Every finding on record at Cambridge Health and Rehabilitation Center

Based on observation, interview and record review the facility failed to ensure drugs and biologicals used in the facility were labeled in accordance with currently accepted professional principles and safe and secure storage of all medication for 1 of 3 medication carts (100 hall cart) and 1 of 2 medication storage rooms (500 hall storage room) inspected for medication labeling and storage. The facility failed to remove three non-administered antibiotic prescriptions dated [DATE] from the 100 Hall medication cart for Resident #133 and Resident #134. The facility failed to ensure promethazine suppositories stored in the 500 Hall medication storage room were appropriately labeled. These failures placed residents at risk for medication errors, administration of improperly identified medications, and compromised medication safety. Findings included:Observation and interview on [DATE] at 10:22am, revealed LVN E unlocked the 100 hall nurse medication cart for inspection. LVN E said she had some medications set aside in her cart that she was going to bring to the DON because they were not pulling up on the residents' MAR as active medication. Observations revealed LVN E pulled blister packs (pre-formed plastic packaging featuring individual cavities to hold pharmaceuticals) of medication out of the cart which showed 2 medication packs for Resident #133 (Levofloxacin and Fluconazole) and one medication pack for Resident #134 (Clindamycin). LVN E said the medications were dated as filled back in March of 2026 and was not sure why they were still on the cart. LVN E removed the medications, locked her cart, and said she was going ask the DON about the medications. Record review and observation of Resident #133's medication found on 100 hall nurse medication cart on [DATE] at 10:22am revealed a prescription for Levofloxacin tab 250mg, give 1 tablet by mouth everyday at bedtime for 10 days dated [DATE], expiration [DATE] with a quantity of 9 tablets dispensed. Further review of the blister pack revealed 7 tablets were left in the blister pack. Record review of Resident #133's second medication found on the cart revealed a prescription for fluconazole 100mg tablet, give 1 tablet by mouth 1 time daily for 7 days dated [DATE], expiration [DATE] and a quantity of 7 tablets dispensed. Further review of the blister pack revealed 5 tablets were left in the blister pack. Record review and observation of Resident #134's medication found on 100 hall nurse medication cart on [DATE] at 10:22am revealed a prescription for Clindamycin capsule 150mg give 3 capsules a day by mouth three times a day for 5 days dated [DATE], expiration [DATE] with a quantity of 36 capsules. Further review of the blister pack revealed 26 capsules were left in the blister pack. Record review of Resident #133's physician orders revealed an order started on [DATE] for Levaquin Oral Tablet 250 MG (Levofloxacin), Give 1 tablet my mouth at bedtime for recurrent UTI for 10 days. Order was discontinued on [DATE]. Record review of Resident #133's physician orders revealed an order started on [DATE] and completed on [DATE] for Fluconazole Oral Tablet 100 MG, give 1 tablet by mouth 1 time daily for 7 days. Record review of Resident #134's physician orders revealed an order started on [DATE] for Clindamycin HCl Oral Capsule 150 MG, give 3 capsules by mouth three times a day for infection for 5 days. Order was marked as completed on [DATE]. Further review of the physician order noted prescription was on hand from pharmacy and on hand from family supplied. Observation and interview on [DATE] at 11:02am, revealed RN B opened the medication storage room on the 500 hall and observation of the refrigerator in the storage room revealed a box labeled Promethegan Promethazine HCl suppositories 25mg for rectal administration. Further observation revealed the box was labeled to have 12 suppositories and expiration date of 2028/04. There was residue of a label that had been torn off the box. The box did not have a resident's name on it, instructions for use, or dispense date. RN B said she was not sure who the medication belonged to and said if the box did not have a label the medication should be discarded. RN B pointed out a locked box in the storage room and stated the DON would have to unlock the box and she would put the medication inside of it to be returned or destroyed. RN B did not know how long the Promethazine suppositories were in the refrigerator and said she had not noticed them in there. Further observation of the box revealed there were 10 suppositories left inside the box. RN B said prescription medications should always have a label on them to know who the medication belonged to and she did not know why it looked like the label had been removed from the box. Interview on [DATE] at 4:00pm, the DON said they have a pharmacist that comes once a month to review their medications and they also check their medication carts and medication rooms for old, expired or unlabeled medications to be discarded. The DON said the nurses and medication aides should be checking their carts at least once throughout their shift for medications that need destruction. The DON said if a resident is discharged and not taking medications with them, then they will put the medications in a locked destruction box. The DON said if a medication has been stopped and there was left over medication such as with Resident #133's and #134's antibiotics; the medications should be removed from the cart because the risk could be administering a medication that should no longer be given. The DON said aside from stock over the counter medications, all prescription medications should be labeled because staff will not know who it belongs to if it is not labeled. The DON said the Promethazine should be removed from the refrigerator and should be placed in the box to be destroyed. Record review of the facility Labeling of Medication Containers policy Revised [DATE] revealed in part, .Labels for individual drug containers shall include all necessary information, such as: a. the residents name; b. the prescribing physician name; c. the name, address, and telephone number of the issuing pharmacy; e. the prescription number; f. the date that the medication was dispensed; i. directions for use. Record review of the facility Storage of Medication policy Revised [DATE] revealed in part, .2. The nursing staff shall be responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner; 3. The facility shall not use discontinued, outdated, or deteriorated drugs or biological. All such drugs shall be returned to the dispensing pharmacy or destroyed.

Based on observation, interview, and record review, the facility failed to provide pharmaceutical services, including procedures to ensure the accurate acquiring, receiving, dispensing, and administering of medications, to meet the needs of residents for 2 of 23 residents (Resident # 10, Resident #115) reviewed for pharmaceutical services. The facility failed to provide Resident #115 with his as needed Cyclobenzaprine used to treat his muscle spasms on 7/6/2026. The facility failed to administer Resident #10's IV antibiotic as ordered on 07/08/2026. These failures placed residents at risk for pain, worsening symptoms, and discomfort. Findings included: Record review of Resident # 10's face sheet dated 09/25/2020 revealed he was admitted to the facility on [DATE] with the following diagnoses: Heart failure (the heart muscle becomes too weak to pump enough oxygen-rich blood to meet the body's needs), congenital malfunction (abnormality present at birth) and current urinary tract infection. Record review of Resident #10's MDS dated [DATE] revealed his BIMS score was 01-indicating severe cognitive impairment. Section: Functional abilities revealed Resident # 10 was dependent on staff for all activities of daily living. Record review of Resident # 10's care plan dated 09/25/2020 revealed: Has a new onset infection, to venous wound Left Lower extremity (wound on the left lower foot). Goal: Will not have rehospitalization, will be free from complications related to infection. Intervention: Administer antibiotics as per Doctor's orders. Record review of Resident # 10's MAR dated 07/01/2026-07/31/2026 revealed the antibiotic medication order stated: Ertapenem Sodium Solution Reconstituted 1 gram. Midline-Intermittent Medications-Flush with 10 milliliters of normal saline before and after medication administration. In an observation of IV antibiotic administration on 07/08/2026 at 08:05 a.m., by LVN A, she flushed the PICC line with 5 milliliters of normal saline (a sterile solution containing chloride in water) and 5 milliliters after she administered the IV antibiotic. She said the order stated 10 milliliters. In an interview with LVN A on 07/08/2026 at 06:Rec15 p.m., she said she did not follow the medication administration order because she was nervous. LVN A said the fact that she did not follow the order could place the resident at risk for PICC line blockage. She said normal saline flushes were used to keep the IV-line patent (clear of any blockages). In an interview with RN A on 07/09/2026 at 10:39 a.m., she said medication error could occur if a nurse did not administer the right medication dose. She said normal saline was part of an IV medication. She said if LVNA did not administer an IV medication per Doctor's order, it was considered a medication error. She said if the medication order read: to flush with 10 milliliters of NS before and after, the nurse would have administered a total of 20 milliliters of NS (A mixture of pharmacy-grade salt and water free of germs). In an interview with LVN B on 07/09/2026 at 11:10 a.m., she said it was the responsibility of the nurses to administer medications per Doctor's orders. She said she would administer medications per Doctor's order for residents' safety. She said if a nurse failed to administer a medication per Doctor's order, there was a possibility of over or under dose. LVN B said if the medication order for Resident # 10 read: flush with 10 milliliters of normal saline (A mixture of pharmacy-grade salt and water free of germs) before and after the medication administration, the total was supposed to be 20 milliliters. In an interview with the DON on 07/09/2026 at 12:24 p.m., she said it was the responsibility of the nurses to administer an IV medication if they were trained. She said all the nurses were trained in IV medication administration. The DON said the IV flush medication error meant Resident # 10 was under dosed. In an interview with the ADM on 07/09/2026 at 12:32 p.m., she said nurses were authorized and licensed to administer medication. She said she could not say much because that was a clinical question. Record review of the facility's Administering Medications Policy Statement stated: Medications shall be administered in a safe and timely manner and as prescribed. Medications must be administered in accordance with the orders. The individual administering the medication must check to verify the right medication, right dosage, right time and right route before giving the medication. Record review of Resident #115's face sheet revealed a [AGE] year-old male admitted to the facility on [DATE] from a hospital. Further review of the face sheet revealed diagnoses of: Cellulitis Of Left Lower Limb (bacterial infection of the deep skin and underlying tissues), Chronic Obstructive Pulmonary Disease (lung disease that blocks airflow and makes it hard to breathe), Type 2 Diabetes Mellitus (a chronic condition where your body becomes resistant to insulin, causing sugar (glucose) to build up in your bloodstream), Post-Traumatic Stress Disorder (a mental health condition triggered by experiencing or witnessing a terrifying or life-threatening event), and Congestive Heart Failure (a chronic syndrome where the heart muscle doesn't pump blood as efficiently as it should). Record review of Resident #115's admission MDS dated [DATE] revealed a BIMS score of 15 out of 15 indicating his cognition was intact. Further review of the MDS revealed he received scheduled pain regimen and had no presence of pain in the last 5 days. Record review of Resident #115's Care Plan initiated on 6/15/2026 and revised 7/7/2026 revealed, at risk for acute/chronic pain related to Cellulitis of the left lower limbs. His interventions revealed in part, .Administer analgesia medication (medications designed to relieve pain without causing a loss of consciousness) as per orders. Record review of Resident #115's History and Physical dated 6/5/2026 revealed within the assessment/plan, .Muscle spasms - continue cyclobenzaprine (a prescription skeletal muscle relaxant used to relieve muscle spasms, tightness, and pain caused by musculoskeletal injuries), ropinirole (a prescription medication used to treat Parkinson's disease and Restless Legs Syndrome) . Record review of Resident #115's physician order started on 6/12/2026 and discontinued on 6/13/2026 revealed an order for Cyclobenzaprine HCl Oral Tablet 10 MG Give 1 tablet by mouth every 8 hours for muscle spasm. Record review of Resident #115's physician order started on 6/12/2026 revealed an order for Cyclobenzaprine HCl Oral Tablet 10 MG Give 1 tablet by mouth every 8 hours as needed for muscle spasm. Record review of Resident #115's June 2026 MAR revealed Cyclobenzaprine HCl Oral Tablet 10 MG Give 1 tablet by mouth every 8 hours for muscle spasm was administered on 6/13/2026 at 7:00am and 3:00pm indicating 2 tablets had been administered. Record review of the facility Packing Slip Proof of delivery dated 6/13/2026 at 8:21pm revealed Resident #115 had a quantity of 30 Cyclobenzaprine 10mg tablets delivered. Record review of Resident #115's June 2026 MAR revealed Cyclobenzaprine HCl Oral Tablet 10 MG Give 1 tablet by mouth every 8 hours as needed for muscle spasm was administered 5 times on: 6/16/2026 at 4:47am 6/17/2026 at 8:40am 6/23/2026 at 6:13am 6/27/2026 at 6:33am 6/28/2026 at 8:14pm Record review of Resident #115's July 2026 MAR revealed Cyclobenzaprine HCl Oral Tablet 10 MG Give 1 tablet by mouth every 8 hours as needed for muscle spasm was administered 4 times on: 7/1/2026 at 8:00pm 7/3/2026 at 8:42am 7/4/2026 at 9:28am 7/4/2026 at 7:10pm Further review of the July 2026 MAR revealed no administrations on 7/5/2026, 7/6/2026, or 7/7/2026. Record review of Resident #115's June and July 2026 MAR revealed he was administered a total of 9 Cyclobenzaprine 10mg tablets from the 30-tablet prescription delivered on 6/13/2026 at 8:21pm. Interview and observation on 7/7/2026 at 10:20am, Resident #115 was sitting in a wheelchair in his room watching television. The resident had a bandage on his left leg dated 7/7. Resident #115 said he had three little holes in his leg under the bandage that were infected and he was at the facility to get treatment for the infection. Resident said he was currently taking antibiotics for the infection and he was also taking a muscle relaxer for spasms that he would get in his legs. Resident #115 said the nurse told him yesterday, they ran out of muscle relaxers when he asked for his as needed muscle relaxer. Resident #115 said he was not in pain but his legs were feeling tense which was why he wanted the muscle relaxer. Resident #115 said he would try asking for his muscle relaxer again today. Interview and observation on 7/7/2026 at 4:07pm, Resident #115 was sitting in a wheelchair in his room watching television. Resident #115 said he still had not gotten any muscle relaxers and said he did ask the staff again for it and they still said it was out but a refill was on the way from the pharmacy. Resident said he was now having spasms all over. Resident #115 said he was not offered any medication from an emergency supply. Interview and observation on 7/7/2026 at 4:13pm, the WCN said Resident #115 could sometimes be confused and probably got his medication and did not remember. The WCN said Resident #115's muscle relaxer was PRN so the nurse would be the one administering it. Observed WCN checking down the hall to find the nurse and was not able to locate her. The WCN asked what the issue with Resident #115's muscle relaxer was, and after being advised that he voiced not getting them because his prescription was out, the WCN said the medication could be pulled from the emergency kit if it was out. The WCN said she would call his nurse, LVN D, and let her know. The WCN was observed looking in her phone and shortly after, LVN D was coming down the hallway and she said, oh there she is. Interview and observation on 7/7/2026 at 4:16pm, LVN D had a small plastic cup in her hand and in it was a single pill package labeled cyclobenzaprine. LVN D said she was headed to Resident #115's room with the medication because he had asked for it about 30 minutes ago. LVN D said his Cyclobenzaprine was out and had been reordered, she went to check if it was in yet and it was not, so she pulled the medication from the pyxis. Observed LVN D enter Resident #115's room with medication and tell him she had muscle relaxer for him. Interview on 7/8/2026 at 2:27pm, Resident #115 said he was told his muscle relaxers were out for like a day and a half before he was given the medication yesterday (7/7/2026) by LVN D. Resident #115 said he did not know the nurse's names who told him the medication was out and said he was not sure if it was LVN D who had previously told him the medication was out and did not give him anything. Resident #115 said he asked for the muscle relaxer on 7/6/2026 in the afternoon sometime when he was informed they did not have any more muscle relaxers. Resident #115 said he had been getting the muscle relaxers now and asked if it was time for him to have another one. Interview on 7/8/2026 at 2:35pm, RN B was at the nurse's station and said she would have to check if Resident #115 could get a muscle relaxer because she had already given him one in the morning and she had to wait 8 hours to give him another one. RN B said Resident #115 did ask for his muscle relaxers often and said the medication was out, but they got a refill last night. RN B denied that Resident #115 ever asked her for a muscle relaxer, and she told him it was out. RN B said if Resident #115 requested the medication while it was out, she would get it from the pyxis. RN B said she had not pulled any cyclobenzaprine from the pyxis for Resident #115 in the past. Record review of the facility Packing Slip Proof of Delivery form dated 7/7/2026 at 9:05pm revealed Resident #115 had 30 tablets of Cyclobenzaprine 10mg delivered. Record review of the facility schedule dated 7/6/2026 revealed LVN D was assigned to 500 hall for the day shift (7:00am – 7:00pm) and RN C was assigned to work 500 hall for the night shift (7:00pm – 7:00am). Interview on 7/8/2026 at 6:09pm, LVN D said yesterday (7/7/2026) Resident #115 asked for his muscle relaxer and she told him that she was going to check if it had been delivered yet because it was on order. LVN D said she did go check and the medication had not arrived from the pharmacy yet, so she went to pull it from the pyxis to administer. LVN D said his refill for Cyclobenzaprine was there at the facility now and stated, it came in last night. LVN D said she could not recall if Resident #115 asked for his Cyclobenzaprine on 7/6/2026 but stated if he had and it was out she would have gotten it from the pyxis like she did on 7/7/2026. LVN D said it was about 30 minutes that had passed from the time he asked for his muscle relaxer on 7/7/2026 to the time she went in and administered it to him. Phone interview on 7/10/2026 at 12:25pm, RN C said she worked the night shift and was familiar with Resident #115. RN C said she did not recall him asking for muscle relaxer on 7/6/2026. RN C said the resident did request the medication from her a few times in the past and she administered it but said lately he had not asked for it so she assumed he had been getting it on the day shift and was okay. RN C said the nurses administer his PRN medication and said if someone told him the medication was out, it would have been a nurse. RN C said if he asked her for the medication and she saw it was out, she would make sure the refill was ordered from the pharmacy and provide him the medication from the pyxis. Interview on 7/10/2026 at 1:00pm, the DON said that sometimes the nurses may get busy and forget about the emergency kit/pyxis. The DON said if nurses are waiting on a medication to be delivered and the resident is requesting it, they should pull the medication from the emergency kit to administer to the resident. The DON said she would have to look into why Resident #115 was out of his Cyclobenzaprine when the MAR indicated he had not used 30 tablets from the prescription. Interview on 7/10/2026 at 4:00pm, the DON said she had staff looking for Resident #115's remaining Cyclobenzaprine that was delivered on 6/13/2026. The DON said she had counted approximately 14 tablets that had been administered according to the MAR, meaning half of the prescription was missing. The DON said no one had found the missing medication yet and said she was not sure if the medication had been misplaced or if the nurses had been administering the medication and forgetting to mark it was given on the MAR. The DON reiterated that Resident #115 should have not gone without Cyclobenzaprine because the nurses have the option to pull the medication from the emergency kit and all the nurses have access to it. Record review of the facility Pharmaceutical Services policy Revised 5/2022 revealed in part, .It is the policy of this facility to provide pharmaceutical services (including procedure that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biological) to meet the needs of each resident.

Based on interview and record review, the facility failed to ensure residents had the right to, and the facility promoted and facilitated resident self-determination through support of resident choice for 3 of 9 confidential residents. The facility failed to allow residents' right to choose to sign out of the facility independently. The facility failed to allow residents' right to choose to sit outside on the front patio without supervision. This failure placed residents at risk of decreased quality of life and loss of dignity. Findings include: In a confidential resident interview on an undisclosed date and time, 3 of 9 residents stated they could not sign out of the nursing facility without their responsible party or family member. They stated it would be great if they could sign out themselves. Residents stated they could not sit on the patio in the front of the building without a staff member with them. They said the staff were busy and could not sit with the residents. One resident in the meeting stated he used the 500-hall patio area because it was fully fenced in, but he needed to ask for the door code to get out. One resident stated they used to use the local transit company to leave the facility but could no longer do so because the facility stopped allowing it. It was reported that a resident died and the state said they could not leave without supervision. In an interview on [DATE] at 12:44pm, The Receptionist said all residents who want to leave the facility were signed out by a family member. She said residents were not allowed to leave without a representative and said it would be on her if she let them out and something happened to them. The Receptionist said there was a binder at the front desk where family members/representatives could sign-out. Record review of the binder at the front desk revealed documents titled, Release of Responsibility for Leave of Absence with a statement at the top of the form and a chart listed below with the date, time out, signature of individual, phone number, and time in. The statement at the top of the form read, I, the undersigned, hereby accept complete responsible (sic) for (resident name) while away from [facility] and absolve the management of said for while the patient is away. I understand that a bed will be reserved for the above name (sic) patient when her (sic) or she returns on or before the appointed date above. In an interview on [DATE] at 1:20pm, the Activity Director said alert and oriented residents used to take the bus and leave independently. He said something changed a while ago and the residents were no longer allowed to go out-on-pass alone. He said he was not sure what changed. He said they had activities on the front patio. He said all residents could not sit on the front patio without a staff member, but they could go to the patio on the other side of the facility because it had a fence. In an interview on [DATE] at 2:43pm, the Administrator said residents were required to sign out so they knew where they were going. She said all residents were required to have someone with them. She said if a resident, including alert and oriented residents, wanted to sit on the front patio they would need to be supervised by staff. She said she would be worried if the resident had any type of cognitive decline that placed them at risk of harm. She said she did not want the residents to be hit by a car. She said some of the residents had asked to leave independently and she shared they could not for their safety. In an interview on [DATE] at 3:00pm, the DON said that residents could leave out-on-pass if they did not have cognitive decline, and said it would be based on their BIMS assessment. She said if a resident could independently make their own decisions, then they could go. Record review of the facility's policy regarding Resident Rights and Responsibilities dated [DATE] read, It is the policy of this facility to inform the resident of their rights as a resident, as well as the rules and regulations governing the resident's conduct and responsibilities during their stay in the facility. Should a resident be found incompetent by a court of law, the resident's representative shall act on behalf of the resident. The facility will inform the resident of their rights and responsibilities in a language that is both clear and understandable to the resident. Record review of the facility's policy regarding Out on Pass or Leave of Absence dated [DATE] read, It is the policy of this facility that continuity of care during resident leave of absence or while out on a pass will be maintained. A leave of absence or a pass requires a physician's approval and order. Nursing will obtain a physician's order for the resident to go out on pass or leave of absence with a resident representative. Whether or not a leave is appropriate for the resident is a decision for the resident's physician in conjunction with the interdisciplinary team.The resident/resident representative will sign resident in and out of facility on the Release of Responsibility for Leave of Absence forms and note the length of time the resident expected to be away.NOTE: This policy does not apply when family members, friends, relatives, etc. (with consent for resident or resident representative) take residents outside of but not away from the facility campus.

Based on observation, interview and record review the facility failed to ensure a level II pre-admission screen and resident review (PASRR) was completed for 1 of 23 residents (Resident #115) reviewed for PASRR screening. The facility failed to correct Resident #115's PASRR screening level 1 to indicate he had a mental illness so he could receive a level II PASRR evaluation. This failure placed the residents at risk for inappropriate placement and missed specialized services. Findings included:Record review of Resident #115's face sheet revealed a [AGE] year-old male admitted to the facility on [DATE] from a hospital. Further review of the face sheet revealed diagnoses of: Cellulitis Of Left Lower Limb (bacterial infection of the deep skin and underlying tissues), Chronic Obstructive Pulmonary Disease (lung disease that blocks airflow and makes it hard to breathe), Type 2 Diabetes Mellitus (a chronic condition where your body becomes resistant to insulin, causing sugar (glucose) to build up in your bloodstream), Post-Traumatic Stress Disorder (a mental health condition triggered by experiencing or witnessing a terrifying or life-threatening event), and Congestive Heart Failure (a chronic syndrome where the heart muscle doesn't pump blood as efficiently as it should). Record review of Resident #115's admission MDS dated [DATE] revealed a BIMS score of 15 out of 15 indicating his cognition was intact. Further review of the MDS revealed the resident was not currently considered by the state level II PASRR process to have serious mental illness and/or intellectual disability or a related condition. MDS indicated resident had a diagnosis of Post-Traumatic Stress Disorder. Record review of Resident #115's care plan initiated on 7/7/2026 revealed, At Risk for Re-traumatization related to history of trauma Post-Traumatic Stress Disorder. The interventions included: Administer medications as ordered. Monitor/document for side effects and effectiveness; Anticipate and meet needs; Approach in a calm manner; His triggers are crowds and noise; Resident can be triggered by loud noises- provide a calm and quiet environment. Record review of Resident #115's PASRR Level 1 screening dated 6/12/2026 revealed there was no evidence or an indicator the resident had a Mental Illness resulting in a negative PASRR Level 1 screening. Record review of Resident #115's History and Physical dated 6/5/2026 revealed within the assessment/plan, .PTSD - Following with mental health, last visit 4/2026; Continue quetiapine, mirtazapine, donepezil, gabapentin, bupropion, prazosin. Record review of Resident #115's July 2026 MAR revealed he was receiving:bupropion HCl ER (SR) Oral Tablet Extended Release 12 Hour 150 MG, give 3 tablets by mouth one time a day for depression started on 6/16/2026 from 7/1/2026 - 7/10/2026Donepezil HCl Oral Tablet 10 MG, give 1 tablet by mouth at bedtime for dementia started on 6/13/2026 from 7/1/2026 - 7/10/2026Mirtazapine Oral Tablet 15 MG, give 1 tablet by mouth at bedtime for depression started on 6/13/2026 from 7/1/2026 - 7/10/2026Quetiapine Fumarate Oral Tablet 400 MG, give 1 tablet by mouth at bedtime for PTSD started on 6/15/2026 from 7/1/2026 - 7/10/2026 Interview and observation on 7/7/2026 at 10:20am, Resident #115 was sitting in a wheelchair in his room watching television. The resident had a bandage on his left leg dated 7/7. Resident #115 said he had three little holes in his leg under the bandage that were infected and he was at the facility to get treatment for the infection. Resident said he was currently taking antibiotics for the infection and he was also taking a muscle relaxer for spasms that he would get in his legs. Resident said he was doing okay in the facility aside from them running out of his muscle relaxers. Interview on 7/9/2026 at 4:10pm, the MDS Coordinator said Resident #115 did have a diagnosis of PTSD but it was not a qualifying mental health diagnosis to mark a positive level I PASRR screening. The MDS Coordinator said qualifying mental health diagnoses were bipolar, schizophrenia, and major depressive disorder. Interview on 7/9/2026 at 5:43pm, the MDS Coordinator said she reached out to her PASRR contact and learned that PTSD was a qualifying mental health disorder for a level II evaluation. The MDS Coordinator said she is now doing an audit of all the residents checking for missed qualifying diagnoses. MDS Coordinator said if a level 1 PASRR screening is incorrect the facility should submit a form called a 1012. She said form 1012 would ask if the resident had a primary diagnosis of dementia and if they did not have a primary diagnosis of dementia, they would complete the correction saying the resident does have a qualifying mental health disorder. The MDS Coordinator said then the local authority would come out to see if the resident qualifies for services. The MDS Coordinator said she was in the process of doing the facility audit and completing the 1012 for Resident #115. Record review of the facility PASRR policy revised 10/2022 revealed in part, .It is the policy of this facility to ensure that each resident is properly screened using the PASRR specified by the State. Based upon the assessment, the facility will ensure proper referral to appropriate state agencies for the provision of specialized service to residents with Mental illness/ mental retardation.

Based on interview and record reviews, the facility failed to develop and implement an effective discharge planning process that focused on the resident's discharge goals for 1 (Resident #76) of 5 residents reviewed for transfer/discharge.The facility failed to ensure that the WCN did not initiate the discharge process with Resident #76.The facility failed to ensure the discharge planner initiated discharge with Resident # 76. These failures placed residents at risk of not having an advocate who can inform them of their options, rights, and the added protection from being inappropriately transferred or discharged . Findings included:Record review of Resident #76's face sheet dated 06/30/2026 reflected a [AGE] year-old male who was admitted to the facility on [DATE]. Diagnoses included: Cerebral infarction (when blood flow to part of the brain is obstructed), diabetes (when the body cannot properly use blood sugar, leading to high blood sugar levels), major depressive disorder (ongoing sadness or loss of interest which may affect how a person feels, think and sleep), chronic kidney location (when the kidney suffers long term damage), osteoarthritis (degenerative joint disease) of the left hip and left knee, idiopathic neuropathy (nerve damages that arises without a known trigger) and communication deficit (difficulty in receiving, processing, sending or comprehending information.Record review of Resident #76's MDS dated [DATE] revealed his BIMS score was 13-indicating normal thinking and memory. Functional abilities revealed he is dependent on staff in the following areas: Toileting hygiene, shower, upper and lower body dressing, personal hygiene, rolling left and right, sitting to lying, lying to sitting on side of bed, sitting to stand, chair/bed-to-chair transfer and toilet transfer. Uses a scooter and always continent for bladder and bowel. He is on the following medications: Antidepressant, diuretic, opioid and anticonvulsant.Record review of Resident #76's care plan revealed: At risk for injury. Goal: Will remain free of injuries. Intervention: Monitor/document for risk of falls measures that need to be taken to reduce risks of falls. Renal insufficiency (kidney fails to filter blood efficiently) related to chronic kidney disease. Goal: Will be able to resume normal activities of daily living. Intervention: Assist with ADLs and ambulate, watch for SOB and match level of assistance to resident's energy. At risk for falls. Goal: Will not sustain any injuries. Intervention: Encouraged to use the call light for assistance.In an interview with WCN on 07/08/2026 at 4:51 p.m., she said staff was scared to care for Resident # 76 because he made false accusations. She said she would give him five pamphlets to review and picked where he wanted to be discharged . The WCN said she told him she wanted to make sure he was safe and happy. She said she gave Resident # 76 five pamphlets and told him she would return after one week. She told him to let her know when he found a facility that he liked from the pamphlets. The WCN said she talked to Resident # 76 about discharge because she was the only staff he liked to talk to.In a face-to-face interview with Resident #76 at the facility on 07/08/2026 at 4:58 p.m., he said when the WCN gave him the verbal fifteen days' notice and the pamphlets to choose from he felt he was being kicked out of the facility. He said the WCN told him she would report to the State authority that no staff wanted to care for him because he made false allegations and that it was a felony to make fake police reports. In an interview with the discharge planner on 07/09/2026 at 9:25 a.m., she said if a resident were to be discharged , it was her responsibility, the Social Worker and the IDT to initiate the discharge process. She said discharge discussions were done if the resident requested or from the standpoint of the health insurance companies. The discharge planner said during a discharge process it was the responsibility of the discharge planner and the SW to hand out pamphlets to the residents to select where they wanted to be discharged . She said if the residents had a list of facilities they wanted to select from, she would go over the list with them. She said she had never delegated the discharge process to the WCN. She said no staff had ever told her they offered discharge pamphlets to residents. She said some pamphlets were outside the SW's office and some in her office. She said if a discharge was not initiated by the rightful personnel, it would be an unsafe discharge.In an interview with SW on 07/09/2026 at 10:18 a.m., he said it was the responsibility of the discharge planner and the SW to issue the discharge notices. He said it was the responsibility of the SW and the discharge planner to notify the residents of the number of days remaining pending discharge. He said the nursing staff should not have initiated the discharge process with Resident # 76. He said if he knew the WCN had initiated the discharge process with Resident # 76, he would have notified the DON and the ADM. The SW said the consequence of not having the rightful personnel to initiate the discharge process would be misinformation.In an interview with ADON on 07/09/2026 at 11:39 a.m., she said the discharge process was the responsibility of the discharge planner and the nursing department. She said she had never delegated the WCN to initiate a discharge process. The ADON said she was not aware the WCN had initiated discharge discussions with Resident #76. She said, if she knew she would have reminded her of her job descriptions. She said no residents had complained that the WCN had initiated discharge process and given them pamphlets to select a facility of their choice.In an interview with the DON on 07/09/2026 at 12:24 p.m., she said it was the responsibility of the IDT (DON, SW, ADON, Director of Rehabilitation, discharge planner and the unit managers) to initiate discharges. She said the IDT would discuss with the residents where they were going and set up home health services if needed, follow up appointments and where they would pick up their medications. She said if someone other than the IDT did initiate discharge that would be an unsafe discharge.In an interview with the ADM on 07/09/2026 at 12:32 p.m., she said the residents could tell any staff they wanted to go home. If they did, the staff should have referred the resident to the discharge planner and the SW. If staff initiated discharge, that could lead to confusion, especially if that is not the staff's area of expertise. She said every staff had their specific job descriptions. Record review of facility's discharge policy Criteria for Transfer and Discharge Section: Admission, Transfer and Discharge revised on 04/2025 stated: It is the policy of the facility that each resident will remain in the facility and not transferred or discharged unless the discharge or transfer is appropriate. Discharge refers to the movement of a resident from a bed in one certified facility to a bed in another certified facility or other location in the community when return to the original facility is not expected.

Based on observations, interviews and record reviews, the facility failed to provide effective and person-centered care for 1 (Resident #142) out of 8 residents sampled for quality of careThe facility failed to ensure physician orders, dietary orders, and therapy services related to Resident #142's diagnosis of dysphasia and the need of therapeutic diet mechanical soft was included in base line care plan This failure could place residents at risk of aspiration or choking and decline in quality of life. Findings include: Record review of Resident #142's Baseline Care Plan dated 7/10/2026 revealed a [AGE] year-old female admitted to SNF on 7/6/2026 with diagnoses of Hemiplegia and Hemiparesis affecting right dominant side (a form of paralysis that affects only one side of the body, usually resulting from damage to the brain or spinal cord and a neurological condition that causes weakness or partial paralysis on one entire side of the body ), Hypertension (a condition where the force of your blood against artery walls is consistently too high), Epilepsy (a chronic neurological disorder characterized by recurrent, unprovoked seizures), Dysphagia (difficulty or discomfort in swallowing food, liquids, or even saliva). Record review of Resident #142's history and physical dated 6/26/2026 from discharged hospital revealed a diet texture of soft & bite sized, liquid consistency of thin, and restrictions: Heart Healthy (2grams salt). Further review revealed a long-term goal to improve swallowing. Additional review revealed concern for aspiration due to coughing while eating. anticipated discharge date of 7/6/2026 to SNF.recommended PT, OT, SLP Record review of Resident #142's Clinical admission dated 7/6/2026 completed by LVN E revealed a therapeutic diet order of soft and bite sized texture - mechanical soft texture. Record review of Resident #142's Progress Note dated 7/7/2026 e-signed by MD revealed History and Physical Note a diet of texture: soft & bite-sized, liquid consistency - thin. Restrictions: Heart healthy (2 grams salt). Further review revealed Impression and Plan aspiration precaution. Record review of Resident #142's Order Summary Report dated 7/8/2026 revealed a verbal dietary order of Regular diet, Regular texture, thin liquids consistency. Record review of Resident #142's Baseline Care Plan dated 7/10/2026 revealed a focus of ADL self-care performance deficit related to hemiplegia with a goal to safely perform eating through review date with included intervention of Eating; requires x1 staff participation to eat. Further review of Baseline Care Plan did not reveal a care area related to Dysphagia diagnosis, or therapeutic diet of Mechanical Soft. Record review of Resident #142's Progress Note dated 7/9/2026 revealed a Therapy Assessment read in part Concerns with swallowing - No. Resident on special diet - No, Residents on a Regular Diet Observation and interview on 7/7/2026 at 1:00pm revealed Resident #142 sitting up in bed with legs over side of bed and bed side table in front of Resident #142. Resident #142 was served lunch that contained carrots, peas, rice, and gravy by CNA H. Observation revealed Resident #142 coughed while she ate lunch. Resident #142 stated it takes time to swallow food when eating. Resident #142 said a swallow study to address swallowing when eating was not completed at the SNF since admitted on [DATE]. Resident #142 was not sure if she needed to be supervised or monitored for help with meals or eating. In an interview on 7/9/2026 at 10:00am with SLP revealed that the process for screening new residents was either night before or morning of the admission and SLPs looked at new admissions information (previous facility or hospital documentation) to review background and chart of the resident. SLPs were to ask residents with swallow concerns about their meals and to complete a swallow assessment for the SNF. SLPs review diet orders from the hospital and ensure the diet orders are moved over to be followed at the SNF. SLP said a swallow study/ assessment was important to be completed first when the resident arrived to the SNF due to safety and helped create a baseline and goals for the residents care. SLP reviewed Electronic Therapy System and did not see any evaluations or assessments for Resident #142 . In an interview on 7/9/2026 at 10:44am Resident #142 said she had not been evaluated by therapy as of 7/9/2026 . An observation on 7/9/2026 at 12:59pm of meal cart on Hall of Resident #142 revealed Meal ticket on tray for Resident #142 read mechanical soft diet An attempted interview on 7/9/2026 at 11:40pm with Medical Assistant for MD said the last visit for Resident #142 was June 22, 2026 and there were no notes or other information available for Resident #142 regarding their diet need or diet order. Interview on 7/10/2026 at 11:19am with CNA H revealed the CNA Portal had information on residents care needs. Resident #142 ate all her meals however CNA H was not aware of a need to monitor or supervise Resident # 142 while eating, any history of swallowing concerns or current diet need for Resident #142 according to of a resident's care needs. CNA H said Resident #142 did not have swallowing issues and had not seen Resident #142 cough when eating. In an interview on 7/10/2026 at 12:36pm with LVN E revealed she remembered clinical assessment for Resident #142. LVN E said on Resident #142's hospital paperwork had a diet of minced or cut and bite sized texture. LVN E said the next day after the assessment (7/7/2026) therapy was to evaluate Resident #142 for any swallowing problems based on the hospital order diet. LVN E said a mechanical soft diet was ordered when it was hard for someone to swallow and to not need to chew as much with the mechanical soft food diet in place. LVN E said Rehab therapy, ADL needs, and current medications would carry over from previous facility unless a new evaluation was completed at SNF. LVN E said the hospital would upgrade the diet at discharge to regular when there was improvement however the diet for Resident #142 was put in at the SNF as mechanical soft since that was ordered. LVN E said SLP was told about the order, and a swallow study was to be done the following day according to the SLP. LVN E reviewed current orders for Resident #142 and noticed the diet was changed to regular. LVN E said diet orders can be changed when there was an evaluation completed to upgrade the diet order. LVN E said she completed a communication form that was given to the dietary department to inform them of the mechanical soft diet for Resident #142. In an interview on 7/10/2026 at 1:19pm with DON said if a swallow study/ test was needed it was scheduled and completed by an outside provider at the SNF to determine if a therapeutic diet was needed for a resident with swallowing concerns. Until the test was done precautions were to observe and check in while the resident was eating. When something of concern was seen while a resident ate it would be reported back to DON to be evaluated. Resident #142 had a care plan approach of x1 assistance however it did not state what type of assistance. DON reviewed clinical assessment of Resident #142 that revealed diet of cut and bite-sized foods, and meal ticket that read mechanical soft. DON reviewed current order in Resident #142's order summary that read regular diet. DON said she was not sure when therapy evaluated Resident #142 to complete swallow study to determine correct diet need for Resident #142. DON said there could be a risk of choking or struggling with swallowing food without correct or completed evaluation of Resident #142's diet needs. DON said the care plan and CNA portal would need to indicate supervision until evaluation was completed. In an interview on 7/10/2026 at 2:05 pm with Administrator said Resident #142 was screened yesterday (7/9/2026) for swallow and coughing concerns and it was determined there was no need for speech therapy due to the screening results. Administrator said the screening was completed by Rehab Department after they were informed that Resident #142 was seen coughing while eating. Administrator said the screening was to observe if a further assessment was needed and review diet order for Resident # 142. Administrator said the screening done on 7/9 read Resident #142 did not need speech therapy as Resident #142 was on a regular diet and there were no concerns of coughing while eating. Administrator said any special instructions for a residents diet would be included in the diet order, but the facility did not have a cut or bite sized diet type and mechanical soft was not a cut or bite sized diet. Administrator said a mechanical soft diet was typically ground meat and for residents that cannot tolerate a regular diet. Administrator said when residents were discharged from hospital or previous facilities the diet order was given to the SNF upon admission and speech screening was not needed for a regular diet order. Administrator reviewed Resident #142's order summary in Electronic Health Record that read regular diet , meal ticket that read mechanical soft' and reviewed hospital discharge diet order of cut or bite sized diet. Administrator said there was a discrepancy with what diet Resident #142 was on based on the reviewed information and would speak to therapy to conduct a new assessment and receive the correct diet order.

Based on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that included measurable objectives and timeframes to meet the resident's medical, nursing, and mental and psychosocial needs identified in the comprehensive assessment for 1 of 23 residents (Resident #69) reviewed for comprehensive person-centered care plans. The facility failed to develop a care plan addressing Resident #69's risk for skin breakdown. Resident #69 had dry, peeling skin on the buttocks that had resulted in a superficial pink area. This failure placed residents at risk for further skin breakdown, worsening skin impairment, pain, and infection Findings included:Record review of Resident #69's face sheet revealed a [AGE] year-old male admitted to the facility on [DATE] and discharged home on [DATE]. His diagnoses included: Chronic Obstructive Pulmonary Disease (a progressive lung condition that restricts airflow), Congestive Heart Failure (a chronic, progressive condition where the heart muscle doesn't pump blood as efficiently as it should), Chronic Kidney Disease, Stage 5 (the kidneys can no longer effectively filter waste, excess water, and toxins from the blood), Parkinsonism (a clinical syndrome characterized by four primary motor symptoms: tremors, stiffness, slow movements, and poor balance or walking difficulties),and Dependence On Renal Dialysis (kidneys have failed, and they require regular, ongoing medical treatments to artificially filter waste and excess fluid from their blood to survive). Record review of Resident #69's admission MDS dated [DATE] revealed a BIMS score of 13 out of 15 indicating his cognition was intact. Further review of the MDS revealed he was always incontinent of bowel and bladder (lacking voluntary control over urination or bowel movements), he was not at risk of developing pressure ulcers/injuries, no unhealed pressure ulcers/injuries, and no ulcers, wounds or skin problems. The MDS indicated skin and ulcer/injury treatments being used were pressure reducing device for chair and application of ointments/medications. Record review of Resident #69's care plan created on [DATE] and revised on [DATE] by WCN revealed a focus area of, Self-Care Performance Deficit related to decrease mobility. Superficial Pink Area/ Sacrum (triangular bone at the base of your spine, right above the tailbone). Interventions noted assistance with ADLs of toilet use, transfers, bed mobility, bathing, and dressing. Record review of Resident #69's care plan created on [DATE] revealed no mention of risk or prevention of skin breakdown. Record review of Resident #69's Braden Scale (an evidence-based assessment tool used by healthcare professionals to evaluate a patient's risk of developing pressure injuries) dated [DATE] revealed a score of 14 out of 23 indicating a moderate risk of developing pressure injuries. Record review of Resident #69's Braden Scaled dated [DATE] revealed a score of 15 out of 23 indicating a mild risk of developing pressure injuries. Record review of Resident #69's physician orders revealed an order started on [DATE] to Apply house barrier cream topically to buttocks/perineal area (the diamond-shaped region of the body located between the thighs, encompassing the external genitals and the anus) as needed and to Apply house barrier cream topically to buttocks/perineal area every shift. Record review of Resident #69's skin check assessments on [DATE], [DATE], and [DATE] by WCN revealed no skin issues. Record review of Resident #69's skin check assessments dated [DATE] by WCN revealed no skin issues but noted, dark discoloration to sacrum. small red blotches, no open areas. no drainage noted. perineal tissue present with erythema (redness of the skin). Mottled (patchy, uneven discoloration) and fragile. pink in color from resolved pressure injury on admission. resident continent bowel and bladder (the ability to voluntarily control your bowel and bladder functions). Record review of Resident #69's skin issue assessment dated [DATE] by WCN reflected there was a new skin issue located on the buttocks and was described as, superficial pink area. bilateral buttocks, that was present on admission and chronic last more than 3 months. The assessment further noted:Wound Bed - pink or redPeriwound (the skin immediately surrounding a wound) condition - New, pink to purple, shiny skin tissueSurrounding Tissue - black / blue, Dry / flaky, Eczematous (skin inflammation that typically features red, itchy, dry, and inflamed skin), Fragile: Skin that is at risk for breakdown, and normal in colorAdditional Care - moisture barrier, moisture control, positioning wedge, turning and repositioning program.Skin issue education - care skin issue, change clothing/briefs, change/shift positions frequently, dressing change, moisture barrier, and treatment of skin issue. Record review of Resident #69's SBAR dated [DATE] at 11:39am by WCN revealed there was a change in condition reported which was noted as, Change in skin color or condition. There were no nursing observations, evaluations, and recommendations noted. Record review of Resident #69's progress note dated [DATE] at 3:42pm revealed, Resident discharged home with [family member] on doctor order during this shift. Superficial pink area noted to bilateral buttocks, resident [family member] aware, doctor aware too. No other skin issues noted on discharge. Discharge paperwork signed by [family member]. Interview on [DATE] at 5:20pm, WCN said she did assess Resident #69's skin and there was dried skin and pink blotches to his inner glutes but there were no open areas to the skin. The WCN said Resident #69 had dried flaky skin to his buttocks since his admission and during his last skin assessment it was noticed that some of the skin had maybe flaked/peeled off leaving behind new pink skin. The WCN said Resident #69's family member had a concern about the area to the buttocks but she said his family member just wanted to know what it was and she explained to her the pink area was not a pressure ulcer, it was a superficial pink spot on the skin where the dry skin had peeled off. The WCN said she did not think Resident #69 was incontinent and said he would go the bathroom. She also said Resident #69 could reposition himself in bed and would get up in his chair in the room. The WCN said he would be considered at risk for skin breakdown because he was a dialysis patient and would sit for long periods of time while getting dialysis. The WCN said they would apply barrier cream to his skin as an intervention to prevent skin breakdown and she did skin assessments and checks every week. Interview on [DATE] at 9:48pm, Resident #69's family member said one of her main concerns with Resident #69 being in a nursing facility was him getting wounds. Resident #69's family member said after the resident was at the facility for a few weeks she asked the resident about staff changing him and he told her there were times he went all day wet without staff changing his brief. Resident #69's family member said she looked at the resident's bottom on [DATE] and saw one area that looked like it was healed but saw two open areas that were new and had a little wetness to it. She said she was so upset, she left the facility and came back the next day on [DATE] and removed the resident from the facility. She said no one ever said anything to her about the resident's skin and him having any type of breakdown. She denied the WCN looking at the resident's skin with her or showing her anything but said she was so angry she could have not heard her. Resident #69's family member said she had some pictures she took of his buttocks on [DATE] when she first saw the skin breakdown. Record review of pictures provided by Resident #69's family member on [DATE] at 9:56pm revealed a photo of bilateral buttocks where the skin was dried and the inner bilateral buttocks had died flaky skin with a pink patch on one side and another pink patch on the other side. No drainage observed in picture and the skin appeared to be dried as well over the pink patches. Interview on [DATE] at 10:59am, LVN D said Resident #69 was incontinent and needed to be changed. LVN D said Resident #69 was at risk for skin breakdown given his incontinence, his medical diagnoses, the fact that he was a large sized man, and would sit for long periods of time to get dialysis. LVN D said Resident #69 could get up and transfer to his chair with assistance and he could also reposition himself. LVN D said some interventions they used to prevent his skin from breaking down were to apply house barrier cream to his perineal and buttocks. LVN D said she did see Resident #69's skin and said he had dried skin to his bilateral buttocks and said the CNA had let her know that there was a pink area which is why she went to inspect the skin. LVN D described the pink area as how the skin looks when a scab or dry skin is peeled off and leaves behind shiny pink new skin. LVN D denied there being any drainage to the pink skin areas and said she applied the barrier cream to the area to help with the dry skin flaking. LVN D could not remember when the pink area appeared but stated Resident #69 had the dry flaky skin to his buttocks since admission. LVN D said the WCN was aware of the pink skin areas. LVN D said she never heard of any issues of him being left wet and stated since the resident was a dialysis patient he did not produce as much urine and was seldomly wet. Interview on [DATE] at 11:01am, CNA C said Resident #69 was incontinent and needed one person to change him. She said Resident #69 was very pleasant and quiet and would not call for the CNA so she would have to often check on him to see if he needed anything. CNA C said Resident #69 brief was never soaked with urine and said most times when she would change him the brief would be dry or not have that much urine. CNA C said she did say something to Resident #69 about him not being wet and he told her it was because he was on dialysis and he never had much urine. CNA C said she did see some dry skin to Resident #69's buttocks since he admitted to the facility but said there was an area where it looked like the dry skin sheared off and there were little pink spots. CNA C said she let the nurse and the WCN know about the pink spots and they advised putting barrier cream to the area. CNA C could not remember when she first saw the pink area to Resident #69's buttocks. CNA C said some interventions they used to prevent Resident #69's skin from breaking down were the barrier cream and she would try to remind him to turn and reposition. Interview on [DATE] at 1:11pm, the MDS Coordinator said Resident #69's care plan was completed by the other MDS Coordinator but she was not available. The MDS Coordinator said comprehensive care plans should be completed 7 days after the admission MDS is completed. The MDS Coordinator said they will typically complete a care plan area of being at risk for skin breakdown because all of the residents are at risk. The MDS Coordinator was not familiar with Resident #69 but stated he should have had a care plan addressing his risk for skin break down and said typical interventions are skin barrier cream, turning and repositioning, assessing the skin, moisture control, and pressure relief. The MDS Coordinator did review Resident #69's care plan and stated she did not see a care plan area addressing risk for skin break down. The MDS Coordinator could not say why the other MDS Coordinator did not include it in the care plan. The MDS Coordinator said they have a nurse manager meeting once a week and have morning meetings where they discuss new developments or things residents may be at risk for to be captured in the care plan, then they come up with interventions together to be added to the care plan. Interview on [DATE] at 4:00pm, the DON stated that they try to put everyone in the facility at risk for skin breakdown. The DON said she saw Resident #69's skin herself and described the area as dry skin and a small pink area of skin where the dry skin had maybe rubbed off. The DON said during her investigation she did find that everyone was saying the resident had dry skin to his buttocks since admission and said she did notice the skin assessments upon admission and there after did not notate the dry skin issues. The DON said she had completed training with staff over the weekend regarding skin assessments. The DON said Resident #69 was someone at risk for skin breakdown and agreed there should have been a care plan area in place with interventions on how to prevent his skin from breaking down. Record review of the facility Care Plans - Comprehensive policy Revised [DATE] revealed in part, .1. Our facility's Care Planning/Interdisciplinary Team, in coordination with the resident, his/her family or representative (sponsor), develops and maintains a comprehensive care plan for each resident that identifies the highest level of functioning the resident may be expected to attain. Each resident's comprehensive care plan is designed to: 1. Incorporate identified problem areas; 2. Incorporate risk factors associated with identified problems.

Based on observation, interview and record review the facility failed to establish and maintain, and infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable disease and infections for 2 of 7 (Resident #3, Resident #4) reviewed for infection control. CNA A failed to change Resident #4's brief every 2 hours. Resident #4 brief was observed being heavily soiled in urine and resident clothing was soiled on 03/20/25. CNA B and CNA C failed to wear full PPE when providing incontinent care for Resident #3. CNA B used hand sanitizer to disinfect Resident #3's bedside table. CNA B took linen from another resident's room to Resident #3's room to provide incontinent care. CNA B and CNA C cleaned Resident #3 back and forward instead of front to back during incontinent care. These failures placed residents at risk for unwanted infections and decrease in quality of life. Findings included: Record review of Resident #4's face sheet dated 03/20/26 revealed a [AGE] year-old female admitted to the facility on [DATE] and again on 12/13/25. Resident diagnoses included anxiety, assistance with personal care, history of falling, osteoarthritis (joint disease that cause cartilage {support bones by allowing the bones to move smoothly over one another}on the bones to wear down, and dementia (progressive brain disorders causing a cognitive decline such as memory loss, confusion, and behavior changes). Record review of Resident #4's quarterly MDS dated [DATE] revealed a BIMS score of 3 indicating that Resident #4 cognition was severely impaired. Section G-Functional Abilities revealed that resident required substantial/maximal assistance with toileting hygiene and lower body dressing. Section H-Bladder and Bowel revealed that resident was always incontinent of both urine and bowel. Record review of Resident #4's Comprehensive Care Plan dated 07/28/24 and revised on 05/19/25 reflected resident being care planned for bowel/bladder incontinence that included the following interventions: -Use disposable briefs, check and change as indicated.-Monitor/document for s/sx of UTI: altered mental status, change in behavior, change in eating patterns. Record review of E-INTERACT dated 03/24/25 done for Resident #4 reflecting resident was difficult to arouse despite several attempts and had not eaten or taken medications. Record review of Resident #4's discharge hospital records dated 03/24/26 reflected the principal complaint: Altered mental status. Further review revealed that a urinalysis was collected on 03/24/26 that revealed bacteria in urine. Record review of Resident #4's Physician Order Summary Report for the month of March 2026 reflected the following orders: -Dated 03/25/26 UA C& S-Dated 03/25/26 Nitrofurantoin (antibiotic used to treat bladder infections) give 100mg by mouth two times day for UTI until 03/31/26. Record review of Resident #4's MAR for the month of March 2026 revealed that the medication Nitrofurantoin 100mg by mouth was initiated at 10:00AM on 03/25/26. Observation on 03/20/26 at 4:16PM of Resident #4 sitting in a recliner chair. Interview on 03/20/26 at 4:16PM with Resident #4 who was alert to name but not place or time. Resident #4 said she believed that her brief was wet and then said she did not know. Interview on 03/20/26 at 4:26PM with CNA D said she had just taken Resident #4 to the bathroom about 30 minutes ago. CNA D said that Resident #4 could stand with the assistance of one person. The surveyor asked CNA D if she could check Resident #4's brief because resident said she was wet and then said she did not know. Observation on 03/20/26 at 4:35PM of CNA D assisting Resident #4 to the bathroom via wheelchair. When CNA D assisted Resident #4 to stand from recliner to transfer to w/c, the surveyor observed the back of resident pants were wet. Resident #4 was able to use handrail in the bathroom to stand with the w/c behind her. When CNA D began to pull resident pants down, it was observed that Resident #4 was wearing a pull up brief as well as another brief underneath the pull up brief. The brief was heavily soiled with urine. Resident skin was intact. Interview on 03/20/26 at 4:50PM with CNA D said Resident #4 was a heavy wetter and that it was Resident #4's family member that doubled briefed resident. CNA D said she only took Resident #4's spouse to the bathroom and that the family member had taken Resident #4 to the bathroom. CNA D said she did check with the family member of Resident #4 to see if indeed the family member had taken Resident #4 to the bathroom. CNA D said she did not check Resident #4 to see if resident required incontinent care or needed to use the bathroom. CNA D said she stopped by Resident #4's room and asked if everything was ok. CNA D said Resident #4 had a doctor appointment earlier in the morning and that she had given Resident #4 a shower prior to going to her doctor's appointment. CNA D said Resident #4's doctor's appointment was at 11:00AM and that the family member took Resident #4 to the doctor's appointment. CNA D said the family member bought Resident #4 back to the facility around 2 or 3PM. CNA D said she checked on residents that required assistance with care about 1-1/2 to 2 hours. CNA D said it was important to provide incontinent care every 2 hours to avoid rashes due to moisture and avoid the residents from soiling their clothes. Interview on 03/24/26 at 12:35PM with the family member of Resident #4 said she took Resident #4 to a dental appointment for 10:30AM on 03/20/26. The family member said Resident #4 returned to the facility around 11:30AM or 12:00PM. The family member said she took Resident #4 to the bathroom around 12:30PM. The family member said Resident #4 wanted to be doubled brief because resident did not like want her clothes to get wet. The family said when she was at the facility, she did everything for Resident #4. The family member said it was a problem with staff not changing Resident #4's brief in a timely manner. The family member said she looked at the camera in the room and would notice that sometimes the staff did not come in the room for hours to change Resident #4. The family member said she had called this to the facility's attention. The family said it would improve for a little while and then the staff would go back to them doing the same thing. The family member said Resident #4 had been lethargic for the past 3 days and now not taking fluids well. The family member said Resident #4 might be dehydrated and may have a UTI. The family member said she was going to return to the facility on [DATE] and if the facility had not done anything, she was going to take resident to the hospital herself. Resident #3 Record review of Resident # 3's face sheet dated 03/25/26 revealed a [AGE] year-old female admitted to the facility on [DATE] and again on 01/19/26. Resident #3's diagnoses included cerebral infarction (decreased blood flow to the brain), fracture of lower end of left femur (longest, strongest, and heaviest bone in the human body, extending from the hip to the knee), reduced mobility, need assistance with personal care, and muscle weakness. Record review of Resident #3's quarterly MDS dated [DATE] revealed a BIMS score of 13 indicating that resident cognition was intact. Section GG-Functional Abilities revealed that Resident #3 was dependent for toileting hygiene. Section H-Bladder and Bowel revealed that Resident #3 was always incontinent of urine and bowel. Record review of Resident #3's Comprehensive Care Plan dated 01/16/24 and revised 01/07/26 reflected resident being care planned for bowel and bladder incontinence r/t disease process, impaired mobility and colostomy. An intervention included check as required for incontinence. Record review of Resident #3's Physician Order Summary Report for the month of March 2026 did not reflect an order for EBP. Observation on 03/25/26 at 11:17AM of incontinent care for Resident #3 by CNA B with the assistance of CNA C was made. Observation revealed an enhanced barrier precaution signage at the door entrance. There was a PPE hanger on the outside of the door. The PPE hanger had a container of micro-kill 2 germicidal wipes, gloves, mask, and disposable gowns. CNA B went across the hallway into another residents room and came out with linen that consisted of large towels and took them to Resident #3's room. CNA B and CNA C washed their hands with soap and water and put on gloves but did not put on disposable gowns. CNA B after removing Resident #3's personal belongings off the bedside table began to clean the resident table with hand sanitizer. CNA B proceeded to place the large towels on top of the bedside table. At 11:20AM CNA B left the room and returned with extra supplies for incontinent care. CNA B washed her hands again and put on a clean set of gloves and began to change Resident #3's brief. Resident #3 was incontinent of urine, and the brief was not heavily soiled. It was observed during incontinent care that Resident #3 had a colostomy bag. The colostomy bag was observed with brown soft feces inside of the bag. While CNA B was cleaning the resident groin and perineal area, she did not clean resident with one wipe at a time consistently instead would use the same wipe going back and forward over the skin repeatedly. When Resident #3 was repositioned to her left side, CNA C began to clean resident buttocks back and forward with the same wipe. Resident #3 did not have any skin breakdown to her buttocks or perineal area. When CNA B and CNA C were done providing incontinent care, they both placed all soiled material inside of a plastic bag, washed their hands and removed the soiled material from the room and took it to the soiled utility room. Interview and observation on 03/25/26 at 11:43AM with CNA B, she said the reason she did not put on a disposable gown when providing care for Resident #3 was because she did not need to wear a disposable gown. CNA B was asked why was the EBP signage at door entrance and why was there a PPE hanger on door with PPE inside? CNA B said the EBP sign and PPE hanger was on the door when Resident #3 was sick. When CNA B read the EBP signage instructing on what PPE to wear, she then said she needed to wear a disposable gown to protect herself as well as the resident from any type of bacteria. CNA B said the reason she took linen from another resident room and brought in Resident #3's room was because the room had a bag of linen inside the room. CNA B said it was not okay to take linen from room to room to avoid cross contamination. CNA B said she did this because it wound have taken too much time to go and get linen to provide care for Resident #3. CNA B said she used the hand sanitizer to disinfect Resident #3's bedside table because it was in the room and to her this was sufficient in disinfecting resident bedside table. When CNA B observed the germicidal wipes on the PPE door hanger she said she forgot to use the germicidal wipes to disinfect the table. CNA B said when providing incontinent care, she was supposed to wipe resident with one wipe at a time from front to back moving downward and not back to front. CNA B said she was taught this to avoid bacteria and to prevent giving the residents any type of infection. CNA B said she had been working at the facility for 1 year and had been a CNA for 17 years. CNA B said she had received in-service on infection control about a month ago, but did not recall if she had been in-served on EBP. Interview on 03/25/26 at 12:14PM with the ADON said she was the Infection Control Preventionist and that the DON was on leave. The ADON said the last time she had in-service staff on infection control, handwashing, cleaning and disinfecting surfaces and to use the purple top container germicidal wipes. The ADON said she in-serviced the staff last on EBP on 03/19/26. The ADON said it was not okay for the staff to use hand sanitizer to disinfect hard surfaces because it would not correctly kill bacteria and was not approved to clean hard surfaces. The ADON said it was important that the staff wear the correct PPE when providing direct care to residents on EBP to decrease exposure of any type of MDRO. The ADON said the staff should be providing incontinent care at least every 2 hours to prevent skin breakdown and infections. The ADON said it was not okay to take linen from one resident room and take to another resident room for infection control purposes. The ADON said when providing incontinent care, the staff should be cleaning the resident from front to back to prevent infections. The ADON said staff should be practicing EBP on resident's that had the following: wounds, gastrostomy tubes, tracheotomy, Foley catheter, intravenous lines, and colostomies by wearing PPE that consisted of gloves and disposable gown. Interview on 03/25/26 at 2:53PM with CNA C said she worked at the facility from7AM-7PM full time and had been working at the facility on and off for 10 years. CNA C said when providing incontinent care she was supposed to clean the resident buttocks upward and away and not back and forward for infection control and to prevent introducing bacteria in the vaginal area which could cause a urine infection. CNA C said she was not aware that she was cleaning Resident #3 in the wrong direction. CNA C said she must have been nervous. CNA C said when a resident was on EBP the staff had to wear gowns and gloves while providing care. CNA C said this was done for infection control. CNA C said residents that were on EBP were residents with wounds, colostomies, and Foley catheter. CNA C said she believed the last time she received in-service on infection control was a week ago. CNA C said once linen was placed inside a resident's room it should not be removed and taken to another resident room to prevent cross contamination. Record review of the facility last in-service given to staff on EBP was done 03/10/26 with CNA B signing she was in-service. Record review of the facility policy on Infection control revised October 2022 reflected in part: .The facility personnel will conduct themselves and provide care in a way that minimizes the spread of infections. Record review of the facility policy on Incontinence revised in 2025 reflected in part: .Residents that are incontinent of bladder and bowel will receive appropriate treatment to prevent infections and to restore continence to the extent possible.

Based on observation, interview, and record review the facility failed to ensure that a resident who is continent of bladder and bowel on admission receives services and assistance to maintain continence for 1 (Resident #4) of 7 residents observed for incontinent care. Resident #4's brief was heavily soiled in urine along with clothing on 03/20/26. This failure placed residents at risk for unwanted skin breakdown. Findings included: Record review of Resident #4's face sheet dated 03/20/26 revealed a [AGE] year-old female admitted to the facility on [DATE] and again on 12/13/25. Resident diagnoses included anxiety, assistance with personal care, history of falling, osteoarthritis (joint disease that cause cartilage {support bones by allowing the bones to move smoothly over one another}on the bones to wear down, and dementia (progressive brain disorders causing a cognitive decline such as memory loss, confusion, and behavior changes). Record review of Resident #4's quarterly MDS dated [DATE] revealed a BIMS score of 3 indicating that Resident #4 cognition was severely impaired. Section G-Functional Abilities revealed that resident required substantial/maximal assistance with toileting hygiene and lower body dressing. Section H-Bladder and Bowel revealed that resident was always incontinent of both urine and bowel. Record review of Resident #4's Comprehensive Care Plan dated 05/01/24 and revised 07/28/24 reflected that resident was being care planned for ADL self-care performance deficit r/t cognitive deficit, dementia, and history of falls. An intervention included: requires staff participation with personal hygiene and oral care. Observation on 03/20/26 at 4:16PM of Resident #4 revealed the resident was sitting in a recliner in her room. Interview on 03/20/26 at 4:16PM with Resident #4 revealed the resident was alert to name but not place or time. Resident #4 said she believed that her brief was wet and then said she did not know. There was no offensive urine odor detected at this time. Interview on 03/20/26 at 4:26PM with CNA D said she had just taken Resident #4 to the bathroom about 30 minutes ago. CNA D said that Resident #4 could stand with the assistance of one person. The surveyor asked CNA D if she could check Resident #4's brief because the resident said she was wet and then said she did not know. Observation on 03/20/26 at 4:35PM revealed CNA D assisting Resident #4 to the bathroom via wheelchair. When CNA D assisted Resident #4 to stand from recliner to transfer to w/c, the surveyor observed the back of resident pants were wet. Resident #4 was able to use handrail in the bathroom to stand with the w/c behind her. When CNA D began to pull resident pants down, it was observed that Resident #4 was wearing a pull up brief as well as a brief underneath the pull up brief. The brief was heavily soiled with urine. Resident skin was intact. Interview on 03/20/26 at 4:50PM with CNA D said Resident #4 was a heavy wetter and that it was Resident #4's family member that doubled briefed resident. CNA D said she only took Resident #4's family member to the bathroom and that the family member had taken Resident #4 to the bathroom. CNA D said she did check with the family member of Resident #4 to see if the family member had taken Resident #4 to the bathroom. CNA D said she did not check Resident #4 to see if the resident required incontinent care or needed to use the bathroom. CNA D said she stopped by Resident #4's room and asked if everything was ok. CNA D said Resident #4 had a doctor appointment earlier in the morning and that she had given Resident #4 a shower prior to going to her doctor's appointment. CNA D said Resident #4's doctor's appointment was at 11:00AM and that the family member took Resident #4 to the doctor's appointment. CNA D said the family member brought Resident #4 back to the facility around 2 or 3PM. CNA D said she checked on residents that required assistance with care about 1-1/2 to 2 hours. CNA D said it was important to provide incontinent care every 2 hours to avoid rashes due to moisture and avoid the residents from soiling their clothes. Interview on 03/24/26 at 12:35PM with the family member of Resident #4 said she took Resident #4 to a dental appointment for 10:30AM on 03/20/26. The family member said Resident #4 returned to the facility around 11:30AM or 12:00PM. The family member said she took Resident #4 to the bathroom around 12:30PM. The family member said Resident #4 wanted to be doubled brief because the resident did not want her clothes to get wet. The family said when she was at the facility, she did everything for Resident #4. The family member said it was a problem with staff not changing Resident #4's brief in a timely manner. The family member said she looked at the camera in the room and would notice that sometimes the staff do not come in the room for hours to change Resident #4. The family member said she had called this to the facility's attention. The family said it would improve for a little while and then go back to them doing the same thing. Interview on 03/25/26 at 12:14PM with the ADON said the facility DON was on leave. The ADON said if a resident family member tells staff they will take the resident to the bathroom, the staff should still be following up to see if this was done. The ADON said the staff should ensure that the resident's needs were met because the residents were still under the care of the facility. The ADON said staff should be providing incontinent care at least every 2 hours. Record review of the facility policy on Incontinence references: Centers for Medicare & Medicaid Services revised 2025 reflected in part: .Based on the resident's comprehensive assessment, all residents that are incontinent will receive appropriate treatment and services. Record review of the facility policy on Quality-of-Life revised October 2009 reflected in part: .Each resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect, and individuality.

Based on observation, interview, and record review the facility failed to ensure residents had the right to personal privacy for 2 (Resident #1 and Resident #2) of 7 residents review for personal privacy. CNA A failed to cover Resident #1 and Resident #2 body when she left the room on 03/25/26 to get assistance. This failure could place residents at risk of feeling uncomfortable or embarrassed. Findings included: Record review of Resident #1's face sheet dated 03/25/26 revealed a [AGE] year-old female admitted to the facility on [DATE]. Resident #1's diagnoses included the following: hemiplegia (severe or total paralysis affecting one side of the body) and hemiparesis (weakness on one side of the body) following cerebral infarction (when blood flow to the brain) affecting the left non-dominant side, contracture (permanent tightening of muscles, tendons, skin, or tissue resulting from injury, lack of movement, or nerve damage) of knee, and dysphagia (difficulty swallowing). Record review of Resident #1's quarterly MDS dated [DATE] reflected a BIMS score of 0 indicating that resident cognition was severely impaired. Section GG-Functional Abilities revealed that resident was dependent upon staff for mobility. Record review of Resident #1's Comprehensive Care Plan reflected resident being care planned for ADL self-care performance deficit created 06/18/23 and revised 04/29/24. An intervention included requiring staff participation to dress resident. Observation on 03/20/26 at 10:39AM revealed of Resident #1's door was open and curtain not pulled. Resident was resting in bed on her back with the head of the bed lowered. There was a Hoyer lift sling underneath the resident's upper body torso. Resident #1 was uncovered and covers were at the foot of bed. Resident #1 was wearing a gown Resident #1 had contractures to the upper and lower body on both sides. Resident #1 was not interview able. Resident did not appear to be in any distress. Resident #2 Record review of Resident #2' s face sheet dated 03/25/26 revealed a [AGE] year-old female admitted to the facility on [DATE] and again on 12/19/17. Resident diagnoses included the following: dementia, osteoarthritis, anxiety, and contracture of joints. Record review of Resident #2's MDS dated [DATE] reflected that resident BIMS score was 3 indicating that resident cognition was severely impaired. Section GG-Functional Abilities reflected that resident was dependent upon staff with ADL care. Record reviews of Resident #2's comprehensive care plan dated 11/17/25 reflected that resident was being care planned for the right to health, safety, and dignity. An intervention included close curtain while providing care. Observation on 03/20/26 at 10:40 AM revealed Resident #2's door was open with curtain not pulled. Resident #2 was resting in bed on her back with the head of bed lowered. Resident #2 was wearing gown with the Hoyer sling underneath the resident's upper body torso. Resident #2 was not covered. Resident #2's covers were at the foot of the bed. Resident was not inter-viewable and did not appear to be any distress. Observation on 03/20/26 at 10:43AM revealed CNA A entered the room of Resident #1 and Resident #2. Interview and observation on 03/20/26 at 10:45AM with CNA A said she had been working at the facility for a year. CNA A said both residents should have been covered for privacy reasons and their dignity. CNA A lowered the head of the bed for Resident #1 and Resident #2 and began to cover both residents. CNA A said she had left the room to get assistance with getting Resident #1 and Resident #2out of bed. Interview on 03/25/26 at 12:14PM with the ADON said the DON was on leave. The ADON said resident should be covered and not exposed to promote their dignity. Record review of the facility policy on Resident Rights/Dignity and Respect revised May of 2007 reflected in part: .It is the policy of this facility that all residents be treated with kindness, dignity and respect.privacy of a resident's body shall be maintained during toileting, bathing and other activities.A closed door or drawn curtain shields the resident from passers-by.

Based on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that included measurable objectives and time frames to meet a resident's medical, nursing, mental, and psychosocial needs that were identified in the comprehensive assessment for one (Resident #1) of six residents reviewed for care plans.The facility failed to specify in the care plan whether Resident #1 would be a 1-person or 2-person assist for bed mobility. Resident #1 sustained a fall out of her bed on 1/6/26 when CNA A attempted to provide a 1-person assist during incontinent care. Resident #1 sustained a comminuted, mildly impacted, intra-articular fracture of the distal left femur and returned to the facility with a leg immobilizer.This failure could lead to residents not having their individual, medical, functional, and psychosocial needs identified and cause a physical or psychosocial decline in health.Findings included:Record review of Resident #1's face sheet dated 2/4/26 indicated she was a [AGE] year-old female with diagnoses of cerebral infarction (ischemic stroke caused by a blockage in brain blood vessels), displaced comminuted fracture of shaft of left femur, lack of coordination, cognitive communication deficit, reduced mobility, need for assistance with personal care, age-related osteoporosis ((a disease that causes bones to become weak and brittle), muscle weakness, other specified disorders of bone density and structure-multiple sites, and hemiplegia (complete paralysis) and hemiparesis (partial weakness) following cerebral infarction affecting left non-dominant side.Record review of Resident #1's most recent comprehensive MDS dated [DATE], revealed a BIMS score of 14 which indicated cognition was intact. Further review of the comprehensive MDS under section GG-Functional Abilities indicated Resident #1 was dependent on staff for rolling left and right. The comprehensive MDS indicated Resident #1 had a fall with major injury since admission/entry or reentry or prior assessment.Record review of Resident #1's quarterly MDS dated [DATE] indicated she was dependent for toileting, shower/bathe, and rolling left and right. In the MDS under Dependent it states - helper does all of the effort. Resident does none of the effort to complete activity or, the assistance of 2 or more helpers is required for the resident to complete the activity. Further review of the Quarterly MDS indicated Resident #1 did not have any falls since admission/entry, reentry, or prior assessment.Record review of Resident #1's care plan dated 1/7/26 indicated Resident #1 had the following care areas: *an ADL self-care performance deficit r/t functional decline contracture left knee, right elbow, wrist, and fingers. The intervention under bed mobility (roll left and right, sit to lying, lying to sitting on side of bed) indicated Resident #1 required staff assistance for bed mobility.*a positioning support device HALO as enabler. Interventions included: educate resident/family on risk and benefits on 1/4 siderails; IDT to discuss all positioning support devices; monitor for reduction of use of siderails; observe the use of positioning/support devices; provide range of motion to maintain mobility and preventive skin care to maintain intact skin.*at risk for falls r/t hx falls, hypotension, generalized weakness. Interventions included: be sure the call light is within reach and encourage to use it to call for assistance as needed; bed in lowest position, educate resident, family, caregivers about safety reminders and what to do if a fall occurs; keep needed items, water, etc., in reach; occupational, physical, speech-language therapy evaluation and treatment per physician orders.Record review of the Kardex as of 1/1/26 indicated Resident #1 required staff assistance for bed mobility. Record review of Resident #1's orders indicated the following:-1/4 right side & left side/HALO to enhance bed mobility, turning and repositioning while in bed, start date 8/28/25 and an end date of 1/19/26.-monitor level of pain using 1- 10 scale, every shift, start date 11/4/25 and an end date of 1/19/26.-Meloxicam oral tablet 15 mg- give 1 table by mouth every 24 hours as needed for pain, start date 5/14/25 and an end date of 1/19/26.-Tylenol oral tablet 325 mg- give 2 tablet by mouth every 6 hours as needed for mild pain, start date 5/13/25 and an end date of 1/19/26.-x-ray to bilateral knees, bilateral ankles, and bilateral femur STAT for post fall, order date 1/7/26. Record review of the incident/accident report for dated January 2026, indicated Resident #1 had a fall on 1/6/26 at 2:00 PM. The incident/accident report did not indicate whether it was witnessed or unwitnessed.Record review of Resident #1's progress note dated 1/6/26 at 2:57 p.m. input by ADON A read: during bed bath resident used mobility bar to turn and misjudged the width of the bed causing her momentum to roll off the bed before staff could stop her. She landed on the floor onto her left side. Nurse assessment completed. V/S stable. She was able to [NAME] without discomfort and assisted back to bed. She states she did not hit her head. She c/o pain to left side once in bed. Medicated for discomfort.Record Review of Resident #1's progress noted dated 1/6/26 at 3:09 pm input by RN A read: patient had a witnessed fall, no head fall, patient complained of shoulder pain and patient is AOx3. X-ray has been scheduled. MD, DON, and family has been notified. Vital sign BP 137/57, P 60, T 97.3, R 20, O2 97%.Record review of Resident #1's progress note dated 1/7/26 at 10:43 am input by LVN B read: resident complains of bilateral leg, knee, and ankle pain. NP notified and has ordered STAT X-rays to bilateral ankle, bilateral knee, and bilateral femur. Writer placed call to arrange this STAT imaging order. The result of this x-ray read the bones are osteoporotic, there is no dislocation or fracture.Record review of Resident's #1 progress note dated 1/7/26 at 10:44 am input by LVN B read: resident given two Tylenol oral tablets, 325 mg for bilateral ankle, knee, and femur pain. Pain at a level 4/10. Medication administered.Record review of Resident #1's progress noted dated 1/15/26 at 9:17 a.m. input by LVN E read: family member requesting Resident #1 to send to hospital to be evaluated for leg/knee pain. Assessed resident, voice complaints 4/10 of (L) knee/leg pain, prn Tylenol was administered, tolerated well. No facial grimacing, body relaxed at this time, no distress. Spoke with NP, with on-call doctor, aware of situation, ok to send to hospital.Record review of Resident #1's hospital record revealed CT scan of lower extremity without contrast, left, dated 1/15/26 indicated a comminuted, mildly impacted, intra-articular fracture of the distal femur. Resident #1 did not require surgery but required a leg immobilizer.During an interview with Resident #1 on 2/4/26 at 12:10 p.m. she said on 1/6/26 CNA A was applying lotion on her legs before she was pushed out of the bed. Resident #1 said she did not think CNA A pushed her on purpose, she said CNA A was not following protocol. Resident #1 said before the fall, sometimes there would be 2 staff assisting her with bed baths and incontinent care, she said the number of staff assisting her would alternate between 1 staff member to 2 staff members.During an interview with CNA A, she said she finished giving Resident #1 a bed bath and proceeded to lay Resident #1 on her side so she could put on her adult brief. CNA A said Resident #1 lied on right side as she was holding onto the mobility bar. CNA A said she asked Resident #1 three times if she had a firm grasp on the mobility bar and Resident #1 told her Yes. CNA A said as soon as she put the brief under Resident #1, she rolled out of the bed. CNA A said Resident #1 landed on her left side in a seated position. CNA A said when she came around to check Resident #1, she said Resident #1 was in shock and let out a sound like ugh, Resident #1 did not say anything. CNA A said she covered Resident #1 with a sheet because she was naked and ran down the hall to call for help. CNA A said RN A, LVN C, and CNA B came back to the room. CNA A said LVN C assessed Resident #1. She said LVN C check her head, her back, and did movement with her legs. CNA A said she and RN A put her on the Hoyer pad and used the Hoyer lift to put her back in bed.During an interview with the MDS Coordinator, she said before the fall Resident #1 was a 1-person assist, now she is 2-person assist. She said the care plan showed Resident #1 required staff assistance meaning she could do some of the movement herself.During an interview with the MDS Resource Coordinator A, he said when the care plan showed staff assistance for a resident, the CNAs know it should be 1-person assist. He said the care plans are designed for 1-person or 2-person assist, depending on the strength of the CNA and also depending on the type of day the resident was having. He said for example, if a resident was having a bad day, it may require 2 to 3 staff to assist the resident with care, or if the resident was having a good day, it may only require 1 staff member to assist the resident with care.During an interview with the DON and Administrator, the Administrator said when a resident has a fall, the aides are not supposed to move the resident and notify the nurse. The DON said the aide should leave the room to get assistance or turn on the call light or holler out in the fall for help but not leave the general area. The DON said when a resident had a fall and there were 2 nurses assessing the resident, the nurse that was in charge of the resident should document the assessment. The DON said when the Kardex shows staff assistance for a resident, the aides should know the resident is 1-person assist. The DON said the Kardex is charted based on what was in section GG of the MDS. The DON said there are some days a resident would need less help than other days, more is better. The DON said if an aide was not familiar with a resident, the charge nurse would give report to the aide, and the aide should know where to access the Kardex. The DON said she did not think there was a risk when the Kardex was not specific for 1-person or 2-person assist.Record review of the facility's policy titled Resident Assessment and Associated Processes, dated 04/2025 read in part . It is the policy of this facility that resident will be assessed, and the findings documented in their clinical health record. Procedure: .Comprehensive assessment: includes the completion of the MDS (Minimum Data Set) as well as the CAA (Care Area Assessment) process, followed by development and/or review of the comprehensive care plan. an accurate comprehensive assessment will be made of the resident's needs, strengths, goals, life history, and preferences, using the RAI (Resident Assessment Instrument) and will include at least the following: physical functioning and structural problem .Record review of the facility's policy titles Comprehensive Person-Centered Care Planning, dated 04/2025 read in part . it is the policy of this facility that the interdisciplinary team shall develop a comprehensive person-centered care plan for each resident that includes measurable objectives and timeframes to meet a resident's medical, nursing, mental, and psychosocial need that are identified in the comprehensive assessment .

Based on interview and record review, the facility failed to ensure the residents environment remained as free of accident hazards as is possible and ensure each resident received adequate supervision for one (Resident #1) of six residents reviewed for accidents and hazards.The facility failed to prevent Resident #1 from having a witnessed fall on 1/6/26 while CNA A provided incontinent care. Resident #1 sustained a comminuted, mildly impacted, intra-articular fracture of the distal femur.These failures could place residents at risk for harm, pain, and injury.Findings included:Record review of Resident #1's face sheet dated 2/4/26 indicated she was a [AGE] year-old female with an initial admission date of 12/22/23 and readmitted to the facility on [DATE]. Resident #1's diagnoses were: cerebral infarction (the pathologic process that results in an area of necrotic tissue in the brain), displaced comminuted fracture of shaft of left femur, lack of coordination, cognitive communication deficit, reduced mobility, need for assistance with personal care, age-related osteoporosis (a disease that causes bones to become weak and brittle), muscle weakness, other specified disorders of bone density and structure-multiple sites, and hemiplegia (complete paralysis) and hemiparesis (partial weakness) following cerebral infarction affecting left non-dominant side.Record review of Resident #1's most recent comprehensive MDS dated [DATE], revealed a BIMS score of 14 which indicated cognition was intact. Further review of the comprehensive MDS under section GG-Functional Abilities indicated Resident #1 was dependent on staff for rolling left and right. The comprehensive MDS indicated Resident #1 had a fall with major injury since admission/entry or reentry or prior assessment.Record review of the Quarterly MDS dated [DATE] under section GG-Functional Abilities indicated Resident #1 was dependent on staff for rolling left and right. Further review of the Quarterly MDS indicated Resident #1 did not have any falls since admission/entry, reentry, or prior assessment.Record review of Resident #1's care plan dated 1/7/26 indicated Resident #1 had the following care areas:*an ADL self-care performance deficit r/t functional decline contracture left knee, right elbow, wrist and fingers, colostomy. Interventions included: resident request not to have a male help her with ADLs; occupational, physical, speech-language therapy evaluation and treatment per physician orders; toilet use- resident requires staff assistance for colostomy management and incontinent care, resident prefer to be double briefed; transfers- resident requires 2 staff assistance for transfers with Hoyer lift; bed mobility (roll left and right, sit to lying, lying to sitting on side of bed)-resident requires staff assistance for bed mobility.*a positioning support device HALO as enabler. Interventions included: educate resident/family on risk and benefits on 1/4 siderails; IDT to discuss all positioning support devices; monitor for reduction of use of siderails; observe the use of positioning/support devices; provide range of motion to maintain mobility and preventive skin care to maintain intact skin.*at risk for falls r/t hx falls, hypotension, generalized weakness. Interventions included: be sure the call light is within reach and encourage to use it to call for assistance as needed; bed in lowest position, educate resident, family, caregivers about safety reminders and what to do if a fall occurs; keep needed items, water, etc., in reach; occupational, physical, speech-language therapy evaluation and treatment per physician orders. Record review of the incident/accident report for dated January 2026, indicated Resident #1 had a fall on 1/6/26 at 2:00 PM. The incident/accident report did not indicate whether it was witnessed or unwitnessed.Resident #1's progress note dated 1/6/26 at 2:57 pm input by ADON read: during bed bath resident used mobility bar to turn and misjudged the width of the bed causing her momentum to roll off the bed before staff could stop her. She landed on the floor onto her left side. Nurse assessment completed. V/S stable. She was able to [NAME] without discomfort and assisted back to bed. She states she did not hit her head. She c/o pain to left side once in bed. Medicated for discomfort.Resident #1's progress noted dated 1/6/26 at 3:09 pm input by RN A read: patient had a witnessed fall, no head fall, patient complained of shoulder pain and patient is AOx3. X-ray has been scheduled. MD, DON, and family has been notified. Vital signs BP 137/57, P 60, T 97.3, R 20, O2 97%.Resident #1's progress note dated 1/7/26 at 10:43 am input by LVN B read: resident complains of bilateral leg, knee, and ankle pain. NP notified and has ordered STAT X-rays to bilateral ankle, bilateral knee, and bilateral femur. Writer placed call to arrange this STAT imaging order.Resident's #1 progress noted dated 1/7/26 at 10:44 am input by LVN B read: resident given two Tylenol oral tablets, 325 mg for bilateral ankle, knee, and femur pain. Pain at a level 4/10. Medication administered.Record review of Resident #1's progress noted dated 1/15/26 at 9:17 a.m. input by LVN E read: family member requesting Resident #1 to send to hospital to be evaluated for leg/knee pain. Assessed resident, voice complaints 4/10 of (L) knee/leg pain, prn Tylenol was administered, tolerated well. No facial grimacing, body relaxed at this time, no distress. Spoke with NP, with on-call doctor, aware of situation, ok to send to hospital.Record review of Resident #1's electronic health record revealed x-ray results of the left shoulder dated 1/6/26 indicated no evidence of fracture, dislocation, or other acute osseous abnormality.Record review of Resident #1's electronic health record revealed x-ray results of the left femur, right femur, left knee, right knee, left ankle, and right ankle dated 1/7/26 and indicated the following: left and right femur-bones are osteoporotic, no dislocation or fracture; left knee-moderate knee osteoarthritis is present, no acute dislocation or fracture, medial collateral ligamentous calcifications are visualized; right knee-moderate to severe knee osteoarthritis is present, no acute dislocation or fracture; left and right ankle-no dislocation or fracture, bones are osteoporotic.Record review of Resident #1's hospital record revealed CT scan of lower extremity without contrast, left, dated 1/15/26 indicated a comminuted, mildly impacted, intra-articular fracture of the distal femur.During an interview with Resident #1 on 2/4/26 at 12:10 PM, she said CNA A was applying lotion on her legs before she was pushed out of the bed. Resident #1 said she did not think CNA A pushed her on purpose, she said CNA A was not following protocol. Resident #1 said she landed on her left side, she said she was shocked when she fell. Resident #1 said she was not assessed on the floor. Resident #1 said an x-ray was done of her left leg and she was not told of the results. Resident #1 said when she was at the hospital, she had a CT scan, and the results showed her femur was cracked. She said she met with the orthopedic surgeon, but at that time surgery was not recommended. She said the orthopedic surgeon put on an immobilizer cast to her left leg. Resident #1 said there needed to be 2 people when turning her. Resident #1 said she complained for 3 days of left leg pain. Resident #1 said before the fall, sometimes there would be 2 staff assisting her with bed baths and incontinent care, she said the number of staff assisting her would alternate between 1 staff member to 2 staff members.During an interview with the family member on 2/4 at 10:44 am, she said no one informed her of the fall for Resident #1. The family member said she asked the facility to take Resident #1 to the hospital because she was in pain. The family member said Resident #1 went to the hospital on January 15th, 2026. She said Resident #1 got a CT scan and the scan showed a fracture to her left femur.During an interview with CNA A on 2/4/26 at 12:40 PM, she said she finished giving Resident #1 a bed bath and proceeded to lay Resident #1 on her side so she could put on her adult brief. CNA A said Resident #1 laid on her right side as she was holding onto the mobility bar. CNA A said she asked Resident #1 three times if she had a firm grasp on the mobility bar and Resident #1 told her yes. CNA A said as soon as she put the brief under Resident #1, she rolled off the bed. CNA A said Resident #1 landed on her left side in a seated position. CNA A said when she came around to check Resident #1, she said Resident #1 was in shock and let out a sound like ugh, Resident #1 did not say anything. CNA A said she covered Resident #1 with a sheet because she was naked and ran down the hall to call for help. CNA A said RN A, LVN C, and CNA B came back to the room. CNA A said LVN C assessed Resident #1. She said LVN C checked her head, her back, and did movement with her legs. CNA A said she and RN A put her on the Hoyer pad and used the Hoyer lift to put her back in bed.During an interview with LVN C on 2/5/26 at 10:23 AM, she said on 1/6/26 when she came to Resident #1's room, Resident #1 was semi on her back on her left side, and her legs were extended out. LVN C asked Resident #1 if she was in pain, Resident #1 told her no. LVN C said she did ROM on both arms and both legs, she checked her head and did vitals. She said she did not document because this information was passed on to RN A and Resident #1 was not her resident. LVN C said she left the room to go back to her hall and came back to Resident #1's room to assist with the Hoyer lift. LVN C said she and RN A were able to slide the Hoyer pad underneath Resident #1. She said she, RN A, CNA A, and CNA B helped Resident #1 back to bed using the Hoyer lift. LVN C did not recall Resident #1 voicing any pain while getting transferred back to her bed.During an interview with RN A, he said when he got to Resident #1's room, Resident #1 was in a seated position. RN A said he checked Resident #1's vital signs and checked her head and body. RN A said Resident #1 was complaining of shoulder pain. RN A said he notified Resident #1's family member, the doctor and the DON. RN A said there were orders for an x-ray to Resident #1's shoulder.During an interview with LVN B on 2/4/26 at 4:46 PM, she said from what she could recall, it was reported to her that Resident #1 had fallen. LVN B said she was asked to follow up for pain on 1/7/26 for Resident #1's lower extremity, she could not recall which side. She said she asked Resident #1 if she was in pain, and Resident #1 told her yes. LVN B said Resident #1's x-ray results came back on a different shift. LVN B said Resident #1's pain to her lower extremity was what prompted the orders for the x-ray.During an interview with the DOR on 2/4/26 at 2:24 PM, he said before Resident #1 had her fall she was maximum assist x2 for transfers and moderate assist for bed mobility. The DOR said now Resident #1 is dependent for bed mobility and required 2-person assist.During an interview with the NP on 2/5/26 at 9:52 AM, she said on 1/6/26 there was an order for x-ray of Resident #1's shoulder put in and that x-ray came back negative. The NP said it was communicated to her on the morning of 1/7/26 that Resident #1 had a fall and pain in her leg. The NP said she ordered x-rays to lower extremities, and those x-rays came back negative.During an interview with the DON on 2/5/26 at 1:00 PM, she said Resident #1 initially complained of shoulder pain, then on the second day she complained of pain to bilateral hips, knees, and legs. The DON said after the fall, Resident #1 was medicated with Tylenol, and it was effective. The DON said Resident #1's baseline is alert and oriented. The DON said Resident #1 was feeding off of her roommate and constantly asking for pain meds at the same time her roommate asked for pain meds. The DON said the NP was at the facility once a week and there were no orders to send Resident #1 to the hospital.During an interview with the Administrator on 2/5/26 at 3:30 PM, she said the expectation of staff for residents having pain was to make sure they are managing the resident's pain, medicating the resident, and if the pain was not manageable, contact the doctor. The Administrator said when she spoke to the doctor, the doctor told her if there was no indication of a fracture then they managed the pain. The Administrator said on 1/15/26, the daughter found out Resident #1 fell and insisted she go to the hospital. Resident #1 did not want to go to the hospital because the pain was manageable. Resident #1 was sent to the hospital on 1/15/26. The Administrator said Resident #1 is now a 2-person assist, and staff had done a skill check on peri care and bed baths.Record review of the facility's policy titled Fall Management System, dated 04/2025 read in part . It is the policy of this facility to provide each resident with appropriate assessment and interventions to prevent falls and to minimize complications if a fall occurs .

Based on observation, interview, and record review the facility failed to ensure residents had the right to a safe, clean, comfortable, and homelike environment including but not limited to receiving treatment and supports for daily living safely for 4 of 6 resident rooms in the 100 hall (Resident #2, Resident #3, Resident #4 and Resident #5) reviewed for environment. The facility failed to ensure Resident #2, Resident #3, Resident #4 and Resident #5's rooms were thoroughly cleaned and sanitized. This deficient practice could place residents at risk of living in an unclean and unsanitary environment which could lead to a decreased quality of life.Findings included:Resident #2Record review of Resident #2's face sheet dated 2/26/26 indicated he was a [AGE] year-old male with an original admission date of 6/24/13 and readmitted to the facility on [DATE]. His diagnoses included: acute hematogenous osteomyelitis (an infection that occurs in the bone) of left ankle and foot, acquired absence of other right toe, acquired absence of other left toe, Type 2 diabetes mellitus (the body cannot use insulin correctly and sugar builds up in the blood) with diabetic neuropathy (nerve damage cause by long-term high blood sugar), muscle weakness, and cognitive communication deficit.Record review of Resident #2's most recent quarterly MDS dated [DATE] revealed he had a BIMS score of 6 which indicated cognition was severely impaired. Resident #2 had a range of motion impairment on both sides of his lower extremities and used a wheelchair for mobility. Resident #2 required substantial/maximal assistance for toileting, shower/bath, upper body dressing, lower body dressing. Resident #2 was frequently incontinent of bladder and bowel. Resident #3Record review of Resident #3's face sheet dated 2/26/26 indicated he was an [AGE] year-old male with an admission date of 1/13/26. His diagnoses included: Alzheimer's disease (a type of dementia that affects memory, thinking and behavior), acute on chronic combined systolic and diastolic heart failure, neurocognitive disorder with Lewy bodies (a brain disorder that can lead to problems with thinking, movement, behavior, and mood), and muscle weakness.Record review of Resident #3's comprehensive MDS date 1/26/26 revealed a BIMS score of 00 indicated severe cognitive impairment. The comprehensive MDS indicated Resident #3 did not have an impairment on range of motion and he used a wheelchair for mobility. Resident #3 needed substantial/maximal assistance with shower/bathe self, partial/moderate assistance with toileting, upper body dressing, lower body dressing, and personal hygiene. Resident #3 was occasionally incontinent of bladder and bowel.Observation of Resident #2 and Resident #3's restroom on 2/26/26 at 9:09 a.m. revealed a pink latex glove on the floor beside the toilet, and a toilet seat riser with the seat covered in a brown dry substance. Resident #2 and Resident #3 were not in the room.Observation of Resident room [ROOM NUMBER] and Resident #3's restroom and interview on 2/26/26 at 11:38 a.m., revealed a pink latex glove on the floor beside the toilet and the toilet seat riser with the seat covered in a brown dry substance. Both residents were in the room and this surveyor asked if housekeeping had come in to clean the room, Resident #3 stated that someone had come in the room earlier, but he was not sure if they cleaned.Observation of Resident room [ROOM NUMBER] and Resident #3's restroom on 2/26/26 at 12:26 p.m., revealed the toilet seat riser with the seat covered in feces, the pink glove had been removed. Resident #2 and Resident #3 were not in the room. Resident #4Record review of Resident #4's face sheet dated 2/26/26 indicated he was a [AGE] year-old male who was admitted to the facility on [DATE]. His diagnoses included: toxic encephalopathy (brain dysfunction caused by toxic exposure), dementia (loss of memory, language, problem-solving, and other thinking abilities), Type 2 diabetes mellitus (the body cannot use insulin correctly and sugar builds up in the blood), polyneuropathy (the widespread damage of multiple peripheral nerves, causing symmetric numbness, tingling, burning pain, and muscle weakness typically starting in the feet and hands), and muscle weakness.Record review of Resident #4's most recent quarterly MDS dated [DATE] revealed a BIMS score of 13 indicating cognition was intact. The quarterly MDS indicated Resident #4 used a wheelchair for mobility. Resident #4 needed substantial/maximal assistance with toileting, shower/bathe, upper body dressing, lower body dressing, putting on/taking off footwear, and personal hygiene. Resident #5Record review of Resident #5's face sheet dated 2/26/26 indicated he was an [AGE] year-old male who was admitted to the facility on [DATE]. His diagnoses included: acute gastritis (a sudden onset of inflammation of the stomach lining) with bleeding, anemia (not having enough healthy red blood cells or hemoglobin to carry oxygen to the body's tissue) in chronic kidney disease, Type 2 diabetes mellitus (the body cannot use insulin correctly and sugar builds up in the blood), chronic kidney disease stage 3A, and muscle weakness.Record review of Resident #5's comprehensive MDS dated [DATE] revealed he had a BIMS score of 12 indicating cognition was moderately impaired. Resident #5's comprehensive MDS indicated he had a range of motion impairment on both sides of his lower extremities and used a wheelchair for mobility. Resident #5 needed substantial/maximal assistance with toileting, lower body dressing, and putting on/taking off footwear. Resident # 5 needed partial/moderate assistance with upper body dressing, supervision or touching assistance with shower/bathe self, personal hygiene.Observation of Resident #4 and Resident #5's room on 2/26/26 at 12:44 p.m. revealed crumbs on the floor and a white plastic spoon. In the restroom the toilet bowl had a dried brown substance and there was one pair of soiled briefs in the corner of the restroom on the floor.During an interview with a family member of Resident #5, on 2/26/26 at 12:45 p.m. she said every time she came to visit, the room was always dirty, and she would end up cleaning the room. The family member said the bed was not made and Resident #5's clothes were all over the floor. She said somedays she would come twice a day, and the room would be dirty.During an interview on 2/26/26 at 12:50 p.m. with Housekeeping Staff A, she said her responsibilities were to clean the resident's rooms and restrooms and pick up trash. Housekeeping Staff A said if a resident was discharged from the facility, she would remove the linens from the bed. Housekeeping Staff A said she was assigned part of the 400 hall and all of the 100 hall to clean. She said when she cleaned the 100 hall, she would start at the back of the hallway and move her way up the hallway. She said if a resident or family member asked to clean a room, she would stop and handle the request. Housekeeping Staff A said when trash and soiled clothing were lying around in a resident's room, it could be hazardous to the resident, and they could get an infection.During an interview with the Housekeeping Supervisor on 2/26/26 at 1:11 p.m., she said the housekeeping staff were responsible for cleaning the rooms, sanitizing tables, cleaning the toilets. She said if a resident was discharged from the facility, the housekeeping staff would clean the bed and if no residents were in the room, the housekeeping staff would open the windows to air out the room. The Housekeeping Supervisor said the housekeeping staff do not clean when food was served to the residents. The Housekeeping Supervisor said she instructed the housekeeping staff if they saw a food cart in the hallway, they were not supposed to clean. The Housekeeping Supervisor said if residents or family members request to clean the room, then the housekeeping staff will clean as soon as possible. The Housekeeping Supervisor said there were some rooms that needed to be cleaned twice a day. The Housekeeping Supervisor said there were some residents that took off their dirty briefs and left them in the restroom. She said the CNAs should be aware of their residents and let the housekeeping staff know when a resident takes off their adult brief. She said the risk to the residents when rooms were not cleaned could be an infection control issue.During an interview with the DON on 2/26/26 at 1:36 pm, she said housekeeping were responsible for cleaning resident rooms, mopping, and wiping down the tables. The DON said CNAs and housekeeping staff had a joint responsibility to remove the trash from resident rooms. The DON said adult briefs should be bagged off. She said the housekeeping staff do not clean while food was on the hall. She said if staff knew that a resident was messy, the housekeeping staff could prioritize cleaning those rooms.Record review of the Homelike Environment policy dated October 2009 read in part . Residents are provided with a safe, clean, comfortable and homelike environment . 2. The facility staff and management shall maximize, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. These characteristics include: a. cleanliness and order .

Based on interview and record review, the facility failed to ensure resident medical records were kept in accordance with accepted professional standards and practices, the facility must maintain medical records on each resident that are complete and accurately documented for one of six residents (Resident #1) reviewed for clinical records.The facility failed to ensure Resident #1's Medication Administration Record (MAR) reflected the administration of Tylenol (medication to treat pain) was accurately documented on 1/8/26.This failure could place residents at risk of not receiving the care and services needed due to inaccurate or incomplete clinical records.Findings included:Record review of Resident #1's face sheet dated 2/4/26 indicated she was a [AGE] year-old female with diagnoses of cerebral infarction (ischemic stroke caused by a blockage in brain blood vessels), displaced comminuted fracture of shaft of left femur, lack of coordination, cognitive communication deficit, reduced mobility, need for assistance with personal care, age-related osteoporosis ((a disease that causes bones to become weak and brittle), muscle weakness, other specified disorders of bone density and structure-multiple sites, and hemiplegia (complete paralysis) and hemiparesis (partial weakness) following cerebral infarction affecting left non-dominant side.Record review of Resident #1's most recent comprehensive MDS dated [DATE], revealed a BIMS score of 14 which indicated cognition was intact. Further review of the comprehensive MDS indicated Resident #1 received a scheduled pain medication regimen, PRN pain medication, and non-medication intervention for pain. Resident #1 had a pain frequency and pain effect on sleep occasionally.Record review of Resident #1's quarterly MDS dated [DATE] indicated she received a scheduled pain medication regimen, PRN pain medication, and non-medication intervention for pain. Resident #1 had a pain frequency, pain effect on sleep, and pain interference with therapy activities rarely or not at all.Record review of Resident #1's orders indicated the following:-monitor level of pain using 1- 10 scale, every shift, start date 11/4/25 and an end date of 1/19/26.-Meloxicam oral tablet 15 mg- give 1 table by mouth every 24 hours as needed for pain, start date 5/14/25 and an end date of 1/19/26.-Tylenol oral tablet 325 mg- give 2 tablet by mouth every 6 hours as needed for mild pain, start date 5/13/25 and an end date of 1/19/26.-x-ray to bilateral knees, bilateral ankles, and bilateral femur STAT for post fall, order date 1/7/26. Record review of Resident #1's progress note dated 1/6/26 at 2:57 pm input by ADON A read: during bed bath resident used mobility bar to turn and misjudged the width of the bed causing her momentum to roll off the bed before staff could stop her. She landed on the floor onto her left side. Nurse assessment completed. V/S stable. She was able to [NAME] without discomfort and assisted back to bed. She states she did not hit her head. She c/o pain to left side once in bed. Medicated for discomfort.Record review of the MAR for January 2026 indicated on 1/8/26, LVN D noted a pain level of 8 under the section labeled Nocs for Resident #1.Further review of the MAR for 1/8/26 did not show Tylenol oral tablet 325 mg (Acetaminophen) was administered to Resident #1.Record review of Resident #1's progress noted dated 1/9/26 at 12:45 a.m. input by LVN D read: resident is s/p fall-c/o pain to her knee area this shift, med x1 with Apap 325 mg as ordered- tolerated well, no other c/o voiced at this time- resident alert and oriented to verbal stimuli- will continue to monitor and f/u as needed.During an interview with LVN D on 2/19/26 at 12:39 p.m., she said she gave Resident #1 Tylenol when she reported to her a pain level of 8. LVN D said when she administered the medication, Resident #1's pain level went down and if she was not mistaken Resident #1 went to sleep. LVN D said she was sure she documented in her paper tablet the pain medication she administered and not documenting in the MAR was probably an oversight. LVN D said Resident #1 was vocal and was able to let you know if she was in any pain. LVN D said the risk of not documenting could be overmedicating the resident.During an interview with the DON on 2/20/26 at 1:53 p.m., she said her expectation of the nurses was, if medication was given to the resident, the MAR should be marked at the same time. The DON said the risk to the resident when medication is not documented in the MAR could be someone can come behind that nurse and give the same medication again.Record review of the facility's job description for Licensed Vocational Nurse dated 12/17/2021 read in part . The primary purpose of your job position is to provide primary care to specific residents under the medical direction and supervision of the residents' attending physicians or the Medical Director of the facility, with an emphasis on assessment, illness prevention and health care management. Essential duties and responsibilities: . perform administrative duties regarding assigned residents, such as completing medical forms, reports, evaluations, studies, charting .Record review of the facility's policy titled Documentation, dated 05/2007 read in part . the resident's clinical record is a concise account of treatment, care, response to care, signs, symptoms and progress of the resident's condition .

Based on observation, interviews, and record review, the facility failed to incorporate recommendations from a PASRR evaluation report into a resident's assessment, care planning, and transition of care for 1 (Resident #1) of 5 residents reviewed for PASRR services.The facility failed to submit a complete and accurate request for NFSS in the LTC online portal within 20 days after the IDT meeting .This failure could place residents who were PASRR positive at risk of not getting the PASRR services for a better quality of life and could lead to a decline in health.Record review of Resident #1's face sheet dated 12/23/25 revealed a [AGE] year-old female, admitted to the facility on [DATE]. Her diagnoses[KS1] included- contracture( a permanent shortening or tightening of the muscles, tendons, ligaments or skin, making it hard to fully move the affected body part or joint unspecified joint, cerebral palsy ( a permanent condition from early brain damage that affects movement, balance and posture causing issues like stiff muscle, poor coordination, tremors and can also impact speech, vision), unspecified, anemia (low blood count), unspecified, tachycardia( irregular heart beat that is too fast), unspecified, profound intellectual disabilities, dysphagia, oropharyngeal phase, cognitive communication deficit, hypothyroidism (not making enough hormones causing body metabolism to slow down), unspecified, constipation, unspecified, gastrostomy status ( tube inserted in stomach through a surgical procedure for feeding), muscle weakness (generalized), stiffness of joint, not elsewhere classified, muscle wasting and atrophy, not elsewhere classified, unspecified site, need for assistance with personal care, unspecified protein-calorie malnutrition. Record review of Resident #1's PASRR evaluation dated 01/07/2019 indicated Resident #1 was positive for Intellectual disability. Record review of PCSP dated 08/04/25 indicated there was a recommendation for Resident #1 to receive a prosthetic device. Record review of Resident #1's quarterly MDS assessment dated [DATE] revealed a BIMS score of 00 meaning severe cognitive impairment. Record review of Resident #1's care plan dated 09/06/25 indicated Resident #1ASRR assessment has identified, DX: profound intellectual disabilities. Specialized services will be provided to maintain the highest level of function.Intervention 08/04/2025: PASRR Annual Meeting conducted at this time. Resident # 1's Diversion Coordinator, Habilitation Coordinator, Physical Therapy, Social Worker and Registered Nurse agreed with the plan. Follow up with local authority's recommendations as indicated by resident current condition. or designee will contact the local authorities to alert them of the resident admission/Readmission Record review of Resident #1's clinical record revealed no evidence of an NFSS form. During [KS2] observation of Resident #1 on 12/23/25 at 10:30AM, Resident #1 was lying was in bed, head to toe assessment done. Resident #1 had upper and lower extremities contracture, not able to respond verbally to any questions or make any eye contact, had Gastrostomy tube and was totally dependent on ADL's[KS3] ( feeding, personal hygiene, incontinent of bowel/bladder and transfer). During an interview on 12/23/25 at 12:05PM, the social worker (SW)[KS4] , said he was not responsible for PCSP recommendations. ,During an interview on 12/23/25 at 12:12PM, the MDS coordinator ALVN, said she was not aware of Resident #1's PCSP recommendation prosthetic device and was not sent to NFSS[KS5] . She said failure to submit an NFSS as required may prevent residents from receiving services needed for their wellbeing. During an interview on 12/23/25 at 12:43PM, Physical Therapy (PT)[KS6] , said he did not recommend any devices for Resident #1 when he attended the PASRR meeting on 8/4/25. He said Resident #1 was receiving speech therapy, physical therapy and occupational therapy for 30 minutes each 3 times a day. He said he would be careful to review PCSP recommendations with PASRR positive residents[KS7] . During an interview on 12/23/25 at 3:57PM, the facility Administrator said MDS Coordinator A[KS8] was responsible for doing PASRR. She said Resident #1's PCSP was an honest mistake[KS9] . She had called and sent an email to the PASRR local office but there was no response, and she would follow up after the holidays. She said failure to submit NFSS as required may prevent residents from receiving services needed for their wellbeing. During an interview with RN on 12/23/25 at 4:30PM, he said Resident #1's NFSS was not submitted because at the time of the meeting, he was not aware of the recommendation of a prosthetic device for Resident #1. He said the local PASRR office new workers checked the wrong recommendation. He said failure to submit an NFSS as required may prevent residents from receiving services needed for their wellbeing. Record review of facility Policy on PASRR dated 07/2007 reflected: It is the policy of this facility to ensure that each resident is properly screened using the PASRR specified by the State.PURPOSE: This facility shall not admit on or after January 1, 1989 any new residents with: I. Mental illness as defined in paragraph (m)(2)(i), 42 CFR 483.20 of the SOM unless the State mental health authority has determined , based on an independent physical and mental evaluation performed by a person or entity other than the State mental health authority prior to admission: A. That because of the physical and mental condition of the individual, the individual requires the level of services provided by a nursing facility and;B. If the individual requires such level of services, whether the individual requires specialized services for mental retardation[KS10] . 2. Mental retardation, as defined in paragraph (m)(2)(ii), 42 CFR 483.20 of the SOM unless the State mental retardation or developmental disability authority has determined prior to admission: A. That because of the physical and mental condition of the individual, the individual requires the level of services provided by a nursing facility, and;B. If the individual requires such level of services, whether the individual requires specialized services for mental retardation. PROCEDURES: 1. A PASRR shall be completed on every resident upon admission. 2. Based upon the assessment, the facility will ensure proper referral to appropriate state agencies for the provision of specialized services to residents with MI/MR. 3. Social Services shall contact the appropriate State Agency for referral of specialized care and services the residents may require. Cambridge Health & Rehab (5333)Exit: 12/23/25

Based on observations, interviews, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for food procurement. 1. The facility failed to ensure foods were dated as opened after usage. 2. The facility failed to ensure that dietary staff did not leave a disposable plastic cup to scoop the cornmeal out of the container. These failures could place residents at risk of cross-contamination and foodborne illness. Findings included: During an observation on 05/13/2025 at 08:12 AM, an initial tour of the kitchen was conducted with the dietary manager of a walk-in dry storage area in the kitchen. Observation revealed that half of a 5-gallon bag of uncooked enriched macaroni that was open and undated. Further observation revealed a plastic cup was also left in a large container of cornmeal. During an interview on 05/15/25 at 10:18 AM, [NAME] A said all items should have dates on the items when they receive it. She also said a plastic cup should never be left in the cornmeal container because it can cause cross-contamination. [NAME] A said the staff was in-serviced 2 weeks ago on cross-contamination. During an interview on 05/15/25 at 10:21 AM, the Dietary manager said all items in the kitchen should be dated. She said the risk of leaving the cup in the cornmeal was cross contamination. During an interview on 05/15/25 at 2:00 PM, the Administrator said the dietary staff should not have had a disposable cup in the cornmeal container. She said her expectations were for staff to follow the dietary policy. She said the risk of leaving the cup in the container was an infection control concern. Record review of the Record review of the Food Receiving and Storage policy, last revised on 07/2014 revealed . Foods shall be received and stored in a manner that complies with safe food handling practices. 13. Food items and snacks kept on the nursing units must be maintained as indicated below: e. e. Other opened containers must be dated and sealed or covered during storage .

Based on observations, interviews and record reviews, the facility failed to provide pharmaceutical services including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals to meet the needs of each resident for one (Resident #21) of 23 residents reviewed for pharmacy services. The facility failed to ensure MA A administered the medication Sevelamer Carbonate (a Phosphate binding medication to control Phosphorus levels for hemodialysis patients) with a meal to Resident #21 as ordered by the resident's physician. This failure to provide medications as ordered could lead to residents not receiving the care they require to reach their highest physical, mental and emotional wellbeing. Findings included: Review of Resident #21's admission face sheet undated reflected he was a [AGE] year-old male who was admitted to the facility on [DATE] and readmitted [DATE]. His diagnoses included end stage renal disease, and type 2 diabetes mellitus with diabetic chronic kidney disease. Record review of Resident # 21's quarter MDS (a standardized assessment tool used to evaluate a residents functional, medical, psychosocial and cognitive status) dated 03/18/2025 indicated a BIMS ( a brief cognitive screening that focuses on orientation and short-term word recall) score of 6 reflecting moderate cognitive impairment. The MDS indicated that Resident # 21 required set up or clean up assistance with eating. Record review of Resident #21's Care Plan, date initiated 03/10/2025, reflected the following: Focus: Resident needed hemodialysis related to renal failure Goal: Resident would have no signs or symptoms of complications from dialysis. Intervention: Monitor labs and report to doctor as needed. Record review of Resident #21's Physician's Order Summary Report active orders dated as of 05/14/2025 reflected the following orders: Sevelamer Carbonate Oral Tablet 800 MG Give 2 tablets by mouth three times a day for renal. Take with meals order dated 03/09/2025. Record review of Resident #21's MAR dated 05/01/2025-05/31/2025 revealed Sevelamer Carbonate Oral Tablet 800 MG Give 2 tablets by mouth three times a day for renal. Take with meals order dated 03/09/2025. The medication was documented as administered on 05/13/2025 at 4:00PM by MA A. An observation and interview on 05/13/2025 at 3:11 PM revealed MA A removed two tablets from the Sevelamer Carbonate medication container. Review of the medication container at this time revealed Take With Meal. As the observation continued Resident #21 was awake and alert sitting on the side of his bed. No food or snacks were observed in the resident's room. Resident #21 was administered the Sevelamer Carbonate by MA A. In an interview at that time, Resident #21 stated he ate his lunch a long time ago and dinner would not be until about 5:00 or 5:30 PM. During the medication administration, the MA did not ask Resident #21 if he had any snacks or needed something to eat. In an interview on 05/14/2025 at 4:45 PM, the facility Pharmacist stated Sevelamer Carbonate was a phosphorus binding medication. The Pharmacist stated the food was needed for the absorption of the medication. The Pharmacist stated taking the medication without food had no major risk except possibly the phosphorus level could go high . He stated the medication was often for short term use. The pharmacist stated this was not a life sustaining drug, and it was not a drug that needed to be administered at the same time. In an interview on 05/14/2025 at 5:03 PM, the HD Nurse stated Sevelamer Carbonate was a Phosphorus binder to help keep the patient's phosphorus levels within normal limits. The HD Nurse stated this medication was not a life sustaining medication. The nurse stated the medication did not need to be given at the same time daily. The risk of not giving the medication with food was absorption of the medication because food was needed for the proper absorption of the medication resulting in high phosphorus levels. In an interview on 05/14/2025 at 5:11PM, the NP stated this medication was given to help control phosphorus for hemodialysis residents. The NP stated the risk was subjective due to the levels being controlled by diet also. The food was to be given with the medication because it was needed for the absorption of the medication. In an interview on 05/15/2025 at 11:10 AM, the DON stated the medication was a phosphorus binder. The risk of not giving with food was poor absorption of the medication. When special instructions for medication administration were needed, the DON stated she expected the physician orders and medication container to be read. The DON stated she would educate on medication administration. In a phone interview on 05/15/2025 at 11:30 AM, MA A stated that she did remember she gave the medication to Resident #21. MA A stated he usually had crackers in the room. MA A stated she did not remember seeing any snacks in the room. MA A stated she did not ask the resident if he had any snacks or needed something to eat with the medication. MA A stated she normally read the medication container so she knew any special instruction for medications. MA A stated it was not done this time because she was being observed. MA A stated she would take more time to read containers before giving a medication. MA A stated she would make sure food was available or provided if needed. In an interview on 05/15/2025 at 11:59 AM, the Administrator stated she was notified of the medication error. The Administrator stated her expectations were the medications was administered following the resident rights. The Administrator stated the risk of not administering with food was absorption because the medication needed food to absorb to work. She stated to prevent this again, medication administration would be monitored, and they would in-service staff on medication administration. Record review of the facility's policy titled Administering Medications revised dated April 2020 read in part .Policy Statement Medications shall be administered in a safe and timely manner, and as prescribed .2. Medications must be administered in accordance with the orders, including yny required time frame .

Based on observation , interview and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for one of three residents (Resident #1) reviewed for infection control. Unknown A and Unknown B failed to use proper PPE for Enhanced Barrier resident (Resident #1). The facility failed to ensure Unknown A and Unknown B wore appropriate PPE when entering Resident #1s' room on 03/13/2025 who was on Enhanced Barrier precautions while they performed direct care. These failures could place residents at risk for spread of infection. Findings included: Record review Resident #1's face sheet, dated 02/26/25, reflected an [AGE] year-old male who was admitted to the facility on [DATE]. Resident #1 had diagnoses which included Anoxic Brain Damage (Brain damage caused by complete lack of oxygen supply to the brain, leading to cell death and potential neurological impairments), Respiratory Failure (A condition where the lungs are unable to adequately perform their primary function of gas exchange, resulting in either insufficient oxygen in the blood (hypoxemia) or excessive carbon dioxide levels (hypercapnia), Type 2 Diabetes Mellitus Diabetic Hyperglycemia (A Condition where blood sugar (glucose) levels are persistently elevated), Alzheimer's Disease (A progressive brain disorder that primarily causes memory loss and cognitive decline, eventually affecting a person's ability to perform everyday tasks), Chronic Kidney Disease Stage 3 (Moderate kidney damage, meaning your kidneys are less able to filter waste and fluid from your blood), Tracheostomy Status (A person's current situation regarding having a tracheostomy), Persistent Vegetative State (A neurological condition where a person is awake but lacks awareness of a self or surrounding, with no purposeful behavior or interaction), Unspecified Dementia (A dementia diagnosis where the specific type and severity are not determined, and there are no co-occurring behavioral, psychotic, mood or anxiety symptoms), Aphasia (A language disorder that affects a person's ability to communicate). Record review of Resident #1's care plan, dated 11/06/24, reflected a focus area that Resident #1 had a tracheostomy related to acute respiratory failure Interventions: .Use Enhanced Barrier Precautions. Record review of Resident 1's quarterly MDS assessment, dated 02/12/25, reflected a BIMS score of 0, which indicated cognition was severely impaired. Section O- Respiratory Treatment- E1. Tracheostomy Care. Record review of screenshots of Resident #1's video monitoring dated 03/13/25 with a time stamps of 7:01 AM revealed Unknown A and Unknown B providing direct care to Resident #1. Unknown A did not have on a mask or gown. Unknown B did not have on a gown. During an observation on 04/03/25 at 11:28am of Resident #1's room door revealed an Enhanced Barrier Precautions signage that stated, Everyone Must: Clean their hands, including before entering and when leaving the room. Providers and Staff must also: Wear gloves and a gown for the following High Contact Resident Care Activities: Dressing, Bathing/Showering, Transferring, Changing Linen, Providing Hygiene, Changing briefs or assisting with toileting, Device care or use: Central line, urinary catheter, feeding tube, tracheostomy. Wound care: any skin opening requiring a dressing. Do not wear the same gown and gloves for the care of more than one person. During an interview on 4/03/25 at 11:32 AM, the DON stated when staff are working with a resident with contact isolation they are to DONN and DOFF PPE. She stated there was an Enhanced Barrier signage outside of the door and the PPE carrier was hanging on the doors of residents that are on Enhanced Barriers. Surveyor showed DON pictures taken from video monitoring of Resident #1's room in which staff did not have on gowns or mask while providing direct care to Resident #1 who was on Enhanced Barriers Precautions. She stated she was unsure of who the exact staff were in the pictures. She stated the staff should always have on PPE whenever providing direct care to a resident that has Enhanced barrier signage outside of the door. She stated the risk of not wearing proper PPE while providing direct care to resident who are on Enhanced Barrier Precautions could be a risk for the staff and the resident for spreading organisms. She stated she was not aware that the staff were providing care without PPE. During an interview on 04/03/25 at 11:43 AM, the ADON/IP who stated a staff member should never provide direct contrat without PPE to a resident that was on contact isolation. She stated she was not aware that staff were providing care to the resident without the proper PPE. She stated the risk of not having full PPE on while providing are to a resident that has Enhanced Barriers was transferring infection to others and cross contamination. Record review of the facility's policy on Infection Control, revised date of 03/2024, reflected, It is the policy of this facility to implement infection control measures to prevent the spread of communicable diseases and conditions . Procedures: 1. Standard Precautions are infection prevention practices that apply to the care of all residents, regardless of suspected or confirmed infection or colonization status. They are based on the principle that all blood, body fluids, secretions, and excretions (except sweat) may contain transmissible infectious agents. Standard Precautions include: a. Proper selection and use of PPE such as gowns, gloves, facemasks, respirators, and eye protection i. Use and type of PPE is based on the predicted staff interaction with residents and the potential for exposure to blood, body fluids, or pathogens (e.g., gloves are worn when contact with blood, body fluids, mucous membranes, non-intact skin, or potentially contaminated surfaces or equipment are anticipated). .3. Enhanced Barrier Protection (EBP): used in conjunction with standard precautions and expand the use of PPE through the use of gown and gloves during high-contact resident care activities that provide opportunities from indirect transfer of MDROs to staff hands and clothing then indirectly transferred to residents or from resident-to-resident. a. PPE: The use of gown and gloves for high-contact resident care activities is indicated, when Contact Precautions do not otherwise apply, for nursing home residents with: b. Examples of high-contact resident care activities requiring gown and glove use for Enhanced Barrier Precautions include: i. Dressing ii. Bathing/showering iii. Transferring iv. Providing hygiene v. Changing linens vi. Changing briefs or assisting with toileting vii. Device care or use: central vascular line (including hemodialysis catheters), indwelling urinary catheter, feeding tube, tracheostomy/ventilator.

Based on interview, and record review the facility failed to provide care consistent with professional standards of practice promoting healing and prevent new pressure ulcers from developing for 1(Resident#1) of 5 residents reviewed for pressure ulcers. The facility failed to ensure that no new pressure wounds were acquired at the facility. Resident #1 acquired a Stage 3 sacral wound. The facility failed to implement new interventions when the sacral wound was not healing, increasing in size and requiring debridement for necrotic tissue. The facility failed to ensure offloading and timely incontinent care was provided for Resident#1's sacral wound . This failure place residents at risk for wounds, infection, and pain. Findings Included: Record review of Resident #1's face sheet revealed a [AGE] year-old male that was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses of spinal stenosis (a condition in which the space inside the bones of the spine get too small), dysphagia(difficulty swallowing foods or liquids), Type 2 Diabetes (a long-term condition in which the body trouble controlling blood sugar), congestive heart failure (a chronic condition in which the heart does not pump blood as well as it should) and chronic kidney failure (a chronic condition that causes permanent damage to the kidneys over time. Resident was bedfast. Record review of Resident #1's discharge summary from local hospital #1 revealed: Resident #1 was discharged from a local hospital and admitted to the facility on [DATE]. It was noted that Resident #1 had red area to groin or buttock both lower extremities. Record review of Resident #1's Care plan dated 4/1/2024 reflected he had bowel and bladder incontinence and at risk for skin breakdown. Goal: Resident #1 will remain free from skin breakdown due to incontinence and brief use through the review date. Interventions: Check as required for incontinence. Wash, rinse and dry perineum. Change clothes PRN after incontinence episodes. Record review of care plan initiated on 9/18/2024 reflected Resident #1 had a potential for pressure ulcer development to buttock r/t decreased mobility, weakness, diabetes, and neuropathy. Goal: Resident #1's skin will remain intact, free from redness, blister, or discoloration. Intervention: Administer treatments as ordered and monitor for effectiveness and weekly head to toe assessment. It did not address the sacral wound. Record review of care plan dated 11/24/2024 revealed Resident #1 had actual impairment to skin integrity r/t contact dermatitis. Goal: Resident #1 will not have a re-hospitalization within 30-days. Intervention: Monitor/document location, size and treatment of skin injury, report abnormalities, failure to heal, sign and symptoms, maceration etc. to MD. Provide wound care to site daily per WCD recommendations . Use enhanced barrier precautions, and weekly WCD consult with recommendations. It did not address the sacral wound. Record review of quarterly MDS dated [DATE] revealed: Section C500- Brief Interview of Mental Status was scored as 08, which meant moderately impaired cognition. Section GG0115- Functional Limitation in Range of Motion was coded as 2 representing upper and lower extremity impairment. Section GG0130- Functional Abilities revealed: Toileting hygiene, shower/bathe self, upper body dressing, lower body dressing and personal hygiene was coded as 2 (Substantial/maximum assistance). Section GG0170 revealed roll left and right, sit to lying, lying to sitting on side of bed, chair/bed-to-chair transfer, toilet transfer and tub/shower transfer was coded as (01)- which presented dependent- helper does all the effort. Section H0300 revealed Urinary continence was coded 3 for always incontinent (no episodes of continent voiding). Section H0400 revealed Bowel continence was codeds 3 for always incontinent (no episodes of continent bowel movements). Section I- Active Diagnosis listed 1- (need for personal care assistance) Section M- Skin condition revealed Risk of pressure ulcer coded 1 was entered representing (Yes). M1040- Other uIcers, wounds and skin problems such as diabetic foot ulcers, open lesions, surgical wounds, MASD (incontinent associated dermatitis, perspiration drainage) Z. was coded which meant none of the above. Section N- Medications G. Diuretic was marked and code indicated Resident #1 was taking and there was an indication for the medication. Record review of Resident #1's MDS revealed that there was no significant change MDS completed although October 14th the WCN weekly assessment stated skin warm and dry to touch with appropriate color. Resident noted to have excoriation to the groin. Treatment initiated. No new skin breakdown noted. The sacral wound was not mentioned. Record review of Resident #1's Discharge return not anticipated MDS dated [DATE] did not mention wounds to the sacral area nor the MASD to the groin. It said that it was in progress. Observations on the following dates revealed Resident #1 was found in the supine position without (wedges/pillows) for offloading the sacral wound: 12/11/2024- 11:55am 12/11/2024 -2:23pm 12/12/2024 - 11:21am 12/13/2024 - 10:09am Record review of Resident #1's Braden Scale for Predicting pressure ulcers assessments revealed the following: 4/29/2024 - Quarterly assessment was Moderate Risk scored was 13. #1-Sensory perception: Very limited: Responds only to painful stimuli. Cannot communicate discomfort except by moaning or restlessness or has a sensory impairment which limits the ability to feel pain or discomfort over 1/2 of body. #2-Moisture: Very moist, but not always. Linen must be changed at least once a shift. #3-Activity: Degree of physical activity: Chairfast: ability to walk severely limited or non-existent. #4-Mobility: Ability to change and control body position: Very limited: makes occasional slight changes in body or extremely position but unable to make frequent or significant changes independently. #5-Nutrition: Usual food intake pattern: Probably inadequate: Rarely eats a complete meal and generally eats only about 1/2 of any food offered. Protein intake include includes only 3 servings of meat or dairy products per day. Occasionally will take a dietary supplement. OR receives less than optimum amount of liquid diet or tube feeding. #6-Friction & Shear: Potential problem: Moves feebly or requires minimum assistance. During a move skin probably slides to some extent against sheets, chair, restraints or other devices. Maintain relatively good position in chair or bed most of the time but occasionally slides down. Signed by LVN A 7/29/2024- Resident #1 was at Moderate Risk the score was 14. Signed by RN A 9/7/2024- Resident #1 was at High Risk the score was 12. It was signed by LVN A 12/13/2024- Resident #1 was at High Risk the score was 12. Resident #1's activity changed from chairfast to bedfast (confined to the bed). It was signed by DON. 12/17/2024- Very High-Risk score the score was 8. #6 moisture changed from very moist to constantly moist- Skin is kept moist almost constantly by perspiration, urine, etc. Dampness is detected every time patient is moved or turned. Signed by LVN B Record review of progress note and weekly assessment for Resident #1 revealed: 10/14/2024 - Resident noted with excoriation to groin region. Treatment initiated pending wound care physician evaluation. No new skin breakdown observed. Signed by LVN B 10/18/2024- Site #1 Sacrum Etiology: Trauma/Injury Measurements 3.5cm x1cm x 0.1 cm Procedure: Autolytic debridement Description: Light serous exudate 100% granulation Treatment: Cleanse area with NS or wound cleanser, pat dry, apply zinc ointment cover with bordered dressing daily. Risk factor: Immobility Interventions: 1. Offloading wound while in bed as needed /tolerated 2. Repositioning resident as needed/tolerated 3. RD to follow Signed by LVN B 10/22/2024- Site #1 Sacrum Measurements 3 cm x1 cm x 0.1 cm Procedure: Autolytic debridement Description: Light serous exudate 100% granulation Treatment: Cleanse area with NS or wound cleanser, pat dry, apply zinc ointment cover with bordered dressing daily. Risk factor: Immobility Interventions: 1. Offloading wound while in bed as needed /tolerated 2. Repositioning resident as needed/tolerated 3. RD to follow Signed by LVN B 11/1/2024 - Site #1 Sacrum Measurements 2 cm x 1 cm x 0.1 cm Procedure: Autolytic debridement Description: Light serous exudate 100% granulation Treatment: Cleanse area with NS or wound cleanser, pat dry, apply zinc ointment cover with bordered dressing daily. Risk factor: Immobility Interventions: 1. Offloading wound while in bed as needed /tolerated 2. Repositioning resident as needed/tolerated 3. RD to follow Signed by LVN B 11/12/2024- Site #1 Sacrum Measurements 2 cm x 1 cm x 0.1 cm Procedure: Surgical excisional debridement Description: Light serous exudate 100% granulation Treatment: Cleanse area with NS or wound cleanser, pat dry, apply zinc ointment cover with bordered dressing daily. Risk factor: Immobility Interventions: 1. Offloading wound while in bed as needed /tolerated 2. Repositioning resident as needed/tolerated 3. RD to follow Signed by LVN B 11/22/2024 - Site #1 Sacrum Measurements 3 cm x 2 cm x 0.1 cm Procedure: Surgical excisional debridement (11/12/2024) Description: Light serous exudate 100% granulation Treatment: Cleanse area with NS or wound cleanser, pat dry, apply zinc ointment cover with bordered dressing daily. Progress: Not at goal MASD to groin region treat with house barrier cream every brief change Risk factor: Immobility Interventions: 1. Offloading wound while in bed as needed /tolerated 2. Repositioning resident as needed/tolerated 3. RD to follow Signed by LVN B 11/28/2024- Site #1 Sacrum Measurements 5 cm x 5 cm x 0.1 cm Procedure: Surgical excisional debridement (11/22/2024) Description: Light serous exudate 100% granulation Treatment: Cleanse area with NS or wound cleanser, pat dry, apply zinc ointment cover with bordered dressing daily. Progress: Not at goal MASD to groin region treat with house barrier cream every brief change. Risk factor: Immobility Interventions: 1. Offloading wound while in bed as needed /tolerated 2. Repositioning resident as needed/tolerated 3. RD to follow Signed by LVN B Record review of Resident #1's Skin IDT dated 12/11/2024 at 12:50pm, revealed Resident #1 was readmitted to facility following a transfer to the hospital due to altered mental status (diagnosed with UTI) . Resident #1 hospitalization was from 12/5-12/10/2024. Resident#1 has stage 2 wound to the sacrum and MASD to groin region. Prior orders from wound care physician include the application of zinc ointment and daily border dressing changes. These orders are being continued, and wound care physician scheduled to re-evaluate on tomorrow 12/12/2024. Care remained ongoing and compliant with prescribed treatment plan. Record review of Resident #1's Wound Care Doctor A assessments: 10/15/2024- Chief complaint -Wound on sacrum Etiology: Trauma/Injury Wound size: 3.5 x 1 x 0.1 cm Treatment plan: Zinc ointment apply once daily for 30 days 2nd dressing: Gauze Island with border apply once daily for 30 days. 10/22/2024- Chief complaint wound on sacrum. Wound size: 3 x1 x 0.1 cm Treatment plan: Zinc ointment apply once daily for 23 days 2nd dressing: Gauze Island with border apply once daily for 23 days. 10/29/2024- Chief complaint: Wound on sacrum Size 2 x 1 x not measurable due to presence of tissue overgrowth Treatment plan: Zinc ointment apply once daily for 16 days. 2nd dressing: Gauze island with border apply once daily for 16 days. Debridement History: The most recent debridement of this wound was an excisional debridement performed on 10/25/2024. 11/5/2024- Sacrum wound size: 2x 0.3 x 0.1 cm Treatment plan: Zinc ointment apply once daily for 9 days. 2nd dressing: Gauze island with border apply once daily for 9 days. Debridement History: The most recent debridement of this wound was an excisional debridement performed on 10/25/2024. 11/12/2024- Sacrum wound size 1.5 x 0.3 x 0.1 cm Treatment plan: Zinc ointment apply once daily for 30 days. 2nd dressing: Gauze Island with border apply once daily for 13 days. Site 1: Surgical excisional debridement procedure Indication for procedure: Necrotic tissue and establish the margins of viable tissue. 11/19/2024- Sacrum wound: 3 x 2 x 0.1 cm Expanded evaluation performed: The progress of this wound and the context surrounding the progress were considered in greater detail today. Reviewed offloading surfaces and discussed surfaces care plan. Considered patient behavior as factor that is complicating wound healing and discussed further with staff and/or family. Discussed wound healing trajectory and expectations with patient and/or family. Treatment plan: Zinc ointment apply once daily for 23 days. 2nd dressing: Gauze Island with border apply once daily for 23 days. Debridement History: The most recent debridement of this wound was an excisional debridement performed on 11/12/2024. 11/26/2024- Sacrum wound size: 5 x 5 x 0.1 Granulation tissue: 60% surface area: 25.00cm Cluster wound: Open ulceration area of 15.00 cm Expanded evaluation performed: The progress of this wound and the context surrounding the progress were considered in greater detail today. Patient not following repositioning or offloading recommendations and counseling provided. Considered patient behavior as factor that is complicating wound healing and discussed further with staff and/or family. Discussed wound healing trajectory and expectations with patient and/or family. Treatment plan: Zinc ointment apply once daily for 16 days. 2nd dressing: Gauze Island with border apply once daily for 16 days. 12/3/2024- Sacrum wound size: 4 x 4x 0.1 cm surface area: 16.00 cm slough: 20%, granulation tissue 80% Wound progress: Not at goal Duration: 50 days Treatment plan: Zinc ointment apply once daily for 9 days. 2nd dressing: Gauze Island with border apply once daily for 9 days. Site #1 Surgical Excisional Debridement Procedure Indication: Necrotic tissue and establish the margins of viable tissue. PROCEDURE NOTE: The wound was cleansed with normal saline and anesthesia was achieved using topical benzocaine. Then with clean surgical technique, 15 blade was used to surgically excise 3.2cm' of devitalized tissue including slough, biofilm and non-viable subcutaneous level tissues were removed at a depth of 0.1 cm and healthy bleeding tissue was observed. As a result of this procedure, the nonviable tissue in the wound bed decreased from 20 percent to O percent. Hemostasis was achieved and a clean dressing was applied. Post-operative recommendations and updates to the plan of care are documented in the Assessment and Plan section below. Site 2-Unstagebale DTI of the left heel undetermined thickness wound size 2 x 2 x not measurable offloading and boot ordered. 12/12/2024 Chief complaint: Wound on sacrum; right medial thigh; left heel; scrotum. Wound size 8 x 8 x 0.1 Surface: 64.00 cm Slough: 20% ADDITIONAL WOUND DETAIL readmission from hospital DRESSING TREATMENT PLAN Primary Dressing(s) Alginate calcium apply once daily for 30 days Secondary Dressing(s) Gauze island w/ border apply once daily for 30 days PLAN OF CARE REVIEWED AND ADDRESSED Recommendations: Off-Load Wound; Reposition per facility protocol; Turn side to side in bed every 1-2 hours Site #1- Surgical excisional debridement procedure Indication: Remove necrotic tissue and establish margins of viable skin. PROCEDURE NOTE The wound was cleansed with normal saline and anesthesia was achieved using topical benzocaine. Then with clean surgical technique, 15 blade was used to surgically excise 12.8cm2 of devitalized tissue Including slough, biofilm and non-viable subcutaneous level tissues were removed al a depth of 0.1 cm and heallhy healthy bleeding tissue was observed. As a result of this procedure, the nonviable tissue in the wound bed decreased from 20 percenl percent to O percent. Homeostasis was achieved and a clean dressing was applied. Post-operative recommendations and updates to the pla11 of care are documented in the Assessment and Plan section below. Record review of Resident #1's local hospital #2 record revealed: Principal problem upon admission on 12/5/2024 was altered mental status. Assessment and Plan: Acute toxic metabolic encephalopathy -multifactorial in the setting of an acute UTI, complicated UTI, E-coli UTI General Information: Resident #1 was confused and lethargic. Wound care assessment on 12/6/2024: Sacral stage 3 pressure injury wound- size L 6.0cm x W 6.0cm x D 0.1cm - no undermining - no tunneling/induration - Wound bed is full thickness with some pink and red non granular tissue. The area is denuded most probably from incontinence - edges well defined -small to moderate serosanguinous drainage - no odor - Peri wound redness noted. Left heel DTPI wound- size L 3.0cm x W 3.0cm x D 0cm - no undermining - no tunneling/induration -Wound with purple/ maroon non blanchable intact skin - edges well defined -No drainage - no odor - Peri wound skin is intact Location: Penis, scrotum, inner thighs, groin, posterior thighs and peri area - Type: MASD/ IAD (Moisture Associated Skin Damage/ Incontinence Associated Skin Damage) Appearance: Bright red erythematous rash and inflammation with denuded skin due to: moisture trapping in skin folds and fecal/ urine incontinence. Posterior thighs are full thickness which I will recommend Zinc paste. Exudate: Clear weeping skin due to inflammation, edema, and skin erosions. Current Pressure Support Surfaces: Bed: LAL mattress; microclimate pad; glide sheet with pillows or wedges and Z flex boots. Mobility: Bed bound. Recommendations: Sacrum and left heel wounds- Cleanse with Vashe (Ref # 108824) and pat dry with gauze. Apply Cavilon skin barrier to the peri wound skin, apply Polymem (Ref# 7114) to the wound base and cover with silicone foam dressing every other day and as needed. 1. Clean penis, scrotum, inner thighs, groin and peri area with Coloplast no rinse wash cloths (Ref# 119680) and warm water 2. Pat dry with towel 3. Apply Cavilon advanced skin barrier twice a week and as needed. Goal/Treatment Plan: 1. Dressing Changes as ordered or PRN if soiled. 2. Using wedges or pillow to turn and reposition the pt every 2 hours to offload pressure to wound, even when on specialty bed. 3. Encourage lowering the head of the bed below 30 degrees is tolerable. 4. Ensure patient is on pressure redistribution and microclimate control bed is order is placed. 5. Offload pressure to patient's heels by floating with pillows or by applying specialty boots. 6. Nutritional consultation for wound healing. The following supplements to aid in wound healing are recommended, unless contraindicated: - 1000 mg Vitamin C daily - 220 mg Zinc sulfate daily - Multivitamin daily - Juven 2 times per day - Accurately monitor and document patient's PO intake, so supplements can be adjusted accordingly. 7. Skin care and skin protection from moisture damage - If possible, keep diapers off patient to reduce moisture - Consider using Pure Wick/ Condom catheter for incontinence management - Apply Cavilon Advanced to perineal and perianal area 2x weekly Photos of Resident wounds were taken at the hospital. Record review of the last IDT care plan review for Resident #1 was conducted on 9/17/2024. No wounds were discussed. An interview on 12/11/2024 at 3:30pm with the Wound Care nurse (LVN B) revealed she had been employed at the facility for about 1 year. She stated she started wound care of Resident #1 after CNA reported observing a skin tear on his sacral area and MASD to groin sometime in October. She said she immediately followed up with the NP about the wounds and house barrier cream was ordered. She said she learned about skin issues from the CNA's and from wound sweeps in which she randomly looked at different residents' skin in search of wounds/tears. She stated Wound Care Doctor A came to the facility every week on Thursday and did measurements of wounds and debridement as needed. She said all documentation is put into PCC as a nursing note and weekly wound care assessments. She said she followed physician orders for treatment of wounds. She said Resident #1 sacral wound was getting better, but after returning from the hospital it looked bad. She said she did not know why there were no notes concerning the MASD because it was treated with barrier cream since it was brought to her attention in October. She said she did not know why there was not documentation of the MASD until 11/12/2024 . She is responsible for documenting wound care after it is provided. An interview on 12/11/2024 at 4:09pm with LVN A revealed he had been employed at the facility for [AGE] years. He stated he only did wound care when the wound care nurse was not there. He said Resident #1 had a wound on the sacral and MASD in the groin area, buttocks and gluteal on left and right sides. He said that resident sacral and MASD to groin wounds were worst when he came back from the hospital, and he had gotten the buttocks and gluteal tears from the hospital. He stated charge nurses rounded every 2 hours and sometimes assist with Resident #1's care due to him being a 2-person assist. He said Resident #1 wounds were not that bad. He said as the charge nurse he is responsible for making rounds and ensuring offloading and timely incontinent care is completed. An interview with RP on 12/11/2024 at 8:04 p.m, revealed her to state Resident #1 was admitted to the facility in March 2024. She stated that she usually visited him after work at least 3 to 4 days a week. She stated on 12/5/2024 while visiting the resident, he was lethargic and had slurred speech. She stated she asked about the facility having labs done. She later decided to have him sent out to a local hospital to err on the side of caution and because she was concerned about him possibly having a stroke. She said EMS was called and he was taken to the hospital. She stated after the hospital did an UA; it was determined that he had a bad UTI. She said while visiting him at the hospital, she learned about the sacral wound, and MASD on the scrotum, groin, and pressure wound on his heel. She stated that she was horrified at what she saw. She stated he did not have wounds prior to being admitted to the facility. She forwarded the photos taken at the hospital. An interview with local hospital #2's discharge planner on 12/12/2024 at 8:52 a.m. revealed her to state that Resident #1 was initially admitted to the hospital on 12/5/2024 for altered mental status. She said on 12/6/2024 photos were taken due to the severity and the number of wounds. She stated Resident #1 also had a visit in Sept. The main complaint then was he had passed out. She said they also had photos from the [DATE]th visit. She said photos were available with a public information request. An interview with the Wound care doctor on 12/12/2024 at 9:20a.m., revealed he had been providing wound care at the facility once a week for 2 years. He stated the sacral wound he was treating was a superficial wound, after returning from the hospital it was a stage 3 pressure wound. He said Resident #1 developed the stage 3 wound in the hospital. He said every time he round, there was a treatment nurse rounding with him. It is the same wound care nurse, LVN B. He said he is currently treating 13-14 residents at the facility. He said if he would have been told about scrotum and other areas, he would have treated the same as today with barrier cream. He stated every week he saw all 13-14 residents. He said every time he round, there was a treatment nurse rounding with him. It is the same wound care nurse, LVN B . He stated today he was at the facility from 6:15am until about 8:15am. He said each resident was assessed, wounds measured, and treated. He said today it took him about 2 hours to treat all residents. An interview with CNA A on 12/12/2024 at 5:07pm, she stated she worked the front of the Hall where Resident #1 resided. She said she helped to shower him on Tuesdays, Thursdays, and Saturdays. She said when someone turned Resident #1, he went back on his back. She said when they placed him in his wheelchair he cried, and so they put him back in bed, and he would only stay in a chair maybe for an hour before he was put back into bed. She could not recall the last time he was placed in a chair or wheelchair. She said Resident #1 had to be turned he could not do anything by himself. He required assistance by 2 people. She said she assisted the WCN with wound care if she needed help. She said Resident #1 had declined since admission. She stated CNAs round every 2 hours for incontinent care and re-positioning. An interview on 12/12/2024 at 5:27pm revealed CNA B had been employed at the facility for 7 years. He said he had been taking care of Resident #1 since he was admitted in March. His usually shift was day shift 6a-6pm, he said all resident briefs are changed as needed. He said they round every 2 hours to check on residents. He said he saw the sacral wound the day the lady came from local veterans' hospital to do skin assessment with the facility's wound care nurse. He could not recall the exact date. He had just given Resident #1 a shower. So, he went back to the room and showed the wound care nurse his sacral area. He said he was taught to complete peri care by: Getting supplies, wipe front to back, pad dry, wipe the bottom again when he turned to the back and pat dry. He said when he changed Resident #1 today, the wound nurse told him the new orders were to place 4x4 gauze between his thighs to prevent the skin from rubbing against the swollen scrotum. He said new orders are in PCC. He said he documented Residents ADL care immediately after he finished providing care. He said neglect is when you do not take care of the residents. For example, you refuse to change or feed them. He said he would report neglect to the Charge nurse and Executive Director. An interview with the DON on 12/13/2024 at 11:16 a.m., she stated she had been employed for about 4 months. She said sacral wounds could come from residents' co-morbidities or could be from residents' briefs needing to be changed more often because some residents get wet more than expected. She said the consequence of having a sacral wound is discomfort and pain. She stated pressure wounds could also be caused by poor nutrition, age, or co-morbidities as she stated. An interview with Clinical Resource A at 11:16 a.m., she stated when wounds were reported they would apply the initial treatment, which could be zinc, barrier cream and request a wound consult. The wound care doctor would take it from there. Sacral wounds could be the result of not being re-positioned properly, briefs not being changed as needed or co-morbidities. She said sometimes their diagnosis can prevent healing. An interview with the Executive Director on 12/13/2024 at 11:16 a.m. reflected her to state she could not recall when she first learned about Resident #1's sacral wound. She stated Resident #1's decline was the result of co-morbidities, and this could have been the reason for the skin breakdown as well. She said she was in constant communication with the physician from the local VA hospital and she was told that he would continue to decline due to his age and co-morbidities. An interview with NP on 12/16/2024 at 12:59pm, she said she had been caring for patients at the facility for a year. She is at the facility once per week normally on Wednesday mornings. She stated she had 10 residents at the facility. She said she was notified about Resident #1's sacral wound sometime in October and she made a recommendation for wound care, PT and OT consultations. She also ordered that Resident #1 wound be cleansed, pat dry apply xerofoam, cover with boarded dressing and to turn the patient every 2 hours. She said she was not aware of the MASD. She said the facility nurses were to inform her of any skin tears or anything skin related. But, she said she only saw Resident #1 concerning chronic conditions, such as his arthritis, CHF and Diabetes, not wounds. She said if she had known about the MASD she would ordered medication. She said in her professional opinion, sacral wounds are avoidable. She said if adequate offloading, re-positioning, and keeping their briefs dry would prevent skin breakdown even with co-morbidities. She said Resident #1 used to be put in the chair, but it had been about a month or so since she last observed him to be sitting up. She said although she was not at the facility all day, Resident #1 had been in bed when she saw him during the past month. An interview with Physician A on 12/17/2024 at 11:06am, he said he was not the medical director at the facility. He had been coming to the facility since 2010. He said Resident #1 he had dementia and other co-morbidities. He stated that his NP saw him once a week. He stated that his NP would be able to provide more detailed information about Resident #1 as he was in a clinic at the time of the call. He stated although Resident #1 had co-morbidities sacral wounds are absolutely avoidable with offloading, turning the patient and keeping their briefs dry. He said not changing briefs often especially for patients that are bedbound and are lying in bed all the time increases their chance for skin breakdown. He stated it only takes about 2 hours for a wound to develop. He stated for all high-risk patients with mobility issues he put in an order for skin assessments and devices as needed. Record review of Wound Care doctor A evaluations on 11/19/2024 revealed he had reviewed offloading surfaces and discussed surfaces care plan with resident and/or staff. On 11/26/2024 he noted that Resident #1 was not following repositioning or offloading recommendations and counseling provided . Record review of POC (Point of Care provided by CNA's) for Resident #1 dated [DATE] revealed: Turned and re-position (did you turn and reposition)- did not have any documentation on second shift (7p-7a) on: 11/13, 11/15, 11/18, 11/20, 11/24, 11/25, 11/27, 11/28 or 11/30/2024 Incontinent care: did not have any documentation on 11/2, 11/4, 11/5, 11/7, 11/9, 11/10, 11/13, 11/16, 11/18, 11/20, 11/24, 11/25, 11/28, or 11/29/2024. Record review of POC (Point of Care provided by CNAs) for Resident #1 dated [DATE] revealed: Turned and re-positioning was not documented on 7p-7a shifton: 12/2, 12/3, 12/12 or 12/13/2024. Incontinent care: did not have any documentation on morning shift 7a-7p on 12/1 7p-7a shift did not have any documentation on 12/2, 12/3/2024. Record review of skin and wound monitoring and management policy revised on 12/2023 revealed: It is the policy of the facility that: 1. A resident who enters the facility without pressure injury does not develop pressure injury unless the individual's clinical condition or other factors demonstrate that a developed pressure injury was unavoidable; and 2. A resident having pressure injury receives necessary treatment and services to promote healing, prevent infection and prevent new avoidable pressure injuries from developing. Pressure injury was defined as localized damage to the skin and/or underlying soft tissue usually over bony prominence or related to a medical or other device. The injury can present as intact skin or open ulcer and may be painful.

Based on interview and record review, the facility failed to ensure care plans were reviewed and revised by the interdisciplinary team after each assessment for 1 of 5 (Resident #1) residents reviewed for care plan timeliness and accuracy in that: The facility failed to ensure Resident #1's care plan accurately addressed his facility acquired sacral wound and MASD (moisture associated skin damage) to his groin. This failure could affect residents by placing them at risk of not having accurate assessments, which could compromise their plan of care. Findings included: Record review of Resident #1's face sheet revealed a [AGE] year-old male that was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses of spinal stenosis (a condition in which the space inside the bones of the spine get too small), dysphagia(difficulty swallowing foods or liquids), Type 2 Diabetes (a long-term condition in which the body trouble controlling blood sugar), congestive heart failure (a chronic condition in which the heart does not pump blood as well as it should) and chronic kidney failure (a chronic condition that causes permanent damage to the kidneys over time. Resident was bedfast. Record review of Resident #1's discharge summary from local hospital #1 revealed: Resident #1 was discharged from the hospital and admitted to the facility on [DATE]. It was noted that Resident #1 had red area to groin or buttock both lower extremities. Record review of Resident #1's Care plan dated 4/1/2024 reflected he had bowel and bladder incontinence and at risk for skin breakdown. Goal: Resident #1 will remain free from skin breakdown due to incontinence and brief use through the review date. Interventions: Check as required for incontinence. Wash, rinse and dry perineum. Change clothes PRN after incontinence episodes. Further care plan review initiated on 9/18/2024 reflected Resident #1 had a potential for pressure ulcer development to buttock r/t decreased mobility, weakness, diabetes, and neuropathy. Goal: Resident #1's skin will remain intact, free from redness, blister, or discoloration. Intervention: Administer treatments as ordered and monitor for effectiveness and weekly head to toe assessment. It did not address the sacral wound. Record review of care plan dated 11/24/2024 revealed Resident #1 had actual impairment to skin integrity r/t contact dermatitis. Goal: Resident #1 will not have a re-hospitalization within 30-days. Intervention: Monitor/document location, size and treatment of skin injury, report abnormalities, failure to heal, sign and symptoms, maceration etc. to MD. Provide wound care to site daily per WCD recommendations. Use enhanced barrier precautions, and weekly [NAME] consult with recommendations. It did not address the sacral wound. Record review of Resident #1's quarterly MDS dated [DATE] revealed: Section C500- Brief Interview of Mental Status was scored as 08, which meant moderately impaired cognition. Section GG0115- Functional Limitation in Range of Motion was coded as 2 representing upper and lower extremity impairment. Section GG0130- Functional Abilities revealed: Toileting hygiene, shower/bathe self, upper body dressing, lower body dressing and personal hygiene was coded as 2 (Substantial/maximum assistance). Section GG0170 revealed roll left and right, sit to lying, lying to sitting on side of bed, chair/bed-to-chair transfer, toilet transfer and tub/shower transfer was coded as (01)- which presented dependent- helper does all the effort. Section H0300 revealed Urinary continence was coded 3 for always incontinent (no episodes of continent voiding). Section H0400 revealed Bowel continence was codes 3 for always incontinent (no episodes of continent bowel movements). Section I- Active Diagnosis listed 1- (need for personal care assistance) Section M- Skin condition revealed Risk of pressure ulcer coded 1 was entered representing (Yes). M1040- Other uIcers, wounds and skin problems such as diabetic foot ulcers, open lesions, surgical wounds, MASD (incontinent associated dermatitis, perspiration drainage) Z. was coded which meant none of the above. Section N- Medications G. Diuretic was marked and code indicated Resident #1 was taking and here was an indication for the medication. Record review of Resident #1's Discharge return not anticipated MDS dated [DATE] did not mention wounds to the sacral area nor the MASD to the groin. It said that it was in progress. Record review of LN weekly skin evaluations for Resident #1 revealed: 10/14/2024 - Resident #1 noted with excoriation to groin region. Treatment initiated pending wound care physician evaluation. No new skin breakdown observed. Signed by LVN B 10/18/2024- Site #1 Sacrum Etiology: Trauma/Injury Measurements 3.5cm x1cm x 0.1 cm Procedure: Autolytic debridement Description: Light serous exudate 100% granulation Treatment: Cleanse area with NS or wound cleanser, pat dry, apply zinc ointment cover with bordered dressing daily. Risk factor: Immobility Interventions: 4. Offloading wound while in bed as needed /tolerated 5. Repositioning resident as needed/tolerated 6. RD to follow Signed by LVN B 10/22/2024- Site #1 Sacrum Measurements 3 cm x1 cm x 0.1 cm Procedure: Autolytic debridement Description: Light serous exudate 100% granulation Treatment: Cleanse area with NS or wound cleanser, pat dry, apply zinc ointment cover with bordered dressing daily. Risk factor: Immobility Interventions: 4. Offloading wound while in bed as needed /tolerated 5. Repositioning resident as needed/tolerated 6. RD to follow Signed by LVN B 11/1/2024 - Site #1 Sacrum Measurements 2 cm x 1 cm x 0.1 cm Procedure: Autolytic debridement Description: Light serous exudate 100% granulation Treatment: Cleanse area with NS or wound cleanser, pat dry, apply zinc ointment cover with bordered dressing daily. Risk factor: Immobility Interventions: 4. Offloading wound while in bed as needed /tolerated 5. Repositioning resident as needed/tolerated 6. RD to follow Signed by LVN B 11/12/2024- Site #1 Sacrum Measurements 2 cm x 1 cm x 0.1 cm Procedure: Surgical excisional debridement Description: Light serous exudate 100% granulation Treatment: Cleanse area with NS or wound cleanser, pat dry, apply zinc ointment cover with bordered dressing daily. Risk factor: Immobility Interventions: 4. Offloading wound while in bed as needed /tolerated 5. Repositioning resident as needed/tolerated 6. RD to follow Signed by LVN B 11/22/2024 - Site #1 Sacrum Measurements 3 cm x 2 cm x 0.1 cm Procedure: Surgical excisional debridement (11/12/2024) Description: Light serous exudate 100% granulation Treatment: Cleanse area with NS or wound cleanser, pat dry, apply zinc ointment cover with bordered dressing daily. Progress: Not at goal MASD to groin region treat with house barrier cream every brief change Risk factor: Immobility Interventions: 4. Offloading wound while in bed as needed /tolerated 5. Repositioning resident as needed/tolerated 6. RD to follow Signed by LVN B 11/28/2024- Site #1 Sacrum Measurements 5 cm x 5 cm x 0.1 cm Procedure: Surgical excisional debridement (11/22/2024) Description: Light serous exudate 100% granulation Treatment: Cleanse area with NS or wound cleanser, pat dry, apply zinc ointment cover with bordered dressing daily. Progress: Not at goal MASD to groin region treat with house barrier cream every brief change. Risk factor: Immobility Interventions: 4. Offloading wound while in bed as needed /tolerated 5. Repositioning resident as needed/tolerated 6. RD to follow Signed by LVN B Record review of Resident #1's Skin IDT dated 12/11/2024 at 12:50pm, revealed Resident #1 was readmitted to facility following a transfer to the hospital due to altered mental status. Resident has stage 2 wound to the sacrum and MASD to groin region. Prior orders from wound care physician include the application of zinc ointment and daily border dressing changes. These orders are being continued, and wound care physician scheduled to re-evaluate on tomorrow 12/12/2024. Care remained ongoing and compliant with prescribed treatment plan. Record review of Resident #1's Wound Care Doctor A assessments: 10/15/2024- Chief complaint -Wound on sacrum Etiology: Trauma/Injury Wound size: 3.5 x 1 x 0.1 cm Treatment plan: Zinc ointment apply once daily for 30 days 2nd dressing: Gauze Island with border apply once daily for 30 days. 10/22/2024- Chief complaint wound on sacrum. Wound size: 3 x1 x 0.1 cm Treatment plan: Zinc ointment apply once daily for 23 days 2nd dressing: Gauze Island with border apply once daily for 23 days. 10/29/2024- Chief complaint: Wound on sacrum Size 2 x 1 x not measurable due to presence of tissue overgrowth Treatment plan: Zinc ointment apply once daily for 16 days. 2nd dressing: Gauze island with border apply once daily for 16 days. Debridement History: The most recent debridement of this wound was an excisional debridement performed on 10/25/2024. 11/5/2024- Sacrum wound size: 2x 0.3 x 0.1 cm Treatment plan: Zinc ointment apply once daily for 9 days. 2nd dressing: Gauze island with border apply once daily for 9 days. Debridement History: The most recent debridement of this wound was an excisional debridement performed on 10/25/2024. 11/12/2024- Sacrum wound size 1.5 x 0.3 x 0.1 cm Treatment plan: Zinc ointment apply once daily for 30 days. 2nd dressing: Gauze Island with border apply once daily for 13 days. Site 1: Surgical excisional debridement procedure Indication for procedure: Necrotic tissue and establish the margins of viable tissue. 11/19/2024- Sacrum wound: 3 x 2 x 0.1 cm Expanded evaluation performed: The progress of this wound and the context surrounding the progress were considered in greater detail today. Reviewed offloading surfaces and discussed surfaces care plan. Considered patient behavior as factor that is complicating wound healing and discussed further with staff and/or family. Discussed wound healing trajectory and expectations with patient and/or family. Treatment plan: Zinc ointment apply once daily for 23 days. 2nd dressing: Gauze Island with border apply once daily for 23 days. Debridement History: The most recent debridement of this wound was an excisional debridement performed on 11/12/2024. 11/26/2024- Sacrum wound size: 5 x 5 x 0.1 Granulation tissue: 60% surface area: 25.00cm Cluster wound: Open ulceration area of 15.00 cm Expanded evaluation performed: The progress of this wound and the context surrounding the progress were considered in greater detail today. Patient not following repositioning or offloading recommendations and counseling provided. Considered patient behavior as factor that is complicating wound healing and discussed further with staff and/or family. Discussed wound healing trajectory and expectations with patient and/or family. Treatment plan: Zinc ointment apply once daily for 16 days. 2nd dressing: Gauze Island with border apply once daily for 16 days. 12/3/2024- Sacrum wound size: 4 x 4x 0.1 cm surface area: 16.00 cm slough: 20%, granulation tissue 80% Wound progress: Not at goal Duration: 50 days Treatment plan: Zinc ointment apply once daily for 9 days. 2nd dressing: Gauze Island with border apply once daily for 9 days. Site #1 Surgical Excisional Debridement Procedure Indication: Necrotic tissue and establish the margins of viable tissue. PROCEDURE NOTE: The wound was cleansed with normal saline and anesthesia was achieved using topical benzocaine. Then with clean surgical technique, 15 blade was used to surgically excise 3.2cm' of devitalized tissue including slough, biofilm and non-viable subcutaneous level tissues were removed at a depth of 0.1 cm and healthy bleeding tissue was observed. As a result of this procedure, the nonviable tissue in the wound bed decreased from 20 percent to O percent. Hemostasis was achieved and a clean dressing was applied. Post-operative recommendations and updates to the plan of care are documented in the Assessment and Plan section below. Site 2-Unstagebale DTI of the left heel undetermined thickness wound size 2 x 2 x not measurable offloading and boot ordered. 12/12/2024 Chief complaint: Wound on sacrum; right medial thigh; left heel; scrotum. Wound size 8 x 8 x 0.1 Surface: 64.00 cm Slough: 20% ADDITIONAL WOUND DETAIL readmission from hospital DRESSING TREATMENT PLAN Primary Dressing(s) Alginate calcium apply once daily for 30 days Secondary Dressing(s) Gauze island w/ border apply once daily for 30 days PLAN OF CARE REVIEWED AND ADDRESSED Recommendations: Off-Load Wound; Reposition per facility protocol; Turn side to side in bed every 1-2 hours Site #1- Surgical excisional debridement procedure Indication: Remove necrotic tissue and establish margins of viable skin. PROCEDURE NOTE The wound was cleansed with normal saline and anesthesia was achieved using topical benzocaine. Then with clean surgical technique, 15 blade was used to surgically excise 12.8cm2 of devitalized tissue Including slough, biofilm and non-viable subcutaneous level tissues were removed al a depth of 0.1 cm and heallhy bleeding tissue was observed. As a result of this procedure, the nonviable tissue in the wound bed decreased from 20 percent to O percent. Homeostasis was achieved and a clean dressing was applied. Post-operative recommendations and updates to the pla11 of care are documented in the Assessment and Plan section below. Record review of Resident #1's local hospital #2 record revealed: Principal problem upon admission on 12/5/2024 was altered mental status. Assessment and Plan: Acute toxic metabolic encephalopathy -multifactorial in the setting of an acute UTI, complicated UTI, E-coli UTI General Information: Resident #1 was confused and lethargic. Wound care assessment on 12/6/2024: Sacral stage 3 pressure injury wound- size L 6.0cm x W 6.0cm x D 0.1cm - no undermining - no tunneling/induration - Wound bed is full thickness with some pink and red non granular tissue. The area is denuded most probably from incontinence - edges well defined -small to moderate serosanguinous drainage - no odor - Peri wound redness noted. Left heel DTPI wound- size L 3.0cm x W 3.0cm x D 0cm - no undermining - no tunneling/induration -Wound with purple/ maroon non blanchable intact skin - edges well defined -No drainage - no odor - Peri wound skin is intact Location: Penis, scrotum, inner thighs, groin, posterior thighs and peri area - Type: MASD/ IAD (Moisture Associated Skin Damage/ Incontinence Associated Skin Damage) Appearance: Bright red erythematous rash and inflammation with denuded skin due to: moisture trapping in skin folds and fecal/ urine incontinence. Posterior thighs are full thickness which I will recommend Zinc paste. Exudate: Clear weeping skin due to inflammation, edema, and skin erosions. Current Pressure Support Surfaces: Bed: LAL mattress; microclimate pad; glide sheet with pillows or wedges and Z flex boots. Mobility: Bed bound. Recommendations: Sacrum and left heel wounds- Cleanse with Vashe (Ref # 108824) and pat dry with gauze. Apply Cavilon skin barrier to the peri wound skin, apply Polymem (Ref# 7114) to the wound base and cover with silicone foam dressing every other day and as needed. 1. Clean penis, scrotum, inner thighs, groin and peri area with Coloplast no rinse wash cloths (Ref# 119680) and warm water 2. Pat dry with towel 3. Apply Cavilon advanced skin barrier twice a week and as needed. Goal/Treatment Plan: 1. Dressing Changes as ordered or PRN if soiled. 2. Using wedges or pillow to turn and reposition the pt every 2 hours to offload pressure to wound, even when on specialty bed. 3. Encourage lowering the head of the bed below 30 degrees is tolerable. 4. Ensure patient is on pressure redistribution and microclimate control bed is order is placed. 5. Offload pressure to patient's heels by floating with pillows or by applying specialty boots. 6. Nutritional consultation for wound healing. The following supplements to aid in wound healing are recommended, unless contraindicated: - 1000 mg Vitamin C daily - 220 mg Zinc sulfate daily - Multivitamin daily - Juven 2 times per day - Accurately monitor and document patient's PO intake, so supplements can be adjusted accordingly. 7. Skin care and skin protection from moisture damage - If possible, keep diapers off patient to reduce moisture - Consider using Pure Wick/ Condom catheter for incontinence management - Apply Cavilon Advanced to perineal and perianal area 2x weekly Photos of Resident wounds were taken at the hospital. Record review of the last IDT care plan review for Resident #1 was conducted on 9/17/2024. No wounds were discussed. No other care plan reviews were conducted after 9/17/2024. An interview on 12/11/2024 at 3:30pm with the Wound Care nurse (LVN B) revealed she had been employed at the facility for about 1 year. She stated she started wound care of Resident #1 after CNA reported observing a skin tear on his sacral area and MASD to groin sometime in October. She said she immediately followed up with the NP about the wounds and house barrier cream was ordered along with a wound doctor consultation. She said she sometimes learned about skin issues from the CNA's and from wound sweeps in which she randomly looked at different residents' skin in search of wounds/tears. She stated the Wound Care Doctor A came to the facility every week on Thursday and did measurements of wounds and debridement as needed. She said all documentation is put into PCC as a nursing note and weekly wound care assessments. She said she followed physician orders for treatment of wounds. She said Resident #1 sacral wound was getting better, but after returning from the hospital it looked bad. She denied that Resident had the buttock, thigh and gluteal wounds before leaving for the hospital stay. She said she did not know why there were no notes concerning the MASD because it was treated with barrier cream since it was brought to her attention in October. She said she did not know why there was not documentation of the MASD until 11/12/2024. She was not sure why Resident #1's care plan had not been updated. She does participate in IDT meetings in which skin condition is discussed. An interview with RP on 12/11/2024 at 8:04 p.m, revealed her to state Resident #1 was admitted to the facility in March 2024. She stated that she usually visited him after work (6pm or so) at least 3 to 4 days a week. She said she had not participated in a care plan meeting for Resident #1 in months. She said not since August or September 2024. She said wounds were not discussed or he did not have them at that time. She denied having a care plan meeting to discuss Resident #1's wounds, goals or interventions. Interview with the DON on 12/13/2024 at 11:16am she stated she had been employed for about 4 months. She said sacral wounds could come from residents' co-morbidities or could be from residents' briefs needing to be changed more often because some residents get wet more than expected. She said the consequence of having a sacral wound is discomfort and pain. She stated the MDS nurse was responsible for updating the care plans but the IDT team met also to discuss any significant changes. An interview with the Executive Director on 12/13/2024 at 11:16 a.m. reflected her to state she could not recall when she first learned about Resident #1's sacral wound. She said that the MASD in his groin area was being treated to her knowledge. She was not sure why it was not in the progress notes because the weekly skin assessment showed up on the nursing progress notes. She said the baseline care plan was to be done within 48 hours, and updated upon significant change, quarterly and annually. She was not sure why the care plan did not address the sacral wound but probably because it was not a stage 3 wound until he returned from the hospital. An interview with the SW on 12/19/2024 at 10:57 a.m., stated the last conversation he had with Resident #1's RP was concerning his wounds on last Friday (12/13/2024). He said she wanted to make sure the facility was taking care of his wounds and keeping him clean. He said Resident #1 was scheduled for a care plan meeting today (12/19/2024), however, he went back to the hospital today. He stated the last care plan meeting was on 9/19/2024. He stated care plan meetings were held quarterly unless there was a hospital stay or upon request from the family. He stated he could not recall the RP asking for a meeting or any concerns prior to last week. In a subsequent interview with the DON on 12/17/2024 at 2:55pm, she stated that all care plans should be done upon admission, significant change, re-entry from a hospital stay (if anything changed), quarterly and annually. She said she was not sure why the care plan had not been updated. She said she would have to check with the team about it. She stated all care plans should be updated as needed. All admission, re-entry or significant changes should have an update. She said if care plans are not completed timely there could be a delay in care, worsening of wounds and pain. An interview with MDS Nurse on 12/19/2024 at 1:15pm, stated baseline care plans are done within 48 hours, quarterly, annually, and upon a significant change. She stated all Residents are at a high risk for pressure wound when they have low mobility. She said Resident #1 was not walking but was alert when he was admitted . She said she was puzzled about why his assessment at the hospital was done the next day after he was admitted . She does not know how they can say the sacral wound was developed at the facility. She said this is why it was not addressed on the care plan. It was merely a skin tear as far as she was aware and that did not require an updated care plan. Record review of the facility's person-centered care plan revised on 12/2023 read in part: It is the policy of this facility that the interdisciplinary team (IDT) shall develop a comprehensive person-centered care plan for each resident that includes measurable objectives and timeframes to meet a resident's medical, nursing, mental and psychosocial needs that are identified in the comprehensive assessment. The IDT team will also develop and implement a baseline care plan for each resident, within 48 hours of admission, that includes minimum healthcare information necessary to properly care for each resident and instructions needed to provide effective and person-centered care that meet professional standards of quality care. The resident's comprehensive plan of care will be reviewed and/or revised by the IDT after each assessment, including both the comprehensive and quarterly review assessments.

Based on observation, interview, and record review the facility failed to ensure residents who entered the facility without pressure ulcers did not develop pressure ulcers and a resident having pressure ulcers received care and treatment consistent with professional standards of practice to promote healing and prevent further development of skin breakdown or pressure ulcers for 1 (CR #1) of 6 residents reviewed for pressure ulcers. -The facility failed to prevent the development of CR #1's Stage IV facility acquired sacrum pressure wound and left heel deep tissue injury resulting in debridement and hospitalization . Resident was diagnosed with sepsis due to MRSA, Sacral osteomyelitis and sacral pressure ulcer. -The facility failed to timely intervene when CR#1's Stage IV Pressure ulcer continued to get worse and did not send him to the local hospital and only suggested hospice. -The facility failed to ensure a wound care specialist physician was notified that CR#1's facility acquired Stage 4 pressure Ulcer was continuing to worsen and the wound care specialist physician did not evaluate and or modify wound treatment during the 12 days to promote healing and prevent the pressure ulcer from worsening. An Immediate Jeopardy (IJ) was identified on 01/28/24. While the IJ was removed on 01/30/24 at 2:02 p.m., the facility remained out of compliance at a severity level of actual harm that is not an Immediate Jeopardy and a scope of pattern as the facility continued to monitor the implementation and effectiveness of their plan of removal. These failures placed residents at risk of developing new pressure wounds, worsening of existing wounds, decline in quality of care, infection and experiencing pain. Findings include: CR #1 Record review of CR #1's face sheet dated 1/10/24 revealed a [AGE] year-old male who admitted to the Nursing Facility on 10/21/2023 with the diagnoses of encephalopathy (damage or disease that affects the brain), epidural hemorrhage with loss of consciousness (bleeding between the inside of the skull and the outer covering of the brain), hyperlipidemia (high cholesterol), hypertension (high blood pressure), paroxysmal atrial fibrillation (irregular heart beat), gastro-esophageal reflux disease (acid reflux), low back pain, muscle weakness, obstructive and reflux uropathy (disorder of the urinary tract that occurs due to obstructed urinary flow), dysphagia (difficulty swallowing), unsteadiness on feet, abnormality of gait, repeated falls, cognitive communication deficit, and need for assistance with personal care. Record review of CR#1's Quarterly MDS dated [DATE] revealed a BIMS score of 10 indicating moderate cognitive impairment. Section on Functional Abilities and goals revealed nothing was answered, no pressure injuries were noted, weight loss was answered no indicating no or unknown if loss of 5% or more in the last month or loss of 10% or more in last 6 months and no weight gain. Skin Conditions revealed CR#1 was indicated for pressure injuries and shows 1 stage 4 pressure ulcer (Stage 4 pressure ulcers are the most serious. These sores extend below the subcutaneous fat into your deep tissues, including muscle, tendons, and ligaments. In more severe cases, they can extend as far down as the cartilage or bone), and there was 1 unstageable (Unstageable pressure injuries are widely understood to be full-thickness pressure injuries in which the base is obscured by slough and/or eschar. Correct identification of these pressure injuries can be challenging among health care professionals and, although treatments vary, debridement is key) - slough and/or eschar (Eschar, pronounced es-CAR, is dead tissue that sheds or falls off from the skin. It's commonly seen with pressure ulcer wounds (bedsores). Eschar is typically tan, brown, or black, and may be crusty). Record review of CR# 1's Comprehensive Care plan undated revealed the following care areas: * an Actual pressure ulcer development r/t impaired mobility. Location #1 Sacral Stage 4 dated initiated 10/23/23 and revised on 11/10/23. A goal was for the resident to have intact skin, free of redness, blisters or discoloration by/through review date. The interventions were for an air mattress applied to bed dated initiated 11/10/23, call light in reach date initiated 10/23/23, encourage fluid intake and assist to keep skin hydrated dated 10/23/23, float heels as resident allows dated 10/23/23 and revised 11/10/23, Follow MD treatment as ordered date initiated 11/10/23, needs assistance to turn/reposition 10/23/23, notify nurse immediately of any new areas of skin breakdown: Redness, blisters, bruises, discoloration noted during bath or daily care date initiated 10/23/23, and weekly head to toe skin assessment date initiated 10/23/23. Requires assistance/potential to restore function to maximum self -sufficiency for mobility characterized by the following functions: positioning, locomotion/ambulation r/t: Impaired coordination date initiated 10/23/23. *ADL Self Care performance deficit r/t impaired cognition and functional decline following lumbar laminectomy and epidural hematoma s/p surgical evacuation date initiated 10/21/23. A goal was to safely perform ADLs at highest level of independence through the review date. The interventions included to explain all procedures/tasks before starting (10/23/23) .toilet use (toilet transfer, toilet hygiene): Requires staff participation to use toilet. Monitor for incontinent episodes and provide care. (date 10/23/23). *Has unplanned/unexpected weight loss r/t poor food intake date initiated 11/13/23. Goal: weight will return to baseline range by review date and will consume two of three meals/day through the review date. The interventions were to give supplements as ordered, Alert nurse/dietician if not consuming on a routine basis, If weight decline persists, contact physician and dietician immediately, Monitor and evaluate any weight loss, Determine percentage loss and follow facility protocol for weight loss, Monitor and record food intake at each meal, Offer and encourage snacks/fluids between meals, Remeron as appetite stimulant. *Has surgical incision to lumbar s/p laminectomy (surgery that creates space by removing bone spurs and tissues associated with arthritis of the spine). Date initiated 10/21/23. A goal was the surgical incision will show signs of healing and remain free from infection by/through review date. The interventions were to administer treatments as ordered and monitor for effectiveness and Monitor/document/report to MD PRN changes in skin status: appearance, color, wound healing, s/sx of infection, wound size and stage. Record review of CR#1's Medication Administration Record/Treatment Administration Record dated December 2023 revealed: -Wound care Left Heel: Cleanse with wound cleanser, pat dry, apply skin prep 3 x week every day shift every Mon, Wed, Fri for purplish blister left heel order date 11/28/23 was completed as ordered. -Wound care to stage 4 (sacral) pressure injury- cleanse with Dakin's solution, pat dry, apply sterile gauze and cover with dry dressing daily and prn when soiled or dislodged. every day shift -order date- 12/14/2023 was completed as ordered. -Wound care to stage 4 (sacral) pressure injury- cleanse with ns solution, pat dry, apply Santyl, apply calcium alginate, cover with dry dressing daily and prn when soiled or dislodged every day shift -order date-11/23/2023 was -d/c date-12/14/2023 was completed as ordered. -Low air loss mattress for skin maintenance- check function every shift order date 11/7/23 revealed it was not completed on 12/1/23 evening shift and 12/25/23 evening shift. Preventive Care-apply skin prep to bilateral heels every shift order date 11/7/23 revealed it was not completed on 12/1/23 evening shift, and 12/25/23 evening shift. Record review of Local Hospital Records for CR #1 dated 10/19/23 revealed review of systems, skin symptoms: no jaundice, no rash. There was no pressure injury noted. Record review of CR#1's licensed Nurse Initial Admission Record completed by LVN A dated 10/21/23 revealed supportive devices were bed cradle, no alternating air mattress, no pressure re-distributing overlay mattress, no infections, and skin integrity revealed vertebrae (upper-mid) surgical incision with no skin issues noted. Record review of CR#1's LN Braden Scale for Predicting Pressure Sore Risk dated 10/21/23 indicated the following: *category: Moderate risk with score being 13.0. *Sensory perception: very limited: responds only to painful stimuli. Cannot communicate discomfort except by moaning or restlessness or has a sensory impairment which limits the ability to feel pain or discomfort over 1/2 of body. *Moisture: rarely moist: skin is usually dry; linen only requires changing at routine intervals. *Activity: Degree of physical activity: bedfast: confined to bed. *Mobility: Ability to change and control body position: Very limited: makes occasional slight changes in body or extremely position but unable to make frequent or significant changes independently. *Nutrition: Usual food intake pattern: Probably inadequate: Rarely eats a complete meal and generally eats only about 1/2 of any food offered. Protein intake include includes only 3 servings of meat or dairy products per day. Occasionally will take a dietary supplement. OR receives less than optimum amount of liquid diet or tube feeding. *Friction & Shear: Potential problem: Moves feebly or requires minimum assistance. During a move skin probably slides to some extent against sheets, chair, restraints or other devices. Maintain relatively good position in chair or bed most of the time but occasionally slides down. Record review of CR#1's IDT- Care Plan Review signed on 10/27/23 revealed an initial review where CR#1's family member did attend, and the resident did not require special treatments, procedures or devices. CR#1 was alert oriented x3 scoring 10 in BIMS. Record review did not reveal any issues with pressure ulcers. Record review of CR#1's Mini Nutritional assessment dated [DATE] at 4:47 p.m. revealed a score of 12 (meaning normal nutritional status) .weight 209 lbs. on 10/21/23, no decrease in food intake, weight loss during the last 3 months: .no psychological stress, mild dementia, BMI 23 or greater . Record review of CR#1's IDT- Care Plan Review signed on 12/20/23 revealed CR#1's family requested to discuss CR#1's care, and nothing was discussed regarding pressure ulcer. Record review of CR#1's IDT Care on 10/27/23 and 12/20/23 Plan Reviews did not reveal any notice about the Stage 4 Sacral Pressure Wound and the progression of the wound. Record review of CR#1's Weight and vitals dated 1/9/24 revealed the following weights: *10/21/23 - 209.8 lbs., *11/6/23 - 191.2 lbs., and *12/7/23 -182.8 lbs. Record review of CR #1's Physician Care Orders dated 1/10/24 revealed the following orders: *11/2/23-Unstageable: Sacral Pressure Injury- cleanse with normal saline solution, pat dry and apply calcium alginate, cover with dry dressing daily and PRN when soiled or displaced every day shift, discontinued date unknown. *11/2/23 -Unstageable: Sacral Pressure Injury- cleanse with normal saline solution, pat dry and apply calcium alginate, cover with dry dressing daily and PRN when soiled or displaced every 8 hours as needed, discontinued date unknown. *11/7/23-Low Air loss mattress for skin: Maintenance-check function every shift. *11/7/23-Preventive Care-apply skin prep to bilateral heels every shift. *11/8/23 -Mirtazapine Oral tablet 15 mg give 1 tablet by mouth one time a day for appetite stimulant discontinued date unknown *11/9/23 -Wound care to stage 4 Sacral pressure injury-cleanse with normal saline solution, pat dry and apply calcium alginate, cover with dry dressing daily and PRN when soiled or displaced every day shift . *11/12/23-Left Heel: Apply skin prep leave open to air daily. Every shift for purplish blister left heel . *11/15/23-Mirtazapine Oral tablet 30 mg give 1 tablet by mouth one time a day for appetite stimulant. *11/28/23-Wound care Left Heel: Cleanse with wound cleanser, pat dry, apply skin prep 3 x week every day shift every Monday, Wednesday, Friday for purplish blister left heel . *12/14/23-Wound care to stage 4 Sacral pressure injury-cleanse with Darkin's solution, pat dry, apply sterile gauze and cover with dry dressing daily and PRN when soiled or dislodged, Every 8 hours as needed. *12/27/23-Send resident to local hospital per family request for wound evaluation. One time only for evaluation until 12/27/23. Record review of CR#1's Wound Care notes dated 11/1/23 by Wound Care Doctor A revealed the following: location: sacrum. Physical Exam Details: Integumentary (hair, skin): Skin and subcutaneous tissue without rashes or lesions. Wound orders- Wound #1 Sacral: Cleanse wound with normal saline, wound dressing-apply alginate, cover wound with dry absorptive dressing, change dressing daily. Pressure relief/Offloading: air mattress, reposition per facility protocol, off-load wound. Additional orders: Plan of care discussed with facility staff, plan of care discussed with patient, follow up next week. Wound measurements: 5x5 cm, depth 0, area 25%. Wound encounter Initial exam, Unstageable pressure injury obscured full thickness skin and tissue loss, moderate sero-sanguineous (contains or relates to both blood and the part of blood -serum), normal for skin. Record review of CR#1's Wound Care Doctor notes dated 11/8/23 by Wound Care Doctor A indicated the following: *sacrum, *nutrition: poor appetite, getting multivitamins, *musculoskeletal: immobile, *Support surfaces: group 2 mattress. *Integumentary: dry wrinkled skin on lower extremities .Wound 1 Sacral Pressure ulcer .measurements 8.5 cm length x 10 cm width x depth 0 and area 85. *Wound description: Wound progress deteriorating, stage 4 pressure injury with moderate sero-sanguineous exudate, surrounding skin is normal for skin and moist yellow slough was 76 to 100% and there was exposed ligament and adipose necrosis. *Debridement details: post debridement measurements 8.5 cm length x 10 cm width x1.5 cm area, percent debrided 100, total area debrided 85 sq cm and volume was 127.5. Record review of CR#1's LN Skin Pressure Ulcer Weekly written by Clinical Resource dated 11/9/23 revealed: Pressure Ulcer Review Site 1, onset date 10/28/23, sacrum with 76-100% slough, Stage 4, size 8.5x10cm, depth 0, tunneling 0, undermining 0, exudate amount was serosanguinous, exudate amount was moderate, no odor, wound bed was slough, wound edges were macerated, and the surrounding tissues was normal for skin. Documented interventions and the residents response to the interventions included: cleanse with normal saline (NS), pat dry, apply calcium alginate, cover with dry dressing. Surgical debridement completed; resident tolerated well. CR #1 was not stated to experience pain. Comments included: Wound rounds completed with wound MD location #1: sacral etiology: Pressure stage 4 ([NAME]) Measurement: 8.5 cm x 10cm x 0 Risk factors: poor appetite, immobile, non-compliant with turning and repositioning and offloading. Laminectomy history. Interventions: 1. Air mattress, 2. Float heel as resident allows, 3. Therapy services, 4. Pain management, 5. RD to follow. Education provided: Wound MD educated resident on risk and benefit of noncompliance with off-loading. MD and Responsible Party notified of wound progression. Record review of CR#1's LN- Skin Pressure Ulcer Weekly dated 11/14/23 signed by LVN B and re-signed by Clinical Resource on 12/5/23 revealed: Pressure Ulcer Review site 1 follow up onset date 10/28/23, Sacrum 76-100% eschar, stage 4, size 6x8 cm, depth 4, tunneling 0, undermining 0, serosanguinous-moderate, no odor, wound bed was black/brown (eschar), wound edges macerated, surrounding tissue was normal for skin, surgical debridement. Cleanse with normal saline, pat dry, apply Santyl, apply calcium alginate, cover with dry dressing . Record review of CR#1's Wound Care Doctor notes revealed CR#1 did not see a Wound Care Doctor from 11/9/23 to 11/20/23 (12 days) with a Stage 4 Sacral Pressure Wound because he was asked not to return to the facility and there was no other Wound Care Doctor Record review of CR#1's LN- Skin Pressure Ulcer Weekly dated 11/21/23 and signed on 11/22/23 by LPN A revealed follow up onset 10/28/23, sacrum 100% adherent devitalized necrotic tissue, stage 4, size 8x9 cm, exudate type: serous (Serous drainage is a clear to yellow fluid that leaks out of a wound. It's slightly thicker than water .Too much serous fluid is a sign of an infection), amount scant, no odor, wound bed black/brown (eschar), wound edges defined, surrounding tissue normal for skin. Document interventions and the residents response to the interventions: cleanse with NS, pat dry, Santyl and calcium alginate and dover with gauze island with dry dressing for 30 days. Wound rounds completed with wound MD, location #1: sacrum etiology: Pressure stage 4 ([NAME]) Measurement: 8 cm x 9 cmx not measurable cm. Description: serous drainage, wound bed 100% eschar, no odor. Wound progression: deteriorated. Treatment: cleanse with normal saline, apply Santyl, apply calcium alginate and cover with dry dressing everyday . Record review of CR#1's Wound Care Doctor notes dated 11/21/23 by wound Care Doctor B revealed the following: CR#1 present with a wound on his sacrum and a rash *Review of Systems: Appetite- Fair, Supplements- Multivitamins, protein, Vitamin C . *Bed- group 2 . *Wound Exam (Site 1): Stage 4 pressure wound sacrum full thickness *wound size (LxWxD): 8x9x no measurable cm. Depth is unmeasurable due to presence of nonviable tissue and necrosis (Necrotic wounds are areas of tissue loss that occur following the death of their component cells. Once an area of tissue becomes devitalized, dead tissue build-up commences which might inhibit the rate at which wound repair occurs) *Surface area: 72.00 cm2 x exudate moderate serous (Serous drainage is a clear to yellow fluid that leaks out of a wound. It's slightly thicker than water .Too much serous fluid is a sign of an infection) and thick adherent devitalized necrotic tissue-100%. *Dressing Treatment Plan: Alginate calcium apply once daily for 30 days; Santyl apply once daily for 30 days. Secondary dressing(s): gauze island w/ bdr apply once daily 30 days. *Plan of Care reviewed and addressed: recommendations: off-load; reposition per facility protocol; turn side to side in bed every 1-2 hours if able. Site 1: Surgical excisional debridement procedure: remove necrotic tissue and establish the margins of viable tissue. *Consent for procedure: treatment options-risks-benefits and the possible need for subsequent additional procedures on this wound were explained were explained on 11/21/23 to the patient who indicated agreement to proceed with the procedures. Procedure note: The wound was cleansed with normal saline and anesthesia was achieved using topical benzocaine. Then with clean surgical technique, 15 blade was used to surgically excise 14.4 cm2 of devitalized tissue and necrotic muscle level tissue were removed at a depth of 0.5 cm and healthy bleeding tissue was observed. As a result of this procedure, the non-viable tissue in the wound bed decreased from 100% to 80%. Hemostasis was achieved and a clean dressing was applied. *Post-operative recommendations and updates to the plan of care are documented in the Assessment and plan section below. *Post-debridement assessment of this previously unstageable necrotic wound has revealed the underlying deep tissue (pressure ulcer described as purple or maroon localized area of discolored intact skin or blood filled blister due to damange of underlying soft tissue from pressure and/or shear) at the muscle/fascia level, which had been obscured by necrosis prior to this point. This Wound has now revealed itself to be a Stage 4 pressure injury. This is not a wound deterioration. *Other diagnosis: Irritant dermatitis from body fluid: location buttock for at least 1 day, *history: bilateral buttocks, *treatment: zinc oxide-based barrier cream as directed. *Coordination of Care: Data and history pertinent to this patient's care were obtained via CR#1, nursing staff, nursing facility records. CR#1's plan of care was discussed with CR#1, nursing staff member. The clinical documentation for this consultation was made available to the referring physician. This documentation has also been made available for access to the appropriate personnel and placement in the medical record. Record review of CR#1's LN-Skin Pressure Ulcer Weekly dated 11/28/23 and signed by LPN A revealed: Follow up, not present on admission, onset date 10/28/23, Sacrum, stage 4, size 8x9 cm, moderate serous exudate, no odor, wound bed black/brown (eschar), wound edges: macerated, surrounding tissue normal for skin, cleanse with normal saline, pat dry, apply Santyl and calcium alginate and cover with dry dressing daily. Pressure ulcer review Site 2, onset date unknown, left heel unstageable deep tissue injury (DTI), size 3x4cm, document interventions and the residents response to the interventions: skin prep to area and leave open to air . Record review of CR#1's Wound Care Doctor notes dated 11/28/23 by wound Care Doctor B revealed CR#1 has wounds on his sacrum and left heel .Focused Wound Exam (Site 1) Stage 4 Pressure Wound Sacrum full thickness. Wound size (LxWxD): 8 x 9 x not measurable, Depth is unmeasurable due to presence of nonviable tissue and necrosis. Surface area: 72.00 cm2, exudate: moderate serous, thick adherent devitalized necrotic tissue: 100%, wound progress: not at goal. Site 1: Surgical excisional debridement procedure: Indication for procedure: Remove necrotic tissue and establish the margins of viable tissue. Consent for procedure: Treatment options-risks-benefits and the possible need for subsequent additional procedures on this wound were explained on 11/21/23 .Focused Wound Exam (Site 2): Unstageable DTI of the left heel partial thickness .Wound size (L x W x D): 3 x 4 x not measurable cm2, surface area: 12.00 cm2, exudate: none. Coordination of Care: . Data and history pertinent to this patient's care were obtained via CR#1, nursing staff, nursing facility records. CR#1's plan of care was discussed with CR#1, nursing staff member. The clinical documentation for this consultation was made available to the referring physician Record review of CR#1's Wound Care Doctor notes dated 12/5/23 by wound Care Doctor B revealed CR#1 has wounds on his sacrum and left heel .Wound size (L x W x D): 9.5 x 9 x not measurable cm. Surface area: 85.50 cm2, moderate serous, thick adherent devitalized necrotic tissue: 70%, granulation tissue: 30%, wound progress: improved evidenced by increased granulation, decreased necrotic tissue. Focused wound exam (site 2): unstageable DTI of the left heel partial thickness. Wound size: (L x W x D): 3x4x not measurable cm, surface area: 12.00 cm2, exudate: none, Wound progress: at goal. Dressing treatment plan: skin prep apply three times per week for 23 days .recommendations: float heels in bed; off-load wound. Summarized Wound Care Assessment and Individualized Treatment Plan . Procedure today: Surgical excisional debridement was performed today on this wound . Record review of CR#1's LN-Skin Pressure Ulcer Weekly dated 12/5/23 and signed by LPN A revealed: Follow-up, not present on admission, onset date unknown, sacrum, full thickness stage 4, size 9.5x 9 cm, depth 0, moderate serous, no odor. Pressure Ulcer Review Site 2, follow up, not present on admission, onset date unknown, left heel unstageable DTI (slough/eschar), 3 x 4 cm, depth 0, skin prep to area and leave open to air . Record review of CR#1's LN-Skin Pressure Ulcer Weekly dated 12/14/23 signed by LPN A, follow-up .sacrum stage 4, 11x11 cm, moderate serous, Pressure Ulcer Review Site 2 Left heel, unstageable DTI with intact skin, skin prep 3 times a week. Additional documentation/comments: Wound rounds with Wound Dr. for location #1: sacrum etiology: Pressure stage 4 ([NAME]) procedure: surgical excisional debridement, measurement 11cmx 11cm x 0cm. Description: moderate serous drainage, wound bed 60% necrotic tissue, 40% granulation tissue. Odor present. Wound progression: improved evident by increased granulation, decreased necrotic tissue. Treatment: clean with Darkin's solution, apply sterile gauze and cover with dry dressing every day. Location #2: left heel etiology: Pressure unstageable DTI with intact skin, measurement: 3 cm x 4 cm x 0 cm. Treatment: Record review of CR#1's LN-Skin Pressure Ulcer Weekly dated 12/19/23 signed by LPN A revealed: Follow up sacrum full thickness, stage 4 size 11 x 12 cm, surgical excisional debridement performed. Cleanse with Darkin's solution, pack with sterile gauze and cover with dry dressing daily. Pressure Ulcer Site 3: Follow up, onset date unknown for Left heel unstageable DTI with intact skin- Resolved. Record review of CR#1's Wound Care Doctor notes dated 12/14/23 by wound Care Doctor B revealed CR#1 has wounds on his sacrum and left heel. Wound size (LxWxD): 11x11x not measurable cm. Surface area: 121.00 cm2, exudate: moderate serous, thick adherent devitalized necrotic tissue: 60%, granulation tissue: 40%, Wound progress: improved evidenced by increased granulation, decreased necrotic tissue .Procedure today: Surgical excisional debridement was performed today on this wound .Dressing Treatment Plan: Skin prep three times per week. Record review of CR#1's Wound Care Doctor notes dated 12/19/23 by wound Care Doctor B revealed CR#1 has wounds on his sacrum, left heel and a rash .Skin: Back- wound present, left lower extremity- dermatitis, right lower extremity-dermatitis. Wound size (L x W x D): 11x12x not measurable cm. Depth is unmeasurable due to presence of nonviable tissue and necrosis. Surface area: 132.00 cm2, exudate: moderate serous, thick adherent devitalized necrotic tissue- 50%, granulation tissue: 50%, Wound progress: improved evidenced by increased granulation, decreased necrotic tissue. Dressing Treatment plan: Gauze sponge sterile apply once daily for 25 days; sodium hypochlorite solution (Dakin's) apply once a day for 25 days. Secondary dressing: gauze island with bdr apply once daily for 25 days Site 1: Surgical excisional debridement procedure: remove necrotic tissue and establish the margins of viable tissue. Consent for procedure: Treatment options-risks-benefits and the possible need to subsequent additional procedure on this wound were explained on 11/21/23 to the patient who indicated agreement to proceed with the procedure(s). Focused Wound Exam (Site 2): Unstageable DTI of the left heel (Resolved on 12/19/23). Record review of CR#1's Daily Skilled notes from 12/21/23-12/25/23 written by RN A had the same entry for all skilled notes: Cognition: alert, oriented x2 .Integumentary: Overall skin description is skin warm and dry to touch. There are No active symptoms effecting the Integumentary system observed. No active skin condition(s) or treatments observed. other skilled treatments: bed mobility: self-performance- total dependence, bed mobility: support provided-two+ persons physical assist, transfer: self-performance total dependence transfer: support provided- two+ persons physical assist, eating: self-performance total dependence- eating: support provided -two+ persons physical assist, toilet use: self-performance total dependence- toilet use: support provided one person physical assist, additional documentation: no education/teaching provided Record review of CR#1's Progress notes dated 12/27/23 at 12:10 p.m. written by ADON B revealed, Social worker came to this ADON stating that resident [CR#1] family had sent an email in regards of wanting resident [CR#1] to be sent to ER at [Local Hospital] for wound evaluation, and to see if an order can be given to send resident [CR#1]. This ADON notified NP Doctor and she gave a verbal order to send resident to ER per family request .and transportation is set for today, pick-up between 2-3pm, this ADON also informed CR#1's family member that family will be paying for transport . Record review of CR#1's Daily Skilled Note dated 12/27/23 at 4:48 p.m. written by LVN C revealed, Vitals dated 12/26/23: blood pressure 115/70, temperature 97.3, no pain .Cognition: alert x2 .Integumentary: Overall skin description is: skin warm and dry to touch. There are No active symptoms effecting the Integumentary system observed. No active skin condition(s) or treatments observed. Record review of CR#1's Hospital Radiology report by MD dated 12/27/23 at 9:17 p.m. revealed: There is a large sacral decubitus ulcer noted that appears to extend down to the level of the bone with lucency of the tip of the coccyx though diffuse overall osteopenia making osteomyelitis difficult to exclude . IMPRESSION: 1. Possible sacrococcygeal osteomyelitis (infection in the bone), MRI would best evaluate. Please correlate. 2. Moderate fecal retention suggesting constipation and possible impaction, please correlate . Record review of CR#1's Hospital Wound Care Documentation dated 12/27/23 at 9:50 p.m. by hospital RN revealed: Wound, pressure injury, bony prominence, sacrum, pressure injury present on admit, Stage 4, Length 14, width 15, depth 3, wound treatment performed on 12/27/23 at 10:50 p.m. by RN, tunneling under skin, moderate exudate, wound exudate was purulent, Strong odor, necrotic tissue-eschar, surrounding tissue boggy-ecchymotic (discoloration of the skin due to the rupture of the blood vessels below the surface), wound status is deteriorating, gauze, damp to dry. Record review of CR#1's Hospital note dated 12/27/23 at 10:08 p.m. revealed, As related to the inpatient hospital stay starting on 12/27/2023 10:08 PM. Provider response text: sepsis due to Sacral osteomyelitis, present on admission Risk Factors: HP 12/27: 78 M with Sacral osteomyelitis, Sacral pressure ulcer, Transaminitis S/S: ED Assessment 12/27: stage 4 wound, 15cm wide x 14cm long x 3cm deep, infected wound tunneling under the skin, with eschar pockets and fowl smelling HP 12/27: Blood pressure on the low side, large decubitus ulcer on the sacrum, CT showed possible sacrococcygeal osteomyelitis Vital sign 12/27: Blood pressure 89/69_82/61, Heart rate 95-106, Lab 12/28: Sedimentation rate (level of protein in blood) 120, C Reactive Protein 82.1, Procalcitonin 0.11, WBC 11.5 Record review of CR#1 Hospital Drug Therapy Management Order Details Dated 12/27/2023 11:05 p.m. signed by MD revealed: Indication for Vancomycin : Bone and joint infection Vancomycin Anticipated Duration : 7 day. Record review of CR#1's Hospital Miscellaneous Progress note dated 12/29/23 at 5:15 p.m. revealed:: ED assessment 12/27: cleaned with saline, packed with wet to dry dressing. HP 12/27: started on cefepime/vancomycin .IV fluids, id/ortho consult in the morning Clinic Nurse 12/28 (gen sx): bedside debridement will be done with wound care nursing, possible colostomy. -- Sepsis due to Sacral osteomyelitis, present on admission, -- Sepsis due to Sacral pressure ulcer, present on admission, -- Sepsis due to Gram positive bacteremia, present on admission ED Assessment 12/27: stage 4 wound, infected wound tunneling under the skin, with eschar pockets and fowl smelling. HP 12/27: Blood pressure on the low side, large decubitus ulcer on the sacrum, CT showed possible sacrococcygeal osteomyelitis Lab 12/27-29: Chloride 113_120_117 (amount of chloride in the blood), CO2 22_22 (the presence of the gas carbon dioxide. Record review of Hospital Progress note dated 12/29/23 at 12:27 p.m. by MD revealed: Discussed with Wound Care. Agree with wound vac would be a good option for. This will all slough [TRUNCATED]

Based on interview and record review, the facility failed to provide basic life support, including cardiopulmonary resuscitation (CPR) for 1 (CR#1) of 12 residents reviewed for advanced directives. 1. The facility failed to immediately initiate CPR on [DATE] at about 7:20 AM when CR#1 was found unresponsive. 2. The facility failed to immediately contact EMS when CR#1 was found unresponsive between 7:00 AM and 7:20 AM. EMS was called at about 7:32 AM. (,d+[DATE]-minute delay). 3. The facility failed to ensure CPR was performed on a cardiac board once initiated by staff. A cardiac board is used in the administration of cardiopulmonary resuscitation (CPR) by creating a flat, rigid surface to use under the person in need of care. An Immediate Jeopardy (IJ) situation was identified on [DATE]. The IJ template was provided to the facility on [DATE] at 6:25 PM. While the IJ was lowered on [DATE], the facility remained out of compliance at a scope of isolated and a severity level of actual harm that is not an Immediate Jeopardy, because all staff had not been effectively trained on CPR, calling a code, and immediately contacting Emergency Medical Services and evaluate the effectiveness of the corrective systems. These failures could place residents who are full-code status (an attempt at all life-saving measures to keep an individual alive) at risk of death. Findings include: Record review of CR#1's face sheet, dated [DATE], revealed CR#1 was a [AGE] year-old male who was admitted to the facility, from the hospital, on [DATE]. He was diagnosed with displaced fracture of base of neck of right femur sequela (condition or injury related femur fracture); unspecified severe protein-calorie malnutrition; Alzheimer's Disease. Unspecified; acute osteomyelitis (inflammation of bone caused by infection) of the left femur; other complications of sequela procedure, not elsewhere classified; generalized muscle weakness; dysphagia (difficulty swallowing foods or liquids) oropharyngeal phase ; unspecified lack of coordination; and cognitive communication deficit. Record review of CR#1's MDS assessment dated [DATE] revealed a BIMS Summary score of 1 indicating severe cognitive impairment. Physical and verbal behaviors exhibited and significantly interfered with the resident's care. The functional status revealed bed mobility, locomotion off the unit, dressing, toilet use and personal hygiene were extensive assistance with two person physical assist and two person assist for transfer. Record review of CR#1's Care Plan , revised on [DATE] revealed, CR#1 had interventions for falls, nutrition, sand pressure ulcers, but no diagnosis or specification for CR#1 requiring those interventions. CR#1 was at risk for falls; therapy evaluation and treatment per order, ensure call light is in reach and encourage its use for assistance, bed in lowest position, bedside floor mats, maintain clear pathways free of clutter. Nutritional problems; administer medications as ordered, monitor/document side effects and effectiveness, unspecified diet as ordered, provide supplements as ordered. Resident had potential for pressure ulcer development; encourage fluid intake and assist keeping skin hydrated, monitor nutritional status, intake and record, serve diet as ordered, weekly head to toe assessment. He also took anxiety medication; give medications as ordered and monitor/document side effects and effectiveness, monitor, record, document behavior symptoms. CR#1 wished to be discharged back to memory care; establish a pre-discharge plan, make arrangements to support independence post-discharge. He also had an unspecified infection; maintain standard precautions when providing care, monitor temperature and pulse. The resident was on hypnotic therapy related to Insomnia; daily recommended dose not to be exceeded unless ordered by MD, inform of risks, benefits and side effects, precede or accompany hypnotic use by other interventions to improve sleep. CR#1 elected full-code status; initiate full-code measures in case of cardia arrest, to include CPR and AED use. He was at risk of impaired cognitive function related to Alzheimer's Disease; keep routine consistent, give step-by-step instructions, use simple instructions and provide cues when necessary. The resident had a self-care performance deficit; transfers required 2-person assist, encourage resident to participate to the fullest extent possible with each interaction. He had the potential for mood problems related to admission; encourage to express feelings, assist to identify strengths and positive coping skills. CR#1 was resistive to care related to Alzheimer's Disease; give clear instructions for all care activities, allow to make decisions about treatment regime. Record review of CR#1's physician orders revealed the following: CR#1 was full-code status. Record Review of CR#1's Progress Notes revealed: Effective Date: [DATE] 08:27 Type: Nursing Resident was resting quietly in bed lying supine (facing upward) on LVN A first round of the shift. CNA B gave resident 3 half sandwiches for snack. CNA B reports to LVN A that resident has been agreeable with brief changes this shift, lifting up his buttocks so he can be changed. LVN A rounded resident more frequently because his legs were observed coming out of the bed on the side of bed next to the air conditioner. SN put resident's legs back in the bed 3 times & covered him with his sheet & blanket. SN asked resident if he needed anything & he didn't answer. Resident was observed resting with eyes closed after the 3rd time of placing his legs back in bed. LVN A & CNA B took turns making rounds on resident to make sure he was comfortable, safe in the bed & needs met. CNA B told SN that she thought resident's color looked yellow. LVN A observed resident to be his normal pale color. SN did not observe resident in any distress on any round SN made. Author: LVN A Nursing - LPN Effective Date: [DATE] 08:34 Type: Nursing DON notified Physician Assistant of resident's passing. DON attempted to notify Family Member. Called 3 times, phone went to voicemail each time, left HIPAA compliant voice message for call back. DON attempted to notify RP. Called and left HIPAA compliant voice message for call back. There is a note not to inform with emergencies so she was not called. Author: DON Effective Date: [DATE] 08:43 Type: Nursing DON notified by phone at about 0725 that resident was found unresponsive. Nursing staff initiated CPR. Author: DON [DATE] 9:11 Author: DON DON spoke to RP and notified him of resident passing. DON explained how resident was found and that CPR was initiated, EMS took over however unable to recover pulse. He stated he would be speaking to his mother to let her know about resident passing. DON informed him that Medical Examiner would be transporting CR#1 to the ME office, where the family can view him at that time. RP verbalizes understanding of this. Record Review of the City Fire department report dated [DATE] revealed in relevant part: Alarm Time: 07:32:54, [DATE]; Arrival Time: 07:39:56, [DATE] Incident Narrative: Fire Department was dispatched to a CPR call to the (facility) address mentioned above. Medic arrived on scene at the same time. Patient contact was made and staff had initiated CPR. Medic assumed care. After providing care and continuing CPR, Medic declared field term. Record review of EMS Patient Care Report revealed in relevant part: Date of Service: [DATE]; Nature of call: Cardiac Arrest/Death; Pt. Found: In bed; Times: En route: 07:35 [DATE] At scene: 07:39 [DATE] At Patient: 07:42 [DATE] In service: 08:15 [DATE] Primary Symptoms: Cardiac Arrest Assessments completed revealed: Cardiac Arrest-Yes prior to Ems arrival Resuscitation Attempted-Attempted verification; initiated chest compressions Initial CPR-[DATE] 07:42:00 Estimated Time of Arrest: >20 minutes CPR Prior to Arrival-Yes Resuscitation Attempted by: Healthcare professional (non-EMS) Patient Dead on Arrival: No CPR Types: Compressions-External Plunger Type Device CPR provided prior to EMS care-Yes AED Used prior to EMS care-Yes, applied with defibrillation End of Cardiac Arrest event-Expired in the field AED used by-Healthcare professional (non-EMS) CPR provided by-Healthcare professional (non-EMS) Narrative: Medic dispatched emergency traffic to listed address for cardiac arrest. Unit responded immediately with no delays en route. Unit arrived on scene of nursing home along with fire department. Crew was met at front door by nursing home staff and guided to PT room. Upon entering room, nursing staff was performing manual chest compression along with BVM ventilation. Nursing staff had AED in place but stated that they had not delivered and defibrillations. PT was found to be a [AGE] year old male lying in supine position on bed inside of nursing home. PT was noted to be pulseless, apneic (involuntarily and temporarily stop breathing), and unresponsive. PT was found to be emaciated (abnormally thin an weak) . Nursing staff stated PT was a full code. Manual CPR and BVM ventilations were taken over from nursing staff. Nursing staff stated that PT was last seen approximately ,d+[DATE] minutes prior to EMS arrival. Nursing staff stated that they performed shift change and PT was found unresponsive and pulseless after shift change. Nursing staff stated that they immediately called 911. BC arrived on scene and report was given. Epinephrine was administered. Cardiac rhythm was noted to change to PEA. ETCO2 was noted to steadily decline throughout call until reading 0, BC was consulted, and decision was made to perform field termination due to ETCO2 reading of 0, no neurologic response including pupillary reaction, and lack of improvement despite interventions. Field termination was performed. Crew remained on scene until law enforcement arrived on scene. Law enforcement arrived on scene, scene was left with law enforcement. In an interview with EMS Medic Supervisor on [DATE] at 11:26 AM, he said when EMS arrived at the scene a facility staff was improperly performing chest compressions on CR#1. He said the staff could not provide an account of what may have been happening with CR#1 prior to him being found unresponsive because he had not been seen by anyone at least 30 minutes prior. He said the resident appeared to be pale, but was still warm to the touch. He said the staff was not performing the compressions deep enough into the resident's chest when EMS arrived. He said the resident was also lying in his bed without a cardiac board underneath him, which was inappropriate. He said the risk associated the improper CPR interventions was further injury and possibly death. He said EMS immediately took over life saving measures for CR#1 from the facility staff. In an interview with CNA B on [DATE] at 2:16 PM, she said when she checked on CR #1 around 8:00 or 9:00 PM, he looked agitated and desperate to get out of his bed. She said CR #1 was typically aggressive with staff when they had to touch him to assist him. She said CR #1 allowed her to assist him with removing his clothing without any resistance. She said CR #1 normally spoke in small phrases. She said CR#1 did not speak at all. She said CR#1 was usually cold and liked to keep his blanket on top of CR#1. She said that night, it seemed like CR#1 did not care about not being covered up with his blanket. She said she went to the nurses station and told LVN A that CR#1 was acting abnormal. She said she checked on CR#1 again between 11:00 PM and midnight. She said the resident still looked agitated and was not speaking. She said CR#1 felt cold to the touch, appeared pale, and his veins were very visible and green. She said CR#1 was looking up at the ceiling in the direction of the light, with both arms stretched out like he was reaching for the light. She said CR#1's legs were off of his bed, so she assisted him with adjusting back into his bed. She said the resident did not resist CNA B touching him this time either. She said between 4:00 AM and 5:00 AM, CNA C assisted her with CR#1's incontinent care. She said CR #1 was still looking at the ceiling and reaching toward the light with both arms. She said CNA C told her CR#1 looked like he was not going to make it. She said she told CNA C that LVN A was already aware of CR#1's condition. She said the last time she saw CR#1 was around 6:00 AM when she passed by CR#1's room, she said she could see he was still lying in his bed with both arms still stretched out toward the ceiling. She said around 6:30 AM, she went back to LVN A to ask if she checked on CR#1. She said she told LVN A CR#1 still did not look good. She said LVN A told her she might go check on CR#1 again. She said she did not know whether LVN A assessed CR#1. She said she did not tell anyone else about the resident's change in condition. She said she did not see CR#1 again before leaving the facility at 7:00 AM. She said a change in condition was when a resident had a change in behavior. She said when she observed a change in condition in a resident, she was supposed to notify the nurse. She said she never observed CR#1 put anything in his mouth. Please note, CR#1's observed behavior of holding his arms up was an unusual behavior that had not been seen before. Record review of CR#1's electronic record revealed no documented nursing assessment related to CAN B's change in condition reports, completed for CR#1 on ,d+[DATE] through [DATE]. In an interview with CNA A on [DATE] at 2:21 PM, she said she arrived at the facility for work and made it to the 400 hall around 7:18 AM. She said LVN A and LVN B were near room [ROOM NUMBER] doing morning report for their shift change. She said she was the only CNA that worked 400 hall during the 7:00 AM to 7:00 PM shift. She said she began doing her rounds on the 400 hall. She said when she got to CR#1's room looked like he had passed away. She said she observed him lying in bed, with his arms crossed, and one hand on top of the other. She said she thought this was strange because CR#1 always did a lot of moving throughout the night. She said she had never found the resident in his bed with his sheets or covers perfectly straightened out on top of him She said she touched his hand and shoulder, and they were ice cold. She said she went into the hall where LVN A and LVN B were, standing near room [ROOM NUMBER], and told LVN A and LVN B, CR#1 had died . She said LVN A walked away from CNA A and LVN B ran to CR#1's room. She said when CNA A and LVN B made it to CR#1's room, LVN B asked where LVN A went and began yelling for LVN A to come assist LVN B. She said LVN B yelled for LVN A to call 911, while LVN B called the DON. She said she went to hall 200 to alert LVN E to assist LVN B in CR#1's room. She said on her way back to the resident's room, LVN B was still standing at the nurse's station. She said when she made it to CR#1's room, LVN C was performing CPR on the resident in his bed. She said LVN E also assisted with CPR on the resident. She said LVN B came into the resident's room a little while later and seemed uninterested in what was happening. She said the police and EMS showed up soon after that. She said she did not know what time it was when she found the resident unresponsive. She said she did not know what time LVN C began CPR on the resident. She said she did not know what time 911 was called. She said she did not know who verified the resident's code status. She said she did not know whether a cardiac board was placed underneath the resident in his bed before facility staff began performing CPR. In an interview with LVN A on [DATE] at 3:11 PM, she said she completed her final round on the 400 hall around 6:30 AM. She said CR#1 was not in distress and there was nothing different about the resident. She said she made sure the resident was breathing by watching the rise and fall of CR#1's chest. She said LVN A and LVN B counted controlled medications together and gave each other report on residents. She said she never observed any of the changes in condition CNA B reported to LVN A. She said she went back to the nurse's station. She said she did not know what time it was, but CNA A came to the nurse's station and told LVN A, LVN B needed LVN A's assistance in CR#1's room because CR#1 was unresponsive. LVN A said when she got to CR#1's room he was unresponsive, with no rise or fall of his chest taking place. LVN A said she assessed CR#1 and he did not have a pulse. LVN A said she was experiencing dire emergency symptoms of Irritable Bowel Syndrome (IBS). LVN A said she left CR#1's room to go to the restroom. LVN A said if she did not go to the restroom at that moment, she would have defecated on herself. LVN A said she saw LVN B go get the crash cart and when LVN A returned to CR#1's room after her emergency, she saw LVN C performing chest compressions. She said CR#1 was in his bed while CPR was performed. She said CR#1 was never moved to the floor. She said the facility crash cart had a backboard on it, but LVN A was not sure whether the board was placed underneath CR#1. LVN A said she did not know if it was appropriate to perform CPR on an individual lying in bed without a cardiac board under the individual. She said she did not know if a code was called throughout the facility for CR#1. She said she did not know at what time, but LVN F called 911. LVN A said she went back to the restroom, and when she returned, she tried to stay out of everyone's way. LVN A said she did not know how long LVN A was in the restroom either time she left CR#1's room. She said EMS had arrived and placed a machine to perform chest compressions on CR#1. She said she did not know what how long EMS worked on CR#1. She said she did not know what time EMS pronounced CR#1 deceased . She said she did not know if anyone documented the full code. She said she did not document anything related to CR#1's code, nor did she review any notes, related to CR#1's full code, for accuracy. Interview with LVN B on [DATE] at 2:51 PM, she said CNA A told LVN A and LVN B, CR#1 was in his room unresponsive. She said she immediately went to CR#1's room. She said she knew CR#1 had been deceased for at least two hours. CR#1 was already deceased because his jaw was contracted and had no color to his skin. She said this was around 7:15 AM. She said she checked his pulse and respiration but none were present. She said around 7:20 AM, she used a blood pressure machine with a cuff, on the resident to check his blood pressure. She said there was no blood pressure read; the machine kept giving an error message. She said even though as nurses, they all knew CR#1 was already deceased , if he was a full code, they would still need to initiate CPR because the EMS operator would ask for this information. She said she felt like LVN A was leaving LVN B to deal with CR#1 being unresponsive, all by herself. She said LVN A made her upset because she tried to leave the facility at the time they found CR#1 unresponsive. She said LVN A was acting very strange. She said she wanted to She said she told CNA A not to let LVN A leave the building. She said she told LVN A that CR#1 was LVN A's resident too, and that she needed to help LVN B. LVN B said she called the DON around 7:30 AM. LVN B called the DON before any of the nurse's initiated CPR or checked for CR#2's code status. LVN B stated the DON told LVN B CR#1 was full code. She said she knew how to check a resident's code status, but the DON did it for her. LVN B said the DON gave LVN B directives to give to the team of nurses that needed to respond to the code. LVN B said the DON instructed to call 911, get the crash cart and to initiate CPR on CR#1. LVN B said she asked LVN A to call 911, but LVN A refused. LVN A said LVN F called 911, LVN C began chest compressions, LVN B brought the crash cart to CR#1's room and LVN E began connecting the ambu bag (medical tool which forces air into the lungs of patients who have either ceased breathing completely or who are struggling to breathe properly and need additional assistance) and AED machine. LVN B said 911 was called around 7:30 AM. LVN B said LVN A went to the restroom while all of this was happening. She said she did not know if a code status was called in the building, but all the nurses were close by and came to assist. She said a board was not placed under CR #1 while CPR was performed by facility staff. LVN B said all of the nurses in the room knew CR#1 was already deceased when they began CPR. She said CR #1 was lying in his bed, flat, in the lowest position, while CPR was performed. She said she heard CR #1's ribs crack when LVN C performed the first set of chest compressions. She said LVN C, LVN D, and LVN E took turns doing chest compressions until EMS arrived and took over. She said the nurses performed CPR on CR#1 while he lay in his bed. She said a cardiac board was not placed underneath CR#1 before they started CPR. She said the nurses performed CPR on CR#1 for about 20 minutes before EMS arrived. LVN B was not sure of time frames of she gave regarding initiating CPR on CR#2. In an interview with LVN C on [DATE] at 4:12 PM, she said at about 7:20 AM, CNA A came to the nurse's station and told her CR#1 was in his bed, deceased . She said she walked over to LVN A and LVN B who were near the resident's room speaking to each other. She said she did not think the resident was deceased because LVN A and B seemed like they were having a normal conversation. She said when she got closer, she could hear LVN A and LVN B talking about the resident being deceased . She said she told LVN A and LVN B that an RN needed to be notified immediately. She said LVN B left, and was gone for more than a minute, but less than 5 minutes. She said LVN B returned, told LVN C CR #1 was a full code and CPR needed to be initiated. She said LVN B and LVN C were the first staff to go into the resident's room to begin CPR. She said the resident's body was cold to the touch and slightly stiff. She said she was the first nurse to do chest compressions on the resident. She said the resident was lying in his bed when she began the chest compressions. She said she knew there was a cardiac board on the crash cart. She said she did not recall seeing a cardiac board under the resident when she began chest compressions. She said she did not recall placing a cardiac board under CR#1 before LVN C began chest compressions on CR#1. In an interview with LVN D on [DATE] at 10:45 AM, she said she did not know what time it was, but she knew she had not been at work longer than an hour. LVN D said her shift began at 7:00 AM. She said she was administering medications to her residents on hall 300. She said she was walking down the hallway to go and get something near the nurses station and saw commotion on the 400 hall. She said she went to see what was going on, then jumped in and offered support. She said she could not remember whether there was a code called throughout the facility or not. She said CR#1 was lying in his bed unresponsive while LVN F was performing chest compressions on the resident. She said she thought there was a white board underneath CR#1's body, but she was not sure. She said she could not tell whether the resident appeared normal or not because she was not familiar with CR#1. She said she did not remember whether CR#1's body felt warm or cold to the touch. She said she could not remember everyone present in CR#1's room because there was so much happening. LVN D said LVN F looked tired. She said she told LVN F she could take over chest compressions. She said all of the nurses stepped back from CR#1 after being instructed by the AED machine to stand clear. She said when the AED machine instructed for chest compressions to begin again, LVN D took over performing chest compressions on CR#1. She said EMS arrived to CR#1's room before LVN D completed a full set of chest compressions. She said EMS immediately took over and she returned to 300 hall because she had to finish administering medication to residents. In an interview with the DON on [DATE] at 10:50 AM, she said she was aware there was a delay in calling 911. She said received a phone call from LVN B informing her CR#1 was deceased . She said she was told CNA A found CR#1 unresponsive in his bed at 7:15 AM. She said she did not remember the exact time of the phone call, but believed it was around 7:30 AM on [DATE]. She said she accessed CR#1's medical information from her phone to verify CR #1's code status, which was full code. She said she instructed LVN B to have all available nurses assist with calling 911, obtaining the crash cart and beginning CPR. She said the 911 call was placed immediately after the DON gave the directive to LVN B. She said she became aware CPR was performed on CR #1 while lying in his bed once she arrived at the facility and received a report from LVN B on [DATE]. She said from what she was told, LVN C was the first nurse to perform chest compressions. She said she could not recall off the top of her head who called 911 and who brought the crash cart to the CR#1's room. She said she also realized there was no one recording or writing and keeping times during CR#1's full code. The DON said there was room for the facility to improve on their preparedness for full code. She said the facility had already began working on making improvements. She said she did not recall asking or being told by any of the nurses involved whether a cardiac board was used during CPR on CR#1. She said if a cardiac board was not used, this was also inappropriate and would need to be addressed. She said the risk of performing CPR on a person without a cardiac board underneath them was chest compressions being performed improperly or not deep enough into the chest. the DON said improper chest compressions could cause injury to an individual's back. Please note, CR#2's code status was only checked by the DON. In an interview with the Administrator on [DATE] at 12:51 PM, he said he received a voicemail from the DON the morning of [DATE], asking him to return the DON's phone call. He said he could not remember the exact time of the phone call, but the Administrator called the DON back as soon as he got to his phone. He said she informed him CR#1 was a full code , and that EMS and police had arrived at the facility. He said he spoke more to the DON when he arrived at the facility that morning. He said based on the current status of the facility's investigation, the staff handled CR#1's full code appropriately. The Administrator said there was no delay in initiating CPR. He said the DON was contacted by one nurse at the same time as another nurse called 911, another nurse grabbed the crash cart, and another nurse began chest compressions. He said all these actions took place simultaneously. He said he was also unaware a cardiac board was not used while CPR was performed on CR#1. He said he was working on obtaining a copy of the EMS report. In an interview with LVN E on [DATE] at 5:48 PM, he said he was working on his hall when CNA A came and told him there was an unresponsive resident and he needed to come and assist. He said when he made it to CR#1's room, LVN D was already doing chest compressions on CR#1. He said the resident was lying on his bed while the nurses performed CPR. He said he did not pay close attention to CR#1's condition or appearance when he came into the room. He said he was not familiar CR#1 prior to this incident. He said he did not notice whether a board was underneath the resident during CPR. He said he was focused on helping to save the resident's life. He said he immediately grabbed the ambu bag and placed it over CR#1's mouth. He said he thought LVN B had brought in the crash cart into CR#1's room, but he was not for sure. He said he could not remember the names of all the people in CR#1's room at that time because there was so much going on. He said he told one of the night nurses to call 911 but was not sure who called 911. He said he was not familiar with the night nurses. He said he did not know what time 911 was called. He said he could not remember which nurses performed chest compressions on the resident, but he knew there was more than one. He said all of the nurses were helping out during the code. He said when EMS arrived, everyone stepped back and let EMS take over. He said he returned to his hall to work because EMS had taken over and the nurses that worked on the hall were there. In an interview with DON on [DATE], she said she was not at the facility at the time of the incident. She said staff called her when they found CR#1 unresponsive. She said when a resident is found unresponsive the expectation was to attempt to alert the resident, assist them in lying flat on their backs, call for help, verify code status and initiate CPR if necessary, call 911, make notifications to DON and responsible party. She said it was possible for these things to happen at the same time depending on how many individuals were available to assist during a full code. She said when a change in condition was reported to a nurse, the nurse was supposed to perform a head to toe assessment, document a change in condition assessment in the resident's electronic health record with vital signs and blood pressure, contact the resident's doctor, notify the responsible party and the DON. She said if the nurse did not observe a change in condition during assessment of the resident, the nurse needed to document the reported concerns and what was observed during the assessment. Record review of facility policy on Cardiopulmonary Resuscitation (CPR) revised ,d+[DATE] revealed: It is the policy of this facility to provide basic life support (BLS), including CPR, to any resident requiring such care prior to the arrival of emergency medical personnel in the absence of advance directives or a Do Not Resuscitate order. Only staff members with current CPR certification for Healthcare Providers should perform the procedure. Only staff members certified to perform CPR shall perform the procedure. Procedure: 1. Check for responsiveness, quality of breathing and pulse simultaneously. 2. If unresponsive, not breathing .and no pulse, activate EMS system: Page of yell loudly for Code Blue to the area. Call 911. If available, bring AED to unresponsive person. 3. Start CPR per American Heart Association guidelines. 4. Do not stop CPR except in one of these situations: Sign of breathing and pulse activity. An AED is ready to use. Another trained responder of EMS personnel take over. Responder is too exhausted to continue. The scene becomes unsafe. AED, if available: a. Turn on AED. b. wipe bare chest dry. c. Attach pads. d. Plug in connector, if necessary. e. Clear rescuers from victim. Communicate clearly to all other rescuers to stop touching the victim. f.let AED analyze heart rhythm. g. If shock is advised, say, everyone stand clear.h. Deliver the shock. i. After delivering the shock, or if no shock is advised: Resume CPR per American Heart Association. Continue to follow the prompts of the AED. If at any time an obvious sign of breathing and pulse activity is noted, stop CPR and monitor breathing and for any changes in condition until EMS personnel take over. This was determined to be an Immediate Jeopardy (IJ) on [DATE] at 6:25 PM. The Administrator was notified. The Administrator was provided the IJ template on [DATE] at 6:25 PM. The POR submitted by the Administrator was accepted on [DATE] at 3:47 PM. The POR revealed: Plan of Removal F678 [DATE] The facility failed to ensure that nursing staff provided CPR in accordance with professional standards. 1. The Medical Director was notified of IJ on [DATE] at 8:22 pm 2. Review of nursing staff personnel files was completed by , Director of Human Resources and validated by , RN, Director of Nursing to ensure current Licensed Nurses held a current CPR card completed [DATE]. 3. Review of all 86 resident physician orders for DNR/Full CODE status was completed by Director of Medical Records, and validated by t, RN, Director of Nurses completed; CODE status is located in the EMR a [TRUNCATED]

Based on interviews and record reviews the facility failed to ensure that licensed nurses have the specific competencies and skill sets necessary to care for residents' needs, as identified through resident assessments, and described in the plan of care for 2 of 21 nurses (LVN A and LVN G) reviewed for competencies and skill sets for assessments. 1. The facility failed to ensure LVN A immediately and properly assessed CR#1 after the resident's change in condition was identified by CNA B as reported to be acting abnormally. 2. The facility failed to immediately and properly assess CR#1 after an additional change in condition was identified by CNA B as reported to appear pale and not look good. 3. The facility failed to assess and monitor CR#1 for approximately 10 hours after a change in condition was identified. 4. The facility failed to complete competency checks for LVN A and LVN G. 5. The facility failed to complete competency checks prior to the nurses assuming job duties An Immediate Jeopardy (IJ) situation was identified on [DATE]. The IJ template was provided to the facility on [DATE] at 6:25 PM. While the IJ was lowered on [DATE], the facility remained out of compliance at a scope of isolated and a severity level of actual harm that is not an Immediate Jeopardy, because all staff had not been effectively trained to ensure residents receive ongoing monitoring after a change in condition is identified. These failures placed residents at risk of harm, including death from delayed medical intervention and prompt treatment. Findings include: In an interview with the DON on [DATE] at 1:26 PM, she said that she did the initial orientation with newly hired nurses and met with them for the electronic software training. She said then, new hires shadowed the floor with a nurse; or, whatever their discipline is over a period of 4 days. The DON said on the 1st day they (new hires) shadowed someone; on the 2nd or 3rd day, they worked with a few residents; and the 4th day the new hire will provided resident care with someone overseeing them. She said a new nurse, as in first nursing job, had a longer orientation. The DON said the facility planned a skills fair for staff on [DATE]. She said part of the purpose of the fair was to have staff complete their checklists, and set up a RT (respiratory training). She said the fair did not happen , and would need to be rescheduled. She said she was setting up a competency check off list. She said the last batch of new hires were given the competency checklist to complete . The DON said the checklist was to be checked off and returned back to the DON. She said prior to this new process, the DON discussed things with new hires, but did not have a formalized document or system. The DON said the nurses that were not new, had a yearly competency check. She said she did not know what was done to assess nurse competency prior to her start at the facility a few months ago. The DON said at that time, she only had competency checks for nurses hired within the last two weeks. She said she did not have competency checks for any other nurses . She said she did not really have competency checks for original nurses. The DON said she implemented the new system within the last 2 weeks. Surveyor requested the competency checks for the new hires as well as a blank document. In an interview with the DON on [DATE] at 2:34 PM, she said she did not have any completed forms for the newly hired nurses, as they had not returned the document to her. DON provided a blank competency check. In an interview with the Administrator on [DATE] at 2:40 PM, he said he had lessons learned on this journey. He said the facility had started performing competency checks on nursing staff. He said the facility would complete competency checks before the new staff could get a schedule. He said, moving forward, during the staff morning meeting, the Administrator would ask about any staff scheduled for orientation. He said he had worked at the facility since [DATE]. The administrator said nursing competency would be taken care of by the nursing team, but now he would be heavily involved in the process. In an interview with Clinical Resource and Clinical Market Leader on [DATE] at 3:02 PM, they said the DON should monitor to ensure the competency of nursing staff simply based on the nurses work being in the building . She said DON does that. Historically there wasn't a system. She said new hires skills check off was a system in place, and DON wasn't doing them, but the annual competency check was in place. Surveyor requested a copy of each nurse's competency check off, but it was not provided to surveyor before exit. At the time of exit, the facility was unable to provide any completed competency check forms for LVN A and LVN G. The facility was unable to provide any new hire competency check off forms. Record review of LVN A Employee file revealed LVN A was hired on [DATE]. The New Employee Orientation Checklist dated [DATE] was blank and not signed off by a supervisor. The employee file did not include a competency check list. Record review of LVN G Employee file revealed her hire date was [DATE]. The employee file did not have a New Employee Orientation Checklist or Competency Checklist. CR#1 Record review of CR#1's face sheet, dated [DATE], revealed CR#1 was a [AGE] year-old male who was admitted to the facility, from the hospital, on [DATE]. He was diagnosed with displaced fracture of base of neck of right femur sequela (condition or injury related femur fracture); unspecified severe protein-calorie malnutrition; Alzheimer's Disease. Unspecified; acute osteomyelitis (inflammation of bone caused by infection) of the left femur; other complications of sequela procedure, not elsewhere classified; generalized muscle weakness; dysphagia (difficulty swallowing foods or liquids) oropharyngeal phase ; unspecified lack of coordination; and cognitive communication deficit. Record review of CR#1's MDS assessment dated [DATE] revealed a BIMS Summary score of 1 indicating severe cognitive impairment. Physical and verbal behaviors exhibited and significantly interfered with the resident's care. The functional status revealed bed mobility, locomotion off the unit, dressing, toilet use and personal hygiene were extensive assistance with two person physical assist and two person assist for transfer. Record review of CR#1's Care Plan , revised on [DATE] revealed, CR#1 had interventions for falls, nutrition, sand pressure ulcers, but no diagnosis or specification for CR#1 requiring those interventions. CR#1 was at risk for falls; therapy evaluation and treatment per order, ensure call light is in reach and encourage its use for assistance, bed in lowest position, bedside floor mats, maintain clear pathways free of clutter. Nutritional problems; administer medications as ordered, monitor/document side effects and effectiveness, unspecified diet as ordered, provide supplements as ordered. Resident had potential for pressure ulcer development; encourage fluid intake and assist keeping skin hydrated, monitor nutritional status, intake and record, serve diet as ordered, weekly head to toe assessment. He also took anxiety medication; give medications as ordered and monitor/document side effects and effectiveness, monitor, record, document behavior symptoms. CR#1 wished to be discharged back to memory care; establish a pre-discharge plan, make arrangements to support independence post-discharge. He also had an unspecified infection; maintain standard precautions when providing care, monitor temperature and pulse. The resident was on hypnotic therapy related to Insomnia; daily recommended dose not to be exceeded unless ordered by MD, inform of risks, benefits and side effects, precede or accompany hypnotic use by other interventions to improve sleep. CR#1 elected full-code status; initiate full-code measures in case of cardia arrest, to include CPR and AED use. He was at risk of impaired cognitive function related to Alzheimer's Disease; keep routine consistent, give step-by-step instructions, use simple instructions and provide cues when necessary. The resident had a self-care performance deficit; transfers required 2-person assist, encourage resident to participate to the fullest extent possible with each interaction. He had the potential for mood problems related to admission; encourage to express feelings, assist to identify strengths and positive coping skills. CR#1 was resistive to care related to Alzheimer's Disease; give clear instructions for all care activities, allow to make decisions about treatment regime. Record review of CR#1's physician orders revealed the following: CR#1 was full-code status. Record Review of CR#1's Progress Notes revealed: Effective Date: [DATE] 08:27 Type: Nursing Resident was resting quietly in bed lying supine (facing upward) on LVN A first round of the shift. CNA B gave resident 3 half sandwiches for snack. CNA B reports to LVN A that resident has been agreeable with brief changes this shift, lifting up his buttocks so he can be changed. LVN A rounded resident more frequently because his legs were observed coming out of the bed on the side of bed next to the air conditioner. SN put resident's legs back in the bed 3 times & covered him with his sheet & blanket. SN asked resident if he needed anything & he didn't answer. Resident was observed resting with eyes closed after the 3rd time of placing his legs back in bed. LVN A & CNA B took turns making rounds on resident to make sure he was comfortable, safe in the bed & needs met. CNA B told SN that she thought resident's color looked yellow. LVN A observed resident to be his normal pale color. SN did not observe resident in any distress on any round SN made. Author: LVN A Nursing - LPN Effective Date: [DATE] 08:34 Type: Nursing DON notified Physician Assistant of resident's passing. DON attempted to notify Family Member. Called 3 times, phone went to voicemail each time, left HIPAA compliant voice message for call back. DON attempted to notify RP. Called and left HIPAA compliant voice message for call back. There is a note not to inform with emergencies so she was not called. Author: DON Effective Date: [DATE] 08:43 Type: Nursing DON notified by phone at about 0725 that resident was found unresponsive. Nursing staff initiated CPR. Author: DON [DATE] 9:11 Author: DON DON spoke to RP and notified him of resident passing. DON explained how resident was found and that CPR was initiated, EMS took over however unable to recover pulse. He stated he would be speaking to his mother to let her know about resident passing. DON informed him that Medical Examiner would be transporting CR#1 to the ME office, where the family can view him at that time. RP verbalizes understanding of this. Record Review of the City Fire department report dated [DATE] revealed in relevant part: Alarm Time: 07:32:54, [DATE]; Arrival Time: 07:39:56, [DATE] Incident Narrative: Fire Department was dispatched to a CPR call to the (facility) address mentioned above. Medic arrived on scene at the same time. Patient contact was made and staff had initiated CPR. Medic assumed care. After providing care and continuing CPR, Medic declared field term. Use: EMS Response Delays: None/No delays Dispatch Time: 07:35:55, [DATE] Enroute Time: 07:35:55, [DATE] Arrival Time: 07:35:56, [DATE] Clear Time: 08:02:01, [DATE] Actions Taken: Provide basic life support (BLS) Record review of EMS Patient Care Report revealed in relevant part: Date of Service: [DATE]; Nature of call: Cardiac Arrest/Death; Pt. Found: In bed; Times: En route: 07:35 [DATE] At scene: 07:39 [DATE] At Patient: 07:42 [DATE] In service: 08:15 [DATE] Primary Symptoms: Cardiac Arrest Assessments completed revealed: Cardiac Arrest-Yes prior to Ems arrival Resuscitation Attempted-Attempted verification; initiated chest compressions Initial CPR-[DATE] 07:42:00 Estimated Time of Arrest: >20 minutes CPR Prior to Arrival-Yes Resuscitation Attempted by: Healthcare professional (non-EMS) Patient Dead on Arrival: No CPR Types: Compressions-External Plunger Type Device CPR provided prior to EMS care-Yes AED Used prior to EMS care-Yes, applied with defibrillation End of Cardiac Arrest event-Expired in the field AED used by-Healthcare professional (non-EMS) CPR provided by-Healthcare professional (non-EMS) Narrative: Medic dispatched emergency traffic to listed address for cardiac arrest. Unit responded immediately with no delays en route. Unit arrived on scene of nursing home along with fire department. Crew was met at front door by nursing home staff and guided to PT room. Upon entering room, nursing staff was performing manual chest compression along with BVM ventilation. Nursing staff had AED in place but stated that they had not delivered and defibrillations. PT was found to be a [AGE] year old male lying in supine position on bed inside of nursing home. PT was noted to be pulseless, apneic (involuntarily and temporarily stop breathing), and unresponsive. PT was found to be emaciated (abnormally thin an weak) . Nursing staff stated PT was a full code. Manual CPR and BVM ventilations were taken over from nursing staff. Nursing staff stated that PT was last seen approximately ,d+[DATE] minutes prior to EMS arrival. Nursing staff stated that they performed shift change and PT was found unresponsive and pulseless after shift change. Nursing staff stated that they immediately called 911. BC arrived on scene and report was given. Epinephrine was administered. Cardiac rhythm was noted to change to PEA. ETCO2 was noted to steadily decline throughout call until reading 0, BC was consulted, and decision was made to perform field termination due to ETCO2 reading of 0, no neurologic response including pupillary reaction, and lack of improvement despite interventions. Field termination was performed. Crew remained on scene until law enforcement arrived on scene. Law enforcement arrived on scene, scene was left with law enforcement. In an interview with EMS Medic Supervisor on [DATE] at 11:26 AM, he said when EMS arrived at the scene a facility staff was improperly performing chest compressions on CR#1. He said the staff could not provide an account of what may have been happening with CR#1 prior to him being found responsive because he had not been seen by anyone at least 30 minutes prior. He said the resident appeared to be pale, but was still warm to the touch. He said the staff was not performing the compressions deep enough into the resident's chest when EMS arrived. He said the resident was also lying in his bed without a cardiac board underneath him, which was inappropriate. He said the risk associated the improper CPR interventions was further injury and possibly death. He said EMS immediately took over life saving measures for CR#1 from the facility staff. Record review of CR#1's electronic record revealed that there was not an assessment completed for CR#1 on ,d+[DATE] through [DATE]. In an interview with CNA B on [DATE] at 2:16 PM, she said when she checked on CR #1 around 8:00 or 9:00 PM, he looked agitated and desperate to get out of his bed. She said CR #1 was typically aggressive with staff when they had to touch him to assist him. She said CR #1 allowed her to assist him with removing his clothing without any resistance. She said CR #1 normally spoke in small phrases. She said CR#1 did not speak at all. She said CR#1 was usually cold and liked to keep his blanket on top of CR#1. She said that night, it seemed like CR#1 did not care about not being covered up with his blanket. She said she went to the nurses station and told LVN A that CR#1 was acting abnormal. She said she checked on CR#1 again between 11:00 PM and midnight. She said the resident still looked agitated and was not speaking. She said CR#1 felt cold to the touch, appeared pale, and his veins were very visible and green. She said CR#1 was looking up at the ceiling in the direction of the light, with both arms stretched out like he was reaching for the light. She said CR#1's legs were off of his bed, so she assisted him with adjusting back into his bed. She said the resident did not resist CNA B touching him this time either. She said between 4:00 AM and 5:00 AM, CNA C assisted her with CR#1's incontinent care. She said CR #1 was still looking at the ceiling and reaching toward the light with both arms. She said CNA C told her CR#1 looked like he was not going to make it. She said she told CNA C that LVN A was already aware of CR#1's condition. She said the last time she saw CR#1 was around 6:00 AM when she passed by CR#1's room, she said she could see he was still lying in his bed with both arms still stretched out toward the ceiling. She said around 6:30 AM, she went back to LVN A to ask if she checked on CR#1. She said she told LVN A CR#1 still did not look good. She said LVN A told her she might go check on CR#1 again. She said she did not know whether LVN A assessed CR#1. She said she did not tell anyone else about the resident's change in condition. She said she did not see CR#1 again before leaving the facility at 7:00 AM. She said a change in condition was when a resident had a change in behavior. She said when she observed a change in condition in a resident, she was supposed to notify the nurse. She said she never saw CR#1 with a ribbon . She said she never observed CR#1 put anything in his mouth. In an interview with CNA C on [DATE] at 12:46 PM, she said around 5:00 AM she assisted CNA B with the CR#1's incontinent care. CNA C said this was her first time helping CNA B with CR#1's incontinent care. She said CR#1 typically fought and grabbed staff during care. She said CR#1 did not like to be touched. She said CR#1 looked ill. She said CR#1 just did not look good at all. She said CR#1 was lying in his bed and appeared pale from the neck up. She said CR#1's body was shaking the entire time CNA B and CNA C provided CR#1 incontinent care. She said she told CNA B that CR#1 needed to be checked by a nurse. She said CNA B told CNA C she already reported CNA B's concerns about CR#1 to LVN A . She said after she and CNA B finished with CR#1, she went back to the 200 hall. She said she only saw CR#1 during incontinent care on that day. She said she did not report her concerns about CR #1 to LVN A because CNA B told her she had already reported to LVN A, and CNA B was CR #1's regular care staff. She said a change in condition was when a resident lost weight or became aggressive. She said if she observed a change in condition in a resident, she would report it to a nurse. In an interview with LVN A on [DATE] at 3:11 PM, she said she saw CR#1 at least 3 times throughout her shift. She said each time she went into CR#1's room that night, LVN A placed CR#1's legs back in his bed because they were hanging off to the side. She said CNA B performed frequent rounds on residents considered fall risks. She said CR#1 was a fall risk. She said some time in the middle of her 7:00 PM to 7:00 AM shift, CNA B told LVN A CR#1 was yellow or pale. She said CNA B did tell LVN A CR#1 looked pale. She said she could not remember the exact time. She said she immediately went to CR #1's room to check on him. LVN A said she stood at CR#1's bedside and observed him. She said CR#1 did not speak to LVN A, but CR#1 did acknowledge LVN A's presence. LVN A said CR#1 was lying in in the center of his bed, on his back. She said she observed CR#1's legs, fingers, chest and face but nothing seemed different about the resident. She said she checked CR#1's breathing by observing the rise and fall of his chest and CR#1 was breathing fine. She said she never saw CR#1 with a ribbon or with his hands stretched out reaching toward the ceiling of CR#1's room. She said based on her nursing knowledge and observations of CR#1, LVN A said she did not see a change of condition in CR#1. She said even though CNA B said CR#1 was pale, LVN A did not see anything negative with CR#1. LVN A said when she performed a resident assessment she checked vitals, asked if they have any complaints or pain, verify medications had been given on time; and, identify any skin issues. She said she checked CR#1's vitals when she began her shift. LVN A said she felt she completed a thorough assessment on CR#1 at the time CNA B expressed concerns about CR#1. LVN A said she did not check CR#1's vitals. She said there was no specific reason why she did not check CR#1's vitals. She said she did not feel like it was necessary to check CR#1's vitals. She said if CR#1 exhibited a change in condition at the time LVN A observed CR#1, LVN A would have checked CR#1's vitals and documented her assessment. She said she should have checked CR#1's blood pressure, but still felt like LVN A performed a thorough assessment on CR#1. She said she had not completed any trainings since transferring to the facility. LVN A said however, as nurse she had been trained on change of condition, nursing assessments, and abuse, neglect and exploitation. She did not notify the DON or CR#1's physician. She said she did not recall whether she told the oncoming nurse, LVN C, about CNA B's concerns for CR#1. LVN A said she did a final round on the 400 hall between 6:00 AM and 6:30 AM. She said when she checked on CR#1 there was no distress. In an interview with CNA A on [DATE] at 2:21 PM, she said she arrived at the facility for work and made it to 400 hall around 7:18 AM. She said LVN A and LVN B were near room [ROOM NUMBER] doing morning report for their shift change. She said she was the only CNA that worked 400 hall during the 7:00 AM to 7:00 PM shift. She said she began doing her rounds on the 400 hall. She said when she got to room [ROOM NUMBER], CR#1 looked like he had passed away. She said she observed him lying in bed, with his arms crossed, and one hand on top of the other. She said she thought this was strange because CR#1 always did a lot of moving throughout the night. She said she had never found the resident in his bed with his sheets or covers perfectly straightened out on top of him She said she touched his hand and shoulder, and they were ice cold. She said she went into the hall where LVN A and LVN B were, standing near room [ROOM NUMBER], and told LVN A and LVN B CR#1 had died . She said LVN A walked away from CNA A and LVN B ran to CR#1's room. She said when CNA A and LVN B made it to CR#1's room, LVN B asked where LVN A went and began yelling for LVN A to come assist LVN B. She said LVN B yelled for LVN A to call 911, while LVN B called the DON. She said she went to hall 200 to alert LVN E to assist LVN B in CR#1's room. She said on her way back to the resident's room, LVN A was still standing at the nurse's station. She said when she made it to CR#1's room, LVN C was performing CPR on the resident in his bed. Interview with LVN B on [DATE] at 2:51 PM, she said CNA A told LVN A and LVN B CR#1 was in his room unresponsive. She said she immediately went to CR#1's room. She said she knew She said she knew CR#1 had been deceased for at least two hours. CR#1 was already deceased because his jaw was contracted and had no color to his skin. She said this was around 7:15 AM. She said she checked his pulse and respiration but none were present. She said around 7:20 AM, she used a blood pressure machine with a cuff, on the resident to check his blood pressure. She said there was no blood pressure read; the machine kept giving an error message. LVN B said she asked LVN A if she observed a change in condition with CR#1. She said LVN A told her LVN A checked on CR#1 30 minutes prior. LVN B said she told LVN A she did not check on CR#1 30 minutes prior. LVN B said she was sitting at the front desk, near the nurses station and remembered looking at the clock at 6:35 AM. LVN B said LVN A was sitting at the nurses station at 6:35 AM. She said she did not know for sure whether LVN A did or did not leave the nurses station to check on CR#1. LVN B said she called the DON once CR#1 around 7:30 AM. In an interview with the DON on [DATE] at 10:50 AM, she said all facility nurses had been trained to complete and document an assessment after a reported resident change in condition. She said an assessment consisted of observing the resident from head to toe, speaking with the resident and checking vital signs and blood pressure. The DON said it was her expectation and standard practice for a change in condition to be documented in a resident's electronic health record. She said even if a nurse assessed a resident and found no change in condition, a nurse was still expected to document what they observed and what they did for the resident. The DON said if a nurse did identify a change in condition, they documented using the change in condition assessment tool in the resident's electronic health record. She said the nurse was also responsible for contacting the resident's doctor and following any directives provided, notifying the DON and the responsible party. She said change in condition notifications were also supposed to be documented in the resident's electronic health record. She said she was unaware a change in condition with CR#1 was reported to LVN A between 8:00 or 9:00 PM on [DATE]. The DON said when she spoke to LVN A immediately following CR#1's full code incident, LVN A told her she assessed CR#1 after CNA B reported a change in condition in CR#1 between 3:30 AM and 7:00 AM. The DON said she was responsible for reviewing and following up on a change in condition assessments. She said she reviewed CR#1's electronic health record on [DATE]. She said LVN A entered a progress note summarizing what the CNA told LVN A and what LVN A observed. She said she could not recall whether she reviewed a change in condition assessment for CR#1. She said vitals were documented for CR#1, which were within normal levels. The DON said she did not realize the vitals documented in CR#1's electronic health record were entered by LVN E around 1:00 AM , until made aware by surveyors. She said she was unaware LVN A did not complete an assessment on CR#1 after his reported change in condition. She said she was not aware LVN A did not check CR#1's vitals signs nor blood pressure. She said LVN A should have performed an assessment on CR#1 after the reported change in condition, documented her findings and made notifications, if it was necessary. She said the risk of not performing an assessment after a reported change in condition was a potential delay in medical care. In an interview with the Administrator on [DATE] at 12:51 PM, he said he was unaware of CR #1's change in condition was reported to LVN A between 8:00 or 9:00 PM on [DATE]. He said based on the current status of the facility's investigation, CNA B reported CR#1's change in condition to LVN A around 3:30 AM on [DATE]. He said he was not aware LVN A did not check CR#1's vitals after CR#1's change in condition was reported to her. He said he was not aware there was no documented change of condition assessment for CR#1 on [DATE] or [DATE]. He said if LVN A did not perform an assessment or check CR#1's vital signs after the change in condition was reported to LVN A, LVN A should have completed both tasks and documented her findings in CR#1's electronic health record. He said the DON was responsible for reviewing resident assessments. He said based on the facility's investigation, the DON reviewed all documentation related to the incident with CR#1 on [DATE]. Record review of LVN A Employee file revealed the New Employee Orientation Checklist dated [DATE] was blank and not signed off by a supervisor. The employee file did not include a competency check list. This was determined to be an Immediate Jeopardy (IJ) on [DATE] at 6:25 PM. The Administrator was notified. The Administrator was provided the IJ template on [DATE] at 6:25 PM. The POR submitted by the Administrator was accepted on [DATE] at 3:47 PM. The POR revealed: Plan of Removal F726 P[DATE] The facility failed to provide an ongoing monitoring of a resident after a change in condition was identified and reported. 1. The Medical Director was notified of IJ on [DATE] at 8:22 pm 2. Review of all 86 resident's progress notes by, RN, and, RN for Change of Condition completed [DATE]- all changes in condition that were identified were documented with appropriate interventions. No negative findings were identified 3. Staff on duty were interviewed by, RN, and, RN for any reports of Change of Condition completed [DATE]- all changes in condition had been identified were documented with appropriate interventions. No negative findings were identified 4. Policy Significant Change in Condition, Response was reviewed by t, RN, Director of Nurses, , RN, Clinical Resource, and via phone with, Medical Director for any revisions needed, policy revised. [DATE] assessment was enhanced to head to toe assessment including vital signs 5. Education initiated with all staff on change of condition recognition, reporting and monitoring. [DATE] completion date [DATE] 6. All staff will complete competency on change of condition initiated [DATE]. Completion date [DATE] 7. This training and competencies will be completed in-person with all staff prior to the start of their next shift. A member of management will be at the facility at each change of shift to ensure all staff complete training prior to going to work on the floor. Staff will not be allowed to work unless they have completed the training and competency checks. This training will also be included in the new hire orientation and will be included for any PRN staff prior to starting work on the floor. These staff will not be allowed to work unless they have received their training and knowledge check. 8. An ad hoc meeting regarding items in the IJ template completed [DATE]. Attendees included the Medical Director, Clinical Resource, Administrator, DON, ADON, Clinical Resources, Market Leader and Clinical Market Leader, and included the plan of removal items and interventions. 9. Due to the allegation of neglect on ,d+[DATE], the night nurse was suspended pending investigation. The day nurse resigned effective immediately on ,d+[DATE]. However, both nurses were educated on Change of Condition on ,d+[DATE] post incident. Monitoring of the plan of removal included: Following acceptance of the facility's Plan of Removal, the facility was monitored from [DATE] to [DATE]. The surveyor confirmed the facility implemented their plan of removal sufficiently from [DATE] - [DATE] to remove the IJ by: Reviewed resident's progress notes and Change of Condition reports reviewed by facility staff on [DATE]. Reviewed Significant Change in Condition, Response policy, revised on [DATE], to include head to toe assessment including vital signs. Reviewed the following in-service : Change of condition recognition, reporting and monitoring; and competency checks between [DATE] and [DATE]. Interviews were conducted with Staff from all shifts from [DATE]-[DATE] with Administrator, DON, Wound Care Nurse, 1 RN, 2 CMA's, 8 LVN's, and 10 CNA's regarding all in-services and they were able to explain the policies and procedures. Interviews were conducted with CNA A, CNA B, CNA C, the DON, and the Administrator to ensure they were in-serviced and understood the steps to be taken after a resident's change in condition has been reported. The Administrator was informed the Immediate Jeopardy (IJ) was removed on [DATE] at 2:42 PM. While the IJ was removed on [DATE], the facility remained out of compliance at a scope of isolated and a severity level of actual harm that is not immediate jeopardy due to the facility's need to provide sufficient training for staff in properly assessing residents, providing ongoing monitoring and identifying changes in condition.

Based on observation, interview, and record review, the facility failed to ensure the environment was free of accident hazards and failed to provide adequate supervision to prevent accidents for 1 resident (Resident #1) of four residents reviewed for accidents and hazards. -The side rail on Resident #1's bed was not properly fastened to the bed frame, causing it to rotate and expose a metal rod. Resident #1 was transferred from the wheelchair to the bed, his lower right leg was punctured with the exposed metal rod, resulting in Resident #1 receiving 10 staples to his right leg. -Staff transferred Resident #1 from the wheelchair to the bed using one-person transfer. Resident #1 required two persons for transfers. An Immediate Jeopardy (IJ) was identified on 08/29/2023 at 02:54 p.m. While the IJ was removed on 08/30/21 at 04:15 p.m., the facility remained out of compliance at a scope of isolated with actual harm, due to the need to evaluate the effectiveness of the corrective systems. This failure could place residents at risk for severe injury, harm, or possible death. Findings include: Record review of the Admission Record for Resident #1 (printed on 08/15/2023) revealed he was [AGE] years old and was admitted to the facility on [DATE]. Diagnoses included, but were not limited to, subdural hematoma (bleeding on/near the brain), Alzheimer's disease, and lack of coordination. Record review of Resident #1's Quarterly MDS assessment dated [DATE] revealed he required extensive assistance of 2 persons for transfers . Record review of a Physician's Order dated 07/30/2023 revealed .May use mobility bars [side rails] to aide in easy turning and repositioning while in bed . Record review of a Skin Alteration report dated 08/09/2023 revealed Resident #1 received a laceration to his right lower leg on that date. The report read in part .CNA stated it occurred when she was attempting to put resident to bed and accidently hit the metal bed railing and it caused a laceration . The resident was sent to the hospital. Record review of a NN dated 08/09/2023 at 10:32 p.m., revealed Resident #1 returned from the hospital. He had received a Tetanus shot and antibiotics. He received 10 staples in his right lower leg to close the wound. Record review of the Incident Report dated 08/09/2023 revealed the resident was oriented to person, but not to place, time, or situation . Observation on 08/15/2023 at 9:50 a.m., revealed Resident #1's bed was a low bed (frame/mattress not elevated from the floor), with fall mats on both sides. There were no side rails. Resident #1 was not in the room. Observation on 08/15/2023 at 10:49 a.m., revealed Resident #1 was in the dining room in a wheelchair. He did not respond to a verbal greeting. In an observation and interview on 08/15/2023 at 12:15 p.m., a family member said the low bed was new since yesterday (08/14/2023). He said he had taken a picture of Resident #1's leg and of the side rail after the injury. Observation on 08/15/2023 at 12:30 p.m. of the photo of the side rail revealed the bed at the time of the injury was not a low bed. The side rail was attached to the bed, but it was pivoted approximately 180 degrees, which created a hook-shaped metal rod pointing upward, slightly above the floor. In an interview on 08/15/2023 at 12:05 p.m., the DON said CNA A was transferring Resident #1 from the wheelchair to the bed. The resident's leg was caught on a metal piece of the side rail. She said CNA A lifted the resident and his leg was released from the bed. She said that was CNA A's last day. In an interview on 08/15/2023 at 2:35 p.m., a family member of Resident #1 said she had concern that he was a one-person transfer. She said she transferred him by herself, but it was difficult. She is a trained professional who transfers persons as part of her occupation. In an interview via telephone on 08/15/2023 at 2:57 p.m., CNA A said she was transferring Resident #1 from his wheelchair to the bed. She said when she stood the resident up, the side rail 'broke' and had 'two things sticking out.' She said one of the pieces became stuck in the resident's leg. She said she sat the resident on the side of the bed and the piece of the side rail came out of his leg. She said she then went and alerted the nurse. She said she was the only staff assisting in that transfer. She said some days it required two staff to transfer him, and some days it could be achieved with one staff. She said she had been employed at the facility for three weeks. She said she received very little orientation and did not know the residents' needs very well. Observation and interview on 08/15/2023 at 3:12 p.m., with the Maintenance Director revealed he said when that type of side rail became loose from the frame rail, it would rotate, exposing the sharp pieces. He demonstrated on the siderail that had been removed from Resident #1's bed. Observation revealed that when the fastening knob was loosened, the siderail was top-heavy and rotated approximately 180 degrees, exposing two pieces of metal rod, each approximately 0.5-inch diameter. The rods were curved approximately 1.5 inches from the end, creating a hook-shape that pointed upward. The demonstration was consistent with the photograph presented by the family member. Record review of a Staff Development/Inservice Attendance Sheet dated 08/09/2023 revealed CNA A attended the in-service of Transfer Training. There was no time of day scribed on the in-service. In an interview on 08/29/2023 at 9:30 a.m., the DON said all of the direct-care staff had been in-serviced on transfers and side-rail safety . On 08/29/2023 at 10:43 a.m., the in-service sign in sheets entitled Transfer Training dated 08/09/2023 was compared with the Nursing/CNA schedules for 08/24/2023 through 08/29/2023 day shift. Twenty nurses and ten CNAs who had not had the in-service had worked during the five days reviewed. On 08/29/2023 at 11:00 a.m., the in-service sign in sheets for side rail safety dated 08/16/2023 was compared with the Nursing/CNA schedules for 08/24/2023 through 08/29/2023 day shift. Eleven nurses and five CNAs who had not received the in-service had worked during the five days reviewed. In an interview on 08/29/2023 at 12:25 p.m. the Administrator said the staff would be required to complete an on-line safety course on side rails prior to returning to work. All staff were to complete the course by 09/03/2023 even if they do not work a shift. An Immediate Jeopardy (IJ) was identified on 08/29/2023 at 2:54 p.m., due to the above failures. The Administrator and the DON were notified. The Administrator was provided with the IJ template on 08/29/2023 at 1:10 p.m. The following Plan of Removal was submitted by the facility, and was accepted on 08/30/2023 at 11:08 a.m Cambridge Health and Rehab Plan of Removal, Version 2.0 August 29. 2023; Revised August 30,2023 F689 Free of accident hazards The facility failed to ensure Resident #1 was free of accident hazards. The facility failed to complete a two-person transfer for Resident #1. 1. The Medical Director, _____ [Physician B], was notified of IJ on 8/29/23 at 4:15 pm. 2. 8/9/23 1912 resident #1 was taken to _____ [Hospital] ED via stretcher with _____ [ambulance service] transportation. 3. 8/10/23 0648 Resident #l returned from _____ [Hospital] ED Via _____ [ambulance service] transportation on a stretcher. Resident resting with eyes closed. No S/S Pain. Dressing to right lower lateral [outer] leg is clean, dry & intact. Resident received a Tetanus shot & shot of 1Gram Ceftriaxone [antibiotic] while there & came back with orders for Augmentin [antibiotic] 875MG but the _____ [pharmacy] doesn't carry that so SN called [Hospital] ED back & received new order for Keflex [antibiotic] 500MG. 1 PO TID X 7 Days. Also received order for Bactroban [antibiotic] 2% ointment to be applied BID with wound care: clean with normal Saline & Gauze, pat dry, apply Bactroban, cover with gauze & secure with Coban [self-adherent wrap] BID. Also order for Mobic [pain medication] 7.5MG 1 PO QD PRN X 10 Days Only. Resident has 10 staples in the wound & will need reevaluation of when they can be removed by facility Dr, NP, or PA. Resident slept well the rest of the night. Resident's son was notified of when resident returned & that he's stable, sleeping well. 4. 8/12/23 Care Conference conducted with family with ED, DON & DOR and recommendations were made to change resident to a 2 person transfer per family preference. 5. Social Worker will monitor Resident for any psychosocial negative effects, to date none have been exhibited. 6. Training and competencies regarding transfer assistance levels and supervision; and preventing accidents and hazards was initiated with ED, DON, Maintenance Director and nursing staff on 8/29/23 and will be completed on 8/30/23 by _____ [DON]; or by _____ [ADON C]; _____ [ADON D]; _____ [RN E]; _____ [LVN F]; _____ [RN G]; _____[DPT]. The trainings included transfer assistance levels and preventing accidents. The facility referenced the following policies: Transfer techniques, incident accident prevention with a focus on assessment of equipment. 7. Training on preventing accidents and hazards was initiated with DON, ED, Maintenance Director and nursing staff on 8/29/23 and will be completed on 8/30/23 by _____ [DON]; or by _____ [ADON C]; _____ [ADON D]; _____ [RN E]; _____ [LVN F]; _____ [RN G]; _____ [DPT]. Training included how to locate the Kardex in POC and location of Maintenance logs for repair requests. 8. This training and competency will be in-person for all nursing staff and prior to starting their next shift. Nursing staff will not be allowed to work until they have completed the training and competency with _____ [DON]; or by _____ [ADON C]; _____ [ADON D]; _____ [RN E]; _____ [LVN F]; _____ [RN G]; _____ [DPT]. This training and competency will also be included in the new hire orientation and will be included for agency/PRN staff prior to starting work on the floor. These staff will not be allowed to work unless they have received their training and competency. 9. An ad hoc meeting regarding items in the IJ template was completed on 8/29/23 at 4:30pm. Attendees included _____ [Administrator], ED, _____ [DON]; _____ [ADON C]; _____ [ADON D]; _____ [RN H]; _____ [RN E]; _____ [LVNF]; _____ [RN G]. The Plan of removal items and interventions were developed, reviewed, and agreed upon. 10. The transfer policy was reviewed by _____ [DON] on 8/29/2023. 11. The incident/accident prevention guidelines were reviewed by ____ [ED] on 08/29/2023. 12. All residents could have been affected by the alleged deficient practice. Currently there are 87 residents living in the facility. Therapy will assess all residents for transfer needs by 8/30/23. This information will be added to the Care Profile and all care plans will be updated by 8/30/2023 The MDS resource is reviewing all MDS, care plans and Kardex and therapy recommendation for transfer status and will update specific resident MDS if needed by 8/30/2023. Staff will be trained on where this information is located for Kardex. 13. Incidents/ accidents were reviewed after the accident for Res #1 on 8/10/2023, no other equipment or side rail issues were identified. Incidents/ accidents were reviewed during QAPI on 8/28/23 - no other concerns were identified. 14 .Therapy, Maintenance and Nursing staff completed bed rail audits of all residents with a side rail the week of 8/15-8/18. Rounds were made on 8/28/23 by Clinical Resource to identify other concerns with side rails and no other concerns were identified. Rounds are being made today 8/30/23 by _____ [SLP], Therapy Resource and _____ [RN I] to check side rails for safety. Monitoring for implementation of the POR: In an interview on 08/30/2023 at 2:40 p.m. the DPT said all the residents have been assessed by the Therapy Department and the Care Plans have been updated. Record review revealed the Therapy Department had assessed each resident. Random search of five residents revealed correct Care Plan information. Observation on 08/30/2023 at 2:50 p.m. revealed LVN J and ADON C provided wound care for Resident #1. Five of the ten staples were removed, per physician orders. No concerns with technique were noted. Record review on 08/30/2023 at 3:30 p.m. revealed all staff who have worked up to the present shift have completed the online training and the in-person in-services for side rails and transfer techniques. Review of Resident #1's clinical record revealed the Social Worker visited him on 08/30/2023. Review of the Employee Checklist dated 08/30/2023 revealed most direct care staff have completed the online training. In an interview on 08/30/2023 at 3:40 p.m., the Administrator said the remaining employees would complete the online training and in-services prior to starting their next shift. Interviews on 08/30/2023 from 4:00 p.m. to 4:10 p.m. with one MA and three CNAs revealed they all said they had the in-services on side rail safety and transfers. The Administrator and DON were informed the Immediate Jeopardy was removed on 08/30/23 at 04:15 p.m. However, the facility remained out of compliance at a scope of isolated and severity level of actual harm with potential for more than minimal harm that is not immediate jeopardy, due to the facility's need to evaluate the effectiveness of the corrective systems.

Based on observation, interview and record review, the facility failed to ensure that each resident received adequate supervision and assistance devices to prevent accidents for two (Resident #2 and Resident #6) of six residents reviewed for accidents and supervision. 1. CNA A performed Peri care on Resident #2 by herself when Resident was coded to have 2-person assistance resulting in the Resident falling and sustaining small subarachnoid hemorrhage, hairline frontal bone fracture, frontal hematoma and superior left orbital fracture on 5/18/21. 2. CNA B attempted to transfer Resident #6 on the Hoyer lift by herself on 8/30/21 and stopped due to Surveyor intervention. These failures could place residents at risk for pain, significant injury, and decreased level of functioning and quality of life. Findings include: Record review of the face sheet for Resident #2 revealed a [AGE] year-old male admitted to the facility on [DATE] and readmitted on [DATE]. His diagnoses included [CONDITION(S)], contracture to right knee, contracture to left knee, muscle weakness, major depressive disorder, [CONDITION(S)], and chronic pain. Record review of Resident #2's quarterly MDS dated [DATE] revealed he had a BIMS of 7 out of 15 which indicated he had severely impaired cognitive skills. Further review of the MDS revealed that Resident #2 was totally dependent on two persons for bed mobility, transfer, dressing, toilet use, and personal hygiene. Record review of Resident #2's Care plan revised on 02/05/18 revealed the following: -transfer: Resident required total assist of 2 staff. -bed mobility requires staff assist to reposition and turn in bed. -personal hygiene: requires total assist of 1 staff participation. -dressing: requires staff assist to dress Record review of Resident #2's care plan revised 2/5/18 revealed the resident was at risk for falls. Goal included to not sustain serious injury through the review date. Record review of Resident #2's Nurse's notes, written by Nurse A on 5/18/21, read in part, At approximately 1515 [3:15 PM] this writer was called to resident's room by staff on entering room observe resident lying on the floor between the bed and wall, alert, oriented to name and verbally responsive , answers questions appropriately. Blood noted to face, on cleansing appears to nostrils from nostrils, no other open areas noted. Resident stating it hurt, my head hurt. On assessment noted golf ball sized raised area to left forehead, left shoulder redness and swelling, left foot base of great toe redness. Ice pack applied to forehead. ROM very limited due to paralysis and contractures, within normal limit. V/S B/P 134/87, hr 89, rr 18, t 97.3(temporal), O2 sat 96.0 on room air.1530 [3:30 PM] Dr. Notified, order received to transfer resident to hospital. Record review of Resident #2's Hospital discharge summary dated 5/19/21 read: Discharge diagnoses: traumatic subarachnoid hemorrhage, frontal bone fracture, frontal hematoma and superior left orbital fracture. Further review of the summary read, he was reported to be at his baseline mental status .work up in the ED was notable for hairline frontal bone fracture, small associated subarachnoid hemorrhage, frontal hematoma, left superior orbital fracture and hematoma .he was evaluated by neurosurgery who stated no surgical intervention or follow-up imaging was necessary .no interventions planned .will discharge back to his facility . Record review of the facility's provider investigation Report for Resident #2 dated 05/19/21 read: Description of the allegation: while doing peri-care on the resident, he slipped out of the low air loss mattress face down. Description of injury: Frontal bone/[MEDICATION(S)] fracture involving anterior and posterior table, non-displaced. Left orbital fracture involving the roof medical wall. Left maxillary [MEDICATION(S)] anterior wall fracture minimally displaced. Alleged perpetrator and witness: CNA A Further review of the facility's provider investigation Report for Resident #2 revealed an undated form completed by the facility titled 5 whys tool. The form read: The problem: Fall with injury from bed during care. Why does this occur? Resident was being turned and changed with 1 staff member. Why is that? Resident is totally dependent and unable to assist with his care. Why is that? Care plan and plan of care unclear for this resident, (states dependent as well as 1-2 staff). Why is that? Resident care should have been given with 2 staff. Why is that? Staff education needed. Record review of the statement written by CNA A dated 5/18/21 read I CNA A on 5/18/21 around 3:45pm gave peri-care to Resident #2. After cleaning the resident up, I applied barrier cream on left side of the resident's back and turned him to the right to apply barrier cream. He slipped from the low air mattress to the floor. I immediately notified the nurse and DON. Observation of Resident #2 on 8/30/21 at 12:15p.m., revealed resident in bed. Resident appeared alert but not oriented, could not answer surveyor questions. Resident did not appear to be in any distress at this time. There were no concerns during at this time. Phone interview with CNA A on 8/31/21 at 10:37a.m., she said she had completed peri care on Resident #2 and had turned him to the side to apply barrier cream when he slipped and fell on the floor. CNA A stated the bed was to the lowest position. She said Resident #2 was a 2 person assist but she did the care by herself. CNA A said she asked other aides to help but no one came to assist her, so she did the peri care by herself. CNA A said she knew it was important to have 2 staff to assist for resident safety, but she was just not able to find anyone to help her. She said she immediately notified nursing of the incident and they assessed him and sent him out to hospital. CNA A said she was suspended and was in serviced for 3 days by therapy on proper bed mobility and transfer techniques. Interview with the DON on 8/31/21 at 10:53a.m., she said Nurse A was no longer with the company. Interview and record review with the DON on 8/31/21 at 11:00a.m., she said on the day of the incident with Resident #2 the staff went and got her and told her the resident had a fall and was bleeding. She said she went to Resident #2's room and found him on the floor with blood around him. DON said there were other nurses in the room assessing the resident by the time she got there. She said when they assessed him, they did not notice any open areas but did see a bump by his eyebrow, so they notified the physician who gave instructions to send him out. DON said that CNA A was present in the room as well at this time. She said she asked CNA A what happened, and she said that she turned Resident #2 to put lotion or some cream on him and he slipped and fell . DON said she thought Resident #2 only required one person assist for ADL care. She said they did look into Resident #2's care following the incident, the MDS and care plans and all but could not remember how much assistance he needed at that time since it was a while ago. At this time Surveyor went over MDS dated [DATE] with the DON. DON reviewed the MDS and said, looks like most of his ADL's required 2 persons, it appears that he should've had 2. DON said that for Resident's that require 2 staff assistance the CNA's were supposed to ask other CNA's for help. She said if the CNA's could not find anyone to assist, they could always ask the charge nurse or herself. She said that the CNA's were not supposed to do the care alone if 2 staff was required to prevent injuries. The DON said, she did not know if Resident #2's fall could have been prevented if there were 2 staff. DON said that the nurse manager's and herself were responsible for monitoring and training the CNA's to ensure they followed proper guidelines. Interview with MDS Nurse on 8/31/21 at 12:03p.m., she said she was responsible for doing the Medicaid MDS's and care plans. She said when she did the MDS assessment's on Resident's she spoke with CNA's to determine how much assistance a resident requires for ADL's. She said when she did the MDS dated [DATE] for Resident #2, she spoke with CNA's who worked with him to see how much assistance he needed, and it was determined that he required 2 staff for ADL's. MDS Nurse said CNA A should not have done peri care by herself and should have had another staff member with her for safety reasons. 2. Record review of the face sheet for Resident #6 revealed a [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included congestive heart failure, altered mental status, dysphagia, peripheral vascular disease, and [CONDITION(S)]. Record review of Resident #6's annual MDS dated [DATE] revealed that her BIMS was 15 out of 15 which indicated she was cognitively intact. The MDS revealed she required extensive assistance from 2 persons for bed mobility, dressing, toilet use and personal hygiene and totally dependent on 2 staff for transfer. The MDS indicated the resident weighed 196lbs. Record review of Resident #6's care plan's revised on 11/26/20 read in part, .requires total x 2 staff participation with transfers-Hoyer lift . Observation on 8/30/21 at 10:53a.m., revealed CNA B entered Resident #6's room with Hoyer lift and closed the door. Observation and Interview on 8/30/21 at 10:56a.m., inside Resident #6's room revealed the Resident seated in shower wheelchair with sling already underneath her. CNA B attached the sling hooks onto the Hoyer lift. CNA B stated she was going to transfer Resident #6 from the shower chair to her wheelchair. CNA B confirmed that she was going to do the transfer alone. CNA B said the Resident #6 was supposed to be a 2-person transfer, but she could not find her colleague, so she was just going to go ahead and do it herself. CNA B said she did not let her nurse or anyone else know that she needed help with transfer. She said she knew Hoyer transfers needed 2 people to transfer due to safety reasons. She said one person doing the transfer could cause injuries to the resident. At this time, CNA B informed the resident that she was not going to do the transfer and will find someone to assist her and left the room. After CNA B left the room, Resident #6 stated that she knew she was supposed to have 2 people transfer her but sometimes it was only 1 person transferring her. The Resident said that she has never had had any fall or injuries from Hoyer transfer. Interview with RN A on 8/30/21 at 11:05a.m., she said she was the assigned nurse to Resident #6. She said Resident was a 2-person transfer with Hoyer lift. She said CNA B did not notify her she needed help with Hoyer transfer. She said the CNA was supposed to let her know if she could not find another staff member to assist her. RN A said that if CNA B had notified her then she would have helped her. She said it was important for them to do 2-person transfers to avoid falls or other serious injuries. Interview with the DON on 8/30/21 at 2:00p.m., she said she had been the DON at the facility since last September. DON said that Resident #6 was a 2-person assist for transfers on a Hoyer. DON said just this morning, she informed the aides that they needed to have 2 people to do Hoyer transfer. She said that CNA B should not have attempted to transfer Resident #2 by herself and should have asked for help. She said that if staff could not find anyone to assist, they needed to come and find the DON. She said it was important to have 2 people do Hoyer transfer for a safety issue, we need to ensure one can manage the machine and other to manage the resident. It's very important to have both people there. DON said that charge nurses and nurse managers were responsible for overseeing the CNA's. She said that CNA B was fairly new to the facility and needed to have more training. Record review of the personnel file for CNA B revealed she was hired on 7/29/21. The file revealed that she received training on Transfers: Mechanical Lift on 7/29/21. Record review of the facility's policy for Accidents/Hazards/Safety intervention revised 09/18 read in part, .it is the policy of this facility that the resident environment remains as free of accident hazards as is possible and that each resident receives adequate supervision and assistive devices to prevent accidents . Record review of the facility's policy for Mechanical Lift (Hoyer brand) revised 05/07 did not address how many people was needed to do a safe transfer.

Based on observation, interview, and record review, the facility failed to ensure pain management was provided to Residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the Residents' goals and preferences for one Resident (Resident #104) of 5 Residents reviewed for pain management in that - The facility failed to administer a pain patch as ordered by the physician before wound care was done for Resident #104. -Resident #104 cried and yelled from pain while being treated for [REDACTED]. -Resident #104's pain level assessment was inaccurately documented. These failures placed affected one Resident and placed her at risk of experiencing unnecessary pain and placed her at risk for suffering unnecessary pain in the future. Findings included: Record review of the Admission Record for Resident #104 revealed she was [AGE] years of age and was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Record review of the initial baseline care plan dated 11/09/18 revealed that Resident #104 had a care plan for pain related to acute/chronic pain. Goal was to not have interruption of normal activities due to pain through the review date. Interventions included to have a pain assessment every shift and reposition for comfort, Record review of the Admitting History and Physical dated 11/09/18 at 5:30 p.m. revealed Resident #104 was admitted with a Stage 2 pressure sore. Record review of a physician's orders [REDACTED]. Record review of a physician's orders [REDACTED].#104's pain level every shift. Record review of a Social Service Summary dated 11/10/18 at 11:24 a.m. revealed Resident #104 was alert and oriented times 4 and scored a '13' on the Brief Interview for Mental Status (BIMS) which was indicative of intact cognition. Record review of care plan initiated on 11/13/18 revealed pressure ulcer development to sacral stage III related to bed mobility. Interventions included to administer treatments as ordered and monitor effectiveness. Record review of the (MONTH) (YEAR) Medication Administration Record [REDACTED] [MEDICATION NAME] 5% apply to the sacral area for pain one time a day, apply at 8:00 am and remove at 7:59 pm. Observation on 11/15/18 at 10:17 a.m. revealed LVN C performed wound care for Resident #104, assisted by Physical Therapy Assistant (PTA) A. Prior to initiation of the treatment, Resident #104 denied having pain. Resident #104 was assisted onto her right side. Observation revealed the [MEDICATION NAME] 5% patch that was adhered to the Resident's back was dated 11/14/18. LVN C confirmed the date. When the pressure sore wound dressing was removed from the right buttock, observation revealed an unstageable open area of approximately two centimeters diameter. LVN C cleaned the center of the wound, and the Resident cried out in pain. LVN C cleaned the perimeter of the wound, and the Resident yelled Ow! The nurse continue with the treatment. When LVN C dried the area with a dry 4 x 4-inch gauze, the Resident cried out in pain again. The Resident said she had received Tylenol, but it was not helping with the pain. LVN C completed the wound care for the resident. Record review on 11/15/18 at 10:40 a.m. revealed MA G had already signed that she had applied a [MEDICATION NAME] that morning to Resident #104. In an interview on 11/15/18 at 10:45 a.m. the surveyor informed the DON that Resident #104 had expressed pain during the wound care, and that the [MEDICATION NAME] 5% patch on the Resident had not been applied that morning as ordered but was signed out. Observation on 11/15/18 at 10:50 a.m. revealed MA G approaching the DON and the two surveyors. MA G said LVN C told her about the date on the patch and said that she had applied a patch that morning but scribed the wrong date on it. MA G said the Resident's private sitter was in the room and witnessed her place the [MEDICATION NAME] on the Resident. At that time, the DON, MA G, and the two surveyors went to Resident #104's room. Observation on 11/15/18 at 10:52 a.m. revealed Resident #104 to be lying in bed. Resident #104 said she did not remember MA G placing a patch on her back, but she did remember the surveyor being in the room earlier to observe the wound care. The Resident's private sitter was in the room. The DON asked the private sitter if she saw MA G place a patch on Resident #104's back that morning. The sitter said she saw MA G give the Resident oral medicine, but not a patch. The DON asked Resident #104 if she could turn on her side, so she could see the patch. Observation revealed it took two staff to assist the Resident onto her side. The DON confirmed the date on the patch was 11/14/18. Record review of the (MONTH) (YEAR) Treatment Administration Record (TAR) for 11/15/2018 revealed LVN C noted '0' pain for the shift, even though Resident #104 cried in pain when LVN C performed wound care that shift.