, we document any changes." At 01/04/13 at 11:00 a.m. the administrator was informed the concern for harm was valid, unless the facility could show what stage the resident's pressure ulcer on her heel was at the time the cast was removed. The administrator stated, "I am trying to work on getting information from the orthopedist. The nursing note explains that the cast came off on 10/04/12." At 11:45 a.m., the administrator stated, "We have no documentation of what the heel was when the cast was removed." The administrator informed this surveyor on 01/04/13 at 11:45 a.m. that the facility had contacted the orthopedic office to locate the notes for the removal of the cast. The orthopedic office did not have any notes for that day. The administrator stated they told her that the appointment was canceled. The administrator stated they had located the nurse's note that stated the cast had been removed on 10/04/12 and that they had no documentation of the heel skin condition when the cast was removed. During an interview with the DON on 01/04/13 at 12:00 p.m. the DON stated, "The facility removed, air mattresses and floating heels off of the TAR and put them in the care plan. The CNA signs off every day that they have provided the care as written in the care plan." A copy of Resident # 3's sign off sheets for October, November and December were requested and were not provided prior to exit. Review of the facility policy, "Pressure Ulcer Risk Assessment" documented, "Purpose: The purpose of this procedure is to provide guidelines for the assessment and identification of residents at risk for developing pressure ulcers. General Guidelines 1. Pressure ulcers are usually formed when a resident remains in the same position for an extended period of time causing increased pressure or a decrease of circulation (blood flow) to that area, which destroys the tissues. 2. The most common site of a pressure ulcer is where the bone is near the surface of the body including the back of the head, around the ears, elbows, shoulder blades, backbone, hips, knees, ankles and toes. 3. Pressure can also come from splints, casts, bandages and wrinkles in the linen. 4. If pressure ulcers are not treated when discovered, they quickly get larger, become very painful for the resident, and often times become infected. Pressure ulcers are often made worse by continual pressure, heat, moisture, irritating substances on the resident's skin (i.e. perspiration, feces, urine, wound discharge, soap residue, etc.), decline in nutrition and hydration status, acute illness and/or decline in the resident's physical and/or mental condition ....9. Pressure ulcers are a serious skin condition for the resident. 10. Routinely assess and document the condition of the resident's skin per facility wound and skin care program for any signs and symptoms of irritation or breakdown. Immediately report any signs of developing pressure ulcer to the supervisor ....Assessment: 4. Because a resident at risk can develop a pressure ulcer within 2 to 6 hours of the onset of pressure, the at-risk resident needs to be identified and have interventions implemented promptly to attempt to prevent pressure ulcers. The admission evaluation helps those initial care approaches ....Equipment and Supplies: 3. Assessment tools such as the Braden Scale or Norton Plus Pressure Ulcer Scale." The facility policy, "Prevention of Pressure Ulcers" documented, "Interventions and Preventative Measures" Residents with Risk Factors: 2.g. Monitor placement of splints and casts to assure they are not placing friction on the resident's skin." The facility policy, "Skilled Nursing Standards of Performance Skin Care Management" documented, "What Residents/Guest Should Experience: 3. ICSP (interdisciplinary care services plan) will be initiated upon admission to address identified skin concerns and/or risk factors ....5. Assessment with inclusion of risk factors and mobility limitations completed per (name of corporation) standards using: Health & Service Assessment upon admission. Health Service Update completed weekly/monthly depending of level of care. Weekly reassessment of wound progress via use of pressure/Non pressure ulcer form ....20. Pressure reducing/relieving mattresses/cushions used on residents/guests identified at high risk or with wounds. 21. Weekly wound rounds with the clinical team, lead by DNS (director of nursing services), to assess wound progress and determine response to current treatment plan and plan of care. WHAT RESIDENTS/GUESTS SHOULD NOT EXPERIENCE: 1. Team members not intervening to address open wounds or pressure ulcers. 2. Not changing treatments when wounds are not healing or improving." According to Lippincott Manual of Nursing Practice, Eighth Edition, part 2, unit 1, section 9, special health problems of the older adult, page 187, "nursing and patient care considerations in prevention and healing of pressure ulcers; relieve the pressure by: reposition every two hours, using special devices to cushion specific areas such as the heels." treatment of [REDACTED]. Department of Health and Human Services, Publication Number 15, read, in part: "Use devices that totally relieve pressure on the heels, most commonly by raising the heels off of the bed .... " And also," ....individuals in bed should have a care plan that includes the use of devices that totally relieve pressure on the heels, most commonly by raising the heels off of the bed." The National Pressure Sore Advisory Panel revealed the following information: Pressure Ulcer Prevention Points: II. Skin Care: 1. Perform a head to toe skin assessment at least daily, especially checking pressure points such as sacrum, ischium, trochanters, heels, elbows, and the back of the head. IV. Mechanical Loading and Support Surfaces: 10. Use devices that eliminate pressure on the heels. This information was obtained from the website: www.npuap.org <http://www.npuap.org> "Check to ensure that the cast is not too tight and frequently monitor the client's neurovascular status, usually every hour for the first 24 hours after application. You should be able to insert a finger between the cast and the skin ...Once the plaster cast is dry, it is inspected at least once every 8 hours for drainage, cracking, crumbling, alignment, and fit ...Infection most often results from the breakdown of skin under the cast (pressure necrosis) ...Circulation impairment and peripheral nerve damage can result from [MEDICATION NAME] of the cast. Perform frequent neurovascular assessments ...A client with a new cast may require hourly assessments. A client with a cast that is 3 or 4 days old usually requires assessments every 4 to 8 hours ... " Medical Surgical Nursing. Critical Think for Collaborative Care 5th edition, 2006; Donna D. Ignatavicius and M. Linda Workman; Elsevier Saunders; Page 1200. Drug Reference: (1) This information was obtained from Lexi-Comp's Drug Reference Handbooks: Drug Information Handbook for Nursing: 8th Edition 2007 pg. 301 2. For Resident # 9, the facility staff failed to follow the plan of care for the prevention of pressure ulcers on the resident's severely contracted hand. Resident # 9 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The most recent MDS (minimum data set) assessment, a quarterly assessment, with an assessment reference date of 11/09/12 coded the resident as rarely understanding others and rarely making herself understood. The resident was coded as being severely impaired to make cognitive daily decisions. Resident # 9 was coded as being totally dependent on one or two staff members for all of her activities of daily living. Section G0400 coded the resident with limitation in her range of motion in both upper and lower extremities on both sides of her body. In Section M - Skin Conditions, the resident was coded as being at risk for pressure ulcers but did not have any at the time of the assessment. On 01/04/13, at 7:50 a.m., Resident # 9 was observed in her room in bed, fully dressed, lying on her back with the bed in the lowest position. There was nothing in the resident's hands. She had her left arm extended in the air. Both hands were noted to be severely contracted at the wrist and finger joints. Observation was made of LPN (licensed practical nurse) # 4 on 01/04/13 at 8:50 a.m. performing the treatment to Resident # 9's right thumb. The hand was contracted and the nurse had difficulty keeping the thumb and hand apart to complete the wound care. LPN # 4 measured the wound on the inside surface of the first distal knuckle of the right hand. The wound measured: 1 cm (centimeter) x 1 cm in length and width with what the nurse described as 0.5 cm in depth. The area appeared sunken in the center of the wound. The wound bed was yellow in color. The area around the wound was reddened. When asked what stage pressure ulcer the wound appeared to be, LPN # 4 stated it was a stage two pressure ulcer. LPN # 4 cleansed the wound and applied the treatment. She then placed a non-stick dressing on top of the wound and surrounded the thumb with the excess of the dressing. The nurse then placed an additional 4x4 gauze pad under the resident's fingers where they sat on the resident's palm of her hand. Resident # 9 was observed on 01/04/13 at 9:40 a.m. in activities. There was nothing in her hands except the dressing that LPN # 4 had placed on earlier. Resident # 9 was observed on 01/04/13 at 11:20 a.m. asleep in her wheelchair in activities. There was nothing in her hands except the dressing that LPN # 4 had placed on earlier. Review of the physician order summary for December 2012 and January 2013 documented, "Use sock rolls to resident's hand bilaterally to prevent contracture per husband's request." The physician signed the orders on 12/12/12. A physician order dated, 12/12/12 documented an occupational therapy evaluation and treatment order. The care plan dated, 11/21/12 through 02/21/13, documented, "Skin: Turning and repositioning program when in bed. Skin assessment weekly. Use sock rolls in resident's hands bilaterally to ease risk of contractures - injuring palm of hand. Monitor skin under right hand splint for skin breakdown - splint per order. Keep nails cut as much as possible. Pressure ulcer on ? thumb - healed." Review of the "Pressure Ulcer Wound Assessment" documented the resident had a Stage 2 pressure ulcer on her right thumb from 10/05/12 that progressed to healing. No date was documented of the date healed. An "Interdisciplinary Progress Notes" date