Every finding on record at Cedar Ridge Health & Rehab CTR

Based on observation, interview, and record review, the facility failed to maintain Sanitary conditions in the kitchen to promote safe food handling. This failure has the potential to affect all 106 residents residing in the building.The findings include: On 3/9/26 at 10:45 AM, during the lunch observation, V7 (Cook), and V8 (Cook) were seen serving food from the steam table onto plates, then placing the plate on a tray which was delivered to the residents. Directly above the steam table of food, there was a ceiling vent with vents that were pointed down towards the food. The vent itself, the ceiling around the vent, the light close to the vent, and the adjacent wall by the vent was dirty with a lot of greasy dirt and/or lint seen. This vent blows air down onto the steam table with potentially the dirt/lint falling onto food items and being served to the residents.On 3/11/26 at 3:15 PM, V4 (Dietary Manager) stated I don't have any cleaning logs. I just tell V22 (Dietary Aide) to clean the walls about once a week.On 3/11/26 at 3:17 PM, V22 (Dietary Aide) stated I just wiped down the walls and the ceiling about a week ago.On 3/11/26 at 3:20 PM, When showed the greasy grime and dust on the walls, ceiling, vent, and light V4 stated That must just be from a week ago because (V22) stated he cleaned it. I can see what you are seeing now, that is blowing directly onto the steam table. I believe the steam table was in front of the serving window before and someone moved it to where it is now. Maybe they will have to move it back.On 3/12/26 at 10:15 AM, V1 (Administrator) stated I would expect the dietary department to follow their policies on cleaning and food preparation.On 3/12/26 at 10:40 AM, V31 (Regional Director of Dining) stated The staff called me yesterday and told me about the grime on the ceiling, vent, and wall and they even sent me a picture of it. I agree, that did not look like it has been cleaned lately. I had them clean everything and we may be moving the steam table back to where it was.The Facility's Cleaning and Sanitizing and Proper Hair Restraints Policy, dated 9/1/21, documents in part Food contact surfaces are properly cleaned and sanitized before and after use, in order to help prevent food-borne illness and minimize bacterial growth. Non-food contact surfaces are cleaned per individual facility cleaning schedule to maintain optimal cleanliness of kitchen equipment.The Facility's Safe Food Handling Policy, dated 9/1/21, documents in part 1. Dining Services staff will be responsible for food preparation procedures that avoid contamination by potentially harmful physical, biological, and chemical contamination.The Department of Health and Human Services, Centers for Medicare & Medicaid Services, Long-Term Care Facility Application for Medicare and Medicaid (CMS 671), dated 3/9/26, documents that there were 106 residents living in the facility.

Based on observation, interview and record review the facility failed to document when a multi use vial of Aplisol (Tuberculosis/TB testing solution) was opened. This has the potential to affect all 106 residents in the facility.Findings include:On 3/10/2026 at 12:04 PM the facility's medication storage room was observed with V27 (Licensed Practical Nurse/LPN). V27 pulled an opened bottle of Aplisol from the medication refrigerator. There was no date documented on the bottle or packaging that documented when the bottle was open or when it would expire. V27 stated she did not know when the bottle was first opened.The medication label on the bottle of Aplisol states Refrigerate. Protect from light. Discard in use vial after 30 days. V27 states that this entire facility would use this medication.On 3/12/2026 at 9:54 am V11 (Wound Nurse) who states she is covering for the Director of Nursing in her absence, stated that multi use vials including TB solution should be dated when they are opened.The facility's policy, Medication Storage, revised on 8/23/22, documents the facility stores all drugs and biologicals in a safe, secure, and orderly manner and in accordance with state and federal regulations. Medications shall be administered prior to the manufacturer's expiration date.The form CMS-671, Long-Term care facility application for Medicare and Medicaid, dated 3/9/2026 documents there are 106 residents residing in the facility.

Based on observation, interview, and record review, the facility failed to ensure residents were safely transferred via mechanical lift, failed to ensure fall interventions were in place according to resident Care Plans, and failed to provide an appropriate shower chair resulting in a resident to sustain a fall for 4 of 7 (R22,R28, R54, R69) residents reviewed for accidents in the sample of 52. Findings Include:1.R28's admission Record print date of 3/11/26 documents R28 has diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, COPD (chronic obstructive disease), chronic atrial fibrillation, hypertension, polyneuropathy, depression, and anxiety. R28's MDS (Minimum Data Set) dated 1/19/26 documents R28 is cognitively intact and requires partial/moderate assistance with wheelchair transfers and showers. R28's undated Care Plan documents R28 is at risk for falls related to left hemiparesis, difficulty walking, and lack of coordination with a goal of minimizing risks for falls. R28's fall occurrence note dated 1/12/26 at 3:41 PM documents incident description: resident slipped in shower room. Did not hit head. Fall was witnessed by staff. Resident evaluated and placed in w/c (wheelchair) and dressed. Resident states no discomfort or pain. Resident statement on what was being attempted when fall occurred in shower room, wet floor, wet chair, wet w/c. Resident description of fall: slipped in shower. Date/time of incident: 1/12/26 at 3:15 PM. Resident is alert. R28's fall report dated 1/12/26 documents resident slipped and fell in the shower, did not hit head. Witnessed by staff. Resident description: Slipped in shower. The facility's IDT (Interdisciplinary Team) note dated 1/12/26 documents resident noted on the floor in the shower room. RCA (root cause analysis): Resident slipped on the floor when showering. Intervention: Staff educated to utilize accessible shower chair for this resident to prevent standing during showering. On 3/11/26 at 8:33 AM R28 stated when she fell in the shower room the CNA (Certified Nursing Assistant) did not place a gait belt around her, transferred her onto a small shower chair, and the shower chair moved out from under her during the transfer resulting in her falling onto the shower floor. R28 stated she hurt her side, it was bruised, but she did not go to the hospital. R28 stated the CNAs still do not place a gait belt around her when she showers although they do use a bigger shower chair now. On 3/11/26 at 10:12 AM V20 (MDS Nurse) stated the intervention for R28's fall on 1/12/28 was staff educated to utilize accessible shower chair for resident to prevent standing during shower. Surveyor asked what kind of chair R28 was placed on and V20 stated she did not know. On 3/11/26 at 10:46 AM V1 (Administrator) stated R28's fall intervention was to use a shower chair rather than the shower bench. V1 stated she expects CNAs to follow the facility policy for transfers. On 3/11/26 at 11:10 AM V21 (CNA) stated she was with R28 on 1/12/26 when R28 fell in the shower. V21 stated she had R28 on the small shower chair, the shower chair does not have an opening in the seat so she had R28 stand up so she could clean her buttocks and when R28 stood up, the shower chair moved back a bit so when R28 sat back down she missed the chair and fell. Surveyor asked why V21 used that shower chair and V21 stated the other kind was not available. Surveyor asked V21 if R28 had a gait belt on and V21 replied no. Surveyor then asked if the shower chair in use at the time of the fall had breaks on it and V21 replied no. 2. R54's admission Record, print date of 3/11/26, documents R54 has diagnoses including facial weakness following cerebral infarction, type 2 diabetes mellitus with diabetic chronic kidney disease, dysphagia following cerebral infarction, hypertension, obstructive and reflux uropathy, and atherosclerosis. R54's MDS dated [DATE] documents R54 is moderately cognitively impaired and requires partial/moderate assistance with transfers. R54's Fall Risk Evaluation dated 2/17/26 documents R54 is at high risk for falling. R54's undated Care Plan documents R54 is at risk for fall related to generalized weakness, lack of coordination, and difficulty walking. Interventions include non-skid mat to wheelchair. R54's progress note dated 2/16/26 at 2:16 PM documents Incident Description: observed on floor in room. Resident statement on what was attempted when fall occurred unsteady gait, requires assistance with transfers. Resident Description of Fall: I was trying to get to the bathroom and slid out of my chair. R54's fall report dated 2/16/26 documents resident observed on floor in room. Resident description: I was trying to go to the bathroom and slid out of my chair. IDT (Interdisciplinary Team) note: Resident observed sitting on the floor next to his bed. RCA (Root Cause Analysis): Resident slipped from wheelchair. Intervention: Non-skid mat to wheelchair. On 3/11/26 at 11:43 AM Surveyor observed V15 (CNA) transfer R54 from his bed to his wheelchair. No non-skid mat was observed on R54's wheelchair seat. On 3/11/26 at 12:42 PM V20 (MDS Nurse) stated the intervention for R54's fall on 2/16/26 was a non-skid mat in his wheelchair. On 3/11/26 at 1:06 PM V14 (Registered Nurse/RN) checked R54's wheelchair along with Surveyor and V14 confirmed R54 did not have a non-skid mat in his wheelchair nor anywhere in his room. 3. R69's admission Record with print date of 3/11/26 documents R69 has diagnoses including metabolic encephalopathy, pulmonary fibrosis, acute pulmonary edema, type 2 diabetes mellitus with chronic kidney disease, hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, chronic respiratory failure with hypoxia, emphysema, congestive heart failure, atherosclerosis, pulmonary hypertension, cognitive communication deficit, difficulty in walking and repeated falls. R69's MDS dated [DATE] documents R69 is moderately cognitively impaired and is dependent on staff for transfers and all mobility. On 3/9/26 at 9:25 AM V16 (CNA) and V15 (CNA) were observed as they transferred R59 from her bed and into her wheelchair via a mechanical lift. As R69 was lifted into the air via the mechanical lift sling the battery to the lift stopped functioning resulting in the legs of the lift to be stuck in the closed position and R69 was stuck in the air. V16 stated to V15 we will have to transfer her sideways. V15 then took her hands off R69 and the transfer sling leaving R69 hanging from the lift without any staff support/touch. V15 then moved R69's wheelchair and placed it sideways against the lift. V16 pressed the emergency release button on the mechanical lift. As R69 was being lowered into the wheelchair V15 raised the wheelchair's front tires up and off the floor due to the mechanical lift legs being stuck in the closed position. On 3/12/26 at 10:03 AM V16 (CNA) stated during a mechanical lift transfer one CNA operates the lift and the other CNA guides the resident in the lift sling. Surveyor asked V16 if it is acceptable for a staff member to ever take their hands off the lift sling when the resident is suspended in the air and V16 replied no, there should always be hands on the sling/resident. On 3/11/26 at 3:57 PM V1 (Administrator) stated she expects facility staff to follow the facility's policies. On 3/12/26 at 11:08 AM V20 (MDS Nurse) stated she would expect resident fall interventions to be in place as documented in resident Care Plans. V20 also stated there should always be 2 CNAs present when transferring residents with a mechanical lift and she would expect one of the CNAs to always keep their hands on the resident/sling during the transfer. 4. R22's Face Sheet, print date of 03/12/25, documents R22 has diagnoses of but not limited to dementia, Chronic Obstructive Pulmonary Disease (COPD), Type II diabetes mellitus (DM), and protein-calorie malnutrition. R22's MDS, documents R22 is moderately cognitively impaired, she is dependent on staff for all her ADLs, and she is incontinent of bowel and bladder. R22's Care Plan, admission date of 08/23/23, documents R22 is at risk for falls r/t (related to) dementia, COPD, PVD (Peripheral Vascular Disease), MI (Myocardial Infarction), presence of right artificial hip joint, osteoarthritis, pain in right and left knee. Interventions include but are not limited to fall mats and keep bed in low position. On 03/09/2026 at 09:22 AM, R22 is lying in her bed with her head elevated. Fall mat seen folded up and sitting up by the head of the bed in between the bed and the wall with the window. On 03/10/2026 at 11:44 AM, R22 is lying in bed facing towards the window. R22's fall mat was seen folded up and standing up by the head of the bed. On 03/12/25 at 8:30 AM, V1 (Administrator) stated they do not have a fall prevention policy of any kind but there is a statement at the end of one of the policies she has already given us. The Facility's policy Transfer Policy, revision date 05/19/22, documents Policy: To promote safe transfer for the residents, as well as the staff. Gait belts, Hoyer lifts, and/or sit to stand lifts will be used, unless otherwise specified. The facility's policy Accidents and Incidents, revised date 09/07/23, documents 5. The Interdisciplinary Team (IDT) will conduct a thorough investigation of the accident/incident. Findings of the investigation, including root cause of the accident/incident and appropriate interventions will be indicated in the incident report and implemented. 6. The MDS (Minimum Data Set) nurse shall update the care plan with implemented interventions and communicate interventions with line staff.

Based on interview and record review, the facility failed to provide food and drink that is palatable, attractive, and at a safe and appetizing temperature for 6 of 10 residents (R9, R17, R20, R45, R58, R60) reviewed for palatable and appetizing food in the sample of 52.The findings include: 1. R45's admission Record, dated 3/11/26, documents R45 was originally admitted on [DATE]. R45's Minimal Data Set (MDS), dated [DATE], documents R45 is cognitively intact. On 3/9/26 at 1:03 PM, R45 stated the food is not good and sometimes warm, sometimes cold. 2. R58's admission Record, dated 3/11/26, documents R58 was originally admitted to the facility on [DATE]. R58's MDS, dated [DATE], documents R58 has a moderate cognitive impairment. On 3/9/26 at 9:50 AM, there was contact and droplet isolation signs on R58's door. R58 stated he eats in his room and the food is terrible, taste like institutional food with no taste and is always cold by the time he gets it. 3. R60's admission Record, dated 3/11/26, documents R60 was originally admitted to the facility on [DATE]. R60's MDS, dated [DATE], documents R60 is cognitively intact. On 3/9/26 at 10:18 AM, R60 seen in her room, contact and droplet isolation sign on door with PPE outside door due to R60 testing positive for COVID. R60 stated the food is lousy and taste bland to her and most of the time is cold and no longer warm. 4. R17's admission Record, dated 3/12/26, documents R17 was originally admitted to the facility on [DATE]. R17's MDS, dated [DATE], documents R17 has a moderate cognitive impairment. On 3/9/26 at 10:27 AM, R17 stated she eats in her room, and the food is not good and is cold by the time she gets it, and she usually has them warm her food up. 5. On 03/09/2026 at 09:39 AM, R20, who is cognitively intact stated the food here isn't good. She said the food is always cold. If you don't like what they have you can get a substitute like a cheeseburger, but the cheeseburger is cold. She said she eats a lot of salads but the meat in the salad is lunch meat. 6. On 03/09/2026 09:50 AM, V19 (R9's family member) stated the food is always cold. V19 says he comes to the facility every day and he eats his meals with R9. On 3/12/26 at 10:18 AM, V1 (Administrator) stated We have been working on the cold food issue. Just this week, I told them that when plating food, to put that plate into the warming cart immediately instead of having multiple trays on the counter and then putting them in the cart. I would expect the dietary department to follow their policies on cleaning and food preparation. On 3/12/26 at 10:38 AM, V4 (Dietary Manager) stated I'm aware of the complaints of cold food and we have been working on it. We just started yesterday by plating the food one at a time, placing the plate onto an insulated bottom, then putting an insulated top over the plate, adding the drinks to the tray and placing it in the warming cart. On 3/12/26 at 10:45 AM, V31 (Regional Director of Dietary) stated The cook was plating several plates at a time while at the steam table, then those plates would be transferred to the counter for someone to put drinks and a desert on the tray, then those trays would have to be put on a cart. I feel that was a delay, so I told the cooks to do one plate at a time, then place on a tray. That cook quit because she didn't like to do it that way. The Facility's Resident Council minutes, dated September 17, 2025, documents in part Old News: Food Temps. The Facility's Resident Council minutes, dated October 17, 2025, documents in part Old News: Food Temps. 4. Dietary: Cold food has improved a little. The Facility's Resident Council minutes, dated December 2025, documents in part c. Dietary: B-Hall residents voices concerns with eggs being cold at times. The Facility's Resident Council minutes, dated January 2026, documents in part f. Dietary: Food is getting better, B-Hall residents voiced they are always the last hall to get hall trays, (R45) stated he got cold eggs. The Facility's Resident Council minutes, dated February 2026, documents in part IV: Old News: CNAs talking on the phone while passing trays. c. Dietary: Residents are saying that food temps are getting a little better. The Facility's Grievance Summaries, dated 9/17/25, documents Resident (R55) stated she feels nausea when she eats food from the kitchen and the food is cold. The Facility's Food Palatability Policy, dated 9/1/21, documents in part Food will be prepared by methods that conserve nutritive value, flavor and appearance. Food will be palatable, attractive, and served at a safe and appetizing temperature. Food and liquids are prepared and served in a manner, form, and texture to meet resident's needs.

Based on observation, interview, and record review, the facility failed to provide timely and complete incontinent care for 2 of 8 residents (R93, R96) reviewed for incontinent care in the sample of 52.The findings include: 1. R93's admission Record, dated 3/9/26, documents R93 was originally admitted to the facility on [DATE] with diagnosis of Dementia, Cirrhosis of liver, Type 2 DM, Spondylopathies, Chronic Kidney Disease (CKD)-stage 3, HTN, Polyneuropathy, Uropathy, Anemia, Major depressive disorder, COVID, Osteoarthritis, and Neuralgia/Neuritis. R93's Care Plan, dated 3/3/26, documents R6 has an ADL (Activities of Daily Living) self-care performance deficit. Interventions: Bathing: Uses adaptive equipment Shower Chair/Bed with total assist but R93 prefers to have bed baths, Personal Hygiene: 1 person assist. 1/6/26: R93 is unable to dress or groom independently related to: Polyneuropathy, Lumbar Disc Degeneration, Polyarthritis. 2/6/26: R93 is at risk for impaired skin integrity related to confined to a bed all or most of the time, decreased sensory perceptions, dementia, depression, history of poor nutritional intake, history of pressure ulcers, impaired cognition, incontinent of bladder, incontinent of bowel, poor nutritional intake. Interventions: Notify nurse of any new areas of skin, breakdown noted during bathing or daily care, provide incontinence care PRN. 3/3/26: R93 is at risk for fluid volume deficit related to diuretic medication. R93 has episodes of bladder and bowel incontinence. Interventions: Provide disposable incontinence products, provide peri care after each incontinent episode; apply house barrier after incontinence care as needed, Report any redness, irritation, skin excoriation/breakdown peri-area. R93's Minimum Data Set, (MDS), dated [DATE], documents R93 has a moderate cognitive impairment and is dependent on staff for toileting and dressing. R93 requires substantial/maximal assistance from staff for bathing, with partial/moderate assistance from staff for personal hygiene. R93 is always incontinent of both bowel and bladder. On 3/9/26 at 10:10 AM, R93 seen getting transferred from bed to her recliner by V23 (Certified Nursing Assistant/CNA) and V24 (CNA). R93's bed linen were saturated in urine with a large wet spot noticed in middle of her bed where her buttocks would be sitting and a strong smell of urine. On 3/10/26 at 8:20 AM, R93 seen in bed eating breakfast, R93 stated she has not been cleaned up yet, they woke her up for breakfast and no one provided incontinent care, and she is currently wet from overnight. On 3/10/26 at 9:45 AM, R93 still lying in bed, stated staff picked up her breakfast tray, stated she is still wet and has not been checked or cleaned yet. On 3/10/26 at 10:25 AM, V9 (CNA) stated This is the first time we are getting R93 out of bed this morning. On 3/10/26 at 10:30 AM, V9 (CNA) and V10 (CNA) performed peri-care on R93, and upon removing the incontinence brief, it appeared to be saturated in urine. On 3/12/26 at 10:50 AM, V32 (CNA) stated I check on the residents every two hours. I come on at 6:30 AM and immediately start checking the residents. Those residents who are on the restorative program, we try to get up first and get them to the dining room. Then we go back and get the other residents up. We do incontinence care when we get them up. On 3/12/26 at 10:52 AM, V25 (CNA) stated I check my residents every two hours, and probably even more because I am always up and down the hall all day long and stopping in resident rooms to check on them. We start at 6:30 AM and start getting residents up and do incontinent care at that time. All residents are checked from 6:30 AM until lunch for incontinence. On 3/12/26 at 11:55 AM, V1 (Administrator) stated I would expect the staff to follow policies. 2. R96's Care Plan, dated 1/12/2026, documents that R96 has episodes of incontinence related to decreased sensation to void, impaired mobility. It also documents Check and change every 2 hours and PRN (as needed). R96's MDS, dated [DATE], documents that R96 is cognitively intact, always incontinent of bowel and bladder, and dependent on staff for toileting. On 3/10/2026 at 9:41 AM observed V25 (CNA) and V26 (CNA) perform incontinent care on R96. R96 was incontinent of urine and bowel. V25 and V26 assisted R96 on her left side, using a wet washcloth V25 then cleansed R96's anal area and part of R96's buttocks. V25 and V26 then assisted R96 on to her back onto visual stool soiled bath blanket. Using a wet washcloth V25 then cleansed R96's peri area and inner thigh. With each swipe allowing R96's stump to move about in stool. V25 then touched R96's pubis area with soiled gloves leaving small amount of stool on pubis area. V25 and V26 then turned R96 onto her left side and cleansed the anus and inner thighs. The facility's Incontinent Care policy, dated 5/16/2022, documents that Purpose: To provide guidelines to all nursing staff for providing proper incontinence care in order to keep skin clean, dry, free of irritation and odor. Policy: ALL incontinent residents will receive incontinence care in order to keep skin clean, dry and free of irritation and/or odor. Incontinence care will be provided as required. Procedure 8. Wash all soiled skin areas and dry very well, especially between skin folds; changing gloves and performing hand hygiene as required to prevent cross-contamination.

Based on interview, observation, and record review the facility failed to provide effective pain management for 1 (R10) out of 1 resident reviewed for pain in the sample of 44. This failure resulted in R10 experiencing ongoing pain during peri-care as evidence by visual and audible reports of pain expressed. Findings include: R10 was readmitted to the facility on [DATE] from the hospital with diagnosis of, in part, surgical aftercare on the digestive system, calculus of bile duct with cholecystitis, biliary acute pancreatitis, acute and chronic respiratory failure, and transient cerebral ischemic attack. R10's Minimum Data Set (MDS) dated [DATE], documented she is moderately cognitively impaired, is depended on staff for toileting hygiene, lower body dressing, rolling left and right, siting to standing and all types of transfers. R10's MDS further documented she required partial/moderate assistance from staff for personal hygiene and required substantial/maximal assistance from staff with showering/bathing. R10's Care Plan dated 11/19/24 documented R10 has a self-care deficit as evidenced by needing assistance with activities of daily living (ADLs), including bathing requiring two-person physical assistance. R10's Care Plan further document she is at risk for pain and for staff to utilize the following interventions: in part, notify physician if interventions are unsuccessful or if current complaint is a significant change from residents past experience of pain, observe/document for probable cause of each pain episode, remove/limit causes where possible, observe/record/report to nurse resident complaints of pain or requests for pain treatment. R10's Care Plan continued to document she is incontinent of Bowel/Bladder and for nursing staff to report to MD abnormal symptoms or conditions; skin break-down, excoriation, rash, bladder pain, dysuria, urinary pain, retro-peritoneal pain, excessive or inadequate urinary output, or abnormal urine characteristics; color, odor, clarity, hematuria, Et cetera (etc.). On 1/27/25 at 4:01 PM, V21 (Licensed Practical Nurse/LPN) stated she was not aware of any reddened skin marks on R10's peri-region and was not told in report of any by the previous nurse. V21 stated a nurse will have to look at them but she had not seen them today yet. No pain score was documented for R10 on 1/27/25. On 1/27/25 at 1:25 PM V19 (Certified Nursing Assistant/CNA) and V20 (CNA) entered R10's room to perform peri-care. R10's old brief was saturated with urine and stool upon removal. While performing peri-care, reddened areas with open wounds resembling skin tears/macerations were present on R10's right inner thigh, left butt cheek, and posterior left thigh as well as bright red skin to R10's labia. Any time one of those reddened areas was wiped R10 would cry owe while grimacing. V20 stated these marks have been there since she came back from the hospital and the nurses have been applying barrier cream to it, while the CNA's apply petroleum-based ointment. V20 stated V21 was aware of the red marks on R10. V20 applied petroleum-based ointment to all the reddened skin marks before completing care. No barrier cream was applied or in R10's active orders at this time. V19 and V20 completed peri-care at 2:10 PM on R10 on 1/27/25. R10's Pain Scores did not have a score completed on 1/27/25. R10 had stated during peri-care on 1/27/25 while V19 and V20 were present, it was hurting her, and she yelled owe with each wipe while grimacing. On 1/28/25 at 10:09 AM, V19 and V20 entered R10's room to provide peri-care after an incontinence episode. R10 stated my butt hurts, people don't care and don't do anything about it. R10 told V20 not to wipe so rough. R10 stated her pain was as 22 out of 10 on a pain scale. V19 and V20 proceeded to provide peri-care. V20 wiped R10's buttock and posterior thighs using up an entire package of wipes while R10 repeatedly yelled in pain with each wipe. V20 told V19 we will need another thing of wipes. V19 left to go get more wipes. V13 (CNA) returned with more wipes and V25 (Registered Nurse) with barrier cream. V20 completed peri-care on R10's front region using three wipes per section, each wipe having R10 yell out in pain. R10 stated it hurts, it hurts so much. V20 told R10 she was sorry but needed to get her cleaned up. V13 and V20 stated if a resident needs more time to finished completing a bowel movement, like R10 had been doing while V20 proceeded to wipe, they can offer a bedpan or put a brief on them and give them more time to finish. V19, V20, and V13 did not offer R10 more time to finish or a break from wiping nor any other pain-relieving alternative throughout peri-care. On 1/28/25 at 10:04 AM, R10 stated she was not doing so good today after them wiping my butt so many times; it was very painful, I'm sore. On 1/28/25 at 1:55 PM, R10 stated she is still in pain from being wiped, she is doing horrible. R10 stated the staff never offer her breaks if it is too painful for her while receiving peri-care. R10 stated she tells the aides she is in pain from them wiping her, but they tell her they need to get her cleaned. R10 stated they just started putting on that white barrier cream yesterday, before that it was the petroleum-based ointment the aides can apply but I've been complaining of pain down there for at least two weeks now. On 1/29/25 at 10:28 AM, V1 (Administrator) stated she expects the Certified Nursing Assistants to report pain to other staff. The facility's Activities of Daily Living (ADL) Support Policy dated 5/2/23 documented care and services to prevent and/or minimize functional decline will include appropriate pain management. The resident's response to interventions will be documented, monitored, evaluated, and revised as appropriate. The facility's Management of Pain Policy dated 5/16/22 documented our mission is to facilitate resident independence, promote resident comfort and preserve resident dignity. The purpose of this policy is to accomplish that mission through an effective pain management program, providing our residents the means to receive necessary comfort, exercise greater independence, and enhance dignity and life involvement. The policy further documented they will achieve these goals through providing, in part, promptly and accurately assessing and diagnosing pain, encouraging residents to self-report pain, monitoring treatment efficacy and side effects, preventing and minimizing anticipated pain when possible, using non-pharmacological and complementary and alternative medicine when appropriate, and using pain medication judiciously to balance the resident's desired level of pain relief with the avoidance of unacceptable adverse consequences.

Based on Interview, Observation, and Record Review, the facility failed to provide dignity during feeding assistance and ensure resident call lights are within reach of the resident for 4 of 20 residents (R8, R65, R93, R94) reviewed for resident dignity in the sample of 44. The Findings Include: 1. On 1/26/25 11:45 AM, V6 (Restorative Certified Nursing Assistant/CNA) was seen standing between R65 and R93 at a dining room table. V6 stood and used her right hand to feed R93, then used her left hand to feed R65. R65's Care Plan, dated 1/23/25, documents R65 has a Self-Care Deficit with Interventions: Take to dining room for meals, Eating - Setup help / Cueing required. R65's Minimum Data Set (MDS), dated [DATE], documents R65 is cognitively intact and is dependent on staff for eating. 2. R93's Care Plan, dated 11/4/24, documents R93 has Self-Care Deficit with Interventions: Eating - Independent required. R93's MDS, dated [DATE], documents R93 has a severe cognitive impairment and required partial/moderate staff assistance for eating. On 1/26/25 at 12:15 PM, V2 (Director of Nursing/DON) was seen handing a chair to V6 and told her she was supposed to be sitting down in a chair while assisting the residents. 44556 3. R8's Face Sheet, original admitted [DATE], documented R8 has diagnoses of but not limited to hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, Type II diabetes mellitus with diabetic chronic kidney disease and diabetic polyneuropathy, adult failure to thrive, and pressure ulcer of sacral region, stage 4. R8's MDS, dated [DATE], documented R8 is cognitively intact with a Brief Interview for Mental Status (BIMS) of 13 out of 15 and is dependent on staff for most of her activities of daily living (ADLs). R8's Care Plan, admitted [DATE], documented R8 has Self-Care Deficit As Evidenced by: Needs assistance with ADLs Related to Hemiplegia & Hemiparesis Left Non-Dominant Side, Alzheimer's, Dementia, Morbid Obesity, Neuromuscular Dysfunction of Bladder, and bowel incontinence. Interventions include but not limited to Encourage R8 to use bell to call for assistance. On 01/27/25 at 09:41 AM, R8 is lying in bed with the head elevated. R8 did not have a call light within easy reach for her to call for assistance when needed. One call light was lying on the floor and the other was hooked to the privacy curtain between the beds. 4. R94's Face Sheet, admitted [DATE], documented R94 had diagnoses of but not limited to malignant neoplasm of brain, chronic obstructive pulmonary disease (COPD), and symptomatic epilepsy and epileptic syndromes with complex partial seizures, not intractable, without status epilepticus. R94's MDS, dated [DATE], documented R94 is severely cognitively impaired with a BIMS of 06 out of 15 and requires substantial/maximal assistance with toileting hygiene, practical/minimal assistance with dressing, personal hygiene, supervision/touching assistance with walking 10 and 50 feet, and independent with bed mobility. He is occasionally incontinent of bladder and always continent of bowel. R94's Care Plan, admitted [DATE], documented R94 is at risk for falls and injuries related to (r/t) Medical Factors: Brain Cancer, Epilepsy, COPD, Emphysema, Interstitial Pulmonary Disease, Prediabetes, Chronic Kidney Disease Stage 3A, Hypertension, Hyperlipidemia, Low Back Pain, gastroesophageal reflux disease (GERD), and incontinence. Interventions include but are not limited to Keep call light within reach. On 01/26/25 at 10:24 AM, R94 was lying in his bed resting. His call light was not within easy reach for him to be able to call and ask for assistance if needed it was lying on the fall mat that was on the floor next to his bed. On 01/29/25 at 09:15 AM, V26 (Licensed Practical Nurse/Nurse Manager) stated most everyone on this hall can use their call light. She said R94 can use his light and R8 is blind so they hook her call light on her chest so she can find it, but she can use it. On 01/29/25 02:20 PM, V1 (Administrator) was asked what her expectations of the staff when it comes to residents having their call lights within easy reach? V1 said We follow our policy. The Facility's Meal Assistance policy, revised date of 02/17/20, documented Purpose: To provide guidance to facility staff on meal assistance and expectation. Policy: Residents shall receive assistance with meals in a manner that meets the individual needs of each resident. Policy Interpretation and Implementation Dining Room Residents: 1. All residents will be encouraged to eat in the dining room. 2. Facility staff will serve resident trays and will help residents who require assistance with eating. 3. Resident who cannot feed themselves will be fed with attention to safety, comfort, and dignity, for example: a. Not standing over residents while assisting them with meals. The Facility's call light guidance policy, revised date of 08/20/22, documented Purpose: To provide guidance to all facility staff on the use, response and placement of call lights. It further documents Procedure: 2. A call light activation device shall be kept within resident reach while in resident rooms and bathrooms. The Facility's Resident Rights policy, revision date of 07/11/22, documented Purpose: To provide guidance to facility staff on resident rights. Policy: Employees shall treat all residents with kindness, respect, and dignity. Policy Interpretation and Implementation 1. Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to: a. a dignified existence, b. be treated with respect, kindness, and dignity.

Based on Interview, Observation, and Record Review, the Facility failed to provide feeding assistance to Activities of Daily Living (ADL) Dependent residents requiring feeding assistance for 4 of 8 residents (R11, R24, R37, R59) reviewed for feeding assistance in the sample of 44. The Findings Include: 1. On 1/26/25 at 11:45 AM, R24 was seen sitting at the dining room table with his lunch tray and was not touching his food. When asked about being the only staff member assisting residents, V6 (Certified Nursing Assistant/CNA) stated I usually have someone helping me but not sure where she is. R24 was just staring at his plate and did not pick up his fork to eat. V6 would see this and yell to R24, sitting at another table, to take a bite. R24's Care Plan, dated 11/8/24, documents R24 has Self-Care Deficit with Interventions: Eating - Setup help/Cueing required. R24's Minimum Data Set (MDS), dated [DATE], documents R24 has a moderate cognitive impairment and requires Supervision/Touching Assistance for eating. 2. On 1/26/25 at 11:45 AM, R59 was seen sitting at a dining room table with his lunch tray and was not touching his food. When asked about being the only staff member assisting residents, V6 (CNA) stated I usually have someone helping me but not sure where she is. At 12:00 PM, V5, CNA, came into the dining room and sat with R59 who immediately began eating once assisted. R59's Care Plan, dated 12/29/24, documents R59 has Self-Care Deficit with Interventions: Eating - One-person physical assist required. R59's MDS, dated [DATE], documents R59 has a severe cognitive impairment and requires substantial/maximal assistance from staff for eating. On 1/29/25 at 8:52 AM, V13 (CNA) stated that R24, R59, R65, and R93 all eat in the small dining room because they require feeding assistance and staff is supposed to be in there assisting them. 42108 3. R11's Care Plan, dated 1/29/2025, (R11) has Self-Care Deficit As Evidenced by: Needs assistance with ADLs Related to Dementia, Chronic Kidney Disease Stage 3A, Peripheral Vascular Disease, Atherosclerotic Heart Disease, Hypertension (HTN), Hypothyroidism, Hyperlipidemia, Anemia, History of Pulmonary Embolism, Anxiety, Depression, Insomnia, Low Back Pain, Cervical Spondylosis, Lumbar Spondylosis, Essential Tremor, Osteoarthritis, Neuromuscular Dysfunction of Bladder, Irritable Bowel Syndrome, GERD, and incontinence. Resident refuses medication at times. Resident refuses care at times. Resident prefers bed in high position. Resident refuses shower at times. Eating - Supervision required. [NAME] is at risk for altered nutrition and hydration related to diagnosis of Alzheimer's Disease, moderate protein-calorie malnutrition, CKD, Anemia, vitamin deficiency. R11's MDS, dated [DATE], documents that R11 is cognitively impaired and requires supervision or touching assistance for eating. On 1/27/2025 from approximately at 8:30 AM observed R11 lying in bed. R11's breakfast tray was in front of R11 on the overbed table. A bowl of hot cereal with the lid on top, a ball of meat with gravy was on the tray untouched. The eggs were untouched and there was partially eaten toast. There was no staff present. On 1/27/2025 at approximately 8:40 AM when asked how the food was, R11 responded she guess it was fine. When asked about why the food was not eaten. R11 stated that she would like to eat more but she needed help. R11 stated that they come in and out but never stay. On 1/27/2025 at approximately 8:55 AM R11 lying in bed, eyes closed sleeping in the bed with the tray in front of her. No change in the food on the tray. V18 (CNA) entered the room and asked R11 if she was done. R11 opened her eyes and said yes. V18 removed the tray from room. On 1/29/2025 at 9:02 AM V2 (Director of Nursing) stated that she would address this with the staff and make sure that R11 is getting assistance with her meals. 4. R37's Care Plan, dated 11/19/2024, (R37) As Evidenced by: Needs assistance with ADLs Related to Morbid Obesity, Dementia, Chronic Kidney Disease Stage 3, Atherosclerotic Heart Disease, Hypertension, Atrial Fibrillation, Heart Failure, Presence of Cardiac Pacemaker, Peripheral Vascular Disease, Hyperlipidemia, Anemia, Major Depressive Disorder, Lymphedema, BPH, Flaccid Neuropathic Bladder, Obstructive Reflex Uropathy, and bowel incontinence. 2/25/2022 Eating - Independent required. R37's MDS, dated [DATE], documents that R37 is mildly cognitively impaired and requires set up or clean up assistance with meals. On 1/26/2025 at approximately 8:40 AM R37 was sitting in a chair in R37's room. R37's breakfast tray was in front of R37. R37's drink is covered. R37 was eating cereal with his hands. On 1/26/2025 at R37 stated that he doesn't get enough to eat. When asked why he is was eating with his hands R37, R37 stated that it is easier. On 1/29/2025 at 1:04 PM R37 was sitting in his room with the meal tray in front of him, in R37's reach. R37's bowls remained covered. R37 was not eating. On 1/29/2025 at 1:04 PM R37 stated that his hands are sore, and he can't close them enough to grasp the silverware. R37 stated that the plastic is hard for him to grasp, and he doesn't always eat his meal because he can't open everything. R37 stated that he has pain in his hands and the staff don't always help. The facility's ADL Support policy, dated 5/2/23, documents Policy: Resident will be provided with care, treatment, and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADLs). Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene.

Based on observation, interview, and record review the facility failed to supervise a resident with cigarettes, safely transfer residents using a mechanical lift, and implement fall interventions for 4 of 5 (R3, R41, R68, R94) residents reviewed for supervision. Findings include: 1. R41's Care Plan, dated 12/17/2024, documents that (R41) has Self-Care Deficit As Evidenced by: Needs assistance with ADLs Related to Parkinson's, chronic obstructive pulmonary disease (COPD), Chronic Respiratory Failure, Asthma, Interstitial Pulmonary Disease, Pulmonary Hypertension, Obstructive Sleep Apnea, Diabetes, end stage renal disease (ESRD), Hypertension, Congestive Heart Failure, Peripheral Vascular Disease, Hyperlipidemia, Anemia, Hypothyroidism, gastroesophageal reflux disease (GERD), Constipation, Convulsions, Morbid Obesity, Neuropathy, Gout, Arthritis, Left Above Knee Amputation, Right Below Knee Amputation, Low Back Pain, and incontinence. Transfer: Two-person physical assistance required Transfer: Mechanical Lift required, Transfer - uses adaptive devices mechanical Lift. R41's Minimum Data Set (MDS), dated [DATE], documents that R41 is cognitively intact and dependent on staff for transfers. On 1/27/2025 at approximately 10:20 AM observed V17 (Certified Nursing Assistant/CNA) and V18 (CNA) transfer R41 from the bed to the chair using a mechanical lift. V17 and V18 applied the lift pad and applied the hooks to the lift. V18 then started manually pumping the lift using the handle. V18 attempted to pull the lift from the bed and met resistance. V18 was not able to clear R41 from the bed. V17 then lowered the bed and wheels became stuck under the bed. V18 then pulled the lift with force from the bed causing R41 to swing freely in the lift. V18 at the control and V17 standing behind the wheelchair. V18 then attempted to move R41 in the lift and met resistance allowing R41 to swing freely in the lift. V17 then brought wheelchair to the lift and leaned it back with front wheels off the floor. V18 then lowered R41 into the wheelchair. On 1/29/2025 at approximately 9:30 AM R41 stated that she does not like being transferred with the lift that was used on her. R41 stated that she doesn't feel safe. R41 stated that she feels like she is going to fall. 2. R68's Care Plan, dated 11/25/2024, (R68) has Self-Care Deficit As Evidenced by: Needs assistance with Activities of Daily Living (ADLs) Related to Dementia, COPD, Peripheral Vascular Disease, Atherosclerotic Heart Disease, Bradycardia, Hypertension (HTN), Paroxysmal Atrial Fibrillation, Presence of Cardiac Pacemaker, Major Depressive Disorder, Anxiety, Hyperlipidemia, GERD, Anemia, Insomnia, Hypothyroidism, Constipation, R68's MDS, dated [DATE], documents that R41 is mildly cognitively impaired and requires substantial/maximal assistance with transfers. On 1/27/2025 at 9:50 AM observed V17 (CNA) and V18 (CNA) perform incontinent care. Upon completion of incontinent care V17 and V18 transferred R68 from the bed to the chair using a mechanical lift. V17 and V18 applied the lift pad and applied the hooks to the lift. V18 then started manually pumping the lift using the handle. V18 standing at front of lift next to controls and V17 standing behind the chair. V18 pulled the lift from over the bed and to the middle of room. V18 then placed the wheelchair beneath the lift and V18 lowered R68 into the chair. During transfer staff was not in contact with R68 allowing her to swing freely in the sling. 44556 3. R94's Face Sheet, admitted [DATE], documented R94 had diagnoses of but not limited to malignant neoplasm of brain, COPD, and symptomatic epilepsy and epileptic syndromes with complex partial seizures, not intractable, without status epilepticus. R94's MDS, dated [DATE], documented R94 is severely cognitively impaired with a Brief Interview for Mental Status (BIMS) of 06 out of 15 and requires substantial/maximal assistance with toileting hygiene, practical/minimal assistance with dressing, personal hygiene, supervision/touching assistance with walking 10 and 50 feet, and independent with bed mobility. He is occasionally incontinent of bladder and always continent of bowel. R94's Care Plan, admitted [DATE], documented R94 is at risk for falls and injuries related to (r/t) Medical Factors: Brain Cancer, Epilepsy, COPD, Emphysema, Interstitial Pulmonary Disease, Prediabetes, Chronic Kidney Disease Stage 3A, Hypertension, Hyperlipidemia, Low Back Pain, GERD, and incontinence. Interventions include but are not limited to Keep call light within reach. R94's Fall Risk Assessment, dated 01/07/25, documented R94 was a high fall risk. On 01/26/25 at 10:24 AM, R94 was lying in his bed resting. His call light was not within easy reach for him to be able to call and ask for assistance if needed. The call light was lying on the fall mat that was on the floor next to his bed. On 01/29/25 at 09:15 AM, V26 (Licensed Practical Nurse/LPN/Nurse Manager) stated most everyone on this hall can use their call light. She said R94 can use his light. On 01/29/25 02:20 PM, V1 (Administrator) was asked what her expectations of the staff when it comes to care plan interventions being in place? V1 stated We follow our policy. 44967 4. R3's Admission Record, dated 1/27/25, documents R3 was originally admitted to the facility on [DATE] with diagnosis of Cerebral Infarction with Hemiplegia/Hemiparesis affecting right dominant side, Aphasia, HTN, Heart Failure, Epilepsy, Anemia, Occlusion and Stenosis of left carotid artery, Osteoarthritis of knees, Intervertebral disc displacement lumbar, Contracture of right upper arm, Major Depressive disorder, and Right Above Knee Amputation (AKA). R3's Care Plan, dated 1/16/24: documents R3 has a history of smoking in his room. Interventions: R3 will be reminded of smoking times, R3 will be reminded appropriate smoking areas per smoking policy. 1/15/24: R3 is a smoker. At times is non-compliant with smoking policy. Resident refuses at times to wear coat when going outside to smoke on cold days. Interventions: Instruct resident about smoking risks and hazards and about smoking cessation aids that are available, instruct resident about the facility policy on smoking: locations, times, safety concerns, monitor oral hygiene, notify charge nurse immediately if it is suspected resident has violated facility smoking policy, observe clothing and skin for signs of cigarette burns, the resident can smoke unsupervised. R3's MDS, dated [DATE], documents R3 has a moderate cognitive impairment and requires substantial/maximal assistance for chair to bed transfer, and is independent on transporting himself with his wheelchair. On 1/26/25 at 10:48 AM, R3 was seen sitting in his electric wheelchair with a cigarette package in his shirt pocket along with a lighter. R3 stated he goes out to smoke on the patio when it's time, and he carries his own cigarettes and lighter with him. R3 stated normally, there is not a staff member outside with him. On 1/26/25 at 1:05 PM, R3 seen going outside to smoke with cigarettes and lighter in his shirt pocket and obtained a cigarette from his shirt and lighted his own cigarette. On 1/27/25 at 9:20 AM, R3 went from the dining room to his room to obtain his cigarettes and lighter. R3 was then seen wheeling himself out to smoke and then lit his own cigarette. There were two staff members outside smoking by the door and was not near R3. On 1/27/25 at 9:25 AM, the other two staff members seen outside smoking came inside and left R3 outside by himself smoking. On 1/27/25 at 9:45 AM, R3 came back inside and to his room. On 1/29/25 at 10:35 AM, V27 (CNA) stated No resident should have their cigarettes or lighter with them. When they go out to smoke, the staff outside with them will give them one. On 1/29/25 at 10:40 AM, V28 (Activity Director) stated The residents are not allowed to have their own cigarettes or lighters. The staff member that goes outside with the residents will give them a cigarette and light it for them. We are constantly taking cigarettes and lighters from (R3) and I just took his away yesterday. His sister visits him and will bring him more. The Facility's Smoking Policy, dated 11/2019, documents This facility will comply with all state and local smoking regulations. Compliance will include recognition of a person's right to use nicotine materials and the facility taking responsibility to provide an area for smoking and providing everyone's safety. All residents who smoke will be assessed to determine safety risk. The facility has the right to establish smoking times and to control the distribution of all smoking materials. The Facility's Using a Mechanical Level II Policy, dated 11/1/23, documents in part The purpose of this procedure is to establish the general principles of safe lifting using a mechanical lifting device. 1. At least two nursing assistants are needed to safely move a resident with a mechanical lift. Steps in the Procedure: 7. Make sure the lift is stable and locked. 9. Double check the sling and machine's weight limits against the resident's weight. 12.c. Before resident is lifted, double check the security of the sling attachment. e. Check the stability of the straps. 13. Lift the resident two inches from the surface to check the stability of the attachments, the fit of the sling and the weight distribution. 16. Gently support the resident as he or she is moved, but do not support any weight. The Facility's Transfer Policy, dated 5/19/22, documents To promote safe transfer for the residents, as well as the staff. Gait belts, Mechanical lifts, and/or sit to stand lifts will be used, unless otherwise specified. Procedure: 3. A minimum of two staff members is recommended when transferring with a Mechanical lift. 4. When using a Mechanical lift, pay close attention to be sure that the Mechanical lift sling is properly positioned and that the straps are securely in the strap holders. The Facility's Fall Prevention Program/Protocol, revised date of 09/06/23, Purpose: To provide guidance to facility staff regarding the prevention/limitation of falls within the facility. Responsibility: It is the responsibility of the Director of Nursing and /or designee to ensure all staff are aware of the elements of the program. It further documents Early Prevention and Fall Risk detection. 4. Guardian Angel Rounds shall be completed at least daily to ensure fall interventions remain in place.

Based on observation, interview, and record review the facility failed to do timely and complete incontinent care for 4 of 5 residents (R39, R41, R68, R79) reviewed for incontinent care in a sample size of 44. The Findings Include: 1. R79's Admission Record, dated 1/27/25, documents R79 was originally admitted to the facility on [DATE] with diagnosis of Bipolar disorder, Depression, Hallucinations, Traumatic Brain Injury, Pancytopenia, Type 2 Diabetic Mellitus (DM), Thrombocytopenia, Urinary incontinence, Hydrocephalus, COVID, and Urinary Tract Infections (UTIs). R79's Care Plan, dated 1/30/24, documents R79 is incontinent of Bowel/Bladder. Interventions: Observe and record bowel and bladder pattern each shift, clean peri-area with each incontinence episode. It continues R79 has Self-Care Deficit as evidenced by: Needs assistance with Activities of Daily Living (ADLs) related to TBI, Obstructive Sleep Apnea, Diabetes, Tachycardia, Hallucinations, Bipolar Disorder, Depression, Pancytopenia, Thrombocytopenia, and Incontinence. Interventions: Care in pairs at all times, toilet Use - one-person physical assist required, transfer: One-person physical assistance required. R79's Minimum Data Set (MDS), dated [DATE], documents R79 has a moderate cognitive impairment and requires partial/moderate assistance from staff for Activities of Daily Living (ADLs). R79 is frequently incontinent of both bowel and bladder. On 1/26/25 at 8:55 AM, R79 was seen being assisted out of the restroom by V5 (Certified Nursing Assistant/CNA). R79's front of his pants were saturated in urine. V5 left R79 is his wet pants and pulled the bedside table over in front of his wheelchair and prepared his breakfast tray for him. V5 had a clean pair of pants she pulled out and laid on his bed but did not change R79's pants prior to breakfast. 2. R39's Admission Record, dated 1/27/25, documents R39 was originally admitted to the facility on [DATE] with diagnosis of Dementia, Cirrhosis of Liver, Type 2 DM, Spondylopathies, Chronic Kidney Disease, Hypertension (HTN), Polyneuropathy, Obstructive and reflux uropathy, Calculus of Ureter, Neuralgia/Neuritis, Polyosteoarthritis, Spinal stenosis lumbar, Major Depressive Disorder, COVID, and anxiety disorder. R39's Care Plan, dated 1/20/25, documents R39 has Self-Care Deficit. Interventions: Toilet Use: Two-person physical assistance required, Transfer: Two-person physical assistance required with Mechanical Lift required. It continues R39 is incontinent of Bowel. Interventions: Observe/document/report PRN (as needed) any possible causes of incontinence: bladder infection, constipation, loss of bladder tone, weakening of control muscles, decreased bladder capacity, diabetes, stroke, medication side effects, clean peri-area with each incontinence episode. R39's MDS, dated [DATE], documents R39 has a severe cognitive impairment and is dependent on staff for toileting, dressing, and transfers. R39 is always incontinent of urine and occasionally incontinent of bowel. On 1/27/25 at 10:04 AM, V12 (CNA) and V13 (CNA) was seen in R39's room to provide peri-care. R39's brief was unfastened and tucked between her legs. V13 wiped R39's left groin once, her right groin once, and once down the middle of R39's vagina. R39 was rolled to her left side and the brief was tucked under her. V13 wiped R39's anal area. V13 put barrier cream on R39's buttock and anal area. R39 was rolled to her right and a clean brief was pulled up and between her legs. R39 was rolled to her back and the brief fastened. There was no wiping of R39's buttocks, esp. her left buttock and hip while R39 was turned on her right side. There was no wiping of R39's abdominal fold just above the pubic area, and no drying of R39. On 1/29/25 at 9:10 AM, V2 (Director of Nursing/DON), stated I would expect the staff to perform complete and timely incontinent care including cleaning all areas of the resident. 42108 3. R41's Care Plan, dated 6/5/24, (R41) is incontinent of Bowel/Bladder. Clean peri-area with each incontinence episode. R41's MDS, dated [DATE], documents that R41 is frequently incontinent of bowel. On 1/27/2025 at approximately 10:20 AM V17 (CNA) and V18 (CNA) performed incontinent care. R41 was incontinent of urine. V17 wet wash cloth with soap and washed beneath R41's arm and breast. V18 then opened R41's brief revealing soft stool. V18 then wiped R41's vaginal area with up and down motion V18 then cleansed buttocks using back and forth motion and then applied clean brief. V18 did not clean all soiled areas and apply skin protective skin lubricant. 4. R68's Care Plan, dated 08/08/2024, documents that (R68) is incontinent of Bowel/Bladder. It continues, clean peri-area with each incontinence episode. R68's MDS, dated [DATE], documents that R68 is always mildly cognitively impaired, always incontinent of urine and frequently incontinent of bowel, and dependent on staff for toileting. On 1/27/2025 at 9:50 AM observed V18 (CNA) perform incontinent care. R68 was incontinent of urine and bowel. V18 applied soap to a wet towel. V18 then opened R68's incontinent brief that was soiled with urine and stool. V18 then washed R68's neck and breast. With same towel washed R68's vaginal area with one wipe. V18 then turned R68 on her side. Using the same towel V18 wiped R68's buttocks with a back-and-forth motion. V18 did not cleanse R68's inner or back thighs. V18 then applied R68's clean brief. V18 did not clean all soiled areas and apply skin protective skin lubricant. The facility's Incontinence Care Policy, dated 5/16/2022, documents All incontinent residents will receive incontinence care in order to keep skin clean, dry, and free of irritation and/or odor. Incontinence care will be provide as required. Procedure: Wash all soiled skin areas and dry very well, especially between skin folds. Apply skin protective skin lubricant and rub well into skin.

Based on interviews, observations, and record reviews the facility failed to serve food with an appetizing appearance and taste for 7 out of 7 residents, (R61, R10, R15, R2, R87, R53), reviewed for Nutritive Value/Appearance, Palatable/Preferred Temperature in a sample of 44. Findings include: 1.R61's Minimum Data Set (MDS) dated [DATE] documented she is cognitively intact. 1/26/25 at 9:35 AM R61 stated the food here is nasty, so I buy my own food to eat and have a refrigerator to keep it in. 2.R10's MDS dated [DATE] documented she is moderately cognitively impaired. 1/26/25 at 10:05 AM R10 stated the food is not good. 3.R15's MDS dated [DATE] documented she is cognitively intact. 1/26/25 at 10:11 AM R15 stated the food is not good and doesn't taste good, so I buy my own food and keep it in my personal refrigerator. 4.R2's MDS dated [DATE] documented he is cognitively intact. 1/26/25 at 9:30 AM R2 stated the food is grubby and doesn't look appetizing. 5.R87's MDS dated [DATE] documented he is cognitively intact. 1/26/25 at 9:32 AM R87 stated the food is bad and not appealing. Resident Council Meeting Minutes dated 10/16/24 documented under dietary that the meat cooked the other day was tough. Resident Council Meeting Minutes for the month of September 2024 documented under dietary that the dinner was not fresh. On 1/28/25 at 11:30 AM, the menu for lunch 1/28/25 was Stuffed bell pepper, buttered corn, sherbet, and beverage. On 1/28/25 at 12:22, a sample tray was tested by this surveyor with the following concerns, the stuffed pepper was broken up (not intact) with the meat separated from the pepper and the sauce spread over both, the buttered corn was bland. On 1/29/25 at 10:28 AM, V1 (Administrator) stated she expects her dietary department to follow recipes according to the menu. The facility's Food and Nutrition Services Manual dated 9/1/21 documented food will be prepared by methods that conserve nutritive value, flavor, and appearance; food will be palatable, attractive, and served at a safe and appetizing temperature; food and liquids are prepared and served in a manner, form, and texture to meet resident's needs. 42108 6. R53's MDS, dated [DATE], documents that R53 is cognitively intact. On 1/27/2025 at 9:05 AM observed R53 lying in bed with plate in front of R53. A partially eaten black circular meat observed on plate. R53 hit sausage against plate an audible taping was heard. On 1/27/2025 at 9:05 AM R53 stated that the breakfast does not taste well. R53 stated that the meat is tough and hard to chew. R53 stated that he could not eat it because of how hard it was. R53 stated see and held sausage in the air. R53 stated Watch this and hit sausage on plate.

Based on observation, interview, and record review, the facility failed to perform hand hygiene and glove changes for 6 of 7 residents (R9, R27, R41, R65, R68, R93) reviewed for hand hygiene in the sample of 44. The Findings Include: 1. On 1/26/25 11:45 AM, V6 (Restorative Certified Nursing Assistant/CNA) was seen standing between R65 and R93 at a dining room table. V6 stood and used her right hand to feed R93, then used her left hand to feed R65. There was no hand hygiene seen done prior to or between assisting the residents. R65's Care Plan, dated 1/23/25, documents R65 has a Self-Care Deficit with Interventions: Take to dining room for meals, Eating - Setup help/Cueing required. R65's Minimum Data Set (MDS), dated [DATE], documents R65 is cognitively intact and is dependent on staff for eating. 2. R93's Care Plan, dated 11/4/24, documents R93 has Self-Care Deficit with Interventions: Eating - Independent required. R93's MDS, dated [DATE], documents R93 has a severe cognitive impairment and required partial/moderate staff assistance for eating. 3. On 1/26/25 at 9:15 AM, V7 (Registered Nurse/RN) was seen passing meds to residents on C-hall. Hand Hygiene was not seen performed between residents. V7 was seen popping out pills from a medication card for R27, with a pill falling onto the medication cart, V7 picked up the pill with her bare hands, put it in a medicine cup, then gave them to R27. There was no hand hygiene seen done. 4. On 1/26/25 at 9:25 AM, V7 was also seen putting medications into a medicine cup, and while picking up the medicine cup to take to R9, there was a random pill lying on the medication cart next to the medicine cup. V7 went through the cup to find out which pill was missing, noted it was a Multivitamin (MVI), and got another MVI pill from the bottle and put into the medication cup with her bare hands, then walked the medications into R9's room to administer them. There was no hand hygiene seen done. 42108 5. R68's Care Plan, dated 08/08/2024, documents that (R68) is incontinent of Bowel/Bladder. It continues, clean peri-area with each incontinence episode. R68's MDS, dated [DATE], documents that R68 is always mildly cognitively impaired, incontinent of urine and frequently incontinent of bowel, dependent on staff for toileting. On 1/27/2025 at 9:50 AM observed V17(Certified Nursing Assistant/CNA) and V18 (CNA) perform incontinent care. R68 was incontinent of urine and bowel. V18 applied gloves and applied soap to a wet towel. V18 then opened R68's incontinent brief that was soiled with urine and stool. V18 then washed R68's neck and breast. With same towel washed R68's vaginal area with one wipe. V18 then turned R68 on her side. Using the same towel. Using the same soiled gloves V18 applied R68's then applied R68's clean brief, pants, bra, and shirt. V18 then removed the soiled gloves. The facility's Incontinent Care Policy, dated 5/16/2022, documents Procedure 5. perform hand hygiene, apply gloves. 8. Wash all soiled skin areas and dry very well, especially between skin folds; changing gloves and performing hand hygiene as required to prevent cross-contamination. 12 perform hand hygiene. 15. hand hygiene. The facility's Medication Administration Policy/Procedure, dated 9/27/2022, documents Oral Medications: 7. Do not touch the medication with your hands.

Based on interview and record review the facility failed to confirm the need for an antibiotic and failed to ensure a resident received all doses of the antibiotic(s) as ordered for 5 of 5 (R34, R39, R85, R89, R95) residents reviewed for the antibiotic stewardship program in the sample of 44. Findings include: 1. On 1/26/2025 the facility provided a document, not labeled, and not dated, listing Resident Name, DOB (date of Birth), Onset Date, Infection, and organism. On 1/28/2025 at approximately 2:00 PM V24 (Infection Preventionist) stated that this was the tracking tool used for infections and antibiotic usage. V24 stated that she was not sure what infection R39 had. The Facility's Infection Control Log, not dated, documents that R39 had an unknown infection starting 12/13/2024. The infection control log does not document if R39 received antibiotics, the residents medical record number, unit and room number, adverse effects, and outcomes. A review of R39's medical record was performed. No documentation of culture results in medical record. R39's Physician Order Sheet POS, dated December 2024, documents 12/13/2024 Linezolid Tablet 600 MG Give 1 tablet by mouth every 12 hours for Infection for 8 Administrations. R39's Medication Administration Record (MAR) dated December 2024 documents R39 received this antibiotic. 2. On 1/26/2025 the facility provided a document listing Resident Name, DOB, Onset Date, Infection, and organism. On 1/28/2025 at approximately 2:00 PM V24 (Infection Preventionist) stated that this was the tracking tool used for infections and antibiotic usage. V24 stated that she was not sure what infection R85 had and why she was on antibiotics. V24 stated that she thinks it was COVID. The Unlabeled, not dated, list provided by the facility, documents that R85 had an unknown infection starting 12/17/2024. No organism listed. The infection control log does not document if R85 received antibiotics. A review of R85's medical record was performed. No documentation of culture results in medical record. R85's POS, dated December 2024, documents 12/17/2024 Cefdinir Capsule 300 MG Give 1 capsule by mouth two times a day for infection. R85's Medication Administration Record (MAR) dated December 2024 documents R85 received this antibiotic. 3. On 1/26/2025 the facility provided a document listing Resident Name, DOB, Onset Date, Infection, and organism. The document is untitled and not dated. On 1/28/2025 at approximately 2:00 PM V24 (Infection Preventionist) stated that this was the tracking tool used for infections and antibiotic usage. The Unlabeled, not dated, list provided by the facility, documents that R95 had a Urinary Tract Infection starting 12/10/2024. No organism listed. The infection control log does not document R95's antibiotics. A review of R95's medical record was performed. No documentation of culture results in medical record. R95's POS, dated December 2024, documents 12/10/2024 Amoxicillin Oral Tablet 500 MG (Amoxicillin) Give 1 tablet by mouth two times a day for UTI for 2 Days R95's Medication Administration Record (MAR), dated December 2024, documents R95 received this antibiotic. 4. On 1/26/2025 the facility provided an unlabeled and not dated, document listing Resident Name, DOB, Onset Date, Infection, and organism. On 1/28/2025 at approximately 2:00 PM V24 (Infection Preventionist) stated that this was the tracking tool used for infections and antibiotic usage. The Unlabeled, not dated, list provided by the facility, documents that R34 had an unknown infection starting 12/25/2024. No organism listed. The infection control log does not document if R34 received antibiotics. R34's Physician's Order Sheet (POS), dated December 2024, documents 12/25/2024 Azithromycin Tablet 250 MG Give 500 mg by mouth in the morning for INFECTION for 1 Day. 12/27/2024 Azithromycin Tablet 250 MG Give 1 tablet by mouth one time a day for bacterial infection for 4 Days. R34's Medication Administration Record (MAR) dated December 2024 documents R34 received this antibiotic. 44556 5. R89's Face Sheet, original admitted [DATE], documented R89 has diagnoses of but not limited to infection following a procedure, deep incisional surgical site, subsequent encounter, and local infection to the skin and subcutaneous tissue. R89's MDS, dated [DATE], documented R89 is cognitively intact with a Brief Interview for Mental Status (BIMS) of 14 out of 15 and is dependent on staff for transferring from bed to chair, chair to bed, and toileting transfer. R89's Care Plan, admitted [DATE], documented R89 is at risk for complications related to (r/t) a wound infection and requires antibiotics. Interventions include but not limited to Administer antibiotic as per medical doctor (MD) orders. Follow facility policy and procedures for line listing, summarizing, and reporting infections. R89's Wound culture, dated 12/17/2024 from the hospital documented R89's wound had the following organisms 1. Esherichia Coli, 2. Enterococcus Faecalis, 3. Proteus Mirabilis. R89's Physician's Orders, dated 12/26/24, documented R89 was ordered Ceftriaxone Sodium injection reconstituted 2 grams (GM), use 2000 milligrams (mg) intravenously one time a day for wound infection. R89's Physician's Orders, dated 12//27/24, documented Vancomycin HCl Intravenous Solution 1000 milligrams (MG)/200 milliliters (M)L (Vancomycin HCl) Use 1000 mg intravenously every 12 hours for infection, and a weekly vancomycin trough on Tuesday. R89's MAR for the month of December 2024 was reviewed and had no documentation on 12/29/24 that R89 had her Ceftriaxone IV antibiotic. There was no documentation on 12/28/24 and 12/29/24 that R89 received her Vancomycin IV antibiotic. R89's MAR for the month of January 2025 was reviewed and had no documentation R89 received her Ceftriaxone IV antibiotic on 01/09/25, 01/11, 01/12, 01/17, 01/18, 01/19, 01/21, 01/25, and 01/26/25. There was also no documentation R89 received her Vancomycin IV antibiotic on day shift on 01/09/25, 01/11, 01/12, 01/17, 01/18, 01/19, and 01/26/25. On 1/26/2025 the facility provided an unlabeled and not dated, document listing Resident Name, DOB, Onset Date, Infection, and organism. R89's name, DOB, Onset Date, Infection, or organism was on this list. On 01/29/25 at 09:02 AM, V2 (Director of Nursing) brought in documents for this surveyor to review regarding R89's missed doses of IV antibiotics. She said she did education with nurses, and they are filling them now. The documents were reviewed and documented R89 received the evening dose of her IV antibiotics but there was no documentation R89 received the morning doses. On 01/29/25 at 01:25 PM, V29 (Pharmacist) said she would consider seven missed does of 9 doses of Ceftriaxone and 7 doses of Vancomycin is a significant medication error. She said that is a lot of missed doses. V29 said it could affect R89 by causing the infection to take longer to get rid of and it could cause the infection to even get worse depending how bad the infection was. The facility's Antibiotic Stewardship Policy/Procedure, dated 12/13/23, documents Policy: It is the policy to maintain an Antibiotic Stewardship Program (ASP) with the mission of promoting the appropriate use of antibiotics to treat infections and reduce possible adverse events associated with antibiotic use.

Based on interviews, observations, and record reviews the facility failed to follow wound care orders for 1 out of 1, (R87), reviewed for quality of care in a sample of 44. Findings include: R87 was admitted to the facility on [DATE] with diagnosis of, in part, chronic multifocal osteomyelitis of left ankle/foot, cellulitis, type two diabetes mellitus with foot ulcer and neuropathy, peripheral vascular disease and acquired absence of right leg above knee. R87's Minimum Data Set (MDS) dated [DATE], documented he is cognitively intact, requires substantial/maximal assistance from staff for lower body dressing, and is dependent on staff assistance for putting on/taking off footwear. R87's care plan dated 12/30/25 documented R87 has diabetic ulcers to the left heel and left dorsal mid foot relate to diabetes and lack of sensation to affected area. R87's interventions for the ulcers are documented as follows: Enhanced Barrier Precautions (EBP), Observe/document wound: Size, Depth, Margins: peri-wound skin, sinuses, undermining, exudates, edema, granulation, infection, necrosis, eschar, gangrene at least weekly, document progress in wound healing on an ongoing basis, notify medical doctor (MD) as indicated, observe/document/report as needed any signs/symptoms of infection: green drainage, foul odor, redness and swelling, red lines coming from the wound, excessive pain, fever, observe/document/report as needed changes in wound color, temp, sensation, pain, or presence of drainage and odor, and treatment as ordered. On 1/27/25 at 9:41 AM, R87's left foot dressing was not intact, the rolled gauze was dangling on the floor as he sat in his chair. The gauze is saturated with a moderate amount of yellow/serous fluid and does not have a date on it. R87 stated he is on intravenous antibiotics for his left foot wound infection currently. On 1/27/25 at 12:56 PM, V14 (Wound Care Nurse) went into R87's room to provide wound care. The old dressing continued to be not intact, the rolled gauze was dangling off R87's left foot and his heel wound saturated through all the layers of the gauze with a moderate to large amount of yellow drainage. V14 removed the entire old dressing which did not include bordered gauze or an abdominal pad. V14 stated the dressing should have include an elastic wrap which was also not in place. On 1/27/25 at 12:59 PM, V14 stated the nurses know the current wound care orders and know to apply an elastic wrap. R87's orders dated 1/24/2025 at 7:19 PM and 7:21 PM documented the following, Cleanse left trans metatarsal amputation site with wound cleanser, normal saline or soap and water, pat dry. Apply skin barrier to peri-wound, allow to dry prior to application of primary or secondary dressing. Apply silver sulfadiazine, Collagen Hydrogel, Collagen Particles to wound bed, cover with calcium alginate sheet (cut to fit) and Bordered Gauze dressing. Secure with Rolled Gauze dressing and 4 elastic bandage. Change daily and as needed. Cleanse Left Heel with wound cleanser, normal saline or soap and water, pat dry. Apply skin barrier to peri-wound allow to dry prior to application of primary or secondary dressing. Apply silver sulfadiazine, Collagen Hydrogel, and Collagen Particles to wound bed, cover with Calcium Alginate sheet (cut to fit area), abdominal pad, and rolled gauze dressing. Wrap foot in 4 elastic bandage, transitioning to 6 elastic bandage as you wrap the remainder of the lower extremity. Daily and as needed. On 1/29/25 at 10:28 AM, V14 stated she expects staff to follow out wound care orders as written by the provider. On 1/29/25 at 3:00 PM, V1 stated the facility does not have a policy on treatment and care for diabetic ulcers.

Based on observations, interviews, and record reviews the facility failed to provide treatment and services to prevent and/or heal pressure ulcers for 1 out of 1 resident (R10) reviewed for treatment/services to prevent/heal pressure ulcers in a sample of 44. Findings include: R10 was readmitted to the facility on [DATE] from the hospital with diagnosis of, in part, surgical aftercare on the digestive system, calculus of bile duct with cholecystitis, biliary acute pancreatitis, acute and chronic respiratory failure, and transient cerebral ischemic attack. R10's Minimum Data Set (MDS) dated [DATE], documented she is moderately cognitively impaired, is depended on staff for toileting hygiene, lower body dressing, rolling left and right, siting to standing and all types of transfers. R10's MDS further documented she required partial/moderate assistance from staff for personal hygiene and required substantial/maximal assistance from staff with showering/bathing. R10's Care Plan dated 11/19/24 documented R10 has a self-care deficit as evidenced by needing assistance with activities of daily living (ADLs), including bathing requiring two-person physical assistance. R10's Care Plan further document she is at risk for pain and for staff to utilize the following interventions: in part, notify physician if interventions are unsuccessful or if current complaint is a significant change from residents past experience of pain, observe/document for probable cause of each pain episode, remove/limit causes where possible, observe/record/report to nurse resident complaints of pain or requests for pain treatment. R10's Care Plan also documented she is at risk for impaired skin integrity (resident refuses turning and repositioning at times), observe skin integrity during AM/PM care, notify medical doctor (MD) of skin breakdown, provide peri-care. R10's Care Plan continued to document she is incontinent of Bowel/Bladder and for nursing staff to report to MD abnormal symptoms or conditions; skin break-down, excoriation, rash, bladder pain, dysuria, urinary pain, retro-peritoneal pain, excessive or inadequate urinary output, or abnormal urine characteristics; color, odor, clarity, hematuria, Et cetera (etc.). On 1/29/25 a copy of R10's Care Plan dated 11/6/24 was requested and the facility provided a copy with the care plan for risk of impaired skin integrity revised 1/29/25 adding that the resident refuses any other treatment for redness other than petroleum based ointment and resident prefers to use wipes for peri-care, there was also a new section added for R10 having actual impairment to skin integrity of her buttocks and bilateral gluteal folds related to Moisture Associated Skin Damage (MASD). R10's Re-Admission assessment dated [DATE] at 6:20 PM, completed by V13 (Nurse Manager) documented R10 had pressure sores to her right and left buttock. R10's orders dated 1/12/25 at 12:52 PM, documented R10 to have a skin inspection/nursing weekly assessment completed on Sundays in the evening shift. No skin and wound assessment, measurements, or an initial treatment plan for pressure ulcers was completed on 1/13/25 after V13 (Nurse Manager) documented finding two areas of pressure sores. On 1/26/25 at 10:05 AM R10 stated the staff could change me more often. I'll put my call light on to be cleaned, they'll come quickly to shut it off then tell me they will be back soon to clean me up but not return for hours. R10 stated she feels like an inconvenience to staff when they miss my bed baths. Some staff will be rude and ask what I need now. On 1/27/25 at 4:01 PM, V21 (Licensed Practical Nurse/LPN) stated she was not aware of any reddened skin marks on R10's peri-region and was not told in report of any by the previous nurse. V21 stated a nurse will have to look at them but she had not seen them today yet. On 1/27/25 at 10:30 PM, R10's Orders documented the following: barrier cream to bilateral buttock every shift; as needed every shift for prophylactic and barrier cream to groin every shift every shift for prophylactic and every 8 hours as needed for prophylactic. On 1/27/25 at 1:25 PM V19 (Certified Nursing Assistant/CNA) and V20 (CNA) entered R10's room to perform peri-care. R10's old brief was saturated with urine and stool upon removal. While performing peri-care, reddened areas with open wounds resembling skin tears/macerations were present on R10's right inner thigh, left butt cheek, and posterior left thigh as well as bright red skin to R10's labia. Any time one of those reddened areas was wiped R10 would state owe while grimacing. V20 stated these marks have been there since she came back from the hospital and the nurses have been applying barrier cream to it, while the CNA's apply A&D ointment. V20 stated V20 was aware of the red marks on R10. V20 applied A&D ointment to all the reddened skin marks before completing care. No barrier cream was applied or in R10's active orders at this time. On 1/28/25 at 10:04 AM, R10 stated she was not doing so good today after them wiping my butt so many times; it was very painful, I'm sore. On 1/28/25 at 10:09 AM, V19 and V20 entered R10's room to provide peri-care after an incontinence episode of urine and stool. R10 stated my butt hurts, people don't care and don't do anything about it. R10 told V20 not to wipe so rough. R10 stated her pain was as 22 out of 10 on a pain scale. V19 and V20 proceeded to provide peri-care. V20 wiped R10's buttock and posterior thighs using up an entire package of wipes while R10 repeatedly yelled in pain with each wipe. V20 told V19 we will need another thing of wipes. V19 left to go get more wipes. V13 (CNA) returned with more wipes and V25 (Registered Nurse/RN) with barrier cream. V20 completed peri-care on R10's front region using three wipes per section, each wipe having R10 yell out in pain. V20 told R10 she was sorry but needed to get her cleaned up. V13 and V20 stated if a resident needs more time to finished completing a bowel movement, like R10 had been doing while V20 proceeded to wipe, they can offer a bedpan or put a brief on them and give them more time to finish. V19, V20, and V13 did not offer R10 more time to finish or a break from wiping. On 1/28/25 at 1:55 PM, R10 stated she is still in pain from being wiped, she is doing horrible. R10 stated the staff never offer her breaks if it is too painful for her while receiving peri-care. R10 stated she tells the aides she is in pain from them wiping her, but they tell her they need to get her cleaned. R10 stated they just started putting on that white barrier cream yesterday, before that it was the petroleum-based ointment the aides can apply but I've been complaining of pain down there for at least two weeks now. On 1/28/25 at 10:42 AM, V25 (RN) stated the orders for barrier cream started yesterday. On 1/29/25 at 8:09 AM, V26 (Nurse Manager) stated she remembered R10 came back from the hospital with the pressure sores on 1/12/25 for the left and right buttock. V26 stated when we find sores on a resident after returning from the hospital, the next steps we take are to put in place a treatment plan, notify the wound nurse to go make an assessment and then the wound nurse tells the nurse practitioner for orders. On 1/29/25 at 9:15 AM, V14 (Wound Nurse) stated she was not aware of any wounds on R10 after her return from the hospital. V14 stated she was notified of skin concerns on R10 yesterday and R10 has Moisture Associated Skin Damage (MASD). On 1/29/25 at 11:44 AM, V14 (Wound Care Nurse) documented R10's Braden Scale for Predicting Pressure Sore Risk was High Risk. On 1/29/25 at 2:10 PM, R10 had Skin Inspection Assessments completed on the following dates 1/14/25 and 1/19/25 after her return from the hospital and being scored a High Risk by V14 (Wound Care Nurse). On 1/29/25 at 10:28 AM, V1 (Administrator) stated she expects the Certified Nursing Assistants (CNAs) to report pain to other staff. The facility's Incontinence Care Policy dated 5/16/22 documented all incontinent residents will receive incontinence care in order to keep skin clean, dry and free of irritation and/or order. The policy continued to document procedure included inspection of the skin and report all irritated areas to charge nurse. The facility's Activities of Daily Living (ADL) Support Policy dated 5/2/23 documented residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming, and personal and oral hygiene. The policy continued to document that appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with hygiene (bathing, dressing, grooming, and oral care) and elimination (toileting). The policy further documented care and services to prevent and/or minimize functional decline will include appropriate pain management. The resident's response to interventions will be documented, monitored, evaluated, and revised as appropriate. The facility's Pressure Ulcer Policy dated 8/31/23 documented nurses are to complete skin assessments daily on residents deemed High Risk for skin breakdown. The policy further documented when a pressure ulcer is identified, whether in house or upon a resident's admission, the area will be assessed using the skins and wound assessment, a skin inspection assessment shall be completed, and initial treatment started per physician's orders. Daily skin checks shall be initiated on residents with a pressure wound to provide increased monitoring from nursing staff. The policy also documented it is the responsibility of the charge nurse/designee to measure and document on the pressure areas weekly. The facility's Non-pressure Skin Impairment Policy dated 1/3/23 documented it is the responsibility of the nursing department to ensure non-pressure skin impairments are identified and progress is tracked as required.

Based on interview and record review the facility failed to ensure a resident is free from significant medication errors for 1 or 5 residents (R89) reviewed for medications in a sample of 44. Findings Include: R89's Face Sheet, original admitted [DATE], documented R89 has diagnoses of but not limited to infection following a procedure, deep incisional surgical site, subsequent encounter, and local infection to the skin and subcutaneous tissue. R89's Minimum Data Set (MDS), dated [DATE], documented R89 is cognitively intact with a Brief Interview for Mental Status (BIMS) of 14 out of 15 and is dependent on staff for transferring from bed to chair, chair to bed, and toileting transfer. R89's Care Plan, admitted [DATE], documented R89 is at risk for complications related to (r/t) a wound infection and requires antibiotics. Interventions include but not limited to Administer antibiotic as per medical doctor (MD) orders. Follow facility policy and procedures for line listing, summarizing, and reporting infections. R89's Wound culture, dated 12/17/2024 from the hospital documented R89's wound had the following organisms 1. Esherichia Coli, 2. Enterococcus Faecalis, 3. Proteus Mirabilis. R89's Physician's Orders, dated 12/26/24, documented R89 was ordered Ceftriaxone Sodium injection reconstituted 2 grams (GM), use 2000 milligrams (mg) intravenously one time a day for wound infection. R89's Physician's Orders, dated 12//27/24, documented Vancomycin HCl Intravenous Solution 1000 milligrams (MG)/200 milliliters (M)L (Vancomycin HCl) Use 1000 mg intravenously every 12 hours for infection, and a weekly vancomycin trough on Tuesday. R89's Medication Administration Record (MAR) for the month of December 2024 was reviewed and had no documentation on 12/29/24 that R89 had her Ceftriaxone IV antibiotic. There was no documentation on 12/28/24 and 12/29/24 that R89 received her Vancomycin IV antibiotic. R89's MAR for the month of January 2025 was reviewed and had no documentation R89 received her Ceftriaxone IV antibiotic on 01/09/25, 01/11, 01/12, 01/17, 01/18, 01/19, 01/21, 01/25, and 01/26/25. There was also no documentation R89 received her Vancomycin IV antibiotic on day shift on 01/09/25, 01/11, 01/12, 01/17, 01/18, 01/19, and 01/26/25. On 01/29/25 at 09:02 AM, V2 (Director of Nursing) brought in documents for this surveyor to review regarding R89's missed doses of IV antibiotics. She said she did education with nurses, and they are filling them now. The documents were reviewed and documented R89 received the evening dose of her IV antibiotics but there was no documentation R89 received the morning doses. On 01/29/25 at 01:25 PM, V29 (Pharmacist) said she would consider seven missed does of 9 doses of Ceftriaxone and 7 doses of Vancomycin is a significant medication error. She said that is a lot of missed doses. V29 said it could affect R89 by causing the infection to take longer to get rid of and it could cause the infection to even get worse depending how bad the infection was. The Facility's Medication Administration Policy/Procedure, revised date of 09/27/22, documented Policy Medications will be administered safely to residents within the facility by licensed nurses at the specified time/time frame, following the recommended administration method and will be documented as required. It further documented 12. Chart the medication administered on the electronic medication administration record.

Based on interview, observation, and record review, the Facility failed to ensure staff were wearing the appropriate Personal Protective Equipment (PPE) and following the required infection control practices. This has the potential to affect all 101 residents living in the Facility. Findings include: On 2/13/24 at 7:35 AM, the front door of the Facility had a sign documenting a current COVID-19 outbreak status. The Facility's Undated Covid Dates Report documented there were 12 residents being isolated for COVID-19 on 2/13/24. The Facility's Undated Covid Dates Report documented R7 and R8 were being isolated for COVID-19 on 2/13/24. On 2/13/24 at 7:43, the door to R7's and R8's room was standing wide open, and there was no isolation supply cart outside the room. On 2/13/24 at 7:50 AM, V5 (Certified Nursing Assistant/CNA) was walking through dining room during breakfast service with her N-95 mask worn below her nose. She pulled the mask up over her nose and stated the Facility does require staff to wear masks during the outbreak, and she was going to get her eye shield right then. On 2/13/24 at 8:10 AM, there was a sign on R4's door documenting Enhanced Barrier Precautions which stated the requirement for gown, gloves, and mask. V8 (Housekeeper) donned gown and gloves and knocked on R4's door, then sprayed a rag for cleaning and entered the room with her face mask worn below her nose. V8 came out of R4's room with an empty meal tray and opened the meal cart in the hallway with the same gloves that had been worn in R4's room for cleaning. V8 deposited R4's dirty meal tray in the cart and returned to R4's room to resume cleaning with her mask remaining below her nose. On 2/13/24 at 8:14 AM, V9 (CNA) opened the meal cart with the handle V8 (Housekeeper) had just used, removed a tray, and delivered the tray to R6. On 2/13/24 at 8:15 AM, V7 (Licensed Practical Nurse), stated R4 has a wound infection. On 2/13/24 at 8:20 AM, V10 (CNA) was walking down the B Hallway wearing a mask that did not cover her nose. On 2/13/24 at 11:25 AM, R3 stated staff does not wear masks all the time during an outbreak, and some staff did not wear a mask in his room when he was being isolated for COVID-19. On 2/13/24 at 11:38 AM, R4's door was standing wide open, and R4 was lying in bed. V11 (Admissions Director) was at R4's bedside placing a meal tray on the bedside table directly next to R4's bed. V11 was not wearing gloves or a gown. After leaving R4's room, V11 stated, I don't provide any patient care to her. On 2/14/24 at 9:25 AM, V8 (Housekeeper) stated she cleans all the different halls in the Facility. On 2/14/24 at 2:56 PM, V2 (Director of Nursing), stated she would expect staff to follow their infection control policies and ensure face masks cover the nose. The Facility's Transmission Based Precautions Policy revised 3/22/23 documents it is the responsibility of all staff and agents of the facility to adhere to the transmission-based precaution guidelines, and gloves will be worn when entering the room of residents with Enhanced Barrier Precautions. It documents gloves will be removed and hand hygiene performed before leaving the room. The Facility Census signed and dated 2/13/24 documents there are 101 residents living in the Facility.

Based on observation, interview and record review, the Facility failed to prepare, and serve food in a manner which prevents potential contamination. This has the potential to affect all 100 residents living in the Facility. Findings Include: On 1/2/23 at 9:00 AM, during the initial tour of the kitchen, the ice machine did not have an air gap. On 1/2/23 at 9:05 AM, V23 (Dietary Manager) stated, It's a new ice machine. I will call maintenance to look at it. We fill all the drinks from that machine and put food on ice. On 1/2/23 at 11:00 AM, the tray line was observed. The meal was taco salad, and the lettuce was on the steam table. Temperatures were taken of the last tray to come off the tray line. The hamburger was 135 degrees Fahrenheit, the refried beans were 135 degrees Fahrenheit, and the lettuce was 70 degrees Fahrenheit. On 1/5/23 at 1:19 PM, V23 (Dietary Manager) stated that he had it (the lettuce) on the steam table to build the taco salad quicker and that he had it (the lettuce) on ice. The Facility policy Quick Resource Tool: Safe Food Handling documented, The Dining Service Director/Cooks will be responsible for food preparation techniques which minimizes the amount of time that food items are exposed to temperatures greater than 41 degrees Fahrenheit and or less than 135 degrees Fahrenheit or per state regulation. Dining service staff will be responsible for food preparation procedures that avoid contamination by potentially harmful physical biological, and chemical contamination. The Resident Census and Conditions of Residents CMS (Central Management Service) form 672 dated 1/2/23 documents that the facility had 100 residents living in the facility.

Based on interview and record review, the facility failed to obtain laboratory results documenting the organisms being treated prior to initiating and/or continuing antibiotic therapy for 3 of 23 residents (R69, R91, R94) reviewed for antibiotic stewardship in a sample of 41. Findings include: 1. R69's Face Sheet, undated, documented that she was admitted to the facility on [DATE] from an area hospital. R69's Nurse Progress notes, dated 11/28/23, documented that the hospice nurse placed R69 on an antibiotic, due to her urine had changed in character and resident had some pain related to having a catheter. No laboratory work was ordered. R69's Physician Order Summary, undated, documented an order Sulfamethoxazole-Trimethoprim 800-160 milligrams (mg) for 10 days with a Start Date 11/28/23. R69's Hospital Lab results, dated 12/8/23, documented, R69's urine specimen was setup for culture but there were no results documenting that the culture and sensitivity were received. R69's Physician Order Summary, undated, documented an order for Amoxicillin-Potassium Clavulanate 875-125 mg for 7 days with a Start Date 12/13/23 and End date of 12/20/23. 2. R91s Face Sheet, undated, documented that R91 was admitted to the facility 11/27/23 from an area hospital. R91's Hospital Lab results, dated 12/9/23, documented that a urine specimen was setup for culture but there were no results documenting that culture and sensitivity were received. R91's Physician Order Summary, undated, documented an order for Sulfamethoxazole-Trimethoprim 800-160 mg for 7 days with a Start Date 12/11/23 and End date of 12/18/23. 3. R94's Face Sheet, undated, documented R94 was admitted to the facility on [DATE] from an area hospital. R94's Lab results, dated 12/9/23, documented that a urine specimen was setup for culture but there were no results documenting culture and sensitivity were received. R94's Physician Order Summary, undated, documented an order for Amoxicillin-Potassium Clavulanate 875-125 mg for 5 days with a Start Date 12/16/23 and End date of 12/23/23. R94's Electronic Medication Administration (eMARS), dated 12/2023, documented that R94 received 1 out of 1 dose of Amoxicillin-Potassium Clavulanate 875-125 mg for 7 days with an Order Date 12/14/23. R94's Electronic Medication Administration (eMARS), dated 12/2023, documented that R94 received 16 out of 16 doses of Amoxicillin-Potassium Clavulanate 875-125 mg for 7 days with an Order Date 12/15/23. R94's Electronic Medication Administration (eMARS), dated 12/2023, documented that R94 received 5 out of 5 doses of Amoxicillin-Potassium Clavulanate 875-125 mg for 7 days with a Start Date 12/23/23. On 1/5/24 at 8:21 AM, V19 (Registered Nurse) stated that when a new admit or re-admission from the hospital arrives with an order for an antibiotic, the medical provider is contacted to determine if the antibiotics will be continued. V19 was unaware of the policy regarding antibiotic stewardship. On 1/5/24 at 8:27 AM, V20 (Licensed Practical Nurse) stated that oftentimes the resident will not have any paperwork from the hospital upon arrival, other the medication list, at that point the medical provider is contacted, and he orders what medication is to be continued or stopped. She continued to state that oftentimes when the staff receives a report from the sending nurse, they will provide the name of the organism that is being treated. On 1/5/24 at 8:35 AM, V3 (Assistant Director of Nursing/ADON), stated that the process of receiving an admission or new admit on antibiotics start with identifying the organism and reviewing if the organism is sensitive to the antibiotic prescribed. She continued to state that the Infection Preventionist is responsible for obtaining the lab results from the hospital if the resident does not arrive with that paperwork and that more often than not the paperwork does not contain the lab work. On 1/5/24 at 1:45 PM, V4 (Infection Control Preventionist/ICP), stated that she was new in the job and has been going through the Infection Control Log to ensure that lab results are available for the medical provider before initiating any antibiotics. She continued to state that for the most part, the medical providers have been receptive but they are some that are old school and are unwilling to change their way of prescribing antibiotics and that education is ongoing for the medical providers and staff. The Facility policy /procedure, Antibiotic Stewardship, revised 3/9/23, documented, The IP, or designee, will review antibiotic utilization as part of the antibiotic stewardship program and identify specific situations that are not consistent with the appropriate use of antibiotics. a. Therapy may require further review and possible changes if: (1) The organism is not susceptible to antibiotic chosen; (2) The organism is susceptible to narrower spectrum antibiotic; (3) Therapy was ordered for prolonged surgical prophylaxis; or (4) Therapy was started awaiting culture, but culture results and clinical findings do indicate continued need for antibiotics.

Based on interview, observation, and record review the facility failed to ensure that residents who require Dialysis received such services, consistent with professional standards of practice for 2 out of 3 residents (R1, R2) in a sample of 3. This failure resulted in R2 having to be sent to the emergency room and admitted with fluid overload. Findings include: 1.) R2's Physician Order (PO) dated 07/13/23 documents Chronic combined systolic (congestive) and diastolic (congestive) heart failure, type 2 Diabetes Mellitus with diabetic chronic kidney disease, End stage renal disease, and dependence on renal dialysis. R2's PO dated 08/09/23 documents Dialysis - FYI - Dialysis Treatments 3 X Week at 2:45 PM At: (local dialysis center) Every M-W-F. R2's Care Plan dated 08/08/23 documents, Hemodialysis r/t End Stage renal failure. R2's MDS (Minimum Data Set) dated 07/20/23 documents that resident has no cognitive impairment. The MDS documents that R2 requires extensive assistance of one person for dressing, toilet use, and personal hygiene. The MDS documents that R2 is not steady, only able to stabilize with staff assistance. The MDS documents that R2 requires dialysis. R2's Nursing Note dated 08/07/23 at 10:22 AM documents Due to transportation issue, resident missed dialysis treatment on this shift, resident is her own POA and is aware, (V5) NP (Nurse Practitioner), is made aware, this nurse contacted (local dialysis center) and made aware. R2's Nursing Note dated 08/09/23 at 12:05 AM documents 11:17 pm: seen resident sitting on her bed, coughing nonstop, complained of shortness of breath and chest tightness. Legs were also swollen and painful as stated. R2's Nursing Note dated 08/09/23 at 12:16 AM documents 11:30 pm hooked on oxygen inhalation at 2 lpm (liters per minute) called POA (V6) but unable to reached her, instead this nurse left a voicemail. NP (V5) was notified thru (name of app). DON (Director of Nursing), Notified. 12 MN sent resident out to (local hospital), assisted by 2 EMTs (Emergency Medical Technician) via gurney. R2's Hospital Record dated 08/09/23 documents, Pt from (facility) via EMS (Emergency Medical System), for c/o (complaint of) shortness of breath and leg and abdominal swelling. Pt states the driver at the facility called in on Monday so none of the patients were able to go to dialysis. Breathing labored, 96% RA (room air), dry cough. Pt hypotensive 89/78. Pt vomiting. Dialysis cath. (catheter) to right chest. End-stage renal failure on hemodialysis with volume overload. Hyponatremia (low sodium). Hyperkalemia (high potassium). Anion Gap metabolic acidosis: patient has about electrolyte abnormalities with anion gap metabolic acidosis likely due to infection as well as missing hemodialysis. Patient to be dialyzed today. On 08/11/23 at 12:05 PM, R2 was observed lying in bed in the local hospital on the fifth floor. 2.) R1's Physician Order dated 02/24/23 documents Type 2 Diabetes Mellitus with Diabetic Nephropathy, End Stage Renal Disease, and Dependence on renal dialysis. R1's Physician order dated 08/09/23 documents, New Dialysis days Mondays & Fridays (local dialysis center). Chair time 2:00pm. R1's Care Plan dated 08/08/23 documents Hemodialysis r/t End Stage renal failure. R1's MDS dated [DATE] documents that resident has no cognitive impairment. The MDS documents that R1 requires limited assistance of one person for bed mobility, transfer, locomotion on unit, locomotion off unit, dressing, and personal hygiene. The MDS documents that R1 requires extensive assistance of one person for toilet use. The MDS documents that R1 is not steady, only able to stabilize with staff assistance. The MDS documents that R1 receives dialysis. R1's Nursing Note dated 08/07/23 at 10:17 am documents Due to transportation issue, resident missed dialysis treatment on this shift, NP (V5) is made aware, resident is his own POA and is aware. On 08/11/23 at 8:15 AM, R1 stated that he missed his Dialysis appointment Monday 8/07/23 because they did not have a driver. He has missed 2 or 3 appointments because of no driver. On 08/11/23 at 9:51 AM, V4 (Medical Director) stated that in his professional opinion it's a serious health concerns that residents are missing dialysis. On 08/11/23 at 10:20 AM, V3 (Driver) stated that on Monday when she called off, she was the only driver for the facility. The facility has hired 3 more driver on Tuesday or Wednesday. She stated that it does not require a special license. The only special training is using the wheelchair lift and how to strap in residents. She stated that the driver must be on the facility's insurance to drive. She stated that she is unsure if the facility uses public transportation or not. On 08/11/23 at 11:16 AM, V1 (Administrator) stated on Monday the driver called and some of the residents were unable to go to their dialysis appointments. She stated that the facility was unable to get any their sister facilities to assist. At that time, the facility did not have outside transportation, but they do now. She stated that now the facility has 4 drivers and outside transportation. On 08/11/23 at 12:05 PM, R2 stated, I would never ever refuse dialysis. R2 stated that she has had to be dialyzed three since being in the hospital. Facility's policy Care of Resident with End-Stage Renal/Dialysis dated 07/22/22 documents Residents with end-stage renal disease (ESRD) will be cared for according to currently recognized standards of care.

Based on interview and record review, the facility failed to have staff to monitor resident after returning from the hospital for one of three residents (R2), reviewed for monitoring in the sample of 17. This failure resulted in R2 being sent back out to the hospital after being found unresponsive with no heartbeat, spontaneous respirations, and blood pressure. Findings Include: R2's Nurse's Transfer Note dated [DATE] documents Sent To: a (local hospital) Date: [DATE] 14:45 (2:45 PM) the reason(s) for Transfer: Abnormal Pulse Oximetry (low oxygen saturation), MD notified of transfer. R2's Nurses Note dated [DATE] documents 3:53 AM resident (R2) came back to the facility. R2 was AO, (alert and oriented) x,d+[DATE]; VS (Vital Signs), BP (blood pressure) ,d+[DATE], PR (pulse) 65, R (respirations) 22, O2 sat (Oxygen saturation), 83% on RA (room air). R2 was on 2L (liters), O2 via nasal cannula, but R2 keeps removing the nasal cannula, until such time that he refused it, and recent O2 81% on RA. HOB (head of bed) elevated, resident kept comfortable, bed on its lowest position. R2's Nurses Note, dated [DATE] at 10:05 PM documents, sent this resident (R2) to the hospital. 02 saturation at 64% on room air. Resident (R2) refused to put on nasal cannula. Contacted MD (Medical Doctor), advised to send out to the hospital. Contacted resident POA (Power of Attorney), informed of resident being sent out to ER (emergency room ). R2's Nurses Note dated [DATE] at 4:30 AM documents, received R2 back from the ER. 02 saturation at 89% on room air. R2's Electronic Health Record, Vitals Section dated [DATE] documents, O2 sats were only taken twice on [DATE] at 8:29 AM and 12:09 PM. On [DATE] at 12:09 PM oxygen saturation was 94%. On [DATE] at 8:29 AM oxygen saturation was 95%. R2's vital signs at 12:09 PM were temp (temperature) 97, pulse 70, and B/P, ,d+[DATE] and respirations were 18. R2's vital signs at 08:29 AM were temp 97, 72 pulse, B/P was ,d+[DATE], and 18 respirations. R2's Nurses Note dated [DATE] at 9:31 PM documents at approximate 6:30 PM found this resident (R2) unresponsive. HR 0, BP 0, not without spontaneous breathing, CPR initiated, called 911 and relatives were informed. Around 6:45 PM EMTs arrives, attached R2 to the cardiac monitor, with a rhythm, so he was transferred to a gurney, and left the facility around 6:50 PM with EMTs. On [DATE] at 11:20 AM V4 (CNA) stated on [DATE] unknow time, he (R2) was found on the bed with no shirt, socks, and no shoes. He didn't have on any oxygen. His daughter came to nurses' station. She asked me to go to her father's room and check on him. I went into his room to help her get him situated, although I was assigned to C hall. He was laying horizontal on his bed. His roommate R4 was screaming for Norco, but the nurse for that hall didn't show up. So, I told the Corporate Staff in the facility. V6 (former Director of Nursing), sent V7 (RN) over to give R4 his medications. V8 was the CNA on that hall. The rest of the patients on that hall did not get their medications either. V7 (RN) was over there around 3pm or 4pm because R4 had been putting on his call light since 2:30 PM for Norco. On [DATE] I went into R2's room he didn't have on oxygen, and the oxygen level was 74, and he had to be sent out to the hospital. On [DATE] at 11:15 AM V2 (Director of Nurses/DON) stated it depends on the resident and clinical condition. If the oxygen saturation is in the 80's, they should call the doctor, and if they are symptomatic, they should send them out right away. On [DATE] at 1:35 PM, V7 (RN) stated, I am familiar with (R2), but I do not normally work with him. On [DATE] I was working the C Hall, it was before 6:30 PM. Some of the nurse aids told me they found (R2) unconscious. We started CPR (cardiopulmonary resuscitation) and called all for initial support. We did not know that no nurse was working the A hall until this happened. There was no nurse working the A hall when (R2) coded. On [DATE] at 10:02 AM, staffing schedules for [DATE] was requested. There were two nurses on the A Hall and B hall that were crossed off and V14 was documented, as a call off. The only nurse not crossed off on the schedules was documented as V7 (Registered Nurse/RN). V13, V15, V7 were the nurses documented as working after the cross outs on the form. On [DATE] at 1:30 PM V8 (Human Resources/CNA) stated, there were three nurses in the building, and they were to split A-hall. I don't know what rooms they were assigned. Around dinner time which is between 5:45 to 6 PM R2 ate a little because V9 (CNA) fed him. Around 6:30 PM I was collecting trays, I looked into R2's room and say he was unresponsive. I went into R2's room and rubbed his chest twice and then called his name out twice. I went out and I called V7 that was the first nurse I saw. V7 walked up to R2 and started CPR. It was noted that there were no meds passed on this A-hall and the nurses did not divide the hall and care for the 23 residents, there was CNAs that were caring for residents. On [DATE] at 9:00 AM V11 (Medical Director) stated, he (R2) had just returned from the hospital, and he should have been checked on frequently. The vital signs are important, but checking on him was most important, and it could have contributed to him coding. On [DATE] at 1:54 PM the facility, only provided a notification of change of condition policy. Not a change of condition policy. The Facility Policy entitled notification of change of condition dated [DATE] documents, it is the responsibility of the charge nurse to notify the family, DON (Director of Nursing), and Physician of any change in resident condition.

Based on observation, interview and record review, the facility failed to provide timely and complete incontinent care to prevent urinary tract infections (UTI) and provide timely treatment for residents with UTIs for 3 of 4 residents (R1, R3, and R4) reviewed for incontinent care and UTIs in the sample of 10. This failure resulted in R1 developing a UTI which was not treated for 14 days causing pain. Findings include: 1. On 5/5/23 at 9:40 AM R1 stated, I am wet, and she is going to change me. My diaper doesn't hold all the pee because they don't change me often enough. R1 stated V4 (Certified Nursing Assistant/CNA) was working last night and was the one who changed her diaper last. R1 stated the last time she was changed was around 9:30 PM or 10:00 PM last night, just before V4 went home. R1 stated she was not changed again until now, at 9:40 AM. V4 confirmed she did change R1 last night just before she went home, which she said was around 10:00 PM. V4 removed R1's diaper and it was saturated with brown colored urine and R1 had also had a bowel movement. R1's perineal area and inner thighs were red with deep wrinkles over her buttocks, and R1 stated, It itches down there. My gown is wet because the diaper was too wet, and it leaked through. V4 put a bath towel under the faucet in R1's sink to wet it and put a small amount of soap on the towel. V4 assisted R1 to turn onto her left side and cleansed the fecal material from her buttocks and rectum, using a back and forth wiping motion, not turning to clean areas on the towel when she moved to different areas. V4 threw that soiled towel directly onto the floor. V4 then rolled R1 onto her back and used one wet wash cloth to wipe her lower abdomen, right and left groin, and over her pubic region, using a back-and-forth motion to cleanse areas, but not folding wash cloth to use clean areas as she moved from one area to the next. V4 did not spread R1's labia to cleanse her inner folds. V4 then threw the washcloth on the floor. V4, wearing the same soiled gloves, applied barrier cream to R1's groin and inner thighs, and turned her to her side and applied barrier cream to her buttocks. V4 then removed her gloves for the first time since starting incontinent care and donned new gloves without performing hand hygiene. V4 then put a new diaper on R1, put R1's socks and pants on, and left the room, still wearing her gloves, to get another towel. V4 came back into room and wet that towel in the sink but did not use it. V4 removed R1's wet gown and put an undershirt and sweatshirt on R1 without cleansing her abdomen or lower back that was wet with urine. V4 lowered R1's bed, removed a pillow from R1's wheelchair, and then removed her gloves and left the room to get someone to come and help her transfer R1 from the bed into her chair. When V4 left room, R1 stated it's usually about once a week that she must lay wet in bed for the whole night. R1 stated she thought her incontinent care from V4 was ok today. R1 stated On nights they usually only wipe her one time over her front and call it done. R1 stated, I get bladder infections all the time. I was just in the hospital with one not too long ago. R1's Minimum Data Set (MDS) dated [DATE] documents she is alert and oriented and is dependent on staff for bed mobility. The MDS documents R1 requires extensive assist with transfers, dressing, and toileting. It documents she is always incontinent of bowel and bladder. R1's Care Plan, undated, documents Care Plan Problem as Self-Care Deficit as Evidenced by: Needs assistance with ADLs (Activities of Daily Living) related to pain, weakness, DM (Diabetes Mellitus), HTN (hypertension), ASHD (atherosclerotic heart disease), osteoarthritis, macular degeneration, and obstructive uropathy. R1's Care Pan interventions document Toilet Use - One-person physical assist required. Personal Hygiene - One-person physical assist required. Bed Mobility - One-person physical assist required. Another of R1's Care Plans, undated, documents (R1) is incontinent of Bowel / Bladder related to stress, urge, mixed, Diabetes, history of frequent UTI with history of ESBL (Extended spectrum beta-lactamase infection), diuretics, and anti-depressant. Interventions for this care plan include Clean peri-area with each incontinence episode. R1's Hospital Records were reviewed and document R1 was hospitalized with the diagnosis of Urinary Tract Infections on the following dates: 9/8/22-9/15/22: Diagnosis: Sepsis and ESBL UTI 10/17/22-10/25/22: Diagnosis: Acute Cystitis and Acute Lower UTI, which was treated with antibiotics for 7 days while in hospital. Urine culture was positive for Klebsiella pneumoniae and E-coli. 11/11/22-11/17/22: Diagnosis: Sepsis/UTI caused by Klebsiella pneumoniae and Providencia stuartii. R1 was treated with intravenous antibiotics to treat the UTI while in hospital. 12/30/22-1/11/23: Diagnosis: Acute complicated UTI/acute cystitis with hematuria due to ESBL. R1 received 10 days of intravenous antibiotics to treat UTI during this hospitalization . 3/6/23-3/11/23: Diagnosis: Sepsis/UTI caused by Klebsiella Pneumonaie. R1's Progress Notes dated 2/8/23 at 8:57 AM documents, Resident complaining of burning sensation when urinating. Notified MD (medical doctor). Orders to do a UA (Urinalysis) on resident. Resident approves. Review of progress notes do not document any attempts to obtain UA on 2/8/23. R1's Progress Note dated 2/9/23 at 3:16 PM documents, UA to be done for lab pick up one time only for 1 day. Attempted to collect UA today but urine was contaminated with resident's feces. Endorsed to next shift. There was no documentation of R1's urine being obtained until her Progress Note dated 2/17/23 at 1:45 PM which documented, Resident's urine collected today via straight cath (catheter) to check for UTI, sample sent to the lab. R1's Progress Note dated 2/21/23 at 3:38 PM documents, Received call from (staff) at (MD) office regarding the resident's complaint of burning while urinating and is requesting a urinalysis. This nurse informed caller that her urine has been collected today and has been sent to the lab. The MD office requested for a copy once result is available. (MD) office Fax # ***-***-****. R1's Progress Note dated 2/21/23 at 5:43 PM documents, Bactrim DS Oral Tablet 800-160 mg Give 1 tablet by mouth two times a day for UTI for 10 days. Not available. R1's Medication Administration Record (MAR) documents R1 received her first dose of Bactrim DS for her UTI on 2/21/23, 14 days after she first complained of signs and symptoms of a UTI. On 5/12/23 at 2:35 PM R1 stated she had a urinary tract infection in February. She stated she had pain and burning when she urinated and told the nurse about it, and they said they were going to check her urine to see if she had an infection. R1 stated the only way they can get her urine sample is by straight cathing her. R1 stated she did not know why they didn't get her sample right away, but she continued to have the pain and burning until they finally got her some medicine for it. R1 stated she does not want to get the facility in trouble, but they need to shape up. On 5/12/23 at 9:00 AM V1 (Administrator) presented a statement for V17 (R1's Nephrologist) that V1 stated showed R1's UTIs are unavoidable. The statement documented, This is a patient with a history of frequent urinary tract infections as a result of a long-term history of diabetes and incomplete bladder emptying. She has had multiple infections and unfortunately has developed more resistant bacterial infections given the frequent need for antibiotic exposure including ESBL strains which is an unavoidable potential outcome in this setting. On 5/12/23 at 8:52 AM V17 (Nephrologist) stated R1's medical conditions do increase her risk of UTIs, but not receiving timely and thorough incontinent care is going to increase the risk of her having more frequent UTIs. He stated R1 is at risk for UTIs no matter what, but he would expect her to have thorough incontinent care whenever she is incontinent to decrease the frequency of infections. He stated not getting appropriate care definitely would contribute to her UTIs. 2. On 5/12/2023 at 9:51 AM R3 turned her call light on. R3 stated she was needing changed as she was wet and had a bowel movement in her diaper. On 5/12/2023 at 9:52 AM V18 (CNA) stated she did not change R3 yet since she's been here. V18 stated the midnight shift probably changed her before they left. On 5/12/2023 at 9:56 AM V20 (Licensed Practical Nurse/LPN) answered R3's call light. R3 told her she needed changed she had peed three or four times in her diaper and had a bowel movement. V20 told R3 she would let her CNA know. R3 kept saying to V20 (LPN), I know it's not 11:00 to get changed yet but I need changed. V20 stated again, I'll let the CNA know you need changed. On 5/12/2023 at 10:10 AM, V9 (CNA) unfastened tape on R3's adult incontinent brief and opened it. R3's diaper was saturated with strong smelling urine and there was a large amount of bowel movement in adult incontinent brief. R3 stated she wants washed good and wants her petroleum jelly to put on her bottom, legs, and above her waist because she's been sitting in urine all morning. V9 used the no rinse perineal cleanser. R3 stated Nobody has ever used that stuff before. V18 (CNA) sprayed perineal cleanser from the bottle to R3's right side and left side of her groin, and middle of groin area. R3 yelled Don't spray that stuff like that, it's cold! V18 swiped in a front to back motion with one swipe to right, left, and middle groin area with a dry washcloth. V18 never used a wet washcloth to the left, right, or middle of the groin area. V18 did not separate R3's labia to cleanse the urine and feces from R3's inner folds, and stool was observed to the middle part of R3's groin area after cleansing was completed. V18 did not cleanse R3's left or right inner thighs. V18 and V9 rolled R3 over to her right side and there was a large amount of bowel movement/stool on R3's buttocks and inner thighs. V9 sprayed cleanser on a wet washcloth and swiped front to back over R3's buttock area, then V9 swiped nine times cleansing the stool from R3's anal area. Brown stool was noted on R3's soaker pad underneath the diaper. V9 did not cleanse R3's left side of buttocks or hip area. V9 then put petroleum jelly on R3's left hip and buttocks area without cleansing those areas. V9 did not cleanse R3's left or right backside of the inner thighs. V9 placed the clean incontinent brief and clean soaker pad underneath R3, then V9 and V18 rolled R3 over on her left side. Brown stool was still noted on R3's left upper inner thigh with Vaseline spread over the stool. R3's right hip area noted to be red, with no open areas. V9 did not cleanse R3's right buttocks or hip area when she had rolled her over to her left side. No petroleum jelly was applied to right buttocks area. R3's MDS dated [DATE] documents R3 is alert and oriented. It further documents R3 is dependent on staff for bed mobility, transfers, and toileting, and she is occasionally incontinent of bladder and always incontinent of bowel. R3's Care Plan, undated, documents Self-Care Deficit as Evidenced by: Needs assistance with ADLs Related to generalized weakness, difficulty walking, DM, COPD (Chronic Obstructive Pulmonary Disease), CHF (Congestive Heart Failure), Osteoarthritis, hypothyroidism, HTN, HLD (Hyperlipidemia), ASHD. Interventions for this care plan document Bed Mobility - One-person physical assist required, Transfer: One-person physical assistance required, Personal Hygiene - One-person physical assist required, and Toilet Use - One-person physical assist required. 3. On 5/10/23 at 9:55 AM R4 was sitting up in her wheelchair in her room. R4 said she could not hear good, so surveyor communicated with paper and pen. Surveyor questioned R4 on paper if she was getting changed/incontinent care timely. R4 stated, No. They change me when they put me to bed at night and then don't change me again until I get up in the morning. They get me up at 4:15 AM and I am always soaked, and my bed is wet, but I have to lay there until they are ready to get me up. They never change me through the night. I'm wet right now but I won't get changed until 1:00 PM, right after lunch. They are busy during breakfast and then they have stuff to do. It doesn't matter if I put on my call light, that's when I get changed. At 10:00 AM R4 put her call light on to let staff know she is wet. R4 stated, It doesn't matter. They won't come. I'll get changed after lunch like I always do. R4 did go ahead and put on call light, and it was promptly answered by V9 (CNA). R4 stated, I need my diaper changed. V9 stated, Ok, I'll be right back. Within a few minutes V9 returned with another CNA (V8) who stated she is R4's CNA. V8 used a bath towel and wet it in R4's sink. V8 stated the facility is short on washcloths. R4 stood up from R4's wheelchair and V8 removed R4's wet incontinent brief. V8 then used the wet towel to wipe in a back-and-forth motion, never switching to a clean part of the towel, to clean R4's buttocks and rectum, then put a new incontinent brief on her and assisted R4 to sit back down in her wheelchair. V8 did not attempt to cleanse R4's vagina or lower abdomen or groin. V8 stated this is the only way R4 will let us do care, with her standing. V8 stated R4 doesn't want to lay down. Another CNA walked into R4's room and R4 started getting agitated, stating, How many people want to see my a**? The CNA remained in the room as V8 was just putting R4's incontinent brief back on. V8 stated the last time R4 had been checked and changed was probably around 6:30 AM because she (V8) arrived to work at 6:40 AM and R4 was already up and dressed in her chair and her bed was made. V8 stated this was normally the time they changed R4, before lunch. After V8 and other CNA left the room, R4 asked what had been said because she was unable to hear. Informed her V8 said this was normally the time they changed R4, before lunch, and R4 stated, No this is not. It's always around 1:00 PM. During her care, R4 apologized to V8, stating, I know this is not my time to get changed. While care observed R4's buttocks noted to be red. V8 stated, Her skin is just red, but she doesn't have any open areas. R4's Electronic Medical Record (EMR) documents R4 was hospitalized from 2/10/23 to 2/13/23 with diagnosis of UTI. Urine culture done on 2/12/23 documented the causative bacteria for UTI was Raouitella planticola >100,000 and Proteus Mirabillus >10,000-49,000. R4's Physician Order dated 2/24/23 documents: Bactrim DS 800/160 mg Q12H (every 12 hours) x7 days to treat her UTI. R4's Physician Order dated 2/13/23 documents: Cephalexin 250 mg Q12H for UTI for 5 administrations. On 5/12/23 at 11:45 AM V2 (Director of Nursing/DON), stated she is not sure what happened with R1's urinalysis not being done in a timely manner. She stated sometimes R1 can be a little difficult with care. V2 stated she would expect any residents who are incontinent to be toileted before and after meals and at a minimum at least every two hours. V2 stated when incontinent care is performed, she expects staff to thoroughly cleanse any areas on the resident that is soiled with urine or feces. She stated on female residents she would expect staff to spread the labia and thoroughly cleanse the vaginal folds and urethra. V2 stated she would expect staff to change gloves and perform hand hygiene any time they are soiled, when going from clean to dirty area and when coming into and leaving a resident's room. The facility's ADL Support Policy, revised 5/2/23, documents, Purpose: to provide staff with guidance on providing support with ADLs to residents. Policy: Residents will be provided with care, treatment, and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADLs). Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming, and personal and oral hygiene. The facility's Incontinence Care Policy revised 5/16/22 documents, Purpose: To provide guidelines to all nursing staff for providing proper incontinence care in order to clean skin clean, dry, free of irritation and odor. Policy: All incontinent residents will receive incontinence care in order to keep skin clean, dry, and free of irritation and/or odor. Incontinence care will be provided as required It is the responsibility of the CNA to provide incontinence care. It is the responsibility of the charge nurse to ensure that all incontinent residents receive appropriate incontinence care. It is the responsibility of the Director of Nursing that all nursing staff have received adequate training on the provision of proper incontinent care.

Based on interview and record review the facility failed to identify a change of condition for 1 of 8 residents (R2), reviewed for change of condition in the sample of 8. The facility failed to adequately monitor a resident (R2) taking diabetic medication. The facility failed to notify the physician of a blood glucose level of 49. These failures resulted in R2 being hospitalized with a diagnosis of hypoglycemia (low blood glucose level) for multiple days. Findings include: R2's Nurse's Notes dated 3/4/2023 at 1:45 PM, Arrived at facility via daughter personal car. Resident propelled into facility via w/c (wheelchair), by staff and admitted continues post hospitalization for generalized weakness and UTI, (urinary tract infections). Skin assessment completed with noted left great toe removed from past amputation. R2's discharge papers from hospital document, Miscellaneous RX (prescription), Supply (Test Strips), Use to check blood sugar QID, (four times a day). R2's Nurse's Notes dated 3/4/2023 at 7:55 PM, document a blood glucose level of 359. (This was not documented on the Medication Administration Record (MAR). R2'S Physician Order Sheet (POS), dated March 2023 document, a diagnosis of Unspecified adrenocortical insufficiency, hyperkalemia, type 2 diabetes mellitus with diabetic chronic kidney disease, hypertensive chronic disease with stage 1 through stage 4 chronic kidney, and bacteriuria. R2's Patient Medical Records document R2 had an adrenalectomy on 1/13/2023. R2's Care Plan dated 3/4/2023 document, This nurse will administer the medication(s) per MD order and monitor for adverse reactions. Insulin. R2's Nurse's Notes dated 3/5/20 at 6:33 PM, (V4) ordered via phone call for resident to have blood sugars checked before meals and at bedtime. Also, ordered to have Regular Insulin Humalog on the mentioned schedule with a sliding scale. 151-200 = 5 units, 201-250- 6 units, 251-300= 7 units; 301-350= 8 units. R2's Nurse's Notes dated 3/5/23 at 6:36 PM, given order by (V4) to have her glargine 15 units twice a day, (in the morning and at bedtime). R2's Medication Administration Records (MAR), dated March 2023 documents, R2's blood sugar glucose orders were not being documented until 3/5/23 and she missed, 4 blood glucose readings and no sliding scale insulin was administrated. R2's POS dated March 2023 does not document Monitor blood sugar before meals and HS (bedtime), related to type 2 diabetes mellitus with diabetic chronic kidney disease until 3/7/2023 (60 hours later). R2's Nurse's Notes dated 3/7/2023 at 5:21 PM, Resident had a blood sugar of 49 at 5:15 PM. Mild slurring of speech and sweating noted. No insulin given. Other due medication given with grape juice. Offered vanilla pudding, but resident refused. Resident stated that she will go to the dining hall to eat. For rechecking of sugar after she eats. R2's Nurse's Notes dated 3/7/2023 at 8:24 PM, Found resident on bed with dinner slightly untouched at approximately 5:45 PM. She was staring blankly and with slurring of speech, incomprehensible. Immediately rechecked blood sugar 41 mg/dl. Offered milk and juice but unable to swallow. Contacted DON, (Director of Nursing), for report. Glucagon 1mg/ml given intramuscularly for immediate treatment of hypoglycemia. Rechecked blood sugar after approximately 10 minutes. 45 mg/dl. Called ambulance for transportation to ER, (emergency room ). Contacted POA (Power of Attorney), resident's daughter for an update. On 3/17/2023 at 8:15 AM, V4, (Medical Director), stated, I never saw (R2) as a patient she was not here long enough. I would expect all orders from the hospital to be followed. I am not sure what happened with her, but I did put in an order on for the Accu-checks on 3/7/2023. I would expect staff to notify me if the blood sugar levels are over 350 and 60. I was never notified that her levels were off and/or high or low. If they would have notified me, I would have sent her out sooner and it probably would have helped her if her levels were adjusted sooner. On 3/17/2023 at 10:49 AM, V2 (DON) stated, (R2) was admitted over the weekend and I think when they were transferring the notes they did not carried over. When I came in on Monday, I saw the notes were not carried over and we contacted the doctor and got an order. R2's Hospital Notes dated 3/8/2023 at 10:47 AM, document, The patient is a very pleasant **-year-old female examined in the emergency department. According to long term care facility staff, they measure blood glucose level at 41. They administered 1 mg of glucagon intramuscularly and at the time of EMS (emergency medical services), were unable to establish a line, but on arrival the patient's blood sugar was 51. On 3/17/2023 at 11:00 AM V11 (Registered Nurse/RN), stated, I was taking care of (R2) when she was sent out to the hospital. I found (R2) in her room slurring her speech and staring into space. (R2)'s blood sugar was low. I just panicked. I did not know what to do. I found some glucagon on my cart and called (V2) to ask her if it was ok to give. (V2) said yes to give (R2) the glucagon and sent her to the ER. Then I was to call (V4) (Medical Director) and let him know. I know I was supposed to call (V4) first, but I panicked. I am not sure of the parameters of low or high blood sugar. I know I am supposed to call the doctor if the blood sugar is low or high. I would check the computer to see what it says about the parameters. I am not sure why I did not contact the physician and only contacted the DON, and I am not sure why I did not give her the glucagon when she first started running low at 49. I did not watch her or supervise her while she was trying to eat but did come back to check on her later. She only took a couple sips of her juice, and I never told any staff to watch her or monitor when she said, she wanted to go and eat. I told her I would check her blood sugar after she eats. But when I came back later, she was worse. I am not sure why I did not contact the Physician or give her the glucagon then and follow protocol. On 3/16/2023 at 2:36 PM, V10 (RN) at Hospital stated, (R2) was admitted (hospital) to the emergency room , on 3/7/2023 and was then admitted to the 5th floor for 11 days. Per Hospital Records R2 was seen in the emergency room and admitted at 9:30 PM on 3/7/23. The Change of Condition Notification Policy updated 10/7/2022 documents To provide guidelines for facility staff to follow to ensure that there is appropriate physician and responsible party notification of any change in a resident's condition. Acute Condition Changes-Clinical Protocol updated 1/1/2023 documents Direct care staff, including nursing assistants will be trained in recognizing subtle but significant changes in the resident and how to communicate these changes to the Nurse. The physician and nursing staff will review the details of any recent hospitalization and will identify complications and problems that occurred during the hospital stay that may indicate instability of the risk of having additional complications. The physician will help identify medications and medication combinations that are associated with adverse consequences that could cause significant changes in condition. The nursing staff will contact the physician based on the urgency of the situation. For emergencies, they will call or page the physician and request a prompt response. 35156

There are two deficient practice statements. A. Based on observation, interview and record review the Facility failed to assess, monitor, implement interventions and provide supervision to prevent elopement for one of 22 residents (R65) reviewed for wandering/elopement risks in the sample of 55. This resulted in R65 eloping from the facility, being found by the local police department, and sent to hospital and diagnosed with acute hypothermia. The Immediate Jeopardy began on [DATE], when R65 eloped from the facility in his wheelchair. R65 was found 200 feet from the facility, out of his wheelchair, down a hill. The facility was unaware R65 was missing until they were notified by the police. R65 was taken to hospital where he was diagnosed with acute hypothermia. On [DATE] at 3:28 PM, V1 (Administrator), V2 (Director of Nursing), V29 (Regional Director of Nursing), V27 (Vice President of Regulatory Compliance) and V30 (Assistant Director of Nursing) were notified of the Immediate Jeopardy. The surveyors confirmed by observations, record review and interview that the Immediate Jeopardy was removed on [DATE] but non-compliance remains at Level Two because additional time is needed to evaluate the implementation and effectiveness of in-service training. Findings include: R65's Face Sheet documents he was admitted to the facility on [DATE]. R65's [DATE] Physician's Order Sheet (POS) document R65 has diagnoses of encephalopathy, type 2 diabetes, altered mental status, and a history of alcohol abuse. R65's Minimum Data Set (MDS) dated [DATE] documents R65 had severely impaired cognition. The MDS documents, Has the resident wandered? And the response was Behavior not exhibited. R65's MDS documents he requires extensive assist of two plus staff members for transfers. R65's MDS documents his balance is not steady and he is only able to stabilize with staff assistance. R65's Care Plan, dated [DATE] document R65 is at risk for falls due poor balance, unsteady gait and cognitively impaired. The Care Plan documented that R65 had diagnoses of encephalopathy and alcohol abuse. R65's Care Plan also documents R65 has a self-care deficit as evidenced by R65 requires assistance with activities of daily living (ADLS). R65's Care Plan does not document R65 had any wandering and or elopement behaviors before [DATE]. R65's Offense/Incident Report Police Report dated [DATE], documents, On [DATE] at approximately 7:40 PM, (V8 Police Officer) received a call from dispatch pertaining to an elderly man lying on the ground behind (Facility). Upon arrival I met with (ambulance) individual who were on scene and behind the residence was talking with an individual on the ground. (R65) was talking to the paramedics and explained to them that he escaped the nearby nursing home (Facility). While standing there with the paramedics I could hear an audio sounding alarm coming from the nursing home which was 75 feet away. As I traveled towards the nursing home on foot, I located the wheelchair with an alarm sounding about 25 from the southern exit doors of the nursing home. I brought the wheelchair back where (R65) was located, assisted in getting him up in the wheelchair, and was able to safely get (R65) in the ambulance. Once (R65) was loaded and transported to (Hospital) I loaded the wheelchair into my squad car and transported it to the nursing home. (Central Command) advised me that they made several attempts to contact the nursing home but did not reach anyone. (V12 Officer) and I arrived at the front door with the wheelchair (Central Command) advised that they did reach the staff members and they would meet us at the door. (V13 Licensed Practical Nurse/LPN) was able to provide me with (R65's) information. I informed her of the situation and that (R65) was transported to the hospital. I provided the wheelchair with alarm to the staff member and cleared the area around 8:07 PM. On [DATE] at 9:00 AM, V8 stated that R65 was coherent when he arrived on the scene on [DATE]. V8 stated that he (V8) was cold so R65 had to be cold. V8 stated it was about 35 degrees outside. V8 stated he did not notice any scratches or bruises on R65 but stated that it was dark. V8 stated R65 had soiled himself. V8 stated R65 was wearing sweatpants, socks, and a hoodie. V8 stated R65 was not wearing any shoes or slippers. R65's Emergency Medical Service (EMS) Report dated [DATE] at 7:58 PM, document EMS arrived on scene with Police Departments. EMS crew arrived at patient side to find the patient laying in the backyard of a residence. Patient is alert and orientated to person. Patient stated he is a resident at a medical facility. Police found the patient's wheelchair about 10 yards from the patient. Patient is found approximately 200 feet from the nursing home. Patient is unable to tell EMS how long he has been outside. Patient has urinated his pants and is cold to the touch. Patient was unable to tell EMS if he had any injuries. On [DATE] at 8:43 AM, an observation was made of the location R65 was found on [DATE]. There is a concrete sidewalk that runs south of the facility that follows along a sloped hill. The sloped hill is south of the sidewalk. There is a large ditch to the southwest of the facility. The ditch is approximately 30 feet from the facility. The ditch is sloped on both sides. The ditch is approximately 10 feet deep. There is row of residential houses that run south of the facility. The house that R65 was found nearby, according to the police report is approximately 60 feet from the facility and 30 feet from the ditch. R65's emergency room visit dated [DATE] to [DATE] document, Patient presents emergency room having been found at the bottom of the hill next to (Facility) nursing home. Patient was out of his wheelchair on the ground. Someone noticed him at the base of the hill and the Emergency Medical Service (EMS) was called. (R65) was diagnosed with mild hypothermia. The Report documented Hypothermia due to cold environment. The Report documented R65's blood pressure was ,d+[DATE]. The weather conditions website documents on [DATE] at 7:34 PM, the temperature was 30 degrees Fahrenheit (F). R65's Nurse's Notes dated [DATE] documented Resident return to facility from (Hospital) emergency department, transferred by EMS, (Emergency Medical Services.) Resident diagnosis for Acute Hypothermia, Resident is lying in bed with no complaints of pain, resident was singing and talking with me, he responds to verbal command, no complaints of pain or discomfort at this time. On [DATE] at 9:15 AM, V3 (Certified Nursing Assistant/CNA), stated, I was off the day (R65) got away. (R65) he is in a wheelchair and wanders around all over the place. He can't sit still. I believe he had a (name of alarm system) before the incident. On [DATE] at 9:23 AM, V4 (CNA) stated, I was working that night (R65) got away. We got a call from the police that they had found (R65) in a ditch. They said he did not have any shoes on, or coat and he almost froze to death. I never heard any alarm going off letting us know anybody had gone out a door. The police said (R65) was pretty cold and they were not sure if he was going to make it. I heard he went out the C hall door. They said that night that (V1 Administrator) watched the cameras and saw him go out the C hall door. Maintenance came in later and checked it and the alarm was not going off. (R65) was always all over the facility. He did not like to stay in one place and was antsy. He likes to move around a lot. I am not sure if he had a wander guard before or after he got out. On [DATE] at 9:32 AM, V5 (LPN) stated, I heard (R65) got out of the facility because the alarm was not working. I was not working that day. (R65) liked to wander and was going around the facility in his wheelchair all of the times. He was a wanderer. On [DATE] at 4:16 PM, V7 (Registered Nurse/RN), stated, I worked the B hall the night (R65) got out. I do not know how he got out and I did not hear any alarms alerting me that any resident had left the building. I was doing medication pass and one of my coworkers told me the police had notified them that (R65) was missing. (R65) liked to go around in circles with his wheelchair. He was always moving, constantly moving he could not stay still. I am not aware of how he got out of the building. On [DATE] at 4:23 PM, V11 (RN) stated, I was not working the night (R65) got out of the building, but I heard the doors were not working and no alarm sounded, and nobody saw (R65) leave and he got out of the building unnoticed. (R65) was constantly propelling himself around the facility and was wandering around the facility. On [DATE] at 4:28 PM, V31 (CNA) stated, (R65) likes to wander around the facility and is very confused. He is constantly propelling himself with his feet in his wheelchair and is all over the place. I was not working the night (R65) got out of the building, but I heard he got out on the C hall because the door was not locked. Nobody knew he was missing until the police showed up. We are not sure why the door was not locked. I could not tell you. On [DATE] at 8:43 AM V9 (Maintenance Director) states all exit door alarms are checked every morning and evening. V9 stated they just started documenting the daily checks, prior to that they were only documenting the weekly checks but were checking them daily. V9 stated maintenance is who does the daily and weekly checks of the door alarms and wander guards at the exits. V9 stated the activity department checks the (name of alarm system) on the residents. V9 stated all exit doors have a (name of alarm system). V9 stated he takes a (name of alarm system) and checks in and then the Activity Department has a wand that they use to check the individual resident's (name of alarm system). V9 stated if the (name of alarm system) is yellow, it is working properly, when it goes off, it will go back and flash red and yellow and make a chirping noise, the alarm itself will not go off until the (name of alarm system) crosses the threshold, usually when the door is opened and then the door alarm sounds, and the intercom comes on and states where that the alarm is going off and the location. V9 stated the exit doors have 2 alarms on them, one must be reset by a key and maintenance and the nurses have a key and then the reset button must be held down for 10 seconds before the alarm will stop sounding and it will then be reset. V9 stated the only door that does not have a key access is the employee door and that one just has a keypad that a code must be entered in. V9 stated on [DATE] at around 8:30PM, and was told that R65 had escaped, slipped out of the building and he was being told that he had to come in and check all the door alarms. V9 stated all the door alarms and (name of alarm system) were functioning except the C-Hall exit door and it had been turned off. V9 stated he was unable to confirm with staff when the alarm was turned off if it was before or after R65 eloped. V9 state the door alarms had been checked about 12 hours prior on [DATE] and the alarm was on and functioning. On [DATE] at 09:10 AM, V10 (Activity Director) states they (Activity Department) check the resident's (name of alarm system) on the actual residents every Sunday and document it. V10 stated social services does the elopement assessment and they let activities know who needs a (name of alarm system). V10 stated if a nurse or social services lets them know, they will get one for the resident. V10 stated activities are here 7 days a week but if they are not, the nurses have access to a (name of alarm system) in the e-hall nurses' cart. V10 stated there are elopement binders at the front desk and each nurse's station of all residents at risk for elopement. On [DATE] at 10:10 AM V19 (Social Services) states once a resident is determined to be at risk for elopement, they discuss it in the clinical meeting, and it is sent out via communication line which goes out to all managers to let them know there is a new resident at risk for elopement. V19 stated they (social services) verbally let the staff know that a new resident is at risk for elopement and the nurses check the elopement book. V19 stated they do not have staff sign an in-service sheet or communication sheet verifying that they were notified of a new resident at risk for elopement. V19 stated R65 had an elopement assessment completed upon admission and was not at risk for elopement on [DATE]. V19 stated R65 did not have a (name of alarm system) prior to his elopement on [DATE]. V19 stated they completed a new elopement assessment after his elopement on [DATE] and now he is at risk. On [DATE] at 2:24 PM, V13 (LPN stated) When the police came, I went to the door and talked with them. They told me they thought (R65) had gotten out of the back doors because they had found him in a large ditch at the back of the building. It was very cold that night and they said, (R65) was really cold, and they had found him because his chair alarm was going off and someone in the neighborhood had heard the alarm and called the police. Thank God, we found him in time. The police then took him to the hospital. I called (V2 the Director of Nursing). I am not sure what exactly happened but his nurse on the B hall was passing out medications when they brought him back. No alarms went off and those are loud alarms. I think somebody must have shut off the alarm and forgot to turn it back on. We don't usually even use those doors. Those alarms are so loud, and no alarm was going off. (V1 Administrator) came up later on and the maintenance man and tested the door and the C hall door and the alarm was not working so we think that is how he got out. (R65) wanders a lot and is very confused. We know he was out there for about an hour, because (V1) looked at the cameras and said he went out the door at 7:03 PM so they thought he had been outside without the proper clothing for over an hour in the cold weather. On [DATE] at 10:05 AM, V18 (Medical Director) stated, I would expect residents who have wandering tendencies and confusion to be monitored and supervised. For hypothermia I would expect the body to slow down, their physical ability slows down to the point of death if they were not treated and removed from the cold. Again, hypothermia, and blood pressure of ,d+[DATE] would be linked with hypothermia and that would make sense that his body was starting to shut down with his blood pressure dropping. If (R65) would not be found and removed from the cold, it would have been bad, and he could have died . On [DATE] at 10:32 AM, V1 (Administrator) stated, The facility (V17 LPN), contacted me that (R65) had left the building. I do not know how he got out. I have not reviewed any cameras. Staff were contacted by the police that is how we knew (R65) was missing. We are still in the process of investigating. The Missing Policy with and revision dated of [DATE] document, To provide the facility staff with guidelines for ensuring the health, safety and welfare of all residents, and protocol to be followed when a resident is noted to be missing. The Monitoring Wandering Resident Policy with a revision date of [DATE] document, Purpose to provide a system for monitoring wandering residents. Every effort will be made to prevent wandering episodes while maintaining the least restrictive environment for residents who are at risk for elopement. A Wandering or incident prone residents may be monitored frequently to confirm location. It is the responsibility of the Charge Nurse to determine what changes have occurred that would trigger elopement episodes. Interventions into the elopement episodes will be entered onto the residents' care plan and medical record. Should an elopement episode occur the contributing factors, as well as the interventions tried, will be documented on the nurse's notes. If a resident repeatedly attempts to exit seek, the charge nurse will start a monitoring schedule as appropriate and add to the communication or 24-hour nursing report. Staff will be aware of what residents are at risk for elopement and have a binder at each nursing station. The Immediate Jeopardy which began on [DATE] was removed on [DATE] when the facility took the following actions to remove the immediacy: Immediate actions taken for residents identified: - All door alarms were immediately checked on [DATE] by V9 and V9 is responsible for door alarm checks ongoing. - Resident R65 was sent to hospital E.R for Evaluation on [DATE]. - Upon return from Hospital E.R (name of alarm system) was placed on resident R65 on [DATE]. - V1 (Administrator) notified R65's primary care physician (V18 )on [DATE] regarding R65's transfer to the hospital. - Elopement books reviewed and updated [DATE] by V10 (Activity Director.) - New Elopement assessments completed on all residents [DATE] by V2 (Director of Nursing) and V1. - Care plan reviewed and updated on residents at risk for elopement [DATE] by V27 (Regional Nurse Consultant) and V29 (Vice President of Regulatory Compliance). - Upon return from the hospitalER on [DATE] resident R65 was put on 1 on 1 monitoring for 24 hours and then dropped down to frequent checks (15 minutes) on [DATE] on and discontinued on [DATE]. - Staff education on [DATE] on all staff regarding elopement procedure and policy and wandering policy and procedure by V1 and V9. - New employees including agency will be educated on the elopement policies prior to being placed on the orientation schedule by Department Managers. Initiated [DATE] and ongoing. Measures put into place/Systems changes: - Maintenance educated to verify functionality of door alarms daily [DATE] by V1. - Staff educated on Elopements, wandering policies [DATE] by V37, MDS Coordinator. - Staff educated on procedure of if a resident is missing [DATE] by V37. - Staff educated on responding to door alarms and not turning door alarms off by V9 on [DATE]. - Stop Signs placed on all outside exit doors [DATE] by V37. - The wandering and missing resident policies regarding elopement have been reviewed on [DATE] by V29. How the corrective actions will be monitored: - V1, V2 and/or designee will conduct 3 random observations weekly of door alarms functionality times 3 months to assure all door alarms are functioning. - Any identified issues will be brought to QA and discussed with IDT and education will be provided as needed x 3 months. - Random audits of interventions in place to ensure resident at risk have interventions in place will occur weekly times 3 months, and then ongoing thereafter. 42636 B. Based on observation, interview, and record review, the facility failed to develop and implement interventions to prevent falls for 4 of 4 residents (R1, R22, R31 and R51) reviewed for falls in the sample of 55. Findings include: 1. R1's Face Sheet, undated, documents R1 has a diagnosis of a Left Femur Fracture. R1's Progress Note, dated [DATE] at 3:21 PM, documents R1 was sitting on the floor in between his bed and the heater. The Progress Note documents R1 was not able to move his left leg properly and was complaining of left leg/hip pain and R1 was sent to the emergency room . R1's Hospital History & Physical, dated [DATE], documents R1 was admitted with a left hip fracture. R1's Minimum Data Set (MDS), dated [DATE], documents R1 has severe cognitive impairment, requires assistance with activities of daily living (ADLs) and R1's balance is unsteady during transitions and walking. R1's Care Plan, dated [DATE], documents R1 is at risk for falls with interventions for a bed alarm and to move the bed against the wall to provide more room for resident. R1's Care Plan goes on to document R1 has a fracture of the left hip related to a fall with an intervention to have the bed in the lowest position. On [DATE] at 2:03 PM, R1 was observed in bed. R1's bed was not in its lowest position. R1's bed alarm was not in place and the bed was not against the wall. 2. R31's Progress Note, dated [DATE] at 1:10 PM, documents R31 fell in the hallway while trying to walk out of his room. R31's Progress Note documented R31 sustained a skin tear to R1's left hand. The Progress Note documented R31 is confused and agitated. R31's Progress Note, dated [DATE] at 5:08 AM, documents R31 fell in the hallway while trying to walk out of his room. The Progress Note documented no injuries were note and, R31 is confused and agitated. R31's Progress Note, dated [DATE] at 7:07 PM, documents R31 was found sitting on the floor in his room. The Progress Note documented no injuries were noted. R31's Progress Note, dated [DATE] at 1:28 PM, documents R31 was found lying on the bathroom floor. The Progress Note documented R31 had no injuries and low bed in place. R31's Progress Note, dated [DATE] at 11:06 AM, documents R31 was on the floor in the bathroom. The Progress Note documented the nurse found R31 sitting on his buttocks in front of the wheelchair and toilet with feces smeared on the floor beside him. No injuries were noted. R31's Progress Note, dated [DATE] at 5:23 AM, documents R31 was lying on the floor. The Progress Note documented the Aide stated R31 is on the floor again. R31's MDS, dated [DATE], documents R31 has severe cognitive impairment, requires assistance with ADL care and has an unsteady balance during transitions and walking. R31's Care Plan, dated [DATE], documents R31 it at risk for falls with interventions with interventions for non-skid strips next to the bed and in the bathroom and a pressure pad alarm while in bed. On [DATE] at 2:05 PM, R31 was observed in his room, the non-skid strips were not in place next to the bed or in the bathroom and there was no pressure pad alarm present. 3. R22's Face Sheet documents that resident was admitted on [DATE]. R22's Physician Order dated [DATE] documents diagnose of repeated falls and syncope and collapse. R22's Minimum Data Set (MDS) dated [DATE] documents R22 is cognitively intact. R22's MDS documents R22 requires extensive assistance of two plus persons for bed mobility and transfer. R22's MDS documents R22 requires extensive assistance of one-person for corridor walk in room, walk in, dressing, toilet use, and personal hygiene. R22's MDS documents R22 is not steady, only able to stabilize with staff assistance and uses walker and wheelchair for mobility. R22's Nursing Note dated [DATE] at 6:56 AM documents The nurse was called to the room and informed that the resident fell when trying to get off the toilet by herself. Staff assisted her to her wheelchair and brought her out of the restroom and the nurse assessed her and no open areas or new bruises were noted. The nurse asked her what happened, and she said she fell when she was trying to get up and hit her head. VS (Vital Signs) obtained 98.0 (temperature)-90 (pulse)-20 (respirations)-,d+[DATE] (blood pressure) -98% (oxygen saturation level) RA (room air). Nurse called (V18) and orders were received to send resident to (local hospital). The nurse called DON (Director of Nursing) and informed her of the incident. The nurse called residents husband and no answer received and nurse called (R22's daughter) and informed her about the incident, and she said she will call (R22's Husband) to inform him about incident. Resident is sitting up in her wheelchair in awaiting transport. (Local ambulance service) called and report called to (local hospital). R22's Fall Investigation dated [DATE] at 7:15 AM documents Nurse called to resident room upon entering observed resident of floor in bathroom. When asked what happened resident reported she fell trying to get up and hit her head. Assessed for pain and injury, MD and family notified. Staff assisted resident up to w/c after nurse assessed her. VS 98XXX[DATE]-,d+[DATE]-98%. IDT Meeting: Root Cause: Attempting self-transfer. Intervention: Resident educated on using call light and waiting for assistance. R22's Care Plan, was reviewed on [DATE]. There was no Care Plan related to R22's risk of falling and her falling on [DATE]. The facility initiated a Care Plan related to falls on [DATE] and provided it to surveyor. On [DATE] at 8:25 AM, V2 (DON) stated that she would expect that if a resident had a history of falls and a diagnosis of repeated falls that the resident would have a care plan for falls. 4. R51's Face Sheet, undated, documents R51 has diagnoses of Cerebral Infarction and Alzheimer's Disease. R51's Progress Note, dated [DATE] at 9:00 AM, documents staff notified the nurse that R51 had scooted herself out of her room for the second time and no injuries were noted. R51's Progress Note, dated [DATE] at 5:55 AM, documents the fire alarms went off at approximately 3:30 AM and R51 attempted to get herself out of bed and fell on to the floor. The Note documented R51 sustained no injuries. R51's Progress Note, dated [DATE] at 11:11 PM, document at approximately 9:37 PM, R51's bed alarm was sounding and R51 was lying on the floor pad. A scratch was noted to the right big toe. R51's Progress Note, dated [DATE] at 12:21 AM, documents R51 was lying on her right side on the floor next to her bed. The Note documented R51 had redness and bruising was noted to the right upper forehead/temporal area and an ice pack was applied. R51's Progress Note, dated [DATE] at 5:52 AM, document R51 rolled out of bed. The Note documented an abrasion was noted to R51's left knee. R51's MDS, dated [DATE], documents R31 has modified independence with cognitive skills for daily decision making, requires assistance with ADL care and has an unsteady balance during transitions and walking. R51's Care Plan, dated [DATE], documents R1 is at risk for falls with interventions for non-skid strips to both sides of the bed, non-skid material to the chair and a pressure pad alarm in bed. On [DATE] at 2:00 PM, R51 was observed in bed. The non-skid strips to both sides of the bed were not in place, the non-skid material was not in place and the pressure pad alarm was not present. On [DATE] at 9:00 AM, V2 (DON) stated she would expect fall interventions to be in place. The Accidents & Incidents policy, with a revision date of [DATE], document The Nursing team will complete an investigation with the root cause and new interventions. The Charge Nurse must conduct an immediate investigation of the accident/incident and implement immediate appropriate interventions to affected parties.

Based on observation, interview, and record review the facility failed to provide turning and repositioning for pressure relief, failed to ensure no pressure causing items were positioned under resident, and failed to provide treatment for pressure ulcer prevention and treatment for 2 of 3 residents (R1, R3) reviewed for pressure ulcers in the sample of 5. This failure resulted in R3's development of a facility acquired Stage 3 pressure ulcer from oxygen tubing. Findings Include: 1. R3's Face sheet documents admission to facility on 9/1/2022 with diagnosis of Cerebral Infarction due to Occlusion of Right Middle Cerebral Artery, Type 2 Diabetes, Acute Pulmonary Edema, Benign Prostatic, Hyperplasia, Hemiplegia and Hemiparesis. R3's order sheet dated 9/9/2022 documents Skin inspection/ Nursing weekly assessment on Thursday. R3's admission nursing assessment dated [DATE] documents R3 is unable to move left arm and left leg. Skin assessment is clear with no skin issues. R3's Minimum Data Set (MDS), dated [DATE] documents R3 has no pressure ulcer/injury or dressings on admission. R3 is at risk for developing pressure ulcers, has no unhealed pressures or injuries. R3 has no cognitive deficits. R3 is totally dependent and requires 2-person physical assist for bed mobility. R3's progress notes dated 10/5/2022 at 4:49PM document Skin/Wound Note: Nurse notified of new area to R3's left scapula by therapy and DON (Director of Nursing). R3 appeared to have an open blister measuring 8.5cm (centimeters) X 1.4cm. R3 states he is unsure of how wound had gotten there but stated it has been there for a few days and he has noticed a slight pain in the area while moving. R3 stated that his daughter had come in to visit on 10/3/22 and saw it and took a picture, but it was not reported to staff. Daughter was called and she states that she noticed it 10/3/22 while giving her dad a back massage. Daughter states she did not see wound when she came 9/28/22 to give back massage. V12 (R3's Physician) called and notified. New orders in place, wound consultant referral is being initiated. Staff will continue to monitor. R3's care plan with a revision date of 10/6/2022 documents actual pressure ulcer to left scapula. R3 requires assist with turning and positioning. Interventions include: (wound consultant) referral, assessment of ulcer, monitor for signs and symptoms of infection, drainage, foul odor, swelling, redness, notify MD (medical doctor) of signs of infection, treatments as ordered, monitor for pain indicators, assess pressure weekly by licensed nurse, notify MD as needed if ulcer fails to show progress in healing R3's Braden assessment dated [DATE] documents score of 15.0. R3 has potential for impaired skin integrity related to immobility, hemiparesis, CKD (chronic kidney disease), incontinence. Interventions include observe skin integrity, baths/showers per schedule, skin evaluation, turn and reposition. R3's skin care assessment dated [DATE] documents open area to upper mid vertebrae, open. R3's initial wound consultant note dated 10/12/2022 documents initial consult of R3 was noted on 10/5/22 to have an ulcer of his left back, which nursing reports is secondary to his oxygen tubing. Currently treating with Bactroban and collagen. Albumin 3.6, protein 6.4. R3 has history of Type 2 Diabetes and HgA1c 5.1. Wound Ulcer#1: location left back. Pressure ulcer injury stage 3. Size 5cm X 0.5cm X 0.3cm. Treatment: Cleanse with NS (normal saline) or wound cleanser, apply Bactroban and collagen cover with silicone bordered foam change daily and prn. Nursing is repositioning every 2 hours and prn (as needed). R3's Skin and Wound evaluation dated 10/12/2022 documents: Location left scapula, in house acquired, exact date of 10/3/2022. Wound measurements 6.5cm X 7.0cm X 1.4cm. 100% of wound granulated. Wound pink/red ruptured serum filled blister. Moderate exudate, serosanguineous drainage. No odor, no edema. On 12/1/2022 at 11:00AM, V2 (DON), stated From what I recall, (R3) had developed a blister to back left shoulder blade area. We determined it was from lying on his oxygen tubing. On 12/2/2022 at 10:25AM, V8 (Nurse Practitioner) stated I think I only saw (R3) a couple of times. He went out to the hospital. (R3) wouldn't have gotten the wound if he hadn't been lying on his oxygen tubing. It was a stage 3 pressure ulcer because of the scaring. On 12/2/2022 at 10:45AM, V9 (Licensed Practical Nurse /LPN), stated I don't remember (R3). If a resident is on oxygen the CNAs (Certified Nurse Assistants) will move the tubing out of the way when they turn the resident. 2. R1's Face sheet documents an admitted [DATE] with diagnosis of Hemiplegia and Hemiparesis following a Cerebral Infarction Affecting Left Dominant Side, Acute Embolism of Deep Veins of Lower Right Extremity, Type 2 Diabetes, Chronic Kidney Disease, Morbid Obesity. R1's care plan updated 7/14/2022 documents actual pressure ulcer to coccyx: Interventions include: ordered treatments, pain meds, turn and reposition every 2 hours, pressure reducing mattress, catheter leg strap, check dressing placement every shift, monitor for signs and symptoms of infection, assess pressure ulcers weekly by licensed nurse, notify MD if ulcers fail to show progress healing, provide offload of pressure site, monitor for incontinence and provide peri care after each incontinent episode, labs as ordered, encourage fluids, diet as ordered, encouraged to reposition as able. R1's care plan updated 7/14/2022 documents R1 has a self-care deficit related to weakness, hemiparesis, obesity, diabetes, CKD. Interventions include, Bed mobility, 2 persons assist, mechanical lift transfer, assistance with ADLs (activities of daily living), turn and reposition every 2 hours. R1's progress notes dated 7/14/2022 documents: new admission skin assessment: R1 admitted with coccyx wound from hospital. Area assessed. New order received for (wound consultant) to evaluate and treat and (name brand liquid protein supplement) for healing. R1 on LAL (low air loss) mattress. R1 has peg (percutaneous endoscopic gastrostomy) tube, no other skin issues noted. R1's Braden scale assessments dated 7/14/2022 documents on admission R1 has a score of 13.0 moderate risk of pressure ulcer development. R1's Braden scale assessments dated 10/13/2022 documents R1 has score of 12.0 high risk for pressure ulcer development. R1's MDS dated [DATE] documents R1 has no cognitive deficits. R1 requires extensive assist with bed mobility. R1 was admitted to facility with 1 stage 4 pressure ulcer to coccyx. R1's skin inspection assessment dated [DATE] to 11/17/2022 documents new concerns identified. Sacrum stage 4 pressure ulcer left gluteal fold pressure, right lower leg lesion, right antecubital dryness and left antecubital dryness. R1's initial wound consultant notes in facility dated 7/18/2022 document: Initial consult. Wound/Ulcer #1 Coccyx stage 4 pressure ulcer, measurements 9cm X 14.4cm X 4.5cm. Undermining. Treatments cleanse with NS, apply Santyl then pack with calcium alginate, cover with silicone bordered foam dressing. Change daily and prn. R1's wound consultant notes dated 8/1/2022 documents: Wound/Ulcer #1 measurements 9cm X 14.4cm X 4.1 cm. Undermining. Treatments cleanse with NS, apply Santyl then pack with calcium alginate, cover with silicone bordered foam dressing. Change daily and prn. Wound/Ulcer #2 Left Buttock noted on 8/1/2022. Pressure injury stage 2. Measurements 3cm X 3cm X 0.2cm. Cleanse with NS and apply foam dressing. Change every 3 days and prn. R1's wound consultant notes dated 8/8/2022 documents: R1 readmitted from inpatient hospital stay. Diagnosis sepsis. readmitted [DATE]. Noted to have several new pressure ulcers including mid back, left posterior thigh/gluteal fold. #1 Wound/ulcer Coccyx stage 4 measurements 11cm X 15cm X 6.5cm. Treatment's cleanse with NS, apply Santyl then pack with calcium alginate, cover with silicone bordered foam dressing. Change daily and prn. #2 Wound/ulcer left buttock pressure ulcer stage 2 measurements 2.5cm X 2.5cm X 0.2cm. Cleanse with NS and apply foam dressing. Change every 3 days and prn. #3 Wound/ulcer midback stage 2 measurements 2cm X 0.8cm X 0.2cm. Cleanse with NS and apply foam dressing. Change every 3 days and prn. #4 Wound/ulcer pressure stage 3 Left posterior thigh/gluteal fold. Measurements 5cm X 5cm X 0.3cm. 2 ulcers measured as one. Cleanse with NS and apply foam dressing. Change every 3 days and prn. R1's wound consultant notes 9/28/2022. R1 readmitted to facility on 9/27/2022. Wound/Ulcer #1 Coccyx measurement 9cm X 12cm X 3.5cm. No change in treatment. Wound/ulcer #2 left buttock measurements 0.2cm X 0.2cm X 0.2cm. No change in treatment. Wound/ulcer #3 left abdomen found on 9/27/2022. Measurements 0.5cm X 2cm X 0.2cm. Cleanse with NS, apply silicone bordered foam change every 3 days and prn. Wound/ulcer #4 left posterior thigh/gluteal fold. 1.5cm X 2cm X 0.3cm. Debridement completed. Treatment cleanse with NS apply Santyl, cover with foam, change daily. R1's wound consultant notes dated 11/30/2022 document Wound #1 Coccyx measurements 7cm X 8cm X 1.8cm with undermining. No change in treatment. Improving. Wound #2 Right lower leg measurements 2cm X 1.6cm X 0.3cm. No change in treatment, stable. Wound #4 left posterior thigh/gluteal fold measurements 0.3cm X 0.5cm X 0.3cm. No change in treatments. Improved. R1's 10/2022 Treatment Administration Record does not document treatments being completed on 10/21, 10/22, 10/25, and 10/28. R1's 11/2022 Treatment Administration Record does not document treatments completed on 11/12, 11/16, 11/17, 11/19, 11/20, 11/21, 11/22, 11/23, 11/24, 11/25, 11/27, and 11/30/22. On 12/2/2022 at 9:50AM, V1 (Administrator) stated (R1) refuses to eat and refuses to be repositioned. I was just in there this morning and tried to get her to eat and she would not. We try to educate her on needing to stay off her back, but she is noncompliant. On 12/2/2022 at 10:45AM, V9 (LPN) stated (R1) usually just wants left alone. She likes best to be on her back. On 12/1/2022 at 12:40PM, V5 (CNA) stated, We reposition (R1) every 30-45 minutes. She doesn't like to be on her back. She tells us what she wants. On 12/1/2022, R1 remained lying in bed on her back without benefit of repositioning from 12:40 PM until 3:49 PM based on 15 minutes or less observation intervals. The positioning wedge remained on floor and no heel floats were in room. R1's heels remaining directly on bed. On 12/1/2022 at 12:40 PM, V4 (LPN) completed wound care to R1. Wound care completed per orders.V5 and V6 (CNAs) assisted V4 with R1's wound care. R1 was not turned and repositioned following wound care. Facility policy with a revision date of 1/10/2022 states Prevention of Pressure Injuries. The objective is to establish a protocol for identifying and managing risks and prevention of the resident's skin integrity as well as healing any existing injuries to skin integrity or other skin conditions. Reposition all residents with or at risk of pressure injures on an individualized schedule, as determined by the interdisciplinary team. Choose a frequency for repositioning that is based on the resident's risk factors, other interventions in place, and current practice guidelines. Provide support devices an assistance as needed to provide safety and facilitate independent function.

Based on observation, interview and record review, the facility failed to initiate a treatment and reevaluate the treatment when the pressure ulcer deteriorated for 1 of 4 residents (R2) reviewed for pressure ulcers in the sample of 8. This failure resulted in R2 not receiving a change in treatment for 6 weeks as R2's pressure ulcer deteriorated and R2's pressure ulcer progressing from shear to a Stage 3 pressure ulcer. Findings include: On [DATE] at 2:13 PM, R2 was observed lying in her bed on her left side. She responded to conversation, but her speech was unintelligible. V8 Certified Nursing Assistant (CNA), and V9 CNA assisted R2 to roll further onto her left side and a dressing was noted to her sacrum. The dressing was loose at the bottom and V8 raised the dressing to expose a deep pressure ulcer about the size of a golf ball on R2's sacrum. There was a moderate amount of brownish-yellow drainage on the dressing which was dated [DATE]. The wound base was covered in dark brown necrotic tissue. On [DATE] at 2:25 PM, V18 Wound Nurse stated she monitors the residents' wounds, but V19 Registered Nurse (RN)/Treatment Nurse does the treatments. V18 stated R2's wound on her sacrum was present on her admission to the facility. R2's Face Sheet documents she was admitted to the facility on [DATE] with the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R2's Minimum Data Set (MDS), dated [DATE] documents she is cognitively impaired and is dependent on staff for bed mobility and transfers. The MDS also documents R2 had no pressure ulcers, venous or arterial ulcers and no other ulcers, wounds or skin problems. R2's Care Plan, undated documents, Focus: Actual Pressure Ulcer Site: Left Buttock/Coccyx. Requires turning and repositioning: Increased skin moisture, General Health Status. Present on Admit [DATE]. R2's admission nursing assessment dated [DATE] at 8:09 PM documents, under Skin Assessed and Condition on Admission: Site: other: left buttocks; open area with measurements recorded as 2 centimeters (cm) in length and 1 cm in width. No treatment was ordered or documented on this assessment. On [DATE] V2 Director of Nursing (DON) presented an unsigned, untitled handwritten document dated [DATE] which she stated were the measurements of residents' wounds for those residents not followed by the wound specialist. On the bottom right corner of the document V2 had circled a note that listed R2's last name and documented, coccyx/buttock 2 X 0.5 X (unknown). No treatment was documented for this wound. R2's Wound Assessment Report dated [DATE] documents, Location: Coccyx/Sacrum Area; admitted with; Type: Shear; epithelial and granulation tissue present; small amount of serous drainage; wound measurements: 2cm X 0.5 cm X 0.1 cm. The peri-wound tissue was macerated. Treatment: XXXX Paste. Evaluation: First observation, no reference. R2's Wound Assessment Report dated [DATE] documents: Location: Coccyx/Sacrum Area; admitted with; Type: shear; epithelial and granulation tissue present; small amount of serous drainage; measurements: 2.5 cm X 1 cm X 0.2 cm; peri-wound tissue is intact. Treatment: topical medical- grade honey dressing. Evaluation: worsening. Treatment: topical medical- grade honey dressing. R2's Wound Assessment Report dated [DATE] documents: Location: Coccyx/sacrum area; admitted with; Type: shear; epithelial and granulation tissue present; 50% necrotic tissue; small amount of serous drainage; measurements: 2.5 cm X 1.5 cm (no depth recorded). peri-wound tissue intact. Treatment: topical medical- grade honey dressing. Evaluation: Worsening. R2's Wound Assessment Report dated [DATE] documents: Location: Coccyx/sacrum area; acquired on [DATE]; Type: shear; epithelial and granulation tissue present; 50 % necrotic/slough tissue present; small amount of serous drainage present; measurements: 3 cm X 2 cm (no depth recorded); peri-wound tissue intact; Treatment: topical medical- grade honey dressing. Evaluation: Worsening. R2's Wound Assessment Report dated [DATE] documents: Location: Coccyx/Sacrum area; acquired; Type: shear; epithelial and granulation tissue present; 50 % necrotic/slough tissue present; small amount of serous drainage; measurements: 3 cm X 2 cm X 1cm; peri-wound tissue intact; treatment: topical medical- grade honey dressing. Evaluation: Improving. The measurements and wound description did not support evidence of improvement. R2's Wound Assessment Report dated [DATE] documents: Location: Coccyx/sacrum area. admitted ; pressure (no stage marked); epithelial and granulation tissue present; 50% necrotic/slough present; small amount of serous drainage; measurements: 3.5 cm X 1.5 cm X 0.5 cm. peri-wound tissue intact; Treatment: topical medical- grade honey dressing. Evaluation: Improving. R2's Wound Assessment Report dated [DATE] documents: Location: Coccyx/Sacrum area; admitted with; pressure (no stage marked); epithelial and granulation tissue present; slough present; measurements: 2.5 cm X 1.5 cm X 1.5 cm; peri-wound tissue intact; Treatment: topical medical- grade honey dressing Evaluation: Improved. According to this assessment, the wound increased in depth. R2's Wound Assessment Report dated [DATE] documents: Location: Coccyx/sacrum area; admitted with; pressure (no stage documented); epithelial and granulation tissue present; slough present; small amount of serous drainage; measurements: 3 cm X 1.5 cm X 1 cm; peri-wound tissue intact; Treatment: [MEDICATION(S)]/Calcium Alginate. Evaluation: unchanged. R2's Wound Assessment Report dated [DATE] documents: Location: Coccyx/sacrum area; admitted with; pressure (no stage documented); epithelial and granulation tissue present; 20% necrotic/ slough present; small amount of serous drainage; Measurements: 3.5 cm X 2.5 cm X 1.5 cm; peri-wound tissue intact; Treatment: [MEDICATION(S)]/Calcium Alginate; Evaluation: worsening. R2's Order Review Report dated [DATE] documents the following current, discontinued and completed orders (all orders for R2 since her admission to the facility): [DATE]: XXXX [MEDICATION(S)] Wound Dress Paste-apply to bilateral buttocks, coccyx topically every shift for preventative skin care. Cleanse bilateral buttocks, sacrum and coccyx with soap and water. Apply XXX Paste every shift. [DATE]: [MEDICATION(S)] 1%- Apply to coccyx topically as needed for soilage or dislodgement. Cleanse coccyx area with soap and water, normal saline (ns) or wound cleanser. Apply [MEDICATION(S)] cream, cover with calcium alginate and bordered gauze dressing. Change daily and as needed (prn). There was no order for topical medical- grade honey dressing treatment found in R2's Order Review Report. Review of R2's Wound Assessments and Order Review Report from [DATE] until [DATE] when R2 was transferred to the emergency room document her pressure ulcer worsened, but no new treatment orders were added even though there was no evident improvement in the wound after 6 weeks with the same treatment. R2's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . R2's MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . No treatments were documented before [DATE]. R2's MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . R2's MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . There were no treatment orders for topical medical- grade honey dressing documented on R2's MARs since she was admitted . R2's Progress Notes by her physician and nurse practitioner dated [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE] do not include assessment of or plan for her pressure ulcer on her buttocks or coccyx. R2's physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . Integumentary: Venous stasis changes. (Wound Specialist) ordered, please see wound assessments for treatments and plans, dark yellow tissue noted, no odor or drainage. On [DATE] at 12:20 PM, V2 DON, stated this was V18's Wound Nurse notes when she measured the wound on R2's coccyx/sacral area. V2 reviewed the timeline of the wound, along with measurements, and stated as the slough cleared, they could see the wound better and determined it was a stage 3 pressure ulcer. She stated during the time the wound was being treated, R2 was also treated for [MEDICAL RECORD OR PHYSICIAN ORDER] . (No culture of the wound was ordered until [DATE].) R2 was transferred to the emergency room and expired the next morning on [DATE]. V2 stated R2's wound was initially treated with XXXX Paste, which has topical medical- grade honey dressing in it, and then just topical medical- grade honey dressing and then [MEDICATION(S)] and calcium alginate to clean off the slough. She stated the topical medical- grade honey dressing is not documented because the wound nurse forgot to write the order. V2 stated they tried to get in touch with R2's family to get consent for the wound specialist to evaluate and treat R2's wound but they didn't answer the phone calls. She stated there were nurses on duty when family came to visit that could have gotten consent from family while they were there for the wound specialist to treat R2's wounds. On [DATE] at 11:20 AM, V20 R2's physician returned call. She reviewed R2's orders for wound treatment and her progress notes. V20 stated she did not have any additional information regarding R2's wound. She stated R2's wound was discussed in wound meetings and did show some improvement on some of the wound assessments, but stated she relies on the wound nurse's reports to keep her updated. V20 stated if a wound does not show improvement after a few weeks, she would probably change the treatment. V20 stated she was reviewing the orders and did not see where the order had been changed after the treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility's policy, Skin Integrity, dated [DATE], documents, Purpose: Residents identified to be at risk for skin breakdown (pressure ulcers) will have a routine assessment and interdisciplinary (IDT) care plan process implemented to maintain and/or improve skin integrity. The objective is to create an on-going process to identify and actively manage risk and/or skin integrity issues, and determine appropriate referrals or interventions to achieve positive clinical outcomes. It continues, Procedure: 15. If skin integrity issues are identified post-admission to the facility the following documented information is required: Wound specifics: location of wound-as specifically as possible, size of wound including length, width and depth in centimeters. For superficial wound depth state the smallest measure on the measuring guide (for example, 0.1 cm) or less than 0.1cm; amount of drainage, and description of wound bed; presence of necrotic tissue, eschar or slough, color, moist or dry, odor, signs and symptoms of infection, description of surrounding tissue, stage of wound, notification of physician, notification of responsible party. It further documents, 19. If wound has shown no signs of improvement in ,d+[DATE] weeks reevaluate interventions and plan of care.

Based on interview, record review, and observation, the facility failed to provide fall safety measures for 1 of 3 residents (R2) reviewed for falls in the sample of 13. This failure resulted in R2's sustaining fractures to her left and right femur requiring hospitalization and surgical repair. Findings Include: R2's Electronic Health Record (EHR) Weight Log, dated 6/3/21, documents R2 weighs 282.2 pounds. R2's EHR Diagnoses List documents R2 has diagnoses to include Displaced Fracture of the lateral Condyle of the left Femur, [CONDITION(S)], Abnormality of Gait, End Stage [CONDITION(S)]. R2's Minimum Data Set (MDS), dated [DATE], documents R2 requires extensive assistance of two staff persons for bed mobility and transfers. R2's MDS also documents for range of motion R2 has an impairment on one side of her lower extremities. R2's MDS further documents that R2 is cognitively intact. R2's Activities of Daily Living (ADL)/Bed Mobility Care Plan, dated 5/19/21, documents R2 requires a two person assistance for bed mobility. A two person assistance for pulling (R2) up in bed. May require a one to two person assist for repositioning in bed depending on resident condition. Pressure redistribution device (air mattress). Side rails: half side rails up as per Dr's order for safety during care provision to assist CNA. R2's Occupational Therapy Plan of Care, dated 5/18/21, documents skilled occupational therapy (OT) is necessary to increase static/dynamic sitting balance, strength coordination, and activity tolerance in order to return to previous level of functioning with self care task and improve patient positioning. Without therapy (R2) is at risk for increased assistance from staff, and decrease positioning in her wheelchair. R2's OT Plan of Care/Current level of functioning further documents (R2) is able to perform supine to and from sitting with minimal assistance, but she does require verbal instructions and or cueing. R2's OT was discontinued on 5/25/21 due to her fall and subsequent break. R2's OT-Therapist Progress & Discharge Summary, dated 5/25/21, documents patient required moderate assist to roll fully to her right side using bed rail. Stand by assist/supervision to roll to her left side using bed rail. R2's Fall Investigation Report, dated 5/25/21, documents, I (V18) was called to the room by (V14, Certified Nursing Assistant, CNA). (V14) stated, She (R2) rolled out of bed, when she turned too far, for the CNA to place the (mechanical lift pad under (R2) her. V14 was attempting to get the resident up. The report documents R2 stated she rolled out of bed, when she turned too far for the CNA to place a mechanical lift pad under her. The report documents R2 stated she felt like her knees popped. R2's Fall Investigation Report, dated 5/25/21, also documents (R2) was sent to the emergency room related to a fall with pain to bilateral legs. She (R2) was diagnosed with bilateral Femur fractures. The root cause of the fall was (R2) rolled herself over in the bed and slid out of the bed. (R2's) intervention was resident (R2) has a Brief Interview for Mental Status (BIMS) score of 15, and upon return to the facility (R2) will be educated to let staff assist with rolling in bed. R2's Fall Investigation Witness Statements, dated 5/25/21, documents (V14) stated she was placing the (mechanical Lift Pad) under (R2) and (R2) turned and fell to the floor. (V14) kept (R2) from hitting her head, and supported her back when caught. (R2) told (V14) she was trying to help by turning by herself and she turned too far, (R2) rolled from the bed. The bed was in the normal position. V17's Witness Statement, dated 5/25/21, documents, I entered the room and the resident (R2) was on the ground. (R2) she was rolling over in bed and rolled out. (R2) was left on the floor and staff stayed with her. The medical doctor was contacted and gave orders to send to the emergency room for evaluation. Emergency Medical Services (EMS) arrived and transported the resident (R2) to a (local hospital). V18's Witness Statement, dated 5/25/21, documents nurse was called to the room by CNA (V14) that said the resident rolled out of bed, while turning herself. (R2) confirmed this. CNA (V14) was going to put a mechanical lift pad under (R2), and when the CNA (V14) was walking over to assist her, the resident (R2) turned herself and starting sliding off of the bed. The CNA (V14) was able to keep the resident (R2) from hitting her head. R2's Fall Investigation Report, dated 5/25/21, does not document a witness statement from the unknown agency CNA. R2's Local Hospital Records, dated 5/25/21, documents, The resident (R2) has a comminuted fracture involving the distal femoral metaphysis. She has moderate size joint effusion. It further documents she arrived from the local nursing home,where she (R2)complained of bilateral knee pain . (R2) was being transferred back to bed from the wheelchair. In the mechanical lift, and suddenly hit the floor the resident is a right BKA (below knee amputation). (R2) requested to be sent to another regional teaching hospital. R2's Regional Teaching Hospital History and Physical Report, dated 5/26/21, documents, (R2) [AGE] year old female fell out of bed, while being transferred in a mechanical lift lift. She (R2) was negative for a head strike. (R2) is non ambulatory on baseline, but complains of lower extremity pain. (R2's) imaging shows bilateral distal femur fractures. (R2) has a complicated medical history including [CONDITION(S)] ( Hypertension), HLD ( Hyperlipidemia), CAD (Coronary Artery Disease), GERD ( Gastroesophageal Reflux), AFIB ( [CONDITION(S)] Fibrillation), Allergic Rhinitis, Gout, Depression, [CONDITION(S)], OSA (Osteoarthritis). R2's fall risk assessment, dated 05/30/21, documents R2 is at high risk for falls. On 6/4/21 at 8:05 AM, R2 was lying in bed on an air mattress positioned on her back with bilateral half side rails in place. R2 stated, Usually there is one staff in here to turn me and put me on the mechanical lift pad. She (V14, CNA) got the pad on one side, and when I started to turn to the other side. I rolled out of the bed onto the floor. On 6/3/21 at 8:45 AM, R2 stated she fell out of bed onto the floor while getting ready to get into the hoyer lift. R2 stated her air mattress had been deflated while she was working with therapy. R2 stated her mattress had not yet fully inflated when transfer care started. R2 stated V14, CNA, was rolling her to put her in the sling for the hoyer lift and R2 helped roll and landed on the floor. R2 stated she instantly had pain, that the V14, CNA, moved her to a lying position on her back and got the nurse. She was then sent out to the hospital via EMS. R2 stated that it isn't unusual for only one CNA to transfer her. On 6/3/21 at 12:40 PM, V14 stated, I was in the room, that girl, the agency CNA (she does not remember her name), was with me. I normally do this by myself. The agency staff was waiting to help me transfer her (R2). I proceeded to put the pad (the mechanical lift pad) on the right side. I was walking around to the left side, and she (R2) threw her leg over and was falling to the floor. I ran around just in time to stop her from hitting her head. The agency CNA wasn't standing by the bed. I hadn't went to get the (the mechanical) lift yet. She (R2) moves better on her right side. She (R2) doesn't move well on the left side. On 6/3/21 at 2:51 PM, V18, Licensed Practical Nurse (LPN), stated, I was called to the room by the CNA (V14). The day shift CNA (V14) stayed over. When I got in the room, (R2) was lying on the floor. She went to turn over, and fell from the bed. She felt her knees pop, when she landed. (V17, Infection Control Nurse) left a message for the doctor and we started the paperwork to get her sent out. On 6/3/21 at 10:30 AM, V9, Physician, stated, I saw (R2) after it happen. I talked with the emergency room Physicians and (V2) the DON. It was an accident. She had surgery on her left leg, and they just stabilized her right leg. On 6/8/21 at 10:40 AM, a fall policy was requested from V1, Administrator. A fall policy was not provided. An Accident and Incidents policy was provided. The facility's Accident and Incidents policy and procedure, dated 5/15/19, does not address the issue of fall prevention.

Based on interview, observation and record review, the facility failed to provide timely reassessment, monitoring and services to maintain and/or improve ambulation abilities for one of 21 residents (R51) reviewed for activities of daily living in the sample of 21. This failure resulted in R51 declining in ambulation from 200 feet to barely making steps. Findings include: 1. R51's Minimum Data Set (MDS), dated [DATE], documented R51 as having severe cognitive impairment with a Brief Interview of Mental Status (BIMS) score of 5. The MDS also documented R51 requires extensive assist of one staff for mobility and transfers. The Restorative Program PT/OT (physical/occupational therapy) program sheet, dated 5/15/17, documented R51 was ambulating 200 feet with a wheeled walker at that time by the two restorative Aides. On 12/26/17 for the lunch meal, R51 was propelled out of his room to the dining room by V21, R51's wife. R51 remained in his wheelchair for lunch. On 12/27/17 at 10:46 AM V12, Certified Nurse Aide (CNA) said R51 usually propels his own wheelchair but now they have to propel him so he needs to have the pedals on. V12 stated V21 asked about the pedals and why he had them. At 11:30 AM, V21 propelled him to the dining room in his wheelchair. On 12/27/17 at 12:14 PM V12 and V28, CNA, positioned R51's wheelchair next to his bed and applied a gait belt. R51 was given cues to push up as V12 attempted to stand him up from the wheelchair. R51 was unable to stand at first then was lifted by V12. R51 did not move his feet to pivot to the bed but was pushed in the direction of the bed. V12 stated sometimes he does better than others. At 12:18 PM, V12 was asked if R51 ever walks to dine and confirmed R51 was on the walk-to-dine restorative program but if he's tired, she'll take him in the wheelchair. On 1/3/18 at 11:25 AM, V21, R51's wife, stated she visits daily from morning to late afternoon. V21 stated R51 does not walk any more to the dining room adding that (V12) tries to get him to walk into the bathroom from the dining room from bed. V21 stated R51 needs to use his legs more and staff need to stand him more. V21 stated R51 has declined with the last couple of falls he's had. R51's Progress Notes documented falls on 11/23/17 and 12/11/17. R51's Restorative Nursing Assistant Sheets, dated (MONTH) (YEAR), has staff initials documenting restorative nursing was done daily from 12/1/17 through 12/30/17. The Intervention documented Ambulate at least 200 feet with FWW (wheeled walker) with CGA (Contact Guard Assistance) as tolerated q-day (every day) 7 days a week. The Certified Nursing Assistant sheet intervention documented Ambulate in a walk to dine program at lunch with the wheeled walker every day 7 days a week and also had staff initials as done daily for the entire month of (MONTH) (YEAR). Quarterly Assessments completed by V19, MDS Coordinator, dated 8/21/17 and 11/13/17, documented the same exact information and reflect R51's current goals for ROM and Restorative with no revisions noted. On 1/3/18 at 11:38 AM, V19 and V3, MDS Coordinators/Licensed Practical Nurses, stated R51 was on a walk-to-dine program daily at the lunch meal and also on an ambulation program to walk daily. V3 and V19 were not aware that R51 was no longer walking to the dining room ambulating with the restorative person. Neither one could explain why the programs were documented as being done when they were not. Both stated R51 had not been reassessed since his decline. On 1/4/18 at 7:55 AM, V22, Restorative CNA stated R51 has really declined since his last fall. V22 stated R51 will take a few steps on a good day. V22 stated he reported the decline to V19. V22 stated yesterday (1/3/18) that he helped another CNA to transfer him and R51 was barely able to bear weight. V22 stated R51 was not even feeding himself anymore. On 1/4/18 at 8:30 AM, V2 Director of Nurses (DON) stated V19 requested a therapy evaluation which is going to be done today. The facility's policy/procedure entitled Restorative Nursing Program (RNP) dated (MONTH) (YEAR) documents A Referral to the Restorative Nursing Program can occur at the termination of therapy services or at any time the resident is deemed appropriate for the program. To this end, a resident may move from skilled therapy to concurrent skilled and restorative intervention as a progression through treatment. The therapist (Physical, Occupational or Speech) will document which parts of the program are to be executed under the RNP and which are benign carried out under skilled therapy. The Objective documents the Restorative Nursing Program is designed to foster maximum independence in functional activities through facilitation of newly learned or rehabilitated skills. The policy also documents the restorative program will be recorded by nursing and must document objective goals, approaches, frequency, and duration of the program. The policy documents a progress note summarizing resident status written by a licensed nurse will be done at least quarterly or with any MDS assessment where restorative information is captured. Any change of condition affecting functional status should result in a referral to therapy. Therapy will evaluate the resident and determine the appropriate action.

Based on interview and record review, the facility failed to provide adequate supervision, develop and implement effective interventions to prevent falls for one of 8 residents (R51) reviewed for falls in a sample of 21 and 1 resident (R100) outside the sample. This failure resulted in R51 receiving a head injury that required sutures from two subsequent falls, and R100 receiving a left [MEDICAL CONDITION] requiring hospitalization after a fall. Findings Include: 1. R100's Care Plan, revised on 3/10/2017, documented R100 had the following Diagnoses: [REDACTED]. Fall Risk Assessments dated 5/18/2017 and 8/09/2017 documented R100 had a history of [REDACTED]. The Fall Risk Assessments documented a score 45 or higher, indicating a high risk for falls. The Facility's Verification of Incident Investigation/Administrative Summary, dated 5/21/17 at 5:00 PM documented R100 was found on the floor with the follow-up action being, Educated resident to have family ask for assistance from staff &(and) educated family to not take R100 to bathroom without asking staff's assistance. The Facility's Verification of Incident Investigation/Administrative Summary, dated 7/14/17 at 12:30 PM documented R100 fell in room, and the follow-up actions taken being, Monitor for further injury x(times) 72 hours. Educated resident to ask for assist instead of putting self in harm's way. R100's Minimum Data Set (MDS), dated [DATE], documented R100 had a Brief Mental Status score of 8, indicating moderately impaired cognition. R100's MDS documented R100 required extensive assistance with toileting. R100's MDS dated [DATE], documented R100 had moderately impaired cognitive skills for daily decision making and required extensive assistance with toileting. R100's Progress Note, dated 10/3/2017 at 11:19 PM documented R100 had a fall in the bedroom during self ambulation from bathroom, during nursing rounds on the floor in the bedroom and requires staff assistance with transfers. R100's Progress Note documented R100 was unable to move his left, lower extremity and the extremity was turned outward. The Facility's Situation Background Assessment Recommendation (SBAR) dated 10/3/2017 documented 1. Res (resident) fell during self elevation, unable to move L(left) hip, LLE(left lower extremity) rotates outward. The Facility's Verification of Incident Investigation/Administrative Summary dated 10/3/17 at 11:22 PM documented R100 fell outside bathroom door after taking self to bathroom. Assessment: fall with L(left) lower leg shorter than R(right). Sent to ER (emergency room ) for eval (evaluation): admitted c(with) hip fx(fracture). Follow-up actions taken:Resident is not a good candidate for surgery going to hospice in the hospital. The Hospital History and Physical, dated 10/04/17, documented (R100) presented to the ED (Emergency Department) after a fall resulted in left hip deformity. Medical History: Neurological: [MEDICAL CONDITION]/Dementia, [MEDICAL CONDITION]. Physical Exam: (R100) is not oriented to place or time. R100 is not able to reliably follow commands or expressed R100s wishes. Assessment/Plan since the patient was wheelchair-bound only functional return that would likely occur with surgery would be been able to sit up in bed for eating meals and using the commode the family is very interested in pursuing non-operative options including pain control and hospice palliative care. R100's Care Plan, dated 10/3/17, documented R100 was at risk for falls related to paralysis, gait/balance problems, and incontinence. R100's Care Plan documented Interventions/Tasks, (R100) sent to emergency room and was admitted with left [MEDICAL CONDITION]. Following fall in facility on 10/3/17. Review information on past falls and attempt to determine cause of falls. Educate resident/family/caregivers/IDT(interdisciplinary team) as to causes. R100's Care Plan also documented an intervention for the 10/3/17 fall Resident educated regarding calling for assist with transfers. Other interventions listed for previous falls on R100's Care Plan were as follows: Date initiated on 7/29/2016: Resident educated on asking for assistance and to not attempt to self transfer;. Date Initiated 10/17/2016: Resident educated regarding calling for assist with transfers; Date Initiated 07/14/2017: Educated resident to call for assist with turning on and off air conditioner. The Care Plan fails to address updated, effective interventions after each fall. There is no intervention listed for the 5/21/17 fall. On 12/29/17 at 2:11 PM, V17, Certified Nurse's Aide (CNA), stated V17 wasn't the one to find R100 when R100 fell on [DATE]. V17 stated R100 sometimes got up to go to the bathroom by R100s self, and R100 would do that more in the night time. Staff was aware of that. V17 further stated R100 would use the urinal to urinate, but when R100 had to have a bowel movement, R100 would use the toilet. V17 further stated V17 cared for R100 on a consistent basis. On 1/4/18 at 10:40 AM, V29, Licensed Practical Nurse (LPN), stated that R100's fall happened in-between shift exchange. V29 stated most times V29 worked as the nurse caring for R100. V29 stated R100 was confused and was not to ambulate to the bathroom, as R100 was at the minimum assist of one, and sometimes a transfer assist of two, with toileting. V29 further stated R100 did get up on R100s own and V29 found R100 on the floor by R100s bed and R100s wheelchair was next to the door where the aides left it. On 01/04/18 at 12:55 PM, V31, Medical Director, stated in part it is the expectation of the facility to have interventions in place to prevent falls, and to revise effective interventions based on the causative factor of each fall. 2. R51's MDS, dated [DATE], documented R51 had severe cognitive impairment with a Brief Interview of Mental Status (BIMS) score of 5. The MDS also documented R51 required extensive assist of one staff for mobility and transfers. The MDS documented R51's balance was unstable and R51 was only able to stabilize with staff assistance. Verification of Incident Investigating/Administrative Summaries show R51 had had multiple falls since R51s admission on 3/2/17. R51's Care Plan, dated 3/5/17 documented staff are to review past falls and attempt to determine cause of falls, report possible root causes and after remove any potential causes if possible. The Intervention added as a revision was to have resident's wheelchair brakes inspected and to have anti roll back placed on R51s wheelchair. The Verification of Incident Investigating/Administrative Summary dated 4/1/17 documented R51 was found in the bathroom on the floor at 3:45 pm. The report documented R51 fell from the toilet. The report documented Interventions which included a personal alarm on R51s wheelchair and a low bed. There is no information as to whether R51 had an alarm on and if it was sounding and if R51 attempted to toilet R51s self or was attended by staff. On 1/4/17 at 11:45 AM, V2, Director of Nurse's (DON) stated on 4/1/17, R51's wife put R51 on the toilet by herself and R51 fell off. V2 stated R51's wife was educated. V2 stated R51 had a wheelchair alarm initiated on admission and it was on that day but the wife removed it. The Verification of Incident Investigating/Administrative Summary dated 9/18/17 at 2:20 AM, documented R51 was found on the floor next to R51s bed. R51 said 'I slipped on the rug. Resident alarms (bed/chair) recently dc'd (Discontinued) due to maintain compliance with CMS (Centers for Medicaid/Medicare Services). The interventions includes orders for a concave mattress and keep bed in lowest position but did not address R51s need for additional supervision or his tendency to get up unattended as a problem. The Verification of Incident Investigating/Administrative Summary, dated 10/3/17 at 9:30 PM, documented R51 was again found on the floor between the bed and the wall. The summary documented resident is in (low) bed and waiting for concave mattress to be delivered. Resident has a recently increase uric acid level and gout. The care plan dated 12/17 fails to reflect any new interventions put in place in response to this fall. A copy of the invoice for the concave mattress documents it was delivered 10/10/17. The Verification of Incident Investigating/Administrative Summary, dated 11/23/17 at 10:00 PM, documented R51 sustained a laceration Left upper forehead when R51 bumped R51s head on the bed during ADL (Activities of daily living) care. The report documents the laceration to be 3 cm (centimeters) by 1/4 cm. No further interventions were put in place to prevent this from occurring again according to the care plan and investigative summary. The causative factor is not identified. On 1/3/18 at 2:09 PM, V2, Director of Nurses (DON) provided two statements from the CNA's, V26 and V25, who were providing ADL care when R51 sustained the 3cm laceration to his forehead. V26's statement dated 11/24/17 documents (R51) was being changed + (and) R51 reached over + grabbed siderail + pulled R51s self into the rail. V25's statement documented R51 pulled R51s self into the siderail and banged R51s head. No interventions or revisions to the care plan were completed/documented in response to this incident to prevent further occurrences. The Verification of Incident Investigating/Administrative Summary, dated 12/10/17 at 10:00 pm, documented R51 was again found on the floor next to the bed. The assessment documented R51 had a laceration to R51s left forehead and cheek and a skin tear to left arm. R51 was transferred to the emergency department for treatment. The Situation Background Assessment Recommendation (SBAR) dated 12/10/17 documents resident was found in room next to bed on the floor with left side of head facing downward. Laceration to forehead and cheek bone noted to left side of face, left eye swollen shut. The Episodic Fall Care Plan section documented R51 had bed rails on, a sensor pad alarm in bed, and a low bed with a mattress on the floor. Progress notes document R51 was transferred out to the emergency department for sutures and returned to the facility on [DATE] at 3:46am. There is no documentation on the laceration until 12/21/17 when it was measured after the sutures were removed on 12/18/17. The laceration measured 2cm x 2cm x 0.1cm on 12/21/17. On 12/27/17 at 10:42 AM, R51's wife, V21, said R51 fell and had sutures recently. V21 stated that is why R51 came to the nursing home because R51 would fall at home and she couldn't get R51 up. V21 said R51 has had several falls since his admission. V21 said typically R51 did not move around in bed or was restless stating R51 would just lay flat and sleep. R51's forehead, cheek and eye area had light yellow, green bruising with a noted healed laceration area about R51s left eye. R51 also had a large scabbed area on upper left shoulder and forearm. R51's bed had a concave mattress on it and a thin mattress for beside in the bedroom. On 1/4/17 at 10:25 AM, V2 stated R51's alarm was discontinued on 9/12/17 as the facility started to phase out the alarms for everyone in the building. There was no documentation the facility determined causative factors in each of the falls R51 had or if there was a pattern since two of the falls occurred at bedtime and one other in the bathroom. The current care plan did not address R51's need for added supervision given the discontinuation of the alarm, possible toileting needs or R51s cognitive impairment and inability to use a call light or involve R51s self in activities. Facility Policy entitled Fall Management, dated (MONTH) 2014, documents in part, Purpose To evaluate risk factors and provide interventions to minimize risk, injury, and occurrences. Fall Prevention Procedure 1. Evaluate risk factors for sustaining falls upon admission, with comprehensive assessment, and while conducting interdisciplinary care plan reviews. 2. Initiate a fall prevention care plan when appropriate with strategies to minimize risk and potential for injuries. 3. Review, revise, and evaluate care plan effectiveness at minimizing falls and injuries during IDT (interdisciplinary) walking rounds and as needed. Care Plan Documentation Guidelines. Problem: Identify fall risk and associated risk factors. Goal: Document goals for minimizing falls and injuries. Approaches: outline fall prevention strategies and approaches.

Based on observation, interview and record review the facility neglected to identify, accurately assess and monitor pressure ulcers, neglected to timely treat and seek new treatments when the pressure ulcer was declining, neglected to inform the physician and follow their policy and procedures for pressures ulcers for 3 of 7 residents (R1, R2, R8) reviewed for pressure ulcers in the sample of 20. This neglect resulted in R1 developing a Stage 4 pressure ulcer which became infected, a Stage 3 reoccurring Pressure Ulcer, and an unstageable pressure ulcer. R2 developed a facility acquired Stage 4 pressure ulcer that became infected. R8 developed two avoidable pressure ulcers. The failure resulted in an Immediate Jeopardy. While the Immediacy was removed on 1/8/15 the Facility remains out of compliance at Severity Level 2 as the facility continues to educate staff and evaluate the effectiveness of the facility policies and procedures and their system of assessing pressure ulcers and implementing timely intervention. Findings include: 1. R1's current face sheet documents [DIAGNOSES REDACTED]. R1's, 5/1/14 Physicians Order Sheet documents: Admit to Hospice with Terminal [DIAGNOSES REDACTED]. The most recent Minimum Data Set ((MDS) dated [DATE], documents R1's Brief Interview of Mental Status (BIMS) was left blank. The MDS documents R1 is totally dependent on two or more staff members for transferring, bed mobility, toileting, and is totally dependent on one staff for dressing, eating, personal hygiene and bathing. R1 is always incontinent of bowel and bladder. The MDS documents R1 has a Stage 1 or greater pressure area. Prevention measures for R1's pressure area were as follows: A. pressure reducing device for chair, B. pressure reducing device for bed, D. Nutrition or hydration intervention, E. Pressure Ulcer care, G. Application of nonsurgical dressings(with or without topical medications) and H. Applications of ointments and medications. The MDS did not identify as interventions: C. Turning and repositioning program, F. Surgical wound care, and Applications of dressing to feet. R1's review of R1's weekly " Skin Condition " reports beginning 5/22/14 through 7/11/14, document repeatedly that R1 had redness to her coccyx and was treated with [MEDICATION NAME] per Standing Order of Z1. On 7/11/14, this treatment was discontinued, and a new Standing Order was started to begin treating R1's buttocks with "stock antifungal cream" three times per day. On 8/8/2014, R1's, Skin Condition report documents "Duoderm applied to excoriated area on buttocks." On 8/15/14 through 8/29/14 the skin report continues to document R1 has an open area on Right ear, treatment continues to left buttock, Duoderm applied. R1's medical record and nursing notes for this time evidenced no documentation that Z1 MD, had been informed R1's buttocks continued to be excoriated and the facility staff were using Duoderm to treat it. On 9/5/14, R1's Skin Condition report documents "open area to right ear, sero-sanguineous. Left Buttock / Duoderm on wound noted, Right Buttock, 2 open areas, each measuring 1.0cm (centimeter) x .5cm and another 1.0cm x .5cm area." On 9/19/14, E3, Licensed Practical Nurse, Wound Nurse, (LPN) documented in R1's Nursing Notes: "N.O. (Nurse Order) from Hospice regarding incontinent associated lesion to buttock, for wound gel and to cover with [MEDICATION NAME]. Change daily and PRN (as needed) as area has declined. On 10/4/14, R1's Nurses Note documents: "late entry: spoke with Hospice and family re: decline in residents wound to buttock. Asking for Santyl, as slough remains to wound bed. Hospice continues to want wound gel and [MEDICATION NAME] every 3 days to wound." On 9/17/14, R1's Nutrition Notes document: "wound report 9/4 excoriation butt .2 [MEDICAL CONDITION], s/t (skin tear) right ear .6 x .8." Notes dated 10/17/14 document; R1's wound report 10/9 incontinent lesion butt, 2.3 x 2.1x Necro and 4.2 x1. On 10/20/14, Z2, Hospice Nurse documents "R1 seen today face to face for hospice recertification. R1 with dementia, with continuing decline. R1 resides at LTC facility and is totally dependent on staff for all ADLS. R1 is incontinent of bowel and bladder. R1 sits in a broda chair or is bed bound. R1's husband is present during my visit today and states R1 continues to drinks 2 boost per day and eats 50-75% of her meals. R1 rarely verbalizes, only yes or no occasionally and nonsensically. R1 has recurrence of Stage 2 to her right upper helix. R1 leans on that ear chronically in her broda char. Repositioning techniques have been started." IDT/Services: "sitting in broda chair leaning to right. This puts pressure on right ear which is beginning to show reddened scabbed area again. Positioned with C- pillow to keep pressure off of ear. Also spoke with nurse asking to keep pressure off ear." On 11/4/14, R1's Nutrition Notes document; R1 skin 10/30 incontinent lesion butt 2.1 x 3.1 x necrosis; wound left ankle .5 x .5. Nurse says butt worse." On 11/13/14 Z3, Wound Manager/Nurse Practitioner, (WM/NP) documents: F/u (follow up) of this [AGE] year old female with a coccyx ulcer, currently treating with Santyl, Dakins', moistened gauze and dry dressing. Nursing requests that I examine her right ear, which was noted on 11/12/14 to have a pressure ulcer. Currently treating with TAO (triple antibiotic ointment). Nursing reports that the coccyx ulcer has increased necrosis and odor noted. Physical Exam: well nourished, groomed and normal body habitus; Wound #1 Pressure Ulcer/Coccyx, Unstageable; Status: Not healed; Pre-Debridement length: 4.50cm Width: 5cm (increased size) Unable to determine pre-depth area: 22.5 cm 2. Description: Wound base color: yellow 40%, black 50%, Pink 10%: Necrotic tissue: Extensive; Procedures: Excisional debridement; Pre Op Diagnosis: [REDACTED]. Wound #2 Pressure Ulcer/Right Ear; Pressure ulcer/Stage III ; Acquired: 11/12/14; Pre-Debridement length: 2.00cm Width: 0.50cm Depth area: 0.30cm: Area: 1 cm 2, Volume: 0.3cm Description: Slough: minimal, Wound base color: yellow 30%, Pink 70%: Notes: Nursing to obtain pillow to help off-load pressure of ear." On 11/16/14, Z3, WM/NP, documents, "Nursing reports that this [AGE] year old female was noted on 9/29 to have a coccyx ulcer, which appears to be secondary pressure. Wound #1 Pressure Ulcer/Coccyx, Pressure ulcer/unstageable, Coccyx, acquired: 9/29/14; Acquired at outside facility: No (in facility); Pre-Debridement length: 4.50cm (cm), Width: 4.00 cm, Unable to determine pre-depth area: 16 cm 2. Description: Wound base color: yellow 100%, necrotic tissue: Extensive; Procedures: Excisional debridement; Pre-Op Diagnosis: [REDACTED]. On 11/17/14, laboratory results for R1 document organisms of: 1) Proteus Mirabilis-moderate growth; 2) streptococcus agalactiae-Grp B- Heavy growth; 3) alpha [DIAGNOSES REDACTED] streptococci- heavy growth in coccyx wound. On 11/20/14, Z3, WM/NP, documents "R1's tissue culture of her coccyx was + (positive) for Proteus Mirabilis and Streptococcus Agalactiae. Notes: Nursing to obtain pillow to help off-load pressure of ear." (2nd mention) The American Society for Microbiology, "Infection and Immunity" dated May 2004, documents: Proteus Mirabilis, is a common cause of urinary tract infections. Website: www.ncbi.nlm.nih.gov/. Mayo Foundation for Medical Education and Research, 1998-2015, documents: Group B Streptococcus is a common bacterium carried in the intestines or lower genital tract. Website: Mayoclinic.org/. R1's Nutritional Status/Quarterly Progress Record documented by E26, Food Service Manager, on 8/30/14 and 11/21/14 both indicate, "Plan/Follow-up: current pressure ulcer(s): No. On 11/24/14, Z3,WM/NP documents: F/u (follow up) of this [AGE] year old female with a coccyx ulcer, currently treating with Santyl, [MEDICATION NAME], and Calcium Alginate and dry dressing. F/u of right ear ulcer, currently treating with Santyl. Nursing reports that she has a left lateral ankle ulcer that they would like me to evaluate, currently treating with skin prep, which was noted on 10/29/14. Physical Exam: well nourished, groomed and normal body habitus; Wound #1 Pressure Ulcer/Coccyx, unstageable; Acquired: 9/29/14; Pre-Debridement length: 5.00cm Width: 4.20cm Unable to determine pre-depth; Area: 21 cm 2. Undermining: 1 cm from 12 O'clock, Undermining: 2 cm from 3 O'clock; Wound base color: yellow 30%, Pink 70%: Wound #2 Pressure Ulcer/Right Ear; Wound type/grade: Pressure ulcer/Stage III; Body Part: Ear right; Acquired: 11/12/14; Acquired in facility ; Status: healed. Wound #3 Pressure ulcer/left ankle; Unstageable; Ankle left lateral; Acquired 10/29/14; Acquired in facility; Pre-Debridement length: 1.0cm Width: 1.0cm Unable to determine pre-depth Area: 1 cm 2. Description: Euchar: fully covered; Wound base color: black 100%; On 12/18/14, R1's Change of Condition-Skin Condition report documents "new onset, excoriation, open area and redness, side of/under left breast. Current size of wound: length=3.2 cm, width 1.3 cm, depth=n/a (not applicable). Progress Note update: staff notified this nurse of open area noted under R1's left breast. Upon assessment 3.2 x 1.3 cm excoriated area noted to left area under left breast with 1.6 x 0.4 cm reddened area next to open area." On 12/19/14, R1's, Non-Pressure Skin condition report documents: Site/locations: left side of chest, Condition is: scab, Length 1.2, Width 2.2 cm, Depth: Scab. On 12/26/14, R1's Measurements: Length: 1.4, Width, 1.6, Depth: Scab. On 12/19/14, R1's "Skin Integrity Care Plan: Non-Pressure Wound", documents: scab intact blister to left chest, left arm. Skin Prep TID (three times daily) to intact blisters and monitor scabbed area every shift for any changes until healed. On 12/19/14, Hospice documentation indicates: "R1 has a 4.8 x 3.6 cm - Stage 4 wound to sacrum, Stage 2 wounds to left ankle and under left breast, 3.2 x 1.3 cm, and Stage 1 wound to right ear helix." On 12/30/14 at 12:35 PM, E3, Wound Nurse stated R1's redness to her coccyx started in 5/2014, as an "incontinent lesion" and has since declined to a Stage 4 pressure ulcer. E3 stated that Z3, WN/NP started seeing R1 in 11/2014, but only after a 3-4 week delay in treatment due to internal issues with Hospice. E3 stated R1's pressure areas were declining during this time. E3 stated she noted the area to be declining in 8/2014 or 9/2014, and knew the wound needed debridement. The Hospice provider was supposed to have a wound nurse come, but never did during that time. E3 stated she had never called R1's physician (Z1) to update him on R1's progression of pressure ulcer because she thought hospice took care of getting the physician's orders [REDACTED]. On 12/30/14 at 2:30 PM, E2, DON stated that R1 had pressure area on her coccyx and her ear. E2 stated that E3 monitors the areas and she is not aware of any other pressure areas to R1. E2 stated there were issues with Hospice and E3 was reporting to Hospice that R1's pressure ulcer on her coccyx had gotten worse and was not healing. E2 stated she was not sure how long the pressure areas to coccyx and ear had been going on and she would have to look at the record. E2 stated, E3 fills out a monthly wound report that E2 reviews. E2 stated that the weekly skin assessments have not been done by facility staff, and E3's wound measurements were being copied from Z3's W/M, notes. Additionally, E2 stated, regarding residents at risk for skin breakdown; she would expect staff to turn and reposition R1 frequently, apply a low air loss mattress and be calling Z1, MA/MD. E2 further stated that there is no documentation on turning and repositioning of residents, staff does not document on that. On 1/7/15 at 9:07 AM, E2, DON, and E3 Wound Nurse, stated; when R1 was admitted to the facility on [DATE] she had a pressure reducing mattress, which is standard for all residents admitted to their facility. E2 stated on 8/2/14 through 9/19/14, R1 had excoriation to coccyx, developed an incontinence lesion and a Duoderm was applied. E3, stated during this time R1's pressure ulcer on her coccyx had started to decline and knew it needed debridement. On 9/29/14, Hospice wound nurse was supposed to come and evaluated R1 but never came. E2 stated they had no further orders from Hospice, and on 10/4/14, E3 was becoming impatient with hospice and requested orders for Santyl. Hospice did not want to do Santyl. E3 stated "No doctor was called /notified at that time". On 11/3/14 a low air loss mattress ordered from wound management. On 11/6/14 wound management started seeing R1 and noted R1 had unstageable pressure ulcer to coccyx and debrided it. On 1/7/15 at 11:45 AM, E2 and E3 stated that R1's right ear pressure ulcer initially broke open 10/5/14 and then healed. They both stated that a neck pillow was provided by R1's husband upon admission and then it was lost for a week or two and Hospice provided another pillow. E2 and E3 stated that R1 was on a pressure reducing mattress since admission and R1, but did not have low air loss mattress implemented until wound management involved. E2 and E3 both stated they were unsure why it took so long to get R1 a low air loss mattress. Both stated that R1's wounds had been declining prior to wound management involvement on 11/6/14. E2 and E3 stated that R1 is turned and repositioned every 2 hours or more when needed and even turned and reposition every hour since 11/3/14. E2 stated "there is no documentation to provide to show that R1 has been turned and repositioned every hour or every 2 hours. E3 stated that R1 is currently turned and a pillow is placed behind R1's back to keep R1 on side. E3 stated that she doesn't think that the pillow is providing enough support to off load R1's pressure areas to coccyx, right ear and left ankle. E3 further stated that a wedge would be more appropriate for R1 to ensure proper off loading and is "something I need to get." On 1/7/15 at 1:45 PM, E2, DON stated she cannot find any notes from Hospice for R1 and does not know where hospice keep their chart in the facility. On 1/8/15 at 8:45 AM, E2 produced R1's hospice record and stated she had called the Hospice Provider, and had her bring the records to the facility that morning for review. On 1/7/15 at 2:00 PM, Z2, Registered Nurse/Hospice Case Manager stated she cared for R1 once a week for the past 6 months. Z2 stated that R1 developed a Stage 1 to Stage 2 on coccyx and now it has declined to --"what you see is what you get". Z2 stated "the facility was supposed to be getting orders for treatment of [REDACTED]. Z2 stated the hospice medical director is not allowed to give orders at this facility due to his inability to access the electronic computer system. Z2 further stated that Hospice nurses make recommendations or suggestions to the facility staff and the facility is supposed to get the order from R1's attending physician. " On 1/7/15, Z2, continued, stating "R1 had a pressure area to the right ear from a cervical collar that hit the tip of the ear and pressed against the right ear. The right ear was open, and would heal then reopen off and on. R1 favored laying her head to the right side against the wheelchair. R1's left outer ankle is a Stage 2 to Stage 3 that had recently opened up--around after 10/2014. Z2 stated that R1 would be sitting continuously in the recliner in her room and then in the wheelchair. Z2 stated Hospice did supply a neck pillow when R1's C-collar was lost, to help keep the ear pressure ulcer from opening up. Z2 stated that she would classify R1 as High Risk for pressure ulcers. Z2 also stated R1 has an infection in her coccyx wound. " On 1/7/15 at 2:30 PM, Z1, Medical Doctor, stated that he recalled R1, R1 is under the care of Hospice and her care is with Hospice. Z1 further stated he does not know anything about any of R1's pressure areas and is not involved in R1's care of pressure ulcers. Z1 stated the Facility contacted him once for a referral for wound management for R1 but was never notified by facility of R1's pressure ulcers since that time. On 1/8/15 at 10:45 AM, E2, DON, and E3 were asked if there were other pressure areas on R1. E2 stated she was not aware of any other areas. E3, Wound nurse stated at that time that there were no other areas on R1. On 1/8/15 at 10:45 AM, E3, Wound nurse did a skin check on R1. R1 was lying in bed, alert and answering questions appropriately. R1's left breast/side was observed as E3 did a skin check. R1 had a quarter-sized reddened area to the underside of her left breast. E3 stated R1 is receiving no treatment or skin prep to the area at this time. E3 further stated that Hospice orders the treatments for R1's pressure areas. On 1/8/15 at 11:50 AM, E3, Wound nurse stated she classified pressure areas as incontinence [MEDICAL CONDITION], but was told by Z3, WM/ NP, that the areas should not be classified that way. On 1/8/15 at 9:20 AM, Z3, WM/NP stated that she started seeing R1 on 11/6/14 and that R1 has really done well since starting with wound management. Z3 stated that R1 had a pressure ulcer to right ear that has closed and reopened at least twice since she started treated her. Z3 stated that R1's right ear recently reopened again and that R1 likes to lay on the right side. Z3 stated that R1 was provided with a neck pillow and is on low air loss mattress. Z3 stated the facility needed to figure out a way to keep R1 off her right side. Z3 further stated that gel pillows could help R1's right ear heal. Z3 stated that R1 has a Stage 4 pressure ulcer to her coccyx that the facility told her started 9/29/14. Z3 stated when she first started seeing R1 her pressure ulcer on her coccyx was unstageable. Z3 stated R1 needs a wound vac and would be healed by now but R1 is on hospice. Z3 stated R1 initially had necrosis to her coccyx but has improvement since R1 was debrided. Z3 stated that R1's pressure ulcer to her coccyx currently has undermining. Z3 further stated that R1 has " group B strep " in her coccyx wound and feces and urine could be the cause of R1's wound infections. Z3 stated that R1 has a left lateral ankle that is looking better but slow healing since starting with wound management, and at this time is unstageable. Z3 stated she gives E3, wound nurse recommendations for each resident's interventions to keep pressure areas from progressing. Z3 further stated that she does not think that placing a pillow under R1's back off-loads R1 enough to provide relief to the Stage 4 pressure area to coccyx. Z3 further stated a wedge would be more appropriate for R1 to offload pressure areas for R1's three pressure ulcers. On 1/12/15, E3 stated R1's wound continued to decline and wound management requested for R1 to be laid down more frequently and that R1 should be turned every hour from side to side and only on her back only for meals. Both stated, on 11/3/14, the facility implemented turning every residents every 1 hour if they have active pressure ulcers. E3 stated that R1's right ear was sloughing on 11/13/14 and that R1 leans to right side and puts pressure on it. On 1/12/15, E2, and E3, reviewed R1's Risk for Pressure Ulcers form dated 4/17/14, which documented R1 as " no risk " for pressure ulcers. The Pressure Ulcer form continued to document on 5/14/14, 8/30/14 and 11/21/14 that R1 was a "mild risk", even after though R1 had developed of a Stage 3 to right ear, an unstageable to left ankle and a Stage 4 to coccyx. E2 stated, "R1's assessments were not accurate and R1 was at a high risk for pressure ulcers". E3 agreed with the assessments being inaccurate. On 1/13/15 at 1:40 PM, E2, Director of Nursing stated E3, Wound Nurse would take orders from the Hospice nurse and input them into the computer. E2 stated she is unsure how the Facility coordinates R1's care with Hospice since this was new to her. E2 further stated that she would expect nursing staff to notify Z1, Attending of R1 and Medical Director, if R1 had no current physician on file or if residents don't have any preference. 2. R2's Physician order [REDACTED]. R2 had no pressure ulcers on admission to this facility. On 11/17/14, E3, Licensed Practical Nurse, documented in the Nurses Notes "incontinence associated lesion on R2's right and left buttock with measurements of (0.6 x 0.6) on the right side and (0.8 X 0.9) on the left side " . The Facility Standing orders for Incontinence Associated Lesion dated 11/17/14 were started. The treatment is documented: cleanse area with normal saline, apply Duoderm every 3 days, and monitor dressing every shift and for signs and symptoms of infection. On 11/17/14 a Skin Integrity Care Plan: Non-Pressure Wound, was implemented, for incontinence associated lesion to buttock with interventions for pressure reducing mattress to bed, pressure reducing cushion to wheelchair, apply lotion to skin following bathing, observe skin integrity during am/pm care, maintain head of bed in lowest possible position, encourage resident to reposition as able. R2's Minimum Data Set ((MDS) dated [DATE], documented R2's Brief Interview for Mental Status (BIMS) as a 2, moderately impaired. Under functional status, Activities of Daily Living, Bed Mobility documents R2 as a 3/2 (Extensive assist/One person physical assist). R2's MDS dated [DATE], under skin and ulcer treatments documents A. Pressure reducing device for chair. B. Pressure reducing device for bed. The MDS did not identify for skin ulcer interventions; C. Turning/repositioning program. On 11/18/14 at 11:50 AM, E3 Licensed Practical Nurse (LPN) Wound Nurse, documented on the Change of Condition report, "Area to right buttock has been compromised due to pressure and has developed into a pressure area. A low air loss mattress was implemented on 11/18/14. On 11/18/14, the Skin Integrity Care Plan Non-Pressure Wound, documented "Area was compromised by pressure and order changed to Santyl, Resident seen by Z3 Specialized Wound Management (SWM) Nurse Practitioner (NP). Z3, SWM/NP documented in her notes she saw R2 on 11/20/14, not on 11/18/14 as was documented on R2 ' s care plan. Z3 documented R2's pressure ulcer as unstageable, with measurements of 1.0 X 1.5. Z3 changed R2's treatment to clean wound with normal saline, apply Santyl to wound, cover with gauze and dry dressing. Change daily and as needed. On 11/24/14, Z3 saw R2 and documented pressure ulcer to coccyx unstageable with measurements of 1.5 X 1.5. Continue to cleanse pressure ulcer with normal saline, apply santyl to wound, cover with gauze and dry dressing. Change daily and as needed. The facility's pressure ulcer evaluation record dated 11/2014, documented wound measurements to be 1.5 X 1.5, unable to determine stage. On 12/4/14, Z3 was at the facility, but R2 was unavailable. Nursing reported to Z3 that R2 was stable. Z3 documented will follow up next week. On 12/11/14, Z3 saw R2 and documented unstageable pressure ulcer to coccyx with measurements of 1.5 X 1.5. Z3 performed excisional debridement of necrotic tissue. treatment of [REDACTED]. On 12/18/14, Z3 saw R2 and documented unstageable pressure ulcer with measurements of 1.1 X 1.0. Continue to cleanse pressure ulcer with normal saline, apply Santyl, cover with gauze and dry dressing. Change daily and as needed. The facility's pressure ulcer determination record dated 12/19/14, documented, unable to determine stage, with measurements of 1.1 X 1.0. See SWM notes. On 12/22/14, Z3 saw R2 and documented Stage IV pressure ulcer with measurements of 1.0 X 1.0 X 1.5, with undermining of 1 centimeter (cm) from 12 O'clock and 0.7 cm from 9 O'clock. Exposed structure: tendon. Z3 documented instructions for staff on importance of R2 being up for 2 hours max at a time to help with off-loading and promote in healing. The facility's pressure ulcer determination record dated 12/22/14 documented stage IV pressure ulcer with measurements of 1.0 X 1.0 X 1.5. See SWM notes. On 12/25/14 at 3:30 PM, E30, LPN documented on Nurses Notes that Z4, Power of Attorney (POA), notified E30, that R2 had an odor coming from R2's coccyx wound. Z4 told E30 "I know the wound is getting worse and there is an odor to it. I know the odor is not coming from bowel movement (BM)." E30, notified Z6, Nurse Practitioner of Z4's concerns of the odor coming from R2's wound and new orders were received for one time dose of [MEDICATION NAME] 1 gram intramuscular (IM) now. Culture coccyx wound. Complete Blood Count (CBC) in AM. Laboratory results from wound culture obtained 12/25/14, documented; Positive for Escherichia, many white blood cells, gram negative rods, many gram positive cocci, many gram positive rods. On 12/29/14, Z3 saw R2 and documented stage IV pressure ulcer with measurements of 3.00 X 5.00 X 1.50. Undermining: 9 cm from 3 O'clock. Undermining: 1 cm from 9 O'clock. Undermining 2.5 cm from 12 O'clock. Undermining:1 cm from 3 O'clock. Exposed structure: Bone, Tendon. Treatment changed to cleanse pressure ulcer with normal saline, apply Santyl, Dakins' 0.125% moisten gauze packing, cover with gauze dry dressing. Change daily and as needed. Z3- instructed staff on importance of R2 being side to side turn only to help with off-loading and promote in healing. R2 is currently on bed rest. Foley catheter was placed for wound healing. On 12/30/14 at 12:30 PM, E2 Director of Nurses (DON), was asked if the facility has any documentation of when staff turn and reposition residents. E2 said "No". The facility's pressure ulcer evaluation record dated 12/30/14 documented Stage IV with measurements of 3 X 5, see SWM notes. The facility's Resident Treatment Administration Record (TAR) for December 2014, documents the nurses initials in a box each day the dressing change was done. No Nurses Notes were available to describe the wounds characteristics or odors. On 12/25/14, the TAR initials that E23 LPN did the wound treatment and dressing change. No documentation or description of the wound size, odor or condition was available. On 1/5/15 at 12:25 PM, E3 LPN Wound Nurse was asked where she documents the size, depth, tissue, drainage of a wound after doing treatment. E3 said," whoever does the dressing change signs it off on the TAR, there is no documentation of the wounds except when SWM comes." When E3 was asked if the measurements on the facility's pressure ulcer evaluation record were her measurements and assessment of R2's wounds, E3 said "No, they are SWMs measurements and assessments". E3 said the pressure ulcer evaluation record dated 12/30/14 were SWMs measurements for 12/29/14. They were not E3's measurements for 12/30/14 as documented. The Facility's Policy "Skin Integrity Standard" dated March 2005 and updated June 2010, documented, Procedure: - Documentation of the turning and repositioning at least every two (2) hours while in bed or in a chair. Dependent residents sitting or in bed may need a position change for 'tissue offloading' every hour. Weekly "head to toe" assessment of all residents by Licensed nurse with narrative documentation of findings. - Weekly narrative documentation must include: description of skin tissue, color, turgor, rashes, bruising, skin tears, [MEDICAL CONDITION], incision lines and any other skin related issues. - If skin integrity issues are identified post-admission to the facility the following documentation is required: #2. Notation on the 24 hour report indicating the skin condition. #5. Incident report completed for in house acquired Stage III and/or IV. Use in tracking/trending and QA&A program. - Director of Nurses DON/Designee completes weekly random skin assessments. On 1/7/15, at 11:45 AM, E2, DON, stated she had not been doing the weekly random skin assessments as directed by facility policy. 3. R8's was admitted to the facility on [DATE] after discharge from a local hospital. Discharge documents indicate R8 had a Stage 1 pressure ulcer to the left heel and a blister on the right heel, no measurements were given by local hospital. The Facility Nurses Notes dated 12/5/2014 at 10:00 pm document in part; "Pink area noted to coccyx." There is no documentation R8 ' s heels were observed or if measurements were taken of R8's heel ulcers upon readmission. On 12/9/2014 the "Pressure Ulcer Evaluation Record" of the right heel documents a Deep Tissue Injury area width a length of 2.6 centimeters with a width a 2.8 centimeters. These measurements were taken 4 days after readmission. R8's Minimum Data Set ((MDS) dated [DATE] documents R8 has a Brief Interview of Mental Status (BIMS) of 15 which indicates no mental impairment. This same MDS document diagnoses, in part, of [MEDICAL CONDITION], Congenital Musculoskeletal deformities, and [MEDICAL CONDITION]. On 1/13/15 at 1:00 PM, R8, stated he had gotten the pressure areas to his heels before admission, while in the hospital. On 12/19/2014 the "Pressure Ulcer Evaluation Record" of the right heel documents a deep pressure area width a length of 2.6 centimeters with a width a 2.8 centimeters. On 1/13/2015 at 10:30 AM, E2 Director of Nurses, stated, She is unsure why a full skin assessment was not completed on R8 upon readmission. E2 further stated, a full skin assessment should be completed upon all resident admissions and readmissions. On 1/13/2015 at 10:35 AM, E3 Wound Nurse, stated "yes 10 days had passed without measurements of R8's heel wounds during the period of 12/9/2014 and 12/19/2014". E3 stated, "I assess every week as long as the assessment happens sometime in the following week , it's ok". On 1/1/15 R8's left heel, previously a blister, now measures 1.7cm x 2.1cm x 0.2cm. The Immediate Jeopardy situation was identified to have begun on 11/17/14, when the Facility neglected to notify Z1 of a change of condition to R1's skin, neglected to accurately identify, assess, seek timely treatment and the pressure ulcer worsened and became infected.The facility failed to accurately identify new pressure ulcers for R2, and R8 and failed to properly assess and initiate timely and preventative treatment to avoid worsening and infection of R2's pressure ulcers. E1 and E2 were notified of the Immediate Jeopardy on 1/8/15 at 12:50 PM. Beginning 1/8/15, in interviews, observation and record review the Facility took the following actions to remove the Immediacy: 1. 1/8/15 - The Facility reviewed R1 and R2 head to toe, to ensure there were no other new or declining pressure ulcers. All treatment orders were reviewed to ensure they were clinically appropriate for each resident ' s status. 2. 1/8/15 - The facility reviewed all current residents with known pressure ulcers to ensure accurate assessment, monitoring / measuring, and treatment of [REDACTED]. 3. 1/8/15 - The Facility initiated head to toe skin checks on all residents to identify any new pressure ulcers and ensure they had clinically appropriate orders for their skin conditions. 4. 1/8/15 - The Facility began contacting each resident's physician, with pressure ulcers, to review and update treatment orders. 5. 1/8/15 - All Facility RN ' s, LPN ' s, and C.N.A ' s began re-education on the Facility's policy for appropriate assessment, reporting, monitoring, treatment, and physician notification, when there is a change in status of a resident ' s skin condition, or change in conditi

Based on observation, interview and record review the facility failed to accurately assess and identify residents at risk, implement interventions to prevent the development of pressure ulcers, failed to promptly notify the physician, provide timely appropriate treatments, infection management, and interventions to prevent the worsening progression of pressure ulcers for 4 of 7 residents (R1, R2, R8, R14) reviewed for pressure ulcers in the sample of 20. This failure resulted in R1 developing a facility acquired Stage 4 pressure ulcer to the coccyx which became infected, develop a reoccurring Stage 3 pressure ulcer to right ear and develop an unstageable pressure ulcer to the left ankle. R4 developed a facility acquired Stage 4 pressure ulcer to the coccyx with undermining which also became infected. The failure resulted in an Immediate Jeopardy. While the Immediacy was removed on 1/8/15 the Facility remains out of compliance at Severity Level 2 as the Facility continues to educate staff and evaluate and monitor the effectiveness of the Facility policies, procedures and it ' s system of assessing pressure ulcers and implementing timely interventions. Findings include: 1. R1's current face sheet documents [DIAGNOSES REDACTED]. R1's 5/1/14 Physicians Order Sheet documents: Admit to Hospice with Terminal [DIAGNOSES REDACTED]. The most recent Minimum Data Set ((MDS) dated [DATE], documents R1's Brief Interview of Mental Status (BIMS) was left blank. The MDS documents R1 is totally dependent on two or more staff members for transferring, bed mobility, toileting, and is totally dependent on one staff for dressing, eating, personal hygiene and bathing. R1 is always incontinent of bowel and bladder. The 11/21/14, MDS, documents R1 has no limitations in range of motion. The MDS documents no weight loss or gain of 5% or more in last 6 months. The MDS documents Determination of Pressure Ulcer risk: resident has a Stage 1 or greater pressure area. "Skin and Ulcer Treatments" identified for R1's pressure area were as follows: A. pressure reducing device for chair, B. pressure reducing device for bed, D. Nutrition or hydration intervention, E. Pressure Ulcer care, G. Application of nonsurgical dressings(with or without topical medications) and H. Applications of ointments and medications. The MDS did not identify as interventions: C. Turning and repositioning program, F. Surgical wound care, and Applications of dressing to feet. R1's, hospital laboratory results done just prior to admission, dated 4/14/14 document; R1's protein 6.7 g/dl (grams per deciliter) with a normal range of 6.3-8.7 g/dl, and an [MEDICATION NAME] 3.5 g/dl with a normal range of 3.5-5.2 g/dl. R1's review of R1's weekly " Skin Condition " reports beginning 5/22/14 through 7/11/14, document repeatedly that R1 had redness to her coccyx and was treated with [MEDICATION NAME] per Standing Order of Z1. On 7/11/14, this treatment, and a new Standing Order was started to begin treating R1's buttocks with "stock antifungal cream" three times per day. On 5/16/14, Z10, Dietician, documented in R1's Nutritional Progress Notes: " R1 labs from 4/23 WNL (Within Normal limits), weight 124. Skin 4/27 excoriation butt and peri area. Notes dated 6/17/14 document; weight 115, R1's labs 5/6 TP/Alb (total protein/[MEDICATION NAME]) WNL. Notes dated 8/15/14 document: weight 110, skin 8/2 excoriated butt, 8/1 s/t (skin tear) to right ear 1.2 x 6, 8/12 s/t right ear 1x8; excoriation butt .2 [MEDICAL CONDITION]. " On 8/8/2014, R1's, Skin Condition report documents "Duoderm applied to excoriated area on buttocks." On 8/15/14 through 8/29/14 the skin report continues to document R1 has an open area on Right ear, treatment continues to left buttock, Duoderm applied. R1's medical record and nursing notes for this time evidenced no documentation that Z1 MD, had been informed R1's buttocks continued to be excoriated and the facility staff were using Duoderm to treat it. On 9/5/14, R1's Skin Condition report documents "open area to right ear, sero-sanguineous. Left Buttock / Duoderm on wound noted, Right Buttock, 2 open areas, each measuring 1.0cm (centimeter) x .5cm and another 1.0cm x .5cm area." On 9/19/14, E3, Licensed Practical Nurse, Wound Nurse, (LPN) documented in R1's Nursing Notes: "N.O. (Nurse Order) from Hospice regarding incontinent associated lesion to buttock, for wound gel and to cover with [MEDICATION NAME]. Change daily and PRN (as needed) as area has declined. On 10/4/14, R1's Nurses Note documents: "late entry: spoke with Hospice and family re: decline in residents wound to buttock. Asking for Santyl, as slough remains to wound bed. Hospice continues to want wound gel and [MEDICATION NAME] every 3 days to wound." On 9/17/14, R1's Nutrition Notes document: " wound report 9/4 excoriation butt .2 [MEDICAL CONDITION], s/t right ear .6 x .8. Notes dated 10/17/14 document; R1's wound report 10/9 incontinent lesion butt, 2.3 x 2.1x Necro and 4.2 x1. On 10/20/14, Z2, Hospice Nurse documents "R1 seen today face to face for hospice recertification. R1 with dementia, with continuing decline. R1 resides at LTC facility and is totally dependent on staff for all ADLS. R1 is incontinent of bowel and bladder. R1 sits in a broda chair or is bed bound. R1's husband is present during my visit today and states R1 continues to drinks 2 boost per day and eats 50-75% of her meals. R1 rarely verbalizes, only yes or no occasionally and nonsensically. R1 has recurrence of Stage 2 to her right upper helix. R1 leans on that ear chronically in her broda char. Repositioning techniques have been started." IDT/Services: "sitting in broda chair leaning to right. This puts pressure on right ear which is beginning to show reddened scabbed area again. Positioned with C- pillow to keep pressure off of ear. Also spoke with nurse asking to keep pressure off ear." On 11/4/14, R1's Nutrition Notes document; R1 skin 10/30 incontinent lesion butt 2.1 x 3.1 x necrosis; wound left ankle .5 x .5. Nurse says butt worse." On 11/13/14 Z3, Wound Manager/Nurse Practitioner, (WM/NP) documents: F/u (follow up) of this [AGE] year old female with a coccyx ulcer, currently treating with Santyl, Dakins', moistened gauze and dry dressing. Nursing requests that I examine her right ear, which was noted on 11/12/14 to have a pressure ulcer. Currently treating with TAO (triple antibiotic ointment). Nursing reports that the coccyx ulcer has increased necrosis and odor noted. Physical Exam: well nourished, groomed and normal body habitus; Wound #1 Pressure Ulcer/Coccyx, Unstageable; Status: Not healed; Pre-Debridement length: 4.50cm Width: 5cm (increased size) Unable to determine pre-depth area: 22.5 cm 2. Description: Wound base color: yellow 40%, black 50%, Pink 10%: Necrotic tissue: Extensive; Procedures: Excisional debridement; Pre Op Diagnosis: [REDACTED]. Wound #2 Pressure Ulcer/Right Ear; Pressure ulcer/Stage III ; Acquired: 11/12/14; Pre-Debridement length: 2.00cm Width: 0.50cm Depth area: 0.30cm: Area: 1 cm 2, Volume: 0.3cm Description: Slough: minimal, Wound base color: yellow 30%, Pink 70%: Notes: Nursing to obtain pillow to help off-load pressure of ear." On 11/16/14, Z3, WM/NP, documents, "Nursing reports that this [AGE] year old female was noted on 9/29 to have a coccyx ulcer, which appears to be secondary pressure. Wound #1 Pressure Ulcer/Coccyx, Pressure ulcer/unstageable, Coccyx, acquired: 9/29/14; Acquired at outside facility: No (in facility); Pre-Debridement length: 4.50cm (cm), Width: 4.00 cm, Unable to determine pre-depth area: 16 cm 2. Description: Wound base color: yellow 100%, necrotic tissue: Extensive; Procedures: Excisional debridement; Pre-Op Diagnosis: [REDACTED]. On 11/17/14, laboratory results for R1 document organisms of: 1) Proteus Mirabilis-moderate growth; 2) streptococcus agalactiae-Grp B- Heavy growth; 3) alpha [DIAGNOSES REDACTED] streptococci- heavy growth in coccyx wound. On 11/20/14, Z3, WM/NP, documents "R1's tissue culture of her coccyx was + (positive) for Proteus Mirabilis and Streptococcus Agalactiae. Notes: Nursing to obtain pillow to help off-load pressure of ear." (2nd mention) The American Society for Microbiology, "Infection and Immunity" dated May 2004, documents: Proteus Mirabilis, is a common cause of urinary tract infections. Website: www.ncbi.nlm.nih.gov/. Mayo Foundation for Medical Education and Research, 1998-2015, documents: Group B Streptococcus is a common bacterium carried in the intestines or lower genital tract. Website: Mayoclinic.org/. R1's Nutritional Status/Quarterly Progress Record documented by E26, Food Service Manager, on 8/30/14 and 11/21/14 both indicate, "Plan/Follow-up: current pressure ulcer(s): No. On 11/24/14, Z3,WM/NP documents: F/u (follow up) of this [AGE] year old female with a coccyx ulcer, currently treating with Santyl, [MEDICATION NAME], and Calcium Alginate and dry dressing. F/u of right ear ulcer, currently treating with Santyl. Nursing reports that she has a left lateral ankle ulcer that they would like me to evaluate, currently treating with skin prep, which was noted on 10/29/14. Physical Exam: well nourished, groomed and normal body habitus; Wound #1 Pressure Ulcer/Coccyx, unstageable; Acquired: 9/29/14; Pre-Debridement length: 5.00cm Width: 4.20cm Unable to determine pre-depth; Area: 21 cm 2. Undermining: 1 cm from 12 O'clock, Undermining: 2 cm from 3 O'clock; Wound base color: yellow 30%, Pink 70%: Wound #2 Pressure Ulcer/Right Ear; Wound type/grade: Pressure ulcer/Stage III; Body Part: Ear right; Acquired: 11/12/14; Acquired in facility ; Status: healed. Wound #3 Pressure ulcer/left ankle; Unstageable; Ankle left lateral; Acquired 10/29/14; Acquired in facility; Pre-Debridement length: 1.0cm Width: 1.0cm Unable to determine pre-depth Area: 1 cm 2. Description: Euchar: fully covered; Wound base color: black 100%; On 12/18/14, R1's Change of Condition-Skin Condition report documents "new onset, excoriation, open area and redness, side of/under left breast. Current size of wound: length=3.2 cm, width 1.3 cm, depth=n/a (not applicable). Progress Note update: staff notified this nurse of open area noted under R1's left breast. Upon assessment 3.2 x 1.3 cm excoriated area noted to left area under left breast with 1.6 x 0.4 cm reddened area next to open area." On 12/19/14, R1's Change of Condition-Skin Condition documents "new onset, blister/scab, left side of chest and left arm. Current size of wound: length=0.3 x 0.3 blister, width= blank, depth=1.2 x 2.2 scab. Skin prep to blister TID (three times a day) and monitor scabbed area every shift for any changes until healed. Progress note update: R1 noted to have a scabbed area to left chest by breast that measured 1.2 x 2.2 cm. R1 also was noted to have a blister intact to left arm that matched area to chest that measured 0.3 x 0.3 cm. Wrote orders from hospice for skin prep to intact blister TID to arm and monitor area to chest every shift till healed. On 12/19/14, R1's, Non-Pressure Skin condition report documents: Site/locations: left side of chest, Condition is: scab, Length 1.2, Width 2.2 cm, Depth: Scab. On 12/26/14, R1's Measurements: Length: 1.4, Width, 1.6, Depth: Scab. On 12/19/14, R1's "Skin Integrity Care Plan: Non-Pressure Wound", documents: scab intact blister to left chest, left arm. Skin Prep TID (three times daily) to intact blisters and monitor scabbed area every shift for any changes until healed. On 12/19/14, Hospice documentation indicates: "R1 has a 4.8 x 3.6 cm - Stage 4 wound to sacrum, Stage 2 wounds to left ankle and under left breast, 3.2 x 1.3 cm, and Stage 1 wound to right ear helix." On 12/30/14 at 9:45 AM, E3, Wound Nurse stated that R1 is being treated by Z3, WM/NP for the Stage 3 pressure ulcer to her right ear, the unstageable wound to R1's left outer ankle and the Stage 4 wound to her coccyx. On 12/30/14 at 9:45 AM, E3, Wound Nurse and E5, Certified Nurses Aide, CNA, changed R1's dressing to R1's coccyx. R1's dressing to her coccyx had visible brown feces saturating the dressing covering her coccyx pressure ulcer. E3 removed R1's dressing that was saturated with bowel and cleansed the area around R1's stage 4 pressure ulcer with gauze soaked in normal saline. E3 stated she was finished changing R1's dressing to her coccyx and that she cleansed the wound and area surrounding the wound with normal saline. E3, stated she normally uses soap and water to clean visible feces from wound area not normal saline. E3 did not say why she failed to use soap for this cleaning. On 12/30/14 at 12:35 PM, E3, Wound Nurse stated R1's redness to her coccyx started in 5/2014, as an " incontinent lesion " and has since declined to a Stage 4 pressure ulcer. E3 stated that Z3, WN/NP started seeing R1 in 11/2014, but only after a 3-4 week delay in treatment due to internal issues with Hospice. E3 stated R1's pressure areas were declining during this time. E 3 stated she noted the area to be declining in 8/2014 or 9/2014, and knew the wound needed debridement. The Hospice provider was supposed to have a wound nurse come, but never did during that time. E3 stated she had never called R1's physician (Z1) to update him on R1's progression of pressure ulcer because she thought hospice took care of getting the physician's order [REDACTED]. On 12/30/14 at 1:00 PM, E4, Care Plan Nurse stated she is not sure if R1's care plan is individualized for interventions for R1's three pressure areas. E4 stated she will have to ask E3, Wound Nurse. On 4/23/14, 5/30/14, 8/30/14, and 1121/14, The Skin Integrity Care Plan: Prevention, documents in part; Potential for impaired skin integrity R/T: impaired mobility, Cognitive deficits, incontinence, [MEDICAL CONDITION]. No pressure ulcers will develop in the next 90 Days. Interventions listed included (in part); Pressure reducing mattress to bed, Pressure reducing cushion to Wheel Chair, Lotion to skin after bathing, Observe skin integrity during AM/PM care. Notify MD promptly of skin breakdown, Monitor incontinence, provide peri-care, Evaluate Skin Weekly, Encourage to reposition as able. On 12/30/14 at 1:10 PM E3, stated that R1's Care Plan does not individualize interventions to keep R1's three pressure areas from declining. E3 further stated that no interventions were written for R1's pressure areas to keep them from declining until 11/6/14 when Z3 WM/NP began visiting R1. On 12/30/14 at 2:30 PM, E2, DON stated that R1 had pressure area on her coccyx and her ear. E2 stated that E3 monitors the areas and she is not aware of any other pressure areas to R1. E2 stated there were issues with Hospice and E3 was reporting to Hospice that R1's pressure ulcer on her coccyx had gotten worse and was not healing. E2 stated she was not sure how long the pressure areas to coccyx and ear had been going on and she would have to look at the record. E2 stated, E3 fills out a monthly wound report that E2 reviews. E2, stated she would expect staff to turn and reposition R1 frequently, apply a low air loss mattress and be calling Z1, MA/MD, E2 further stated that there is no documentation on turning and repositioning of residents, staff does not document on that. On 1/7/15 at 9:07 AM, E2, DON, and E3 Wound Nurse, stated; when R1 was admitted to the facility on [DATE] she had a pressure reducing mattress, which is standard for all residents admitted to their facility. E2 stated on 8/2/14 through 9/19/14, R1 had excoriation to coccyx, developed an incontinence lesion and a Duoderm was applied. E3, stated during this time R1's pressure ulcer on her coccyx had started to decline and knew it needed debridement. On 9/29/14, Hospice wound nurse was supposed to come and evaluated R1 but never came. E2 stated they had no further orders from Hospice, and on 10/4/14, E3 was becoming impatient with hospice and requested orders for Santyl. Hospice did not want to do Santyl. E3 stated "No doctor was called /notified at that time". On 11/3/14 a low air loss mattress ordered from wound management. On 11/6/14 wound management started seeing R1 and noted R1 had unstageable pressure ulcer to coccyx and debrided it. On 1/7/15 at 11:45 AM, E2 and E3 stated that R1's right ear pressure ulcer initially broke open 10/5/14 and then healed. The both stated that a neck pillow was provided by R1's husband upon admission and then it was lost for a week or two and Hospice provided another pillow. E2 and E3 stated that R1 was on a pressure reducing mattress since admission and R1, but did not have low air loss mattress implemented until wound management involved. E2 and E3 both stated they were unsure why it took so long to get R1 a low air loss mattress. Both stated that R1's wounds had been declining prior to wound management involvement on 11/6/14. E2 and E3 stated that R1 is turned and repositioned every 2 hours or more when needed and even turned and reposition every hour since 11/3/14. E2 stated "there is no documentation to provide to show that R1 has been turned and repositioned every hour or every 2 hours. E3 stated that R1 is currently turned and a pillow is placed behind R1's back to keep R1 on side. E3 stated that she doesn't think that the pillow is providing enough support to off load R1's pressure areas to coccyx, right ear and left ankle. E3 further stated that a wedge would be more appropriate for R1 to ensure proper off loading and is "something I need to get." On 1/7/15 at 1:45 PM, E2, DON stated she cannot find any notes from Hospice for R1 and does not know where hospice keep their chart in the facility. On 1/8/15 at 8:45 AM, E2 produced R1's hospice record and stated she had called the Hospice Provider, and had her bring the records to the facility that morning for review. On 1/7/15 at 2:00 PM, Z2, Registered Nurse/Hospice Case Manager, stated she cared for R1 once a week for the past 6 months. Z2 stated that R1 developed a Stage 1- Stage 2 on coccyx and now it has declined to --"what you see is what you get". Z2 stated " the facility was supposed to be getting orders for treatment of [REDACTED]. Z2 stated the hospice medical director is not allowed to give orders at this facility due to his inability to access the electronic computer system. Z2 further stated that Hospice nurses make recommendations or suggestions to the facility staff and the facility is supposed to get the order from R1's attending physician. " On 1/7/15, Z2, continued, stating "R1 had a pressure area to the right ear from a cervical collar that hit the tip of the ear and pressed against the right ear. The right ear was open, and would heal then reopen off and on. R1 favored laying her head to the right side against the wheelchair. R1's left outer ankle is a Stage 2 to Stage 3 that had recently opened up--around after 10/2014. Z2 stated that R1 would be sitting continuously in the recliner in her room and then in the wheelchair. Z2 stated Hospice did supply a neck pillow when R1's C-collar was lost, to help keep the ear pressure ulcer from opening up. Z2 stated that she would classify R1 as High Risk for pressure ulcers. Z2 also stated R1 has an infection in her coccyx wound. " On 1/7/14 at 2:30 PM, Z1, Medical Doctor, stated that he recalled R1, R1 is under the care of Hospice and her care is with Hospice. Z1 further stated he does not know anything about any of R1's pressure areas and is not involved in R1's care of pressure ulcers. Z1 stated the Facility contacted him once for a referral for wound management for R,1 but was never notified by facility of R1's pressure ulcers since that time. On 1/8/15 at 10:45 AM, E2, DON, and E3 were asked if there were other pressure areas on R1. E2 stated she was not aware of any other areas. E3, Wound nurse stated at that time that there were no other areas on R1. On 1/8/15 at 10:45 AM, E3, Wound nurse did a skin check on R1. R1 was lying in bed, alert and answering questions appropriately. R1's left breast/side was observed as E3 did a skin check. R1 had a quarter-sized reddened area to the underside of her left breast. E3 stated R1 is receiving no treatment or skin prep to the area at this time. E3 further stated that Hospice orders the treatments for R1's pressure areas. On 1/8/15 at 11:50 AM, E3, Wound nurse stated she classified pressure areas as incontinence [MEDICAL CONDITION], but was told by Z3, WM/ NP, that the areas should not be classified that way. On 1/13/15 at 1:40 PM, E2, Director of Nursing stated E3, Wound Nurse would take orders from the Hospice nurse and input them into the computer. E2 stated she is unsure how the Facility coordinates R1's care with Hospice since this was new to her. E2 further stated that she would expect nursing staff to notify Z1, MA/MD, if R1 had no current physician on file or if residents don't have any preference. On 1/8/15 at 9:20 AM, Z3, WM/NP stated that she started seeing R1 on 11/6/14 and that R1 has really done well since starting with wound management. Z3 stated that R1 had a pressure ulcer to right ear that has closed and reopened at least twice since she started treated her. Z3 stated that R1's right ear recently reopened again and that R1 likes to lay on the right side. Z3 stated that R1 was provided with a neck pillow and is on low air loss mattress. Z3 stated the facility needed to figure out a way to keep R1 off her right side. Z3 further stated that gel pillows could help R1's right ear heal. Z3 stated that R1 has a Stage 4 pressure ulcer to her coccyx that the facility told her started 9/29/14. Z3 stated when she first started seeing R1 her pressure ulcer on her coccyx was unstageable. Z3 stated R1 needs a wound vac and would be healed by now but R1 is on hospice. Z3 stated R1 initially had necrosis to her coccyx but has improvement since R1 was debrided. Z3 stated that R1's pressure ulcer to her coccyx currently has undermining. Z3 further stated that R1 has " group B strep " in her coccyx wound and feces and urine could be the cause of R1's wound infections. Z3 stated that R1 has a left lateral ankle that is looking better but slow healing since starting with wound management, and at this time is unstageable. Z3 stated she gives E3, wound nurse recommendations for each resident ' s interventions to keep pressure areas from progressing. Z3 further stated that she does not think that placing a pillow under R1's back off-loads R1 enough to provide relief to the Stage 4 pressure area to coccyx. Z3 further stated a wedge would be more appropriate for R1 to offload pressure areas for R1's three pressure ulcers. On 1/12/15, E3 stated R1's wound continued to decline and wound management requested for R1 to be laid down more frequently and that R1 should be turned every hour from side to side and only on her back only for meals. Both stated, on 11/3/14, the facility implemented turning every residents every 1 hour if they have active pressure ulcers. E3 stated that R1's right ear was sloughing on 11/13/14 and that R1 leans to right side and puts pressure on it. On 1/12/15, E2, and E3, reviewed R1's Risk for Pressure Ulcers form dated 4/17/14, which documented R1 as "no risk" for pressure ulcers. The Pressure Ulcer form continued to document on 5/14/14, 8/30/14 and 11/21/14 that R 1 was a "mild risk" , even after though R1 had developed of a Stage 3 to right ear, an unstageable to left ankle and a Stage 4 to coccyx. E2 stated, "R1's assessments were not accurate and R1 was at a high risk for pressure ulcers". E3 agreed with the assessments being inaccurate. On 4/23/14, 5/30/14, 8/30/14, and 1121/14, The Skin Integrity Care Plan: Prevention, documents in part; Potential for impaired skin integrity R/T: impaired mobility, Cognitive deficits, incontinence, [MEDICAL CONDITION]. No pressure ulcers will develop in the next 90 Days. Interventions listed included (in part); Pressure reducing mattress to bed, Pressure reducing cushion to Wheel Chair, Lotion to skin after bathing, Observe skin integrity during AM/PM care. Notify MD promptly of skin breakdown, Monitor incontinence, provide peri-care, Evaluate Skin Weekly, Encourage to reposition as able. There are no therapeutic devices listed for pressure ulcer prevention, and repositioning of R1 is not adequately addressed in this care plan, as the MDS documents she would need assistance of 2 staff. 2. R2's Physician order [REDACTED]. R2 had no pressure ulcers on admission to this facility. In the nurses notes dated 11/17/14, E3, Licensed Practical Nurse, documented an "incontinence associated lesion on R2's right and left buttock with measurements of (0.6 x 0.6) on the right side and (0.8 X 0.9) on the left side " . The Facility Standing orders for Incontinence Associated Lesion dated 11/17/14 were started. The treatment is documented: cleanse area with normal saline, apply Duoderm every 3 days, and monitor dressing every shift and for signs and symptoms of infection. On 11/17/14 a Skin Integrity Care Plan: Non-Pressure Wound, was implemented, for incontinence associated lesion to buttock with interventions for pressure reducing mattress to bed, pressure reducing cushion to wheelchair, apply lotion to skin following bathing, observe skin integrity during am/pm care, maintain head of bed in lowest possible position, encourage resident to reposition as able. R2's Minimum Data Set ((MDS) dated [DATE], documented R2's Brief Interview for Mental Status (BIMS) as a 2, moderately impaired. Under functional status, Activities of Daily Living, Bed Mobility documents R2 as a 3/2 (Extensive assist/One person physical assist). R2's MDS dated [DATE], under skin and ulcer treatments documents A. Pressure reducing device for chair. B. Pressure reducing device for bed. The MDS did not identify for skin ulcer interventions; C. Turning/repositioning program. On 11/18/14 at 11:50 AM, E3 Licensed Practical Nurse (LPN) Wound Nurse, documented on the Change of Condition report, "Area to right buttock has been compromised due to pressure and has developed into a pressure area. A low air loss mattress was implemented on 11/18/14. On 11/18/14, the Skin Integrity Care Plan Non-Pressure Wound, documented "Area was compromised by pressure and order changed to Santyl, Resident seen by Z3 Specialized Wound Management (SWM) Nurse Practitioner (NP). Z3, SWM/NP documented in her notes she saw R2 on 11/20/14, not on 11/18/14 as was documented on R2 ' s care plan. Z3 documented R2's pressure ulcer as unstageable, with measurements of 1.0 X 1.5. Z3 changed R2's treatment to clean wound with normal saline, apply Santyl to wound, cover with gauze and dry dressing. Change daily and as needed. On 11/24/14, Z3 saw R2 and documented pressure ulcer to coccyx unstageable with measurements of 1.5 X 1.5. Continue to cleanse pressure ulcer with normal saline, apply santyl to wound, cover with gauze and dry dressing. Change daily and as needed. The facility's pressure ulcer evaluation record dated 11/2014, documented wound measurements to be 1.5 X 1.5, unable to determine stage. On 12/4/14, Z3 was at the facility, but R2 was unavailable. Nursing reported to Z3 that R2 was stable. Z3 documented will follow up next week. On 12/11/14, Z3 saw R2 and documented unstageable pressure ulcer to coccyx with measurements of 1.5 X 1.5. Z3 performed excisional debridement of necrotic tissue. treatment of [REDACTED]. On 12/18/14, Z3 saw R2 and documented unstageable pressure ulcer with measurements of 1.1 X 1.0. Continue to cleanse pressure ulcer with normal saline, apply Santyl, cover with gauze and dry dressing. Change daily and as needed. The facility's pressure ulcer determination record dated 12/19/14, documented, unable to determine stage, with measurements of 1.1 X 1.0. See SWM notes. On 12/22/14, Z3 saw R2 and documented Stage IV pressure ulcer with measurements of 1.0 X 1.0 X 1.5, with undermining of 1 centimeter (cm) from 12 O'clock and 0.7 cm from 9 O'clock. Exposed structure: tendon. Z3 documented instructions for staff on importance of R2 being up for 2 hours max at a time to help with off-loading and promote in healing. The facility's pressure ulcer determination record dated 12/22/14 documented stage IV pressure ulcer with measurements of 1.0 X 1.0 X 1.5. See SWM notes. On 12/25/14 at 3:30 PM, E30, Licensed Practical Nurse, LPN, documented on Nurses Notes that Z4, Power of Attorney (POA), notified E30, that R2 had an odor coming from R2's coccyx wound. Z4 told E30 "I know the wound is getting worse and there is an odor to it. I know the odor is not coming from bowel movement (BM)." E30 notified Z6, Nurse Practitioner of Z4's concerns of the odor coming from R2's wound and new orders were received for one time dose of [MEDICATION NAME] 1 gram intramuscular (IM) now. Culture coccyx wound. Complete Blood Count (CBC) in AM. Laboratory results from wound culture obtained 12/25/14, documented; Positive for Escherichia, many white blood cells, gram negative rods, many gram positive cocci, many gram positive rods. In reviewing Nurses Notes and TAR for 12/25/14, no documentation was found by E23, Licensed Practical Nurse, LPN, who did R2's dressing change on 12/25/14. No documented Change of Condition report or mention of the odor to R2's pressure ulcer was written in the nursing notes, even though orders for treatment of [REDACTED]. In a later interview on 1/13/15 at 9:15 AM, E23 was asked if she recalled an odor to R2's pressure ulcer on 12/25/14 when changing R2's dressing. E23 said "No, I don ' t remember smelling a foul odor". E23 was asked what she would do if there was a change in a wound. E23 said "If there was a change in a wound she would chart it in the Nurses Notes and do a change of condition report". On 12/29/14, Z3 saw R2 and documented stage IV pressure ulcer with measurements of 3.00 X 5.00 X 1.50. Undermining: 9 cm from 3 O'clock. Undermining: 1 cm from 9 O'clock. Undermining 2.5 cm from 12 O'clock. Undermining:1 cm from 3 O'clock. Exposed structure: Bone, Tendon. Treatment changed to cleanse pressure ulcer with normal saline, apply Santyl, Dakins' 0.125% moisten gauze packing, cover with gauze dry dressing. Change daily and as needed. Z3- instructed staff on importance of R2 being side to side turn only to help with off-loading and promote in healing. R2 is currently on bed rest. Foley catheter was placed for wound healing. On 12/30/14 at 12:30 PM, E2 Director of Nurses (DON), was asked if the facility has any documentation of when staff turn and reposition residents. E2 said "No". The facility's pressure ulcer evaluation record dated 12/30/14 documented Stage IV with measurements of 3 X 5, see SWM notes. The facility's Resident Treatment Administration Record (TAR) for December 2014, documents the nurses initials in a box each day the dressing change was done. No Nurses Notes were available to describe the wounds characteristics or odors. On 12/25/14, the TAR initials that E23 LPN did the wound treatment and dressing change. No documentation or description of the wound size, odor or condition was available. On 1/5/15 at 12:25 PM, E3 LPN Wound Nurse was asked where she documents the size, depth, tissue, drainage of a wound after doing treatment. E3 said," whoever does the dressing change signs it off on the TAR, there is no documentation of the wounds except when SWM comes." When E3 was asked if the measurements

Based on observation, interview and record review the facility failed to provide complete incontinent care for 3 of 6 residents (R1, R5 and R14) observed for incontinent care in the sample of 20. Findings include: 1. R5's most recent MDS dated [DATE] documents R5 is totally dependent on staff for all activities of daily living and incontinent of bowel and bladder. On 1/5/15 at 1:33 PM, E12 and E13, CNAs, provided perineal care to R5. R5's adult disposable briefs was slightly saturated with urine. E12 and E13 washed their hands and prepared a basin of soapy water using liquid soap from the wall soap dispenser and a second basin of water for rinsing. Using a soapy washcloth, E12 wiped R5's groin area and across the vaginal area with back to front strokes. E12 failed to spread the labial folds. E12 dried the area but did not rinse the soap off of R5. E13 turned R5 to her left side. E12 cleansed the buttocks and rectal area with a soapy washcloth and dried the area. E12 failed to rinse the soap off of R5. 2. R14's most recent MDS dated [DATE] documents R14 needs extensive assist with transfers, dressing and toileting and is incontinent of bowel and bladder. On 1/8/15 at 3:30 PM, R14 was incontinent of bowel and bladder. E15, CNA, washed her hands and prepared washcloths wet with water and regular soap. E15 wiped the inner thighs and the shaft of the penis and rinsed the area. E16 failed to retract the foreskin. E15 failed to dry the wet area before turning R14 to his left side. E15 used a wet soapy towel to cleanse the buttocks and rectal area. E14 failed to dry the wet areas before applying protective barrier to R14's buttocks. On 1/13/15 at 9:39 AM, E27, Director of Staff Development, stated she expects staff to wash, rinse and dry and to thoroughly wash the the vaginal area in females and retract the foreskin in males during perineal care. E7 stated it is important to wash in a front to back direction to prevent infection. The Facility Policy on Incontinent Care dated 8/2014 documents, "Purpose: To keep skin dry, free of irritation and odor. To prevent skin breakdown. To prevent infection. Procedure: 5. Wash all soiled skin areas including skin folds, washing from front to back, rinse and dry." The policy does not show specific procedure for cleaning male and female genitalia. R1's December 2014 face sheet documents [DIAGNOSES REDACTED]. R1's Minimum (MDS) data set [DATE] documents R1's Brief Interview of Mental Status (BIMS) was left blank. The MDS further documents that R1 is totally dependent on two or more staff members for transferring, bed mobility, toilieting and totally dependent on one staff member for dressing, eating, personal hygiene and bathing and that R1 is always incontinent of bowel and bladder. On 12/30/14 at 9:00AM, E6, Certified Nurse Assistant (CNA) and E7, CNA provided incontinent care to R1, who had visible brown feces on her peri-anal area that saturated the coccyx wound dressing. E6 wiped R1's peri-anal area with a wet washcloth to remove brown feces. E6 then transferred the soiled washcloth to her (E6) opposite hand to dispose in trash bag. E6 placed both soiled gloved hands in the clean wash basin with clean washclothes to retrieve new washcloth. E6 wiped R1's peri-anal area again with brown feces on washcloth and E6 stated R1 was "still pooping." At no time did E6 rinse or dry R1's peri-anal area. E6 left visible brown feces around R1's wound to her coccyx and R1's wound dressing was visibly soiled with brown feces. E6 covered R1 back up and stated she was done with care. On 12/30/14 at 9:45 AM, E3, Wound Nurse and E5, CNA changed R1's dressing to R1's coccyx. R1's dressing to her coccyx had visible brown feces saturating the dressing covering her coccyx pressure ulcer and also feces around the peri-anal area. E3 removed R1's dressing that was saturated with bowel and cleansed the peri-anal area around R1's Stage 4 pressure ulcer with gauze soaked in normal saline. E3 stated she was finished cleaning R1 coccyx and that she cleansed the wound and peri-anal area surrounding the wound with normal saline. E3 further stated she would normally used soap and water to clean visible feces from peri-anal area not normal saline.

A. Based on interview and record review the Facility failed to timely resolve issues with the the Hospice provider and ensure coordination and implementation of services for 1 of 2 residents (R1) reviewed who received Hospice Services in the sample of 20. This failure resulted R1 having a coccyx Stage 1 pressure ulcer worsen into a Stage 4, in R1 developing a reoccurring Stage 3 pressure ulcer to right ear and R1 developing an unstageable pressure ulcer to the left ankle. Findings include: 2. R1's current face sheet documents [DIAGNOSES REDACTED]. R1's Physicians Order Sheet documents: Admit to Hospice with Terminal [DIAGNOSES REDACTED]. On 5/21/14, R1's Nurses Notes document the following orders; Admit to local hospice provider. Terminal [DIAGNOSES REDACTED]. Do Not Resussitate. Activity as tolerated. Diet as tolerated. Oxygen at 2 - 4 liters/as needed/for shortness of breath. Continue current medication. The Hospice Care Plan dated 5/30/14, documented the following; Hospice to provide medication as appropriate, pain medication as needed, services based on identifying needs 24/7, provide supplies, and provide visits and assess pain every visit. Notify Hospice and MD of any changes as indicated. (Facility) nursing staff to communicate with and assist haopice. Decline in condition to be expected Related/To terminal [DIAGNOSES REDACTED]. The Facility Social Service Care Plan dated 6/2/14, documents R1 is now receiving Hospice services for End Stage Dementia, and will be receiving with a goal to keep R1 comfortable and pain free. R1's weekly Skin Condition reports from May 2014 through July 2014 document R1 had ongoing reddness to coccyx and was treated with antifungal cream ([MEDICATION NAME]). No physician update or order for antifungal cream was found in R1's clinical record, and no care plan for this event is documented. There are no updates to either the Facility or Hospice Care plans identifying treatments or interventions during this time. R1's Nursing Notes dated 9/19/14 document: "N.O. (Nurse Order) from hospice regarding incontinet associated lesion to buttock for wound gell cover with [MEDICATION NAME]. Change daily and PRN (as needed) as area has declined. " R1's Nursing Notes dated 10/4/14 document: "late entry: spoke with hospice and family re: decline in residents wound to buttock. Asking for santyl as slough reamins to wound bed. Hospice continues to want wound gel and [MEDICATION NAME] every 3 days to wound." On 1/7/15 at 9:07AM, E2, Director of Nursing, and E3, Licensed Practical Nurse / Treatment Nurse, stated that R1 was admitted to the facility on [DATE]. E2 stated that R1 had a pressure reducing mattress, which is standard for all residents admitted to their facility. E2 stated on 8/2/14, R1 had excoriation to coccyx and a duoderm was applied. On 9/19/14, R1 continued to have excoriation and incontinent lesion. E3 stated that R1's pressure ulcer on her coccyx had started to decline and she knew it needed debridement. On 9/29/14, Hospice wound nurse was supposed to come and evaluated R1 but never came. E2 stated they had no further orders from Hospice. E3, continued, on 10/4/14, E3 was becoming impatient with hospice and requested orders for Santyl from hospice. Hospice did not want to do Santyl. No doctor was notified for the decline in R1's pressure ulcer. On 11/6/14 wound management started seeing R1 and noted R1 had an unstageable pressure ulcer to coccyx and debrided it. Additionally, Z3 ordered a low air loss mattress for R1. On 11/12/14, E3 stated R1's wound continued to decline and wound management requested for R1 to be layed down more frequently and should be turned every hour from side to side and back only for meals. Both stated on 11/3/14, the facility implemented turning every 1 hour and staff should turn residents every 2 hours and if have active pressure ulcer then turn every hour. E3 stated that R1's right ear was sloughing 11/13 and that R1 leans to right side. On 4/23/14, 5/30/14, 8/30/14, and 11/21/14, The Skin Integrity Care Plan: Prevention, documents in part; Potential for impaired skin integrity R/T: impaired mobility, Cognitive deficits, incontinence, [MEDICAL CONDITION]. No pressure ulcers will develop in the next 90 Days. Interventions listed included (in part); Pressure reducing mattress to bed, Pressure reducing cushion to Wheel Chair, Lotion to skin after bathing, Observe skin integrity during AM/PM care. Notify MD promptly of skin breakdown, Monitor incontinence, provide peri-care, Evaluate Skin Weekly, Encourage to reposition as able. There are no therapeutic devices listed for pressure ulcer prevention. Repositioning of R1 is not adequately addressed in this care plan, as the MDS documents she would need assistance of 2 staff. The care plan documents that R1 is expected to decline and is receiving Hospice care. The care plan fails to document R1's pressure ulcers, or interventions to improve R1's wound status, or document treatment interventions prescribed by Hospice. On 11/20/14 Z3, Wound Mangament notes document "R1's tissue culture of her coccyx was + (positivie) for Proteus mirabillis and steptoccus Agalactiae. Notes: Nursing to obtain pillow to help off-load pressure of ear." Hospice documentation dated 12/19/14 indicates: "R1 has a 4.8 x 3.6 cm, Stage 4 wound to sacrum, a Stage 2 wounds to left ankle and under left breast, 3.2 x 1.3 cm, and Stage 1 wound to right ear helix." No Hospice care plans were provided for R1's pressure ulcers. On 12/30/14 at 12:35 PM, E3, Wound Nurse stated R1's redness to her coccyx started in 5/2014, as an " incontinent lesion " and has since declined to a Stage 4 pressure ulcer. E3 stated that Z3, WN/NP started seeing R1 in 11/2014, but only after a 3-4 week delay in treatment due to internal issues with Hospice. E3 stated R1's pressure areas were declining during this time. E3 stated she noted the area to be declining in 8/2014 or 9/2014, and knew the wound needed debridement. The Hospice provider was supposed to have a wound nurse come, but never did during that time. E3 stated she had never called R1's physician (Z1) to update him on R1's progression of pressure ulcer because she thought hospice took care of getting the physician's orders [REDACTED]. On 1/7/15 at 11:45 AM, E2 and E3 both stated that Hospice was following R1 and the facility was getting orders from Hospice for R1's pressure areas. On 1/7/15 at 1:45 PM, E2, DON stated she cannot find any notes from Hospice for R1 and does not know where hospice keep their chart in the facility. On 1/8/15 at 8:45 AM, E2 produced R1's hospice record and stated she had called the Hospice Provider, and had her bring the records to the facility that morning for review. On 1/7/15 at 2:00 PM, Z2, Registered Nurse, RN/Hospice Case Manager stated she has cared for R1 once a week for the past 6 months. Z2 stated that R1 developed a Stage 1 to Stage 2 on coccyx and now it has declined to --"what you see is what you get". Z2 stated "the facility was supposed to be getting orders for treatment of [REDACTED]. Z2 stated the hospice medical director is not allowed to give orders at this facility due to his inability to access the electronic computer system. Z2 further stated that Hospice nurses make recommendations or suggestions to the facility staff and the facility is supposed to get the order from R1's attending physician (Z1)." On 1/7/14 at 2:30 PM, Z1, Medical Doctor, stated that he recalled R1 and that R1 is under the care of Hospice. Z1 stated he does not medically manage R1 and her care is done with Hospice. Z1 further stated he does not know anything about any of R1's pressure areas and is not involved in R1's care of pressure ulcers. Z1 stated the Facility contacted him once for a referral for wound management for R1 but was never notified by facility of R1's pressure ulcers. On 1/8/15 at 9:20 AM, Z3, Nurse Practicioner stated that she started seeing R1 on 11/6/14 and that R1 has really done well since starting with wound management. Z3 stated that R1 had a pressure ulcer to right ear that has closed and reopened at least twice since she started treated her. Z3 stated that R1's right ear recently reopened again and that R1 likes to lay on the right side. Z3 stated that R1 was provided with a neck pillow and is on low air loss mattress. Z3 stated the facility needed to figure out a way to keep R1 off her right side. Z3 further stated that gel pillows could help R1's right ear to heal. Z3 stated that R1 has a stage 4 pressure ulcer to her coccyx that the facility told her started 9/29/14. Z3 stated when she first started seeing R1 her pressure ulcer on her coccyx was unstageable. Z3 stated R1 needs a wound vac and would be healed by now, but R1 is on Hospice. On 1/13/15 at 1:40 PM, E2, Director of Nursing stated that E3, Wound Nurse, would take orders from Z2, Hospice Nurse and input them into the computer. E2 stated she is unsure how the coordination of care with Hospice is supposed to happen as this was new to her. E2 stated that Hospice was writing orders for R1's pressure ulcers. A review of R1's care plans from 10/29/14 through 12/11/14 found documentation that the facility had begun to individualize it's care plans for R1's three pressure ulcers, but all three updates failed to address ongoing problems for R1 with positioning and pressure relief. None of the updates included information that Hospice was involved in R1's care. The Initial Care Plan of 5/30/14 remained unchanged, although it was documented as updated on 8/30/14 and 11/21/14. A review of the Facility's "Service Agreement By and Between" signed by the Hospice Provider 8/31/99, and signed by the Facility 9/7/99, documents: 2:13 "Plan of Care" means a written care plan established, maintained, reviewed and modified, if necessary, at intervals established by the Interdisciplinary Group, which includes (a) an assessment of each Hospice Patient's needs, (b) an identification of the Hospice Services, Including management of discomfort and symptom relief, needed to meet such Hospice Patients needs and ...., (c) details concerning the scope and frequency of such Hospice Services, and (d) details concerning the Nursing Facility Services to be provided to the Hospice Patient.... 3.2 Design and Maintenance of Care Plan, (a) Nursing Facility Residents: In accordance with the Federal and State laws and regulations, Hospice shall coordinate with Nursing Facility to develop a Plan of Care for each new Residential Hospice Patient. Hospice shall Furnish Nursing Facility with a copy of the Plan of Care. (c)Modifications ..... the Interdisciplinary Group will review and modify, if necessary, the Plan of Care. The Hospice will consult and coordinate with Nursing Facility... with respect to any modification of the Plan of Care, and will provide the Nursing Facility with any modification of the Plan of Care. In a previous interview on 12/30/14 at 1:00 PM, E4, Care Plan Nurse, stated she is not sure if Hospice had done a care plan, the she had not been involved in coordinating care with hospice. On 1/13/15 at 1:40 PM, When E2, DON was asked if the facility had any proceedures for coordinating care with the Hospice Provider, no additional information was given by E2. B. Based on observation, interview and record review, the Facility failed to provide adequate pain management services to address pain for 1 of 9 residents (R13) reviewed for pain management in the sample of 20. Findings include: 1. R13's Electronic Physician order [REDACTED]. R13's POS documents [MEDICATION NAME] ER 20 mg tablet every 12 hours, [MEDICATION NAME] 10 mg by oral route every 4 hours as needed, [MEDICATION NAME] 700 mg/patch adhesive to each knee daily. R13's most recent Minimum Data Set ((MDS) dated [DATE] documents a BIMS (Brief Interview of Mental Status) score of 15 (no cognitive impairment). R13's Pain assessment dated [DATE] documents, "...chronic and constant severe pain of both lower legs, an 8 on a scale of 1 (no pain) to 10 (worst pain). Pain Management includes [MEDICATION NAME] 700 mg/Patch, [MEDICATION NAME] ER 20 mg twice a day and [MEDICATION NAME] 10 mg every 4 hours as needed. Pain Management Evaluation: Continue with current interventions as pain appears adequately managed. Interdisciplinary Team update on 12/12/14 documents pain management remains the same. " R13's Comprehensive Care Plan: Pain Management dated 10/29/14 and reviewed 12/12/14 documents, "Consult with MD when pain regimen changes are indicated: inadequate pain relief. Non pharmacological approaches: frequent position changes, exercise/physical activity, resting periods during activities of daily living. R13's POS with order date 10/22/14 documents, "Refer (R13) to Pain Management per (Z5, Nurse Practitioner). R13's POS with order date 11/12/14 documents, "Consult with pain management due to chronic leg pain. " On 1/5/15 at 10:08 AM, R13 was in bed and rubbing her right leg. R13 stated she was in pain, a '4' on her right leg and she just had her scheduled pain medication two hours earlier and it only worked for a short time. R13 stated she gets pain medication twice a day and she can ask in between as needed but the medication only helps temporarily. R13 stated she has told staff her pain medication is not working and has not worked for a long time. R13 stated she cannot do her restorative exercises on her right leg because of the pain. R13 stated even if she asks for pain medication every 4 hours it will just work for an hour or so and the pain is back. R13 stated she has not been to any pain management consult since she was readmitted in October 2014 after a back surgery related to her spinal fusion. On 1/8/15 at 9:02 AM, R13 was in bed, grimacing, and stated her pain was an '8' on her right leg and a '6' on her left leg and she just took a pain pill an hour ago. R13 stated it seems like she is having pain all the time. On 1/12/15 at 10:05 AM, E19, Certified Nursing Aide, CNA, provided range of motion exercises to R13. R13 refused to do the right leg because it was painful. R13 stated it was a "6" on the right leg. A review of R13's clinical record indicated no documentation that pain management consultation was done as ordered on [DATE] and again on 11/12/14. On 1/8/15 at 9:25 AM, E23, Licensed Practical Nurse, stated she cannot recall R13 having a pain management consult since R13's return to the facility sometime in October 2014. On 1/13/15 at 1:10 PM, E2, Director of Nursing stated she had called Z5 and asked where to go for R3's pain management consult. E2 stated Z5 never got back to them to provide information on pain management consultants. E2 added the facility does not have any pain consultants that they can send their residents to. The Facility Operating Standard Pain Management Process dated 6/2009, documents, "The objective of the pain management process is to identify resident need and determine potential referrals/interventions to affect positive functional change through pain reduction, modification of the perception of pain, and enhancement of the quality of life...Guidelines, (in part): Review of continued effectiveness and appropriateness of Pain Management Plan of Care during routine IDT (Interdisciplinary Team) walking rounds. "

A. Based on observation, interveiw and record review, the Facility failed to adequately assess, monitor and treat wounds for one of four residents (R12) reviewed for wounds in the sample of 21. Finding include: R12's Electronic Medical Record documents R12's partial [DIAGNOSES REDACTED]. R12's Minimum Data Set (MDS), dated [DATE], documents her cognitive functioning is severely impaired. The MDS documents she requires extensive assist of one to two staff with transfers, grooming and toileting. The MDS documents she is frequently incontinent of bladder and bowel. R12's Braden Pressure Ulcer Risk Assessment on 6/5/2013, 9/4/2013 and 12/4/2013 scores resident at 13 (moderate risk for breakdown). The Faciliy's Pressure Ulcer Log, dated 2/14/2014 documents R12 had a Stage II pressure ulcer which was Facility acquired on 1/16/2014. The 2/2014 Physicians Orders (PO) listed in the Electronic Clinical Record (ECR) for R12 include the treatments originally odered 1/30/2014, " Menthol-Zinc Oxide 0.2% topical paste (Brand name is [MEDICATION NAME]) TID." The Progress Note attached to the Care Plan dated 1/16/2014 at 10:00am documents,"Res. (Resident) presents with small open area to coccyx that measures 1 x 0.2 x 0.1. Res. was having [MEDICATION NAME] tx (treatment) R/T (related to)Hx (history) of pressure ulcers to area. Res. is incontinent of bowel and bladder, requires total care, on a T &P (turning and repositioning)q (every) two hour schedule and now down after meals. New order to cleanse with Normal saline apply Silver Alginate to area after skin prepping peri area, then cover with Duoderm and change every 3 days." On 2/19/14 at 9:45AM, E32, Certified Nurse Aide (CNA) assisted R12 to bed and postioned her on her left side. E32 covered her with a blanket. When questioned if she was done providng care, E32 stated she was done. E32 did not check to see if R12 was incontinent of urine. Surveyor asked E32 to check R12 for incontinence. E32 removed R12's urine soaked and blood stained brief down to R12's knees. R12 had four partial to full thickness open areas over and around sacrum. The surrounding tissue was white, and macerated around these open areas. There was no dressing on her coccyx/sacral area. During perineal care, on 2/19/2014 at 9:45AM, E32 (CNA) was interviewed. E32 stated she assisted R12 out of bed that morning, and R12 did not have a dressing over the wounds at that time. E32 did not apply barrier cream or any other ointment to R12's perineal area. On 2/18/2014, at 10:30AM E14, Licensed Practical Nurse (LPN) Treatment Nurse was interviewed. E14 reported she had not assessed R12's wound on her sacral/coccyx area since Friday, 2/14/2014. The Pressure Evaluation Record dated 2/06/2014 documents R12 had one wound, just a "sliver" measuring 1.0 cm x 0.1cm with no measureable depth. E14 reported the current treatment was [MEDICATION NAME] lotion that the CNAs apply". On 2/19/2014 at 2:10PM E14, LPN, checked R12's bottom for changes in skin condition. E12 commented that no one had reported any changes to her today regarding R12's skin. E14 removed R12's brief, verified she did not have any Menthol-Zinc Oxide 0.2%-20% oint ([MEDICATION NAME]) or barrier cream on R12's bottom or a Duoderm. E14 measured the five open areas on R12's bottom as follows: A. 1.0cm x 0.2cm x 0.2cm which is the original stage 2 last documented as 1.0cm x 0.1cm with no depth on 2/6/2014. B. 0.8cm x 0.3cm x 0.1cm just below wound A over coccyx/sacral area. C. 1.0cm x 1.0cm x 0cm - right upper outer sacral area, circular in shape with defined boarders. D. 1.0cm x 1.2cm x 0cm - right lower outer sacral area, circular in shape with defined boarders. E. 0.8cm x 0.6cm x 0cm - left lower outer sacral area, circular in shape and defined boarders. E14 cleased the areas with Normal saline and applied a Duoderm to the area. E14 stated she was told by E2, Director of Nurses, the CNAs cannot apply the Methol Zinc Ointment since it was considered a treatment and has to be done by the nurse. On 2/20/2014 Specialize Wound Management Nure Practicioner (SWM,NP) assessed R12. The SWM,NP report documents,in part, as follows, "Nursing reports that this 82y/o (year old) female has a pressure ulcer, which was noted on 1/16(2014), currently treating with Duoderm, which was changed this week. She has a history of chronic IAD (Incontinence Associated [MEDICAL CONDITION]) of the bilateral buttock, which complicates healing. Nursing report that they have tried several different TX (treatments) to heal the coccyx, including [MEDICATION NAME]. On 2/19(/2014) she was noted to have bilateral buttock wounds, which appear to be secondary to trauma. Currently treating with duoderm." The Facility Policy for Incontinence Care, dated 2006, documents, in part, the Purpose is to "Identify skin problems as soon as possible so treatment can be started." B. Based on interview and record review, the facility failed to assess, identified causative factors and implement person-centered interventions to address behavioral symptoms for one of six residents (R16) reviewed with dementia related behaviors in the sample of 16. Findings include: R16's Admission Physician order [REDACTED]. The Facility's Verification of Incident Investigation/Administrative Summary, dated 1/10/2013, documents "Res. (R16) hit roommate (R2) with a pillow." The Summary documents "(R16) was placed on 1:1 (one-to-one) by staff immediately. Resident was sent to (Hospital Psychiatric Unit) but was sent back to us the same night. When returned placed in a private room. Res (Resident) was placed on 15 min (minute) checks. Follow-up with house psychiatrist within next (14-21 days). Social Service daily 1:1 visits for 2 weeks, then 3 (times) weekly x 2 weeks then weekly x 2 weeks." R16's physician's orders [REDACTED]. The FDA Black Box Warning Regarding "Atypical Antipsychotics in Dementia", http:www.fda.gov/Drugs/default.htm, documents "Elderly patients with dementia-related [MEDICAL CONDITION] treated with atypical antipsychotic drugs are at an increased risk of death to placebo." R16's Electronic Medication Administration Record, [REDACTED]. R16's Electronic Behavior Tracking for January and February 2014 was reviewed. R16's Behavior Tracking documented R16's targeted behaviors for the use of the [MEDICATION NAME] as hitting, kicking, slapping, verbally aggressive towards others, continuous yelling, screaming, spitting and resisting medications. The tracking did not document when these behaviors occurred or what non-pharmacological interventions were attempted prior to staff administering the [MEDICATION NAME]. On 2/21/2014, at 1:45PM, an interview was conducted with E30, Licensed Practical Nurse (LPN). E30 stated R16 yells at staff when she attempts to ambulate without assistance from staff. E30 stated R16 really likes the therapy department and likes to sit down in the therapy room. On 2/21/2014, at 1:47 PM, an interview was conducted with E10, Certified Nurse's Aide (CNA). E10 stated she cares for R16 on a routine basis. E10 stated R16 has behaviors with care. E10 stated R16 thinks she is more independent than she is and will yell and throw things at staff if they attempt to assist her. E10 stated the best way to deal with R16's behaviors is "let her do as much as possible for herself." E10 stated R16 has more behaviors in the morning when she wakes up. E10 stated sometimes you need to leave her alone and come back later. E10 stated R16 became aggressive with other residents in the past. E10 stated "Yes, when she had a roommate she was, but she was fine during the day. We would keep her busy." E10 stated during the day, staff would take her to activities or take her to the therapy room. E10 stated that she became aggressive with her roommate at night because she would attempt to help her roommate or get into bed with them. E10 stated staff would keep her busy during the afternoon and that helps. R16's medical record was reviewed and there was no documented thorough assessment regarding R16's specific behaviors, potential causes/triggers of her problem behaviors including information from facility staff regarding R16's behaviors. R16's Care Plan, dated 9/7/2013 and revised on 11/5/2013 and 1/2/2014, documents she has Dementia with psychotic features, hitting/slapping, aggression, confrontation, refusing care, verbally abusive to staff/peer and combative. This standardized Behavior Care Plan is pre-printed and staff "check" areas which are applicable to any residents' behaviors. R16's Behavior Care Plan was not individualized to address her specific needs and routines related to her behaviors and dementia. R16's Care Plan documented Social Service would meet with R16; however, the Care Plan did not address what interventions would be implemented during these meeting to address her behaviors. Furthermore, R16's Care Plan had not been revised to address staff use of [MEDICATION NAME] to address her behaviors.