Every finding on record at Bryan Health and Rehab

Based on observation, record review and interviews with the resident and staff, the facility failed to ensure a dependent resident could access a call bell that was out of reach for 1 of 21 residents reviewed for accommodation of needs (Resident #16). Findings included:Resident #16 was admitted to the facility on [DATE].Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #16 was severely cognitively impaired and needed assistance with activities of daily living. During an observation on 6/15/2026 at 11:26 a.m., and at 11:31 a.m. Resident #16 was observed sleeping and the call bell button was clipped to the call cord and hanging from the outlet on the wall, away from Resident #16's reach. In an interview with Resident #16 on 6/15/2026 at 11:32 a.m. she stated she was sleeping and did not know who moved the call bell button from her side and clipped it to the call cord. Resident #16 stated she could not reach the call bell button where it was currently placed. During an interview with Nurse Aide (NA#1) on 6/15/2026 at 11:33 a.m. she stated that she did not know who clipped the call bell button to call cord on the wall and out of reach for Resident #1. NA#1 stated that she had a rough morning with Resident #1 who was resisting care and focused on the resident hence not noticing that the call bell was out of reach for Resident #16. NA#1 revealed that Resident #16 does use the call bell to ask for help. NA #1 placed the call bell on the bed to where Resident #16 could reach it. In a telephone interview with Nurse #1 on 6/16/2026 at 10:26 a.m. she revealed she was Resident #16's nurse on 6/15/2026 during the first shift and was not aware that the call bell was out of reach. She stated that she remembers Resident #16 was difficult in the morning not agreeing to be changed as she was soiled, and NA#1 had come to her seeking help with the resident. Nurse #1 stated that she accompanied NA#1 to Resident #16's room and focused on getting Resident #16 up and did not notice the call bell button was clipped to the call cord and hanging from the wall. Nurse #1 stated that the call bell button is supposed to be placed where Resident #16 would access it. During an interview conducted on 6/16/2026 at 1:28 p.m., the Director of Nursing (DON) revealed she was not sure why Resident #16's call bell was out of reach. She stated that Resident #16 can walk to the nursing station if she needs something. The DON stated that she expected the call bell to be placed where a resident would reach it if they wanted to use the call bell. An interview was conducted with the Administrator on 6/17/2026 at 11:04 a.m. The Administrator stated that she expected nursing staff to have the call bells placed within reach of the residents.

Based on observation, resident and staff interviews, the facility failed to ensure the resident call light system was functioning properly for 1of 21 residents observed for resident call system (Resident #16). Findings included:Resident #16 was admitted to the facility on [DATE] with diagnoses that included depression, dementia and facial weakness.Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #16 was severely cognitively impaired and needed assistance with activities of daily living. An observation of Resident #16's call light was conducted on 6/15/2026 at 11:26 a.m. and at 11:31 a.m. When the call light was pressed, it did not illuminate on the outside of her door in the hallway. A handheld bell was observed in her room.In an interview with Resident #16 on 6/15/2026 at 11:32 a.m. she stated she sometimes does use the call bell and was not aware that it was not working. Resident #16 used the call bell at the time, but the call light did not come on.During an interview with Nurse Aide (NA#1) on 6/15/2026 at 11:33 a.m. she stated that she was not aware the call bell was not working. NA#1 further revealed that if she had observed a non-working call bell she would report immediately to the maintenance manager. In a telephone interview with Nurse #1 on 6/16/2026 at 10:26 a.m. she revealed she was Resident #16's nurse on 6/15/2026 during the first shift and stated that she was not aware the call bell was not working until NA#1 alerted her and they replaced it with a new one.An interview was conducted with the Environmental Services Director (ESD) on 6/16/2026 at 1:04 p.m. He stated that he conducts monthly checks on all call bells in all rooms and was surprised that Resident #16's call bell was not working. He further stated that he had done call bell audits for the month of June. The ESD stated that nursing staff would report to him if a call bell was not working and he would replace as they had enough replacements in stock. During an interview conducted on 6/16/2026 at 1:28 p.m., the Director of Nursing (DON) revealed she was not sure why Resident #16's call bell was not working. She revealed that call bell audits are done monthly to make sure they are working. She stated that she always expects the call bell light to be working.An interview was conducted with the Administrator on 6/17/2026 at 11:04 a.m. The Administrator stated that the facility conducts monthly call bell checks to make sure they are working properly. She further stated that she is not sure if staff knew the call bell was not working and sometimes things do happen.

Based on record review and staff interviews, the facility failed to revise the nutritional care plan to include significant weight loss for 1 of 1 resident reviewed for nutrition (Resident #1) and to revise the care plan in the area of pressure ulcers for 1 of 2 residents reviewed for pressure ulcers (Resident #28). The findings included: 1. Resident #1 was admitted to the facility on [DATE] with diagnoses that included stroke, diabetes, and dysphagia. The care plan for Resident #1 last reviewed on 7/20/24 revealed that she received a therapeutic diet related to diabetes with finger stick blood sugar monitoring. It was noted that she had decreased left side sensation and a history of pocketing food. She has no teeth and might have discomfort when chewing, so she received mechanical soft food consistency. She had the potential for weight loss related to low intake. Interventions included: Provide adaptive equipment (Divided Plate), provide diet as ordered, provide supplements as ordered, monitor lab work to determine the effect of the therapeutic diet, and finger stick blood sugar monitoring as ordered. A review was also performed on 2/17/25 including the problem that Resident #1 had a diagnosis of diabetes (type 2). Interventions included: Administer hypoglycemic medications per doctor's order. If blood glucose is less than or equal to 60 milligrams (mg) per deciliter (dL), treat per facility policy and doctor's order. Monitor for signs of hypoglycemia and hyperglycemia. Another problem reviewed on 4/4/25 revealed that Resident #1 resisted care (refused meals and medications). Interventions included: Reiterate the purpose and advantages of care for the resident, do not alienate or criticize the resident when resistant to care, convey an attitude of acceptance toward the resident, and maintain a calm environment and approach to the resident. The quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #1 was cognitively intact and set up/cleanup assistance from staff with eating. She received a mechanical soft and therapeutic diet. She was 66 inches tall, weighed 133 pounds. The MDS indicated Resident #1 had significant weight loss and was not on a physician-prescribed weight-loss regimen. In an interview with the MDS Coordinator on 4/30/25 at 10:14 AM, she revealed that she was responsible for the care plan if a resident triggered for weight loss on the MDS assessment. As far as the gradual decline of weight, nursing and dietary were responsible for the care plan. Resident #1 was triggered for weight loss in the quarterly MDS assessment dated [DATE], so the care plan should have been updated then to include the weight loss. During a follow-up interview on 4/30/25 at 1:13 PM, the MDS Coordinator stated that the care plan for Resident #1 was not updated after the significant weight loss triggered in the quarterly MDS assessment dated [DATE] because there were a lot of assessments due at that time, and it must have been missed by mistake. An interview was conducted with the Director of Nursing (DON) on 4/30/25 at 4:20 PM. She revealed the care plan for Resident #1 should have been updated when she triggered for significant weight loss. The Administrator was interviewed on 4/30/25 at 4:25 PM. She revealed that if Resident #1 had a significant weight loss, there should have been a nursing/dietary intervention appropriate for her included in the care plan. 2. Resident #28 was admitted to the facility on [DATE] with diagnoses which included dementia and contractures of the lower extremities. Review of the Wound Management Report dated 11/15/24 revealed Resident #28 was identified to have an unstageable pressure ulcer due to slough (nonviable tissue) or eschar (dead tissue) on the bottom of the right foot at the area of the right great toe. The pressure ulcer was noted to have measurements of 2 centimeters (cm) x 1 cm with no drainage noted. The Minimum Data Set (MDS) quarterly assessment dated [DATE] revealed Resident #28 had severe cognitive impairment. Resident #28 was coded for stage 2 pressure ulcer and pressure ulcer treatment and care. The care plan last reviewed on 2/27/25 revealed no care plan was in place for Resident #28's pressure ulcer. An observation of Resident #28's right foot was conducted on 4/30/25 at 10:57 am with the Wound Treatment Nurse. Resident #28 was noted to have a pressure ulcer to the bottom of the right foot near the base of the right great toe. An interview was conducted with the MDS Nurse on 4/30/25 at 12:42 pm who revealed she was responsible to update Resident #28's care plan when the right foot pressure ulcer was identified. The MDS Nurse stated she was aware that Resident #28 had a pressure ulcer on her right foot but stated she must have gotten caught up in something and missed updating the care plan. During an interview on 4/30/25 at 1:35 pm the Director of Nursing (DON) stated the MDS Nurse was responsible to ensure Resident #28's care plan was updated to reflect the pressure ulcer to the right foot. An interview was conducted on 4/30/25 at 2:42 pm with the Administrator who stated the MDS Nurse was responsible to create the care plan for the management of Resident #28's right foot pressure ulcer.

Based on observation, record review, and interviews with the resident, staff, Psychotherapist and Nurse Practitioner, the facility failed to ensure that a resident with known visual impairment was evaluated for treatment and services to maintain her vision for 1 of 1 resident reviewed for vision and hearing (Resident #2). The findings included: Resident #2 was admitted to the facility on [DATE] with diagnoses which included macular degeneration. The progress note dated 6/28/24 at 1:33 pm by the Social Worker revealed Resident #2 was prepared for a room change and expressed concern about knowing where things were in the new room given her eyesight deficits. The Social Worker further noted staff would assist Resident #2 to acclimate her to the new room. The Minimum Data Set (MDS) annual assessment dated [DATE] revealed Resident #2 was cognitively intact and was coded for moderately impaired vision with corrective lenses. Under activity preferences, Resident #2 was coded that having books, newspapers, and magazines to read were important but she was coded as not being able to do. Resident #2 had a care plan, last reviewed on 2/13/25, for impaired vision related to diagnosis of macular degeneration with interventions which included arrange ophthalmologist or optometrist consult as indicated. Review of the psychotherapy visit note dated 4/16/25 revealed Resident #2 was seen for an initial assessment with the Psychotherapist. The visit note revealed that Resident #2 reported being depressed and revealed her vision loss had exacerbated her depressed feelings. A telephone interview was conducted on 4/30/25 at 1:12 pm with the Psychotherapist who revealed Resident #2 had reported that she enjoyed reading her Bible and was no longer able to engage in that due to her vision loss. She stated she did not discuss this with the facility but included it in her visit note which was in Resident #2's electronic medical record. An attempt to conduct a telephone interview with the Physician on 4/30/25 at 11:41 am was unsuccessful. An interview and observation were conducted on 4/28/25 at 2:24 pm with Resident #2 who reported she had glasses but was not able to see well with them because everything was blurry. She stated she could not remember the last time she was seen by an eye doctor or if an appointment was offered. Resident #2 stated she was not sure if new glasses would help but she would like to see about getting a new pair so she could see better. Resident #2 stated staff knew she had very poor vision and they (staff) kept her things in the same spot so she would know where to find them. Resident #2's glasses were noted to be on the bedside table at the time of the interview and observation. An interview was conducted with Nurse Aide (NA) #1 on 4/28/25 at 2:28 pm who revealed Resident #2 did wear glasses when out of bed and while eating but she did not normally wear them when in bed. An interview was conducted with Nurse #1 on 4/30/25 at 9:11 am who revealed Resident #2 did have glasses and at times did report the glasses were not working for her. Nurse #1 stated Resident #2 used to get eye injections for macular degeneration but she stated Resident #2's vision would not get better even with the injections because her vision loss was just age related. An observation and interview were conducted on 4/30/25 at 9:12 am of Resident #2 who was observed in bed moving her hand around the top of the bed covers. Resident #2 stated she was trying to find the end of her call bell so she could ring for the nurse but she could not see the end of the call bell. The call bell was noted to be attached to the top of the blanket and within reach of Resident #2's right hand. Resident #2's glasses were observed on the bedside table at the time of the observation. During an interview on 4/30/25 at 9:13 am with NA #2 she revealed Resident #2's vision was very poor and sometimes seemed worse than other times, but she did not report that her eye glasses were not working for her. She stated Resident #2 had glasses and they were normally on her bedside table when not worn. NA #2 stated she made sure Resident #2 had her glasses on when she was eating and out of bed. NA #2 stated Resident #2 had her personal items set up close to her in the same spot so she could know where things were by feeling for them. An interview was conducted with the Social Worker on 4/30/25 at 10:04 am who revealed she was aware Resident #2 had previously been seen by a provider out of the facility for macular degeneration. The Social Worker stated the in-house vision provider would see residents with new vision concerns or past trouble with their vision but she stated Resident #2 was not on the list to be seen. She stated she would normally sign a resident up for the in-house vision provider when notified by nursing or requested by the resident. The Social Worker confirmed she did not add Resident #2 to the in-house vision provider visit list because she was not notified of the need, but she stated Resident #2 was able to be seen if needed. An attempt to interview Resident #2's Responsible Party on 4/30/25 at 11:13 am was unsuccessful. A telephone interview was conducted on 4/30/25 at 1:53 pm with the Nurse Practitioner who revealed she was aware of Resident #2's macular degeneration but not aware of any other issues with her vision. The Nurse Practitioner stated if Resident #2 was having difficulty seeing she would have expected a vision evaluation to be completed. An interview was conducted on 4/30/25 at 10:11 am with the Director of Nursing (DON) who revealed Resident #2 had previously been seen by an outside provider for injections for her macular degeneration but once she was returned from the hospital the RP no longer wanted to pursue aggressive interventions so the next appointment for the injection was cancelled and no further appointments were scheduled. The DON stated she was not sure if she would have added Resident #2 to the in-house provider vision list because she did not want to see the in-house provider in the past. The DON stated a vision evaluation for Resident #2 was something they could talk about with the provider and Resident #2's RP. During an interview on 4/30/25 at 2:43 pm with the Administrator who revealed Resident #2 was initially admitted to the facility as an assisted living resident and had previously refused in-house services at that time. The Administrator stated she believed the in-house provider for vision was not offered to Resident #2 due to her previous refusals. The Administrator stated if Resident #2 would accept to see the in-house provider for vision she would be seen because Resident #2 had the right to be able to do the things she enjoyed.

Based on record review and staff interviews, the facility failed to develop care plans to address anticoagulant use for 4 of 4 residents reviewed for anticoagulant medication (Resident #3, Resident #26, Resident #45, and Resident #39), and the use of a splint for contracture management for 1 of 1 resident reviewed for range of motion (Resident #19). The findings included: 1. Resident #3 was admitted to the facility on [DATE] with diagnoses that included heart failure, acute embolism (Blockage of a lung artery), and thrombosis (occur when blood clots block blood vessels) of superficial veins of right upper extremity. Resident #3's most recent Annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #3 was cognitively intact and coded for anticoagulant medication. The active physician's orders revealed an order dated 09/27/2022 for Eliquis (anticoagulant medication) tablet 5 milligrams twice a day at 8am/8pm. The active comprehensive care plan last reviewed on 10/01/2022 revealed anticoagulant medication therapy was not referenced in the care plan. During an interview with the MDS Nurse on 12/7/2022 at 10:19am she revealed she forgot to document Resident #3's anticoagulant therapy on the care plan during the annual review of the plan. An interview was conducted with the Director or Nursing (DON) on 12/07/2022 at 12:03pm. She stated she expected Resident #3's care plan to be comprehensive and updated timely. During an interview on 12/07/2022 at 4:13 pm the Administrator revealed a care plan was expected to be implemented for any medication or diagnosis that required monitoring or treatment. 2. Resident #26 was admitted to the facility on [DATE] with diagnoses that included acute pulmonary edema, and acute systolic heart failure. Resident #26's most recent Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed he was moderately impaired and coded for anticoagulant medication. The active physician's orders revealed an order dated 12/13/2021 for Eliquis (anticoagulant medication) tablet 5 milligrams twice a day at 7am/7pm. The active care plan for Resident #26 revealed no reference to his prescribed anticoagulant medication. During an interview with the MDS Nurse on 12/07/2022 at 10:19am she revealed she forgot to document Resident #26's anticoagulant therapy on the care plan. An interview was conducted with the Director or Nursing (DON) on 12/07/2022 at 12:03pm. She stated she expected Resident #26's care plan to be comprehensive and updated timely. During an interview on 12/07/2022 at 4:13 pm the Administrator revealed a care plan was expected to be implemented for any medication or diagnosis that required monitoring or treatment. 41772 3. Resident #45 was admitted to the facility on [DATE] with diagnoses that included acute on chronic systolic congestive heart failure and atrial fibrillation. Review of a physician ' s order dated 7/5/22 revealed an order for Eliquis (a medication used to prevent blood clots) 2.5 milligrams twice a day. Review of the most recent Minimum Data Set (MDS) dated [DATE] revealed that Resident #45 had severe cognitive impairment. Review of Resident #45s care plan last reviewed 9/9/22 revealed no care plan for anticoagulant therapy. An interview was conducted with the MDS nurse on 12/7/22 at 2:40 PM. The MDS nurse stated that Resident #45 should have had an anticoagulant therapy care plan. She was unable to state why the care plan was not implemented. An interview was conducted with the DON on 12/7/22 at 3:00 PM. The DON stated that a care plan was to be implemented for residents on anticoagulant therapy. The DON stated she expected care plans to be updated timely to reflect the residents care. 45045 4. Resident #39 was admitted to the facility on [DATE] with diagnosis of atrial fibrillation. A physician order dated 5/21/21 for Eliquis (anticoagulant medication used to treat and prevent blood clots and to prevent stroke in people with atrial fibrillation) 2.5 milligram twice a day. Record review of the Minimum Data Set (MDS) Quarterly assessment dated [DATE] revealed Resident #39 was coded for anticoagulant medication. Record review of Resident #39's care plan last reviewed on 11/10/22 revealed no care plan for anticoagulant therapy. During an interview on 12/07/22 at 10:40 am Nurse #1 revealed care plans were implemented by the MDS Nurse or Director of Nursing (DON). During an interview on 12/07/22 at 10:44 am the MDS Nurse revealed she was responsible to implement the comprehensive care plan for Resident #39. She stated a care plan was required for the anticoagulant medication but was unable to state why one was not implemented. An interview with the DON on 12/07/22 at 1:35 pm revealed a care plan was to be implemented for anticoagulant medication for monitoring of the medication and risks associated with the medication. The DON stated medication and care plans were discussed during the clinical meeting and was unable to state how the care plan was missed for Resident #39's Eliquis. 5. Resident #19 was admitted to the facility on [DATE] and had a diagnosis of trigger finger of right ring finger. A physician order dated 3/30/22 to ensure splint is in place on right ring finger after meals and at bedtime, may be removed for active use, four times a day for trigger finger (inflammation of the tendon of the finger which causes the finger to get stuck in a bent position and then snap straight). Record review of Resident #19's care plan, last reviewed on 11/10/22 revealed no care plan for splint to right ring finger. During an interview on 12/07/22 at 10:54 am the Minimum Data Set (MDS) Nurse revealed she was responsible for implementing resident care plans. She stated Resident #19's splint to her finger needed a care plan but was unable to state why she did not implement one. Interview with the Director of Nursing (DON) on 12/07/22 at 1:30 pm revealed the MDS Nurse, or nursing management implemented a care plan. The DON stated the splint should have been discussed in the clinical meeting and a care plan added for Resident #19's finger splint. During an interview on 12/07/22 at 4:13 pm the Administrator revealed a care plan was expected to be implemented for any medication or diagnosis that required monitoring or treatment.

Based on observation and staff interviews, the facility failed to label and date food items stored for resident use in 1 of 1 nourishment rooms observed. Findings included: An observation of the nourishment room was conducted on 12/07/22 at 2:48 pm with Medication Aide (MA) #1 and the refrigerator/freezer were inspected. The following items were found inside the refrigerator: an opened, half empty, plastic bottle of orange soda without a name or date, and two plates with a slice of pie covered with plastic wrap on each plate without a name or date. Also, a disposable container of food was observed on the counter near the refrigerator without a date. During an interview on 12/07/22 at 2:50 pm MA #1 revealed the two slices of pie, and the orange soda were to be labeled with the date and name when placed in the refrigerator. MA #1 stated the disposable container of food belonged to a staff member and was not to be kept in the resident nourishment room. During an interview on 12/07/22 at 2:58 pm Nurse Aide (NA) #1 revealed the disposable container of food in the nourishment room belonged to her and it was her lunch. NA #1 stated the food was to be stored in the break room not in the nourishment room. During an interview on 12/07/22 at 4:17 pm the Administrator revealed the Dietary Department was responsible to monitor the nourishment room every morning and ensure items were labeled. During an interview on 12/07/22 at 4:22 pm the Dietary Manager revealed she checked the nourishment room in the morning and did not observe the two slices of pie during her observation. She stated the container of food, and the orange soda were not present when she was in the nourishment room.

Based on record review and staff interviews, the facility failed to have a Registered Nurse (RN) in the building for 8 hours a day, 7 days a week for 4 of 30 days reviewed for staffing (4/4/21, 4/11/21, 4/17/21, 4/25/21). The findings included: The nurse staffing sheets were reviewed for April 2021. On Sunday 4/4/21, 4/11/21, & 4/25/21 and Saturday 4/17/21, there was not a RN scheduled to work. During an interview with the Director of Nursing (DON) on 6/3/21 at 11:07 AM, she revealed there were times there was not a RN in the facility for 8 hours a day, 7 days per week. The DON stated she was not aware a RN had to be physically in the building. The DON stated she was available by telephone at these times. During an interview with the Administrator on 6/3/21 at 11:10 AM, she revealed she was aware there were times there was not an RN in the facility for 8 hours a day, 7 days per week. The Administrator stated she had been attempting to hire a full time RN to ensure coverage but had not hired one. The Administrator revealed she had attempted to staff the position through a staffing agency but had been unable to fill the position.

Based on document review and staff interviews, the facility failed to provide a surety bond which covered the total balance of the resident trust fund accounts for 39 of 46 residents reviewed. The findings included: Review of the facility surety bond read in part Long Term Care Residents of Our Community Hospital, Inc. dated 4/12/21 - 4/12/22, for the amount of $45,000.00. During an interview with the Business Office Manager (BOM) on 6/3/21 at 12:03PM revealed the current balance of the resident trust fund as of 6/3/21 was $65,412.48. During an interview with the Administrator, she revealed the current amount of the surety bond did not cover the balance in the resident trust fund. She stated she was in the process of updating the amount to ensure it covered the balance in the resident trust fund.

Based on record review and staff interviews the facility failed to send written notification of the reason for discharge to the hospital to the resident and to the resident's emergency contact for 2 of 2 discharges for 1 of 1 resident (Resident #25) reviewed for hospitalization . The deficient practice had the potential to affect other residents that were discharged to the hospital. The findings included: Resident #25 was admitted to the facility on [DATE] and had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The Admission Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was cognitively intact. Review of the medical record revealed Resident #25 was discharged to the hospital on 3/15/21 and was readmitted to the facility on [DATE]. The resident was also discharged to the hospital on 4/23/21 and readmitted to the facility on [DATE]. An interview was conducted with the facility's Social Worker on 6/2/21 at 3:53 PM. The Social Worker stated when a resident was sent out to the hospital, the family was notified by phone and a written letter was not sent to explain in writing why the resident was discharged to the hospital. The Social Worker further stated once a month she sent a list of discharges to the ombudsman. On 6/2/21 at 4;15 PM the resident's emergency contact stated in an interview he had not received written information from the facility regarding why the resident was sent to the hospital on either occasion. On 6/3/21 at 2:26 PM an interview was conducted with the Administrator and the Director of Nursing (DON). The Administrator stated she thought the written discharge notice was to be sent when a resident was discharged to a place to receive a lower level of care and did not realize the notice was to be sent when a resident was discharged to the hospital.

Based on record review, staff and family interviews, the facility failed to provide a bed hold policy for a resident when discharged to the hospital for 2 of 2 discharges for 1 of 1 resident reviewed for hospitalization (Resident #25). The deficient practice had the potential to affect other residents that were discharged to the hospital. The findings included: Resident #25 was admitted to the facility on [DATE] and had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The Admission Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was cognitively intact. Review of the medical record revealed the resident was discharged to the hospital on 3/15/21 and was readmitted to the facility on [DATE]. The resident was discharged to the hospital again on 4/23/21 and was readmitted to the facility on [DATE]. On 6/2/21 at 3:50 PM an interview was conducted with Nurse #1 who stated she did not send the bed hold policy with any resident when sent out to the hospital. On 6/2/21 at 3:53 PM an interview was conducted with the facility's Social Worker who stated when a resident was admitted to the facility a copy of the bed hold policy was given to the resident's responsible party (RP) or to the resident if the resident was their own responsible party. The Social Worker further stated their policy stated the family or resident had 24 hours to call the facility and set up a bed hold if desired. On 6/3/21 at 2:26 PM an interview was conducted with the Administrator and the Director of Nursing (DON). The Administrator stated their policy stated the family must call the facility within 24 hours to set up a bed hold and she would revise their policy. The Administrator further stated there had not been a problem with bed availability when residents returned from the hospital. The Director of Nursing stated that copies of the bed hold policy were at the nurse's station and she thought the nurses were sending the policy with residents when they were discharged to the hospital. The DON stated the resident was his own responsible party.

Based on observations, facilituy staff, wound clinic staff, Power of Attorney (POA) and Physician interviews, and record reviews the facility failed to assess a pressure ulcer and failed to carry out a wound clinic referral which resulted in a decline and infection of the wound for 1 of 5 residents (Resident #47) reviewed for pressure ulcers. Findings included: Resident #47 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #47 was discharged to the hospital on [DATE]. Resident #47's care plan dated 2/19/2019 revealed a plan which focused on risk for pressure ulcer related to immobility and incontinence with a goal that her skin would remain intact. The interventions were to conduct a systematic skin inspection, keep clean and dry as possible, turn and reposition every 2 hours, reduce friction by using a pull sheet and report any redness or skin breakdown to nurse. The care plan was not updated after this date. Resident #47's Braden Skin assessment dated [DATE] revealed she was at a mild risk for pressure sores. An admission progress note by the Director of Nursing (DON) dated 2/19/2019, revealed the Resident #47 was admitted on [DATE] from the hospital with redness on her buttocks from incontinence. Resident #47's admission Minimum Data Set (MDS) assessment dated [DATE] revealed her cognition was moderately impaired. She required total staff assistance for activities of daily living (ADLs), except for eating, in which she was independent. She had no pressure ulcer on admission, and she was not coded as palliative or hospice care. The Treatment Aministration Records (TAR) for (MONTH) 2019 through (MONTH) 2019 revealed daily documentation that dressing treatments had been conducted as ordered and were signed off by nursing staff. No description of the wound was included on the TAR. Nursing progress notes addressing care and description of Resident #47's sacrum area are as follows: On 2/26/2019 DON's note revealed the excoriated areas to the buttocks had increased in size. On 3/4/2019 Nurse #1's note revealed the excoriated areas on buttocks and sacral fold continued and a new treatment was initiated. On 3/23/2019 Nurse #2's note revealed resident #47 sat in the wheelchair for long hours of the day and night and was turned every two hours for pressure relief. It also revealed the dressing was dry and intact. The care plan had not been updated to address Resident #47's pressure relieving device for the wheelchair. On 3/25/2019 Nurse #3's note revealed Resident #47 was on bedrest and had an air mattress on the bed. On 3/25/2019 Nurse #3's note revealed the wound was 16 centimeters (CM) x 10 CM and was measured per pharmacy request. There was no documentation included that addressed the appearance or deterioration of the wound On 3/27/2019 Nurse #1's note revealed a new wound care treatment had been initiated and an indwelling catheter was inserted. On 4/9/2019 Nurse #4's note revealed the wound bed was covered with dark gray tissue with a moderate amount of foul-smelling purulent drainage. The wound also had some yellow slough. On 4/10/2019 Nurse #4's note revealed the depth of the wound was worsening and the entire area around the wound was tunneling. The wound was packed using six or seven 4 x 4 gauzes. On 4/12/2019 Nurse # 5's nurses noted revealed the wound had a foul odor with moderate yellowish and bloody drainage and had yellow slough hanging from the wound. On 4/13/2019 the Nurse #4's note revealed the outer area of the wound continued to decline by an increase in depth and tunneling all around the wound. There was some scattered necrotic tissue with yellow stringy adhered tissue to the outer edge of the wound. Daughter at bedside questioning the decline in the wound. On 4/14/2019 Nurse #4's note revealed the dressing was changed with no change to the wound observed. Resident #47's temperature was 101 and Tylenol was given with a decrease in temperature to 97.0. On 4/15/2019 Nurse note revealed Resident #47 was transported to the emergency room with the chief complaint of wound infection and was admitted with the [DIAGNOSES REDACTED]. The Emergency department provider notes dated 4/15/2019 revealed Resident #47 had a stage four sacral decubitus with the bone visible in the wound. The wound edges were somewhat indurated. The wound culture dated 4/22/2019 revealed pseudomonas in the wound and the physician planned to discharge Resident #47 on 4/22/2019 with an antibiotic. A review of the medical record revealed no other nurse notes pertaining to care of the wound care from 3/5/2019 through 3/22/2019, and from 3/28/2019 through 4/8/2019. Physician orders [REDACTED]. Physician orders [REDACTED]. The Physician orders [REDACTED]. A review of physician orders [REDACTED]. The physician order [REDACTED]. Resident #47's 30-day MDS assessment dated [DATE] revealed her cognition was moderately impaired and she required total staff assistance for ADLs, except for eating and locomotion which were independent. The assessment noted there was no pressure ulcer and she was not coded as palliative or hospice care. Resident #47's Braden Skin assessment dated [DATE] revealed she was at a high risk for pressure sores. On 6/18/2019 at 10:30 AM, an interview was conducted with Nursing Assistant (NA) #1, who stated Resident #2 did not like to be turned in bed but would turn over to her side when encouraged. On 7/16/2019 at 11:45 AM an interview was conducted with the Medication Technician (MT). The MT stated Resident #47 stopped eating shortly after she was admitted to the facility, and she would whine and shake her head no when care was provided for her. On 6/19/2019 at 3:10 PM, an interview was conducted with Nurse #1, who was familiar with Resident #47's care and stated she was admitted for rehabilitation and it took a lot of encouragement for the resident to participate in activities of daily living. Nurse #1 also stated Resident #47 had an indwelling catheter and a [MEDICATION NAME] agent was used on the wound, but the wound was not improving. Preventative measures were used which included wedges to prop up, pressure relieving mattress on the bed and cushion in the wheelchair. On 7/16/2019 at 10:19 AM, a second interview was conducted with Nurse #1. The nurse stated when Resident #47 was first admitted her sacral area was red but not opened and they were using a cream on it. The nurse stated the wound opened and orders were changed to a hydrogel with gauze covering it. The nurse stated she had informed the Physician of the treatment and the condition of the wound, but he elected to keep the same treatment regimen at that time. The nurse stated Resident #47 was very noncompliant in her nutrition and she had to be prompted and encourage to eat, and she would refuse food. The nurse stated she would refuse to turn and that contributed to her wound decline. The nurse stated Resident #47 would drink her med pass and she was getting the dressing changed daily. The nurse stated she was not told to measure the wound and thought the DON/ADON (Assistant Director of Nursing) were covering that. On 7/15/2019 at 3:46 PM, an interview was conducted with Nurse #3 who stated Resident #47's dressing was changed daily when she cared for her. The Nurse stated the previous MDS nurse measured pressures wounds weekly and documented the results in the medical record. Nurse #3 stated when the previous MDS nurse left the facility it was not conveyed to the floor staff to measure and document on wounds. Nurse #3 stated floor staff had always conducted the dressing changes and that remained in place. The Nurse stated the Resident #47 would get out of bed daily when she first came to the facility, but shortly after, and she was unsure of the time frame, the resident did not want to get up, did not eat well and the wound change happened very fast. The Nurse stated she was working when the resident's family member was at the facility, observed the wound and wanted the resident to be sent to the hospital. The Nurse stated she called the Physician and he ordered the wound clinic visit and a change of treatment, and she informed the family who was okay with the orders. On 7/16/2019 at 10:40 AM an interview was conducted with Nurse #4. The Nurse stated she cared for Resident #47 after she was moved to her hall, but she already had the declining pressure ulcer. The Nurse stated she did not measure the wound and did not think anyone was measuring it, as floor nurses were never informed to measure the wounds even after the previous MDS/wound nurse had resigned. The nurse stated she changed the dressing daily. The nurse stated she did not call the Physician about the wound but had added the resident to the Physician's list to be seen on 4/17/19, but the resident was discharged to the hospital on [DATE]. The nurse stated she thought the wound deteriorated because of a series of things which included her lack of motivation to move, and her poor appetite. The nurse stated Resident #47 was totally dependent on staff because of lack of will and not lack of function. On 7/15/2019 at 4:47 PM, an interview was conducted with Nurse #5 who stated she cared for Resident #47 when she was moved to her hall after the pressure wound was already deteriorated. The Nurse stated she measured the wound for the Pharmacist one time. The nurse stated she did not know the expectation for measuring the wound as the previous MDS nurse had measured all wounds and documented them weekly before she left the facility. The nurse stated she changed the dressings daily as per the orders and treatment record, but the resident had very poor intake and refused eating and getting out of bed. On 7/16/2019 at 4:01 PM, an interview was conducted with the Certified Occupational Therapy Assistant (COTA), and Physical Therapy Assistant (PTA) who stated when they started working with Resident #47, she could stand and pivot for transfer on 2/20/2019. The COTA stated by 3/1/2019 Resident #47 had declined to using a sit to stand lift for transfers, and by 3/6/2019 she could not sit unassisted in the chair and required 100% cueing. The COTA and PTA stated Resident #47 was discharged from therapy on 4/10/2019 because she was making no progress and by that time, she needed total assistance for activities of daily living (ADLs) and required maximum assistance to roll in bed. On 6/19/2019 at 1:20 pm an interview with the DON revealed that she was called into the resident room on 2/19/2019 to assess Resident #47's buttock and found an area on the buttock right in the middle of the buttock cheek that was beginning to open but had not yet opened. The DON stated a barrier cream for Resident #47's buttocks was started on 2/19/2019, when she was admitted and that was standard treatment used as a preventative measure for all residents in the facility. On 7/16/2019 at 3:22 PM, an interview was conducted with the DON who stated the wound might have been avoidable if the resident was not already declining when she was admitted to the facility. The DON stated Resident #47 would not move or eat and the facility talked to Resident #47's family member to have her help convince Resident #47 to turn. The DON confirmed the resident was not on hospice, palliative or comfort care while she was a resident at the facility. The DON stated the wound was not consistently measured and she had told staff to measure once per week, but that was not done. The DON stated she expected the nurses to measure the wound weekly and report wound status to the Physician. The interview with the Physician on 6/20/2019 at 12:36 pm revealed that the nurse called and informed him of the cancelled appointment and that was when he gave a new order for treatment. The Physician stated by Resident #47 not going to the wound clinic appointment, it presented a chance for the wound to fester or get worse and it slowed the healing of the wound. He also stated he believed sending Resident # 2 to the clinic would have hastened the healing process. On 7/16/2019 at 2:32 PM, a second interview was conducted with the Physician who stated Resident #47's pressure wound should have been avoidable, but he did not know why it was not. The Physician stated he thought her not wanting to participate in therapy and laying on the wound too much made the wound worse. The Physician stated staff did informed him the wound was getting worse and he ordered the wound clinic visit, and after another call by staff he ordered a change of treatment. A review of an appointment calendar dated 3/28/2019 revealed Resident #47 was scheduled for an appointment with the wound clinic on 3/28/2019 at 3:30 pm. The calendar showed the appointment was cancelled on 3/27/2019 by Medication Technician #1. The interview with Medication Technician (MT)#1 on 6/19/2019 at 1:51 pm revealed the appointment was cancelled on 3/27/2019 because the family was unable to go with her and the physician would not see Resident #47 the first time without a family member present. The MT stated that she informed the doctor of the cancellation and wrote it on the appointment schedule. On 7/16/2019 at 11:45 AM a second interview was conducted with the MT who stated she was at the desk when the ADON stated the family had called and informed staff they could not be at the wound clinic appointment, so he had cancelled her appointment and told the MT to call the transport and cancel them for that date. The MT understood the ADON would reschedule the resident for another appointment. On 7/16/2019 at 11:58 AM an interview was conducted with the ADON who stated a family member had called and could not go with the resident to the wound clinic appointment. The ADON stated the clinic wanted a family member present and so he cancelled the appointment. The ADON stated he was unfamiliar with the resident and did not ask the wound clinic if they could see the resident without the family member present. The ADON stated he could not remember if he tried to reschedule an appointment with the wound clinic and had no way to verify that. The interview with a staff member at the wound clinic on 6/19/2019 at 4:00 pm revealed the physician liked to have a family member accompany a patient for the initial visit. She further stated the clinic could have sent the facility the consent to treat form and the facility could have faxed it to the POA for a signature, and then the facility could have just sent the consent form with a copy of Resident #2 history and Physical for the physician to review before the appointment. An interview with the Power of Attorney on 6/20/2019 at 11:00 revealed she had the capability to send and receive faxes. She further revealed the facility did not informed her Resident #47 appointment had been cancelled before her visitation on 4/14/2019. A review of Resident #47 physician orders [REDACTED].

Based on record review and staff interviews the facility failed to complete and submit comprehensive Minimum Data Set (MDS) assessments within the required timeframe for 3 of 18 (Residents #199, #200, and #201) residents assessments reviewed. The findings included: 1. Resident #199 was admitted to the facility on [DATE] and the most recent MDS assessment for review was a quarterly dated 1/8/2019. Current MDS assessments were unavailable for review. On 7/15/2019 at 3:04 PM, an interview was conducted with the MDS nurse who stated she began her employment at the facility on 4/1/2019 and found resident assessments were overdue to be completed and submitted. The MDS nurse stated the Administrator had started a Performance Improvement Plan (PIP), and she had submitted a calendar to keep track of all the residents while she worked to get all assessments up to date. The MDS nurse stated Resident #199 had a comprehensive assessment due on 4/10/2019 but the assessment had not yet been completed or submitted. On 7/17/2019 at 10:00 AM, an interview was conducted with the Administrator who stated she had created a PIP on 4/1/2019 when the new MDS nurse started, to schedule all resident assessments to be caught up by 8/1/2019. The Administrator stated the plan was to do all the MDS assessments that were due currently and then go back and pick up the old ones until all were caught up. The Administrator stated going forward she expected the MDS assessments to be completed and transmitted on time. 2. Resident #200 was admitted to the facility on [DATE], and the most recent MDS assessment available for review was a quarterly dated 1/14/2019. Current MDS assessments were unavailable for review. On 7/15/2019 at 3:04 PM, an interview was conducted with the MDS nurse who stated she began her employment at the facility on 4/1/2019 and found resident assessments were overdue to be completed and submitted. The MDS nurse stated the Administrator had started a Performance Improvement Plan (PIP), and she had submitted a calendar to keep track of all the residents while she worked to get all assessments up to date. The MDS nurse stated Resident #200 had a comprehensive assessment due on 4/16/2019 but the assessment had not yet been completed or submitted. On 7/17/2019 at 10:00 AM, an interview was conducted with the Administrator who stated she had created a PIP on 4/1/2019 when the new MDS nurse started, to schedule all resident assessments to be caught up by 8/1/2019. The Administrator stated the plan was to do all the MDS assessments that were due currently and then go back and pick up the old ones until all were caught up. The Administrator stated going forward she expected the MDS assessments to be completed and transmitted on time. 3. Resident #201 was admitted to the facility on [DATE], and the most recent MDS assessment was a quarterly dated 1/14/2019. Current MDS assessments were not available for review. On 7/15/2019 at 3:04 PM, an interview was conducted with the MDS nurse who stated she began her employment at the facility on 4/1/2019 and found resident assessments were overdue to be completed and submitted. The MDS nurse stated the Administrator had started a Performance Improvement Plan (PIP), and she had submitted a calendar to keep track of all the residents while she worked to get all assessments up to date. The MDS nurse stated Resident #201 had a comprehensive assessment due on 4/16/2019 but the assessment had not yet been completed or submitted. On 7/17/2019 at 10:00 AM, an interview was conducted with the Administrator who stated she had created a PIP on 4/1/2019 when the new MDS nurse started, to schedule all resident assessments to be caught up by 8/1/2019. The Administrator stated the plan was to do all the MDS assessments that were due currently and then go back and pick up the old ones until all were caught up. The Administrator stated going forward she expected the MDS assessments to be completed and transmitted on time.

Based on record review and staff interviews the facility failed to complete and submit quarterly Minimum Data Set (MDS) assessments within the required timeframe for 4 of 18 (Residents #1, #26, #28, and #198) residents assessments reviewed. The findings included: 1.Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #1 most recent Minimum Data Set (MDS) assessment was dated 1/16/2019. The quarterly MDS assessment due 4/2019 was not available for review. On 7/15/2019 at 3:04 PM, an interview was conducted with the MDS nurse who stated she began her employment at the facility on 4/1/2019 and found resident assessments were overdue to be completed and submitted. The MDS nurse stated the Administrator had started a Performance Improvement Plan (PIP), and she had submitted a calendar to keep track of all the residents while she worked to get all assessments up to date. The MDS nurse stated she had completed Resident #1's quarterly assessment due on 4/17/2019 but it had not yet been submitted. On 7/17/2019 at 10:00 AM, an interview was conducted with the Administrator who stated she had created a PIP on 4/1/2019 when the new MDS nurse started, to schedule all resident assessments to be caught up by 8/1/2019. The Administrator stated the plan was to do all the MDS assessments that were due currently and then go back and pick up the old ones until all were caught up. The Administrator stated going forward she expected the MDS assessments to be completed and transmitted on time. 2.Resident #26 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #26's annual MDS assessment dated [DATE] and her quarterly assessment dated [DATE] had been completed and submitted for review. The assessment due for 3/2019 was not available for review. On 7/15/2019 at 3:04 PM, an interview was conducted with the MDS nurse who stated she began her employment at the facility on 4/1/2019 and found resident assessments were overdue to be completed and submitted. The MDS stated the Administrator had started a Performance Improvement Plan (PIP), and she had submitted a calendar to keep track of all the residents while she worked to get all assessments up to date. The MDS nurse stated she had completed Resident #26's quarterly assessment due 6/2019 but had not completed or submitted her quarterly assessment due 3/5/2019. On 7/17/2019 at 10:00 AM, an interview was conducted with the Administrator who stated she had created a PIP on 4/1/2019 when the new MDS nurse started, to schedule all resident assessments to be caught up by 8/1/2019. The Administrator stated the plan was to do all the MDS assessments that were due currently and then go back and pick up the old ones until all were caught up. The Administrator stated going forward she expected the MDS assessments to be completed and transmitted on time. 3.Resident #28 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #28's annual MDS assessment was dated 6/4/2019, but his quarterly due 3/2019 was unavailable for review. On 7/15/2019 at 3:04 PM, an interview was conducted with the MDS nurse who stated she began her employment at the facility on 4/1/2019 and found resident assessments were overdue to be completed and submitted. The MDS stated the Administrator had started a Performance Improvement Plan (PIP), and she had submitted a calendar to keep track of all the residents while she worked to get all assessments up to date. The MDS nurse stated she had completed Resident #28's annual assessment due 6/2019 but had not completed or submitted his quarterly assessment due 3/6/2019. On 7/17/2019 at 10:00 AM, an interview was conducted with the Administrator who stated she had created a PIP on 4/1/2019 when the new MDS nurse started, to schedule all resident assessments to be caught up by 8/1/2019. The Administrator stated the plan was to do all the MDS assessments that were due currently and then go back and pick up the old ones until all were caught up. The Administrator stated going forward she expected the MDS assessments to be completed and transmitted on time. 4. Resident #198 was admitted to the facility on [DATE], and her last MDS assessment for review was a quarterly on 1/8/2019. The resident had no recent MDS assessments available for review. On 7/15/2019 at 3:04 PM, an interview was conducted with the MDS nurse who stated she began her employment at the facility on 4/1/2019 and found resident assessments were overdue to be completed and submitted. The MDS stated the Administrator had started a Performance Improvement Plan (PIP), and she had submitted a calendar to keep track of all the residents while she worked to get all assessments up to date. The MDS nurse stated Resident #198's quarterly assessment was due 4/10/2019 and her annual was due 7/10/2019 but she had not yet completed the assessments. On 7/17/2019 at 10:00 AM, an interview was conducted with the Administrator who stated she had created a PIP on 4/1/2019 when the new MDS nurse started, to schedule all resident assessments to be caught up by 8/1/2019. The Administrator stated the plan was to do all the MDS assessments that were due currently and then go back and pick up the old ones until all were caught up. The Administrator stated going forward she expected the MDS assessments to be completed and transmitted on time.

Based on record review and staff interview the facility failed to transmit a Discharge Tracking MDS (Minimum Data Set) assessment within the required timeframe for 1 of 14 residents (Resident #2) reviewed for assessments. The findings included: Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of Resident #2's medical record revealed the last assessment completed and submitted to the Center for Medicare/Medicaid System (CMS) data base was a 14-day MDS assessment, dated 2/21/2019. On 7/15/2019 at 3:04 PM, an interview was conducted with the MDS nurse who stated she began her employment at the facility on 4/1/2019 and found resident assessments were overdue to be completed and submitted. The MDS stated the Administrator had started a Performance Improvement Plan (PIP), and she had submitted a calendar to keep track of all the residents while she worked to get all assessments up to date. The MDS nurse stated she had missed Resident #2, and he had discharged on [DATE], so she would get the Discharge Tracking MDS submitted. On 7/16/2019 at 3:41 PM, an interview was conducted with the Administrator who stated she expected the MDS to be transmitted on time.

Based on observations, record review and staff interviews, the facility failed to apply hand rolls (cloth) daily for contracture management for 1 of 2 residents reviewed. (Resident #26). The findings included: Resident #26 was originally admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. According to the Quarterly Minimum Data Set ((MDS) dated [DATE], Resident #26 was cognitively impaired and required total assistance in most areas of activities of daily living. Review of Section G of the MDS in the area of functional status, revealed Resident #26 had impairment in both hands. Review of Resident #26's Care Plan which was updated on 6/3/19, revealed Resident #26 had bilateral contractures in both hands and arms. Resident #26 was at risk for further contracting and new contractures. Start date: 12/13/18. Goal, target date: 3/13/19, noted to prevent further contractures, decrease tone and increase range of motion. Interventions included maintain body functional alignment when at rest in bed and chair. Reposition frequently. Hand roll (cloth) in both hands at all times. Remove for bathing, replace with new hand roll (cloth) and change as needed. During an interview on 7/14/19 at 1:58 PM, Resident #26's family member revealed someone used to provide range of motion for Resident #26, however, she said no one had done anything recently. An observation revealed both of Resident #26's hands were contracted. There were no hand rolls in her hands. During an observation on 7/16/19 at 11:30 AM, Resident #26 was observed in bed asleep. There were no hand rolls in her hands. During an observation on 7/16/19 at 2:54 PM, Resident #26 was observed asleep in bed. There were no hand rolls in her hands. Both of her hands were clinched tight. Small pillows were placed under each hand. Her hands were against the pillows on her chest. During an observation on 7/16/19 at 4:49 PM, Resident #26 was asleep in bed. There were no hand rolls in her hands. Both of her hands were clinched tight. Small pillows were placed under each hand. Her hands were against the pillows on her chest. During an observation on 7/17/19 at 9:30 AM, Resident #26 was observed asleep in bed. The resident did not have hand rolls in her hands. During an interview on 7/17/19 at 9:33 AM, NA#1 revealed Resident #26 required total care. She stated range of motion exercises were provided during her bath. She stated she usually put hand cloths between both of her hands and she put a pillow between her legs and heel protectors on her feet. NA#1 revealed she repositioned Resident #26 every two hours. She stated she placed pillows on her shoulders and back. She stated she had worked with Resident #26 since she was admitted to the facility. NA#1 stated she did not work on Resident #26's hall today and she did not know if Resident #26 had hand rolls in her hands. During an interview on 7/17/19 at 9:47 AM, Nurse #4, who was assigned to Resident #26 revealed in reference to Resident #26's contractures, hand rolls were placed in her hands and the resident was usually positioned with pillows. She stated range of motion exercises was usually provided with her care. During an interview on 7/17/19 at 10:52 AM, NA#2 who was assigned to work with Resident #26 revealed she had worked with Resident #26 before and she knew about the hand rolls that were to be placed in her hands. She stated she placed the hand rolls in Resident #26's hands at 9:30 AM or 10:00 AM this morning. She stated she had to get Resident #26's hands opened a little. She stated she was aware Resident #26 was to have the hand rolls in her hands. During an interview on 7/17/19 at 1:56 PM, the Administrator stated she expected preventive intervention should have been utilized as appropriate. She revealed the hand rolls should have been placed in Resident #26's hands to prevent further decline.

Based on observations, facility record reviews and staff interviews, the facility failed to post the daily nurse staffing sheet on the correct days for 2 of 4 days and failed to document accurate information on the daily nurse staffing sheets for 3 of 4 days (7/14/19, 7/15/19, and 7/16/19) of the survey. The findings included: On 7/14/19 at 2:16PM, an observation was made of the posted facility daily staffing sheet. The nurse staffing sheet was dated 7/12/19, combined the skilled nursing facility beds and the assisted living beds with the census listed as 46/6. On 7/14/19 at 3:13 PM, an observation was made of the posted facility daily staffing sheet. The nurse staffing sheet was dated 7/12/19, combined the skilled nursing facility beds and the assisted living bed with the census listed as 46/6. On 7/16/19 at 11:23 AM an observation was made of the posted facility daily staffing sheet. The nurse staffing sheet was dated 7/15/19, combined the skilled nursing facility beds and the assisted living bed with the listed census as 47/6. On 7/16/19 at 11:26 AM the Assistant Director of Nursing posted the daily staffing sheet with the date recorded as 7/16/19. The nurse staffing sheet combined the skilled nursing facility beds and the assisted living bed with the census listed as 46/6. During an interview on 7/16/19 at 3:57 PM the Assistant Director of Nursing stated he completed the nurse staff posting on Mondays. He stated the resident census number had been incorrect the day before, so he adjusted the number and posted the daily staffing sheet with the correct census number. On 7/17/19 at 8:57 AM the Director of Nursing stated she would expect the daily staff sheet would be posted every day and reflect all staff working each shift. On 7/17/19 at 12:36 PM the Administrator stated she expected the staff posting would be posted daily and available for residents and visitors to see prior to the beginning of 1st shift on the date covered.

Based on observations, facilituy staff, wound clinic staff, Power of Attorney (POA) and Physician interviews, and record reviews the facility failed to assess a pressure ulcer and failed to carry out a wound clinic referral which resulted in a decline and infection of the wound for 1 of 5 residents (Resident #47) reviewed for pressure ulcers. Findings included: Resident #47 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #47 was discharged to the hospital on [DATE]. Resident #47's care plan dated 2/19/2019 revealed a plan which focused on risk for pressure ulcer related to immobility and incontinence with a goal that her skin would remain intact. The interventions were to conduct a systematic skin inspection, keep clean and dry as possible, turn and reposition every 2 hours, reduce friction by using a pull sheet and report any redness or skin breakdown to nurse. The care plan was not updated after this date. Resident #47's Braden Skin assessment dated [DATE] revealed she was at a mild risk for pressure sores. An admission progress note by the Director of Nursing (DON) dated 2/19/2019, revealed the Resident #47 was admitted on [DATE] from the hospital with redness on her buttocks from incontinence. Resident #47's admission Minimum Data Set (MDS) assessment dated [DATE] revealed her cognition was moderately impaired. She required total staff assistance for activities of daily living (ADLs), except for eating, in which she was independent. She had no pressure ulcer on admission, and she was not coded as palliative or hospice care. The Treatment Aministration Records (TAR) for (MONTH) 2019 through (MONTH) 2019 revealed daily documentation that dressing treatments had been conducted as ordered and were signed off by nursing staff. No description of the wound was included on the TAR. Nursing progress notes addressing care and description of Resident #47's sacrum area are as follows: On 2/26/2019 DON's note revealed the excoriated areas to the buttocks had increased in size. On 3/4/2019 Nurse #1's note revealed the excoriated areas on buttocks and sacral fold continued and a new treatment was initiated. On 3/23/2019 Nurse #2's note revealed resident #47 sat in the wheelchair for long hours of the day and night and was turned every two hours for pressure relief. It also revealed the dressing was dry and intact. The care plan had not been updated to address Resident #47's pressure relieving device for the wheelchair. On 3/25/2019 Nurse #3's note revealed Resident #47 was on bedrest and had an air mattress on the bed. On 3/25/2019 Nurse #3's note revealed the wound was 16 centimeters (CM) x 10 CM and was measured per pharmacy request. There was no documentation included that addressed the appearance or deterioration of the wound On 3/27/2019 Nurse #1's note revealed a new wound care treatment had been initiated and an indwelling catheter was inserted. On 4/9/2019 Nurse #4's note revealed the wound bed was covered with dark gray tissue with a moderate amount of foul-smelling purulent drainage. The wound also had some yellow slough. On 4/10/2019 Nurse #4's note revealed the depth of the wound was worsening and the entire area around the wound was tunneling. The wound was packed using six or seven 4 x 4 gauzes. On 4/12/2019 Nurse # 5's nurses noted revealed the wound had a foul odor with moderate yellowish and bloody drainage and had yellow slough hanging from the wound. On 4/13/2019 the Nurse #4's note revealed the outer area of the wound continued to decline by an increase in depth and tunneling all around the wound. There was some scattered necrotic tissue with yellow stringy adhered tissue to the outer edge of the wound. Daughter at bedside questioning the decline in the wound. On 4/14/2019 Nurse #4's note revealed the dressing was changed with no change to the wound observed. Resident #47's temperature was 101 and Tylenol was given with a decrease in temperature to 97.0. On 4/15/2019 Nurse note revealed Resident #47 was transported to the emergency room with the chief complaint of wound infection and was admitted with the [DIAGNOSES REDACTED]. The Emergency department provider notes dated 4/15/2019 revealed Resident #47 had a stage four sacral decubitus with the bone visible in the wound. The wound edges were somewhat indurated. The wound culture dated 4/22/2019 revealed pseudomonas in the wound and the physician planned to discharge Resident #47 on 4/22/2019 with an antibiotic. A review of the medical record revealed no other nurse notes pertaining to care of the wound care from 3/5/2019 through 3/22/2019, and from 3/28/2019 through 4/8/2019. Physician orders [REDACTED]. Physician orders [REDACTED]. The Physician orders [REDACTED]. A review of physician orders [REDACTED]. The physician order [REDACTED]. Resident #47's 30-day MDS assessment dated [DATE] revealed her cognition was moderately impaired and she required total staff assistance for ADLs, except for eating and locomotion which were independent. The assessment noted there was no pressure ulcer and she was not coded as palliative or hospice care. Resident #47's Braden Skin assessment dated [DATE] revealed she was at a high risk for pressure sores. On 6/18/2019 at 10:30 AM, an interview was conducted with Nursing Assistant (NA) #1, who stated Resident #2 did not like to be turned in bed but would turn over to her side when encouraged. On 7/16/2019 at 11:45 AM an interview was conducted with the Medication Technician (MT). The MT stated Resident #47 stopped eating shortly after she was admitted to the facility, and she would whine and shake her head no when care was provided for her. On 6/19/2019 at 3:10 PM, an interview was conducted with Nurse #1, who was familiar with Resident #47's care and stated she was admitted for rehabilitation and it took a lot of encouragement for the resident to participate in activities of daily living. Nurse #1 also stated Resident #47 had an indwelling catheter and a [MEDICATION NAME] agent was used on the wound, but the wound was not improving. Preventative measures were used which included wedges to prop up, pressure relieving mattress on the bed and cushion in the wheelchair. On 7/16/2019 at 10:19 AM, a second interview was conducted with Nurse #1. The nurse stated when Resident #47 was first admitted her sacral area was red but not opened and they were using a cream on it. The nurse stated the wound opened and orders were changed to a hydrogel with gauze covering it. The nurse stated she had informed the Physician of the treatment and the condition of the wound, but he elected to keep the same treatment regimen at that time. The nurse stated Resident #47 was very noncompliant in her nutrition and she had to be prompted and encourage to eat, and she would refuse food. The nurse stated she would refuse to turn and that contributed to her wound decline. The nurse stated Resident #47 would drink her med pass and she was getting the dressing changed daily. The nurse stated she was not told to measure the wound and thought the DON/ADON (Assistant Director of Nursing) were covering that. On 7/15/2019 at 3:46 PM, an interview was conducted with Nurse #3 who stated Resident #47's dressing was changed daily when she cared for her. The Nurse stated the previous MDS nurse measured pressures wounds weekly and documented the results in the medical record. Nurse #3 stated when the previous MDS nurse left the facility it was not conveyed to the floor staff to measure and document on wounds. Nurse #3 stated floor staff had always conducted the dressing changes and that remained in place. The Nurse stated the Resident #47 would get out of bed daily when she first came to the facility, but shortly after, and she was unsure of the time frame, the resident did not want to get up, did not eat well and the wound change happened very fast. The Nurse stated she was working when the resident's family member was at the facility, observed the wound and wanted the resident to be sent to the hospital. The Nurse stated she called the Physician and he ordered the wound clinic visit and a change of treatment, and she informed the family who was okay with the orders. On 7/16/2019 at 10:40 AM an interview was conducted with Nurse #4. The Nurse stated she cared for Resident #47 after she was moved to her hall, but she already had the declining pressure ulcer. The Nurse stated she did not measure the wound and did not think anyone was measuring it, as floor nurses were never informed to measure the wounds even after the previous MDS/wound nurse had resigned. The nurse stated she changed the dressing daily. The nurse stated she did not call the Physician about the wound but had added the resident to the Physician's list to be seen on 4/17/19, but the resident was discharged to the hospital on [DATE]. The nurse stated she thought the wound deteriorated because of a series of things which included her lack of motivation to move, and her poor appetite. The nurse stated Resident #47 was totally dependent on staff because of lack of will and not lack of function. On 7/15/2019 at 4:47 PM, an interview was conducted with Nurse #5 who stated she cared for Resident #47 when she was moved to her hall after the pressure wound was already deteriorated. The Nurse stated she measured the wound for the Pharmacist one time. The nurse stated she did not know the expectation for measuring the wound as the previous MDS nurse had measured all wounds and documented them weekly before she left the facility. The nurse stated she changed the dressings daily as per the orders and treatment record, but the resident had very poor intake and refused eating and getting out of bed. On 7/16/2019 at 4:01 PM, an interview was conducted with the Certified Occupational Therapy Assistant (COTA), and Physical Therapy Assistant (PTA) who stated when they started working with Resident #47, she could stand and pivot for transfer on 2/20/2019. The COTA stated by 3/1/2019 Resident #47 had declined to using a sit to stand lift for transfers, and by 3/6/2019 she could not sit unassisted in the chair and required 100% cueing. The COTA and PTA stated Resident #47 was discharged from therapy on 4/10/2019 because she was making no progress and by that time, she needed total assistance for activities of daily living (ADLs) and required maximum assistance to roll in bed. On 6/19/2019 at 1:20 pm an interview with the DON revealed that she was called into the resident room on 2/19/2019 to assess Resident #47's buttock and found an area on the buttock right in the middle of the buttock cheek that was beginning to open but had not yet opened. The DON stated a barrier cream for Resident #47's buttocks was started on 2/19/2019, when she was admitted and that was standard treatment used as a preventative measure for all residents in the facility. On 7/16/2019 at 3:22 PM, an interview was conducted with the DON who stated the wound might have been avoidable if the resident was not already declining when she was admitted to the facility. The DON stated Resident #47 would not move or eat and the facility talked to Resident #47's family member to have her help convince Resident #47 to turn. The DON confirmed the resident was not on hospice, palliative or comfort care while she was a resident at the facility. The DON stated the wound was not consistently measured and she had told staff to measure once per week, but that was not done. The DON stated she expected the nurses to measure the wound weekly and report wound status to the Physician. The interview with the Physician on 6/20/2019 at 12:36 pm revealed that the nurse called and informed him of the cancelled appointment and that was when he gave a new order for treatment. The Physician stated by Resident #47 not going to the wound clinic appointment, it presented a chance for the wound to fester or get worse and it slowed the healing of the wound. He also stated he believed sending Resident # 2 to the clinic would have hastened the healing process. On 7/16/2019 at 2:32 PM, a second interview was conducted with the Physician who stated Resident #47's pressure wound should have been avoidable, but he did not know why it was not. The Physician stated he thought her not wanting to participate in therapy and laying on the wound too much made the wound worse. The Physician stated staff did informed him the wound was getting worse and he ordered the wound clinic visit, and after another call by staff he ordered a change of treatment. A review of an appointment calendar dated 3/28/2019 revealed Resident #47 was scheduled for an appointment with the wound clinic on 3/28/2019 at 3:30 pm. The calendar showed the appointment was cancelled on 3/27/2019 by Medication Technician #1. The interview with Medication Technician (MT)#1 on 6/19/2019 at 1:51 pm revealed the appointment was cancelled on 3/27/2019 because the family was unable to go with her and the physician would not see Resident #47 the first time without a family member present. The MT stated that she informed the doctor of the cancellation and wrote it on the appointment schedule. On 7/16/2019 at 11:45 AM a second interview was conducted with the MT who stated she was at the desk when the ADON stated the family had called and informed staff they could not be at the wound clinic appointment, so he had cancelled her appointment and told the MT to call the transport and cancel them for that date. The MT understood the ADON would reschedule the resident for another appointment. On 7/16/2019 at 11:58 AM an interview was conducted with the ADON who stated a family member had called and could not go with the resident to the wound clinic appointment. The ADON stated the clinic wanted a family member present and so he cancelled the appointment. The ADON stated he was unfamiliar with the resident and did not ask the wound clinic if they could see the resident without the family member present. The ADON stated he could not remember if he tried to reschedule an appointment with the wound clinic and had no way to verify that. The interview with a staff member at the wound clinic on 6/19/2019 at 4:00 pm revealed the physician liked to have a family member accompany a patient for the initial visit. She further stated the clinic could have sent the facility the consent to treat form and the facility could have faxed it to the POA for a signature, and then the facility could have just sent the consent form with a copy of Resident #2 history and Physical for the physician to review before the appointment. An interview with the Power of Attorney on 6/20/2019 at 11:00 revealed she had the capability to send and receive faxes. She further revealed the facility did not informed her Resident #47 appointment had been cancelled before her visitation on 4/14/2019. A review of Resident #47 physician orders [REDACTED].

Based on staff interviews, physician interview and record review, the facility failed to complete a Minimum Data Set (MDS) Significant Change in Status Assessment (SCSA) within 14 days after the development of a pressure ulcer and placement of an indwelling catheter for 1 of 5 residents (Resident #47) reviewed for pressure ulcers. Findings included: Resident #47 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #47's Admission Minimum Data Set ((MDS) dated [DATE] revealed her cognitive status was moderately impaired. She was noted as incontinent of both bowel and bladder. The MDS revealed no pressure ulcers or other skin conditions and she did not have a urinary catheter in place upon admission. Further record review revealed no MDS SCSA was completed for Resident #47 after the completion of her 2/26/19 admission MDS. The Director of Nursing (DON) documented on 2/26/2019 the excoriated areas to the resident's buttocks had increased in size. No nursing documentation regarding the condition of Resident #47's wound was observed in the resident's record from 3/5/2019 through 4/8/2019. On 3/23/2019 the physician ordered to cleanse sacral wound with normal saline, apply medicated ointment and cover with a dry dressing daily for 14 days. On 3/27/2019 the physician ordered to insert an indwelling catheter due to the presence of a Stage 3 sacral decubitus (a sore that has gone through the second layer of skin into the fat tissue). On 4/13/19 Nurse # 4 documented the outer area of the resident's sacral wound continued to increase in depth and tunneling all around the wound. There was some scattered necrotic tissue with yellow stringy adhered tissue to the outer edge of the wound. An interview on 7/15/2019 at 3:46 pm with Nurse #3 revealed Resident #47 would get out of bed daily, when she first came to the facility, but shortly after, the resident did not want to get out of bed, did not eat well and her sacral wound developed extremely fast. An interview on 6/19/2019 at 1:20 pm with the Director of Nursing (DON) was conducted. The DON stated she was called into Resident #47's room on 2/19/2019 by the physical therapist to assess an area on the resident's sacral area. The DON also stated the middle of the resident's sacral area was reddened and the skin was beginning to open but had not opened yet. She also stated a treatment was started on that day which was a routine barrier cream that was used for all the residents in the facility as a preventative measure. The interview with the Physician on 6/20/2019 at 12:36 pm revealed Resident # 47 developed a pressure sore on her sacrum after her admission to the facility. On 7/3/2019 at 2:22 pm a telephone interview with the Director of Nursing (DON) revealed the MDS nurse was responsible to complete resident Minimum Data Set SCSA. The DON further stated there was not an MDS nurse working at the facility at the time of the resident's significant change to complete an MDS SCSA for Resident #47. The DON stated a MDS SCSA assessment should have been completed for Resident #47 to reflect the resident developed a pressure ulcer on her sacrum and for the resident's newly placed indwelling urinary catheter.

Based on record review and staff interviews the facility failed to accurately code the Minimum Data Set for wounds for 2 of 5 residents reviewed for MDS accuracy (Resident #101 and Resident #47). The findings included: Resident #101 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of physician's orders [REDACTED].#101 had a stage 1 pressure ulcer on her right heel. Review of Resident #101's MDS assessment dated [DATE] revealed Resident #101 was not assessed as having any pressure ulcers during the 7 day look back period of the assessment. During an interview with Nurse #1 on 6/18/19 at 3:06 PM she indicated Resident #101 had a pressure ulcer and Nurse #1 completed dressing changes on the wound when she was present in the facility in September. An interview was conducted with the Assistant Director of Nursing (ADON) on 6/19/19 at 2:15 PM. He indicated the MDS nurse who completed the assessment was no longer employed by the agency. The ADON stated he signed the MDS assessments completed by the former MDS nurse. He stated he checked the assessments for completeness prior to signing the assessments. The ADON stated Resident #101's pressure ulcer should have been coded on the 9/28/18 MDS assessment. During an interview with the Administrator on 6/19/19 at 2:30 PM she indicated the agency has hired a new MDS Coordinator. The Administrator stated she is providing supervision to the new MDS Coordinator to ensure accuracy of assessments. 2. Resident #47 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The review of a care plan dated 2/19/2019 revealed a plan focused on risk for pressure ulcer related to immobility and incontinence with a goal of Resident #47 skin will remain intact. A review of nurse's notes dated 4/13/2019 revealed treatment completed to sacral area, the outer edge of wound continued to decline with an increase in dept and tunneling noted. The nurse's note continued to reveal the wound had scattered areas of necrotic tissue with grayish- yellow stringy adhered tissue to the outer edge of the wound. A foul odor with a moderate amount of purulent drainage was noted. A discharge Minimum Data Set ((MDS) dated [DATE] completed by the MDS nurse revealed Resident #47 had no unhealed pressure ulcer upon discharge from the facility. Attempts to contact and interview the MDS nurse, who completed the resident's 4/15/19 MDS assessment were unsuccessful. An interview with the Director of Nursing on 6/19/2019 at 2:30 pm revealed the resident had a pressure ulcer when she was discharged from the facility to the hospital on [DATE] and it should have been coded on the resident's 4/15/2019 MDS assessment. The Administrator stated during an interview on 6/19/2019 at 4:15 pm the resident had a pressure ulcer and it should have been coded on the 4/15/2019 MDS. The Administrator stated she is providing supervision to the new MDS Coordinator to ensure accuracy of assessments.

Based on record reviews and staff interview the facility failed to update a resident's pressure ulcer care plan to address the actual development of a pressure ulcer for 1 of 5 residents (Resident # 47) reviewed for pressure ulcers. Findings included: Resident # 47 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #47's comprehensive care plan dated 2/19/2019 revealed a plan which focused on risk for pressure ulcer related to immobility and incontinence with a goal that her skin would remain intact. The interventions were to conduct a systematic skin inspection, keep skin clean and dry as possible, turn and reposition every 2 hours, reduce friction by using a pull sheet, and report any redness or skin break down to nurse. The care plan was not updated after 02/19/19 to address the resident's development of a sacral pressure ulcer. Resident # 47's Admission Minimum Data Set ((MDS) dated [DATE] revealed her cognitive status was moderately impaired. She required total assistance for activities of daily living and was independent with eating. The MDS revealed no unhealed pressure ulcers upon admission. The Director of Nursing (DON) nursing documentation dated 2/26/2019 indicated the excoriated areas to the buttocks had increased in size and barrier cream was being applied to all areas. On 3/4/2019 the physician ordered to cleanse buttocks and sacral folds with normal saline, apply wound collagen gel to excoriated areas, and cover with border gauze every day until healed. No nursing documentation regarding Resident #47's sacral wound/pressure ulcer or skin condition was observed in the resident's medical record from 3/5/2019 through 4/8/2019. On 3/23/2019 the physician ordered to cleanse sacral wound with normal saline, apply santyl ointment and cover with dry dressing daily for 14 days, and refer to the wound clinic. On 3/27/2019 the physician ordered to insert an indwelling catheter due to the presence of a stage 3 sacral decubitus (a sore that has gone through the second layer of skin into the fat tissue), clean sacral area with one-fourth strength Dakin's solution (an antiseptic), pack with santyl and cover with gauze, apply collagen wound gel to outer area, apply gauze, and cover with border gauze. Nurse # 4 nursing documentation dated 4/9/2019 indicated the sacral wound bed was covered with dark gray tissue with a moderate amount of foul-smelling purulent drainage and had some yellow slough. Nurse # 4 nursing documentation dated 4/13/2019 indicated the outer area of the sacral wound continued to increase in depth and tunneling all around the wound. There was some scattered necrotic tissue with yellow stringy adhered tissue to the outer edge of the wound. The physician orders [REDACTED].#47 to the emergency room for evaluation of a wound infection. On 7/3/2019 at 2:22 pm a telephone interview with the DON revealed the MDS Nurse was responsible for updating and revising resident care plans. The DON further stated the MDS Nurse resigned from the position several months ago and there was not an MDS Nurse at that time to update the care plans and another staff member was not been assigned the responsibility to update resident care plans.

Based on observation, staff and resident interview and record review, the facility failed to possess manufacturer instructions for the van securement system; failed to properly secure wheelchairs to the floor securement system for 2 of 2 alert and oriented residents (Residents #24 and #49), failed to monitor securement of wheelchairs in the facility van and failed to have a process to ensure the securement system was in good working order for 1 of 1 facility van. Immediate Jeopardy began on 9/17/15 when 2 of 2 alert and oriented residents (Resident #24 and Resident #49), who were transported in their wheelchairs in the facility van on a social outing, stated their wheelchairs did not feel securely fastened. Immediate jeopardy was removed on 11/13/15 at 5:27 PM when the facility provided and implemented a credible allegation of compliance that included the permanent removal of the van from service. The facility remains out of compliance at a lower scope and severity of D (an isolated deficiency, with no actual harm with potential for more than minimal harm that is not immediate jeopardy) to ensure implementation of the change in process in arranging for transportation for appointments and activities events. The findings included: An online document regarding the facility van securement system entitled Operation Instructions for (name of company and identifier of product series) read in part, Secure the Wheelchair 2. Attach the Front Tie-Downs The front tie-downs need approximately a 45 degree angle from the floor. Install the track fitting into a floor track. Pull on fitting to ensure it is properly locked in the track. Loop the other end of the tie-down around a solid structural frame member of the wheelchair as close to the corner junction of the seat cushion as possible and connect hook to the D-ring. Pull loose end of tie-down through the buckle, until tight. Repeat with other front tie-down. 3. Attach the Rear Tie-Downs The rear tie-downs need approximately a 45 degree angle from the floor. Install the track fitting into a floor track. Pull on fitting to ensure it is properly engaged in the track. Loop the other end of tie-down around a solid structural frame member of the wheelchair as close to the corner junction of the wheelchair back and seat as possible, and connect hoot to the D-ring (for S-hook tie downs, see step 4). Unlock buckle and rotate handle to open position, pull loose end of tie-down to remove slack, rotate handle to closed locked position to tension the tie-down. Repeat with other rear tie-down. 4. S-hooks Place the S-hooks around a solid structural from member of the wheelchair as close to the corner junction of the seat cushion as possible and apply tension to the tie-down. The text following step 4 was enclosed in a box and was in bold print: Caution: Do not attach tie-downs to the wheels or any detachable portion of the wheelchair. Tie-down must have a clear, straight path from floor to where it attaches to the wheelchair. 5. Attach the Lap Belt Place the ends of the lap belt around the occupant. Thread them down and through opening between wheelchair side panel and seat, or through gap between wheelchair back and seat. During an interview on 11/5/15 at 9:12 AM, Nursing Assistant (NA) #3 indicated it was her responsibility to transport residents in the facility van. She stated she believed the van needed new buckles for strapping in the wheelchairs as she did not have the strength in her hands to operate the buckles. NA #3 said she reported problems she was having with the buckles to someone in maintenance but could not recall who or when. She indicated nothing had been done. On 11/5/15 at 9:15 AM NA #3 demonstrated how she secured wheelchairs in the van. (For the purpose of the demonstration, she only secured one side of the wheelchair.) She was observed to lock the wheelchair near the tracks on the floor into which the straps from the securement system were locked. NA #3 first wrapped one securement strap around the front aspect of the wheelchair frame and fastened it above the wheel via snap hook into D-ring. NA #3 attempted to tighten the strap but stated it did not stay tightened. She demonstrated this by pulling on the strap to tighten it and pointing out how it immediately loosened. Next, NA #3 wrapped the securement strap, locked into the rear track, between 2 spokes of the back wheel. She said she did not have the strength to operate the buckle that allowed for strap length adjustment and tightening. Finally, NA #3 applied the belt located on a track on the side wall of the van approximately at shoulder/head level. She ran the strap through the space between the arm and metal side of the chair, across the lap, through the opposite side space between the arm and metal side and hooked the belt in the D-ring. NA #3 indicated she was trained on securing wheelchairs by the former driver and she had been driving the van for the last 7-8 years. NA #3 stated she had never experienced any incidents or accidents when transporting residents but worried that something could happen due to them not being properly secured, although she did the best she could. The Director of Facility Operations (DOFO) was interviewed on 11/5/15 at 9:32 AM. He stated NA #3 was the only person who drove the van. The DOFO indicated he did some maintenance on the wheelchair securing system about a year ago and was not aware of any further problems. He also said his department did not perform any routine checks of that system but relied on the driver to make him aware if she had concerns. The DOFO added that he was not aware of any current problems. On 11/5/15 at 9:56 AM, Resident #24 was interviewed. Her quarterly Minimum Data Sets (MDSs) dated 7/11/15 and 10/11/15 revealed she was cognitively intact and had no behavioral problems. The resident indicated she rode in her wheelchair in the facility van on several occasions, the last being about 3 weeks ago on a pleasure outing. The resident stated her chair did not feel secured because it rocked back and forth and side to side. Resident #24 said she felt fearful that the wheelchair would come loose. On 11/5/15 at 10:06 AM, Resident #49 was interviewed. His quarterly MDSs dated 5/14/15 and 8/14/15 revealed he was cognitively intact and had no behavioral problems. The resident indicated he rode in his wheelchair in the facility van. He indicated the wheelchair wobbled from side to side. The resident indicated he last rode the van in a group outing in September. On 11/5/15 at 1:30 PM, the DOFO and Facility Operations Staff (FOS) #1 were observed in the van rearranging the location of the securement straps in the floor tracks. The DOFO was observed adjusting the length of the strap for one of the rear wheels by pulling very hard on the strap. Both he and FSO #1 said it should not be that difficult to adjust the straps. FSO #1 went on to demonstrate how to secure a wheelchair in the van. The process observed was different from that of NA #3's process in that the straps were not wrapped at any point and were tightened after being fastened. During an interview on 11/5/15 at 4:00 PM, the Administrator indicated the he was unable to locate any information about the van with the manufacturer's specifications for the wheelchair securement procedure. He explained the van was used when purchased, approximately in 2001, and the seller showed the former facility driver how to secure the wheelchairs. The Administrator stated the driver was responsible for securing the wheelchairs and had been trained by the previous driver who retired some years back. The facility had no periodic review procedure to validate the equipment was functioning properly and that the driver was securing the wheelchairs properly. The Administrator added the facility had had no accidents or incidents with the van. During an interview on 11/6/15 at 11:47 AM, the Director of Nursing (DON) stated that the facility frequently used outside transport services for medical appointments and the facility van was used mainly for resident outings. She stated that the van would remain out of service until all safety concerns had been resolved or a decision reached to permanently stop using that van. A follow-up interview was conducted with Resident #24 on 11/13/15 at 10:10 AM during which she repeated the information provided on 11/5/15. During an interview on 11/13/15 at 10:30 AM, the Assistant Director of Nursing (ADON) indicated Resident #24 was alert, oriented and reliable. During an interview on 11/13/15 at 10:35 AM, the Activities Director (AD) indicated Resident #49 was alert, oriented and reliable. A follow-up interview was conducted with Resident #49 on 11/13/15 at 10:02 AM. He repeated that his wheelchair wobbled from side to side when he rode in the van. During an interview on 11/13/15 at 10:33 AM, the ADON indicated Resident #49 was alert, oriented and reliable. During an interview on 11/13/15 at 10:35 AM, the AD indicated Resident #49 was alert, oriented and reliable. During a follow-up interview on 11/13/15 at 10:43 AM, the DOFO indicated he recalled some time ago, unsure of when, NA #3 had a problem with one of the buckles. He found the strap to be twisted in the buckle. He untwisted the strap and the problem was solved. The DOFO said the securement system is very basic and should not require routine maintenance. The DOFO indicated he was not aware of manufacturer instructions for inspection and maintenance of the securement system. He stated it was the responsibility of the driver to report any concerns to him. On 11/13/15 at 11:10 AM a follow-up interview was conducted with NA #3 via telephone. She indicated she believed the securement straps needed new buckles because the current buckles were so difficult to use. NA #3 said she had no specific checklist to follow to verify the securement system was OK. On 11/13/15 at 4:05 PM, the AD indicated she had recently been told the facility no longer had a van to transport residents on outings. She added that no activities requiring resident transport were scheduled at this time. On 11/13/15 at 5:05 PM, the facility van was observed with no straps/securements present. On 11/13/15 at 5:15 PM the administrator was observed to remove the van keys from the nurses' station and lock them in a drawer in his office. He stated maintenance had the other set of keys in their office. The administrator was notified of immediate jeopardy on 11/13/15 at 2:36 PM. On 11/13/15 at 5:27 PM the facility provided the following credible allegation: The Our Community Hospital van used for resident transport has been taken out of service permanently effective November 6, 2015. All wheelchair residents are being transported by a transport service. The wheelchair tie-down straps will be removed from the van. No activities will be missed and an outside transport company will be used for activities and appointments. Activities Director and transporter have been notified of the decision. The Credible Allegation was validated on 11/13/15 at 5:30 PM. A telephone interview with NA #3 revealed she had been made aware that the facility van was no longer to be used for resident transport. An interview with the AD revealed she had been made aware that the facility van was no longer to be used for resident transport, and that the facility would use an outside transport service when outings were scheduled.

Based on staff interview and record review, the facility failed to have or procure manufacturer instructions for the inspection and maintenance of the wheelchair securement system, failed to provide the Director of Facility Operations with maintenance instructions for the securement system, failed to provide clear expectations and training for the use of the securement system, failed to develop a checklist for safe wheelchair securement, and failed to ensure driver competency in wheelchair securement procedures for 2 of 2 alert and oriented residents (Residents #24 and #49) and 1 of 1 facility van. Immediate Jeopardy began on 9/17/15 at 9:00 AM when 2 of 2 alert and oriented residents (Resident #24 and Resident #49), who were transported in their wheelchairs in the facility van on a social outing, stated their wheelchairs did not feel securely fastened. Immediate jeopardy was removed on 11/13/15 at 5:27 PM when the facility provided and implemented a credible allegation of compliance that included the permanent removal of the van from service. The findings included: Cross refer to F323: Based on observation, staff and resident interview and record review, the facility failed to possess manufacturer instructions for the van securement system; failed to properly secure wheelchairs to the floor securement system for 2 of 2 alert and oriented residents (Residents #24 and #49), failed to monitor securement of wheelchairs in the facility van and failed to have a process to ensure the securement system was in good working order for 1 of 1 facility van. The administrator was notified of immediate jeopardy on 11/13/15 at 2:36 PM. On 11/13/15 at 5:27 PM the facility provided the following credible allegation: The Our Community Hospital van used for resident transport has been taken out of service permanently effective November 6, 2015. All wheelchair residents are being transported by a transport service. The wheelchair tie-down straps will be removed from the van. No activities will be missed and an outside transport company will be used for activities and appointments. Activities Director and transporter have been notified of the decision. The Credible Allegation was validated on 11/13/15 at 5:30 PM. A telephone interview with NA #3 revealed she had been made aware that the facility van was no longer to be used for resident transport. An interview with the AD revealed she had been made aware that the facility van was no longer to be used for resident transport, and that the facility would use an outside transport service when outings were scheduled.

Based on record review, staff and family interviews, the facility failed to revise 1 of 15 (Resident #50) sampled residents whose care plans were reviewed to include an unstagable pressure ulcer on the right heel. The facility also failed to invite 1 of 1 (Resident #60) sampled cognitively impaired residents responsible party to participate in care plan conference. Findings include: 1. Resident #50 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. A computerized PATIENT ASSESSMENT REPORT completed 09/30/10 indicated there was a 5 cm (centimeter) by 2.5 cm unstagable area present on Resident #50's right heel. A review of a WEEKLY SKIN Report dated 11/22/10; under the section for pressure ulcers documented Resident #50 as having a 4.2 x 3.2 stage 4 wound on the right heel with black eschar. An entry made on 09/30/10 at 1:34 PM in the computerized PATIENT CARE NOTES documented Resident #50 had an area to the right heel, 5 x 2.5 cm unstagable which had been seen by the physician with no new orders and a heel protector in place. Review of Resident #50's RESIDENT CARE PLAN indicated the care plan was reviewed and updated on 10/19/10. Under problem #7 the care plan identified Resident #50 at risk for skin breakdown related to incontinence, impaired mobility and history of breakdown with a Braden (tool used to measure risk of skin breakdown with a score of 14 or less are considered to be at risk) score of 13. The goal on the care plan was skin will remain intact over the next 90 days 01/17/11. In an interview with the Treatment Nurse on 12/01/10 at 3:00 PM, he said the Minimum Data Set (MDS) Coordinator was responsible for updating the RESIDENT CARE PLAN if a resident developed any pressure ulcers. The Treatment Nurse said the MDS Coordinator received a WEEKLY SKIN REPORT each week from him. The Treatment Nurse said he would expect the resident's care plan would be updated to reflect the change in a resident's skin condition at least weekly. The Treatment Nurse said Resident #50's care plan should have had something about the area on her right heel on her care plan. The MDS Coordinator was unavailable for interview. In an interview with the Cheif Nursing Officier (CNO) on 12/01/10 at 9:50 AM, the CNO said it was the responsibility of the MDS Coordinator and other disciplines to update the resident's care plans at the time of an occurrence as well as quarterly. The CNO said all disciplines receive a copy of the WEEKLY SKIN REPORT at their Risk Meetings and she would expect new wounds to be documented on a resident's care plan within one week of development. 2. Resident #60 was re-admitted to the facility on [DATE]. The resident's re-admission Minimum Data Set ((MDS) dated [DATE] indicated that the resident had both long and short term memory problems and was severely impaired in daily decision making. On 11/29/10 at 3:02 PM, during a family interview resident #60's responsible party stated they had never been invited to a Care Plan meeting. Review of resident #60's 11/19/10 care plan showed the Care Plan Cover Sheet was signed on 11/19/10 by staff members only. In an interview on 12/02/10 at 10:07 AM, the Social Worker (SW) indicated the MDS nurse made a monthly list of residents who were scheduled for care plan meetings. The SW would then mail out letters to the resident's responsible parties inviting them to attend the meetings. The SW stated that she did not make any follow up attempts to contact the responsible parties after the letters were mailed. The SW was unable to produce copies of letters inviting resident #60's responsible party to the care plan meetings in November of 2010. The SW was unable to produce any other documentation that the resident's responsible party had been invited either verbally or by telephone to the care plan meetings. In an interview on 12/2/10 at 10:15 AM, the Chief Nursing Officer (CNO) stated that it was her expectation that letters to the responsible parties inviting them to care plan meetings would be sent in a timely manner with follow-up and documentation.

Based on record review and staff interviews, the facility failed to follow interventions on 1of 15 (Resident #50) sampled residents whose care plans were reviewed which resulted in finding an unstagable pressure ulcer on the resident's right heel. Findings include: Resident #50 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. A computerized PATIENT ASSESSMENT REPORT completed 08/23/10 indicated Resident #50's skin had been assessed and no abnormalities were found. The next assessment was completed on 09/30/10 and indicated there was a 5 cm (centimeter) by 2.5 cm unstagable area present on Resident #50's right heel. There were no other skin assessments completed on Resident #50 from 08/23/10 to 09/30/10. Review of WEEKLY SKIN Reports under the section for pressure ulcers did not list Resident #50 until 09/30/10. The report documented Resident #50 as having a 5 x 2.5 unstagable wound on the right heel. Review of computerized PATIENT CARE NOTES for Resident #50 documented an entry on 08/23/10 at 10:10 as having no skin breakdown, bruising, or skin tears noted during the weekly skin assessment. On 09/30/10 at 1:34 PM, there was an entry that documented an area to the right heel, 5 x 2.5 cm unstagable that was seen by the physician. Review of Resident #50's RESIDENT CARE PLAN indicated the care plan was reviewed and updated on 10/19/10. Under problem #7 the care plan identified Resident #50 at risk for skin breakdown related to incontinence, impaired mobility and history of breakdown with a Braden (tool used to measure risk of skin breakdown with a score of 14 or less are considered to be at risk) score of 13. Under the approach section of the care plan: it was listed for the nurse's aide to inspect skin daily with bath and report any abnormalities such as red, swollen, broken, or painful areas to the nurse. Under approach #5, it was listed for the nurse to do a weekly skin assessment q (every) week and record and report abnormalities to the MD (doctor). In an interview with Treatment Nurse on 12/01/10 at 3:00 PM, he said it was the facility's policy to do a weekly skin assessment on all residents identified at risk for pressure ulcer development. The Treatment Nurse said the facility used the Braden Scale (tool used to measure risk of skin breakdown with a score of 14 or less are considered to be at risk) to identify a resident's risk on admission and quarterly thereafter. The Treatment Nurse said Resident #50 was scored at 13 and should have had weekly skin assessments done. The Treatment Nurse said a nurse's aide had asked him to look at Resident #50's right heel on 09/30/10. The Treatment Nurse did not remember the nurse's aides name. The Treatment Nurse stated the area on Resident #50's right heel had been dark in color, boggy, and unstagable when he first saw it. The Treatment Nurse said he would expect to find a wound at a stage 1 (persistent redness underlying tissue soft, not open) when first observed. The Treatment Nurse said he did not know why there were no weekly skin assessments completed on Resident #50 between 08/23/10 and 09/30/10. In an interview with the Chief Nursing Officer (CNO) on 12/02/10 at 9:50 AM, the CNO said it was the policy of the facility for the treatment nurse to do a weekly skin assessment on residents identified at risk for pressure ulcers. The CNO said she would expect a pressure ulcer to be identified at a stage 1. The CNO said she had been aware that the pressure ulcer on Resident #50's right heel was found as unstagable. The CNO said the nurse's and nurse's aides attended care plan meetings so they would be aware of the interventions on Resident #50's care plan. The CNO said it was her expectation that the staff follow the interventions on the resident's care plan. In an interview with Nurse #1 on 12/02/10 at 10:50 AM, Nurse #1 said the area on Resident #50's right foot had been reported by a nurse's aide to the Treatment Nurse at which time the ulcer was found to be unstagable. Nurse #1 said she would expect a nurse's aide to report any changes in color or temperature to her immediately upon finding it. Nurse #1 said no one had reported anything to her on Resident #50 prior to the Treatment Nurse's documentation of an unstagable area on the right heel.

Based on observation, record review, and staff interviews, the facility failed to perform weekly skin assessments on 1 of 2 sampled residents (Resident #50) identified at risk for pressure ulcer development which resulted in an unstagable pressure ulcer on the residents right heel. Findings include: The facility policy states in part; "An assessment will be conducted on admission using the Braden Skin Assessment, to determine the risk of impairment to the resident's skin integrity. Residents with a score of fourteen (14) or less are considered at risk for skin breakdown. Preventive measures will be implemented and addressed in the resident's plan of care for those residents with a score of 14 or less. In addition to the Braden Skin Assessment Tool, a weekly skin inspection will be done on all residents. The weekly skin inspection will aide the nurses and staff in identifying changes immediately." Resident #50 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. An annual Minimum Data Set (MDS) assessment completed on 04/10/10 documented Resident #50 as having no pressure ulcers. Review of Resident #50's Resident Assessment Protocol's (RAP's), dated 04/19/10, identified her at risk for pressure ulcers. The RAP summary documented Resident #50 as having no skin breakdown and to receive weekly skin checks. A quarterly MDS assessment completed on 07/10/10 documented Resident #50 as having no pressure ulcers. A computerized BRADEN SCALE DETAIL sheet documented Resident #50's score on 07/19/10 and 10/18/10 as 13. A computerized PATIENT ASSESSMENT REPORT completed 08/23/10 indicated Resident #50's skin had been assessed and no abnormalities were found. The next assessment was completed on 09/30/10 and indicated there was a 5 cm (centimeter) by 2.5 cm unstagable area present on Resident #50's right heel. Review of WEEKLY SKIN Reports under the section for pressure ulcers did not list Resident #50 until 09/30/10. The report documented Resident #50 as having a 5 x 2.5 unstagable wound on the right heel. Review of computerized PATIENT CARE NOTES for Resident #50 documented an entry on 08/23/10 at 10:10 as having no skin breakdown, bruising, or skin tears noted during the weekly skin assessment. On 09/30/10 at 1:34 PM, there was an entry that documented an area to the right heel, 5 x 2.5 cm unstagable that was seen by the physician. There were no other skin assessments completed on Resident #50 from 08/23/10 to 09/30/10. Resident #50's RESIDENT CARE PLAN, revised 10/19/10, identified Resident #50 at risk for skin breakdown under problem #7. An observation was made on 12/01/10 at 8:30 AM of Resident #50's right heel. There was an area approximately 5 cm x 2 cm black eschar (necrotic tissue) present on the right heel. In an interview with the Treatment Nurse on 12/01/10 at 3:00 PM, the Treatment Nurse said a nurse's aide had asked him to look at Resident #50's right heel on 09/30/10. The Treatment Nurse did not remember the nurse's aides name. The Treatment Nurse stated the area on Resident #50's right heel had been dark in color, boggy, and unstagable when he first saw it. The Treatment Nurse said he had the physician look at Resident #50's right heel. The Treatment Nurse said he would expect to find a wound at a stage 1 (persistent redness underlying tissue soft, not open) when first observed. In an interview with Chief Nursing Officier (CNO) on 12/02/10 at 9:50 AM, the CNO said it was the policy of the facility for the treatment nurse to do a weekly skin assessment on residents identified at risk for pressure ulcers. The CNO said she would expect a pressure ulcer to be identified at a stage 1. The CNO said she had been aware that the pressure ulcer on Resident #50's right heel was found as unstagable. In an interview with Nurse #1 on 12/02/10 at 10:50 AM, Nurse #1 said the area on Resident #50's right foot had been reported by a nurse's aide to the Treatment Nurse at which time the ulcer was found to be unstagable. Nurse #1 said she would expect a nurse's aide to report any changes in color or temperature to her immediately upon finding it. Nurse #1 said no one had reported anything to her on Resident #50 prior to the Treatment Nurse's documentation of an unstagable area on the right heel.