Every finding on record at Conroe Health Care Center

Based on observation, interview and record review, the facility failed to provide necessary treatment and services to promote Based on observation, interview and record review, the facility failed to provide necessary treatment and services to promote healing and prevent worsening pressure sores for 1 of 8 resident (Resident #57) reviewed for pressure sores. - The facility failed to provide repositioning and pillows/wedges to prevent Resident #57's development of a stage 2 pressure ulcer, ( an area of damage to the skin or underlying tissue that occurs when continuous pressure is placed on a particular part of the body that has skin loss to where the fat under the skin is visible but not bone, tendon or muscle), This failure could place resident at risk of development of new pressure sores, worsening of current sores, pain, suffering and infection. Finding Included: Record review of Resident #57's Face Sheet dated 04/09/25 revealed, an [AGE] year-old female who admitted to the facility on [DATE] with diagnoses which included: muscle wasting, muscle weakness, lack of coordination, depression, and other reduced mobility. Record review of Resident #57's Admission MDS dated [DATE] revealed, resident was rarely/never understood, rarely/never understood others, had severely impaired vision. An interview for mental status was not conducted, resident had a short- & long-term memory problem, had no assessable memory/recall ability, had moderately impaired cognitive skills for daily decision making, and had an acute onset mental status change as indicated by inattention, disorganized thinking, and altered level of consciousness. Prior to admission Resident #57 was dependent for self-care, indoor mobility, and functional cognition. The resident's functional abilities such as roll left to right, sit to lying sit to stand and transfers could not be assessed due to her medical condition or a safety concern. Resident #57 was always incontinence of both bladder and bowel, was at risk of developing pressure ulcers and had no current or healed pressure ulcers and had moisture associated skin damage. Record review of Resident #57's Quarterly MDS dated [DATE] revealed, severely impaired cognition as indicated by a BIMS score of 00 out of 00, rarely/never understood others, rare/never makes self-understood, highly impaired signs and symptoms of delirium( a state of confusion due to medical conditions) which included inattention and altered level of consciousness. Resident #57 was unable to answer questions about social isolation, she was dependent on staff for all aspects of self-care such as: eating, oral hygiene, toileting, upper/lower body dressing, personal hygiene. Resident #57's was dependent on staff to roll from her back to the left and right side, and she could not be assessed for her ability to move from sit to lying, sit to stand, transfer herself or walk due to her medical conditions or safety concern, and she was always incontinent of both bladder and bowel. Resident #57 had a risk of developing pressure ulcers/injuries, and she had 1 stage 3 pressure ulcer. A wound care observation on 04/09/25 at 10:30 AM with the Wound Care Nurse revealed, Resident #57 lying on her left side. Both of the resident's knees were contracted and she had a pillow between her knees, bilateral moon boots and the Wound Care Nurse placed a wedge behind the resident's back. , Scars from old and present pressure ulcer were observed on the sacrum(triangular-shaped bone connected to the hip) and coccyx. There was an open area to the coccyx that was pink in the center with white edges that was approximately 1 inch round with no visible drainage. The Wound care nurse said the resident was usually confused and yelled often and Resident #57 had not been in the facility long before she developed the pressure ulcer to her sacrum. She said the facility tried to prevent the wound through nutrition, but it was an unavoidable wound, and the resident had a history of old pressure ulcers. In an interview on 04/10/25 at 09:32 AM, LVN B said when a resident nurse admits to the facility the admitting nurse completes a head-to-toe assessment on the resident identifying any wounds, bruises, or areas of concern. She said LVNs are not able to stage wounds, so the Wound Care Nurse completes a follow up assessment, identifying any new area of concerns and clarifying any areas identified in the admitting assessment. LVN B said she was Resident #57's admitting nurse in December of 2024 and when the resident arrived, she was bedbound, lying on her left side with bilateral (both sides) contractures to her lower extremity. She said on admission she observed redness to Resident #57's coccyx which she documented as redness to bottom but there were no other bruises/injuries or any scars indicating healed pressure ulcer. LVN B said she should have specifically documented where the redness was and if the area was blanchable ( a wound that appears red but becomes pale when pressure is applied and returns to the original color when released indicating healthy blood flow to the area) or non-blanchable ( a wound that shows not change color indicating signs of tissue damage). She said residents who are bed bound can develop pressure ulcers from being in a position for too long or being wet so measures like repositioning(turning), and the use of pillows and/or wedges are initiated upon admission to prevent the development of pressure ulcers. LVN B said based on the information she documented, from her review of the resident's chart, she could not determine if pillows/wedges were in place for Resident #57 or how often she was repositioned from her admission in December of 2024 to her development of a stage 2 pressure ulcer in January of 2025. LVN B said failure to implement measure to prevent pressure ulcers placed residents at risk of developing or worsening of pressure ulcers and pain. In an interview on 04/10/25 at 09:55 AM, the Wound Care Nurse said upon admission, the admitting nurse completed an admission screening that involved a head-to-toe assessment of the resident and documented it in the resident's chart. The Wound Care Nurse said while the admitting nurse can document what she observes on the resident skin, LVNs cannot stage wounds. She said after the resident's initial assessment, she was responsible for completing an initial skin assessment and weekly skin assessments going forward. The Wound Care Nurse said she reviewed the admitting screener prior to her skin assessment and normally addressed any discrepancies between her assessment and that of the admission nurse. She said when Resident #57 admitted to the facility in December of 2024 she had contractures, but her skin was intact. The Wound Care Nurse said bed bound residents like Resident #57 should have interventions such as diligent positioning, pillows and padding as interventions immediately upon admission to prevent the development of pressure ulcers. She said bed bound residents with contractures could develop a stage II or III pressure ulcer in as little as 2 hours with no previous signs or areas of concerns. After reviewing the resident's chart, the Wound Care Nurse said she did not know why LVN B stated Resident #57 had redness to her buttock upon admission, she did not remember if she clarified the redness to the bottom LVN B documented in the resident's admission screener, but she should have and she could not determine if the resident had positioning pillows or if she was repositioned frequently after admission. The wound care nurse said Resident #57 developed a stage 2 pressure ulcer in the facility. In an interview on 04/10/25 at 10:21 AM, the DON said upon admission residents are assessed head to toe and all concerns should be documented. She said the facility had standard orders and she expected positioning pillows in place and documented in the progress notes for bed bound residents or those with contractures. The DON said the standard of care for a bed bound resident included re-positioning, and an order should be entered to ensure the resident is rolled left-to-right at minimum every 2 hours. She said bed bound residents could go from no areas of concern to a stage II pressure in a week, so repositioning was important. The DON said failure to reposition a bed bound resident placed them at risk for discomfort, skin breakdown and opening of the skin. The DON said she expected more details in Resident #57's admission assessment of buttock with redness and the Wound Care Nurse should have followed up on the area of concern identified by the admitting nurse. She said the follow up should have been documented in Resident #57's chart and she did not see any documentation in the resident's chart to show that the Wound Care Nurse followed up on the LVN B's initial assessment of Resident #57. She said upon Resident #57's admission the admitting nurse should have entered order of some sort preferably a positioning order that included how the resident should have been positioned and how often. The DON said based on the Resident #57's record she could determine if she had positioning pillows or how often she was repositioned from admission up to the development of the stage 2 pressure ulcer. The DON said any turning or repositioning is charted in the resident's chart with the bed mobility, roll left-right task. In an interview on 04/11/25 at 08:42 AM, the Wound Care Nurse said the wound care physician did not see all residents and he did not see Stage 2 pressure ulcers. She said Resident #57's coccyx ulcer just changed to a stage 3, so she was not followed by a wound care doctor because she did not see a need for him to. Record review of Resident #57's undated Care Plan revealed, the following focus areas: *12/12/24: limited physical mobility; intervention- observe for signs and symptoms of pain/discomfort with mobility and intervene, as necessary. *01/13/25- stage 3 pressure ulcer on coccyx (tailbone); intervention- turn and reposition per facility protocol and as needed. Focus *02/11/25- impaired to skin integrity of right foot, blisters to right food and right great toe related to edema ( observed swelling from fluid buildup), fragile skin and immobility; intervention- positioning pillows, hell suspension. *02/18/25- impairment to skin for right and left knees related to abrasion, fragile skin & contracture; intervention- the resident needs pillows, skin to skin padding at all bony prominence to protect skin while in bet and turn and reposition per facility protocol and as needed. Record review of Resident #57's Order Summary Report of all orders entered since admitted d 04/10/25 revealed the following: *An order to treat the open area to the resident's coccyx on 01/13/25. *An order to place wedge between knees when laying down in bed every shift to prevent wounds entered on 03/03/25. Further review there were no orders for repositioning, turning, positioning pillows or wedges prior to 01/13/25. Record review of Resident #57's Admit Screener dated 12/09/24 at 05:00 PM completed by LVN B revealed, Resident #57's skin color was normal. She had a sore with discoloration to upper mid back and buttock with redness. Record review of Resident #57's Progress Note completed by the Wound Care Nurse and dated 12/10/24 at 07:45 AM revealed, on admission the resident had bruising over her hands and a small abrasion on her upper mid back. Record review of Resident #57's Skin Observation dated 12/13/24 at 07:45 AM completed by the Wound Care Nurse revealed, the resident an existing bruise and an existing abrasion on her upper back. The scattered bruising to both of her hands, a small abrasion upper to mid back and had no other skin concerns. Record review of Resident #57's December 2024 TAR revealed, the only skin area treated was the resident's upper back. Record review of Resident #57's Unavoidable Skin Breakdown completed by the Wound Care Nurse dated 01/13/25 revealed, the location of the skin breakdown was the coccyx. The resident's immobility, cognitive deficits and protein/caloric malnutrition, low lab values placed her at risk for developing or delayed healing of pressure injury. Preventative interventions initiated included: heels offloaded as tolerated, lifting devices to move & turn, weekly skin checks, skin to skin padding, nutritional supplements, vitamins/minerals and Turn & reposition. Record review of Resident #57's Progress Note completed by the Wound Care Nurse on 01/14/25 at 09:41 AM revealed, new stage two pressure ulcer to the coccyx, scant drainage with a pink wound bed. Treatment was initiated and supplements and additional pillows/wedges were in place. Record review of Resident #57's Skin Observation dated 01/17/25 revealed, the resident had a new pressure ulcer on her Coccyx that measured 0.7 cm X 0.5cm X 0.1 cm. 01/14/25 a new pressure ulcer, stage two located on her coccyx with scant drainage. The wound was pink, and treatment was initiated with wound dressing, supplements, and additional pillows/wedges for offloading. Record review of Resident #57's December January 2025 Documentation Survey Report revealed, the resident only had orders to roll left and right once a shift (6 AM- 6PM and 6PM to AM). Record review of Resident #57's ADL report for 12/2024 through 01/31/25 revealed, Bed Mobility occurred on: 12/09/24- 07:14 PM 12/10/24- 03:35 PM 12/11/24- 02:47 AM, 04:10 PM 12/12/24- 01:09 AM, 11:28 am 12/13/24- 05:16 AM, 05:55 AM, 08:54 PM 12/14/24- 05:21 PM 12/15/24- 05:25 AM, 09:45 AM, 11:33 PM 12/16/24- 12:40 PM 12/17/24- 03:25 AM, 02:38 PM, 10:47 PM 12/18/25- 03:12 PM, 11:16 PM 12/19/24- 10:33 AM 12/20/24- 02:12 AM, 05:07 PM, 10:23 PM 12/21/24- 02:18 PM 12/22/24- 02:26 AM, 02:20 PM 12/23/24- 02:29 AM, 04:02 PM 12/24/24- 01:41 AM, 02:38 PM 12/25/24- 01:55 AM, 09:51 AM, 08:36 PM 12/26/24- 11:59 PM 12/27/24- 02:29 11:49 PM 12/28/24- 09:38 AM, 09:24 PM 12/29/24- 10:41 AM, 10:22 PM 12/30/24- 03:57 PM 12/31/24- 02:08 AM, 04:13 PM, 09:30 PM 01/01/25- 01:20 PM, 10:22 PM 01/02/25- 07:48 PM 01/03/25- 07:48 PM 01/04/25- 01:57 AM, 10:19 AM, 10:46 PM 01/05/25- 10:26 AM 01/06/25- 12:21 AM, 04:12 PM, 10:37 PM 01/07/25- 12:57 PM, 10:27 PM 01/08/25- 11:22 AM 01/09/25- 02:21 AM, 10:35 PM 01/10/25- 01:05 AM, 10:00 PM 01/11/25- 09:51 AM, 10:10 PM 01/12/25- 05:25 PM, 09:08 PM 01/13/25- 12:27 PM, 11:29 PM 01/14/25- 02:11 PM, 11:43 PM Record review of the facility's undated Turning and Repositioning policy revealed, the facility's policy to implement turning and repositioning as part of their systematic approach to pressure injury prevention and management. All residents at risk of, or with existing pressure injuries, will be turned and repositioned, unless it is contraindicated due to a medical condition.

Based on interview and record review, the facility failed to ensure the resident has the right to send and receive mail, and to receive letters, packages and other materials delivered to the facility for 1 (Saturday) of 6 mail delivery days reviewed for privacy. - The facility failed to ensure mail was delivered within 24 hours to residents on Saturdays. This failure could place residents at risk of not receiving mail in a timely manner that could result in a decline in the resident's well-being, quality of life and cause them to feel disconnected from family, friends, and current world issues. Findings included: During a confidential group interview on 04/09/25, four of four residents identified by the facility as being alert, oriented and interviewable, revealed that mail was not delivered on Saturday. In an interview on 04/09/25 at 01:30 PM, the Administrator said the facility delivered mail to residents on the weekend. He said on Saturday it was the responsibility of the weekend receptionist and the Managers on Duty to ensure that residents received their mail. The Administrator said the MODs rotated who worked on the weekend and they consisted of the MDS Nurse, Administrator, Business office Manager, Activity Director, and the HR Staff. In an interview on 04/09/25 at 01:32 PM, the Activities Director said she had worked for the facility for 4 years and worked alternating weekends as a MOD. She said she did not know where mail was kept and ensuring residents received mail on the weekend was not one of the assigned duties of the MOD. In an interview on 04/09/25 at 01:35 PM, the HR staff said she had worked in the facility since 1989 and worked as a MOD on alternating weekends. She said passing mail on the weekend was the responsibility of the receptions because she did not go to the lobby area. She said ensuring residents received mail on the weekend was not one of the MOD's responsibilities. In an interview on 04/09/25 at 01:43, the Receptionist said she worked as the receptionist on some weekends, and she never passed out mail. She said the other weekend receptionist was new and she did not pass out mail either because she did not know where the mail went. She said it was the facility's policy/procedure to hold mail that arrived on Saturday to be delivered with Monday's mail. In an interview on 04/09/25 at 01:45 PM, the Social Worker said she had worked for the facility for 4 months. She said she was a MOD on alternating weekends, and she had never delivered mail. The social worker said she had not received any education from administration that mail had to be delivered on the weekend. In an interview on 04/11/25 at 01:08 PM, the Administrator said there were no physical risk to residents if they did not receive their mail on Saturday. He said the failure to deliver mail on Saturday could result in an emotional risk of resident's feeling like they are being let down. Record review of the undated facility policy Mail and Electronic Communication revealed, 4- mail and packages will be delivered to the resident within 72 hours of delivery on premises or to the facility's post office box (including Saturday deliveries).

43049 Based on observation, interview, and record review the facility failed develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, which include measurable objectives and timeframes to meet resident's medical and nursing, needs for 3 of 7 residents (Residents #52, #59, #16) reviewed for comprehensive patient centered care plans. - The facility failed to develop a care plan that addressed Resident #52's dietary interventions to address low body weight and promote weight gain. - The facility failed to ensure Resident #16 and #59's care plans documented goals and interventions for hypertension. This failure could place residents at risk of weight loss and deteriorating health. This failure could place residents at risk of unsafe blood pressures and not receiving proper care and services. Findings included: Resident #52: Record review of Resident #52's Face Sheet dated 04/09/25 revealed, a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses which included: high blood pressure, diabetes, kidney failure and dementia with agitation. Record review of Resident #52's Quarterly MDS dated [DATE] revealed, severely impaired cognition as indicated by a BIMS of 02 out of 15, height of 5 feet and 6 inches and weight of 119 pounds. She had a mechanically altered diet (change of food texture such as pureed food and thickened liquids to ease swallowing). Record review of Resident #52's undated care plan revealed, no documented dietary orders or interventions. An observation on 04/08/25 at 09:15 AM revealed, Resident #52 in bed under her sheets with fall mats on the floor. The resident was in no immediate distress, she was confused, frail, and skinny. In an interview on 04/10/25 at 11:20 AM, the MDS Nurse said she was responsible resident care plans, but the information was an interdisciplinary process. She said care plans should address all the resident's diagnoses and failures, fail to do so could lead to staff not knowing how to provide care for the resident. In an interview on 04/11/25 at 07:55 PM, the Dietician said she was following Resident #52 because the resident was under weight for her age. She said the resident responded well to the interventions in place and was gaining weight. In an interview of 04/11/25 at 12:15 PM, the MDS Nurse said if a resident was under weight and received interventions to gain weight the resident should have a dietary plan under the nutrition section of the comprehensive care plan. In an interview on 04/11/25 at 12:26 PM, the DON said since Resident #52 was considered underweight and received interventions to gain weight it should be noted in her care plan. She said failure to accurately assess residents could place them at risk of not having their needs met and worsening of health conditions. Record review of Resident #52's dated 03/21/25 at 04:13 PM completed by the Dietician revealed, weight gain. The resident's BMI was 19.4 and she was underweight for her age. Resident #52 had 20.2% weight gain in the last 180 days. Resident #52 was on a fortified diet ( adding nutrients to food to improve its nutritional content of food) and received House Shakes ( a nutritional supplement for residents with health concerns) three times daily. Record review of Resident #52's Weight Summary dated 04/09/25 revealed: 04/04/25 124.4 Lbs Standing 03/06/25 120.2 Lbs Standing 02/06/25 121.0 Lbs Standing 01/06/25 119.0 Lbs Standing 12/06/24 115.0 Lbs Standing 11/22/24 110.0 Lbs Standing 11/15/24 105.0 Lbs Standing 11/08/24 100.0 Lbs Standing 11/01/24 102.8 Lbs Standing 10/25/24 107.4 Lbs Standing 10/18/24 100.0 Lbs Standing Record review of Resident #52's Order Summary dated 04/09/25 revealed, Regular diet Mechanical Soft texture, Regular consistency, mech soft as tolerated per hospice, fortified foods at all meals start date 11/21/24. House Shake three times a day start date 12/18/24. Record review of the facility undated policy titled Weight Monitoring revealed, Information gathered from the nutritional assessment and current dietary standards of practice are used to develop an individualized care plan to address the resident's specific nutritional concerns and preferences. The care plan should address the following, to the extent possible: a. Identified causes of impaired nutritional status b. Reflect the president's personal goals and references c. Identify resident-specific interventions d. Time frame and parameters for monitoring e. Updated as needed such as when the resident's condition changes, goals are met, interventions are determined to be ineffective or new causes of nutrition-related problems are identified. f. If nutritional goals are not achieved, care planned interventions will be reevaluated for effectiveness and modified as appropriate. g. The resident and/or resident representative will be involved in the development of the care plan to ensure it is individualized and meets personal goals and preferences. Resident #59 Record review of Resident #59's face sheet dated 04/10/2025 revealed a [AGE] year-old first admitted to the facility on [DATE]. His diagnoses included stroke, and heart disease. Record review of Resident #59's quarterly MDS dated [DATE] revealed a BIMS score of 15 indicating intact cognition. He had impairment to one side of upper and lower extremity. He used a wheelchair for mobility. He required partial assistance with most ADLs. Section I - Active Diagnoses included Hypertension. Record review of Resident #59's physician's orders dated 04/10/2025 revealed an order for Amlodipine 5mg one time a day related to hypertension. Record review of Resident #59's April 2025 MAR indicated he last received Amlodipine 5mg on 4/09/25 at 7:00 AM. Record review of Resident #59's undated care plan revealed hypertension, goals and interventions were not addressed. Resident #16 Record review of Resident #16's face sheet dated 04/10/2025 revealed an [AGE] year-old first admitted to the facility on [DATE] and initially admitted on [DATE]. Her diagnoses included stroke, hypertension (elevated blood pressures), and peripheral vascular disease (a slow progressive disorder of the blood vessels),. Record review of Resident #16's annual MDS dated [DATE] revealed a BIMS score of one out of 15 indicating severe impaired cognition. She was dependent on assistance from staff for most ADLs. She was always incontinent of urine and frequently incontinent of bowel. Section I - Active Diagnoses included Hypertension. Record review of Resident #16's physician orders dated 04/10/2025 revealed an order for Amlodipine 5mg one time a day related to hypertension. Carvedilol 6.25mg one tablet two times a day for hypertension. Losartan 25mg daily related to hypertension. Record review of Resident #16's April 2025 MAR indicted she last received Amlodipine 5mg on 04/09/25 at 9:00 AM, Carvedilol 6.25mg on 04/09/25 at 8:00 AM and Losartin 25mg on 04/09/25 at 8:00 AM. Record review of Resident #16's undated care plan revealed hypertension, goals and interventions were not addressed. Interview on 04/10/25 at 11:00 AM, the MDS nurse stated the care plan was a reference guide and provides information if the resident was at high risk or if there is anything specific to watch out for. She stated she used an MDS tool kit, the residents' diagnoses, resident medications, and every extra information to help develop the MDS and care plan. She stated she used clinicals or hospital records and mainly uses the diagnoses. She stated the MDS does trigger the care plan. She stated whatever triggered she would include in the care plan. She stated if the resident has HTN or cardiovascular disease, it would be in the care plan. She stated if a resident receives anti-hypertensives at the facility, she would need to actively check the medication list. She stated it would not be a trigger from the cause section of the MDS. She stated it was important to care plan so the staff would know to monitor BPs and to be aware of s/sx of cardiac issues. She stated she did not know why Resident #16 and #59's care plans did not address hypertension and moving forward she would need to actively update the care plans. Interview on 04/10/25 at 12:17 PM, the DON stated the purpose of the care plan was to let everyone know what type of care to provide for the resident. The DON stated she initiated the care plan with new admits, MDS nurse and nursing would be responsible for the care plan as well. She stated if a resident had a diagnosis of hypertension, it should be in the care plan. She stated Resident #16 and #59's hypertension was most likely overlooked. She stated not everyone would be aware the resident had hypertension in case a crisis happened if hypertension were not addressed in the care plan. The DON stated going forward she would need to follow up on the care plans for Resident #16 and #59. Record review of the facility undated policy titled Comprehensive Care Plan revealed, It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs and ALL services that are identified in the resident's comprehensive assessment and meet professional standards of quality Policy Explanation and Compliance Guidelines: .3. The comprehensive care plan will describe, at a minimum, the following: a. The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being .

Based on observation, interview, and record review the facility failed to accurately assess each resident's status for 2 of 8 resident (Resident #57 and Resident #68) reviewed for accuracy of assessments. - The facility failed to document Resident #57s lower extremity impairment in the resident's Quarterly MDS - The facility failed to document Resident #68's use of corrective lenses in the resident's quarterly MDS This failure could place residents at risk of inaccurate assessments, which could compromise their plan of care . Findings included: Resident #57 Record review of Resident #57's Face Sheet dated 04/09/25 revealed, an [AGE] year-old female who admitted to the facility on [DATE] with diagnosis which included: muscle wasting, muscle weakness, lack of coordination, depression, and other reduced mobility. Record review of Resident #57's Admission MDS dated [DATE] revealed, resident was rarely/never understood, rarely/never understood others, had severely impaired vision. She had moderately impaired cognitive skills for daily decision making and had an acute onset mental status change as indicated by inattention, disorganized thinking, and altered level of consciousness. The resident's functional abilities such as roll left to right, sit to lying sit to stand and transfers could not be assessed due to her medical condition or a safety concern. The MDS said Resident #57 did not have an upper extremity (shoulder, elbow, wrist, hand) or lower extremity (hip, knee, elbow, wrist, hand) impairment. Record review of Resident #57's Quarterly MDS dated [DATE] revealed, severely impaired cognition as indicated by a BIMS score of 00 out of 00, rarely/never understood others, rare/never makes self-understood, had signs and symptoms of delirium( a state of confusion due to medical conditions) which included inattention and altered level of consciousness. Resident #57's was dependent on staff to roll from her back to the left and right side, and she could not be assessed for her ability to move from sit to lying, sit to stand, transfer herself or walk due to her medical conditions or safety concern. The MDS said Resident #57 did not have a upper extremity (shoulder, elbow, wrist, hand) or lower extremity (hip, knee, elbow, wrist, hand) impairment. Record review of Resident #57's Undated Care Plan revealed, Focus- resident wears Glasses due to Glaucoma(group of eye conditions that damage nerves in the eye that can lead to vision loss and blindness). Focus- resident is hard of hearing and wears hearing aids on both ears. An observation on 04/08/25 at 09:35 AM revealed, Resident #57 in bed well dressed, well-groomed in no immediate distress. The resident was on her left side, with legs contracted below her knees and pillows/wedges were placed around her. Resident #57 was non-responsive to the surveyor, looked at the ceiling and did not respond to the surveyors prompts or presence. An observation on 04/09/25 at 10:30 AM with the Wound Care Nurse revealed, Resident #57 lying on her left side. Both of the resident's knees were contracted and she had a pillow between her knees, bilateral (both sides) heal protection boots and the Wound Care Nurse placed a wedge behind the resident's back. In an interview on 04/10/25 at 09:32 AM, LVN B said she was Resident #57's admitting nurse in December of 2024 and when the resident arrived, she was bedbound, lying on her left side with bilateral (both sides) contractures to her lower extremity. In an interview on 04/10/25 at 09:55 AM, the Wound Care Nurse said when Resident #57 admitted to the facility in December of 2024 she had lower extremity contractures. Resident #68 Record review of Resident #68's Face Sheet dated 04/10/25 revealed, an [AGE] year-old man who admitted to the facility on [DATE] with diagnosis which included: high cholesterol, high blood pressure, unsteadiness on feet and a history of falling. Record review of Resident #68s Quarterly MDS dated [DATE] revealed, intact cognition as indicated by a BIMS score of 13 out of 15, moderate difficulty hearing with the use of hearing aids and impaired vision with no corrective lenses. Record review of Resident #68's undated Care Plan revealed, Focus- hard of hearing and wears hearing aids on both ears, intervention- encourage resident to wear hearing aids daily to promote good communication. Focus: impaired visual function wears glasses related to glaucoma ( a group of eye diseases that damage the nerve in the eye that carries information from the eye to the brain). An observation on 04/11/25 at 09:20 AM revealed, Resident #68 in his wheelchair by his bed. The resident had on glasses as he read from a bible placed on his bed. In an interview on 04/10/25 at 11:20 AM, the MDS Nurse said the purpose of the MDS was to capture every aspect of care the resident received while at the facility. She said it was an interdisciplinary process with multiple parties' inputs, but she did the data review to ensure accuracy. She said Resident #68 wore glasses and Resident #57 was bed bound with contractures and it should have been documented in their MDS and Care Plans. She said failure to complete the MDS accurately could result in inaccurate billing and an inaccurate description of the resident. In an interview on 04/11/25 at 12:26 PM, the DON said Resident #57 admitted with contractures that led to a lower extremity functional impairment which had not changed since the resident admitted . She said she expected Resident #57's MDS to include her functional impairment to both legs and her diagnosis to include contractures but she does not believe it was in the resident's record. The DON said Resident # 68 wore glasses and his MDS should say he wore corrective lenses. She said failure to accurately assess a resident could place them at risk of not having their needs and worsening of health conditions. Record review of the undated facility policy titled Conducting an Accurate Resident Assessment revealed, the purpose of this policy is to assure that all residents receive an accurate assessment, reflective of the resident's status at the time of the assessment, by staff qualified to assess relevant care areas. Accuracy of assessment means that the appropriate, qualified health professionals correctly document the resident's medical, functional, and psychosocial problems and identify resident strengths to maintain or improve medical status, functional abilities, and psychosocial status using the appropriate Resident Assessment Instrument (RAI) (i.e., comprehensive, quarterly, significant change in status). 2. Qualified staff who are knowledgeable about the resident will conduct an accurate assessment addressing each resident's status, needs, strengths, and areas of decline. The assessment will be documented in the medical record. 5. Information provided by the initial comprehensive assessment establishes baseline data for the ongoing assessment of resident progress.

Based on observation, interview and record review the facility failed to ensure drugs and biologicals used in the facility were labeled in accordance with currently accepted professional principles, and included the appropriate professional principles, and included the appropriate accessory and cautionary instructions, and the expiration date when applicable for 1 of 8 residents (Resident #35 ) and 2 of 3 medication carts ( Front Hall nursing Cart & Station 1 Med Cart) reviewed for drug labeling and storage. - The facility failed to ensure the Front Hall Nursing Cart did not contain Resident #35's open and in-use bottle of Oxcarbazepine, a seizure medication, with no open date. - The facility failed to ensure the Station 1 Med Cart did not contain Aspirin with no visible expiration date. These failures could place residents at risk of adverse medication reactions and drug diversions. Findings included: Front Hall Nursing Cart Record review of Resident #35's face sheet, dated 04/11/25, revealed a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #35 had diagnoses which included: type 2 diabetes, unspecified convulsions, and epilepsy (a brain disorder characterized by recurrent, unprovoked seizures). Record review of Resident #35's Quarterly MDS, dated [DATE], revealed the resident had a seizure disorder or epilepsy and had a feeding tube. Record review of Resident #35's, undated, Care Plan revealed focus- resident is on seizure medication for seizure management for epilepsy; intervention- administer anticonvulsant medications as prescribed. Record review of Resident #35's Physician Order dated 12/05/24 revealed Oxcarbazepine 300 MG/5 mL- Give 5 mL via G-tube two times a day for unspecified convulsions. In an observation on and interview 04/09/25 at 10:20 AM, inventory of the Front Hall Nurse Cart with LVN D revealed: - An open and in-use bottle of Oxcarbazepine liquid for Resident #35 with no open date and manufactures instructions to use within 7 weeks of first opening the bottle. LVN E said staff were expected to check their carts daily as used for expired and inappropriately labeled medications. She said multidose containers should be labeled with the date opened to track their expiration date. LVN E said if there was no open date the medication should not be used because it was considered expired. LVN E said when medications expired, they became ineffective and if used could place residents at risk of side effects, so they were immediately pulled from use, and discarded. Station 1 Med Cart In an observation and interview on 04/09/25 at 10:55 AM, inventory of the Station 1 Med Cart with MA A revealed an open and in use bottle of Aspirin 325 mg with no visible expiration date. The expiration date was rubbed off. MA A said nursing staff was expected to check their carts daily for inappropriately labeled medications. She said if the expiration date was not legible the medication should not be used because it could be expired. MA A said when medication expired it lost its potency/efficacy and use could leave resident at risk for untreated health conditions. In an interview on 04/09/25 at 11:35 AM, the DON said nursing carts should be checked for expired and inappropriately labeled medication daily as used. She said all medications must have expiration dates and multidose containers must be dated when opened to track its expiration date. She said if a multidose container did not have an open date, it could not be used because it could be expired. The DON said when a medication expired it could lose its efficacy so it should be taken off the cart and placed in the drug disposal bin. She said if expired medications were used, they could place residents at risk for worsening of health conditions and side effects like upset stomach. Record review of the facility's, undated, policy titled Labeling of Medications and Biologicals revealed, 4. Labels for individual drug containers must include: a. The resident's name; b. The prescribing physician's name; c. The medication name (generic and/or brand name); d. The prescribed dose, strength, and quantity of the medication; e. The prescription number (if applicable); f. The date the drug was dispensed; g. Appropriate instructions and precautions (such as shake well, take with meals, do not crush, special storage instructions); h. The expiration date when applicable; i. The route of administration.

Based on observation, interview and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for one of one kitchen reviewed for dietary services. The facility failed to ensure foods were sealed, labeled, or dated while in storage. This failure could place residents at risk of foodborne illness. Findings include: Observation of the kitchen on 4/8/2025 at 9:10 AM revealed the following: - the freezer contained an opened box, which was undated and unsealed bag of fully cooked chicken and cheese filling in a flour tortilla and an open box, which was undated, unsealed bag of breaded pork fritter patties. Observation of the kitchen on 4/9/2025 at 9:10 AM revealed the following: - the freezer contained an opened box, which was undated and unsealed bag of wavy lasagna sheet pasta. In an interview on 04/08/2025 at 9:10 AM with the Dietary Manager, she stated the importance of keeping food resealed and dated was to ensure the freshness of foods and keeping contaminants out of the food that was stored. In an interview on 04/09/2025 at 11:40 AM with the Dietary Manager, she stated the importance of keeping food resealed and dated was to ensure the freshness of foods and protecting the food from contaminants and was disappointed to find the package opened in the freezer today. In an interview 04/09/2025 at 11:45 AM with the Dietician, she stated the importance of keeping food resealed and dated was to ensure the freshness of foods and keeping contaminants out of the food that was stored. Record review of the facility's policy on Food Safety Requirements reflected .Storage of food in a manner that helps prevent deterioration or contamination of the food, including from growth of microorganisms Record review of the facility's policy on Date Marking for Food Safety reflected .The facility adheres to a date marking system to ensure the safety of ready-to-eat, time/temperature control for safety food

Based on observations, interviews, and record reviews the facility failed to ensure residents were free of significant medication error for two of seven residents (Resident #59 and #16) reviewed for significant medication errors. -The facility failed to ensure that MA B did not administer anti-hypertensive medications to Resident #59 and #16 based on BPs and pulse results obtained 1.5 hours prior to administration. This failure places residents at risk of discomfort or jeopardizing his/her health and safety. Findings include: Record review of Resident #59's face sheet, dated 04/10/2025, revealed a [AGE] year-old who was first admitted to the facility on [DATE]. His diagnoses included stroke, swallowing disorder, one sided paralysis on one side of the body , abnormal liver function vitamin deficiency, Hyperlipidemia (a condition that causes the high levels of lipids, or fats in the blood), heart disease, muscle weakness, and unsteady on feet. Record review of Resident #59's quarterly MDS, dated [DATE], revealed a BIMS score of 15, which indicated intact cognition. He had impairment to one side of upper and lower extremity. He used a wheelchair for mobility. He required partial assistance with most ADLs. Section I - Active Diagnoses included Hypertension. Record review of Resident #59's physician's orders, dated 04/10/2025, revealed an order for Amlodipine 5mg one time a day related to hypertension, hold for SBP<110 (the top number of the BP reading, measures the pressure in your arteries when the heart beats and pumps out blood), DBP<55(the bottom number of the BP reading, measures the pressure in the arteries when the heart is resting between beats), HR<55. Order start date was 09/19/24. Record review of Resident #59's April 2025 MAR revealed on 4/09/25, MA B documented administration of Amlodipine 5mg at 9:00 AM. The documented BP was 179/92 and pulse 73. Record review of Resident #59's, undated, BP summary revealed on 4/09/25 at 6:00 AM, BP was 179/62, in a lying position, using the left arm and recorded by MA B. Record review of Resident #59's, undated, pulse summary revealed on 4/09/25 at 6:00 AM, pulse was 72 bmp (beats per minute), regular and recorded by MA B. Observation on 04/09/25 at 7:35 AM of Resident #59's 8:00 AM medication pass revealed MA B administered Amlodipine 5mg oral tablet. MA B did not check Resident #59's BP and pulse prior to administration. Record review of Resident #16's face sheet, dated 04/10/2025, revealed an [AGE] year-old who was first to the facility on [DATE] and initially admitted on [DATE]. Her diagnoses included stroke, malnutrition, dementia, hypertension (elevated blood pressures), peripheral vascular disease (a slow progressive disorder of the blood vessels), Hyperlipidemia - a condition that causes the high levels of lipids, or fats in the blood), hypothyroidism (underactive thyroid gland) and adult failure to thrive (a gradual decline in health and functional abilities). Record review of Resident #16's annual MDS, dated [DATE], revealed a BIMS score of one out of 15, which indicated severe impaired cognition. She was dependent on assistance from staff for most ADLs. She was always incontinent of urine and frequently incontinent of bowel. Section I - Active Diagnoses included Hypertension. Record review of Resident #16's physician orders, dated 04/10/2025, revealed an order for Amlodipine 5mg one time a day related to hypertension, hold for SBP<110, DBP<60, HR<60. Order start date was 10/08/24. Carvedilol 6.25mg one tablet two times a day for hypertension. Order start date was 12/31/24. Losartan 25mg daily related to hypertension, hold for SBP<110, DBP<60, HR<60. Record review of Resident #16's April 2025 MAR revealed on 4/09/25, MA B documented administration of Amlodipine 5mg at 9:00 AM. The documented BP was 189/92 and pulse 92. Losartan 25mg was documented as given at 8:00 AM. The documented BP was 189/92 and pulse 92. Carvedilol 6.25 mg was documented as given at 8:00 AM. The documented BP was 189/92 and pulse 92. Record review of Resident #16's, undated, BP summary revealed on 4/09/25 at 5:57 AM, BP was 189/62, in a lying position, using the left arm and recorded by MA B. Record review of Resident #16's, undated pulse summary revealed on 4/09/25 at 5:57 AM, pulse was 92 bpm regular and recorded by MA B. Observation on 04/09/25 at 7:45 AM of Resident #16's 8:00 AM medication pass, MA B administered Losartan 25mg oral tablet and Carvedilol 6.25mg oral tablet. MA B did not check BP and pulse prior to administration. Interview on 04/09/25 at 11:20 AM, MA B stated she checked Resident #59 and Resident #16's BPs and pulse at 6:00 AM when she started her shift then she passed medications later. , MA B stated a blood pressure medication given one to 2 hours after checking the blood pressure could affect the resident, she guessed and she should have checked the blood pressures just before giving the medications. She did not say how it could affect the residents. MA B stated Resident #16's BPs run high all the time. MA Bstated she did not think using BP results from 1-2 hours prior to administration of a BP medication would be inaccurate Interview on 04/09/25 at 11:35 AM, the DON stated the expectation was the BPs should be checked right then and there when getting ready to administer that resident's BP medication. The DON stated if checked too early the BP could drop by the time the medication was actually administered, especially if it was an anti-hypertensive. The DON stated the nurses and med aides were responsible to follow the physician orders. The DON stated the nursing staff needed to be educated about not using BP results from 1-2 hours prior to administration. Interview on 04/09/25 at 11:53 AM, MA A stated BPs checked 1-2 hours prior to administration could be inaccurate and would not want to bottom out (to an unsafe low reading) the resident's BPs. She stated this was why she would always check her own BPs and not rely on vitals signs, which included BPs checked by someone else. She stated BPs could change in 1 to 2 hours. Interview on 04/09/25 at 12:00 PM, LVN E stated the resident's BPs could drop in 1-2 hours. He stated the BP may not change much but it was best practice to check BP before giving the BP medication. He stated if someone else checked the BP, he would not know what position the resident was in when the BP was checked. He stated it would not be following the 5 rights of administering medications if the BP was checked hours before administration. Interview on 04/10/25 at 8:17 AM, MA B stated she received training on medication administration about 2 years ago when she transferred from working as a CNA on the floor to the medication aide position. Interview on 04/10/25 at 1:55 PM, the Medical Director stated BPs should be checked within 5 to 10 minutes of the medication administration. The Medical Director stated he would not recommend using results from 1 to 2 hours prior to determine administration of the BP medication because it was important if the BP was low the medication would need to be held to prevent hypotension or bradycardia (drop in heart rate). Record review of the facility's policy and procedures for Medication Administration with the copyright date of 2024, read in part: .Medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection. Policy Explanation and Compliance Guidelines .8. Obtain and record vital signs, when applicable or per physician orders. When applicable, hold medication for those vital signs outside the physician's prescribed parameters .Example guidelines for Medication Administration (unless otherwise ordered by physician), this list is not all-inclusive .Medication requiring vital signs prior to administration .Anti-Hypertensives

Based on observation, interview and record review the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff and the public for 1 of 1 Med Rooms (Station 1 Med Room ) reviewed for environment. -The facility failed to ensure the Station 1 Med Room Insulin Refrigerator did not have mildew growing in it. These deficient practices could place residents at risk of injury from exposed nails and/or infections and adverse reactions from contaminatd medications. The findings included: An observation and interview with LVN E on 04/09/25 at 10:35 AM revealed the temperature of the insulin fridge in the Station 1 Med Room was 34 degrees Fahrenheit. There was a puddle of water on the first shelve with a black powdery, flat growth that appeared to be mildew floating in it. LVN E said nursing staff were expected to check the cleanliness of the insulin fridge when they checked the temperature. He said mildew/mold in the insulin fridge could place residents at risk of contamination . In an interview on 04/09/25 at 11:35 AM, the DON said the med rooms should be organized, med refrigerators cleaned, and monitored every shift. She said the nurses and med aids should clean the fridge when there was moisture build up and failure to do so could place residents at risk of contamination of their medications leading to side effects. Record review of the facility's, undated, policy titled Environmental Services Inspection revealed, it is the policy of this facility to regularly monitor environmental services to ensure the facility is maintained in a safe and sanitary manner and assessed on a regular basis. 1. The Director of Environmental Services will perform random and/or routine inspections. 2. All opportunities will be corrected immediately by environmental services personnel.

Based on observation, interview, and record review the facility failed to ensure the resident had the right to be treated with respect and dignity for 1 of 8 residents (Resident #1) reviewed for dignity. - The facility failed to timely empty Resident #80's urinal timely resulting in it backflowing on the resident and the resident emptying it in the trash can at his bedside. This failure could place residents at risk of feeling uncomfortable and disrespected. Findings included: Record review of Resident #80's face sheet dated 04/11/25 revealed, an [AGE] year-old male who admitted to the facility on [DATE] with diagnosis which included: muscle weakness, age related physical debility, and Alzheimer's disease. Record review of Resident #80's Admission MDS dated [DATE] revealed, moderately impaired cognition as indicated by a BIMS score of 10 out of 15, no rejection of care, no verbal or physical behavioral problems, substantial assistance with toileting hygiene and upper body dressing. Resident #80 was not on a toileting program (scheduled toileting, prompted voiding or bladder training), and was always continent of both bladder and bowel. Record review of Resident #80's undated care plan revealed, focus- limited physical mobility or risk for decline with mobility related to impaired mobility and weakness; goal- participate in ADLs to his ability. An observation and interview on 04/08/25 at 09:10 AM revealed, Resident #80 in bed. There was a male urinal on his bed side table with a small amount of dark yellow fluid, and dark yellow fluid was observed in the bedside trash can. Resident #80 said sometimes staff were slow to respond to his call light or providing services especially when it came to his urinal. He said the staff did not empty his urinal often so he was forced to dump it in a cup in his trash can and sometimes he missed which made staff upset with him. Resident #80 said he dumped his urine into the trash can because he could not use his urinal when it was high because it would backflow onto him. Resident #80 placed a finger on his urinal at approximately 1/4 full to indicate what volume of fluid the container held when it began to backflow on him if used. Resident #80 said has urinal was on top of his bedside table because he had nowhere else to place it. An observation and interview on 04/11/23 at 07:45 AM revealed, Resident #80 in his room with his urinal 1/8 full, no liquid was observed in his trash can. Resident #80 said he notified the facility when his urinal was approximately 1/4 full. He said at 1/4 full it had to be emptied if not it would backflow on him when he used it, which he did not like. In an interview on 04/11/25 at 07:51 AM, CNA A said she cared for Resident #80. She said Resident #80 would pour urine into a Styrofoam cup provided for water and place it in his trash can, but she had not asked the resident why he did this. She said the facility did not require urinals to be emptied at any frequency or at any particular volume, but they should be emptied urinals whenever they needed to be emptied. CNA A said both nurses and CNAs are responsible for emptying resident urinal, and she herself emptied resident urinals every hour. She said urinals should be emptied timely to prevent cross contamination and prevent bacteria growth. In an interview on 04/11/25 at 04/11/25 at 08:38 AM, LVN C said Resident #80 liked to keep his urinal at his bedside table. She said the resident's behaviors included emptying his urinal into a cup in his trash can and sometimes It would spill. LVN C said when the urine spilled the resident would get aggravated. She said resident did not always use his call bell when he needed his urinal emptied so she emptied it when was in his room. LVN C said it was the responsibility of all nursing staff to empty residents' urinals when they were in the resident's room providing care and the facility did not have a particular frequency. She said she had not received any complaints from the resident regarding delays in emptying his urinal or it backflowing on him. LVN C said failure to promptly empty a resident's urinal could place them at risk of spilling it on themselves leading to skin irritation and the resident might not like it. In an interview on 04/11/25 at 12:26 PM, the DON said resident urinals are usually kept at their bedside, on the nightstand, or drawer handle so they are easily accessible. She said CNAs and Nurses round on residents frequently and they are expected to empty urinals when they are half full or less and placed within reach of the resident. The DON said the facility does not have a specified frequency to which urinals should be emptied as it depended on the resident's pattern, but staff are expected to check on residents at least every 2 hours. She said failure to empty a resident's urinal frequently could result in spills during use, odors and leave the resident not too happy. The DON said she had not heard about Resident #80 emptying his urinal into a cup in the trash can, and if such behaviors existed it should have been documented in the resident's chart. On 04/02/25 at 12:26 PM, at the end of an interview a request was made to the DON for the facility policy on incontinence care. The policy was not provided prior to exit. Record review of the undated facility policy Resident Rights revealed, The resident has the right to a dignified existence. 4- Respect and dignity, the resident has a right to be treated with respect and dignity. Record review of the undated facility policy Promoting/Maintaining Resident Dignity revealed, It is the practice of this facility to protect and promote resident rights and treat each resident with respect and dignity as well as care for each resident in a manner and in an environment, that maintains or enhances resident's quality of life by recognizing each resident's individuality. Compliance guidelines: 1. All staff members are involved in providing care to residents to promote and maintain resident dignity and respect resident rights. 2. During interactions with residents, staff must report, document and act upon information regarding resident preferences. 4. The resident's former lifestyle and personal choices will be considered when providing care and services to meet the resident's needs and preferences.

Based on observations, interviews, and record review, the facility failed to ensure residents had a safe and homelike environment, including but not limited to receiving treatment and support for daily living safely for 1 of 8 residents reviewed (Resident #62) reviewed for a homelike environment. - The facility failed to ensure the bump rail located by window of Resident #62's room was attached to the wall without nails sticking out and the wall trim was not missing. This failure could place residents at risk of decreased feelings of self-worth, emotional destress, and physical injury. Findings included: Record review of Resident #62's Face Sheet revealed, a [AGE] year-old female who admitted to the facility on [DATE] with diagnosis which included: muscle weakness, lack of coordination, anxiety disorder and mild intellectual disabilities. Record review of Resident #62's Quarterly MDS dated [DATE] revealed, moderately impaired cognition as indicated by a BIMS score of 12 out of 15. She had no hallucinations, no physical or verbal behavioral symptoms, no rejection of care, no wandering behaviors and used a walker. Record review of Resident #62's undated Care Plan revealed, focus- resident wished to continue to reside at the facility for long term care. Focus- psychosocial ( social factors that impact a person's mind) problem related to depression; intervention- encourage participation and involvement in resident's preferred, scheduled, and alternate activities offered in the facility. An observation and interview on 04/08/25 at 09:30 AM revealed, Resident #62 sitting in bed. The resident was well dressed, well-groomed and in no immediate distress. She said her room needed improvement and pointed out the missing trim close to the floor and a dislodged bump rail with 3 nails sticking out at the bottom of the wall by her roommate's bed. She said she reported the missing trim and broken bump rail to social services and the DON , but nothing was done. She said she understood that to the staff this was just a job but to her and others this was their home, and it should not be like that. In an interview on 04/09/25 at 11:00 AM, the Administrator said there were no associated grievances from Resident #62 regarding repairs to the trim or bump rail in her room and he was never notified In an interview on 04/09/25 at 11:05 AM, the Administrator said he walked the facility with the Maintenance Director Weekly. He said the weekly inspection involved checking all resident rooms from ceiling to floor to identify any necessary repairs. The Administrator said any identified issues were entered into the facility maintenance system and then immediately repaired. He said he performed the weekly walk last Tuesday(04/02/25) and this was the first time he saw the dislodged bump rail so it must have just happened. The Administrator said the dislodged bump rails with the exposed nails could place residents at risk for wounds or injuries. In an interview on 04/09/25 at 01:47 PM, the Maintenance Director said he rounds on resident rooms twice a week to ensure all rooms are in good order. He said facility was the residents' home, so he wanted them to be happy and comfortable. He said he last did rounds in resident rooms last Thursday (04/03/25) and the bump rail in room [ROOM NUMBER] was not dislodged. The Maintenance Director said all bump rails/chair rails were expected to be secured to the wall and the dislodged bump rail with exposed nails was a safety issue because residents could cut themselves. In an interview on 04/10/25 at 09:30 AM, Resident #62 said the trim and bump rail was dislodged from out of the wall since she started living in the facility a year ago. She said she notified the Administrator but not action had been taken. Record review of the undated facility policy titled Environmental Services Inspection revealed, it is the policy of this facility to regularly monitor environmental services to ensure the facility is maintained in a safe and sanitary manner and assessed on a regular basis. 1. The Director of Environmental Services will perform random and/or routine inspections. 2. All opportunities will be corrected immediately by environmental services personnel.

Based on observation, interview, and record review the facility failed to ensure the resident received treatment and care in accordance with professional standards of practice, for 1 of 8 residents (Resident #67) reviewed for Quality of Care. -The facility failed to initiate the facility fall procedure after the state surveyor reported the suspect fall of Resident #67 to the DON. This failure could place residents at risk for pain and injury. Findings included: Record review of Resident #67's Face Sheet dated 04/10/25 revealed, a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses to include: muscle wasting, and unspecified lack of coordination. Record review of Resident #67's Quarterly MDS dated [DATE] revealed, intact cognition as indicated by a BIMS score of 15 out of 15, and the resident had 2 falls since the prior assessment in which she suffered no injury. Record review of Resident #67's undated Care Plan revealed, focus- resident was at high risk for falls related to impaired mobility/weakness; intervention 01/30/25 bed in lowest position and fall mat on the right side of bed. An observation and interview on 04/08/25 at 09:45 AM revealed, Resident #67 had a fall mat on the right side of her bed and the resident's bed was low to the ground. The resident sat up in her bed with her feet on the floor. Resident #67 said she thought she fell last night but did not remember if she reported it to the staff. The resident had no visible bruises or injuries and appeared to be alert and oriented. In an interview and observation on 04/08/25 at 09:48 AM, the surveyor notified the DON that Resident #67 reported she thought she fell the previous night. The DON said Resident #67 was under fall protocols, had multiple falls in the past but the resident was confused and she probably did not fall because she did not hear anything about it. The DON left the surveyor and entered Resident #67's room. In an interview on 04/10/25 at 10:21 AM, the DON said when she interviewed Resident #67 the resident said the fall might have happened in her dream, so she treated it like it did not happen. She said she did not implement the facility fall protocol, she did not treat it as an unwitnessed fall, and she did not initiate physical or neurological assessments An observation and interview on 04/11/25 at 08:10 AM revealed, Resident #67 on her right side in bed. The resident was alert and oriented with no visible bruising. Resident #67 said she had falls in the past, mostly in the bathroom, and when she fell the facility checked on her. The resident appeared confused and said she did not remember falling on 04/07/25 and she did not remember notifying any staff or member of the survey team that she fell during the current week. In an interview on 04/11/25 at 12:26 PM, the DON said immediately after a fall staff are expected to initiate the facility fall procedure. Nursing staff assessed the resident for injuries and if there were no injuries the resident is transferred back into bed safely and notifications were sent to the MD, DON, and family. She said all falls should be documented in an accident/incident report and the resident's progress notes. The DON said if the fall was unwitnessed, neuro checks should be initiated immediately at set frequency to assess for altered mental status that could be associated with a head injury. She said once the surveyor notified her that Resident #67 fell , she talked to the resident who appeared confused and the resident said she did not think she fell , and she fell in her dream. The DON said she observed nothing was wrong with the resident, so she did nothing. She did not initiate neuro checks, did not do a formal assessment, and did not do an accident/incident report. The DON said she should have treated it like a fall and initiated the facility fall protocol. She said failure to take immediate action following the fall could put residents at risk for unidentified injuries, altered mental status and decreased mobility. Record review of Resident #67's Clinical Assessments revealed, no fall assessments or neuro checks were completed on 04/08/25 through 04/10/25. Record review of Resident #67's Progress notes revealed, there was no documentation of a suspected fall from 04/07/25 through 04/09/253. Record review of Resident #67's Progress note dated 04/10/25 at 11:31 AM the DON wrote Data : Notified of recent unwitnessed fall. During interview resident actually denied falling, stated I don't think I fell , I think I was dreaming. Resident denies pain, headache, dizziness at this time. Action : Assessment completed with PERRLA within baseline. PT/OT screening for safe transfer evaluation. MD/RP notified Response : Will continue to monitor. Record review of the undated facility policy titled Fall Prevention Program revealed, A fall is an event in which an individual unintentionally comes to rest on the ground, floor, or other level, but not as a result of an overwhelming external force (e.g., resident pushes another resident). The event may be witnessed, reported, or presumed when a resident is found on the floor or ground, and can occur anywhere. 9. When any resident experiences a fall, the facility will: a. Assess the resident. b. Complete a post-fall assessment. c. Complete an incident report. d. Notify physician and family. e. Review the resident's care plan and update as indicated. f. Document all assessments and actions. g. Obtain witness statements in the case of injury. Record review of the undated facility policy titled Incidents and Accidents revealed, 5. The following incidents/accidents require an incident/accident report but are not limited to . oFalls, o Medication or treatment errors oObserved accidents/incidents. 6. In the event of an incident or accident, immediate assistance will be provided, or securement of the area will be initiated unless it places one at risk of harm. 7. Any injuries will be assessed by the licensed nurse or practitioner and the affected individual will not be moved until safe to do so. First aid will be given for minor injuries such as cuts or abrasions. 10. In the event of an unwitnessed fall or a blow to the head, the nurse will initiate neurological checks as per protocol and document on the neurological flow sheet. Abnormal findings will be reported to the practitioner. 12. The nurse will enter the incident/accident information into the appropriate form/system within 24 hours of occurrence and will document all pertinent information. 13. Documentation should include the date, time, nature of the incident, location, initial findings, immediate interventions, notifications, and orders obtained or follow-up interventions.

Based on observation, interview and record review the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for 1 of 8 residents (Resident #42) reviewed for accidents and supervision. -The facility failed to provide adequate supervision to prevent, a bruise, as a result of an injury of unknown origin to Resident #42s sternum (the long flat bone located in the center of the chest). These failures could place residents at risk of minor and major injuries. Findings included: Record review of Resident #42's face sheet, dated 04/11/25, revealed a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #42 had diagnoses which included: type 2 diabetes, paralysis affecting the right side, history of falling, muscle weakness, difficulty walking and high blood pressure. Record review of Resident #42's Annual MDS, dated [DATE], revealed moderately impaired cognition as indicated by a BIMS score of 08 out of 15. Resident #42 had no history of falls. Record review of Resident #42's, undated, Care Plan revealed focus- potential impairment to skin, related falls due to weakness. On 03/24/25 hematoma (a collection of blood outside blood vessels caused by injury or trauma) to the back of the head due to falls. On 03/29/25 swelling bruise to pinky ginger when pinched in the door hinge; intervention- follow facility protocols for treatment of injury. Focus- blood thinning therapy; intervention- take precautions to avoid falls. Record review of Resident #42's Progress Notes from 03/10/25 to 04/08/25 revealed, 03/24/25- resident had a fall and had a bruise and bump on top of her scalp. She complained of pain in her head and neck. Resident #42 was sent out to the ER . There was no mention of bruising to the resident's neck or chest. Record review of Resident #42's electronic record revealed, the resident had skin assessments on: 03/24/25, 03/31/25 and 04/07/25 . Record review of Resident #42's Skin Assessment, completed by the Wound Care Nurse, on 03/24/25, revealed the resident's skin was intact. There were no other comments. Record review of Resident #42's Skin Assessment, completed by the Wound Care Nurse, on 03/31/25, revealed the resident's skin was intact. She had scattered bruising on both hands, no new skin concern. Record review of Resident #42's Skin Assessment completed by the Wound Care Nurse, on 04/07/25, revealed, the resident's skin was intact. She had scattered bruising on both hands, no new skin concern. An observation on 04/08/25 at 09:43 AM revealed Resident #42 was in bed well groomed, in no immediate distress, watching TV. She had scabs on her face and a dark purple bruise with a red edge on her sternum. The resident said she did not know how she got the bruise to her sternum, and nothing happened, but she said the scabs on her face were from picking. Resident #42 did not report pain associated to the bruise, said she had no other bruises and she felt safe in the facility. In an interview on 04/10/25 at 01:25 PM, LVN D said Resident #42's bruise on her chest was there for a while but it occurred when she was not working. She said she thought the bruise was as a result of a fall, but after she reviewed the resident's accident/incident reports she said there was no documentation of Resident #42 having a bruise on her chest. LVN D said the Wound Care Nurse should follow Resident #42 since there were accident/incident reports and the resident had not complained of any pain associated to the bruise. An observation and interview on 04/11/25 at 08:17 AM revealed Resident #42 in bed with a dark blue bruise on her upper sternum with 4 lines going out from the center. She said she did not know how she got the bruise; she denied falling and said maybe she rubbed it with her hand. Resident #42 said the nurse and the DON looked at it on 04/08/25 and were monitoring it daily. In an interview on 04/11/25 at 08:42 AM, the Wound Care Nurse said bruises start off dark purple, then changed to light purple then brown to tan as they healed. She said Resident had a fall in March left her bruised all the way down the side of her chest. The Wound Care Nurse said she did not know about a bruise on the resident's chest but Resident #42 did have a wound on her neck. She said the wound on the sternum was probably followed as a wound on her neck and failure to identify an injury could place the resident at risk of developing a hematoma or nodule (a raised lump that forms when blood pulls under the skin due to an injured blood vessel.) The Wound Care Nurse said she recently assessed Resident #42 and she did not have a nodule. In an interview on 04/11/25 at 12:26 PM, the DON said bruises started as red purple then changed to yellow and then green as they healed depending on the site of the body that was injured. She said Resident #42 had a bruise on her upper sternum that was purple, and it was present on the resident since 04/01/25. The DON said nursing staff were expected to document on a new bruise and continue to document on it daily until it resolved, and the Wound Care Nurse should have documented it on her weekly assessment. The DON said she reviewed Resident #42's chart and there was no documentation of the bruise on the resident's sternum. She said after investigation she believed the failure in documentation was due to the resident's past fall that the staff attributed the bruise to. The DON said based on the documentation in Resident #42's chart it could not be determined when and how the bruise occurred. Record review of the facility's, undated, policy titled Incidents and Accidents revealed, .5. The following incidents/accidents require an incident/accident report but are not limited to . observed accidents/incidents, self-inflected injuries, and unobserved injuries. 6. In the event of an incident or accident, immediate assistance will be provided, or securement of the area will be initiated unless it places one at risk of harm. 7. Any injuries will be assessed by the licensed nurse or practitioner and the affected individual will not be moved until safe to do so. First aid will be given for minor injuries such as cuts or abrasions. 10. In the event of an unwitnessed fall or a blow to the head, the nurse will initiate neurological checks as per protocol and document on the neurological flow sheet. Abnormal findings will be reported to the practitioner. 12. The nurse will enter the incident/accident information into the appropriate form/system within 24 hours of occurrence and will document all pertinent information. 13. Documentation should include the date, time, nature of the incident, location, initial findings, immediate interventions, notifications, and orders obtained or follow-up interventions.

Based on observation, interview and record review the facility failed to provide pharmaceutical services, including procedures that assured the accurate acquiring, receiving, dispensing and administrating of all drugs and biologicals, to meet the needs of each resident for 1 of 1 Med Rooms (Station 1 Med Room) reviewed for pharmacy services. -The facility failed to ensure the Station 1 Medication Room did not contain expired oral Vancomycin (an antibiotic) for Resident #54 and Resident #200. This failure could place residents at risk of not receiving the therapeutic benefit of medications and/or adverse reactions to medications. Findings Include: In observation and interview on 04/09/25 at 10:35 AM, inventory of the Station 1 Med Room with LVN E revealed - An open and in-use bottle of Vancomycin Oral solution for Resident #200 labeled Do Not Use After: 04/07/25 in the refrigerator. - A sealed bottle of Vancomycin Oral Solution for Resident #54 labeled Do Not Use After: 04/07/25 in the refrigerator. LVN E said nurses checked the Med Room daily as used for expired medications. He said the Vancomycin solutions were expired, and they should have been pulled from the refrigerator. He said both Resident #54 and Resident #200 were no longer in the facility and their medications should have been pulled immediately after their discharge . LVN E said when medication were expired there were changes in the chemical structure which made it less effective, or it could become spoiled. He said if residents were administered expired medication, they could experience upset stomach or side effects . In an interview on 04/09/25 at 11:35 AM, the DON said nurses were expected to inspect the med rooms daily to ensure they were clean, orderly, all medications were labeled appropriately, had visible expiration dates, and were not expired. She said when a resident discharged all mediations should be pulled from the med carts and med rooms by the discharging nurse and all expired medications should be removed from the fridge daily as used by all nursing staff. The DON said, when medications expired, they could lose efficacy and use could place residents at risk of upset stomach, side effects or not receiving the therapeutic effect of their medications which could result in worsening of health conditions. Record review of the facility policy titled Storage of Medications revised 11/2020 revealed, 4- discontinued, outdated, or deteriorated drugs or biologicals are returned to the dispensing pharmacy or destroyed. Record review of the facility policy titled Medication Storage in the facility revised 08/2014 revealed, G- all expired medications will be removed from the active supply and destroyed in the facility regardless of the amount remaining. The medication will be destroyed in the usual manner.

Based on observations, interviews, and record review, the facility failed to ensure that a resident who needed respiratory care was provided such care consistent with professional standards of practice for 1 (CR #1) of 5 residents reviewed for respiratory care. - The facility failed to ensure consistent oxygen therapy was provided to CR #1 who was on hospice and a DNR. CR #1 was pronounced deceased at approximately 3:48 p.m. on [DATE]. -The facility failed to respond to CR #1's numerous requests for help for an approximate 2 ,d+[DATE] hour period. -The facility failed to monitor CR #1's oxygen administration via nasal cannula while she was in bed. An Immediate Jeopardy (IJ) was identified on [DATE]. The IJ template was provided to the facility on [DATE] at 12:21 p.m. While the IJ was removed on [DATE], the facility remained out of compliance at a severity level of no actual harm with potential for more than minimal harm and a scope of pattern because all staff had not been trained on [DATE]. This failure placed residents who received oxygen therapy at risk of respiratory complication and/or death. The findings included: Record review of CR #1's Face Sheet, dated [DATE], revealed a [AGE] year-old female whose initial admitted to the facility was [DATE]. Her diagnoses included acute and chronic respiratory failure with hypoxia (not enough oxygen in blood), chronic obstructive pulmonary disease (progressive lung disease) with (acute) exacerbation (sudden worsening of symptoms), and heart failure. Record review of CR #1's Quarterly MDS Assessment, dated [DATE], revealed a BIMS score of 0, indicating severe cognitive impairment. Further review revealed the resident was dependent (the assistance of 2 or more helpers were required for the resident to complete the activity) on eating, toileting, showering/bathing, and dressing. Section O, Special Treatments, Procedures, and Programs, Respiratory Treatments, C1, revealed she was on oxygen therapy. Record review of CR #1's MAR dated, [DATE] - [DATE], revealed an order for oxygen administration at 3 LPM via nasal cannula or BiPAP continuous every shift, start date: [DATE], observation oxygen therapy every shift, start date: [DATE], and ipratropium albuterol inhalation solution every 4 hours, start date: [DATE]. CR #1's MAR reflects she was administered her ipratropium albuterol inhalation solution every 4 hours as ordered. Record review of CR #1's care plan, close date [DATE], revealed the resident had COPD, a history of respiratory failure, and was at risk for shortness of breath and interventions included oxygen as ordered. Further review revealed the resident received oxygen therapy r/t COPD/CHF and removed N/C at will. Interventions included check O2 saturations and provide respiratory treatments as ordered and O2 via NC per physician order. Observation on [DATE] at 7:05 a.m. of several video footage clips, dated [DATE], from approximately 11:46:38 a.m. to 15:30:41 (3:30 p.m.) revealed at 11:46:18 a.m. CR#1 removed her nasal cannula. At approximately 11:57:20 a.m., CNA C entered the room with the resident's meal tray and at approximately 11:59:03 a.m. was no longer in the room; the nasal cannula was still not in place. At approximately 12:30:48 p.m., an unidentifiable staff member walked past the resident and toward the door from the other side of the room; nasal cannula was still not in place. At approximately 12:39:09 p.m. a different unidentifiable staff member entered the room and exited at approximately 12:39:29 p.m.; nasal cannula was still not in place. At approximately 14:09:43 (2:09 p.m.) resident was having stomach breathing and at approximately 14:43:27 (2:43 p.m.) resident begins gasping for air. At approximately 15:28:54 (3:28 p.m.) CNA D found CR #1 unresponsive; nasal cannula was not in place. At approximately 15:28:58 (3:28 p.m.) Nurse A and CNA D were at CR #1's bedside; nasal cannula was still not in place. CR #1 was observed calling out nurse, help, and/or help me numerous times from approximately 12:07:56 p.m. to 14:26:33 (2:26 p.m.) with no response from staff; the nasal cannula was still not in place. Video footage clips did not show any other staff members entering CR #1's room between 12:39 p.m. until 3:28 p.m. During an interview on [DATE] at 7:30 a.m., CNA B said he had been picking up shifts at the facility for less than a year. He said he worked on [DATE] from 6:00 a.m. to 6:00 p.m. and was assigned to CR #1. He said he was familiar with the resident but on [DATE] was the first time he had picked up a shift in a while, approximately longer than 3 months. He said he started his shift by conducting rounds at approximately 6:30 a.m. He said he asked the residents what they needed, what they would like to drink, and passed out drinks for breakfast. He said CR #1 was awake during his first round and she asked him to reposition her in bed, asked for a nurse, and after that she was okay. He said he completed his rounds every 2 hours including before breakfast, after breakfast, before lunch, and after lunch. He said during his rounds he did not notice anything out of the ordinary or abnormal that stood out. He said the resident had to be fed. He said he passed out the resident's breakfast and lunch meals, but she turned down breakfast and took 2 bites out of her lunch and turned down the rest. He said the corner person (listed as CNA D on the nursing schedule) was assigned to his hall and residents when he took his lunch break from 2:30 p.m. to 3:00 p.m. He said CR #1 was still alive when he went on break. He said the resident tended to call out for the nurse and when she did, he would check on her. He said sometimes the resident would need water. He said he never heard the resident call out for the nurse on [DATE]. He said he did not know if the resident was on continuous oxygen and would have to ask the nurse. He said he recalled seeing an oxygen machine and tubing. He said the resident had on the oxygen tubing. He said CR #1's oxygen was on the entire time he was on shift and up until the time she passed away. He said if there was a resident that did not have their oxygen tubing in place, he would notify the nurse. He said he did not recall anyone else helping him out in the hall. He said CR #1 passed away at approximately 1:40ish p.m. During an interview on [DATE] at 8:14 a.m., Nurse A said she worked on [DATE] and one of her assigned residents was CR #1. She said she checked on the resident during her morning rounds but could not recall if she passed by her room door or went inside. She said the resident was awake and alert. She said that day, [DATE], the resident was doing a lot of yelling, but it was her normal behavior when no one was in the room. She said that day she believed the resident started hollering out nurse but did not recall what time it began. She said when the resident started hollering out nurse either another nurse, CNA, herself, or another staff member would go and check on her to see what she needed. She said with CR #1, in general, she would yell out all the time unless she had company, or someone was not with her, or if she just felt like yelling out nurse or help. She said when she did a lot of yelling it was usually an indicator that she was going to have a good day because it was something she normally did. She said she was sure at some point during her shift she went inside the resident's room and checked in on her but did not recall when and said it was hard to separate the days. She said she tried to pay a little more attention to her because she tended to remove her nasal cannula. She said she did not recall if the resident had her nasal cannula on when she checked on her that morning. She said she did not recall if she had to put the residents nasal canula back on because the resident had taken it out. She said every time she walked down the resident's hall, she would peek her head through the doorway to make sure the nasal cannula was on because of her tendency to remove the tubing from her nasal passage. She said she knew the nasal cannula was in place when she passed away. She said she knew this because the airway was the first thing she checked. She said when she was pronounced deceased that was when she took the nasal tubing from her nasal passage, turned the oxygen concentrator off, and disconnected everything. She said it was one of the CNA's that called her into the room but did not recall which CNA. She said once inside the room she assessed the resident, but was unable to get a BP reading, O2 sat with the oximeter, or a pulse. She said she notified Nurse B who pronounced the resident deceased . She said she did not recall if the resident specifically called out help or help me at any point during her shift but did remember the resident calling out nurse. She said the resident would yell most of the day, so any staff checked on her. She said she was not able to personally check on the resident every time she called out nurse because that was impossible but other staff members would check in on her when she called out nurse. She said she would check on her more than every 2 hours in passing or by entering her room, and every time she saw the resident, she had on her nasal cannula. She said she never noticed any labored breathing when she checked in on her. She said there were no significant changes with the resident before she passed away. She said the potential effect of not getting enough O2 to the brain, could cause hallucinations, talking out of their heads, and all the way up to death. During an interview on [DATE] at 10:27 a.m., CNA C said she worked on [DATE] from 6:00 a.m. to 6:00 p.m. She said she and CNA B went inside CR #1's room after breakfast and changed and repositioned her in bed. She said that day [DATE], she was calling out all her kids names and momma. She said CR #1 refused to drink or eat her breakfast. She said when she left the room she still had on her nasal cannula. She said she did not see CR #1 any other time that morning or during lunch. During an interview on [DATE] at 11:10 a.m., CNA D said she stepped in for CNA B when he went on his break, and was watching his hall, but did not recall what time it was or if it was after or before lunch. She said she saw CR #1 during his break. She said CR #1 was propped up in her bed, and her legs were elevated up in the bed a little bit. She said when she was with CR #1, she did not call out for the nurse. She said when she was working the hall, she heard the resident call out 'nurse, nurse, and she went inside her room and asked her what was wrong and she just repeated herself and said nurse, nurse. She said she told Nurse A and Nurse A said she was going down there to her room. She said she never heard the resident call out for help or say help me during this time. She said she checked on the resident approximately 2 times. She said the resident was afraid of being by herself and would call out for the nurse all the time. She said the first and second time she checked on the resident her nasal cannula was on. She said she never noticed her nasal cannula not being on. She said the resident did not sleep very well during the daytime, was always up and active, and sometimes got up and in her wheelchair for lunch and dinner. She said sometime after lunch she was passing drinks when she went inside CR #1's room to give her a drink and said she called her name 2 times, and she did not respond. She said she then ran and got Nurse A because she was not responding. She said once Nurse A arrived in the room she stepped out and stayed by the door but did not have a visual of inside the room. She said another nurse entered the room. She said the resident's nasal cannula was on. During an interview on [DATE] at 2:01 p.m., Nurse B said she probably would have seen her a little after 7 a.m. She said she saw her several times that day because her bed was situated to where you could see her from the doorway. She said the resident says nurse a lot. She said she did not remember her saying nurse that day but remembers her saying hey. She said when she said hey, she got up and got to the top of the hall and saw a CNA going into her room. She said that day there was nothing unusual and the resident was her normal self. She said she could not say she heard her say help or help me on [DATE]. She said she was shocked when staff called her because she did not seem to be at that point of passing away. She said the several times she saw her throughout the day she said the resident had her nasal cannula on. She said she saw her 30 to 45 minutes before the end of her shift. She said she walked past her room and the resident appeared to be fine. She said the resident was awake and fidgeting with her blanket. She said she was headed to clock out at approximately 3:30 p.m. when Nurse A called her name and said it appeared that the resident was no longer breathing. She said she went to the room, the resident was warm to the touch, had no spontaneous breathing, and no rising of the chest. She said the resident was a DNR, she did an examination, and pronounced her deceased . She said at no time during her shift did any CNA tell her that the resident's nasal cannula came out. She said it depended on the clinical status of the resident if there was a potential effect of them not having continuous O2. She said it could potentially lead to a health decline, respiratory distress, but it would depend on their clinical status. During an interview on [DATE] at 2:40 p.m., the DON said CR #1 had an order for continuous O2. She said she was contacted when the resident passed away by Nurse B. She said it was kind of shocking in a way because CR #1 did not have a change in condition that she had been notified about because that was one of the requirements that she must be notified. She said she was notified by Nurse B at approximately 4:09 p.m. that she passed away. She said Nurse B did the protocol of pronouncing her deceased . She said she called Nurse A and was told CR #1 did not have a change in condition, and nothing was out of the ordinary. She said the resident's actions were normal and she would holler out nurse occasionally but that was usual for CR #1. She said Nurse A said it looked like she peacefully went to sleep and had on her oxygen. She said after they pronounced her deceased the concentrator was turned off and they removed the nasal cannula. During an interview on [DATE] at 2:20 p.m., Hospice Nurse B said she last saw CR #1 on [DATE]. She said CR #1 was in her wheelchair, kind of in the entry of her room door, was alert, and nothing about her was unusual and O2 was in place. She said there were definitely no signs of imminent death. During an interview on [DATE] at 2:46 p.m., Hospice Nurse C said she saw CR #1 on [DATE]. She said the resident was in bed, asleep, but easily aroused. She said the resident had no labored breathing and all vitals were normal and O2 was in place. She said she was not actively passing away when she saw her. During a follow-up interview on [DATE] at 8:54 a.m., the NP said she would not know if CR #1 going for approximately 3 ,d+[DATE] hours without her O2 would contribute or cause her death. She said but if someone were to go without O2 for a long period of time they could go into respiratory distress. During an interview on [DATE] at 9:09 a.m., the MD said if the resident did not get O2 for a long period of time, anything more than 1 to 2 hours and depending on her O2 saturation, she would need to be back on O2 to keep closer to at least 92% sat. She said it was hard to say how much time but the brain being deprived of that much O2 could cause brain death. She said there was a possibility that not having the O2 for that period of time could be a contributing factor, but the resident had other comorbidities, conditions, and was on hospice. Record review of the facility's Provision of Quality Care, undated, read in part .Based on comprehensive assessments, the facility will ensure that residents receive treatment and care by qualified persons in accordance with professional standards of practice, the comprehensive person-centered care plans, and the residences choices .1. Each resident will be provided care and services to attain or maintain his/her highest practicable physical, mental, and psychosocial well-being . Record review of the facility's Oxygen Administration policy, undated, read in part .Oxygen is administered to residents who need it, consistent with professional standards of practice, the comprehensive person-centered care plans, and the resident's goals and preferences . The Administrator, DON, and Regional Nurse were notified on [DATE] at 12:21 p.m. that an IJ was identified due to the above failures and the IJ template was provided. The following Plan of Removal (POR) was accepted on [DATE] at 8:20 p.m.: Re: Removal of Immediate Jeopardy/Letter of Removal [ ] Facility License: [ ] Facility ID/# [ ] [DATE]th, 2024 Dear Program Manager, This letter represents the facility's respectful request for [ ] to accept our revised removal plan with immediate implementation of corrected measures placing the facility back in substantial compliance. Allegation of Immediate Jeopardy: Resident #1 (CR #1), a [AGE] year-old female under hospice care with a diagnosis of chronic respiratory failure, COPD, and heart failure, did not receive consistent oxygen therapy as per physician orders. The resident was left without a nasal cannula for over 3 hours and called out repeatedly for help without response from staff. The resident passed away on [DATE], raising serious concerns about oxygen monitoring and response to resident needs. The following measures represent the immediate action [ ] has taken to address the alleged-deficient practice and to prevent serious harm from occurring or recurring. Immediate Actions to Address Immediate Jeopardy Date of Action: [DATE] Objective: Ensure that all residents are safe, their oxygen therapy is monitored, and that staff are trained in prompt response to resident needs. 1. Resident Assessments o Action: Conduct an immediate physical assessment of all residents receiving oxygen therapy to verify device placement, functionality, and settings. Document the condition of each resident and verify the delivery of prescribed oxygen. o Completion Date: [DATE] o Responsible Party: Director of Nursing (DON)/Designee 2. Review Resident Records o Action: Audit all records of residents with oxygen therapy orders to ensure each order matches the current oxygen delivery setup, including flow rates and frequency. o Action: Review each resident's care plan related respiratory status and oxygen requirements. o Action: Residents that require continuous oxygen therapy will have visual compliance checks and O2 saturations completed by a licensed nurse every shift. o Completion Date: [DATE] o Responsible Party: DON/Designee 3. Environmental and Equipment Checks o Action: Conduct an audit of all oxygen equipment to ensure functionality, clean cannulas, and confirm that oxygen tanks and concentrators are operational. Replace any defective equipment immediately. o Completion Date: [DATE] o Responsible Party: Maintenance Team, overseen by the DON 4. Immediate Staff Training on Resident visual monitor of supplemental oxygen compliance o Action: Provide training to all nursing staff on the importance of promptly responding to resident calls and monitoring oxygen therapy. Reinforce procedures for identifying distress in residents. Signage for all staff to identify which patient is on oxygen. o Completion Date: [DATE] o Trainer: DON/Designee 5. Documentation of Immediate Training and Competency Checks o Action: Require return demonstrations from staff on proper oxygen device placement, O2 concentrator operation and protocols for checking and monitoring residents. Complete competency checklists for each licensed staff member currently on duty. o Action: Inservice's and demonstrations from staff on proper oxygen device placement and protocols for checking and monitoring residents will be completed for all active employed nurses prior to the start of the next scheduled shift. o Action: Education for all staff to identify who is on continuous O2 and who is on PRN O2. Notify the charge nurse if oxygen is not in place or other oxygen related concern. o Completion Date: [DATE] o Responsible Party: DON/Designee, documentation of completion on file. Facility's Plan to Ensure Compliance Quickly Goal: To establish comprehensive, sustainable protocols to monitor oxygen therapy, ensure swift response to resident needs, and maintain safe resident environments. 1. Training Sessions on Respiratory Care and Resident Monitoring o Action: Schedule in-depth training sessions for all nursing and CNA staff on respiratory care, focusing on the monitoring and maintenance of oxygen therapy devices and prompt response protocols. o Completion Dates: Initial training on [DATE]; competency checks completed by [DATE] or prior to next scheduled shift. o Trainer: DON/Designee o Competency Verification: All staff will be required to pass a posttest and return demonstration, documented in personnel files. 2. Resident Monitoring Logs Implementation o Action: Develop a resident monitoring log to be kept in each room, with sections for every 2-hour oxygen checks x 12, then every 4hrs x 12 then every shift ongoing documented in resident's EHR. o Completion Date: [DATE] o Responsible Party: DON to develop logs; Charge Nurse to implement and monitor 3. Quality Assurance and Performance Improvement (QAPI) Meeting o Action: Conduct a QAPI meeting to review the incident, corrective actions, and policy updates. Create a recurring agenda item for monitoring compliance with the new protocols. o Date of Meeting: [DATE] o Responsible Party: Administrator and QAPI Committee 4. Ongoing Audits and Compliance Checks o Action: Schedule weekly audits to ensure compliance with oxygen monitoring and response protocols. Document findings and review corrective actions in monthly QAPI meetings. o Start Date: [DATE], continuing weekly until confirmed compliance o Responsible Party: Administrator 5. Progressive Action/Counseling o Nurse A, B and CNA's B, C and D will receive 1:1 in servicing prior to next scheduled shift. They will also receive a skills validation test weekly x 4 weeks. o Medical Director was notified via telephone in regard to the IJ involving resident and attended ad-hoc QAPI via telephone. Documentation and Follow-Up Documentation of Training and Competency Checks: All staff training records, return demonstrations, and competency verifications will be filed in each employee's personnel record by [DATE]. Audit Logs and Monitoring Forms: Logs for each resident on oxygen therapy will be maintained and reviewed weekly. Compliance will be tracked, and corrective actions will be implemented as necessary. Outcome: Through these corrective actions, the facility aims to protect resident safety, enhance monitoring and responsiveness, and achieve sustained compliance with respiratory care standards. Warm Regards, [ ] [ ] [ ] [ ] Email: [ ] Phone: [ ] Fax: [ ] On [DATE]-[DATE], state surveyor monitoring confirmed the facility implemented their plan or removal (POR) to sufficiently remove the IJ by: Record review revealed resident assessments were completed on [DATE] on all 6 residents receiving continuous oxygen therapy. Record review revealed resident record reviews were completed on [DATE] on all 16 residents with oxygen orders. Record review revealed environmental and equipment checks were completed on [DATE]. Record review revealed training and competency checks were completed from [DATE]-[DATE] for 15 nurses. Record review revealed in-services were developed and 13 nurses, 24 CNAs, and 5 MAs were in-serviced regarding the following: -responding to resident calls -monitoring residents and oxygen therapy -identifying residents in distress -identifying which residents were on oxygen -notifying nurse of oxygen concerns Record review revealed 14 nurses completed an oxygen administration policy review test from [DATE]-[DATE]. Record review revealed 19 CNAs completed an oxygen posttest from [DATE]-[DATE]. Interviews were conducted from [DATE] to [DATE] with staff from all shifts: the DON, the ADON, 3 RNs, 5 LVNs, 9 CNAs, and 2 MAs. Nursing staff verbalized an understanding on responding to resident calls and monitoring of oxygen, identifying residents in distress, and identifying which residents were on oxygen. Nurses also verbalized an understanding on oxygen device placement, O2 concentrator operation, and protocols. The Administrator was notified the Immediate Jeopardy was removed on [DATE] at 6:51 p.m. The facility remained out of compliance at a severity level of no actual harm with the potential for more than minimal harm that was not immediate jeopardy and a scope of pattern due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place.

Based upon observation, interview and record review the facility failed to ensure drugs and biologicals used in the facility must be labeled in accordance with currently accepted professional principles, and under proper temperature controls for 3 out of 10 residents (Resident #2, Resident #13 and Resident #25) and 2 of 3 medication carts (100 Hall Nursing Cart and 200 Hall Front Nursing Cart) reviewed for drug labeling and storage. - The facility failed to ensure the 100 Hall Nursing Cart Nursing Cart did not contain an in-use insulin pen for Resident #25 with no open date. - The facility failed to ensure the 200 Hall Front Nursing Cart did not contain open and in-use Acidophilus probiotic with manufacturers' instructions to refrigerate after opening and in-use insulin pens for Resident #13 and Resident #25 with no open date This failure could place residents at risk of adverse medication reactions and drug diversions. Findings included: 100 Hall Back Nursing Cart Record review of Resident #25's Face Sheet dated [DATE] revealed, a [AGE] year-old female admitted to the facility on [DATE] with diagnoses of: anxiety disorder, high cholesterol, stomach ulcer and type 2 diabetes. Record review of Resident #25's MDS dated [DATE] revealed, intact cognition as indicated by a BIMS score of 15 out of 15, use of a wheelchair and supervision for most ADLs. Record review of Resident #25's undated Care Plan revealed, focus- resident has orders for insulin r/t type 2 diabetes; intervention- administer insulin as ordered. Record review of Resident #25's Order Summary Report dated [DATE] revealed, Insulin Lispro- inject 5 units under the skin three times a day for diabetes. In an observation and interview on [DATE] at 08:20 AM, inventory of the 100 Hall Nursing Cart with LVN H revealed: - An open an in-use Insulin Lispro Pen for Resident #25 with no open date. LVN H said nursing staff are expected to check their carts daily for inappropriately labeled medications. She said insulin must be labeled with the date opened in order to track the expiration date because when insulin expired it becomes less effective. LVN H said since the insulin pen did not have an open date it must be discarded in the sharps container because use of expired insulin could place residents at risk for uncontrolled blood sugars. 200 Hall Front Nursing Cart Resident #2 Record review of Resident #2's Face Sheet dated [DATE] revealed, a [AGE] year-old female who admitted to the facility with diagnoses of: reduced mobility, lack of coordination, depression and type 2 diabetes. Record review of Resident #2's Quarterly MDS dated [DATE] revealed, moderately impaired cognition as indicated by a BIMS score of 12 out of 15, substantial assistance with most ADLs, and always incontinent of both bladder and bowel. Record review of Resident #2's undated Care Plan revealed, focus- diagnosis of diabetes; intervention- administer medications as ordered. Record review of Resident #2's Order Summary Report dated [DATE] revealed, - Insulin Lispro- inject insulin as per sliding scale : if 150 - 200 = 2; 201 - 250 = 4; 251 - 300 = 6; 301 - 350 = 8; 351 - 400 = 10; 401 - 999 = 12, for type 2 diabetes Resident #13 Record review of Resident #13's Face Sheet dated [DATE] revealed, a [AGE] year-old female who admitted to the facility on [DATE] revealed, paralysis, difficulty swallowing, muscle weakness and wasting and type 2 diabetes. Record review of Resident #13's MDS dated [DATE] revealed, severely impaired cognitive skills for daily decision making, dependent for most ADLs, always incontinent of bladder and frequently incontinent of bowel. Record review of Resident #13's undated Care Plan revealed, focus- order for insulin r/t diabetes; intervention- administer insulin as ordered. Record review of Resident #13's Order Summary Report dated [DATE] revealed, - NovoLIN N Insulin- inject 12 units under the skin at bedtime for type 2 diabetes - NovoLIN N Insulin- inject 21 units under the skin one time a day for type 2 diabetes. In an observation and interview on [DATE] at 08:35 AM, inventory of the 200 Front Nursing Cart with LVN P revealed: - An open and in-use Insulin Lispro Pen for Resident #2 with no open date. - An open and in-use Novolin N insulin pen for Resident #13 with no open date - 1 open and in-use bottles of Acidophilus probiotic with open date of [DATE] and manufacturer's instructions of store unopened container at room temperature, REFRIGERATE AFTER OPENING. - 1 open and in-use bottles of Acidophilus probiotic with open date of [DATE] and manufacturer's instructions of store unopened container at room temperature, REFRIGERATE AFTER OPENING. LVN P said nursing staff are expected to check their carts daily for inappropriately labeled medications as well as medications stored at the wrong temperature. She said medications that required refrigeration must be refrigerated because it might be not work if left at room temperature. LVN P said the bottles of Acidophilus were always left in the carts, she did not know that the facility's selected Acidophilus required refrigeration after opening and since it was at the wrong temperature it must be discarded. She said multi-dose insulin containers should be labeled with the date opened in order to track the expiration date. LVN P said since the insulin pens had no open dates they might be expired and since expired insulin is less effective it must be discarded in the sharps container. She said the use of expired insulin could place residents at risk for uncontrolled blood sugars. In an interview on [DATE] at 11:33 AM, the DON said nursing staff are expected to check their carts daily at the beginning of their shift for expired, inappropriately stored and inappropriately labeled medications. She said ultimately the ADON, DON were responsible for ensuring the carts are monitored and perform audits of carts every other week to ensure nursing staff maintained their carts. She said once a multi-dose container such as insulin is opened it must be labeled with a date order in order to track the expiration date and insulin pens with no open dates cannot be used since their expiration date cannot be determined and they might be expired. The DON said after insulin expired it became less potent and use can result in uncontrolled blood sugars so it must be reordered from the pharmacy and discarded in the sharps containers located on the medication carts. The DON said medications should be stored at the manufacturers specified temperatures and when medications are stored at the wrong temperature there could be an unknown impact on their efficacy. She said the used of expired or inappropriately labeled medications could place residents at risk for adverse reactions and have unpredictable effects on health conditions. Record review of the facility policy titled Storage of Medications revised ,d+[DATE] revealed, 4- Drug containers that have missing, incomplete, improper, or incorrect labels are returned to the pharmacy for proper labeling before storing. 7- Medications requiring refrigeration are stored in a refrigerator in the drug room at the nurses' station or other secured location.

Based on observation, interview and record review the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals to meet the needs of 1 of 10 residents (Resident #34) and 1 of 3 medication Carts (200 Hall Back Nursing Cart) reviewed for pharmaceutical services. - The facility failed to ensure the 200 Hall Back Nursing Cart did not contain expired Basaglar Insulin for Resident #34. This failure could place residents at risk of not receiving the desired therapeutic effect of their medications and uncontrolled health conditions. Findings Included: Record review of Resident #34's Face Sheet dated 01/31/24 revealed, a [AGE] year-old female admitted to the facility on [DATE] with diagnoses of: right dominance paralysis, muscle weakness and type 2 diabetes. Record review of Resident #34's Quarterly MDS dated [DATE] revealed, intact cognition as indicated by a BIMS score of 15 out of 15, use of a wheelchair and dependent for most ADLs. Record review of Resident #34's undated Care Plan revealed, focus- patient has diabetes and takes Basaglar insulin as directed; intervention- diabetes medication as ordered by doctor. Record review of Resident #34's Order Summary Report dated 01/31/24 revealed, Basaglar Insulin- inject 25 units under the skin two times a day for type 2 diabetes effective 05/09/23. Record review of Resident #34's January MAR dated 01/31/24 revealed, - 01/31/23 at 05:00 Basaglar- 25 units under the skin for type 2 diabetes. In an observation and Interview on 01/31/24 at 08:55 AM, inventory of the 200 Hall Back Nursing Cart with LVN J revealed: - An open in-use and expired Basaglar Insulin Pen for Resident #34 with a DO NOT USE AFTER 01/29/24 label. LVN J said nursing staff were expected to check their carts daily as used for expired medications. She said all multidose insulin containers were additionally labeled with the open or use by date. LVN J said when insulin expired it may become less effective and its use could place residents at risk for uncontrolled blood sugars. LVN J said since the insulin pen label said it expired on 01/29/24 it should be discarded in the sharps container and reordered from the pharmacy. In an interview on 01/31/24 at 11:33 AM, the DON said nursing staff were expected to check their carts daily at the beginning of their shift for expired, inappropriately stored and inappropriately labeled medications. She said ultimately the ADON, DON were responsible for ensuring the carts were monitored and perform audits of carts every other week to ensure nursing staff were maintaining their carts The DON said after insulin expired it became less potent and use could result in uncontrolled blood sugars so it must be reordered from the pharmacy and discarded in the sharps containers located on the medication carts. Record review of the facility policy titled Storage of Medications revised 11/2020 revealed, 4- discontinued, outdated, or deteriorated drugs or biologicals are returned to the dispensing pharmacy or destroyed. Record review of the facility policy titled Medication Storage in the facility revised 08/2014 revealed, G- all expired medications will be removed from the active supply and destroyed in the facility regardless of the amount remaining. The medication will be destroyed in the usual manner.

Based on observation, interview, and record review the facility failed to ensure a resident was assessed and had consents for bed rails for 2 of 3 residents (Resident #46 and Resident #6) reviewed for bed rails. -The facility failed to obtain consent prior to installing and utilizing bedrails for Residents #46 and #6. These failures could affect residents who utilized some type of bed rails in the facility and could put the residents at risk for potential injuries. Findings included: Record review of Resident #46's face sheet dated 01/31/2024 revealed a [AGE] year-old male admitted to the facility on [DATE]. His diagnoses included Parkinsonism (a group of conditions that affect movement and mimic Parkinson's disease), dementia, chronic pain, anxiety, constipation, HTN (elevated blood pressure) and depression. Record review of Resident #46's annual MDS dated [DATE] revealed a BIMS score of 15 out of 15 indicating intact cognition. He was dependent on staff for dressing and personal hygiene. He required partial/moderate assistance with turning in bed and was dependent on staff when moving from sitting to lying and lying to sitting. He was receiving hospice care. Further review revealed no bed rails were used. Record review of Resident #46's undated care plan revealed: Focus - Resident #46 utilized an enabling device to help with positioning and/or promote independence. Date initiated was 12/22/2022. Goal - Resident #46 will utilize enablers to promote increased independence. Interventions included: educate resident/or resident representative on risks and benefits of assistive device, including risk of entrapment if applicable. Ensure valid consent uploaded to resident's record prior to initiating side rails. Side rails: quarter size enabler device side per physician order for safety during care provision, to assist with bed mobility. Observe for injury or entrapment related to side rail use. Record review of Resident #46's active physician's orders as of 01/31/2024 revealed no orders for side rail use as indicated in the care plan. Record review of Resident #46's unsigned bed rail evaluation dated 12/19/2023 revealed the recommendations were removal of the bed rails as they did not meet the resident's needs. Record review of Resident #46's electronic medical records revealed no signed consent for bed rails. Observation on 01/30/2024 at 9:55 AM, revealed Resident #46 was lying on his back in bed. The bed was up against the wall to the left of the resident and the bed side rail was raised on the left of the resident. The bed rail was approximately 2 feet in length. The bed side rail to the right of the resident was in the lowest position . Record review of Resident #6's face sheet revealed a [AGE] year-old male admitted to the facility on [DATE] and initially admitted on [DATE]. His diagnoses included stroke, respiratory failure, traumatic brain injury, encephalopathy (disorder of the brain that affects its function or structure), muscle wasting, joint pain, paranoid schizophrenia, contracture of muscle to the left upper arm and to the left lower leg. Record review of Resident #6's quarterly MDS dated [DATE] revealed he had no speech; he sometimes expressed ideas and wants. He sometimes understood others. He had impaired vision. He had short term and long-term memory problems. His cognitive skills were severely impaired. He was dependent on staff for all ADLs. Further review revealed no bed rails were used. Record review of Resident #6's care plan revealed: Focus - Resident #6 was a moderate risk for falls. Goal - Resident #6's risk and injury potential will be minimized through the next review date. Interventions included: adaptive devices as recommended by therapy or MD. Observe for safe use. Observe to ensure appropriate use of safety/assistive devices. Record review of Resident #6's active physician's orders as of 01/31/2024 revealed no orders for assistive devices. Record review of Resident #6's Bed Rail Safety Review dated 10/20/2023 and e-signed by the ADON on 12/05/2023 revealed the recommendations were to remove bed rails as they do not meet the resident's needs. Record review of Resident #6's electronic medical records revealed no signed consent for bed rails. Observation on 01/30/2024 at 10:10 AM, revealed Resident #6 was in bed, awake and did not respond to greeting. He had severe contractures to his left arm and hand. A grab bar attached to the bed frame on the resident's left side was raised in a locked position. The bed was up against the wall to the right of the resident and there was no bed rail to the right of the resident. Interview on 02/01/2023 at 10:00 AM, Resident #46 said he used the siderail to hold himself up when brief was changed. In a telephone interview on 02/01/2024 at 10:20 AM, the RP for Resident #6 stated she filled out paperwork in June or July 2023 but could not recall if she signed a consent for bedrails. The RP stated it was news to her about the bedrail and that there were no bed rails when she last visited about one week ago. Interview on 02/01/24 at 8:45 AM, the Surveyor requested bed rail consents for Resident #46 and #6. The Administrator said there were no consents. The Administrator said the ADON was responsible for bed rail evaluations. On 02/01/2024 at 10:13 AM, Surveyor attempted to contact Resident #46's RP via telephone to inquire about consent for bed rails. There was no answer and unable to leave a message d/t the voicemailbox was full. Interview on 02/01/2024 at 11:10 AM, the ADON stated risks to a resident using bed side rails would be injury. She stated Resident #46 and Resident #6 were both low risk for injury. The ADON stated for Resident #46, he was very dependent on staff at this point in his illness. She stated he probably wanted to be able to use the side rail for turning and thought he still could. She stated Resident #46's bed rail to the right of the resident was zip tied in the downward position . She stated the bed rail could not be moved, therefore did not think that would be an issue. She stated the bed rail on the other side was not tied down. She stated the bed for Resident #46 came from hospice services and it came with the bedrails. The ADON stated she was unaware Resident #6 had a bed rail. The ADON stated Resident #6 could not move at all so bed rails would be of no benefit. She said bed rails for Residents #46 and #6 would be removed immediately. She stated if Resident #46 should request bed rails, then he would be reevaluated . Record review of the facility policy for Bed Safety and Bed Rails, revised August 2022, read in part: .Resident beds meet the safety specifications established by the Hospital Bed Safety Workgroup. The use of bed rails is prohibited unless the criteria for use of bed rails have been met. Policy Interpretation and Implementation .8. Before using bed rails for any reason, the staff shall inform the resident or representative about the benefits and potential hazards associated with bed rails and obtain informed consent

Based on interview and record review, the facility failed1`to ensure that it's residents are free of any significant medication errors for one of 22 observed for significant medication errors. (Resident #54) The facility failed to follow physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . This deficient practice could affect residents currently residing in the facility resulting in not receiving needed care to maintain optimum health and placing them at risk for deterioration in their condition. Findings included: Physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Orders included [MEDICATION(S)] HCL 0.1 mg - Give 1 tablet by mouth every 24 hours as needed for SBP above 170 or DBP above 105. (Blood pressure is read using two numbers. Systolic blood pressure measures the pressure in your arteries when the heart beats. The diastolic blood pressure measures the pressure in your arteries when your heart rests between beats) The November 2022 MAR for Resident #54 included [MEDICATION(S)] HCL 0.1 mg - Give 1 tablet by mouth every 24 hours as needed for SBP above 170 or DBP above 105. Record review of a Entry 5 day MDS for Resident #54 dated 10/27/22 indicated he had medically complex conditions including hypertension and renal disease. Record review of a care plan dated 07/09/21 indicated Resident #54 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Interventions included Give anti-hypertensive medications as ordered. Monitor for side effects such as [CONDITION(S)] and increased heart rate and effectiveness. Document and notify physician of the following s/sx: Edema; unplanned weight gain, neck vein distension; difficulty breathing; increased heart rate; elevated blood pressure. Record review of the November 2022 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] *11/2/22 at 8:00 p.m., blood pressure was 161/116; *11/3/22 at 8:00 a.m., blood pressure was 188/110; *11/3/22 at 8:00 p.m., blood pressure was 200/123; and *11/5/22 at 8:00 p.m., blood pressure was 173/100. During an interview on 11/09/22 at 10:00, LVN A said Resident #54's blood pressure would fluctuate, and she didn't know if it was possibly due to his renal status. She said he received blood pressure medication in the evenings and said [MEDICATION(S)] 0.1 mg should have been administered per physician ordered parameters and documentation of the November MAR gave no indication of administration. During an interview on 11/09/22 at 10:15 a.m., the DON reviewed Resident #54's November 2022 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] ? She acknowledged Resident #54 was not administered [MEDICATION(S)] HCL 0.1 mg as prescribed by physician and should have been due to the risk of not administering medications as ordered. An Administering Medications policy dated April 2019 provided by the facility indicated the following: .4. Medications are administered in accordance with prescriber orders, including any required time frame. And 11. The following information is checked/verified for each resident prior to administering medications: [MEDICAL RECORD OR PHYSICIAN ORDER] .

Based on interview and record review, the facility failed to ensure that licensed nurses have the competencies and skill sets necessary to provide nursing and related services to meet the residents' needs for 1 of 22 residents (Resident #54) reviewed for competent nursing staff. The facility failed to follow physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . This deficient practice could affect residents currently residing in the facility resulting in not receiving needed care to maintain optimum health and placing them at risk for deterioration in their condition. Findings included: Physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Orders included [MEDICATION(S)] HCL 0.1 mg - Give 1 tablet by mouth every 24 hours as needed for SBP above 170 or DBP above 105. (Blood pressure is read using two numbers. Systolic blood pressure measures the pressure in your arteries when the heart beats. The diastolic blood pressure measures the pressure in your arteries when your heart rests between beats) The November 2022 MAR for Resident #54 included [MEDICATION(S)] HCL 0.1 mg - Give 1 tablet by mouth every 24 hours as needed for SBP above 170 or DBP above 105. Record review of a Entry 5 day MDS for Resident #54 dated 10/27/22 indicated he had medically complex conditions including hypertension and renal disease. Record review of a care plan dated 07/09/21 indicated Resident #54 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Interventions included Give anti-hypertensive medications as ordered. Monitor for side effects such as [CONDITION(S)] and increased heart rate and effectiveness. Document and notify physician of the following s/sx: Edema; unplanned weight gain, neck vein distension; difficulty breathing; increased heart rate; elevated blood pressure. Record review of the November 2022 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] *11/2/22 at 8:00 p.m., blood pressure was 161/116; *11/3/22 at 8:00 a.m., blood pressure was 188/110; *11/3/22 at 8:00 p.m., blood pressure was 200/123; and *11/5/22 at 8:00 p.m., blood pressure was 173/100. During an interview on 11/09/22 at 10:00, LVN A said Resident #54's blood pressure would fluctuate, and she didn't know if it was possibly due to his renal status. She said he received blood pressure medication in the evenings and said [MEDICATION(S)] 0.1 mg should have been administered per physician ordered parameters and documentation of the November MAR gave no indication of administration. During an interview on 11/09/22 at 10:15 a.m., the DON reviewed Resident #54's November 2022 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] ? She acknowledged Resident #54 was not administered [MEDICATION(S)] HCL 0.1 mg as prescribed by physician and should have been due to the risk of not administering medications as ordered. An Administering Medications policy dated April 2019 provided by the facility indicated the following: .4. Medications are administered in accordance with prescriber orders, including any required time frame. And 11. The following information is checked/verified for each resident prior to administering medications: [MEDICAL RECORD OR PHYSICIAN ORDER] .

Based on interview and record review, the facility failed to ensure residents maintained acceptable parameters of nutritional status, usual such as body weight or abnormal lab values for 1 of 22 residents (Residents #57) reviewed for nutrition. The facility failed to communicate to the physician/nurse practitioner the recommendations made by the Registered Dietician for review and implementation for Resident #57 on 10/10/22. This failure could place residents who the Registered Dietitian made recommendations at risk of weight loss and decline in health status. Findings included: Record review of the admission record dated 11/09/22 indicated Resident #57 was admitted [DATE] was [AGE] years old with diabetes, kidney failure, dependence on [CONDITION(S)], anxiety disorder and low back pain. Record review of physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the MAR for October 2022 indicated Resident #57 was not started on or was given Pro-Stat 30 ml po BID for increased protein needs and renal multivitamin tablet po QD. Record review of the MAR for November 2022 indicated Resident #57 was not started on or was given Pro-Stat 30 ml po BID for increased protein needs and renal multivitamin tablet po QD. Record review of the registered dietician progress notes for Resident #57 dated 10/10/22 indicated Most recent labs done on 10/05/2022. Most recent [MEDICATION(S)] level is 3 . Most recent sodium level is 128 . Nutritional diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . she made recommendations of a nutrition prescription was as follows: 1. add Pro-Stat 30 ml po BID for increased protein needs. 2. add renal multivitamin tablet po QD. 3. continue weekly weights. Record review of nurse's notes for Resident #57 dated 10/10/22 to 11/09/22 indicated no evidence of physician or nurse practitioner being notified of the dietary recommendations. Record review of the MDS dated [DATE] indicated Resident #57's cognition intact and received supervision with feeding herself and received extensive with assistance with all other ADLs. Record review of the care plan dated 10/24/2022 indicated Resident #57 had nutritional problem or potential nutritional problem R/T high BMI (Body Mass Index), Stage 2 PU (Pressure Ulcer), [CONDITION(S)] and fluid restriction. approaches were as follows: The resident will maintain adequate nutritional status as evidenced by maintaining weight, no s/s of malnutrition, and consuming adequate percentages of meals daily through review date. Approaches included: o Obtain and monitor labs as ordered, report results to physician and follow up as o RD (Registered Dietician) to evaluate resident as needed. o Staff to monitor weight and report significant findings to physician as needed. o Staff to serve diet as ordered and monitor/record intake with meals. o Wound Care Specialist to evaluate and treat as needed. During an interview on 11/09/22 at 8:08 a.m., the DON said she placed a red check mark to indicate she followed up on the recommendation for Resident #57 on her list of dietary recommendations received from the dietician. She said there were no orders to start or to delete the recommendation as she reviewed physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . She said the recommendation was not placed on the October MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . The DON said she had 30 days per the facility policy to follow up with the physician and would provide the policy. During an interview on 11/09/22 at 9:33 a.m., Registered Dietician B said she had made a recommendation on 10/10/22 for Resident #57 and should have been sent to the doctor. She said the DON asked her to review Resident #57 today. She reviewed the resident and asked for repeat lab or obtain lab results from [CONDITION(S)] to see if orders were still needed because things can change in 30 days in Resident #57's condition could have changed. During an interview on 11/09/22 at 10:34 a.m., the DON said she had been trained to send the dietary recommendations to the physician or to the nurse practitioner for directions and or orders. She said the negative outcome would be on an individual case by case basis. The DON said she could not really say what the negative outcome would be and had not seen any negative outcome with Resident #57. The DON said the facility did not have a policy or procedure about following up with the physician after the dietician gives recommendations. During an interview on 11/09/22 at 11:12 a.m., Nurse practitioner C said she or the primary physician had never been informed about the dietary recommendations for Resident #57 and said she was unaware of any negative outcomes. The policy titled Dietician dated October 2017 indicated A qualified, competent, and skilled dietician will help oversee the food and nutrition services in the facility.9. Our facility's Dietician is responsible for, but not necessarily limited to: a. Assessing nutritional needs of residents; .

Based on observation, interview and record review, the facility failed to consult with the physician when there was a significant change in the resident's physical, mental, or psychosocial status for 7 of 12 residents (CR #1, Resident #6, #7, #8, #9, #10 and #11) reviewed for change in condition as evidenced by: -The facility failed to consult with CR #1's primary MD and the RP current status of her pressure sore. CR #1 was admitted to the hospital with [REDACTED]. CR #1 was recommended to have an amputation below her right knee due to [DIAGNOSES REDACTED]. -The facility failed to consult with the MD Resident #6, #7, #8, #9,10 and #11's abnormal skin conditions and provided treatment until surveyor intervention. An Immediate Jeopardy (IJ) was identified on [DATE]. While the IJ was lowered on [DATE], the facility remained out of compliance at a severity of Actual harm that is not Immediate Jeopardy and a scope of pattern. The facility remained out of compliance because they had not yet monitored their plan for effectiveness. These failures affected one former resident (CR #1) and six residents currently residing at the facility (Resident #6, #7, #8, #9, #10 and #11) and had the potential to place the other 20 residents identified as diabetic at risk for unidentified pressure sores, worsening of existing pressure sores, infections, pain, unnecessary hospital stays, extensive treatments and death. Findings included: TX,[DATE] and TX,[DATE] CR # 1 Record review of the medical record face sheet revealed CR #1 was admitted on [DATE] and re-admitted on [DATE]. [DIAGNOSES REDACTED]. disease and encounter for adequacy testing for [MEDICAL TREATMENT]. She was [AGE] years old. Record review of CR#1's clinical record revealed she had appointment with wound MD on [DATE] per RP request and was immediately transferred to a local hospital from the MD office. CR #1 was admitted with [DIAGNOSES REDACTED]. Record review of CR #1's care plan initiated [DATE] revealed in part: -Focus: CR #1 has potential impairment to skin integrity of the peri-area/buttocks related to use/side effects of medications and to bilateral feet related to [MEDICAL CONDITION], previous ulcers, diabetes mellitus. -Goal: CR #1 will maintain or develop clean and intact skin. -Interventions: *Encourage good nutrition and hydration in order to promote healthier skin. *Follow facility protocols for treatment of [REDACTED]. *Weekly treatment documentation to include measurements of each area of skin breakdown's width, length, depth, type of tissue and exudate and any other notable changes or observations. Record review of Braden Scale for predicting pressure sore risk for CR #1 dated [DATE] revealed a score of 12 indicating high risk. Record review of the significant change in status MDS assessment reference date of [DATE] revealed CR #1 had a BIMS score of 13 out of a possible 15, indicating she was cognitive intact. CR #1 required extensive assistance of two plus person physical assist for bed mobility and required extensive assistance of one person physical assist for dressing, personal hygiene and toilet use. CR #1 was independent with set up only for eating. She had functional limitation to one side of her lower extremity. CR #1 was always incontinent of both bowel and bladder. Further record review revealed CR#1 had one stage 4 pressure ulcer that was facility acquired that measured 0.8 x 0.1 c.m. CR #1 was identified at risk of developing a pressure ulcer and she was not on a pressure reducing device for a chair or for bed. CR #1 was not on a turning /repositioning program. Further record review of Braden Scale for predicting pressure sore risk for CR #1 dated [DATE] revealed a score of 13 indicating moderate risk. Continued record review of CR#1's care plan revised [DATE] revealed in part: -Focus: CR#1 has potential for pressure ulcer development related to history of ulcers, immobility. Stage 2 to right heel resolved [DATE]. Re-admitted on [DATE] with unstageable right heel resolved [DATE]. readmitted with stage 4 to right buttocks. -Goal last revised [DATE]: CR#1 will remain infection free by/through review date of [DATE]. -Interventions dated [DATE]: *The resident requires the bed as flat as possible to reduce shear. The resident prefers to be repositioned with 2 people, lifter, slider. *Educate the resident/family/caregivers as to causes of skin breakdown; including transfer/positioning requirements; importance of taking care during ambulation/mobility, good nutrition and frequent repositioning. *Follow facility policies/protocols for the prevention/treatment of [REDACTED].*Instruct/assist to shift weight of resident while in wheelchair. Further record review of Interventions dated [DATE]: *CR #1 requires air-mattress on bed. Record review of the skin assessment for CR#1 revealed: -[DATE] at 11:02 a.m. revealed in part Callous to right heel, scar tissue to left and right inner thighs. Skin otherwise intact. Signed by Wound Care Nurse, LVN A. Record review of CR #1's transfer form revealed in part: -[DATE] at 10:47 a.m. Skin Condition: Clear. Record review of CR #1's progress (nurses) notes revealed; -[DATE] at 11:15 a.m. CR #1 returned from [MEDICAL TREATMENT] complaining of increased leg pain to lower extremities. Pain 9 out of 10. MD recommended a transfer to the local emergency room . -[DATE] at 9:00 p.m. CR #1 returned from emergency room . [MEDICATION NAME] 4 mg IM was given at the hospital. Medications to continue with no changes. Instructions for follow up with private MD and patient education material for Neuropathic pain were given . Further record review revealed no skin assessments or documentation indicating that CR #1 was readmitted back to the facility with any pressure sore. Record review of the skin assessment for CR #1 revealed in part: -[DATE] at 2:15 p.m. Right buttock Pressure. Stage 4. 5x4 c.m. (LxW). Notes: Moisture damage to left inner thigh. Stage 4 to right buttocks, dry intact callous to right heel Signed by Wound Care Nurse, LVN A. Further record review revealed no further assessment of the pressure sore. Record review of CR #1's progress (nurses) notes dated [DATE] revealed no assessments or further information related to right buttocks Stage 4 pressure sore. Record review of CR #1's MD orders dated [DATE] revealed in part: Apply [MEDICATION NAME] skin protectant paste to left inner thigh and buttocks every day. Record review of www.allegromedical.com/skin-care-/remedy-[MEDICATION NAME]-protectant-paste-4-oz.html / [MEDICATION NAME] Protectant Paste is a zinc oxide-based barrier paste/cream that protects against moisture and minor irritation. Record review of CR #1's electronic Treatment Administration Record revealed dated [DATE] revealed in part; -Apply [MEDICATION NAME] skin protectant paste to left inner thigh and buttocks every day shift. Start date [DATE]. Continued record review of the skin assessment for CR #1 revealed in part: -[DATE] at 11:17 a.m. Special Equipment/Preventative measures: Air mattress. Location: Right buttocks. Pressure. Stage 4. 5x4 c.m. (LxW). Indicate whether this site was acquired during residents stay or whether it was present on admission: admitted . Treatment: 2.- Current treatment plan: [REDACTED] Signed by Wound Care Nurse, LVN A. Record review of the consolidated MD orders dated [DATE] revealed no MD orders for Collagen to right buttocks. Record review of CR #1's electronic Treatment Administration Record dated [DATE] revealed that CR #1's stage 4 pressure sore to her right buttocks was not treated with Collagen as indicated in the skin assessment dated [DATE]. Record review of https://www.healthproductsforyou.com/c-collagen-dressings.html/Collagen dressings are meant for wounds with minimal to heavy exudates and also partial- and full-thickness wounds. They stimulate new tissue growth and help to heal necrotic wounds. Most collagen dressings have antimicrobial agents incorporated to limit spread of infections. Collagen dressings speed up the recovery period due to the growth of new collagen at the wound site. In an interview on [DATE] at 1:22 p.m. with Wound Care Nurse, LVN A, she said that the stage 4 pressure sore that was found to her right buttocks on [DATE] was admitted from the hospital when CR #1 went to the hospital on [DATE]. Wound Care Nurse, LVN A then said that CR #1's stage 4 pressure sore to her right buttocks had been treated with Collagen every day. When asked about the order for Collagen for CR #1's stage 4 pressure sore, Wound Care Nurse, LVN A stated as she looked at the computer I don't see it. I don't know why. Further interview on [DATE] at 1:34 p.m., Wound Care Nurse, LVN A, she stated that CR #1 stayed at the hospital on [DATE] for several hours and that she probably got the pressure sore while in the ambulance or in the hospital. She then said that the facility did not do a body assessment when CR #1 returned from the hospital on [DATE] and that she found the Stage 4 pressure sore to CR #1's right buttocks during weekly skin assessment on [DATE]. When asked if anyone had reported any skin issues on CR #1 from [DATE] to [DATE], the Wound Care Nurse, LVN A responded No. When asked what interventions she implemented on [DATE] when CR #1's was assessed with [REDACTED].#1 on an air mattress on [DATE] but I did not write the order until [DATE]. In an interview on [DATE] at 2:00 p.m. with the DON, she stated CR #1 developed the Stage 4 pressure sore to her right buttocks while in the hospital. When asked about any assessment that would indicate that CR #1 acquired the pressure sore at the hospital, the DON said We don't have to do skin assessments when residents return from the hospital, facility staff did a detailed assessment before CR #1 went to the hospital on [DATE]. DON continued saying that Braden Scale for predicting pressure sore risk are completed only during new admissions, then weekly x4, quarterly and annual. DON then said but will check the policy about Braden Scale for predicting pressure sore risk assessments. Record review of CR #1's progress (nurses) notes revealed in part; -[DATE] at 7:48 p.m. .air mattress placed on bed today -[DATE] at 11:22 p.m. CR #1 confused tonight, talks about people in the room with her, behind her roommate's desk. Thinks they are hiding behind the curtain. CR #1 stated there is nothing wrong with her . Record review of CR #1's MD orders revealed in part; -[DATE] Clean right heel with normal saline, dry, apply iodine cover with non- adherent dressing and wrap with [MEDICATION NAME] every day one time a day. Order changed on [DATE]. Record review of CR #1's electronic Treatment Administration Record revealed dated [DATE] revealed in part; -Clean right heel with normal saline, dry, apply iodine, cover with non adherent dressing and wrap with [MEDICATION NAME]. Every day one time a day. Start date [DATE]. Continued record review of CR #1's progress (nurses) notes revealed in part; -[DATE] at 4:51 p.m. CR#1 talking to people in room not present. She stated there were children running around in her room screaming MD notified of condition. -[DATE] at 4:08 p.m. Spoke with CR #1's RP regarding concerns of wound to right heel and set up care plan meeting. Informed that what she was referring to as a wound was actually callous from history of wound. CR #1's RP inquired about getting CR #1 set as an out-patient with wound care and if we can transport her there. Will follow up with CR #1's RP regarding this appointment and whether or not we can transport CR #1 . Signed by DON. Record review of CR #1's MD orders revealed in part; -[DATE] Clean right heel with normal saline, dry, apply iodine cover with non- adherent dressing and wrap with [MEDICATION NAME] every day shift. Record review of CR #1's electronic Treatment Administration Record revealed dated [DATE] revealed in part; -Clean right heel with normal saline, dry, apply iodine, cover with non adherent dressing and wrap with [MEDICATION NAME]. Every day on every day shift. Start date [DATE]. Record review of CR #1's progress (nurses) notes revealed in part; -[DATE] at 1:00 p.m. CR #1 noted with increased confusion today, noted conversing with self. MD notified with new order to check ammonia level in A.M . -[DATE] at 10:58 a.m. .Care Plan meeting today with CR #1's RP. Discussed pain management, wound treatments . Record review of document titled Complaint Resolution Record dated [DATE] revealed in part: . Patient name: CR #1. Person making report: CR #1's RP. Concern: Wounds. Action: CR #1 to see wound care MD. Resolution: CR #1 sent to wound care MD and admitted to hospital. Upon return will follow up with RP . Signed by Administrator. Record review of CR #1's MD orders revealed in part; -[DATE] Clean right arm pit boil with normal saline, pat dry, apply triple antibiotic ointment and cover with dry dressing every day and as needed loose/soiled every day shift. -[DATE] Heel protectors to bilateral heels while in bed as tolerated every shift. -[DATE] Check function of air-mattress every shift. Further record review of the skin assessment for CR #1 revealed in part: -[DATE] at 8:31 a.m. Special Equipment/Preventative measures: Air mattress, hell protectors, wedge under ankles. Location: Right buttocks. Pressure. Stage 4. 5x4 c.m. (LxW). Original stage: Stage 4. Indicate whether this site was acquired during residents stay or whether it was present on admission: admitted . Treatment: 1.- Describe any changes to treatment plan in the last week: Zinc everyday. 2.- Current treatment plan: [REDACTED]. Record review of CR #1's electronic Treatment Administration Record revealed that CR #1's stage 4 pressure sore to her right buttocks wound care treatment was never changed to Collagen per skin assessment reports dated [DATE] and [DATE]. Continued record review of the skin assessment for CR #1 revealed in part: -[DATE] at 8:40 a.m. Special Equipment/Preventative measures: Air mattress, heel protectors, wedge under ankles. Location: Right heel. Specify: Dry intact callous. 3x3c.m. (LxW). Indicate whether this site was acquired during residents stay or whether it was present on admission: admitted on [DATE]. Wound edges irregular. 2.- Current treatment plan: [REDACTED] Comments: CR #1 had re-admitted on [DATE] with an unstageable pressure ulcer 4x4 (c.m.) eschar encompasses approx 2x2 (c.m) middle area. Area turned to full eschar than scabbed to a callous as of [DATE] . Signed by Wound Care Nurse, LVN A. Record review of Nutrition/Dietary notes revealed in part; -[DATE] at 3:29 p.m. CR #1 with a stage 4 wound to her right buttocks. Recommendations: Start Nepro every day, vitamin C 500 mg twice a day for 30 days, Zinc Sulfate 220 mg every day for 14 days. Goal: Wound to resolve Record review of CR #1's progress (nurses) notes revealed in part; -[DATE] at 2:34 p.m. Discharge Summary: CR #1 was admitted to a local hospital by the wound care MD for wound evaluation and treatment . -[DATE] at 3:30 p.m. -Late entry on [DATE] at 8:26 a.m. Spoke with Wound Care MD in regards to CR #1's wound on the heel and the boil under the right arm. No concerns stated at this time. Will follow up on [DATE] for an update . Signed by Wound Care Nurse, LVN A. In a phone interview on [DATE] at 10:14 a.m. with the Wound Care MD, he stated that CR #1 visited his office on [DATE] and that his PA (Physician Assistant) saw her. He further said the assessments for [DATE]'s visit read 'right calcaneus (large bone forming the heel) unstageable, strong malodorous present, extensive tissue injury present, cold to touch, wound infection, maceration noted, at risk to loose limb. Necrotic liquefying tissue consistent with gangrene. Wound Care MD further said when CR #1 went to our office, we realized that the foot was in immediate trouble, she had necrotic liquefying tissue consistent with gangrene. CR #1's foot was in trouble, we immediately transferred her to the hospital. I saw CR #1 the next day. When she came to the hospital on [DATE], CR #1 was septic, her white blood cell count was 26 thousand (reference 4,500 to 11,000 white blood cells per microliter normal value). The nursing home wanted my notes but I told them I needed family consent. Further interview with the Wound Care MD, he said this situation does not happen over night. When I saw her the next day on [DATE], I saw her right heel. It was infected, the whole foot was turning necrotic, she had bone exposure notable. I removed eschar tissue the next day on [DATE]. CR#1 was started immediately with IV antibiotics from admission to the hospital. I understand CR #1 later died . [MEDICAL CONDITION], you are going to lose the ability to maintain blood pressure and that's going to lead to [MEDICAL CONDITION]. Record review of CR #1's wound assessment dated [DATE] revealed in part; (from Wound Care MD office) PA Visit: -Right heel: 2.5 x 4.0 x 0.3 c.m. (LxWxD). Undermining: 3 o'clock to 9 o'clock 2.7 c.m. Pressure. Stage 4. Structure exposed: Bone. Odor: Yes. Drainage: Purulent. % of wound bed covered in slough, [MEDICATION NAME], necrotic tissue: 76 - 100%. Wound base color: Black and yellow. Granulation tissue: none. -Coccyx: 2.2 x 1.2 x 0.0 c.m. (LxWxD). Pressure. Stage 3. Drainage: serous. Wound base: red. Periwound: denuded. -Right posterior thigh: 3.8 x 2.0 x 0.0 c.m. (LxWxD). Pressure. Stage 3. Drainage: serous. Wound base: red. -Right 4th and 5th toes interspace: serosanguineous drainage. Periwound: macerated. -Right breast abscess: Drainage: copious purulent. Periwound: [DIAGNOSES REDACTED]. Record review of the hospital History and Physical dated [DATE] revealed in part; .CR #1 [AGE] year old female with history of diabetes mellitus type 2, with [MEDICAL CONDITION] and end stage [MEDICAL CONDITION]. CR #1 has an ulcer in the right heel which was not healing. CR #1 was seen by Wound Care MD and admitted directly to the hospital. CR #1 will need to workup for the right heel ulcer. CR #1 already had left foot transmetatarsal amputation done in the past because of the ulcer. She is non-ambulatory mostly bed and wheelchair bound. Physical examination: Right heel which is about 2.5 x 4.0 x 0.9 stage 4. Coccyx has stage 3 which is 2.2 x 1.2 c.m. and right posterior thigh. Assessment and plan: Multiple decubitus ulcers including the right breast abscess, right heel stage 4, and also ulcer in the right coccyx. Will wait for Wound Care MD to give recommendations regarding wound care. Consult Infectious Disease for antibiotics. Continued with the local wound care and follow up with the labs . Record review of Consultation report dated [DATE] revealed in part; Reason for consultation: Right heel ulcer necrotic wound, right heel, deep wound infection. History and present illness: CR #1 is here for right heel wound. MD is planning for procedure tomorrow for debridement of right heel wound. Worsening condition on that right heel and with odor. Vascular Physical Exam: Right foot necrotic right heel wound with eschar, fluctuance probes bone superiorly and odor. Laboratory data: White blood cells: 29.1 thou/cumm (reference 4,500 to 11,000 white blood cells per microliter normal value). Assessment: [MEDICAL CONDITION], right foot, osteo[DIAGNOSES REDACTED] right heel, stage 4 decubitus heel ulcer, diabetes with [MEDICAL CONDITION] and [MEDICAL CONDITIONS], on [MEDICAL TREATMENT]. Plan: Plan for sharp excisional debridement of the right heel ulcer down to and including bone under local and hold anticoagulant . Record review of Wound Care Consult dated [DATE] by Wound Care MD revealed in part: Chief complaint: Right calcaneus pressure injury, right ischial (sitting bone) pressure injury. CR #1 is a [AGE] year old female with past medical history significant for [MEDICAL CONDITION], diabetes and end stage [MEDICAL CONDITION] on [MEDICAL TREATMENT] and [MEDICAL CONDITION]. CR #1 has unfortunately developed right heel, ischial wounds. Surgical history: left foot amputation of toes, vascular intervention lower extremities. Assessment/Plan: Right calcaneus present injury, unstageable. Wound with infection, necrotic tissue and malodor. Extensive tissue injury present with bone exposure noted. Foot is cold to touch. No pulses palpable. Surgical debridement of wound. Flow heel off mattress and protect. Right ischial pressure injury, unstageable. Wounds with yellow slough in the wound base. Low air loss mattress with repositioning every 2 hours . Record review of the Progress notes dated [DATE] revealed in part; Right heel stage 4 ulcer. Plan is for debridement. I will start on [MEDICATION NAME] antibiotic. Awaiting for results of the culture from the right heel wound. I will start on empiric (broad spectrum antibiotics that treat Gram-positive and Gram-negative bacteria) antibiotics. CR #1 is on anticoagulation for [MEDICAL CONDITION] of the right lower extremity . Record review of CR #1's microbiology report dated [DATE] in part; Source: Wound right heel Procedure: Culture wound/Abscess with Gram Stain Gram Stain Report: Many Gram Negative Rods. Moderate Gram Positive Cocci in Pairs and chains. Final report verified on [DATE] Moderate Proteus mirabilis Moderate [DIAGNOSES REDACTED] pneumonia, Multi-drug Resistant Organism Moderate [MEDICATION NAME] Resistant [MEDICATION NAME] Record review of the Operative/Procedure report dated [DATE] revealed in part; Preoperative Diagnosis: [REDACTED].>1.- Ulcer right heel 7.8 x 9.1 x 1.0 c.m. 2.- Abscess/ gas gangrene 3.- peripheral artery disease/[MEDICAL CONDITION] 4.- Ischemic right foot. Procedure performed: Debridement of right heel wound to muscle tendon and capsule. Description of procedure: It was explained to CR #1 and RP in detail that this is a last ditch effort to save her foot. Procedure: A sharp excisional debridement of the right heel was performed utilizing a 15 blade to remove all necrotic and fibrotic debris from the wound. Upon palpation the wound probed to the level capsule and there was a malodorous smell. There was a noted abscess which was drained. There was no blood flow and as much of the eschar cap was removed as possible. The area was then flushed with copious amounts of normal saline. I discussed with CR #1 that she is likely to lose her leg as she now has bogginess at the 5th toe Record review of the Progress notes dated [DATE] revealed in part; Subjective: Right heel ulcer possible gas gangrene. The condition is worsening. Plan: Concern for gas gangrene tracking up the leg. Recommend a below knee amputation however will attempt all limb salvage possible options as blood flow has been returned. Will debride patient heel and foot tomorrow and evaluate all possible options of limb salvage. If the gas is tracking more proximal than the ankle wound recommend a below knee amputation Record review of Emergency/Urgent Care report dated [DATE] at 1:29 p.m. revealed in part; XXX[AGE] year old female that presented to the ICU in need of a below knee amputation following her [DIAGNOSES REDACTED]. She was given fluids to prepare for her surgery and only had one more unit of fluids to take. Moreover, CR #1 had been dialyzed earlier today. Inpatient code blue was called approximately 3 minutes prior to emergency room arrival . In a phone interview on [DATE] at 8:30 p.m. with the Administrator, she stated I know you are here for CR #1. CR #1's RP told us that CR #1 had a massive [MEDICAL CONDITION] after [MEDICAL TREATMENT] one day. In an interview on [DATE] at 1:22 with Wound Care Nurse, LVN A, she stated that CR #1 did not have any wounds to her heels before going to see the Wound Care MD on [DATE]. She then said that at one point, CR #1 came back from the hospital with an unstageable pressure sore to her right heel and that the pressure sore had healed and had become a hard callus but that the right heel skin was intact. She further said that the facility did not have a wound care MD and that she was the one staging wounds and doing the skin assessments of the residents weekly. Further interview at that time with the Wound Care Nurse, LVN A, she said that the last time she saw CR #1's for wound care was on [DATE] (Friday) and that she did not see CR #1 on [DATE] (Monday) because CR #1 had left for the appointment with the Wound Care MD. In an interview on [DATE] at 2:50 p.m. with CNA A, she stated that she remembered CR #1 that used to complained of leg pain. She further said that CR #1 required 2 person assistance for her ADL's. She then said that she remembered doing care to CR #1 and she had some sores in the middle of her legs and inner thighs and had something on her buttocks too that the Wound Care Nurse, LVN A was treating. CNA A continued saying that CR #1 had dressings on her foot but did not remember which one. Further interview at that time, CNA A said that CR #1 would be up on her chair most of the day and that she did not remember any special precautions for CR #1's legs, except that CR #1 would go to bed after dinner. CNA A then said that any new skin conditions are verbally reported to the Wound Care Nurse A and that there were no forms to complete when reporting skin conditions. In an interview on [DATE] at 3:00 p.m. with CNA C, she stated that if they identify a new pressure sore or skin condition on a resident, they are supposed to notify the charge nurse verbally and that there were no special forms to complete when reporting skin conditions. CNA C then said that she knew CR #1 and then said towards the end, before CR #1 left to the hospital, she was hallucinating, she used to say she was seeing people not present. We will get her up at around 9:30 a.m. She would stay up all day. Towards the end, she would just stay in bed. CR #1 had something on her heels. The nurses said were calluses. She had open areas to her buttocks. The CNAs would put cream. Nurses would provide the cream. The Wound Care Nurses were putting bandages. CR #1 was heavy set. She needed 2 people to be moved in bed, she had pain on her legs. When asked if there were any special precautions or recommendations for CR #1, CNA C stated only to be careful with her legs. In an interview on [DATE] at 3:48 p.m. with the DON, she stated that she saw CR #1's right heel on [DATE] when CR #1's RP had a concern for a wound to the right heel. DON then said that what CR #1's RP was referring CR #1 had on her right heel was a callus. DON then said CR #1 did not have any wounds on her heel, was a dry callus only. CR #1's RP requested a wound consult and was done on [DATE]. CR #1 was then admitted to the hospital. When asked why CR #1 was admitted to the hospital, the DON stated I can't speak for that. They are claiming there was the wound on her heel. There was a meeting with CR #1's RP on [DATE] but I was sick. [DATE] was the last time I saw CR #1's right heel. In an interview on [DATE] at 12:24 p.m. with the Wound Care Nurse, LVN A, she stated that she had just finished taking her wound care certification class online and that she was introduced to different types of wound care treatments. When asked if she had a guide where she would refer when treating a pressure sores or wounds, the Wound Care Nurse, LVN A said No, you can have a Stage 4 and you can use the same treatment like for a Stage 2 pressure sore. She further said that CNA's could go to her or the charge nurses to notify any new skin conditions. Further interview on [DATE] at 12:40 p.m. with the DON and the Wound Care Nurse, LVN A, the DON said the last time I saw CR #1's right heel was on [DATE] and the skin was intact, I only saw a callus on her right heel. The Wound Care Nurse, LVN A then said I saw CR #1 on [DATE], on that Monday before she left for her appointment with the Wound Care MD. CR #1's right heel skin was intact, she still had the callus, area was dry and the color of the skin was normal to her skin color. I talked to the Wound Care MD and he did not have any concerns. They admitted CR #1 to the hospital just for observation. At that time the DON said the Wound Care MD did not have any concerns. Continued interview at that time, the Wound Care Nurse, LVN A said that they started treating the right heel with iodine every day because one day that she was working on the floor, CR #1's RP asked the charge nurse for CR #1 to call the MD and get an order and the charge nurse (did not remember who) implemented the order and that when she returned to work the following day, the order was already there. In an interview on [DATE] at 1:00 p.m. with the DON, she stated that facility staff would usually do a complete head to toe skin assessment when a resident gets transfered to the hospital. DON then said that it was not required to do a complete head to toe skin assessment when residents just go out of the facility for appointments. DON further said that when CNA's report a new skin condition or any type of skin condition, they go directly to the Wound Care Nurse and verbally report the concern. Further interview at that time, the DON stated that the Wound Care Nurse, LVN A was in charge of doing the Braden Scale for predicting pressure sore risk assessments and said that CR #1 had her assessment done on [DATE] and was not due to get another assessment until [DATE]. When asked if residents get assessed again their Braden Scale for predicting pressure sore risk when they develop a new pressure sore, the DON said I need to see. DON continued saying that the facility used the guidelines from the National Pressure Ulcer Advisory Panel as a wound care guide. In an interview on [DATE] at 9:15 a.m. with the DON and Wound Care Nurse, LVN A, the DON stated that she did not have the phone number for the Wound Care MD that treated CR #1. The Wound Care Nurse, LVN A, then said I only have a cell phone number and I am not going to give you his cell number. In an interview on [DATE] at 10:22 a.m. with the DON, she stated that she goes with the Wound Care Nurse, LVN A and observe her during weekly rounds. DON stated that she only observed the wounds but did not touch the skin surrounding the wounds. DON then said that the weekend supervisor was in charge of doing wound care on the weekends and that they had 2 weekend supervisors RN A and RN B. In an interview on [DATE] (TRUNCATED)

Based on observation, interview and record review, the facility failed to be administered in a manner that enabled it to use its resources effectively to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident for 7 of 12 residents (CR #1, Resident #6, #7, #8, #9, #10, and #11) who were reviewed for administration. - The Administrator, who was the abuse coordinator, failed to ensure the facility's policies and procedures were implemented for the prohibition of neglect for CR #1, Resident #6, #7, #8, #9, #10, and #11. - The Administrator failed to ensure the DON carried out her responsibilities in the areas of staff training/monitoring, to provide accurate and complete assessments, appropriate treatment and implement preventive measures to avoid the worsening of pressure sores or the development of new pressure sores. - The DON failed to provide staff training/monitoring, to implement measures to provide the appropriate treatment, complete and accurate assessment and implement preventive measures to prevent the worsening of pressure sores or avoid the development of new pressure sores. An Immediate Jeopardy (IJ) was identified on [DATE]. While the IJ was lowered on [DATE], the facility remained out of compliance at a severity of Actual harm that is not Immediate Jeopardy and a scope of pattern. The facility remained out of compliance because they had not yet monitored their plan for effectiveness. These failures affected 1 CR and six residents (Resident #6, #7, #8, #9, #10, and #11) at the facility and could place 4 residents identified with pressure ulcers at risk for unidentified pressure sores, worsening of existing pressure sores, infections, pain, unnecessary hospital stays, extensive treatments and death. Findings include: TX,[DATE] and TX,[DATE] In an interview on [DATE] at 11:09 a.m. with the Administrator, she said that the Wound Care Nurse was told about skin conditions but she would do the assessments until the day that the assessments were due (weekly). Administrator agreed that by delaying on the assessments, the wounds could have become worse and then said that's one of the things we are changing now. Assessments will be done the day the wounds are identified and we will not wait until the day that the assessments are due. In an interview on [DATE] at 12:35 p.m. with the Administrator, she stated that she was not aware that there was an issue with assessing (wounds). When asked how did she think this incident of IJ came about, the Administrator said the DON was doing skin rounds with the wound care nurse. I believe it was the system on how we assess residents with wounds because we have the treatments in place but starts at the beginning on making sure the assessments are correct. In an interview on [DATE] at 11:56 a.m. with the DON, she stated that she was doing weekly rounds with the Wound Care Nurse, LVN A but that she was not checking her assessments. CR # 1 Record review of the medical record face sheet revealed CR #1 was admitted on [DATE] and re-admitted on [DATE]. [DIAGNOSES REDACTED]. disease and encounter for adequacy testing for [MEDICAL TREATMENT]. She was [AGE] years old. Record review of CR#1's clinical record revealed she had appointment with wound MD on [DATE] per RP request and was immediately transferred to a local hospital from the MD office. CR #1 was admitted with [DIAGNOSES REDACTED]. Record review of CR #1's care plan initiated [DATE] revealed in part: -Focus: CR #1 has potential impairment to skin integrity of the peri-area/buttocks related to use/side effects of medications and to bilateral feet related to [MEDICAL CONDITION], previous ulcers, diabetes mellitus. -Goal: CR #1 will maintain or develop clean and intact skin. -Interventions: *Encourage good nutrition and hydration in order to promote healthier skin. *Follow facility protocols for treatment of [REDACTED]. *Weekly treatment documentation to include measurements of each area of skin breakdown's width, length, depth, type of tissue and exudate and any other notable changes or observations. Record review of Braden Scale for predicting pressure sore risk for CR #1 dated [DATE] revealed a score of 12 indicating high risk. Record review of the significant change in status MDS assessment reference date of [DATE] revealed CR #1 had a BIMS score of 13 out of a possible 15, indicating she was cognitive intact. CR #1 required extensive assistance of two plus person physical assist for bed mobility and required extensive assistance of one person physical assist for dressing, personal hygiene and toilet use. CR #1 was independent with set up only for eating. She had functional limitation to one side of her lower extremity. CR #1 was always incontinent of both bowel and bladder. Further record review revealed CR#1 had one stage 4 pressure ulcer that was facility acquired that measured 0.8 x 0.1 c.m. CR #1 was identified at risk of developing a pressure ulcer and she was not on a pressure reducing device for a chair or for bed. CR #1 was not on a turning /repositioning program. Further record review of Braden Scale for predicting pressure sore risk for CR #1 dated [DATE] revealed a score of 13 indicating moderate risk. Continued record review of CR#1's care plan revised [DATE] revealed in part: -Focus: CR#1 has potential for pressure ulcer development related to history of ulcers, immobility. Stage 2 to right heel resolved [DATE]. Re-admitted on [DATE] with unstageable right heel resolved [DATE]. readmitted with stage 4 to right buttocks. -Goal last revised [DATE]: CR#1 will remain infection free by/through review date of [DATE]. -Interventions dated [DATE]: *The resident requires the bed as flat as possible to reduce shear. The resident prefers to be repositioned with 2 people, lifter, slider. *Educate the resident/family/caregivers as to causes of skin breakdown; including transfer/positioning requirements; importance of taking care during ambulation/mobility, good nutrition and frequent repositioning. *Follow facility policies/protocols for the prevention/treatment of [REDACTED].*Instruct/assist to shift weight of resident while in wheelchair. Further record review of Interventions dated [DATE]: *CR #1 requires air-mattress on bed. Record review of the skin assessment for CR#1 revealed: -[DATE] at 11:02 a.m. revealed in part Callous to right heel, scar tissue to left and right inner thighs. Skin otherwise intact. Signed by Wound Care Nurse, LVN A. Record review of CR #1's transfer form revealed in part: -[DATE] at 10:47 a.m. Skin Condition: Clear. Record review of CR #1's progress (nurses) notes revealed; -[DATE] at 11:15 a.m. CR #1 returned from [MEDICAL TREATMENT] complaining of increased leg pain to lower extremities. Pain 9 out of 10. MD recommended a transfer to the local emergency room . -[DATE] at 9:00 p.m. CR #1 returned from emergency room . [MEDICATION NAME] 4 mg IM was given at the hospital. Medications to continue with no changes. Instructions for follow up with private MD and patient education material for Neuropathic pain were given . Further record review revealed no skin assessments or documentation indicating that CR #1 was readmitted back to the facility with any pressure sore. Record review of the skin assessment for CR #1 revealed in part: -[DATE] at 2:15 p.m. Right buttock Pressure. Stage 4. 5x4 c.m. (LxW). Notes: Moisture damage to left inner thigh. Stage 4 to right buttocks, dry intact callous to right heel Signed by Wound Care Nurse, LVN A. Further record review revealed no further assessment of the pressure sore. Record review of CR #1's progress (nurses) notes dated [DATE] revealed no assessments or further information related to right buttocks Stage 4 pressure sore. Record review of CR #1's MD orders dated [DATE] revealed in part: Apply [MEDICATION NAME] skin protectant paste to left inner thigh and buttocks every day. Record review of CR #1's electronic Treatment Administration Record revealed dated [DATE] revealed in part; -Apply [MEDICATION NAME] skin protectant paste to left inner thigh and buttocks every day shift. Start date [DATE]. Continued record review of the skin assessment for CR #1 revealed in part: -[DATE] at 11:17 a.m. Special Equipment/Preventative measures: Air mattress. Location: Right buttocks. Pressure. Stage 4. 5x4 c.m. (LxW). Indicate whether this site was acquired during residents stay or whether it was present on admission: admitted . Treatment: 2.- Current treatment plan: [REDACTED] Signed by Wound Care Nurse, LVN A. Record review of the consolidated MD orders dated [DATE] revealed no MD orders for Collagen to right buttocks. Record review of CR #1's electronic Treatment Administration Record dated [DATE] revealed that CR #1's stage 4 pressure sore to her right buttocks was not treated with Collagen as indicated in the skin assessment dated [DATE]. In an interview on [DATE] at 1:22 p.m. with Wound Care Nurse, LVN A, she said that the stage 4 pressure sore that was found to her right buttocks on [DATE] was admitted from the hospital when CR #1 went to the hospital on [DATE]. Wound Care Nurse, LVN A then said that CR #1's stage 4 pressure sore to her right buttocks had been treated with Collagen every day. When asked about the order for Collagen for CR #1's stage 4 pressure sore, Wound Care Nurse, LVN A stated as she looked at the computer I don't see it. I don't know why. Further interview on [DATE] at 1:34 p.m., Wound Care Nurse, LVN A, she stated that CR #1 stayed at the hospital on [DATE] for several hours and that she probably got the pressure sore while in the ambulance or in the hospital. She then said that the facility did not do a body assessment when CR #1 returned from the hospital on [DATE] and that she found the Stage 4 pressure sore to CR #1's right buttocks during weekly skin assessment on [DATE]. When asked if anyone had reported any skin issues on CR #1 from [DATE] to [DATE], the Wound Care Nurse, LVN A responded No. When asked what interventions she implemented on [DATE] when CR #1's was assessed with [REDACTED].#1 on an air mattress on [DATE] but I did not write the order until [DATE]. In an interview on [DATE] at 2:00 p.m. with the DON, she stated CR #1 developed the Stage 4 pressure sore to her right buttocks while in the hospital. When asked about any assessment that would indicate that CR #1 acquired the pressure sore at the hospital, the DON said We don't have to do skin assessments when residents return from the hospital, facility staff did a detailed assessment before CR #1 went to the hospital on [DATE]. DON continued saying that Braden Scale for predicting pressure sore risk are completed only during new admissions, then weekly x4, quarterly and annual. DON then said but will check the policy about Braden Scale for predicting pressure sore risk assessments. Record review of CR #1's electronic Treatment Administration Record revealed dated [DATE] revealed in part; -Clean right heel with normal saline, dry, apply iodine, cover with non adherent dressing and wrap with [MEDICATION NAME]. Every day one time a day. Start date [DATE]. Continued record review of CR #1's progress (nurses) notes revealed in part; -[DATE] at 4:51 p.m. CR#1 talking to people in room not present. She stated there were children running around in her room screaming MD notified of condition. -[DATE] at 4:08 p.m. Spoke with CR #1's RP regarding concerns of wound to right heel and set up care plan meeting. Informed that what she was referring to as a wound was actually callous from history of wound. CR #1's RP inquired about getting CR #1 set as an out-patient with wound care and if we can transport her there. Will follow up with CR #1's RP regarding this appointment and whether or not we can transport CR #1 . Signed by DON. Record review of CR #1's MD orders revealed in part; -[DATE] Clean right heel with normal saline, dry, apply iodine cover with non- adherent dressing and wrap with [MEDICATION NAME] every day shift. Record review of CR #1's electronic Treatment Administration Record revealed dated [DATE] revealed in part; -Clean right heel with normal saline, dry, apply iodine, cover with non adherent dressing and wrap with [MEDICATION NAME]. Every day on every day shift. Start date [DATE]. Record review of CR #1's progress (nurses) notes revealed in part; -[DATE] at 1:00 p.m. CR #1 noted with increased confusion today, noted conversing with self. MD notified with new order to check ammonia level in A.M . -[DATE] at 10:58 a.m. .Care Plan meeting today with CR #1's RP. Discussed pain management, wound treatments . Record review of document titled Complaint Resolution Record dated [DATE] revealed in part: . Patient name: CR #1. Person making report: CR #1's RP. Concern: Wounds. Action: CR #1 to see wound care MD. Resolution: CR #1 sent to wound care MD and admitted to hospital. Upon return will follow up with RP . Signed by Administrator. Further record review of the skin assessment for CR #1 revealed in part: -[DATE] at 8:31 a.m. Special Equipment/Preventative measures: Air mattress, heel protectors, wedge under ankles. Location: Right buttocks. Pressure. Stage 4. 5x4 c.m. (LxW). Original stage: Stage 4. Indicate whether this site was acquired during residents stay or whether it was present on admission: admitted . Treatment: 1.- Describe any changes to treatment plan in the last week: Zinc everyday. 2.- Current treatment plan: [REDACTED]. Record review of CR #1's electronic Treatment Administration Record revealed that CR #1's stage 4 pressure sore to her right buttocks wound care treatment was never changed to Collagen per skin assessment reports dated [DATE] and [DATE]. Record review of Nutrition/Dietary notes revealed in part; -[DATE] at 3:29 p.m. CR #1 with a stage 4 wound to her right buttocks. Recommendations: Start Nepro every day, vitamin C 500 mg twice a day for 30 days, Zinc Sulfate 220 mg every day for 14 days. Goal: Wound to resolve Record review of CR #1's progress (nurses) notes revealed in part; -[DATE] at 2:34 p.m. Discharge Summary: CR #1 was admitted to a local hospital by the wound care MD for wound evaluation and treatment . -[DATE] at 3:30 p.m. -Late entry on [DATE] at 8:26 a.m. Spoke with Wound Care MD in regards to CR #1's wound on the heel and the boil under the right arm. No concerns stated at this time. Will follow up on [DATE] for an update . Signed by Wound Care Nurse, LVN A. In a phone interview on [DATE] at 10:14 a.m. with the Wound Care MD, he stated that CR #1 visited his office on [DATE] and that his PA (Physician Assistant) saw her. He further said the assessments for [DATE]'s visit read 'right calcaneus (large bone forming the heel) unstageable, strong malodorous present, extensive tissue injury present, cold to touch, wound infection, maceration noted, at risk to loose limb. Necrotic liquefying tissue consistent with gangrene. Wound Care MD further said when CR #1 went to our office, we realized that the foot was in immediate trouble, she had necrotic liquefying tissue consistent with gangrene. CR #1's foot was in trouble, we immediately transferred her to the hospital. I saw CR #1 the next day. When she came to the hospital on [DATE], CR #1 was septic, her white blood cell count was 26 thousand (reference 4,500 to 11,000 white blood cells per microliter normal value). The nursing home wanted my notes but I told them I needed family consent. Further interview with the Wound Care MD, he said this situation does not happen over night. When I saw her the next day on [DATE], I saw her right heel. It was infected, the whole foot was turning necrotic, she had bone exposure notable. I removed eschar tissue the next day on [DATE]. CR#1 was started immediately with IV antibiotics from admission to the hospital. I understand CR #1 later died . [MEDICAL CONDITION], you are going to lose the ability to maintain blood pressure and that's going to lead to [MEDICAL CONDITION]. Record review of CR #1's wound assessment dated [DATE] revealed in part; (from Wound Care MD office) PA Visit: -Right heel: 2.5 x 4.0 x 0.3 c.m. (LxWxD). Undermining: 3 o'clock to 9 o'clock 2.7 c.m. Pressure. Stage 4. Structure exposed: Bone. Odor: Yes. Drainage: Purulent. % of wound bed covered in slough, [MEDICATION NAME], necrotic tissue: 76 - 100%. Wound base color: Black and yellow. Granulation tissue: none. -Coccyx: 2.2 x 1.2 x 0.0 c.m. (LxWxD). Pressure. Stage 3. Drainage: serous. Wound base: red. Periwound: denuded. -Right posterior thigh: 3.8 x 2.0 x 0.0 c.m. (LxWxD). Pressure. Stage 3. Drainage: serous. Wound base: red. -Right 4th and 5th toes interspace: serosanguineous drainage. Periwound: macerated. -Right breast abscess: Drainage: copious purulent. Periwound: [DIAGNOSES REDACTED]. Record review of Consultation report dated [DATE] revealed in part; Reason for consultation: Right heel ulcer necrotic wound, right heel, deep wound infection. History and present illness: CR #1 is here for right heel wound. MD is planning for procedure tomorrow for debridement of right heel wound. Worsening condition on that right heel and with odor. Vascular Physical Exam: Right foot necrotic right heel wound with eschar, fluctuance probes bone superiorly and odor. Laboratory data: White blood cells: 29.1 thou/cumm (reference 4,500 to 11,000 white blood cells per microliter normal value). Assessment: [MEDICAL CONDITION], right foot, osteo[DIAGNOSES REDACTED] right heel, stage 4 decubitus heel ulcer, diabetes with [MEDICAL CONDITION] and [MEDICAL CONDITIONS], on [MEDICAL TREATMENT]. Plan: Plan for sharp excisional debridement of the right heel ulcer down to and including bone under local and hold anticoagulant . Record review of the Progress notes dated [DATE] revealed in part; Subjective: Right heel ulcer possible gas gangrene. The condition is worsening. Plan: Concern for gas gangrene tracking up the leg. Recommend a below knee amputation however will attempt all limb salvage possible options as blood flow has been returned. Will debride patient heel and foot tomorrow and evaluate all possible options of limb salvage. If the gas is tracking more proximal than the ankle wound recommend a below knee amputation Record review of Emergency/Urgent Care report dated [DATE] at 1:29 p.m. revealed in part; XXX[AGE] year old female that presented to the ICU in need of a below knee amputation following her [DIAGNOSES REDACTED]. She was given fluids to prepare for her surgery and only had one more unit of fluids to take. Moreover, CR #1 had been dialyzed earlier today. Inpatient code blue was called approximately 3 minutes prior to emergency room arrival . In a phone interview on [DATE] at 8:30 p.m. with the Administrator, she stated I know you are here for CR #1. CR #1's RP told us that CR #1 had a massive [MEDICAL CONDITION] after [MEDICAL TREATMENT] one day. In an interview on [DATE] at 1:22 with Wound Care Nurse, LVN A, she stated that CR #1 did not have any wounds to her heels before going to see the Wound Care MD on [DATE]. She then said that at one point, CR #1 came back from the hospital with an unstageable pressure sore to her right heel and that the pressure sore had healed and had become a hard callus but that the right heel skin was intact. She further said that the facility did not have a wound care MD and that she was the one staging wounds and doing the skin assessments of the residents weekly. Further interview at that time with the Wound Care Nurse, LVN A, she said that the last time she saw CR #1's for wound care was on [DATE] (Friday) and that she did not see CR #1 on [DATE] (Monday) because CR #1 had left for the appointment with the Wound Care MD. In an interview on [DATE] at 3:48 p.m. with the DON, she stated that she saw CR #1's right heel on [DATE] when CR #1's RP had a concern for a wound to the right heel. DON then said that what CR #1's RP was referring CR #1 had on her right heel was a callus. DON then said CR #1 did not have any wounds on her heel, was a dry callus only. CR #1's RP requested a wound consult and was done on [DATE]. CR #1 was then admitted to the hospital. When asked why CR #1 was admitted to the hospital, the DON stated I can't speak for that. They are claiming there was the wound on her heel. There was a meeting with CR #1's RP on [DATE] but I was sick. [DATE] was the last time I saw CR #1's right heel. In an interview on [DATE] at 12:24 p.m. with the Wound Care Nurse, LVN A, she stated that she had just finished taking her wound care certification class online and that she was introduced to different types of wound care treatments. When asked if she had a guide where she would refer when treating a pressure sores or wounds, the Wound Care Nurse, LVN A said No, you can have a Stage 4 and you can use the same treatment like for a Stage 2 pressure sore. She further said that CNA's could go to her or the charge nurses to notify any new skin conditions. Further interview on [DATE] at 12:40 p.m. with the DON and the Wound Care Nurse, LVN A, the DON said the last time I saw CR #1's right heel was on [DATE] and the skin was intact, I only saw a callus on her right heel. The Wound Care Nurse, LVN A then said I saw CR #1 on [DATE], on that Monday before she left for her appointment with the Wound Care MD. CR #1's right heel skin was intact, she still had the callus, area was dry and the color of the skin was normal to her skin color. I talked to the Wound Care MD and he did not have any concerns. They admitted CR #1 to the hospital just for observation. At that time the DON said the Wound Care MD did not have any concerns. Continued interview at that time, the Wound Care Nurse, LVN A said that they started treating the right heel with iodine every day because one day that she was working on the floor, CR #1's RP asked the charge nurse for CR #1 to call the MD and get an order and the charge nurse (did not remember who) implemented the order and that when she returned to work the following day, the order was already there. In an interview on [DATE] at 1:00 p.m. with the DON, she stated that facility staff would usually do a complete head to toe skin assessment when a resident gets transfered to the hospital. DON then said that it was not required to do a complete head to toe skin assessment when residents just go out of the facility for appointments. DON further said that when CNA's report a new skin condition or any type of skin condition, they go directly to the Wound Care Nurse and verbally report the concern. Further interview at that time, the DON stated that the Wound Care Nurse, LVN A was in charge of doing the Braden Scale for predicting pressure sore risk assessments and said that CR #1 had her assessment done on [DATE] and was not due to get another assessment until [DATE]. When asked if residents get assessed again their Braden Scale for predicting pressure sore risk when they develop a new pressure sore, the DON said I need to see. DON continued saying that the facility used the guidelines from the National Pressure Ulcer Advisory Panel as a wound care guide. In an interview on [DATE] at 9:15 a.m. with the DON and Wound Care Nurse, LVN A, the DON stated that she did not have the phone number for the Wound Care MD that treated CR #1. The Wound Care Nurse, LVN A, then said I only have a cell phone number and I am not going to give you his cell number. In an interview on [DATE] at 10:22 a.m. with the DON, she stated that she goes with the Wound Care Nurse, LVN A and observe her during weekly rounds. DON stated that she only observed the wounds but did not touch the skin surrounding the wounds. DON then said that the weekend supervisor was in charge of doing wound care on the weekends and that they had 2 weekend supervisors RN A and RN B. In an interview on [DATE] at 11:18 a.m. with the Wound Care Nurse, LVN A and the Administrator present, when asked about the guidelines that the facility uses for wound care, the Wound Care Nurse, LVN A said we go by the National Pressure Ulcer. When asked how did she utilize those guidelines, the Wound Care Nurse, LVN A responded I just reviewed them in the wound care class that I finished a week ago. I have not referred to those guidelines yet. I have only pulled the website to see how it maneuvers. The Wound Care Nurse, LVN A then said I took the test already, that's an online class where you have about 10 modules and you take a test after each module. Some modules take 1 hour, some 30 minutes and some 15 minutes. Then I took the last test and got my certificate. Continued interview on [DATE] at 11:50 a.m. with the Wound Care Nurse, LVN A and the Administrator present, the Wound Care Nurse, LVN A said that she had been doing wound care in the facility since [DATE]. In an interview on [DATE] at 1:55 p.m. with the Wound Care Nurse, LVN A and the DON, when asked if there were any special considerations for diabetic residents and their skin, the Wound Care Nurse, LVN A said we check their skin weekly, but we do it for everybody. The DON then said I need to pull the policy because we are on a weekly skin assessments. In an interview on [DATE] at 9:15 a.m. with RN A, she stated that she was the wound care nurse for weekends. She further said that she had been doing wound care in the facility for 7 months every other weekend. RN A then said that when there was a new wound reported, she would go and assess the wound and that she then had to write the assessments of the wound in a binder for Wound Care Nurse, LVN A to review them. She said that the Wound Care Nurse, LVN A was responsible for writing the assessments on the residents' electronic chart. When asked if she calls the MD to get wound care orders, RN A said No, I relay the information to the Wound Care, LVN A. At that time the DON said as she was passing by, No, we call the MD and get orders. In an interview on [DATE] at 10:15 a.m. with the DON and RN A, when asked about the guidelines that she referred for wound care, RN A stated I just call the Wound Care Nurse, LVN A or the DON. I am sure there is a book or something around, or a computer, I am just not aware. When asked if she had a question about a wound, or the appearance of a wound, what did she do, RN A said I would just google the information. When asked about the training she had for wound care, RN A stated the Wound Care Nurse, LVN A followed me once. At that time the DON replied I came to follow you too. RN A then said No, I don't remember. DON then said I had been trying to call RN A but her phone was off. We got the National Pressure Ulcer Advisory Panel as a wound care guidelines since last month and have tried to get hold of her but her phone has been off. Further interview with RN A and the DON on [DATE] at 10:20 a.m., when asked about CR #1's right heel, RN A stated CR #1's heel was necrotic, black, that's what we were treating for. It was moist black. At that time the DON got up and said to RN A Don't answer any questions until I bring the computer. DON then rushed out of the room. Continued interview with RN A at that time, RN A stated CR #1 was a black woman, it was probably hard to determine that she had a pressure sore to her right heel, but it was a pressure sore. The weekend before CR #1 went to the hospital, the right heel was soft, moist, black and necrotic. Further observation and interview, on [DATE] at 10:23 a.m. the DON entered the room and said to RN A They are supposed to let me know of any skin changes. Continued observation and interview on [DATE] at 10:25 a.m., the Administrator walked inside the room. RN A then said CR #1's right heel was black, it was soft. At that time the Administrator said Don't speak until you know the facts. Administrator then left the room. At that time the DON stated as she looked at the computer Did you assess CR #1's right heel?, RN A then said Yes, well, it was black, it was a pressure sore, it was soft. At that time the DON pointed to RN A to look at the computer. DON then said It was a callous. RN A then said Oh, it was a callous. Further observation and interview at that time, the DON stated as she was reading the computer notes to RN A look on the weekend you worked, [DATE] and [DATE], is that you? Are you saying the right heel was necrotic?. RN A then said well, I am saying black. At that time the Administrator entered the room and heard what RN A was saying and Administrator then said RN B (who was the other weekend wound care nurse) said she did not observe any black areas to CR #1's right heel. Continued interview on [DATE] at 10:33 a.m., the Administrator said to RN A so, where is the documentation that there was change in the skin condition of CR #1's right heel?. At that time RN A stated there was not a change in condition, it has been that way. It was like that on [DATE] and [DATE] (2017) as well, we all knew. In an interview on [DATE] at 10:36 a.m. with the Administrator, she stated she (RN A) is done, if she was aware of a change in condition on CR #1's right heel and did not address it, today is her last day. In a phone interview on [DATE] at 2:29 p.m. with CR #1's RP, she stated that CR #1's death certificate indicated that CR #1's immediate cause of death was acute cardiopulmonary arrest and that the sequentially conditions leading to the cause of death were septic shock with multi system organ failure. CR #1's RP then said that one day in the middle of [DATE], she came to visit CR #1 and that staff had just given her a shower and that she was concerned with how CR #1's right heel looked. CR #1's RP said that the right heel was black and had drainage and that CR #1 kept complaining that she had pain on her legs. CR #1's RP said that she spoke to Wound Care Nurse, LVN A and told her that the wound to CR #1's right heel had drainage and had an odor and the Wound Care Nurse, LVN A kept saying the wound was OK. CR #1's RP then said they were not treating the wound to CR #1's right heel. I had to tell them to start a wound care treatment. I requested an appointment with the Wound Care MD. I was the one that scheduled CR #1 to go and see the Wound Care MD on [DATE], but the facility did not coordinate well the transportation and the ambulance never showed up, so I had to re-schedule the appointment again for [DATE]. I was worried for the condition of CR #1's right heel, the foot had an odor and she was diabetic. I had to talk to them and asked them for a wedge so CR #1 could be repositioned,

Based on observation, interview and record review, the facility failed to implement their written policy and procedure that prohibited neglect for 7 of 12 residents (CR #1, Resident #6, #7, #8, #9, #10 and #11) reviewed for neglect. -The facility failed to accurately assess CR #1's pressure sore to her right heel when was identified as a callus. The facility failed to provide the appropriate treatment, complete assessment, consult with the physician and implement preventive measures to avoid the worsening of the pressure sore. -The facility failed to provide CR #1, who had a Stage 4 pressure sore to her buttocks, with a turning a repositioning schedule when she was left for long periods of time on his wheelchair, resulting in CR #1 being admitted to the hospital with [REDACTED]. -CR #1 was admitted to the hospital with [REDACTED]. -CR #1 was diagnosed with [REDACTED]. CR #1 died prior to surgery. -The facility failed to identify Resident #6, #7, #8, #9, #10 and 11's abnormal skin conditions and did not provide treatment until surveyor intervention. These failures further resulted in an identification of an Immediate Jeopardy (IJ) on [DATE]. While the IJ was lowered on [DATE], the facility remained out of compliance at the severity of actual harm that is not immediate jeopardy with a scope identified as pattern due to the facility's need to evaluate the effectiveness of the corrective systems. These failures affected one former resident (CR #1) and six residents currently residing at the facility (Resident #6, #7, #8, #9, #10 and #11) and had the potential to place the other 20 residents identified as diabetic at risk for unidentified pressure sores, worsening of existing pressure sores, infections, pain, unnecessary hospital stays, extensive treatments and death. Findings included: TX,[DATE] and TX,[DATE] Record review if the facility Policy and Procedure Abuse, Neglect, Exploitation and Misappropriation of Property Prevention, Protection and Response Policy and Procedure revised [DATE] revealed in part; .Neglect as hereafter defined, will not be tolerated by anyone . Neglect: The failure of the facility, its employees or service providers to provide goods and services to a patient that are necessary to avoid physical harm, pain, mental anguish, or mental illness. Neglect occurs when facility staff fails to monitor and/or supervise the delivery of patient care and services to assure that care is provided as needed by the patient . CR # 1 Record review of the medical record face sheet revealed CR #1 was admitted on [DATE] and re-admitted on [DATE]. [DIAGNOSES REDACTED]. disease and encounter for adequacy testing for [MEDICAL TREATMENT]. She was [AGE] years old. Record review of CR#1's clinical record revealed she had appointment with wound MD on [DATE] per RP request and was immediately transferred to a local hospital from the MD office. CR #1 was admitted with [DIAGNOSES REDACTED]. Record review of CR #1's care plan initiated [DATE] revealed in part: -Focus: CR #1 has potential impairment to skin integrity of the peri-area/buttocks related to use/side effects of medications and to bilateral feet related to [MEDICAL CONDITION], previous ulcers, diabetes mellitus. -Goal: CR #1 will maintain or develop clean and intact skin. -Interventions: *Encourage good nutrition and hydration in order to promote healthier skin. *Follow facility protocols for treatment of [REDACTED]. *Weekly treatment documentation to include measurements of each area of skin breakdown's width, length, depth, type of tissue and exudate and any other notable changes or observations. Record review of Braden Scale for predicting pressure sore risk for CR #1 dated [DATE] revealed a score of 12 indicating high risk. Record review of the significant change in status MDS assessment reference date of [DATE] revealed CR #1 had a BIMS score of 13 out of a possible 15, indicating she was cognitive intact. CR #1 required extensive assistance of two plus person physical assist for bed mobility and required extensive assistance of one person physical assist for dressing, personal hygiene and toilet use. CR #1 was independent with set up only for eating. She had functional limitation to one side of her lower extremity. CR #1 was always incontinent of both bowel and bladder. Further record review revealed CR#1 had one stage 4 pressure ulcer that was facility acquired that measured 0.8 x 0.1 c.m. CR #1 was identified at risk of developing a pressure ulcer and she was not on a pressure reducing device for a chair or for bed. CR #1 was not on a turning /repositioning program. Further record review of Braden Scale for predicting pressure sore risk for CR #1 dated [DATE] revealed a score of 13 indicating moderate risk. Continued record review of CR#1's care plan revised [DATE] revealed in part: -Focus: CR#1 has potential for pressure ulcer development related to history of ulcers, immobility. Stage 2 to right heel resolved [DATE]. Re-admitted on [DATE] with unstageable right heel resolved [DATE]. readmitted with stage 4 to right buttocks. -Goal last revised [DATE]: CR#1 will remain infection free by/through review date of [DATE]. -Interventions dated [DATE]: *The resident requires the bed as flat as possible to reduce shear. The resident prefers to be repositioned with 2 people, lifter, slider. *Educate the resident/family/caregivers as to causes of skin breakdown; including transfer/positioning requirements; importance of taking care during ambulation/mobility, good nutrition and frequent repositioning. *Follow facility policies/protocols for the prevention/treatment of [REDACTED].*Instruct/assist to shift weight of resident while in wheelchair. Further record review of Interventions dated [DATE]: *CR #1 requires air-mattress on bed. Record review of the skin assessment for CR#1 revealed: -[DATE] at 11:02 a.m. revealed in part Callous to right heel, scar tissue to left and right inner thighs. Skin otherwise intact. Signed by Wound Care Nurse, LVN A. Record review of CR #1's transfer form revealed in part: -[DATE] at 10:47 a.m. Skin Condition: Clear. Record review of CR #1's progress (nurses) notes revealed; -[DATE] at 11:15 a.m. CR #1 returned from [MEDICAL TREATMENT] complaining of increased leg pain to lower extremities. Pain 9 out of 10. MD recommended a transfer to the local emergency room . -[DATE] at 9:00 p.m. CR #1 returned from emergency room . [MEDICATION NAME] 4 mg IM was given at the hospital. Medications to continue with no changes. Instructions for follow up with private MD and patient education material for Neuropathic pain were given . Further record review revealed no skin assessments or documentation indicating that CR #1 was readmitted back to the facility with any pressure sore. Record review of the skin assessment for CR #1 revealed in part: -[DATE] at 2:15 p.m. Right buttock Pressure. Stage 4. 5x4 c.m. (LxW). Notes: Moisture damage to left inner thigh. Stage 4 to right buttocks, dry intact callous to right heel Signed by Wound Care Nurse, LVN A. Further record review revealed no further assessment of the pressure sore. Record review of CR #1's progress (nurses) notes dated [DATE] revealed no assessments or further information related to right buttocks Stage 4 pressure sore. Record review of CR #1's MD orders dated [DATE] revealed in part: Apply [MEDICATION NAME] skin protectant paste to left inner thigh and buttocks every day. Record review of www.allegromedical.com/skin-care-/remedy-[MEDICATION NAME]-protectant-paste-4-oz.html / [MEDICATION NAME] Protectant Paste is a zinc oxide-based barrier paste/cream that protects against moisture and minor irritation. Record review of CR #1's electronic Treatment Administration Record revealed dated [DATE] revealed in part; -Apply [MEDICATION NAME] skin protectant paste to left inner thigh and buttocks every day shift. Start date [DATE]. Continued record review of the skin assessment for CR #1 revealed in part: -[DATE] at 11:17 a.m. Special Equipment/Preventative measures: Air mattress. Location: Right buttocks. Pressure. Stage 4. 5x4 c.m. (LxW). Indicate whether this site was acquired during residents stay or whether it was present on admission: admitted . Treatment: 2.- Current treatment plan: [REDACTED] Signed by Wound Care Nurse, LVN A. Record review of the consolidated MD orders dated [DATE] revealed no MD orders for Collagen to right buttocks. Record review of CR #1's electronic Treatment Administration Record dated [DATE] revealed that CR #1's stage 4 pressure sore to her right buttocks was not treated with Collagen as indicated in the skin assessment dated [DATE]. Record review of https://www.healthproductsforyou.com/c-collagen-dressings.html/Collagen dressings are meant for wounds with minimal to heavy exudates and also partial- and full-thickness wounds. They stimulate new tissue growth and help to heal necrotic wounds. Most collagen dressings have antimicrobial agents incorporated to limit spread of infections. Collagen dressings speed up the recovery period due to the growth of new collagen at the wound site. In an interview on [DATE] at 1:22 p.m. with Wound Care Nurse, LVN A, she said that the stage 4 pressure sore that was found to her right buttocks on [DATE] was admitted from the hospital when CR #1 went to the hospital on [DATE]. Wound Care Nurse, LVN A then said that CR #1's stage 4 pressure sore to her right buttocks had been treated with Collagen every day. When asked about the order for Collagen for CR #1's stage 4 pressure sore, Wound Care Nurse, LVN A stated as she looked at the computer I don't see it. I don't know why. Further interview on [DATE] at 1:34 p.m., Wound Care Nurse, LVN A, she stated that CR #1 stayed at the hospital on [DATE] for several hours and that she probably got the pressure sore while in the ambulance or in the hospital. She then said that the facility did not do a body assessment when CR #1 returned from the hospital on [DATE] and that she found the Stage 4 pressure sore to CR #1's right buttocks during weekly skin assessment on [DATE]. When asked if anyone had reported any skin issues on CR #1 from [DATE] to [DATE], the Wound Care Nurse, LVN A responded No. When asked what interventions she implemented on [DATE] when CR #1's was assessed with [REDACTED].#1 on an air mattress on [DATE] but I did not write the order until [DATE]. In an interview on [DATE] at 2:00 p.m. with the DON, she stated CR #1 developed the Stage 4 pressure sore to her right buttocks while in the hospital. When asked about any assessment that would indicate that CR #1 acquired the pressure sore at the hospital, the DON said We don't have to do skin assessments when residents return from the hospital, facility staff did a detailed assessment before CR #1 went to the hospital on [DATE]. DON continued saying that Braden Scale for predicting pressure sore risk are completed only during new admissions, then weekly x4, quarterly and annual. DON then said but will check the policy about Braden Scale for predicting pressure sore risk assessments. Record review of CR #1's progress (nurses) notes revealed in part; -[DATE] at 7:48 p.m. .air mattress placed on bed today -[DATE] at 11:22 p.m. CR #1 confused tonight, talks about people in the room with her, behind her roommate's desk. Thinks they are hiding behind the curtain. CR #1 stated there is nothing wrong with her . Record review of CR #1's MD orders revealed in part; -[DATE] Clean right heel with normal saline, dry, apply iodine cover with non- adherent dressing and wrap with [MEDICATION NAME] every day one time a day. Order changed on [DATE]. Record review of CR #1's electronic Treatment Administration Record revealed dated [DATE] revealed in part; -Clean right heel with normal saline, dry, apply iodine, cover with non adherent dressing and wrap with [MEDICATION NAME]. Every day one time a day. Start date [DATE]. Continued record review of CR #1's progress (nurses) notes revealed in part; -[DATE] at 4:51 p.m. CR#1 talking to people in room not present. She stated there were children running around in her room screaming MD notified of condition. -[DATE] at 4:08 p.m. Spoke with CR #1's RP regarding concerns of wound to right heel and set up care plan meeting. Informed that what she was referring to as a wound was actually callous from history of wound. CR #1's RP inquired about getting CR #1 set as an out-patient with wound care and if we can transport her there. Will follow up with CR #1's RP regarding this appointment and whether or not we can transport CR #1 . Signed by DON. Record review of CR #1's MD orders revealed in part; -[DATE] Clean right heel with normal saline, dry, apply iodine cover with non- adherent dressing and wrap with [MEDICATION NAME] every day shift. Record review of CR #1's electronic Treatment Administration Record revealed dated [DATE] revealed in part; -Clean right heel with normal saline, dry, apply iodine, cover with non adherent dressing and wrap with [MEDICATION NAME]. Every day on every day shift. Start date [DATE]. Record review of CR #1's progress (nurses) notes revealed in part; -[DATE] at 1:00 p.m. CR #1 noted with increased confusion today, noted conversing with self. MD notified with new order to check ammonia level in A.M . -[DATE] at 10:58 a.m. .Care Plan meeting today with CR #1's RP. Discussed pain management, wound treatments . Record review of document titled Complaint Resolution Record dated [DATE] revealed in part: . Patient name: CR #1. Person making report: CR #1's RP. Concern: Wounds. Action: CR #1 to see wound care MD. Resolution: CR #1 sent to wound care MD and admitted to hospital. Upon return will follow up with RP . Signed by Administrator. Record review of CR #1's MD orders revealed in part; -[DATE] Clean right arm pit boil with normal saline, pat dry, apply triple antibiotic ointment and cover with dry dressing every day and as needed loose/soiled every day shift. -[DATE] Heel protectors to bilateral heels while in bed as tolerated every shift. -[DATE] Check function of air-mattress every shift. Further record review of the skin assessment for CR #1 revealed in part: -[DATE] at 8:31 a.m. Special Equipment/Preventative measures: Air mattress, hell protectors, wedge under ankles. Location: Right buttocks. Pressure. Stage 4. 5x4 c.m. (LxW). Original stage: Stage 4. Indicate whether this site was acquired during residents stay or whether it was present on admission: admitted . Treatment: 1.- Describe any changes to treatment plan in the last week: Zinc everyday. 2.- Current treatment plan: [REDACTED]. Record review of CR #1's electronic Treatment Administration Record revealed that CR #1's stage 4 pressure sore to her right buttocks wound care treatment was never changed to Collagen per skin assessment reports dated [DATE] and [DATE]. Continued record review of the skin assessment for CR #1 revealed in part: -[DATE] at 8:40 a.m. Special Equipment/Preventative measures: Air mattress, heel protectors, wedge under ankles. Location: Right heel. Specify: Dry intact callous. 3x3c.m. (LxW). Indicate whether this site was acquired during residents stay or whether it was present on admission: admitted on [DATE]. Wound edges irregular. 2.- Current treatment plan: [REDACTED] Comments: CR #1 had re-admitted on [DATE] with an unstageable pressure ulcer 4x4 (c.m.) eschar encompasses approx 2x2 (c.m) middle area. Area turned to full eschar than scabbed to a callous as of [DATE] . Signed by Wound Care Nurse, LVN A. Record review of Nutrition/Dietary notes revealed in part; -[DATE] at 3:29 p.m. CR #1 with a stage 4 wound to her right buttocks. Recommendations: Start Nepro every day, vitamin C 500 mg twice a day for 30 days, Zinc Sulfate 220 mg every day for 14 days. Goal: Wound to resolve Record review of CR #1's progress (nurses) notes revealed in part; -[DATE] at 2:34 p.m. Discharge Summary: CR #1 was admitted to a local hospital by the wound care MD for wound evaluation and treatment . -[DATE] at 3:30 p.m. -Late entry on [DATE] at 8:26 a.m. Spoke with Wound Care MD in regards to CR #1's wound on the heel and the boil under the right arm. No concerns stated at this time. Will follow up on [DATE] for an update . Signed by Wound Care Nurse, LVN A. In a phone interview on [DATE] at 10:14 a.m. with the Wound Care MD, he stated that CR #1 visited his office on [DATE] and that his PA (Physician Assistant) saw her. He further said the assessments for [DATE]'s visit read 'right calcaneus (large bone forming the heel) unstageable, strong malodorous present, extensive tissue injury present, cold to touch, wound infection, maceration noted, at risk to loose limb. Necrotic liquefying tissue consistent with gangrene. Wound Care MD further said when CR #1 went to our office, we realized that the foot was in immediate trouble, she had necrotic liquefying tissue consistent with gangrene. CR #1's foot was in trouble, we immediately transferred her to the hospital. I saw CR #1 the next day. When she came to the hospital on [DATE], CR #1 was septic, her white blood cell count was 26 thousand (reference 4,500 to 11,000 white blood cells per microliter normal value). The nursing home wanted my notes but I told them I needed family consent. Further interview with the Wound Care MD, he said this situation does not happen over night. When I saw her the next day on [DATE], I saw her right heel. It was infected, the whole foot was turning necrotic, she had bone exposure notable. I removed eschar tissue the next day on [DATE]. CR#1 was started immediately with IV antibiotics from admission to the hospital. I understand CR #1 later died . [MEDICAL CONDITION], you are going to lose the ability to maintain blood pressure and that's going to lead to [MEDICAL CONDITION]. Record review of CR #1's wound assessment dated [DATE] revealed in part; (from Wound Care MD office) PA Visit: -Right heel: 2.5 x 4.0 x 0.3 c.m. (LxWxD). Undermining: 3 o'clock to 9 o'clock 2.7 c.m. Pressure. Stage 4. Structure exposed: Bone. Odor: Yes. Drainage: Purulent. % of wound bed covered in slough, [MEDICATION NAME], necrotic tissue: 76 - 100%. Wound base color: Black and yellow. Granulation tissue: none. -Coccyx: 2.2 x 1.2 x 0.0 c.m. (LxWxD). Pressure. Stage 3. Drainage: serous. Wound base: red. Periwound: denuded. -Right posterior thigh: 3.8 x 2.0 x 0.0 c.m. (LxWxD). Pressure. Stage 3. Drainage: serous. Wound base: red. -Right 4th and 5th toes interspace: serosanguineous drainage. Periwound: macerated. -Right breast abscess: Drainage: copious purulent. Periwound: [DIAGNOSES REDACTED]. Record review of the hospital History and Physical dated [DATE] revealed in part; .CR #1 [AGE] year old female with history of diabetes mellitus type 2, with [MEDICAL CONDITION] and end stage [MEDICAL CONDITION]. CR #1 has an ulcer in the right heel which was not healing. CR #1 was seen by Wound Care MD and admitted directly to the hospital. CR #1 will need to workup for the right heel ulcer. CR #1 already had left foot transmetatarsal amputation done in the past because of the ulcer. She is non-ambulatory mostly bed and wheelchair bound. Physical examination: Right heel which is about 2.5 x 4.0 x 0.9 stage 4. Coccyx has stage 3 which is 2.2 x 1.2 c.m. and right posterior thigh. Assessment and plan: Multiple decubitus ulcers including the right breast abscess, right heel stage 4, and also ulcer in the right coccyx. Will wait for Wound Care MD to give recommendations regarding wound care. Consult Infectious Disease for antibiotics. Continued with the local wound care and follow up with the labs . Record review of Consultation report dated [DATE] revealed in part; Reason for consultation: Right heel ulcer necrotic wound, right heel, deep wound infection. History and present illness: CR #1 is here for right heel wound. MD is planning for procedure tomorrow for debridement of right heel wound. Worsening condition on that right heel and with odor. Vascular Physical Exam: Right foot necrotic right heel wound with eschar, fluctuance probes bone superiorly and odor. Laboratory data: White blood cells: 29.1 thou/cumm (reference 4,500 to 11,000 white blood cells per microliter normal value). Assessment: [MEDICAL CONDITION], right foot, osteo[DIAGNOSES REDACTED] right heel, stage 4 decubitus heel ulcer, diabetes with [MEDICAL CONDITION] and [MEDICAL CONDITIONS], on [MEDICAL TREATMENT]. Plan: Plan for sharp excisional debridement of the right heel ulcer down to and including bone under local and hold anticoagulant . Record review of Wound Care Consult dated [DATE] by Wound Care MD revealed in part: Chief complaint: Right calcaneus pressure injury, right ischial (sitting bone) pressure injury. CR #1 is a [AGE] year old female with past medical history significant for [MEDICAL CONDITION], diabetes and end stage [MEDICAL CONDITION] on [MEDICAL TREATMENT] and [MEDICAL CONDITION]. CR #1 has unfortunately developed right heel, ischial wounds. Surgical history: left foot amputation of toes, vascular intervention lower extremities. Assessment/Plan: Right calcaneus present injury, unstageable. Wound with infection, necrotic tissue and malodor. Extensive tissue injury present with bone exposure noted. Foot is cold to touch. No pulses palpable. Surgical debridement of wound. Flow heel off mattress and protect. Right ischial pressure injury, unstageable. Wounds with yellow slough in the wound base. Low air loss mattress with repositioning every 2 hours . Record review of the Progress notes dated [DATE] revealed in part; Right heel stage 4 ulcer. Plan is for debridement. I will start on [MEDICATION NAME] antibiotic. Awaiting for results of the culture from the right heel wound. I will start on empiric (broad spectrum antibiotics that treat Gram-positive and Gram-negative bacteria) antibiotics. CR #1 is on anticoagulation for [MEDICAL CONDITION] of the right lower extremity . Record review of CR #1's microbiology report dated [DATE] in part; Source: Wound right heel Procedure: Culture wound/Abscess with Gram Stain Gram Stain Report: Many Gram Negative Rods. Moderate Gram Positive Cocci in Pairs and chains. Final report verified on [DATE] Moderate Proteus mirabilis Moderate [DIAGNOSES REDACTED] pneumonia, Multi-drug Resistant Organism Moderate [MEDICATION NAME] Resistant [MEDICATION NAME] Record review of the Operative/Procedure report dated [DATE] revealed in part; Preoperative Diagnosis: [REDACTED].>1.- Ulcer right heel 7.8 x 9.1 x 1.0 c.m. 2.- Abscess/ gas gangrene 3.- peripheral artery disease/[MEDICAL CONDITION] 4.- Ischemic right foot. Procedure performed: Debridement of right heel wound to muscle tendon and capsule. Description of procedure: It was explained to CR #1 and RP in detail that this is a last ditch effort to save her foot. Procedure: A sharp excisional debridement of the right heel was performed utilizing a 15 blade to remove all necrotic and fibrotic debris from the wound. Upon palpation the wound probed to the level capsule and there was a malodorous smell. There was a noted abscess which was drained. There was no blood flow and as much of the eschar cap was removed as possible. The area was then flushed with copious amounts of normal saline. I discussed with CR #1 that she is likely to lose her leg as she now has bogginess at the 5th toe Record review of the Progress notes dated [DATE] revealed in part; Subjective: Right heel ulcer possible gas gangrene. The condition is worsening. Plan: Concern for gas gangrene tracking up the leg. Recommend a below knee amputation however will attempt all limb salvage possible options as blood flow has been returned. Will debride patient heel and foot tomorrow and evaluate all possible options of limb salvage. If the gas is tracking more proximal than the ankle wound recommend a below knee amputation Record review of Emergency/Urgent Care report dated [DATE] at 1:29 p.m. revealed in part; XXX[AGE] year old female that presented to the ICU in need of a below knee amputation following her [DIAGNOSES REDACTED]. She was given fluids to prepare for her surgery and only had one more unit of fluids to take. Moreover, CR #1 had been dialyzed earlier today. Inpatient code blue was called approximately 3 minutes prior to emergency room arrival . In a phone interview on [DATE] at 8:30 p.m. with the Administrator, she stated I know you are here for CR #1. CR #1's RP told us that CR #1 had a massive [MEDICAL CONDITION] after [MEDICAL TREATMENT] one day. In an interview on [DATE] at 1:22 with Wound Care Nurse, LVN A, she stated that CR #1 did not have any wounds to her heels before going to see the Wound Care MD on [DATE]. She then said that at one point, CR #1 came back from the hospital with an unstageable pressure sore to her right heel and that the pressure sore had healed and had become a hard callus but that the right heel skin was intact. She further said that the facility did not have a wound care MD and that she was the one staging wounds and doing the skin assessments of the residents weekly. Further interview at that time with the Wound Care Nurse, LVN A, she said that the last time she saw CR #1's for wound care was on [DATE] (Friday) and that she did not see CR #1 on [DATE] (Monday) because CR #1 had left for the appointment with the Wound Care MD. In an interview on [DATE] at 2:50 p.m. with CNA A, she stated that she remembered CR #1 that used to complain of leg pain. She further said that CR #1 required 2 person assistance for her ADL's. She then said that she remembered doing care to CR #1 and she had some sores in the middle of her legs and inner thighs and had something on her buttocks too that the Wound Care Nurse, LVN A was treating. CNA A continued saying that CR #1 had dressings on her foot but did not remember which one. Further interview at that time, CNA A said that CR #1 would be up in her chair most of the day and that she did not remember any special precautions for CR #1's legs, except that CR #1 would go to bed after dinner. CNA A then said that any new skin conditions are verbally reported to the Wound Care Nurse A and that there were no forms to complete when reporting skin conditions. In an interview on [DATE] at 3:00 p.m. with CNA C, she stated that if they identify a new pressure sore or skin condition on a resident, they are supposed to notify the charge nurse verbally and that there were no special forms to complete when reporting skin conditions. CNA C then said that she knew CR #1 and then said towards the end, before CR #1 left to the hospital, she was hallucinating, she used to say she was seeing people not present. We will get her up at around 9:30 a.m. She would stay up all day. Towards the end, she would just stay in bed. CR #1 had something on her heels. The nurses said were calluses. She had open areas to her buttocks. The CNAs would put cream. Nurses would provide the cream. The Wound Care Nurses were putting bandages. CR #1 was heavy set. She needed 2 people to be moved in bed, she had pain on her legs. When asked if there were any special precautions or recommendations for CR #1, CNA C stated only to be careful with her legs. In an interview on [DATE] at 3:48 p.m. with the DON, she stated that she saw CR #1's right heel on [DATE] when CR #1's RP had a concern for a wound to the right heel. DON then said that what CR #1's RP was referring CR #1 had on her right heel was a callus. DON then said CR #1 did not have any wounds on her heel, was a dry callus only. CR #1's RP requested a wound consult and was done on [DATE]. CR #1 was then admitted to the hospital. When asked why CR #1 was admitted to the hospital, the DON stated I can't speak for that. They are claiming there was the wound on her heel. There was a meeting with CR #1's RP on [DATE] but I was sick. [DATE] was the last time I saw CR #1's right heel. In an interview on [DATE] at 12:24 p.m. with the Wound Care Nurse, LVN A, she stated that she had just finished taking her wound care certification class online and that she was introduced to different types of wound care treatments. When asked if she had a guide where she would refer when treating a pressure sores or wounds, the Wound Care Nurse, LVN A said No, you can have a Stage 4 and you can use the same treatment like for a Stage 2 pressure sore. She further said that CNA's could go to her or the charge nurses to notify any new skin conditions. Further interview on [DATE] at 12:40 p.m. with the DON and the Wound Care Nurse, LVN A, the DON said the last time I saw CR #1's right heel was on [DATE] and the skin was intact, I only saw a callus on her right heel. The Wound Care Nurse, LVN A then said I saw CR #1 on [DATE], on that Monday before she left for her appointment with the Wound Care MD. CR #1's right heel skin was intact, she still had the callus, area was dry and the color of the skin was normal to her skin color. I talked to the Wound Care MD and he did not have any concerns. They admitted CR #1 to the hospital just for observation. At that time the DON said the Wound Care MD did not have any concerns. Continued interview at that time, the Wound Care Nurse, LVN A said that they started treating the right heel with iodine every day because one day that she was working on the floor, CR #1's RP asked the charge nurse for CR #1 to call the MD and get an order and the charge nurse (did not remember who) implemented the order and that when she returned to work the following day, the order was already there. In an interview on [DATE] at 1:00 p.m. with the DON, she stated that facility staff would usually do a complete head to toe skin assessment when a resident gets transfered to the hospital. DON then said that it was not required to do a complete head to toe skin assessment when residents just go out of the facility for appointments. DON further said that when CNA's report a new skin condition or any type of skin condition, they go directly to the Wound Care Nurse and verbally report the concern. Further interview at that time, the DON stated that the Wound Care Nurse, LVN A was in charge of doing the Braden Scale for predicting pressure sore risk assessments(TRUNCATED)

Based on observation, interview, and record review the facility failed to ensure residents who entered the facility without pressure ulcers did not develop pressure ulcers and a resident having pressure ulcers received appropriate care and treatment consistent with professional standards of practice to promote healing and prevent further development of skin breakdown or pressure ulcers for 7 of 12 residents (CR #1, Resident #6, #7, #8, #9, #10 and #11) who were reviewed for pressure sores; -The facility failed to accurately assess CR #1's pressure sore to her right heel when was identified as a callus. The facility failed to provide the appropriate treatment, complete assessment, consult with the physician and implement preventive measures to avoid the worsening of the pressure sore. -The facility failed to provide CR #1, who had a Stage 4 pressure sore to her buttocks, with a turning a repositioning schedule when she was left for long periods of time on his wheelchair, resulting in CR #1 being admitted to the hospital with [REDACTED]. -CR #1 was admitted to the hospital with [REDACTED]. -CR #1 was diagnosed with [REDACTED]. CR #1 died prior to surgery. -The facility failed to identify Resident #6, #7, #8, #9, #10 and 11's abnormal skin conditions and did not provide treatment until surveyor intervention. -Resident #10's wound to her intergluteal cleft (groove between the buttocks) was not protected with a dressing as ordered. These failures further resulted in an identification of an Immediate Jeopardy (IJ) on [DATE]. While the IJ was lowered on [DATE], the facility remained out of compliance at the severity of actual harm that is not immediate jeopardy with a scope identified as pattern due to the facility's need to evaluate the effectiveness of the corrective systems. These failures affected one former resident (CR #1) and six residents currently residing at the facility (Resident #6, #7, #8, #9, #10 and #11) and had the potential to place the other 20 residents identified as diabetic at risk for unidentified pressure sores, worsening of existing pressure sores, infections, pain, unnecessary hospital stays, extensive treatments and death. Findings included: TX,[DATE] and TX,[DATE] CR # 1 Record review of the medical record face sheet revealed CR #1 was admitted on [DATE] and re-admitted on [DATE]. [DIAGNOSES REDACTED]. disease and encounter for adequacy testing for [MEDICAL TREATMENT]. She was [AGE] years old. Record review of CR#1's clinical record revealed she had appointment with wound MD on [DATE] per RP request and was immediately transferred to a local hospital from the MD office. CR #1 was admitted with [DIAGNOSES REDACTED]. Record review of CR #1's care plan initiated [DATE] revealed in part: -Focus: CR #1 has potential impairment to skin integrity of the peri-area/buttocks related to use/side effects of medications and to bilateral feet related to [MEDICAL CONDITION], previous ulcers, diabetes mellitus. -Goal: CR #1 will maintain or develop clean and intact skin. -Interventions: *Encourage good nutrition and hydration in order to promote healthier skin. *Follow facility protocols for treatment of [REDACTED]. *Weekly treatment documentation to include measurements of each area of skin breakdown's width, length, depth, type of tissue and exudate and any other notable changes or observations. Record review of Braden Scale for predicting pressure sore risk for CR #1 dated [DATE] revealed a score of 12 indicating high risk. Record review of the significant change in status MDS assessment reference date of [DATE] revealed CR #1 had a BIMS score of 13 out of a possible 15, indicating she was cognitive intact. CR #1 required extensive assistance of two plus person physical assist for bed mobility and required extensive assistance of one person physical assist for dressing, personal hygiene and toilet use. CR #1 was independent with set up only for eating. She had functional limitation to one side of her lower extremity. CR #1 was always incontinent of both bowel and bladder. Further record review revealed CR#1 had one stage 4 pressure ulcer that was facility acquired that measured 0.8 x 0.1 c.m. CR #1 was identified at risk of developing a pressure ulcer and she was not on a pressure reducing device for a chair or for bed. CR #1 was not on a turning /repositioning program. Further record review of Braden Scale for predicting pressure sore risk for CR #1 dated [DATE] revealed a score of 13 indicating moderate risk. Continued record review of CR#1's care plan revised [DATE] revealed in part: -Focus: CR#1 has potential for pressure ulcer development related to history of ulcers, immobility. Stage 2 to right heel resolved [DATE]. Re-admitted on [DATE] with unstageable right heel resolved [DATE]. readmitted with stage 4 to right buttocks. -Goal last revised [DATE]: CR#1 will remain infection free by/through review date of [DATE]. -Interventions dated [DATE]: *The resident requires the bed as flat as possible to reduce shear. The resident prefers to be repositioned with 2 people, lifter, slider. *Educate the resident/family/caregivers as to causes of skin breakdown; including transfer/positioning requirements; importance of taking care during ambulation/mobility, good nutrition and frequent repositioning. *Follow facility policies/protocols for the prevention/treatment of [REDACTED].*Instruct/assist to shift weight of resident while in wheelchair. Further record review of Interventions dated [DATE]: *CR #1 requires air-mattress on bed. Record review of the skin assessment for CR#1 revealed: -[DATE] at 11:02 a.m. revealed in part Callous to right heel, scar tissue to left and right inner thighs. Skin otherwise intact. Signed by Wound Care Nurse, LVN A. Record review of CR #1's transfer form revealed in part: -[DATE] at 10:47 a.m. Skin Condition: Clear. Record review of CR #1's progress (nurses) notes revealed; -[DATE] at 11:15 a.m. CR #1 returned from [MEDICAL TREATMENT] complaining of increased leg pain to lower extremities. Pain 9 out of 10. MD recommended a transfer to the local emergency room . -[DATE] at 9:00 p.m. CR #1 returned from emergency room . [MEDICATION NAME] 4 mg IM was given at the hospital. Medications to continue with no changes. Instructions for follow up with private MD and patient education material for Neuropathic pain were given . Further record review revealed no skin assessments or documentation indicating that CR #1 was readmitted back to the facility with any pressure sore. Record review of the skin assessment for CR #1 revealed in part: -[DATE] at 2:15 p.m. Right buttock Pressure. Stage 4. 5x4 c.m. (LxW). Notes: Moisture damage to left inner thigh. Stage 4 to right buttocks, dry intact callous to right heel Signed by Wound Care Nurse, LVN A. Further record review revealed no further assessment of the pressure sore. Record review of CR #1's progress (nurses) notes dated [DATE] revealed no assessments or further information related to right buttocks Stage 4 pressure sore. Record review of CR #1's MD orders dated [DATE] revealed in part: Apply [MEDICATION NAME] skin protectant paste to left inner thigh and buttocks every day. Record review of www.allegromedical.com/skin-care-/remedy-[MEDICATION NAME]-protectant-paste-4-oz.html / [MEDICATION NAME] Protectant Paste is a zinc oxide-based barrier paste/cream that protects against moisture and minor irritation. Record review of CR #1's electronic Treatment Administration Record revealed dated [DATE] revealed in part; -Apply [MEDICATION NAME] skin protectant paste to left inner thigh and buttocks every day shift. Start date [DATE]. Continued record review of the skin assessment for CR #1 revealed in part: -[DATE] at 11:17 a.m. Special Equipment/Preventative measures: Air mattress. Location: Right buttocks. Pressure. Stage 4. 5x4 c.m. (LxW). Indicate whether this site was acquired during residents stay or whether it was present on admission: admitted . Treatment: 2.- Current treatment plan: [REDACTED] Signed by Wound Care Nurse, LVN A. Record review of the consolidated MD orders dated [DATE] revealed no MD orders for Collagen to right buttocks. Record review of CR #1's electronic Treatment Administration Record dated [DATE] revealed that CR #1's stage 4 pressure sore to her right buttocks was not treated with Collagen as indicated in the skin assessment dated [DATE]. Record review of https://www.healthproductsforyou.com/c-collagen-dressings.html/Collagen dressings are meant for wounds with minimal to heavy exudates and also partial- and full-thickness wounds. They stimulate new tissue growth and help to heal necrotic wounds. Most collagen dressings have antimicrobial agents incorporated to limit spread of infections. Collagen dressings speed up the recovery period due to the growth of new collagen at the wound site. In an interview on [DATE] at 1:22 p.m. with Wound Care Nurse, LVN A, she said that the stage 4 pressure sore that was found to her right buttocks on [DATE] was admitted from the hospital when CR #1 went to the hospital on [DATE]. Wound Care Nurse, LVN A then said that CR #1's stage 4 pressure sore to her right buttocks had been treated with Collagen every day. When asked about the order for Collagen for CR #1's stage 4 pressure sore, Wound Care Nurse, LVN A stated as she looked at the computer I don't see it. I don't know why. Further interview on [DATE] at 1:34 p.m., Wound Care Nurse, LVN A, she stated that CR #1 stayed at the hospital on [DATE] for several hours and that she probably got the pressure sore while in the ambulance or in the hospital. She then said that the facility did not do a body assessment when CR #1 returned from the hospital on [DATE] and that she found the Stage 4 pressure sore to CR #1's right buttocks during weekly skin assessment on [DATE]. When asked if anyone had reported any skin issues on CR #1 from [DATE] to [DATE], the Wound Care Nurse, LVN A responded No. When asked what interventions she implemented on [DATE] when CR #1's was assessed with [REDACTED].#1 on an air mattress on [DATE] but I did not write the order until [DATE]. In an interview on [DATE] at 2:00 p.m. with the DON, she stated CR #1 developed the Stage 4 pressure sore to her right buttocks while in the hospital. When asked about any assessment that would indicate that CR #1 acquired the pressure sore at the hospital, the DON said We don't have to do skin assessments when residents return from the hospital, facility staff did a detailed assessment before CR #1 went to the hospital on [DATE]. DON continued saying that Braden Scale for predicting pressure sore risk are completed only during new admissions, then weekly x4, quarterly and annual. DON then said but will check the policy about Braden Scale for predicting pressure sore risk assessments. Record review of CR #1's progress (nurses) notes revealed in part; -[DATE] at 7:48 p.m. .air mattress placed on bed today -[DATE] at 11:22 p.m. CR #1 confused tonight, talks about people in the room with her, behind her roommate's desk. Thinks they are hiding behind the curtain. CR #1 stated there is nothing wrong with her . Record review of CR #1's MD orders revealed in part; -[DATE] Clean right heel with normal saline, dry, apply iodine cover with non- adherent dressing and wrap with [MEDICATION NAME] every day one time a day. Order changed on [DATE]. Record review of CR #1's electronic Treatment Administration Record revealed dated [DATE] revealed in part; -Clean right heel with normal saline, dry, apply iodine, cover with non adherent dressing and wrap with [MEDICATION NAME]. Every day one time a day. Start date [DATE]. Continued record review of CR #1's progress (nurses) notes revealed in part; -[DATE] at 4:51 p.m. CR#1 talking to people in room not present. She stated there were children running around in her room screaming MD notified of condition. -[DATE] at 4:08 p.m. Spoke with CR #1's RP regarding concerns of wound to right heel and set up care plan meeting. Informed that what she was referring to as a wound was actually callous from history of wound. CR #1's RP inquired about getting CR #1 set as an out-patient with wound care and if we can transport her there. Will follow up with CR #1's RP regarding this appointment and whether or not we can transport CR #1 . Signed by DON. Record review of CR #1's MD orders revealed in part; -[DATE] Clean right heel with normal saline, dry, apply iodine cover with non- adherent dressing and wrap with [MEDICATION NAME] every day shift. Record review of CR #1's electronic Treatment Administration Record revealed dated [DATE] revealed in part; -Clean right heel with normal saline, dry, apply iodine, cover with non adherent dressing and wrap with [MEDICATION NAME]. Every day on every day shift. Start date [DATE]. Record review of CR #1's progress (nurses) notes revealed in part; -[DATE] at 1:00 p.m. CR #1 noted with increased confusion today, noted conversing with self. MD notified with new order to check ammonia level in A.M . -[DATE] at 10:58 a.m. .Care Plan meeting today with CR #1's RP. Discussed pain management, wound treatments . Record review of document titled Complaint Resolution Record dated [DATE] revealed in part: . Patient name: CR #1. Person making report: CR #1's RP. Concern: Wounds. Action: CR #1 to see wound care MD. Resolution: CR #1 sent to wound care MD and admitted to hospital. Upon return will follow up with RP . Signed by Administrator. Record review of CR #1's MD orders revealed in part; -[DATE] Clean right arm pit boil with normal saline, pat dry, apply triple antibiotic ointment and cover with dry dressing every day and as needed loose/soiled every day shift. -[DATE] Heel protectors to bilateral heels while in bed as tolerated every shift. -[DATE] Check function of air-mattress every shift. Further record review of the skin assessment for CR #1 revealed in part: -[DATE] at 8:31 a.m. Special Equipment/Preventative measures: Air mattress, hell protectors, wedge under ankles. Location: Right buttocks. Pressure. Stage 4. 5x4 c.m. (LxW). Original stage: Stage 4. Indicate whether this site was acquired during residents stay or whether it was present on admission: admitted . Treatment: 1.- Describe any changes to treatment plan in the last week: Zinc everyday. 2.- Current treatment plan: [REDACTED]. Record review of CR #1's electronic Treatment Administration Record revealed that CR #1's stage 4 pressure sore to her right buttocks wound care treatment was never changed to Collagen per skin assessment reports dated [DATE] and [DATE]. Continued record review of the skin assessment for CR #1 revealed in part: -[DATE] at 8:40 a.m. Special Equipment/Preventative measures: Air mattress, heel protectors, wedge under ankles. Location: Right heel. Specify: Dry intact callous. 3x3c.m. (LxW). Indicate whether this site was acquired during residents stay or whether it was present on admission: admitted on [DATE]. Wound edges irregular. 2.- Current treatment plan: [REDACTED] Comments: CR #1 had re-admitted on [DATE] with an unstageable pressure ulcer 4x4 (c.m.) eschar encompasses approx 2x2 (c.m) middle area. Area turned to full eschar than scabbed to a callous as of [DATE] . Signed by Wound Care Nurse, LVN A. Record review of Nutrition/Dietary notes revealed in part; -[DATE] at 3:29 p.m. CR #1 with a stage 4 wound to her right buttocks. Recommendations: Start Nepro every day, vitamin C 500 mg twice a day for 30 days, Zinc Sulfate 220 mg every day for 14 days. Goal: Wound to resolve Record review of CR #1's progress (nurses) notes revealed in part; -[DATE] at 2:34 p.m. Discharge Summary: CR #1 was admitted to a local hospital by the wound care MD for wound evaluation and treatment . -[DATE] at 3:30 p.m. -Late entry on [DATE] at 8:26 a.m. Spoke with Wound Care MD in regards to CR #1's wound on the heel and the boil under the right arm. No concerns stated at this time. Will follow up on [DATE] for an update . Signed by Wound Care Nurse, LVN A. In a phone interview on [DATE] at 10:14 a.m. with the Wound Care MD, he stated that CR #1 visited his office on [DATE] and that his PA (Physician Assistant) saw her. He further said the assessments for [DATE]'s visit read 'right calcaneus (large bone forming the heel) unstageable, strong malodorous present, extensive tissue injury present, cold to touch, wound infection, maceration noted, at risk to loose limb. Necrotic liquefying tissue consistent with gangrene. Wound Care MD further said when CR #1 went to our office, we realized that the foot was in immediate trouble, she had necrotic liquefying tissue consistent with gangrene. CR #1's foot was in trouble, we immediately transferred her to the hospital. I saw CR #1 the next day. When she came to the hospital on [DATE], CR #1 was septic, her white blood cell count was 26 thousand (reference 4,500 to 11,000 white blood cells per microliter normal value). The nursing home wanted my notes but I told them I needed family consent. Further interview with the Wound Care MD, he said this situation does not happen over night. When I saw her the next day on [DATE], I saw her right heel. It was infected, the whole foot was turning necrotic, she had bone exposure notable. I removed eschar tissue the next day on [DATE]. CR#1 was started immediately with IV antibiotics from admission to the hospital. I understand CR #1 later died . [MEDICAL CONDITION], you are going to lose the ability to maintain blood pressure and that's going to lead to [MEDICAL CONDITION]. Record review of CR #1's wound assessment dated [DATE] revealed in part; (from Wound Care MD office) PA Visit: -Right heel: 2.5 x 4.0 x 0.3 c.m. (LxWxD). Undermining: 3 o'clock to 9 o'clock 2.7 c.m. Pressure. Stage 4. Structure exposed: Bone. Odor: Yes. Drainage: Purulent. % of wound bed covered in slough, [MEDICATION NAME], necrotic tissue: 76 - 100%. Wound base color: Black and yellow. Granulation tissue: none. -Coccyx: 2.2 x 1.2 x 0.0 c.m. (LxWxD). Pressure. Stage 3. Drainage: serous. Wound base: red. Periwound: denuded. -Right posterior thigh: 3.8 x 2.0 x 0.0 c.m. (LxWxD). Pressure. Stage 3. Drainage: serous. Wound base: red. -Right 4th and 5th toes interspace: serosanguineous drainage. Periwound: macerated. -Right breast abscess: Drainage: copious purulent. Periwound: [DIAGNOSES REDACTED]. Record review of the hospital History and Physical dated [DATE] revealed in part; .CR #1 [AGE] year old female with history of diabetes mellitus type 2, with [MEDICAL CONDITION] and end stage [MEDICAL CONDITION]. CR #1 has an ulcer in the right heel which was not healing. CR #1 was seen by Wound Care MD and admitted directly to the hospital. CR #1 will need to workup for the right heel ulcer. CR #1 already had left foot transmetatarsal amputation done in the past because of the ulcer. She is non-ambulatory mostly bed and wheelchair bound. Physical examination: Right heel which is about 2.5 x 4.0 x 0.9 stage 4. Coccyx has stage 3 which is 2.2 x 1.2 c.m. and right posterior thigh. Assessment and plan: Multiple decubitus ulcers including the right breast abscess, right heel stage 4, and also ulcer in the right coccyx. Will wait for Wound Care MD to give recommendations regarding wound care. Consult Infectious Disease for antibiotics. Continued with the local wound care and follow up with the labs . Record review of Consultation report dated [DATE] revealed in part; Reason for consultation: Right heel ulcer necrotic wound, right heel, deep wound infection. History and present illness: CR #1 is here for right heel wound. MD is planning for procedure tomorrow for debridement of right heel wound. Worsening condition on that right heel and with odor. Vascular Physical Exam: Right foot necrotic right heel wound with eschar, fluctuance probes bone superiorly and odor. Laboratory data: White blood cells: 29.1 thou/cumm (reference 4,500 to 11,000 white blood cells per microliter normal value). Assessment: [MEDICAL CONDITION], right foot, osteo[DIAGNOSES REDACTED] right heel, stage 4 decubitus heel ulcer, diabetes with [MEDICAL CONDITION] and [MEDICAL CONDITIONS], on [MEDICAL TREATMENT]. Plan: Plan for sharp excisional debridement of the right heel ulcer down to and including bone under local and hold anticoagulant . Record review of Wound Care Consult dated [DATE] by Wound Care MD revealed in part: Chief complaint: Right calcaneus pressure injury, right ischial (sitting bone) pressure injury. CR #1 is a [AGE] year old female with past medical history significant for [MEDICAL CONDITION], diabetes and end stage [MEDICAL CONDITION] on [MEDICAL TREATMENT] and [MEDICAL CONDITION]. CR #1 has unfortunately developed right heel, ischial wounds. Surgical history: left foot amputation of toes, vascular intervention lower extremities. Assessment/Plan: Right calcaneus present injury, unstageable. Wound with infection, necrotic tissue and malodor. Extensive tissue injury present with bone exposure noted. Foot is cold to touch. No pulses palpable. Surgical debridement of wound. Flow heel off mattress and protect. Right ischial pressure injury, unstageable. Wounds with yellow slough in the wound base. Low air loss mattress with repositioning every 2 hours . Record review of the Progress notes dated [DATE] revealed in part; Right heel stage 4 ulcer. Plan is for debridement. I will start on [MEDICATION NAME] antibiotic. Awaiting for results of the culture from the right heel wound. I will start on empiric (broad spectrum antibiotics that treat Gram-positive and Gram-negative bacteria) antibiotics. CR #1 is on anticoagulation for [MEDICAL CONDITION] of the right lower extremity . Record review of CR #1's microbiology report dated [DATE] in part; Source: Wound right heel Procedure: Culture wound/Abscess with Gram Stain Gram Stain Report: Many Gram Negative Rods. Moderate Gram Positive Cocci in Pairs and chains. Final report verified on [DATE] Moderate Proteus mirabilis Moderate [DIAGNOSES REDACTED] pneumonia, Multi-drug Resistant Organism Moderate [MEDICATION NAME] Resistant [MEDICATION NAME] Record review of the Operative/Procedure report dated [DATE] revealed in part; Preoperative Diagnosis: [REDACTED].>1.- Ulcer right heel 7.8 x 9.1 x 1.0 c.m. 2.- Abscess/ gas gangrene 3.- peripheral artery disease/[MEDICAL CONDITION] 4.- Ischemic right foot. Procedure performed: Debridement of right heel wound to muscle tendon and capsule. Description of procedure: It was explained to CR #1 and RP in detail that this is a last ditch effort to save her foot. Procedure: A sharp excisional debridement of the right heel was performed utilizing a 15 blade to remove all necrotic and fibrotic debris from the wound. Upon palpation the wound probed to the level capsule and there was a malodorous smell. There was a noted abscess which was drained. There was no blood flow and as much of the eschar cap was removed as possible. The area was then flushed with copious amounts of normal saline. I discussed with CR #1 that she is likely to lose her leg as she now has bogginess at the 5th toe Record review of the Progress notes dated [DATE] revealed in part; Subjective: Right heel ulcer possible gas gangrene. The condition is worsening. Plan: Concern for gas gangrene tracking up the leg. Recommend a below knee amputation however will attempt all limb salvage possible options as blood flow has been returned. Will debride patient heel and foot tomorrow and evaluate all possible options of limb salvage. If the gas is tracking more proximal than the ankle wound recommend a below knee amputation Record review of Emergency/Urgent Care report dated [DATE] at 1:29 p.m. revealed in part; XXX[AGE] year old female that presented to the ICU in need of a below knee amputation following her [DIAGNOSES REDACTED]. She was given fluids to prepare for her surgery and only had one more unit of fluids to take. Moreover, CR #1 had been dialyzed earlier today. Inpatient code blue was called approximately 3 minutes prior to emergency room arrival . In a phone interview on [DATE] at 8:30 p.m. with the Administrator, she stated I know you are here for CR #1. CR #1's RP told us that CR #1 had a massive [MEDICAL CONDITION] after [MEDICAL TREATMENT] one day. In an interview on [DATE] at 1:22 with Wound Care Nurse, LVN A, she stated that CR #1 did not have any wounds to her heels before going to see the Wound Care MD on [DATE]. She then said that at one point, CR #1 came back from the hospital with an unstageable pressure sore to her right heel and that the pressure sore had healed and had become a hard callus but that the right heel skin was intact. She further said that the facility did not have a wound care MD and that she was the one staging wounds and doing the skin assessments of the residents weekly. Further interview at that time with the Wound Care Nurse, LVN A, she said that the last time she saw CR #1's for wound care was on [DATE] (Friday) and that she did not see CR #1 on [DATE] (Monday) because CR #1 had left for the appointment with the Wound Care MD. In an interview on [DATE] at 2:50 p.m. with CNA A, she stated that she remembered CR #1 that used to complain of leg pain. She further said that CR #1 required 2 person assistance for her ADL's. She then said that she remembered doing care to CR #1 and she had some sores in the middle of her legs and inner thighs and had something on her buttocks too that the Wound Care Nurse, LVN A was treating. CNA A continued saying that CR #1 had dressings on her foot but did not remember which one. Further interview at that time, CNA A said that CR #1 would be up in her chair most of the day and that she did not remember any special precautions for CR #1's legs, except that CR #1 would go to bed after dinner. CNA A then said that any new skin conditions are verbally reported to the Wound Care Nurse A and that there were no forms to complete when reporting skin conditions. In an interview on [DATE] at 3:00 p.m. with CNA C, she stated that if they identify a new pressure sore or skin condition on a resident, they are supposed to notify the charge nurse verbally and that there were no special forms to complete when reporting skin conditions. CNA C then said that she knew CR #1 and then said towards the end, before CR #1 left to the hospital, she was hallucinating, she used to say she was seeing people not present. We will get her up at around 9:30 a.m. She would stay up all day. Towards the end, she would just stay in bed. CR #1 had something on her heels. The nurses said were calluses. She had open areas to her buttocks. The CNAs would put cream. Nurses would provide the cream. The Wound Care Nurses were putting bandages. CR #1 was heavy set. She needed 2 people to be moved in bed, she had pain on her legs. When asked if there were any special precautions or recommendations for CR #1, CNA C stated only to be careful with her legs. In an interview on [DATE] at 3:48 p.m. with the DON, she stated that she saw CR #1's right heel on [DATE] when CR #1's RP had a concern for a wound to the right heel. DON then said that what CR #1's RP was referring CR #1 had on her right heel was a callus. DON then said CR #1 did not have any wounds on her heel, was a dry callus only. CR #1's RP requested a wound consult and was done on [DATE]. CR #1 was then admitted to the hospital. When asked why CR #1 was admitted to the hospital, the DON stated I can't speak for that. They are claiming there was the wound on her heel. There was a meeting with CR #1's RP on [DATE] but I was sick. [DATE] was the last time I saw CR #1's right heel. In an interview on [DATE] at 12:24 p.m. with the Wound Care Nurse, LVN A, she stated that she had just finished taking her wound care certification class online and that she was introduced to different types of wound care treatments. When asked if she had a guide where she would refer when treating a pressure sores or wounds, the Wound Care Nurse, LVN A said No, you can have a Stage 4 and you can use the same treatment like for a Stage 2 pressure sore. She further said that CNA's could go to her or the charge nurses to notify any new skin conditions. Further interview on [DATE] at 12:40 p.m. with the DON and the Wound Care Nurse, LVN A, the DON said the last time I saw CR #1's right heel was on [DATE] and the skin was intact, I only saw a callus on her right heel. The Wound Care Nurse, LVN A then said I saw CR #1 on [DATE], on that Monday before she left for her appointment with the Wound Care MD. CR #1's right heel skin was intact, she still had the callus, area was dry and the color of the skin was normal to her skin color. I talked to the Wound Care MD and he did not have any concerns. They admitted CR #1 to the hospital just for observation. At that time the DON said the Wound Care MD did not have any concerns. Continued interview at that time, the Wound Care Nurse, LVN A said that they started treating the right heel with iodine every day because one day that she was working on the floor, CR #1's RP asked the charge nurse for CR #1 to call the MD and get an order and the charge nurse (did not remember who) implemented the order and that when she returned to work the following day, the order was already there. In an interview on [DATE] at 1:00 p.m. with the DON, she stated that facility staff would usually do a complete head to toe skin assessment when a resident gets transfered to the hospital. DON then said that it was not required to do a complete head to toe skin assessment when residents just go out of the facility for appointments. DON further said that when CNA's report a new skin condition or any type of skin condition, they go directly to the Wound Care Nurse and verbally report the concern. Further interview at that time, the DON stated that the Wound Care Nurse, LVN A was in charge of doing the Braden Scale for predicting pressure sore risk assessments and said that CR #1 had her assessment done on [DATE] and was not due to get another assessment until [DATE]. When asked if residents get assessed again their Braden Scale for predicting pressure sore risk when they develop a new pressure sore, the DON sai(TRUNCATED)

Based on observation, interview and record review, the facility failed to ensure that residents have the right to be free from neglect for 7 of 12 residents (CR #1, Resident #6, #7, #8, #9, #10 and #11) reviewed for neglect. -The facility failed to accurately assess CR #1's pressure sore to her right heel when was identified as a callus. The facility failed to provide the appropriate treatment, complete assessment, consult with the physician and implement preventive measures to avoid the worsening of the pressure sore. -The facility failed to provide CR #1, who had a Stage 4 pressure sore to her buttocks, with a turning a repositioning schedule when she was left for long periods of time on his wheelchair, resulting in CR #1 being admitted to the hospital with [REDACTED]. -CR #1 was admitted to the hospital with [REDACTED]. -CR #1 was diagnosed with [REDACTED]. CR #1 died prior to surgery. -The facility failed to identify Resident #6, #7, #8, #9, #10 and 11's abnormal skin conditions and did not provide treatment until surveyor intervention. These failures further resulted in an identification of an Immediate Jeopardy (IJ) on [DATE]. While the IJ was lowered on [DATE], the facility remained out of compliance at the severity of actual harm that is not immediate jeopardy with a scope identified as pattern due to the facility's need to evaluate the effectiveness of the corrective systems. These failures affected one former resident (CR #1) and six residents currently residing at the facility (Resident #6, #7, #8, #9, #10 and #11) and had the potential to place the other 20 residents identified as diabetic at risk for unidentified pressure sores, worsening of existing pressure sores, infections, pain, unnecessary hospital stays, extensive treatments and death. Findings included: TX,[DATE] and TX,[DATE] CR # 1 Record review of the medical record face sheet revealed CR #1 was admitted on [DATE] and re-admitted on [DATE]. [DIAGNOSES REDACTED]. disease and encounter for adequacy testing for [MEDICAL TREATMENT]. She was [AGE] years old. Record review of CR#1's clinical record revealed she had appointment with wound MD on [DATE] per RP request and was immediately transferred to a local hospital from the MD office. CR #1 was admitted with [DIAGNOSES REDACTED]. Record review of CR #1's care plan initiated [DATE] revealed in part: -Focus: CR #1 has potential impairment to skin integrity of the peri-area/buttocks related to use/side effects of medications and to bilateral feet related to [MEDICAL CONDITION], previous ulcers, diabetes mellitus. -Goal: CR #1 will maintain or develop clean and intact skin. -Interventions: *Encourage good nutrition and hydration in order to promote healthier skin. *Follow facility protocols for treatment of [REDACTED]. *Weekly treatment documentation to include measurements of each area of skin breakdown's width, length, depth, type of tissue and exudate and any other notable changes or observations. Record review of Braden Scale for predicting pressure sore risk for CR #1 dated [DATE] revealed a score of 12 indicating high risk. Record review of the significant change in status MDS assessment reference date of [DATE] revealed CR #1 had a BIMS score of 13 out of a possible 15, indicating she was cognitive intact. CR #1 required extensive assistance of two plus person physical assist for bed mobility and required extensive assistance of one person physical assist for dressing, personal hygiene and toilet use. CR #1 was independent with set up only for eating. She had functional limitation to one side of her lower extremity. CR #1 was always incontinent of both bowel and bladder. Further record review revealed CR#1 had one stage 4 pressure ulcer that was facility acquired that measured 0.8 x 0.1 c.m. CR #1 was identified at risk of developing a pressure ulcer and she was not on a pressure reducing device for a chair or for bed. CR #1 was not on a turning /repositioning program. Further record review of Braden Scale for predicting pressure sore risk for CR #1 dated [DATE] revealed a score of 13 indicating moderate risk. Continued record review of CR#1's care plan revised [DATE] revealed in part: -Focus: CR#1 has potential for pressure ulcer development related to history of ulcers, immobility. Stage 2 to right heel resolved [DATE]. Re-admitted on [DATE] with unstageable right heel resolved [DATE]. readmitted with stage 4 to right buttocks. -Goal last revised [DATE]: CR#1 will remain infection free by/through review date of [DATE]. -Interventions dated [DATE]: *The resident requires the bed as flat as possible to reduce shear. The resident prefers to be repositioned with 2 people, lifter, slider. *Educate the resident/family/caregivers as to causes of skin breakdown; including transfer/positioning requirements; importance of taking care during ambulation/mobility, good nutrition and frequent repositioning. *Follow facility policies/protocols for the prevention/treatment of [REDACTED].*Instruct/assist to shift weight of resident while in wheelchair. Further record review of Interventions dated [DATE]: *CR #1 requires air-mattress on bed. Record review of the skin assessment for CR#1 revealed: -[DATE] at 11:02 a.m. revealed in part Callous to right heel, scar tissue to left and right inner thighs. Skin otherwise intact. Signed by Wound Care Nurse, LVN A. Record review of CR #1's transfer form revealed in part: -[DATE] at 10:47 a.m. Skin Condition: Clear. Record review of CR #1's progress (nurses) notes revealed; -[DATE] at 11:15 a.m. CR #1 returned from [MEDICAL TREATMENT] complaining of increased leg pain to lower extremities. Pain 9 out of 10. MD recommended a transfer to the local emergency room . -[DATE] at 9:00 p.m. CR #1 returned from emergency room . [MEDICATION NAME] 4 mg IM was given at the hospital. Medications to continue with no changes. Instructions for follow up with private MD and patient education material for Neuropathic pain were given . Further record review revealed no skin assessments or documentation indicating that CR #1 was readmitted back to the facility with any pressure sore. Record review of the skin assessment for CR #1 revealed in part: -[DATE] at 2:15 p.m. Right buttock Pressure. Stage 4. 5x4 c.m. (LxW). Notes: Moisture damage to left inner thigh. Stage 4 to right buttocks, dry intact callous to right heel Signed by Wound Care Nurse, LVN A. Further record review revealed no further assessment of the pressure sore. Record review of CR #1's progress (nurses) notes dated [DATE] revealed no assessments or further information related to right buttocks Stage 4 pressure sore. Record review of CR #1's MD orders dated [DATE] revealed in part: Apply [MEDICATION NAME] skin protectant paste to left inner thigh and buttocks every day. Record review of www.allegromedical.com/skin-care-/remedy-[MEDICATION NAME]-protectant-paste-4-oz.html / [MEDICATION NAME] Protectant Paste is a zinc oxide-based barrier paste/cream that protects against moisture and minor irritation. Record review of CR #1's electronic Treatment Administration Record revealed dated [DATE] revealed in part; -Apply [MEDICATION NAME] skin protectant paste to left inner thigh and buttocks every day shift. Start date [DATE]. Continued record review of the skin assessment for CR #1 revealed in part: -[DATE] at 11:17 a.m. Special Equipment/Preventative measures: Air mattress. Location: Right buttocks. Pressure. Stage 4. 5x4 c.m. (LxW). Indicate whether this site was acquired during residents stay or whether it was present on admission: admitted . Treatment: 2.- Current treatment plan: [REDACTED] Signed by Wound Care Nurse, LVN A. Record review of the consolidated MD orders dated [DATE] revealed no MD orders for Collagen to right buttocks. Record review of CR #1's electronic Treatment Administration Record dated [DATE] revealed that CR #1's stage 4 pressure sore to her right buttocks was not treated with Collagen as indicated in the skin assessment dated [DATE]. Record review of https://www.healthproductsforyou.com/c-collagen-dressings.html/Collagen dressings are meant for wounds with minimal to heavy exudates and also partial- and full-thickness wounds. They stimulate new tissue growth and help to heal necrotic wounds. Most collagen dressings have antimicrobial agents incorporated to limit spread of infections. Collagen dressings speed up the recovery period due to the growth of new collagen at the wound site. In an interview on [DATE] at 1:22 p.m. with Wound Care Nurse, LVN A, she said that the stage 4 pressure sore that was found to her right buttocks on [DATE] was admitted from the hospital when CR #1 went to the hospital on [DATE]. Wound Care Nurse, LVN A then said that CR #1's stage 4 pressure sore to her right buttocks had been treated with Collagen every day. When asked about the order for Collagen for CR #1's stage 4 pressure sore, Wound Care Nurse, LVN A stated as she looked at the computer I don't see it. I don't know why. Further interview on [DATE] at 1:34 p.m., Wound Care Nurse, LVN A, she stated that CR #1 stayed at the hospital on [DATE] for several hours and that she probably got the pressure sore while in the ambulance or in the hospital. She then said that the facility did not do a body assessment when CR #1 returned from the hospital on [DATE] and that she found the Stage 4 pressure sore to CR #1's right buttocks during weekly skin assessment on [DATE]. When asked if anyone had reported any skin issues on CR #1 from [DATE] to [DATE], the Wound Care Nurse, LVN A responded No. When asked what interventions she implemented on [DATE] when CR #1's was assessed with [REDACTED].#1 on an air mattress on [DATE] but I did not write the order until [DATE]. In an interview on [DATE] at 2:00 p.m. with the DON, she stated CR #1 developed the Stage 4 pressure sore to her right buttocks while in the hospital. When asked about any assessment that would indicate that CR #1 acquired the pressure sore at the hospital, the DON said We don't have to do skin assessments when residents return from the hospital, facility staff did a detailed assessment before CR #1 went to the hospital on [DATE]. DON continued saying that Braden Scale for predicting pressure sore risk are completed only during new admissions, then weekly x4, quarterly and annual. DON then said but will check the policy about Braden Scale for predicting pressure sore risk assessments. Record review of CR #1's progress (nurses) notes revealed in part; -[DATE] at 7:48 p.m. .air mattress placed on bed today -[DATE] at 11:22 p.m. CR #1 confused tonight, talks about people in the room with her, behind her roommate's desk. Thinks they are hiding behind the curtain. CR #1 stated there is nothing wrong with her . Record review of CR #1's MD orders revealed in part; -[DATE] Clean right heel with normal saline, dry, apply iodine cover with non- adherent dressing and wrap with [MEDICATION NAME] every day one time a day. Order changed on [DATE]. Record review of CR #1's electronic Treatment Administration Record revealed dated [DATE] revealed in part; -Clean right heel with normal saline, dry, apply iodine, cover with non adherent dressing and wrap with [MEDICATION NAME]. Every day one time a day. Start date [DATE]. Continued record review of CR #1's progress (nurses) notes revealed in part; -[DATE] at 4:51 p.m. CR#1 talking to people in room not present. She stated there were children running around in her room screaming MD notified of condition. -[DATE] at 4:08 p.m. Spoke with CR #1's RP regarding concerns of wound to right heel and set up care plan meeting. Informed that what she was referring to as a wound was actually callous from history of wound. CR #1's RP inquired about getting CR #1 set as an out-patient with wound care and if we can transport her there. Will follow up with CR #1's RP regarding this appointment and whether or not we can transport CR #1 . Signed by DON. Record review of CR #1's MD orders revealed in part; -[DATE] Clean right heel with normal saline, dry, apply iodine cover with non- adherent dressing and wrap with [MEDICATION NAME] every day shift. Record review of CR #1's electronic Treatment Administration Record revealed dated [DATE] revealed in part; -Clean right heel with normal saline, dry, apply iodine, cover with non adherent dressing and wrap with [MEDICATION NAME]. Every day on every day shift. Start date [DATE]. Record review of CR #1's progress (nurses) notes revealed in part; -[DATE] at 1:00 p.m. CR #1 noted with increased confusion today, noted conversing with self. MD notified with new order to check ammonia level in A.M . -[DATE] at 10:58 a.m. .Care Plan meeting today with CR #1's RP. Discussed pain management, wound treatments . Record review of document titled Complaint Resolution Record dated [DATE] revealed in part: . Patient name: CR #1. Person making report: CR #1's RP. Concern: Wounds. Action: CR #1 to see wound care MD. Resolution: CR #1 sent to wound care MD and admitted to hospital. Upon return will follow up with RP . Signed by Administrator. Record review of CR #1's MD orders revealed in part; -[DATE] Clean right arm pit boil with normal saline, pat dry, apply triple antibiotic ointment and cover with dry dressing every day and as needed loose/soiled every day shift. -[DATE] Heel protectors to bilateral heels while in bed as tolerated every shift. -[DATE] Check function of air-mattress every shift. Further record review of the skin assessment for CR #1 revealed in part: -[DATE] at 8:31 a.m. Special Equipment/Preventative measures: Air mattress, hell protectors, wedge under ankles. Location: Right buttocks. Pressure. Stage 4. 5x4 c.m. (LxW). Original stage: Stage 4. Indicate whether this site was acquired during residents stay or whether it was present on admission: admitted . Treatment: 1.- Describe any changes to treatment plan in the last week: Zinc everyday. 2.- Current treatment plan: [REDACTED]. Record review of CR #1's electronic Treatment Administration Record revealed that CR #1's stage 4 pressure sore to her right buttocks wound care treatment was never changed to Collagen per skin assessment reports dated [DATE] and [DATE]. Continued record review of the skin assessment for CR #1 revealed in part: -[DATE] at 8:40 a.m. Special Equipment/Preventative measures: Air mattress, heel protectors, wedge under ankles. Location: Right heel. Specify: Dry intact callous. 3x3c.m. (LxW). Indicate whether this site was acquired during residents stay or whether it was present on admission: admitted on [DATE]. Wound edges irregular. 2.- Current treatment plan: [REDACTED] Comments: CR #1 had re-admitted on [DATE] with an unstageable pressure ulcer 4x4 (c.m.) eschar encompasses approx 2x2 (c.m) middle area. Area turned to full eschar than scabbed to a callous as of [DATE] . Signed by Wound Care Nurse, LVN A. Record review of Nutrition/Dietary notes revealed in part; -[DATE] at 3:29 p.m. CR #1 with a stage 4 wound to her right buttocks. Recommendations: Start Nepro every day, vitamin C 500 mg twice a day for 30 days, Zinc Sulfate 220 mg every day for 14 days. Goal: Wound to resolve Record review of CR #1's progress (nurses) notes revealed in part; -[DATE] at 2:34 p.m. Discharge Summary: CR #1 was admitted to a local hospital by the wound care MD for wound evaluation and treatment . -[DATE] at 3:30 p.m. -Late entry on [DATE] at 8:26 a.m. Spoke with Wound Care MD in regards to CR #1's wound on the heel and the boil under the right arm. No concerns stated at this time. Will follow up on [DATE] for an update . Signed by Wound Care Nurse, LVN A. In a phone interview on [DATE] at 10:14 a.m. with the Wound Care MD, he stated that CR #1 visited his office on [DATE] and that his PA (Physician Assistant) saw her. He further said the assessments for [DATE]'s visit read 'right calcaneus (large bone forming the heel) unstageable, strong malodorous present, extensive tissue injury present, cold to touch, wound infection, maceration noted, at risk to loose limb. Necrotic liquefying tissue consistent with gangrene. Wound Care MD further said when CR #1 went to our office, we realized that the foot was in immediate trouble, she had necrotic liquefying tissue consistent with gangrene. CR #1's foot was in trouble, we immediately transferred her to the hospital. I saw CR #1 the next day. When she came to the hospital on [DATE], CR #1 was septic, her white blood cell count was 26 thousand (reference 4,500 to 11,000 white blood cells per microliter normal value). The nursing home wanted my notes but I told them I needed family consent. Further interview with the Wound Care MD, he said this situation does not happen over night. When I saw her the next day on [DATE], I saw her right heel. It was infected, the whole foot was turning necrotic, she had bone exposure notable. I removed eschar tissue the next day on [DATE]. CR#1 was started immediately with IV antibiotics from admission to the hospital. I understand CR #1 later died . [MEDICAL CONDITION], you are going to lose the ability to maintain blood pressure and that's going to lead to [MEDICAL CONDITION]. Record review of CR #1's wound assessment dated [DATE] revealed in part; (from Wound Care MD office) PA Visit: -Right heel: 2.5 x 4.0 x 0.3 c.m. (LxWxD). Undermining: 3 o'clock to 9 o'clock 2.7 c.m. Pressure. Stage 4. Structure exposed: Bone. Odor: Yes. Drainage: Purulent. % of wound bed covered in slough, [MEDICATION NAME], necrotic tissue: 76 - 100%. Wound base color: Black and yellow. Granulation tissue: none. -Coccyx: 2.2 x 1.2 x 0.0 c.m. (LxWxD). Pressure. Stage 3. Drainage: serous. Wound base: red. Periwound: denuded. -Right posterior thigh: 3.8 x 2.0 x 0.0 c.m. (LxWxD). Pressure. Stage 3. Drainage: serous. Wound base: red. -Right 4th and 5th toes interspace: serosanguineous drainage. Periwound: macerated. -Right breast abscess: Drainage: copious purulent. Periwound: [DIAGNOSES REDACTED]. Record review of the hospital History and Physical dated [DATE] revealed in part; .CR #1 [AGE] year old female with history of diabetes mellitus type 2, with [MEDICAL CONDITION] and end stage [MEDICAL CONDITION]. CR #1 has an ulcer in the right heel which was not healing. CR #1 was seen by Wound Care MD and admitted directly to the hospital. CR #1 will need to workup for the right heel ulcer. CR #1 already had left foot transmetatarsal amputation done in the past because of the ulcer. She is non-ambulatory mostly bed and wheelchair bound. Physical examination: Right heel which is about 2.5 x 4.0 x 0.9 stage 4. Coccyx has stage 3 which is 2.2 x 1.2 c.m. and right posterior thigh. Assessment and plan: Multiple decubitus ulcers including the right breast abscess, right heel stage 4, and also ulcer in the right coccyx. Will wait for Wound Care MD to give recommendations regarding wound care. Consult Infectious Disease for antibiotics. Continued with the local wound care and follow up with the labs . Record review of Consultation report dated [DATE] revealed in part; Reason for consultation: Right heel ulcer necrotic wound, right heel, deep wound infection. History and present illness: CR #1 is here for right heel wound. MD is planning for procedure tomorrow for debridement of right heel wound. Worsening condition on that right heel and with odor. Vascular Physical Exam: Right foot necrotic right heel wound with eschar, fluctuance probes bone superiorly and odor. Laboratory data: White blood cells: 29.1 thou/cumm (reference 4,500 to 11,000 white blood cells per microliter normal value). Assessment: [MEDICAL CONDITION], right foot, osteo[DIAGNOSES REDACTED] right heel, stage 4 decubitus heel ulcer, diabetes with [MEDICAL CONDITION] and [MEDICAL CONDITIONS], on [MEDICAL TREATMENT]. Plan: Plan for sharp excisional debridement of the right heel ulcer down to and including bone under local and hold anticoagulant . Record review of Wound Care Consult dated [DATE] by Wound Care MD revealed in part: Chief complaint: Right calcaneus pressure injury, right ischial (sitting bone) pressure injury. CR #1 is a [AGE] year old female with past medical history significant for [MEDICAL CONDITION], diabetes and end stage [MEDICAL CONDITION] on [MEDICAL TREATMENT] and [MEDICAL CONDITION]. CR #1 has unfortunately developed right heel, ischial wounds. Surgical history: left foot amputation of toes, vascular intervention lower extremities. Assessment/Plan: Right calcaneus present injury, unstageable. Wound with infection, necrotic tissue and malodor. Extensive tissue injury present with bone exposure noted. Foot is cold to touch. No pulses palpable. Surgical debridement of wound. Flow heel off mattress and protect. Right ischial pressure injury, unstageable. Wounds with yellow slough in the wound base. Low air loss mattress with repositioning every 2 hours . Record review of the Progress notes dated [DATE] revealed in part; Right heel stage 4 ulcer. Plan is for debridement. I will start on [MEDICATION NAME] antibiotic. Awaiting for results of the culture from the right heel wound. I will start on empiric (broad spectrum antibiotics that treat Gram-positive and Gram-negative bacteria) antibiotics. CR #1 is on anticoagulation for [MEDICAL CONDITION] of the right lower extremity . Record review of CR #1's microbiology report dated [DATE] in part; Source: Wound right heel Procedure: Culture wound/Abscess with Gram Stain Gram Stain Report: Many Gram Negative Rods. Moderate Gram Positive Cocci in Pairs and chains. Final report verified on [DATE] Moderate Proteus mirabilis Moderate [DIAGNOSES REDACTED] pneumonia, Multi-drug Resistant Organism Moderate [MEDICATION NAME] Resistant [MEDICATION NAME] Record review of the Operative/Procedure report dated [DATE] revealed in part; Preoperative Diagnosis: [REDACTED].>1.- Ulcer right heel 7.8 x 9.1 x 1.0 c.m. 2.- Abscess/ gas gangrene 3.- peripheral artery disease/[MEDICAL CONDITION] 4.- Ischemic right foot. Procedure performed: Debridement of right heel wound to muscle tendon and capsule. Description of procedure: It was explained to CR #1 and RP in detail that this is a last ditch effort to save her foot. Procedure: A sharp excisional debridement of the right heel was performed utilizing a 15 blade to remove all necrotic and fibrotic debris from the wound. Upon palpation the wound probed to the level capsule and there was a malodorous smell. There was a noted abscess which was drained. There was no blood flow and as much of the eschar cap was removed as possible. The area was then flushed with copious amounts of normal saline. I discussed with CR #1 that she is likely to lose her leg as she now has bogginess at the 5th toe Record review of the Progress notes dated [DATE] revealed in part; Subjective: Right heel ulcer possible gas gangrene. The condition is worsening. Plan: Concern for gas gangrene tracking up the leg. Recommend a below knee amputation however will attempt all limb salvage possible options as blood flow has been returned. Will debride patient heel and foot tomorrow and evaluate all possible options of limb salvage. If the gas is tracking more proximal than the ankle wound recommend a below knee amputation Record review of Emergency/Urgent Care report dated [DATE] at 1:29 p.m. revealed in part; XXX[AGE] year old female that presented to the ICU in need of a below knee amputation following her [DIAGNOSES REDACTED]. She was given fluids to prepare for her surgery and only had one more unit of fluids to take. Moreover, CR #1 had been dialyzed earlier today. Inpatient code blue was called approximately 3 minutes prior to emergency room arrival . In a phone interview on [DATE] at 8:30 p.m. with the Administrator, she stated I know you are here for CR #1. CR #1's RP told us that CR #1 had a massive [MEDICAL CONDITION] after [MEDICAL TREATMENT] one day. In an interview on [DATE] at 1:22 with Wound Care Nurse, LVN A, she stated that CR #1 did not have any wounds to her heels before going to see the Wound Care MD on [DATE]. She then said that at one point, CR #1 came back from the hospital with an unstageable pressure sore to her right heel and that the pressure sore had healed and had become a hard callus but that the right heel skin was intact. She further said that the facility did not have a wound care MD and that she was the one staging wounds and doing the skin assessments of the residents weekly. Further interview at that time with the Wound Care Nurse, LVN A, she said that the last time she saw CR #1's for wound care was on [DATE] (Friday) and that she did not see CR #1 on [DATE] (Monday) because CR #1 had left for the appointment with the Wound Care MD. In an interview on [DATE] at 2:50 p.m. with CNA A, she stated that she remembered CR #1 that used to complain of leg pain. She further said that CR #1 required 2 person assistance for her ADL's. She then said that she remembered doing care to CR #1 and she had some sores in the middle of her legs and inner thighs and had something on her buttocks too that the Wound Care Nurse, LVN A was treating. CNA A continued saying that CR #1 had dressings on her foot but did not remember which one. Further interview at that time, CNA A said that CR #1 would be up in her chair most of the day and that she did not remember any special precautions for CR #1's legs, except that CR #1 would go to bed after dinner. CNA A then said that any new skin conditions are verbally reported to the Wound Care Nurse A and that there were no forms to complete when reporting skin conditions. In an interview on [DATE] at 3:00 p.m. with CNA C, she stated that if they identify a new pressure sore or skin condition on a resident, they are supposed to notify the charge nurse verbally and that there were no special forms to complete when reporting skin conditions. CNA C then said that she knew CR #1 and then said towards the end, before CR #1 left to the hospital, she was hallucinating, she used to say she was seeing people not present. We will get her up at around 9:30 a.m. She would stay up all day. Towards the end, she would just stay in bed. CR #1 had something on her heels. The nurses said were calluses. She had open areas to her buttocks. The CNAs would put cream. Nurses would provide the cream. The Wound Care Nurses were putting bandages. CR #1 was heavy set. She needed 2 people to be moved in bed, she had pain on her legs. When asked if there were any special precautions or recommendations for CR #1, CNA C stated only to be careful with her legs. In an interview on [DATE] at 3:48 p.m. with the DON, she stated that she saw CR #1's right heel on [DATE] when CR #1's RP had a concern for a wound to the right heel. DON then said that what CR #1's RP was referring CR #1 had on her right heel was a callus. DON then said CR #1 did not have any wounds on her heel, was a dry callus only. CR #1's RP requested a wound consult and was done on [DATE]. CR #1 was then admitted to the hospital. When asked why CR #1 was admitted to the hospital, the DON stated I can't speak for that. They are claiming there was the wound on her heel. There was a meeting with CR #1's RP on [DATE] but I was sick. [DATE] was the last time I saw CR #1's right heel. In an interview on [DATE] at 12:24 p.m. with the Wound Care Nurse, LVN A, she stated that she had just finished taking her wound care certification class online and that she was introduced to different types of wound care treatments. When asked if she had a guide where she would refer when treating a pressure sores or wounds, the Wound Care Nurse, LVN A said No, you can have a Stage 4 and you can use the same treatment like for a Stage 2 pressure sore. She further said that CNA's could go to her or the charge nurses to notify any new skin conditions. Further interview on [DATE] at 12:40 p.m. with the DON and the Wound Care Nurse, LVN A, the DON said the last time I saw CR #1's right heel was on [DATE] and the skin was intact, I only saw a callus on her right heel. The Wound Care Nurse, LVN A then said I saw CR #1 on [DATE], on that Monday before she left for her appointment with the Wound Care MD. CR #1's right heel skin was intact, she still had the callus, area was dry and the color of the skin was normal to her skin color. I talked to the Wound Care MD and he did not have any concerns. They admitted CR #1 to the hospital just for observation. At that time the DON said the Wound Care MD did not have any concerns. Continued interview at that time, the Wound Care Nurse, LVN A said that they started treating the right heel with iodine every day because one day that she was working on the floor, CR #1's RP asked the charge nurse for CR #1 to call the MD and get an order and the charge nurse (did not remember who) implemented the order and that when she returned to work the following day, the order was already there. In an interview on [DATE] at 1:00 p.m. with the DON, she stated that facility staff would usually do a complete head to toe skin assessment when a resident gets transfered to the hospital. DON then said that it was not required to do a complete head to toe skin assessment when residents just go out of the facility for appointments. DON further said that when CNA's report a new skin condition or any type of skin condition, they go directly to the Wound Care Nurse and verbally report the concern. Further interview at that time, the DON stated that the Wound Care Nurse, LVN A was in charge of doing the Braden Scale for predicting pressure sore risk assessments and said that CR #1 had her assessment done on [DATE] and was not due to get another assessment until [DATE]. When asked if residents get assessed again their Braden Scale for predicting pressure sore risk when they develop a new pressure sore, the DON said I need to see. DON continued saying that the facility used the guidelines from the National Pressure Ulcer Advisory Panel as a wound care guide. In an interview on [DATE] at 9:15 a.m. with the DON and Wound Care Nurse, LVN A, the DON stated that she did not have the phone number for the Wound Care MD that treated CR #1. The Wound Care Nurse, LVN A, then said I only have a cell phone number and I am

Based on interview and record review, the facility failed to provide laboratory services as ordered for 1 of 5 residents reviewed for laboratory services. (CR #1) - The facility failed to complete a laboratory order for a leg x-ray for CR #1 when she reported that she twisted her ankle during a transfer. This failure affected 1 former resident and placed 62 residents at risk of not receiving treatment in a timely manner which could lead to complications and hospitalization . Findings include: Intake # 2 CR#1 Record review of CR #1 ' s medical record revealed she was admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. She was [AGE] years of age. She was discharged from the facility on 3/25/2016. Record review of CR #1 ' s quarterly MDS assessment dated [DATE] revealed she had a BIMS score of 13, indicating no cognitive impairment. Further review of the MDS assessment revealed she required extensive assistance of 2 people for bed mobility and total assistance of 2 people for transfers. She weighed 140 pounds. Record review of CR #1 ' s Care Plan dated 1/2/2016 revealed she required assistance with activities of daily living. She required extensive assistance with bathing, dressing personal hygiene, toileting and transfers. The care plan did not indicate how many people were required to assist with the tasks. The care plan was revised on 3/28/2016 to indicate she required extensive assistance of two people with a hoyer lift for transfers. Record review of CR #1 ' s Progress Notes revealed the following: - 3/21/2016 at 11:40pm written by Unit Manager A: Called to patient room. Patient complaining of pain in left leg, hip area. States that it is too painful to rotate leg and required 2 staff members to change brief. Patient states that she felt that ' ankle was sprain ' during transfer from wheelchair to bed. Orders received for xray of left hip and leg. Xrays shows modest [MEDICAL CONDITION] with no fracture. Patient requesting she receive pain medication. Patient currently received Tylenol four times a day . Record review of a physician's order [REDACTED]. Record review of a Radiology Report dated 3/21/2016 at 9:41pm revealed an image of CR #1 ' s hip and pelvis that showed no fracture. There was modest [MEDICAL CONDITION] of the left hip. Record review of a Witness Statement dated 3/28/2016 written by CNA A revealed that she transferred CR #1 from her wheelchair to the bed. She put her arms on my sholder (sic) and I chought (sic) her pants and lifted her did ' ent (sic) notice a problem at the time . A Witness Statement dated 3/31/2016 written by the DON interviewing CNA A revealed CR #1 complained of left knee pain during the transfer on 3/21/2016, and once she was in bed she no longer complained of pain. In an interview on 4/12/2016 at 1:00pm, Unit Manager A said she assessed CR #1 on 3/21/2016 after she complained of pain. She said CR #1 said she thought she twisted her ankle when she was put to bed. She said she was transferred around 3:00pm, and complained of pain around 7:00pm. She said she assessed her leg, and did not notice any bruises or swelling. She said CR #1 ' s left leg was always contracted and had a foot drop, so it was difficult to assess. She said she called the physician and received an order for [REDACTED]. She said the technician stated that they could not straighten or position her leg for the x-ray. She said she did not think anything of it until later when she realized they only received partial results. In an interview on 4/12/2016 at 3:12pm, Unit Manager A confirmed that she did not notify the physician that the leg x-ray was not completed. Record review of a Witness Statement dated 3/26/2016 written by LVN B read in part . On 3/22/16 I worked that hall and was told in report by night nurse that pt was (complaining) of (pain) to (left) leg and x-ray showed [MEDICAL CONDITION] .Reported this to unit manager and told her about x-ray (complaints of lower level extremity pain) . Record review of a Witness Statement dated 3/31/2016 written by the DON interviewing LVN D read in part . Tuesday night (3/22/16).(Received) in report res (complained of) left leg pain- xrays were negative. Resident (received) scheduled (Tylenol) and left leg positioned on pillows both interventions were effective and pain relieved. In an interview on 4/12/2016 at 2:30pm, CNA C said she cared for CR #1 the week she went to the hospital (3/21/2016-3/24/2016). She said on 3/21/2016, CR #1 told her that her hip, leg and ankle hurt after she was transferred. She said she notified Unit Manager A. She said she heard the x-ray came back negative. She said the next day, CR #1 asked, If my ankle is sprained, would it show up on the x-ray? She said she spoke to Unit Manager A who said it sounded like arthritis. Record review of a physician's order [REDACTED].#1 was sent to the hospital due to shortness of breath and altered mental status. Record review of CR #1 ' s hospital records dated 3/25/2016 revealed she had swelling throughout her left ankle, knee and leg, and had a [MEDICAL CONDITION] tibia and fibula. In an interview on 4/12/2016 at 2:25pm, the DON said she was not sure why staff nurses did not follow up with the leg x-ray. She said she was only made aware of the incident after she was sent to the hospital. She said she called the x-ray company and they said they only had record of one x-ray being ordered. She said the company did note that an x-ray was requested for both the leg and the hip. A policy for lab services was requested, but not provided by the time of exit. According to the facility census, there were 62 residents residing on the 200 hall.

Based on observation, interview, and record review the facility failed to ensure one of five residents (CR #1) reviewed for quality of care received the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being in that: - CR #1 reported that she twisted her ankle during a transfer. X-rays of her hip and leg were ordered, but the leg x-ray was not completed and the physician was not notified the ordered leg x-ray was not completed. - CR #1 continued to complain of pain to her leg for 3 days and she was sent to the hospital due to altered mental status, nausea and diarrhea. X-ray's taken at the hospital revealed a fracture of left tibia and fibula. This failure affected 1 former resident and placed 78 residents who needed assistance with transfers at risk of not receiving care and services for a change of condition which could lead to a delay in treatment, complications, and hospitalization . Findings Include: Intake # 2 CR#1 Record review of CR #1 ' s medical record revealed she was admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. She was [AGE] years of age. She was discharged from the facility on 3/25/2016. Record review of CR #1 ' s quarterly MDS assessment dated [DATE] revealed she had a BIMS score of 13, indicating no cognitive impairment. Further review of the MDS assessment revealed she required extensive assistance of 2 people for bed mobility and total assistance of 2 people for transfers. She weighed 140 pounds. Record review of CR #1 ' s Care Plan dated 1/2/2016 revealed she required assistance with activities of daily living. She required extensive assistance with bathing, dressing personal hygiene, toileting and transfers. The care plan did not indicate how many people were required to assist with the tasks. The care plan was revised on 3/28/2016 to indicate she required extensive assistance of two people with a hoyer lift for transfers. Record review of her ADL Records dated 3/8/2016 to 3/25/2016 revealed the following: - She required limited assistance of one person during transfers on 3/9/2016 at 3:40am, 3/9/2016 at 11:05pm, and 3/25/2016 at 9:33pm. - She required extensive assistance of one person during transfers on 3/9/2016 at 8:37am, 3/9/2016 at 9:59pm, 3/13/2016 at 12:17pm, and 3/17/2016 at 8:58pm. - She required total assistance of one person during transfers on 3/18/2016 at 7:49am, 3/19/2016 at 12:54am, 3/22/2016 at 7:38am, and 3/25/2016 at 12:21pm. - She required extensive assistance of two people during a transfer on 3/19/2016 at 1:32pm. - She required total assistance of two people during transfers on 3/10/2016 at 12:26pm, 3/14/2016 at 10:20am, 3/21/2016 at 1:59pm, 3/15/2016 at 12:29pm, and 3/20/2016 at 1:59pm. Record review of CR #1 ' s physician's order [REDACTED]. Record review of a MAR indicated [REDACTED]. She received another dose of Tylenol 500mg on 3/25/2016 at 10:00am for pain rated at 8 out of 10. Further review of CR #1 ' s MAR indicated [REDACTED]. There was no pain observed between 3/1/2016 and 3/25/2016. Record review of CR #1 ' s Progress Notes revealed the following: - 3/21/2016 at 11:40pm written by Unit Manager A: Called to patient room. Patient complaining of pain in left leg, hip area. States that it is too painful to rotate leg and required 2 staff members to change brief. Patient states that she felt that ' ankle was sprain ' during transfer from wheelchair to bed. Orders received for xray of left hip and leg. Xrays shows modest [MEDICAL CONDITION] with no fracture. Patient requesting she receive pain medication. Patient currently received Tylenol four times a day . - 3/23/2016 at 5:21am: Resident noted with nausea, vomiting and 3 large formed (bowel movements) . Resident has a new order and was medicated with [MEDICATION NAME] (a medication to treat nausea) as ordered with little results noted at this time. - 3/24/2016 at 10:00am: Resident observed hallucinating and reaching for non existing objects. Vital signs stable, afebrile . Urine specimen collected at 10:30am . - 3/25/2016 at 6:28pm: Resident with altered mental status, nausea, loose diarrhea, (oxygen) 88 .glucose read 299 for (4:00 PM). Doctor order to be sent out . Record review of a Witness Statement dated 3/28/2016 written by CNA A revealed that she transferred CR #1 from her wheelchair to the bed. She put her arms on my sholder (sic) and I chought (sic) her pants and lifted her did ' ent (sic) notice a problem at the time . A Witness Statement dated 3/31/2016 written by the DON interviewing CNA A revealed CR #1 complained of left knee pain during the transfer on 3/21/2016, and once she was in bed she no longer complained of pain. In an interview on 4/12/2016 at 1:00pm, Unit Manager A said she assessed CR #1 on 3/21/2016 after she complained of pain. She said CR #1 said she thought she twisted her ankle when she was put to bed. She said she was transferred around 3:00pm, and complained of pain around 7:00pm. She said she assessed her leg, and did not notice any bruises or swelling. She said CR #1 ' s left leg was always contracted and had a foot drop, so it was difficult to assess. She said she called the physician and received an order for [REDACTED]. She said the technician stated that they could not straighten or position her leg for the x-ray. She said she did not think anything of it until later when she realized they only received partial results. She said she checked with her at 6:00am the next morning and she did not complain of pain. Record review of a physician's order [REDACTED]. In an interview on 4/12/2016 at 3:12pm, Unit Manager A confirmed that she did not notify the physician that the leg x-ray was not completed. Record review of a Radiology Report dated 3/21/2016 at 9:41pm revealed an image of CR #1 ' s hip and pelvis that showed no fracture. There was modest [MEDICAL CONDITION] of the left hip. Record review of a Witness Statement dated 3/26/2016 written by LVN B read in part . On 3/22/16 I worked that hall (Resident #1's hall) and was told in report by night nurse that pt (Resident #1) was (complaining) of (pain) to (left) leg and x-ray showed [MEDICAL CONDITION]. Pt also (complained of) nausea later that day and noticed [MEDICATION NAME] (a medication to treat nausea) was DC'd. Reported this to unit manager and told her about x-ray (complaints of lower level extremity pain). She came to me later and stated MD had ordered [MEDICATION NAME] for nausea. I then asked ' Anything for (pain)? ' and she stated no An attempt was made to contact LVN B on 4/12/2016 at 1:50pm but was unsuccessful. Record review of a Witness Statement dated 3/31/2016 written by the DON interviewing LVN D read in part . Tuesday night (3/22/16).(Received) in report res (complained of) left leg pain- xrays were negative. Resident (received) scheduled (Tylenol) and left leg positioned on pillows both interventions were effective and pain relieved. Record review of a Witness Statement dated 3/26/2016 written by the DON interviewing LVN C read in part . Wed. 3/23/16- I cared to (CR #1) during 6p-6a shift- (CR #1) stated ' I sprained my ankle and cannot move in bed. ' Assisted to comfortable position, elevated ankle, scheduled (Tylenol) given with effective results. Denied any other complaints of pain. An attempt was made to contact LVN C on 4/12/2016 at 2:00pm but was unsuccessful. Record review of a Weekly Skin Observation Tool completed by LVN A on 3/24/2016 indicated CR #1 did not have swelling or bruising on her body. Record review of a Witness Statement dated 3/31/2016 written by LVN A read in part . On 3/24/16 I went into resident ' s room to do her weekly skin assessment .was short of breath and pale and stated she was hurting . She said pain was in her legs. When I saw her legs, she complained of more pain to left leg and yelled out when I moved left leg. I saw no bruising, only noted she had dry skin . She asked for more pain medication. I asked if she had recently had any Tylenol and she said at 6AM. As it was close to her next dosage time I informed her she would be getting it soon .I then informed the charge nurse that she was asking for pain medication and did not look well . In a telephone interview on 4/12/2016 at 4:00pm, LVN A said she saw CR #1 during a skin assessment on 3/24/2016. She said she complained of pain to both of her legs, and did not describe the location. She said that was something she did frequently. She said when she was moved, she complained of pain. She said she did not notice bruising, swelling or anything to indicate something was wrong. She said she was concerned about CR #1 that day because she did not look well. She said she was pale and not her normal self. She said she notified her nurse that she complained of pain and she looked ill. Record review of a Witness Statement dated 3/31/2016 written by the DON interviewing LVN D read in part . Thurs Night (3/24/16). Res (complained of) same left leg pain however stated that Tylenol (scheduled) and pillows under left leg relived pain. Denied any (complaints of) increasing pain. In an interview on 4/12/2016 at 12:45pm, LVN F said she cared for CR #1 on 3/24/2016, and helped send her to the hospital on [DATE]. She said Resident #1 did not complain of pain during her shift. She said the physician ordered a urinalysis on 3/24/2016. She said on both days, she was not her usual self and was hallucinating and was sent to the hospital for altered mental status. She said CR #1 required either two staff for transfers or a hoyer lift. She said she was not able to bear weight. In an interview on 4/12/2016 at 12:30pm, CNA B said she cared for CR #1 the week she was sent to the hospital (3/22/2016- 3/24/2016). She said she did not complain of pain. She said CR #1 usually required two staff for transfers. She said she could transfer CR #1 by herself, but could only do it with a gait belt. In an interview on 4/12/2016 at 2:30pm, CNA C said she cared for CR #1 the week she went to the hospital (3/21/2016-3/24/2016). She said on 3/21/2016, CR #1 told her that her hip, leg and ankle hurt after she was transferred. She said she notified Unit Manager A. She said she heard the x-ray came back negative. She said the next day, CR #1 asked, If my ankle is sprained, would it show up on the x-ray? She said she spoke to Unit Manager A who said it sounded like arthritis. She said the next couple of days, CR #1 was asleep most of the day and moaned frequently. She said this behavior was out of the ordinary. Record review of Witness Statements written by LVN E, LVN F and LVN G dated 3/30/2016 and 3/31/2016 revealed the nurses did not hear CR #1 complain of pain between the dates of 3/21/2016 and 3/25/2016. Record review of a physician's order [REDACTED].#1 was sent to the hospital due to shortness of breath and altered mental status. Record review of CR #1 ' s hospital records dated 3/25/2016 revealed she had swelling throughout her left ankle, knee and leg, and had a [MEDICAL CONDITION] tibia and fibula. In an interview on 4/12/2016 at 11:50am, the DON said CNA A did transfer CR #1 alone. She said CR #1 required extensive assistance with transfers and CNA A was reprimanded following the incident. She said she in-serviced nursing staff on transfers and how to review resident ' s plan of care. In an interview on 4/12/2016 at 2:25pm, the DON said CR #1 was always vocal about her care, and said she thinks her pain was managed because she did not complain much about her leg. She said she was not sure why staff nurses did not follow up with the leg x-ray. She said she was only made aware of the incident after she was sent to the hospital. She said she called the x-ray company and they said they only had record of one x-ray being ordered. She said the company did note that an x-ray was requested for both the leg and the hip. Record review of a Provider Investigation Report dated 3/31/2016 revealed CR #1 had a left leg fracture of unknown origin. The investigation findings were inconclusive. The action taken after the investigation included: 1. Therapy department to provide 1:1 in-service with return demonstration on transfers. 2. Updated residents plan of care to hoyer lift to ensure safety. 3. DON to review all new orders received. A document dated 3/30/2016 and signed by the Administrator read in part . On March 26th at 3:45pm I received a message from the DON .she informed me that (CR #1) had gone to the hospital on [DATE] and we were just notified by son at 3:22pm 3/26/16 that his mother had a fractured leg and he wanted to know what happened . I spoke with (CR #1). CR #1 confirmed that her leg was broken. She stated that she hit her leg on her wheelchair during transfer. I asked (CR #1) who transferred her and she said (CNA A) . Administrator reviewed all statements from staff. All statements are consistent that resident received scheduled medication which relieved pain and staff repositioned leg on pillow. She also denied pain when EMS picked her up for hospital transfer. Unable to determine exact cause of injury when it occurred. Resident did not continue to complain of ongoing pain after initial incident . Record review of a policy for Safe Lifting and Movement of Residents dated December 2013 read in part . In order to protect the safety and well-being of staff and residents, and to promote quality of care, this facility uses appropriate techniques and devices to lift and move residents . Resident safety, dignity, comfort and medical condition will be incorporated into goals and decisions regarding the safe lifting and moving of residents . According to the CMS Form 672, there were 78 residents who required assistance of one or two staff for transfers.