Every finding on record at Crystal Rehabilitation and Healthcare Center

Based on interviews, record review and facility policy review, the facility failed to ensure timely assessment, physician notification, and initiation of appropriate treatment for an identified pressure ulcer to prevent further deterioration and promote healing for one (1) of three (3) residents reviewed for pressure ulcers. Resident #1.Findings Include:Record review of facility policy The [Proper Name of Corporation] Skin Integrity Prevention and Treatment Program revealed .Weekly Skin Integrity Checks a. Weekly assessment looking for new wounds-completed by a licensed nurse; b.Document on/in Treatment Record; c. If new area found .Notify Medical Doctor (MD) -obtain treatment orders .Record review of a Progress Note dated 1/17/25 documented by Licensed Practical Nurse #1 (LPN #1) revealed Resident #1 was noted with an open wound to the left upper extremity below the elbow with sanguineous drainage present. The note indicated first aid treatment was initiated and that the oncoming nurse and treatment nurse would be notified; however, there was no documentation to support that a physician was notified or that treatment orders were obtained at that time.Interview with Resident #1 on 12/9/25 at 12:30 PM, revealed the resident was unable to recall when or how the wound to the left elbow occurred.Record review of the January 2025 Treatment Administration Record revealed no wound care treatment orders were obtained from 1/17/25 until 1/22/25.Record review of a Surgical Note dated 1/22/25, from the wound care physician revealed Resident #1 had a Stage IV Pressure Ulcer to the left elbow with pre-op measurements of 1.5 centimeters (cm) length by 1.0 cm width with depth undetermined. The wound presented with moderate serosanguineous drainage, unhealthy surrounding tissue, and slough present requiring surgical debridement of devitalized subcutaneous, muscle, fascia and tendon tissue. Post-op measurement was 1.5 cm length by 1 cm width by 0.3 cm depth. Interview with the Treatment Nurse on 12/9/25 at 12:45 PM, revealed she stated that when a wound is identified, the physician should be notified for treatment orders.Telephone interview with LPN #1 on 12/9/25 at 1:02 PM, revealed she verified the resident had an open wound to the left elbow and acknowledged she did not notify the physician for treatment orders. She agreed the physician should have been notified.Interview with the Director of Nursing (DON) on 12/9/25 at 1:30 PM, revealed there was no documentation to support that wound care treatment was initiated prior to the wound care physician's assessment on 1/22/25. The DON agreed treatment orders should have been obtained when the wound was identified.Record review of the admission Record revealed that the facility admitted Resident #1 on 10/15/21 with a diagnosis of Hemiplegia and Hemiparesis following Cerebral Infarction affecting Left Non-dominant Side.Record review of the Minimum Data Set Assessment (MDS) with an Assessment Reference Date (ARD) of 10/25/25 revealed a Brief Interview for Mental Status (BIMS) score of 15, indicating that Resident #1 is cognitively intact.

Based on staff interview, record review and facility policy review the facility failed to ensure there was an effective Quality Assurance and Performance Improvement (QAPI) program, as evidenced by repeat deficiencies for Activities of Daily Living (ADL) F677 over the last three annual surveys. Findings Include Review of the facility policy titled, (Proper facility name) QAPI Program with no revision date revealed under the Purpose Statement .The purpose of Quality Assurance Performance Improvement committee is to create a system for improving the care for our residents . An interview on 10/24/24 at 10:54 AM with the Corporate Nurse revealed the QAPI committee met with all department heads after the last survey in 6/2023, in 7/23 they met and went over anything that was trending based on the monitoring that was put into place after the survey that resulted in deficiencies and in 9/23, they went back to reviewing normal stuff. She stated that monitoring was supposed to have continued for the deficiencies from the last survey, but she is not sure that it did. She revealed that she thinks that there are repeat deficiencies due to a new Administrator and a new Assistant Director of Nurses (ADON). An interview on 10/24/24 at 11:15 AM with the Administrator confirmed that she understands that the facility should not have had an ADL issue for three years in a row. She thinks the problem is communication between the nurses and the Certified Nursing Assistants (CNA) and the supervision of the CNAs by the nurses to make sure the work is done. An interview on 10/24/24 at 11:25 AM with the Corporate Nurse agreed that there should not be repeated deficiencies for ADLS . She confirmed she had made rounds and every so often she would find issues with the nails. She stated that the Registered Nurses (RN) would fix it, but she is not sure why they would not continue. She confirmed that continued monitoring by the administrative nursing staff could have confirmed ADL issues. Record review of the Corporate Nurse's rounds revealed that on 2/21/24 and 4/10/24 ADL issues were found related to fingernails, toenails and shaving. Record review of the CASPER3 (Certification and Survey Provider Enhanced Reports) confirmed that the facility had an ADL deficiency for their last two annual surveys.

Based on observation, staff interview, record review and facility policy review, the facility failed to inform staff and visitors of residents that were in Transmission-Based Precautions (TBP) for six (6) of six (6) positive COVID-19 residents reviewed. Residents #6, #28, #29, #38, #81, and #84. Cross Reference F882 Findings Include: Record review of the facility policy titled, COVID-19 Policy and Procedures with a revision date of 9/15/23 revealed under, Training: Signage should be posted describing ways to prevent the spread of germs and protect against COVID-19 virus. This record review revealed under Core Principles of COVID-19 Infection Prevention .Instructional signage throughout the facility and proper visitor education on COVID-19 signs and symptoms, infection control precautions, and other applicable facility practices (e.g., use of face covering or mask, specified entries, exits and routes to designated areas, hand hygiene) and appropriate staff use of Personal Protective Equipment (PPE). An interview on 10/22/24 at 9:05 AM, with Certified Nurse Assistant (CNA) #1 revealed the facility is in a COVID-19 outbreak and she thinks they have about 30 residents positive. An observation on the initial tour of the facility on 10/22/24 at 9:15 AM, revealed there was no signage on the residents' doors identifying who was on TBP. An interview on 10/22/24 at 9:50 AM, with the Assistant Director of Nurses (ADON)/Infection Preventionist (IP) confirmed the facility has been in a COVID-19 outbreak for a week and she thinks she was the first positive, but she is not certain. She stated she tested positive on 10/14/24 and had worked that day passing medications on the 100 halls. She stated that she was off work for several days and the Director of Nurses (DON) covered for her, but now she is sick with COVID-19. She stated that on 10/16/24 Resident #6 was lethargic and got sent to the hospital where he tested positive for COVID-19. She stated that after this resident was sent to the hospital, they tested all the residents and found 27 positives, but no one had any symptoms. She confirmed that signs should have been put on the residents' doors indicating they were in TBP. She stated that she just failed to follow-up and make sure it was done after she returned to work on Friday 10/18/24. An interview on 10/23/24 at 2:50 PM, with the Administrator confirmed that signage should have been put on the COVID-19 resident's doors for staff and visitors to know the resident was in Transmission-Based Precautions. She admitted that they needed to be stricter on their infection control to prevent the spread of infections and ensure that all staff and visitors were aware which residents were in TBP. She stated that they continued to monitor residents for symptoms, staff worked to keep residents at least 6 feet away from other staff and residents as possible and require everyone wear a mask when they enter the facility. She also stated that staff self-monitor and let their supervisor know if they are symptomatic. She revealed that the facility COVID-19 vaccination rate for 2023 was 66% and for 2024 so far it is 76%. Record review of facility vaccination rates for COVID-19 confirmed that 2023's rate was 66% and for 2024 so far, the rate is 75.80%. Record review of the resident testing for COVID-19 from 10/16/24 revealed there were 27 positive residents identified that included Residents #6, #28, #29, #38, #81, and #84. Record review of Resident #6's Admission Record revealed the resident was admitted to the facility on [DATE]. Record review of Resident #28's Admission Record revealed the resident was admitted to the facility on [DATE] with. Record review of Resident #29's Admission Record revealed the resident was admitted to the facility on [DATE] . Record review of Resident #38's Admission Record revealed the resident was admitted to the facility on [DATE]. Record review of Resident #81's Admission Record revealed the resident was admitted to the facility on [DATE]. Record review of Resident #84's Admission Record revealed the resident was admitted to the facility on [DATE].

Based on observations, staff interviews, record review and facility policy review, the facility failed to ensure the Infection Preventionist fully implemented the Infection Control Program, as evidence by failure to ensure signage was applied to resident's rooms that were under Transmission-Based Precautions and complete surveillance for the current COVID-19 outbreak for one (1) of three (3) days of survey. Cross Reference F880 Findings Include: Record review of the facility policy titled, COVID-19 Policy and Procedures with a revision date of 9-15-23 revealed under, Training: Signage should be posted describing ways to prevent the spread of germs and protect against COVID-19 virus .Core Principles of COVID-19 Infection Prevention .Instructional signage throughout the facility and proper visitor education on COVID-19 signs and symptoms, infection control precautions, and other applicable facility practices (e.g., use of face covering or mask, specified entries, exits and routes to designated areas, hand hygiene) and appropriate staff use of Personal Protective Equipment (PPE). An interview on 10/22/24 at 9:05 AM, with Certified Nurse Assistant (CNA) #1 stated that the facility is in a COVID-19 outbreak, and she thinks they have about 30 residents that are positive. On the initial tour of the facility on 10/22/24 at 9:15 AM it was observed that there were no signage on resident's doors identifying who was in transmission base precautions due to COVID-19. An interview on 10/22/24 at 9:50 AM, with the Assistant Director of Nurses (ADON)/Infection Preventionist (IP) confirmed the facility has been in a COVID-19 outbreak for a week. She confirmed that signs should have been put on the residents' doors indicating they were in transmission base precautions. She admitted that she had not done any surveillance for this outbreak or had an in-service with staff. She stated that someone had sent a text message out to staff to let them know we were in an outbreak. She stated that she did not realize she needed to do surveillance and just failed to make sure signs were put on the positive resident's doors. An interview on 10/23/24 at 9:30 AM, with the Occupational Therapist revealed that she felt that the facility was not communicating outbreaks to therapy in order for them to be informed to prevent the spread of infection when they were in resident rooms providing care. She confirmed that she had not seen any signage on resident doors prior to entering. An interview on 10/23/24 at 2:50 PM, with the Administrator confirmed that they needed to be stricter on their infection control to prevent the spread of infections. Record review of the facility in-services revealed that the last in-service regarding infection control was on 10/9/24 indicating all trays need to be picked up after every meal. Record review of the resident testing from 10/16/24 revealed there were 27 positive residents identified.

Based on observation, staff and resident interview, record review and facility policy review, the facility failed to implement an Activities of Daily Living (ADL) care plan for a resident that was dependent on staff for nail care and shaving (Resident #11, #13, #47, #51) and failed to implement a care plan for a resident requiring a hand splint (Resident #62) for five (5) of 29 care plans reviewed. Findings Include A review of the facility policy titled, Care Pans, Comprehensive, Person-Centered, revealed, A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident ' s physical, psychosocial and functional needs is developed and implemented for each resident . Resident #11 - Cross Reference F677, F687 Record review of the Care Plan for Resident #11 revealed I have Diabetes Mellitus . Interventions, Refer to podiatrist/foot care nurse to monitor/document foot care needs and to cut long nails .Diabetic Nail care weekly per nurse. During an observation and interview with Resident #11 on 10/22/24 at 10:05 AM, she removed her left sock and shoe and pointed to her left great toe, which was one-half inch (1/2) long and jagged. Resident #11 expressed that she had not seen a podiatrist recently nor could she recall the last time her toenails were cut. Record review of the Podiatric Services Report for Resident #11 revealed that she had not been seen by a podiatrist since 5/1/23. In an observation and interview on 10/23/24 at 9:00 AM, with Registered Nurse (RN) #1, she verified that Resident 11's left great toenail was long and jagged. She also acknowledged that she was unaware of the last time Resident #11's toenails were cut but confirmed that they needed trimming. Interview with the Registered Nurse (RN)/Minimum Data Set Nurse (MDS) on 10/23/24 at 1:35 PM confirmed that if Resident #11 did not receive toenail care or see podiatrist then the care plan was not followed. A record review of the Minimum Data Set Assessment (MDS) with an Assessment Reference Date (ARD) of 7/4/24 for Resident #11 revealed a Brief Interview for Mental Status (BIMS) score of 13, indicating that the resident is cognitively intact. The Admission Record review indicated that the facility admitted Resident #11 on 1/7/16 with a diagnosis of Diabetes Mellitus. Resident #13 Record review of the Care Plans for Resident #13 revealed under, Focus: I have a self-care deficit related to impaired mobility, left hemiplegia/hemiparesis, contractures, and seizures. Also revealed under, Interventions: Bathing/showering: Check nail length and trim and clean on bath day and as necessary. Report any changes to the nurse . prefers nails to be cut short. An observation of Resident #13 on 10/22/24 at 10:12 AM revealed he was lying in bed with his eyes open. The fingernails on both hands were long, measuring approximately one-half (1/2) inch in length past the tip of his fingers. An observation and interview with RN #1 on 10/23/24 at 8:58 AM, confirmed Resident #13 had long nails. An interview with the RN/MDS Nurse on 10/23/24 at 3:40 PM revealed the purpose of the care plan was to help ensure the staff were doing the best care for the residents. She confirmed Resident #13's care plan was not followed for nail care. Record review of the Admission Record revealed the facility admitted Resident #13 on 5/29/21 with medical diagnoses that included type 2 Diabetes Mellitus, and Hemiplegia and Hemiparesis following Cerebral Infarction. Resident #47 Record review revealed a care plan in place for Resident #47 with a focus of Activities of Daily Living (ADL) self-care performance deficit related to impaired balance, limited mobility due to Hemiplegia and Hemiparesis following cerebral infarction with an intervention of prefers bathing on M, W, F (Monday, Wednesday and Friday); check facial hair & nails, prefers mustache and beard trimmed, prefers nails to be cut short. During an observation and interview on 10/22/24 at 9:50 AM, revealed Resident #47's fingernails on bilateral hands were approximately one-half (1/2) inch long past the tips of his fingers, and a brown substance was underneath the fingernails. Resident #47 had facial hair on his chin and neck, approximately one and a half (1.5) inches long. Resident #47 revealed that it's been over two months since his nails were cut and face shaved. He revealed that he goes to the beauty shop monthly, and she cuts his hair, but if he wants to be shaved by her, it costs extra, and he can't afford that. He revealed that the Certified Nurse Assistant's (CNA) don't shave him or even offer. Resident #47 revealed, I like to be shaved and for my fingernails to be cut short. An interview and observation on 10/23/24 at 9:35 AM, with the Assistant Director of Nurses (ADON) revealed that the CNA's are responsible for shaving Resident #47 and cutting and cleaning his fingernails. She confirmed that he needed to be shaved, and his fingernails needed to be cleaned and trimmed and revealed that Resident #47's ADL care plan was not being followed. An interview on 10/23/24 at 1:20 PM, the RN/MDS Nurse revealed she is part of the team that develops each residents' individualized care plan. She revealed if the resident's ADL care plan was not followed then it is a concern because he is not getting the care that he is supposed to be receiving. Record review of the Admission Record for Resident #47 revealed he was admitted to the facility on [DATE] with diagnoses that included Hemiplegia and Hemiparesis following Cerebral infarction affecting right dominant side, and Muscle Weakness. Record review of the MDS with an ARD of 8/19/2024, revealed under Section C, BIMS score of 15 indicating Resident #47 is cognitively intact. Resident #51 In an interview with Resident #51 on 10/22/24 at 9:45 AM, she revealed she had been asking staff about trimming her toenails for over two months. An observation of Resident # 51's nails revealed all toenails to be long and jagged with the right great toenail observed to be approximately one inch in length and jagged in appearance. A review of a care plan for Resident # 51 titled, I have an ADL performance deficit related to (r/t) Activity Intolerance, Impaired balance and Limited Mobility, revealed, Interventions: nails trimmed and clean. In an interview with the ADON on 10/23/24 at 10:12 AM confirmed that staff failed to implement Resident #51's care plan for trimming nails. Review of the Admission Record revealed the facility admitted Resident # 51 on 6/30/22 with diagnoses of Morbid Obesity and Cellulitis. Record review of Resident #51's Section C of the MDS with an ARD of 7/22/24 revealed a BIMS) score of 14, indicating the resident was cognitively intact. Resident #62- Cross Reference F688 A review of a care plan titled, I have an ADL performance deficit for Resident # 62 revealed, Interventions: Staff to apply L (left) hand splint before breakfast and remove after dinner daily for 8 (eight) hours wear as tolerated and provide skin hygiene before and after wear every day shift. Every shift related to Hemiplegia and Hemiparesis affecting the left non-dominant side. An observation and interview on 10/22/24 at 10:15 AM, with Resident # 62 revealed the resident to have a left-hand contracture with no hand splint in use. No hand splint was observed in the resident's room. In an interview with Resident # 62, he revealed that the staff didn't put anything on his hand. In an interview with CNA #2 on 10/23/24 9:37 AM, she confirmed that Resident #62 did not have his splint on his left hand on Tuesday,10/22/24, because he only wears his left-hand splint on Monday, Wednesday, and Friday. In an interview with the ADON on 10/23/24 at 10:12 AM confirmed that staff failed to implement Resident # 62's care plan for the hand splinting device when the device was not applied. She revealed that the purpose of the care plan is to direct the individual care needs of residents. Review of the Admission Record revealed the facility admitted Resident # 62 on 3/01/23 with a diagnosis of Hemiplegia and Hemiparesis following a nontraumatic intracranial hemorrhage. Record review of Resident #62's Section C of the MDS with an ARD of 9/3/24 revealed a BIMS) score of 08, indicating the resident was moderately cognitively impaired. 47874 46013 47157

Based on observation, resident and staff interviews, record review, and facility policy review, the facility failed to provide personal hygiene for four (4) of 26 sampled residents as evidenced by failure to provide nail care (Resident #11, #13, #47, and #51) and shave a resident (Resident # 47). Findings Include: Review of the facility policy titled, Activities of Daily Living (ADL) Supporting with a revision date of March 2018 revealed, Residents will be provided with care, treatment and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADLs). Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene. Resident #11- Cross Reference F687 An interview and observation on 10/22/24 at 10:05 AM with Resident #11 revealed the resident is non-verbal but indicated that she does not receive toenail care. The resident pulled off her left sock and shoe and pointed to her left great toe and her left 5th small toe. This observation revealed that the resident's left great toenail was jagged and 1/2 inch long with a band aid dated 10/21/24 on her left 5th toe. Resident #11 picked up a 1/2-inch sized item off of her bed and verified it was the toenail from her left 5th toe, by shaking her head yes. The resident indicated, by shrugging her shoulders, that she had not recently seen a Podiatrist, nor did she recall the last time her toenails had been cut. An observation and interview on 10/23/24 at 9:00 AM with Registered Nurse (RN) #1 she verified that Resident #11's left great toenail was long and jagged. She stated that if the resident is diabetic then it is the RN's responsibility for cutting the resident's nails. She verified that she had no idea when the resident had last seen the Podiatrist or had her toe nails cut, but that the resident did need them cut. An interview with the Assistant Director of Nursing (ADON) on 10/23/24 at 9:15 AM she confirmed that the nurses were responsible for cutting toenails for residents who were diabetic. She stated that residents' toenails should be checked daily during care and cut if needed. She stated that they did not have a schedule for checking and cutting toenails. She verified that Resident #11 had lost the toenail on her left 5th toe, but she was unsure how. The ADON agreed that the lack of nail care could have contributed to the resident losing her toenail. Record review of the Podiatric Services Report for Resident #11 revealed that she was last seen by a podiatrist on 5/1/23. An Interview with the ADON on 10/23/24 at 1:45 PM verified that Resident #11 had not seen a podiatrist since 5/1/23. She stated that they currently did not have a podiatrist to see the residents and was unsure of how long they had been without one. She verified that foot care and nail care had not been provided for Resident #11 and this could have contributed to her losing her toenail. A review of the Minimum Data Set Assessment (MDS) with an Assessment Reference Date (ARD) of 7/4/24 for Resident #11 revealed a Brief Interview of Mental Status (BIMS) score of 13, indicating that the resident is cognitively intact. The Admission Record review revealed that the facility admitted Resident #11 on 1/7/16 with a diagnosis of Diabetes Mellitus. 47874 Resident #13 An observation of Resident #13 on 10/22/24 at 10:12 AM revealed he was lying in bed with his eyes open. The fingernails on both hands were long, measuring approximately one-half (1/2) inch in length. An observation and interview with RN #1 on 10/23/24 at 8:58 AM confirmed Resident #13 had long nails and could potentially scratch someone or himself. She revealed the nails should be checked with bathing and stated the resident was diabetic and his nails must be cut by a nurse. She revealed the nails should be checked every week to see if they needed trimming. An interview with the ADON on 10/23/24 at 9:05 AM revealed a nurse must cut Resident #13's nails because he was diabetic. She confirmed he could scratch himself and with him being diabetic that could cause issues. She revealed the facility did not have a task set up for the diabetics to get nail care routinely, it was just something they knew to do. Record review of the Admission Record revealed the facility admitted Resident #13 on 5/29/21 with medical diagnoses that included Type 2 Diabetes Mellitus, Hemiplegia and Hemiparesis following Cerebral Infarction. 46013 Resident #47 An observation and interview on 10/22/24 at 9:50 AM, revealed Resident #47's fingernails on both hands were approximately one-half (1/2) inch long past the tips of his fingers with a brown substance underneath the fingernails. Resident #47 had facial hair on his chin and neck, approximately one and a half (1.5) inches long. Resident #47 revealed that it's been over two months since he had his nails cut or his face shaved. He revealed that he goes to the beauty shop every month, and she cuts his hair, but if he wants to be shaved by her, it costs extra, and he can't afford that. He revealed that the Certified Nurse Assistants (CNA) do not offer to shave him. Resident #47 revealed he likes to be shaved and for his fingernails to be short. An observation on 10/22/24 at 1:50 PM revealed that Resident #47's appearance had not changed from the earlier observation. An observation on 10/23/24 at 08:36 AM revealed Resident #47's appearance was unchanged from the previous day. An interview and observation on 10/23/24 at 9:05 AM, Certified Nurse Aide (CNA) #7 revealed that she is assigned to Resident #47 today, and it is the CNA's responsibility to shave the resident and do his nail care. She confirmed that Resident #47 needed to be shaven, and his fingernails were long and dirty. An interview on 10/23/24 at 9:25 AM, the Activities Director (AD) revealed Resident #47 goes to the beauty shop every month to have his hair cut, and sometimes the beauty shop worker will trim up his beard, but she does not shave him. She revealed that shaving him is the responsibility of the CNAs. During an interview and observation on 10/23/24 at 9:35 AM, the ADON revealed that the CNA's are responsible for shaving the resident and cutting and cleaning his fingernails. She confirmed that Resident #47 needed to be shaved, and his fingernails needed to be cleaned and trimmed. Resident #47 stated to ADON that it had been two months since he had been shaved and had his fingernails cleaned and cut. Record review of the Admission Record for Resident #47 revealed he was admitted to the facility on [DATE] with diagnoses that included Hemiplegia and Hemiparesis following Cerebral infarction affecting right dominant side and Muscle Weakness. Record review of the MDS with an ARD of 8/19/2024, revealed under Section C, BIMS score of 15 indicating Resident #47 is cognitively intact. 47157 Resident #51 An observation and interview on 10/22/24 at 9:45 AM, Resident #51 revealed she has been asking staff about trimming her toe nails for over two months. An observation of the resident's nails revealed all toenails to be long and jagged with the right great toenail to be approximately one inch in length and jagged in appearance. She stated she is not a diabetic and can't understand why staff won't cut them. She then stated a nurse told her she would get podiatry to come cut them but that was months ago and that never happened. An observation and interview on 10/23/24 at 9:22 AM of Resident # 51's toenails with Licensed Practical Nurse (LPN) #3, she confirmed the resident's toenails were very long and jagged with the right great toe to be very long. She confirmed the nails appeared that they had not been trimmed in a while and stated there was no medical reason that the nurses or CNAs could not trim them. She then revealed that possible concerns from not trimming the nails are that she could scratch her legs with the jagged nails and also the nails could have grown into the skin causing skin concerns. An interview with the CNA #3 on 10/23/24 at 10:08 AM she revealed she was unaware of why Resident # 51's toenails had not been trimmed. She stated the CNA'S switch sections every other day and stated the nurse trimmed the toenails earlier today and confirmed they were really long and jagged. Review of the Admission Record revealed the facility admitted Resident # 51 on 6/30/22 with diagnoses of Morbid Obesity and Cellulitis. Record review of Resident #51's Section C of the MDS dated [DATE] revealed a BIMS score was 14, indicating the resident was cognitively intact.

Based on observation, staff interview, and facility policy review, the facility failed to maintain an effective pest control regimen against flies as evidenced by fly sightings in a resident room for two (2) of 89 residents. Resident #2, and #7. Findings Include: Cross-Reference F584 Review of the facility policy titled Pest Control undated, revealed under, Policy: Conduct pest control by an outside vendor on a routine basis to maintain the Community in a safe and sanitary condition. Also, revealed under, Procedures: 1. Perform pest control on a consistent basis to ensure that the building is maintained in a pest-free condition. On 10/22/24 at 9:50 AM, an observation of Resident #7 revealed, the resident lying in his bed with the cover over his head. Further observation revealed that there were eight (8) flies on top of the bed spread and two (2) on the privacy curtain. On 10/22/24 at 9:56 AM, an observation of Resident #2 (roommate to Resident #7) revealed the resident was lying in his bed with the cover pulled up over his head. Further observation revealed 4 flies on the bed spread, three (3) flies on the privacy curtain, and one (1) on the footboard. A blue plastic bin was sitting in the floor at the end of the bed that held shoes with five (5) flies hovering over the bin and landing inside randomly. On 10/22/24 at 9:59 AM, an interview with the Housekeeping #1 confirmed the presence of flies in Resident #2 and #7's room. He revealed the flies had been an ongoing concern in their room. He explained the room was cleaned daily, but it was difficult to handle all the flies and cleanliness of that room. On 10/22/24 at 10:58 AM, an interview with the Assistant Director of Nursing (ADON) confirmed the flies had been an issue for a while. She revealed they have a couple of doors on the back that were opened and closed frequently throughout the day and explained that may be where they came in. On 10/22/24 at 12:36 PM, an observation of Resident #2 revealed, he was sitting on the side of his bed eating his lunch meal, with four (4) flies seen flying over and landing on the meal tray. The resident made no attempts to swat the flies. On 10/23/24 at 9:58 AM, interview with Certified Nurse Aide (CNA) #5 confirmed flies and cleanliness had been a concern for Resident #2 and #7's room for a while. She revealed that both residents smear feces and take their briefs off and throw them in the floor. On 10/23/24 at 10:08 AM, an interview with the ADON revealed housekeeping was in the room all the time to address the uncleanliness of the room and the flies. She stated it was a challenge because both residents smeared feces. She revealed keeping the residents' environment clean was everybody's responsibility and had to be a group effort. On 10/23/24 at 1:04 PM, an interview with Maintenance #2 revealed he had been filling in for the position since February 2024 because the facility did not have a maintenance person. He revealed he comes to the facility on ce weekly and makes random room rounds. He revealed he had not been made aware of any fly issues in the building. On 10/23/24 at 1:13 PM, interview with the Administrator (ADM) revealed, she had not been told about any concerns with flies in the building. She revealed that she makes daily rounds and stated she had not seen any flies or been told by staff that flies were an issue. She revealed that the room stayed nasty because both of those residents played in stool. The ADM revealed the pest control company came out on 10/16/24 and they had not done any extra measures to combat fly activity. She acknowledged the residents should have a clean and sanitary environment. On 10/24/24 at 8:16 AM, an interview with the ADON confirmed that anytime flies were around or got onto the food there was a risk for illness.

Based on observation, staff interview, record review, and facility policy review the facility failed to secure electronic health records as evidenced by an Electronic Medication Administration Record (EMAR) visible while the medication cart was unattended on the East Short Wing medication cart for one (1) of three (3) medication carts. Resident #13 Findings Include: Review of the facility policy titled, Resident Rights with a revision date of 1/11/24 revealed, 12 . Privacy and Confidentiality. Resident has the right to personal privacy and to confidentiality of his/her personal and clinical records. An observation on 10/23/24 at 8:05 AM, of a computer that was located on an unattended medication cart on the East Short Wing revealed the computer was opened with Resident #13's EMAR information visible on the screen and the screen was visible to anyone passing by the cart. The visible information included Resident #13's name, medications, and room number. An interview on 10/23/24 at 8:08 AM, Registered Nurse (RN) #1 revealed she is assigned to the medication cart and confirmed that the EMAR for Resident #13 was visible on the screen to anyone walking by and was supposed to be closed when she was away from the cart. She revealed that this is a violation of keeping the resident's medical records private. An interview on 10/23/24 08:44 AM, the Assistant Director of Nurses (ADON) revealed that a resident's information should never be left up on the computer screen while the cart is unattended and revealed that there is a privacy button that is supposed to be pushed before the nurse steps away from the computer. The ADON confirmed this is a privacy issue. Record review of Resident #13's Admission Record revealed the resident was admitted to the facility on [DATE] with diagnoses that included Aphasia, Cerebral infarction, and Traumatic Hemorrhage of Cerebrum.

Based on observations, staff interviews, record review and facility policy review, the facility failed to ensure that residents' dignity was not compromised as evidence by Multi Drug Resistant Organism (MDRO) signs on resident's doors for 12 of 96 residents reviewed for dignity. Findings Include: Record review of the facility policy titled, Resident Rights with a revision date of 1/11/24 revealed that .Resident has a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside Facility. Facility must protect and promote the rights of each resident, including each of the following rights: 1. Exercise of Rights .c. Resident has the right to be treated with dignity and respect for the personal integrity of the individual . An observation on 10/22/24 during initial tour of the resident doors in the facility revealed there were MDRO signs on the doors of the following rooms: 110, 111, 122, 125, 128, 132, 208, 215, 218, 223, 225, and 228. An interview and observation on 10/23/24 at 8:45 AM, with Registered Nurse (RN) #1 confirmed that Residents #4 and #19 had signs on their room doors that read, Multi Drug Resistance Organisms-MDRO is a threat to the residents. She stated that neither of these residents had MDRO. She revealed she thinks they put that up on their doors because those residents needed Enhanced Barrier Precautions (EBP). She revealed she thinks these MDRO signs would be a dignity issue for the resident since it implied the resident had MDRO. An interview and observation on 10/23/24 at 9:00 AM, with the Assistant Director of Nurses (ADON)/Infection Preventionist (IP) confirmed that Resident #4, #19, and #38 had signs on their door that read MDRO, and they do not have MDRO. She realizes that is the wrong sign to have put on their door. She confirmed that none of these residents have MDRO, but even if they did, we would not put that on their doors. She confirmed they had put those signs on the doors of any resident that needed Enhanced Barrier Precautions (EBP) but revealed she has the correct signs for EBP. She stated there was only one resident in the building that has MDRO. She confirmed that those signs were inappropriate and would be a dignity issue for those residents. An interview on 10/23/24 at 9:15 AM, with the Administrator confirmed that having signs on resident doors that read MDRO is a threat to our residents would be a dignity issue for the residents residing in those rooms. Record review of the MDRO signage revealed it read; Multidrug-resistant organisms (MDROs) are a threat to our residents in bold print at the top of the sign. Below the header it read Enhanced Barrier Precautions (EBP) Steps .

Based on staff and resident interview, record review and facility policy review, the facility failed to ensure a Notice of Medicare Non-Coverage (NOMNOC) was provided for two (2) of three (3) residents reviewed for beneficiary notices. Resident A and Resident B. Findings included: Review of the facility policy Form Instructions for the Notice of Medicare Non-Coverage (NOMNOC) CMS-10123 revealed When to deliver the NOMNOC, A Medicare provider .must deliver a completed copy of the Notice of Medicare Non-Coverage (NOMNOC) to beneficiaries/enrollees receiving covered skilled nursing .services. The NOMNOC must be delivered at least two calendar days before Medicare covered services end . A completed Beneficiary Protection Notification Review was provided by the Business Office Manager (BOM) on 10/22/24 at 2:05 PM, that indicated Resident A had a Medicare Part A stay from 6/7/24 through 7/19/24, and Resident B had a Medicare Part A stay from 6/14/24 through 6/21/24, with no supporting documentation, such as a NOMNOC or Advanced Beneficiary Notice (ABN). An interview on 10/23/25 at 8:05 AM, with the BOM revealed that Resident A and Resident B were discharged from skilled services and the facility when their therapy goals were met. She verified that Resident A had 58 skilled days remaining and Resident B had 93 skilled days remaining when they were discharged . She verified that she did not provide either resident with a NOMNOC. She stated that she was not aware that she should have provided the residents with a NOMNOC. She revealed that she thought that NOMNOC's were only provided to residents receiving Medicare Part A services if they were managed care and the managed care determined that they were no longer going to pay for the resident's services. She agreed there was no documentation that either resident initiated their discharge from Medicare Part A services. The BOM added that she is not notified of a resident's discharge from Medicare Part A services until on or after their discharge date . An interview with the Administrator on 10/23/24 at 8:07 AM, she agreed that the NOMNOCs should have been provided to Resident A and Resident B prior to discharge. She stated that the BOM must not have known to do it.

Based on observation, resident and staff interview, and facility policy review, the facility failed to maintain housekeeping and maintenance services necessary to maintain a sanitary and comfortable resident environment, as evidenced by flies in residents room (Resident # 2 and Resident #7), dirty sheet and leaking air conditioning unit (Resident # 13), a dirty personal fan (Resident # 29) and a dirty floor and foul odor in resident's room (Resident # 86) for five (5) of 25 sampled residents. Findings Include: Review of the facility policy titled, Building Inspections undated, revealed under, Policy: Conduct routine building inspections on a monthly basis to identify potential problems and perform any required maintenance. Review of the facility policy titled Cleaning and Disinfection of Resident-Care Items and Equipment with a revision date of 3/23, revealed under, Policy Interpretation and Implementation: c . (3) . Disinfection is performed with an EPA (Environmental Protection Agency)-registered disinfectant labeled for use in healthcare settings. A review of a letter on company letterhead, dated 10/23/24 and signed by the Administrator, revealed the facility does not have a policy for cleaning resident personal fans. Review of the facility policy titled Pest Control undated, revealed under, Policy: Conduct pest control by an outside vendor on a routine basis to maintain the Community in a safe and sanitary condition. Also, revealed under, Procedures: 1. Perform pest control on a consistent basis to ensure that the building is maintained in a pest-free condition. Resident # 2 and Resident #7 An observation of Resident #2 on 10/22/24 at 9:56 AM, revealed that the resident was lying in his bed with the cover pulled up over his head. Further observation revealed four (4) flies on the bed spread, three (3) flies on the privacy curtain, and one (1) fly on the footboard. A blue plastic bin was sitting on the floor at the end of the bed that held shoes with five (5) flies hovering over the bin and landing inside. An observation of Resident #7 (roommate to Resident #2) on 10/22/24 at 9:50 AM, revealed the resident lying in his bed with the cover over his head. Further observation revealed eight (8) flies on top of the bed spread and two (2) flies on the privacy curtain. An interview with Housekeeping #1 on 10/22/24 at 9:59 AM, confirmed the flies in Resident #2 and #7's room. He revealed the flies had been an ongoing concern in the room. He explained it was difficult to handle the flies and cleanliness of the room. An interview with the Assistant Director of Nursing (ADON) on 10/22/24 at 10:58 AM, confirmed the flies had been an issue for a while. She revealed they had a couple of doors at the back of the building that were opened and closed frequently throughout the day, and explained that was probably where they came in. An observation of Resident #2 on 10/22/24 at 12:36 PM, revealed he was sitting on the side of his bed eating his lunch meal with four (4) flies seen flying over and landing on the meal tray. The resident made no attempts to swat the flies. An interview with Certified Nurse Aide (CNA) #5 on 10/23/24 at 9:58 AM, confirmed flies and cleanliness had been a concern for Resident #2 and #7's room for a while. She revealed they both smear feces and take their briefs off and throw them in the floor. An interview with the ADON on 10/23/24 at 10:08 AM, revealed housekeeping was in the room all the time to address the uncleanliness of the room and the flies and verbalized it was a challenge because both residents smeared feces. She revealed keeping the residents' environment clean was everybody's responsibility and had to be a group effort. An interview with Maintenance #2 on 10/23/24 at 1:04 PM, revealed he had not been made aware of any fly issues in the building. An interview with the Administrator (ADM) on 10/23/24 at 1:13 PM, revealed she had not been made aware of any fly concerns in the building. She revealed that she makes daily rounds and stated she had not seen any flies or been told by staff that flies were an issue. She revealed that the resident's room stayed nasty because both of those residents played in stool. The ADM explained housekeeping cleaned the room every day and more often, verbalizing it was a constant thing. She revealed they had not taken any extra measures to combat fly activity in the building. She acknowledged the residents should have a clean and sanitary environment. An interview with the ADON on 10/24/24 at 8:16 AM, confirmed that anytime flies were around or got onto the food there was a risk for illness. Record review of the Admission Record revealed the facility admitted Resident #2 on 2/26/03 with medical diagnoses that included schizophrenia and vascular dementia. Record review of the Admission Record revealed the facility admitted Resident #7 on 10/3/22 with a medical diagnosis of vascular dementia. Resident #13 An observation of Resident #13's room on 10/22/24 at 10:12 AM, revealed two (2) white sheets with a yellowish-brown substance on them that were placed underneath the air conditioning unit. An observation and interview with Housekeeping #3 on 10/22/24 at 10:16 AM, confirmed the sheets were under the unit to capture water because the unit was leaking onto the floor. He revealed they had several units in disrepair, but they do not have a full-time maintenance person. He revealed they have someone who comes once a week to help fix things. An interview with Registered Nurse (RN) #1 on 10/23/24 at 9:01 AM, revealed if they have an issue that needs to be repaired, they were to add it into the computer work-order system for maintenance. An interview with the ADON on 10/23/24 at 10:08 AM, revealed they use a computer system for work order, to input the things needed to be fixed by maintenance. She revealed if something came up that required immediate attention, they would call the administrator, and she would call corporate. An interview with Maintenance #2 on 10/23/24 at 1:04 PM, revealed he had been filling in since February 2024 because the facility did not have a maintenance person. He revealed he comes to the facility on ce weekly and makes random room rounds. He revealed he gets the maintenance issues from the computer work order system, and the administrator shows him some of the things that need repairing. Maintenance #2 revealed he had not been made aware of any issues regarding Resident #13's leaking air conditioning unit. He explained the only reason the unit would leak would be if the filter was dirty and needed cleaning. An interview with the ADM on 10/23/24 at 1:13 PM, revealed she was not aware of Resident #13's leaking air conditioning unit and confirmed a repair request had not been submitted into the work order system for maintenance. She acknowledged the resident's equipment should be in good repair. Record review of the Admission Record revealed the facility admitted Resident #13 on 5/29/21. Resident #86 An observation of Resident #86's room on 10/22/24 at 10:54 AM, revealed a foul odor upon entry. Further observation revealed the resident lying in her bed. There were eight (8) to 10 spots on the floor that were dried, smeared, dark brown and irregular in size, with the largest being approximately five (5) inches by three (3) inches in size. An interview and observation with the ADON on 10/22/24 at 10:58 AM, confirmed the foul odor in Resident #86's room and replied, What is that smell? She confirmed the brown substance on the floor looked like stool and acknowledged the resident should have a clean room and confirmed this was not acceptable conditions for the resident. An interview with the ADON on 10/23/24 at 10:08 AM, revealed keeping the resident's environment clean was everybody's responsibility. She revealed the aides and nurse were responsible for cleaning the stool off the floor when it was encountered. Record review of the Admission Record revealed the facility admitted Resident #86 on 9/12/24 with medical diagnoses that included altered mental status. Resident # 29 An observation and interview with Resident #29 on 10/22/24 at 9:01 AM, revealed a 20-inch round auscultating fan on Resident #29's bedside table with the entire fan blades and the external outer covering of the fan covered in a thick black buildup. Resident #29 stated she uses the fan every night. She confirmed she had asked multiple staff, including housekeeping, to please clean the fan for the last few months, but stated staff always told her they will get the maintenance director to take care of it. An observation of the fan on Resident #29's bedside table with Certified Nurse Assistant (CNA) #2 on 10/23/24 at 10:00 AM, she confirmed the fan was covered in a thick black buildup including the fan blades and the outer cover of the fan. She then stated the fan needed to be cleaned because the dust particles could blow all over the resident and possibly make her sick. An observation of the fan in Resident # 29's room from the doorway with Housekeeper #1 on 10/23/24 at 10:10 AM, he confirmed the fan was covered in a thick black dust built up and stated the housekeepers clean in here every day and should have cleaned the fan to prevent dust build up from blowing on the resident. Review of the Admission Record revealed the facility admitted Resident # 29 on 1/26/2019. Record review of Resident # 29's Section C of the Annual Minimum Data Set (MDS) with an Assessment Reference Date of 8/16/24 revealed in Section C, a Brief Interview for Mental Status (BIMS) score was 15, indicating the resident was cognitively intact. 47157

Based on staff interview, record review, facility policy review, and Resident Assessment Instrument (RAI) review, the facility failed to ensure that the Minimum Data Set (MDS) was coded accurately for four (4) of 26 sampled residents. Resident #13, # 47, 56, and #62. Findings Include: Review of the facility policy titled, MDS Coding Policy with a revision date of January 4, 2023, revealed, Proper facility Name affiliated facilities utilize the most up to date Resident Assessment Instrument (RAI) manual for determination of coding each section of the Resident Assessment, timely and accurately. Resident #13 Record review of the MDS with an Assessment Reference Date (ARD) of 8/12/24 revealed that Resident #13 is taking an anticoagulant medication and was not taking an antiplatelet. Record review of the August 2024 Medication Administration Record (MAR) revealed that Resident #13 did not receive anticoagulant medications for the month of August but did receive Aspirin (ASA) An interview with the Registered Nurse (RN)/MDS on 10/23/24 at 3:40 PM confirmed the MDS was coded wrong and stated that Resident #13 did receive an antiplatelet (ASA) but not an anticoagulant. She confirmed the MDS should be done accurately so that the resident got the care he needed. An interview with the Assistant Director of Nurses (ADON) on 10/24/24 at 8:15 AM revealed her expectation was for the MDS to be coded correctly and when signing off on the assessment ensure it was correct before closing. Record review of Resident #13's Admission Record revealed the facility admitted the resident on 5/29/21. Resident #47 Record review of the MDS with an ARD of 08-19-2024, revealed under section N, Resident #47 received seven (7) days of Anticoagulant medication for the observation look back period of 8/13/24 through 8/19/24. Record review of the MAR for the MDS 7-day observation look-back period for anticoagulant medication revealed Resident #23 did not receive anticoagulant medication between 8/13/24 and 8/19/24. An interview with the MDS Coordinator on 10/23/24 at 1:15 PM confirmed that Resident #47 was coded on the 7-day look-back period for receiving an anticoagulant medication. She revealed that Resident #47 did not receive an anticoagulant medication, and it was coded in error. Record review of the Admission Record for Resident #47 revealed he was admitted to the facility on [DATE]. Resident #56 Record review of the Admission Record for Resident #56 revealed the facility admitted the resident on 12/6/21 and has a diagnosis of Schizophrenia. Record review of Resident #56's annual MDS with an ARD of 11/20/23 revealed in Section A question 1500 that the resident has not been identified as having a diagnosis of mental illness as defined by PASRR (Pre-Admission Screening and Resident Review). Record review of the summary of findings report from PASRR Office for Resident #56 dated 12/16/23 indicated that the individual meets criteria for having a diagnosis of mental illness as defined by PASRR. An interview with the RN/MDS Nurse on 10/23/24 at 1:30 PM verified that Resident #56's MDS with an ARD of 11/20/23 was coded incorrectly. She agreed that the importance of correctly coding MDS was to ensure residents received the care they needed. Resident #62 Review of item GG0115 of the Minimum Data Set (MDS) dated [DATE] : Functional Limitation in Range of Motion: coded 0 for no impairment to upper or lower extremities. A record review of the physician's order for Resident #62 revealed Staff to apply L hand splint before breakfast and remove after dinner daily for 8 (eight) hours, wear as tolerated and provide skin hygiene before and after wear every shift. An interview with RN/MDS on 10/23/24 at 1:47 PM, she revealed after review of the section GG of the MDS dated [DATE] for Resident #62 that it was coded incorrectly. She stated the purpose of coding the MDS correctly is to ensure a correct depiction of the resident is obtained and the resident receives the care and services needed. Review of the Admission Record revealed the facility admitted Resident #62 on 3/1/23 with a diagnosis of Hemiplegia and Hemiparesis following nontraumatic intracerebral hemorrhage affecting left non dominant side. 46013 47158 47157

Based on observations, resident and staff interviews, record reviews and facility policy review, the facility failed to ensure foot care was completed for one (1) of four (4) sampled residents. Resident #11. Cross Reference: F 677 Findings Include: Record review of Foot Care policy revised October 2022 revealed Policy Statement, Residents receive appropriate care and treatment in order to maintain mobility and foot health. Policy Interpretation and Implementation, 1. Residents are provided with foot care and treatment in accordance with professional standards of practice .3. Residents are assisted in making appointments with .specialists (podiatrist, endocrinologist, etc.) as needed. 4. Trained staff may provide routine foot care (e.g. toenail clipping) within professional standards of practice . On 10/22/24 at 10:05 AM, during an observation and interview with Resident #11 she removed her left sock and shoe and pointed to her left great toe, which was one-half inch (1/2) long and jagged. Resident #11 expressed a desire to have her toenails trimmed and indicated that she had not seen a podiatrist recently nor could she recall the last time her toenails were cut. Resident #11 then picked up a one-half inch (1/2) item from her bed and pointed to her left fifth toe, which was covered with a bandage. She indicated that the item was the toenail from her left fifth toe, which had come off. On 10/23/24 at 9:00 AM, an observation and interview with Registered Nurse (RN) #1, she verified that Resident #11's left great toenail was long and jagged. She stated that if a resident is diabetic, it is the nurse's responsibility to trim the resident's nails. She acknowledged that she was unaware of the last time Resident #11's toenails were cut but confirmed that they needed trimming. A review of the Podiatric Services Report for Resident #11 showed that she was last seen by a podiatrist on 5/1/23. On 10/23/24 at 9:15 AM, an interview with the Assistant Director of Nursing (ADON) she revealed that the nursing staff is responsible for trimming toenails for diabetic residents. She stated that residents' toenails should be checked daily during routine care and trimmed as needed, though there is currently no schedule for this. The ADON also confirmed that Resident #11 had lost the toenail on her left fifth toe but was unsure how it occurred. On 10/23/24 at 1:45 PM, a follow-up interview with the ADON she confirmed that Resident #11 had not seen a podiatrist since 5/1/23. She mentioned that the facility is in the process of securing a podiatrist, though one is currently unavailable. She was unsure how long the facility had been without podiatric services. The ADON verified that foot and nail care had not been provided for Resident #11 and acknowledged that this lack of care could have contributed to the loss of the toenail. A review of the Quarterly Minimum Data Set Assessment (MDS) with an Assessment Reference Date (ARD) of 7/4/24 for Resident #11 revealed a Brief Interview for Mental Status (BIMS) score of 13, indicating that the resident is cognitively intact. The Admission Record review indicated that the facility admitted Resident #11 on 1/7/16 with a diagnosis of Diabetes Mellitus.

Based on observation, staff interview, record review and facility policy review, the facility failed to provide the services, care, and equipment to assure a resident maintained, and improved to his/her highest level of range of motion (ROM) and mobility for one (1) of five (5) residents for positioning and mobility reviewed. (Resident # 62). Findings include: A review of the facility policy titled, Contracture Management Program, revealed, Intent: To have a program within the facility geared towards the prevention of new contractures and maintenance or improvement of Range of Motion . An observation on 10/22/24 at 10:15 AM revealed Resident #62 to have a left-hand contracture with no splinting device in use, and no device observed in the resident's room. In an interview with Resident #62, he revealed that the staff did not put anything on his hand. A review of the physician's order for Resident #62 dated 2/23/24, revealed Staff to apply (L) left-hand splint before breakfast and remove after dinner daily for eight (8) hours wear as tolerated and provide skin hygiene before and after wear every day shift. every shift related to Hemiplegia and Hemiparesis following affecting the left non dominant side. An observation of Resident #62's hands on 10/22/24 at 3:15 PM, revealed no splinting device observed on Resident #62's left hand. On 10/23/24 at 9:37 AM, an interview with Certified Nurse Assistant (CNA) #2 she confirmed that Resident #62 did not have his splint on his left hand on Tuesday, 10/22/24 because he only wears his left-hand splint on Monday, Wednesday, and Friday. She then stated she believed therapy was supposed to apply the splint on those days. In an interview with Licensed Practical Nurse (LPN) #3 on 10 /23/24 at 9:50 AM, she confirmed that Resident #62 should have been wearing his left-hand splint on 10/22/24. She revealed the left-hand splint should be applied every morning before breakfast by the CNAs and removed at bedtime by the CNAs. She then revealed that staff not applying the splinting device could result in worsening of the contracture. In an interview with the Occupational Therapist on 10/23/24 at 10:47 AM, she confirmed that Resident #62 should be wearing a left-hand splint daily. She confirmed that staff not applying the splint could result in a decline in ROM. In an interview with the Assistant Director of Nursing (ADON) on 10/23/24 at 10:12 AM, she confirmed staff failed to follow the physician's orders for applying Resident #62's left-hand splint when the splint was not applied as ordered. Review of the Admission Record revealed the facility admitted Resident # 62 on 3/01/23 with a diagnosis of Hemiplegia and Hemiparesis following a nontraumatic intracranial hemorrhage. Record review of Resident #62's Section C of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 9/3/24 revealed a Brief Interview for Mental Status (BIMS) score of 08, indicating the resident was moderately cognitively impaired.

Based on record review, staff interview, and facility policy review, the facility failed to provide adequate supervision and monitoring to reduce the risk of accident and hazards for a cognitively impaired ambulatory resident for (1) one of (4) four residents reviewed for accidents. (Resident # 1) Findings include: Review of the facility policy titled, Safety and Supervision of Residents, dated July 2017 revealed Policy Statement: Our facility strives to make the environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility wide priorities. Systems approach to safety: 2.) Resident supervision is a core component of the system approach to safety. The type and frequency of resident supervision is determined by the individual resident's assessed needs and identified hazards in the environment . 3.) The type and frequency of resident supervision may vary among residents and over time for the same resident. For example, resident supervision may need to be increased when there are temporary hazards in the environment or if there is a change in the resident's condition . A record review of a facility reported incident revealed, on 6/12/24, around 6:35 AM, LPN (Licensed Practical Nurse) #2, who was assigned to Resident #2, observed Resident #1 exiting the room of Resident #2. LPN #2 then heard Resident #2 gasping for air, and upon entering her room, she saw a pillow and sheet covering Resident #2's face. The nurse yelled for help from CNA (Certified Nursing Assistant) #2 who was right outside the room. They immediately removed the sheet and the pillow, grabbed some wipes to dab her face to calm her down. RN (Registered Nurse) Supervisor #1 took vital signs and noted that Resident #2 had an increased respiratory rate and a reddened face. Both nurses continued to check all vitals, performed incontinent care, and positioned Resident #2 comfortably in bed before exiting the room. An interview with the Director of Nursing (DON) on 6/26/24 at 9:25 AM revealed on 6/11/24, the afternoon before the incident, Resident #1 had been moved to another room because of a minor leak in the bathroom. Resident was ambulatory, and they did not want her to be injured until the water leak could be fixed in the bathroom. She stated that Resident #2, her roommate, remained in the room because she is bed bound and would not need to utilize the bathroom. She stated that the move was temporary and was explained to Resident #1. She stated when Resident #1 asked why Resident #2 was not moved, staff explained to her that Resident #2 was not ambulatory and did not use that bathroom. In an interview with CNA #4 on 6/26/24 at 11:41 AM, she revealed she worked 7:00 AM -7:00 PM on 6/11/24 and was assigned to Resident #1's prior room. She stated she observed Resident #1 attempting to enter her previous room at least three times, and she had to be redirected not to go in the room because it was not safe for her. She stated Resident #1 kept stating she could not understand why Resident #2 got to stay in the room and she didn't. CNA #4 stated she was unaware if any increased monitoring was put in place to observe Resident #1 closer. An interview with Resident #1's Resident Representative on 6/26/24 at 11:00 AM, revealed for the most part Resident #1 is alert and oriented but has frequent bouts of confusion and is very forgetful and change is hard for her. He then stated his sister has made the statement several times to him that she was upset and could not understand why she had to move out of her room and Resident #2 did not have to move and that she was upset about it. A phone interview with LPN #2 on 6/26/24 at 12:30 PM revealed she worked 7:00 PM-7:00 AM on 6/11/24 and was assigned to Resident #1's prior room. She stated that before the incident in the early morning of 6/12/24, she had observed Resident #1 going into her prior room on two separate occasions, and she had to be redirected. She stated each time Resident #1 expressed that she did not understand why Resident #2 got to stay in the room and she didn't. She stated she explained the safety reason to Resident #1 but confirmed Resident #1 has some confusion at times. She stated on the morning of 6/12/24 at approximately 6:35 AM she was making her final rounds and observed Resident #1 exiting her prior room. LPN #2 stated she asked Resident #1 what she was doing, and Resident #1 aggressively stated, I have not been in there because the door is locked. She stated she then told Resident #1 she had to be careful there was a leak in that bathroom, and she was going to get hurt. LPN #2 then revealed she heard gasping sounds and coughing coming from the room and she and CNA #2 entered the room and observed Resident #2 with the top sheet and a pillow covering Resident #2's face and immediately removed it. She stated she and CNA #2 stayed with Resident #2 calming her down. LPN #2 was asked if she had increased monitoring of Resident #1 when she observed her on two previous occasions attempting to go into her prior room. She stated no she did not, she just redirected her to stop her from going into the room because she was going to get hurt. In a phone interview with CNA #2 on 6/26/24 at 1:36 PM, she revealed she was assigned to Resident #1's previous room on 6/11/24, 11:00 PM-7:00 AM. She stated she saw Resident #1 walking the halls on the morning of 06/12/24 but thought nothing of it because she often does that. She stated she was making rounds that morning at about 6:30 AM and heard LPN #2 hollering for help and entered the room and observed the top sheet and pillow over Resident #2's face. She stated she and LPN #2 immediately removed the pillow and began calming Resident #2 down. She stated the last time she had seen Resident #2 was at 4:15 AM, and she repositioned her and made sure she was dry. In an interview with the Licensed Social Worker (LSW) on 6/26/24 at 3:00 PM, she revealed she was unaware that Resident #1 had attempted on several occasions to go into her prior room or that she was upset about the room move. She then confirmed that staff should have put increased monitoring in place to reduce her risk of injury because she kept attempting to enter the room. Record review of the June 2024 progress notes and physician's orders revealed no increased monitoring for Resident #1 after the move on 6/11/24 until 6/12/24 at 7:00 AM. In an interview with the DON on 6/26/24 at 3:00 PM, she revealed she was not made aware that Resident #1 had been attempting, on multiple occasions, to go back into her prior room or that she was upset about the move out of her room. In an interview with the Administrator on 6/26/24 at 4:00 PM, she verbalized that Resident #1 had been moved to different rooms in the past, and she had attempted to go back to those rooms too because that was the room she was used to. Record review of the Admission Record revealed the facility had admitted Resident #1 to the facility on [DATE] with diagnoses including Unspecified Convulsions and Seizure Disorder. Record review of the Minimum Data Set (MDS) Section C with an Assessment Reference Date (ARD) of 5/6/24, revealed that Resident # 1 had a Brief Interview for Mental Status (BIMS) score of 8 which indicated that she was severely cognitively impaired. Record review of the Admission Record revealed the facility admitted Resident #2 to the facility on [DATE] with diagnoses including Hydrocephalus, Aphasia, and Quadriplegia. Record review of the MDS, Section C with an ARD of 05/15/24, revealed that Resident #2 is rarely or never understood, which indicated severe cognitive impairment.

Based on staff interviews, resident interview, facility policy review, and record review, the facility failed to ensure residents were free from abuse/neglect, as evidenced by a Certified Nursing Assistant (CNA) not performing needed hygiene care, being rough during care and cursing around residents, for four (4) of 10 residents that were provided care by CNA #5. Resident #1, Resident #2, Resident #3, and Resident #4. Findings include: Review of the facility policy titled Abuse Prohibition Policy, with a review date of 3-2023, revealed INTENT: This protocol was intended to assist in the prevention of abuse, neglect . Each resident has the right to be free from abuse, mistreatment, neglect . POLICY: 1. The facility will prohibit neglect, mental or physical abuse . Record review of the Investigation Summary revealed This is a written investigation summary to follow up on an allegation reported 08/27/2023 .Resident Statement of Events &/or Timeline of Events: On 08/27/2023, LPN #1 (Formal Name) alleged that she witnessed (Formal Name) CNA #5 being aggressive and rude to (Formal Name) Resident #3 while providing care. LPN #1 also alleged that CNA #5 failed to provide incontinent care to Resident #2 (Formal Name) as directed. CNA #5 has been suspended pending investigation .LPN #1 alleged an altercation between Resident #1 and CNA #5 .Upon investigation (Formal Name) CNA #2 alleged that she witnessed CNA #5 use profanity and speak demanding to Resident (Formal Name) #4 . In conclusion, the center is able to substantiate the allegations of Abuse/Neglect. CNA (Formal Name) #5 employment was terminated . An interview on 9/12/23 at 03:09 PM, with CNA #1 revealed on 8/23/23 one (1) of the nurses kept sending for CNA #5 to come and clean Resident #2 because he was constantly having loose stools, that had spilled over his bed, the floor, and his wheelchair. CNA #1 also revealed CNA #5 was exhibiting behaviors of being very frustrated and angrily voicing, I just cleaned him up. CNA #1 noted she was in the breakroom with CNA #5 and revealed she heard CNA #5 mention that Resident #1 had called on the call light requesting for his brief to be changed, but CNA #5 revealed she told Resident #1 he had to wait until she came back from lunch. CNA #5 revealed she had attended Abuse/Neglect in-services and had been told what suspected abuse/neglect was, and that residents are not to be abused/neglected. An interview on 9/12/23 at 03:21 PM, with CNA #2 revealed CNA #5 appeared to be very upset and appeared to be very frustrated on the evening of 8/26/23. She noted she assisted CNA #5 with incontinent care for Resident #4. CNA #2 revealed she asked CNA #5 to roll Resident #4 over so another pad could be placed under him, when CNA #5 quickly grabbed Resident #4 under his upper back and the bend of his knees, and aggressively snatched him up off the bed, forcing him in a cradled, fetal position, in her arms. CNA #2 revealed the action of CNA #5 alarmed her and she was scared the action could be harmful to Resident #4. She revealed she did ask CNA #5, What the hell are you doing picking the resident up and being that rough? She noted she could not recall word for word what CNA #5 said but did remember the first part of her statement was He need to bring his ugly ass. CNA #2 revealed she had attended Abuse/Neglect in-services and was aware the staff were to keep the residents free from abuse/neglect. An interview on 9/12/23 at 03:48 PM with CNA #4 revealed she helped CNA #5 provide incontinent care on 8/26/23 for Resident #2 who had several loose stools, during the shift and had gotten it on several surfaces in the room and himself each time. She revealed she noticed CNA #5 was very upset and cursing in the room with Resident #2 and Resident #3 saying, I am sick of this shit. This shit don't make no sense. CNA #4 shared that CNA #5 appeared to be upset and came back into the room with Resident #2 and Resident #3 each time saying, I am sick of the shit, and both residents were awake. CNA #4 revealed she left CNA #5 in Resident #2's and Resident #3's room to clean up the bowel that had spilled on the floor and Resident #2's wheelchair. CNA #4 noted she was trying to help CNA #5 to not get in trouble, and she knew cursing around the residents was considered mistreatment of the residents. CNA #4 also revealed she had attended in-services on Abuse/Neglect, knew the residents were to be free of abuse/neglect. An interview on 9/12/23 at 04:04 PM with Licensed Practical Nurse (LPN) #2, revealed she was informed by LPN #1, near the end of 3-11 shift for the CNAs, that CNA #5 had been told two (2) times, by LPN #1, to go back and provide additional incontinent care to Resident #2 and to clean the bowel up off his floor and wheelchair. LPN #2 revealed she went to Resident #2's room and observed him in the wheelchair with bowel running out of one of the leg holes of his brief, onto the wheelchair and the floor. LPN #2 noted she did ask CNA #5 to go back to provide incontinent care and to clean the bowel off the floor and wheelchair for Resident #2, before she ended her shift. She instructed CNA #5 that it was neglectful to leave the bowel on Resident #2, and that it was neglectful to not clean the bowel from his floor and wheelchair. LPN #2 noted CNA #5 revealed she had just checked him at the end of shift rounds, that he was not soiled, that she had been busy all night, and was not going back to clean him up. She also noted that CNA #5 clocked out and left the nursing facility. She revealed she had attended Abuse/Neglect in-services and knew the residents had the right to be free of abuse/neglect. A telephone interview on 9/12/23 at 04:12 PM, with LPN #1 revealed CNA #5 asked her to assist with the care for Resident #3, because he grabs a hold of whoever assisted with his care or held onto the bed rails often during care. LPN #1 noted Resident #3 was turned facing her holding onto the bedrail, and CNA #5 snatched his arms to make Resident #3 release the bed rail as she jerked him towards her to turn him over to face her. She further shared CNA #5 was moving fast with providing Resident #3's care and did not appear to be gentle when she was pulling on him to move him around in the bed. LPN #1 revealed she did not say anything to CNA #5 about being aggressive with moving Resident #3, was not sure if it was abusive behavior towards Resident #3 from CNA #5 but shared that it made her feel uncomfortable. She noted she observed bowel on the floor and on the wheelchair for Resident #2, and asked CNA #5 who was responsible to clean it up. She revealed CNA #5 told her she did not know who was supposed to clean it up, but she was not going to be the one to clean it up. LPN #1 also shared that she did tell LPN #2 about CNA #5's behavior towards Resident #3, and about CNA #5 needing to clean the bowel up from Resident #2's and Resident #3's floor. LPN #1 noted she did attend an Abuse/Neglect in-service but could not remember all what was said in the in-services about abuse. She shared that she did not feel the incident between CNA #5 and Resident #3 was suspected abuse because Resident #2 was not punched by CNA #5. An interview on 9/12/23 at 4:20 PM, with Resident #1 revealed he had called over the call system one night for the assistance to have his brief changed because he had a bowel movement. He also revealed his CNA did come to his room that night, told him he had to sit and wait until she came off lunch break, and revealed the CNA never came back to his room to clean him up. He noted he could not remember her name or how long he waited for her. Resident #1 also noted he had to wait to be changed by one of the CNAs that came to work on the next shift. Resident #1 voiced, Being treated that way made me feel shitty and made me feel bad. An interview on 9/14/23 at 10:10 AM, with the Director of Nursing (DON), confirmed the nurses and the CNAs, including CNA #5, had been in-serviced on the Abuse/Neglect policy and were aware that residents of the nursing facility were to be kept free of abuse and neglect. She confirmed that Resident #1, Resident #2, Resident #3, and Resident #4 were not kept free of abuse/neglect by the nursing facility staff. An interview on 9/14/23 at 10:30 AM, with the Administrator confirmed the nursing facility failed to keep Resident #1, Resident #2, Resident #3, and Resident #4 free from abuse/neglect. The Administrator also confirmed, through facility investigation, the nursing facility was not in compliance with the allegations of abuse/neglect by a CNA on 8/26/23 for Resident #1, Resident #2, Resident #3, and Resident #4. Record review of the nursing facility in-services revealed Abuse and Neglect, dated 07/12/23; Abuse Neglect Vulnerable Adult Patient Rights, dated 7/13/23; Elderly Care Acts/Abuse and Neglect, dated 7/20/23; Abuse and Neglect, Reporting Abuse, date 8/9/2023; Abuse Neglect, Patient Rights, dated 8/11/23; and Abuse Neglect, Resident Rights, dated 8/28/23. Record review of the Personnel Record for the CNA#5 revealed the last day worked was 8/26/23, the date of the alleged incident of abuse and neglect and was terminated on 9/1/23. Record review of the Admission Record for Resident #1 revealed an admitted [DATE] with diagnoses of Functional Quadriplegia and Unspecified Focal Trauma Brain Injury Without Loss of Consciousness, Sequela. Record review of a Minimum Data Set (MDS) with an Assessment Reference Date of 9/1/23 with a Brief Interview For Mental Status (BIMS), for Resident #1, revealed a score of 7, indicating Resident #1 is moderately cognitively impaired. Record review of the Admission Record for Resident #2 revealed an admitted [DATE] with diagnoses of Hemiplegia and Hemiparesis Following Nontraumatic Intracerebral Hemorrhage Affecting Right Dominant Side, Dysphagia Following Cerebral Infarction, and Aphasia Following Cerebral Infarction. Record review of Section C of a Minimum Data Set (MDS) Admission Assessment, with an Assessment Reference Date (ARD) of August 28, 2023, for Resident #2, revealed a BIMS score of 99, indicating Resident #2 is severely cognitively impaired. Record review of the Admission Record for Resident #3 revealed an admitted [DATE] with diagnoses of Unspecified Dementia, Unspecified Severity, With Other Behavioral Disturbance, Other Sequelae of Cerebral Infarction, and Transient Cerebral Ischemic Attack, Unspecified. Record review of Section C of a Quarterly MDS Assessment, with an ARD of August 23, 2023, for Resident #3, revealed a BIMS score of 03, indicating Resident #3 is severely cognitively impaired. Record review of the Admission Record for Resident #4 revealed an admitted [DATE] with diagnoses of Acute and Chronic Respiratory Failure, Unspecified Whether With Hypoxia or Hypercapnia, Encounter for Attention to Tracheostomy, Dysphagia Following Cerebral Infarction, and Unspecified Sequelae of Cerebral Infarction. Record review of Section C of a 5-Day MDS Assessment, with an ARD of August 22, 2023, for Resident #4, revealed C0100. Should Brief Interview for Mental Status (C0200-C0500) be Conducted? . Enter Code: 0; 0. No (resident is rarely/never understood). The record review did not reveal a BIMS score.

Based on staff and resident interviews, facility policy review and record review the facility failed to resolve grievances in a manner that would prevent them from reoccurring as evidenced by ongoing resident complaints regarding not receiving ice water for four (4) of 86 residents reviewed during survey. Resident 32, 33, 45 and 62 Findings Include: Record review revealed a typed statement on facility letterhead dated 5/24/23 that revealed the facility did not have a policy regarding unresolved grievances and was signed by the Administrator. Record review of the facility policy titled, Hydration Management with a revision date of January 2023 revealed, .Procedure .Hydration passes three times a day (approximately 10 AM, 2 PM and 7 PM) whereby all residents will be offered beverage. The total volume of fluids offered at each hydration pass will be approximately 4 oz's. During the resident council meeting on 5/23/23 at 2:30 PM, Residents #32, #33, #45 and #62 revealed that they have complained about not getting ice water like they are supposed to, and it is not getting any better. Resident #33 revealed that the staff are supposed to pass ice water at the beginning of their shift, but do not always do that. Resident #45 revealed that it depends on who is working to whether they pass the ice water or not. Resident #62 revealed that weekends seem to be worse, but you never know if you are going to get ice water or not. They revealed that in the past when they have complained about the ice water situation, it would get better for a while and then they slack off again. An interview on 5/24/23 at 10:45 AM, with Certified Nurse Assistant (CNA) #1 revealed it is the responsibility of the CNAs to pass water to the residents at the beginning of their shifts. She revealed she cannot recall a time or reason why they would not have been able to pass ice water. An interview on 5/24/23 at 10:50 AM, with Licensed Practical Nurse (LPN) #1 confirmed it is the responsibility of the CNAs to pass ice water to the residents at the beginning of their shift. An interview on 5/24/23 at 11:00 AM, with the Assistant Director of Nurses (ADON)-Infection Preventionist revealed they have had these issues with resident's complaining about not getting ice water for a while. She revealed the facilities ice machines have been torn up a few times and they had to get ice from the store. She revealed that they have done several in-services with the staff regarding the importance of passing ice water. An interview on 5/24/23 at 11:10 AM, with the Corporate Nurse confirmed the residents complaining about not receiving ice has been an ongoing issue. She revealed the ice machines in the hall broke and they had to use the kitchen ice maker; then they fixed those, and the kitchen went out. She confirmed they had done several in-services regarding this and cannot believe it is still an issue. An interview on 5/24/23 at 11:20 AM, with the Administrator confirmed that the residents had been complaining about not getting ice water for a while. She revealed she has the nurse managers in each hall making rounds and completing a questionnaire on each resident and getting it to her before 9:00 AM so it can be discussed in the standup meeting. She confirmed that according to these questionnaires there are still some random complaints from residents regarding not receiving their ice water. An interview on 5/25/23 at 9:40 AM, with the Activities Director confirmed that residents' complaints about not receiving ice and water have been ongoing. She revealed that it would get better and then it would pop back up again. She revealed she completes a grievance form when the residents have a complaint, and this particular grievance went to the Director of Nurses (DON). Record review of the resident council meeting minutes from 12/14/22 through 5/10/23 revealed that the complaint of ice water not getting passed had been brought up four times with the most recent being from the meeting held on 5/10/23. Record review of the facility in-services regarding ice being passed to residents revealed there had been 4 in-services with nursing staff in the last 12 months. Resident #32 Record review of Resident #32's Admission Record revealed the resident was admitted to the facility on [DATE] with medical diagnoses that included Barrett's Esophagus without Dysplasia. Record review of Resident #32's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 2/17/23 revealed in Section C a Brief Interview for Mental Status (BIMS) of 15, which indicated the resident was cognitively intact. Resident #33 Record review of Resident #33's Admission Record revealed the resident was admitted to the facility on [DATE] with medical diagnoses that included Anxiety Disorder Unspecified. Record review of Resident #33's MDS with and ARD of 3/6/23 revealed in Section C a BIMS of 15, which indicated the resident was cognitively intact. Resident #45 Record review of Resident #45's Admission Record revealed the resident was admitted to the facility on [DATE] with medical diagnoses that included Major Depressive Disorder Recurrent, Unspecified. Record review of Resident #45' MDS with an ARD of 5/3/23 revealed in Section C a BIMS of 13, which indicated the resident was cognitively intact. Resident #62 Record review of Resident #62's Admission Record revealed the resident was admitted to the facility on [DATE] with medical diagnoses of Hemiplegia and Hemiparesis following Cerebral Infarction Affecting Right Dominant Side. Record review of Resident #62's MDS with an ARD of 5/18/23 revealed in Section C a BIMS of 15, which indicated the resident was cognitively intact.

Based on observation, staff and resident interviews, record review, and facility policy review the facility failed to Implement a care plan for Activities of Daily Living (ADL) care Resident #3 , PEG (percutaneous endoscopic gastrostomy) tube medication administration (Resident # 77) and tube feeding (Resident #238) for three ( 3) of 18 residents reviewed. Resident #3, #77 and #238. Findings include: Record review of the facility policy titled Care Plans, Comprehensive Person-Centered dated 10/22 and revised on 1/23 revealed, Policy Statement A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. 8. The comprehensive, person-centered care plan will: .b. Describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being; . Resident #3 Review of Resident #3's care plan titled, Bathing revealed ADL-I prefer whirlpool (T, Th, Sat) on 7-3. Resident will require supervision during showers. Check facial hair and nails. Under Bathing and Showering: Check nail length and trim and clean on bath day and as necessary. Report any changes to the nurse. An observation and interview on 05/22/23 at 10:40 AM, revealed Resident #3 to have long fingernails on both hands with dirty brownish material under the nails. The nails are past the tips of the fingers. The bottom of both feet had black colored material on them. The resident had a beard that was scraggly. The resident stated that he usually has a beard but does not want it this long. An observation on 5/23/23 at 9:10 AM, revealed Resident #3 continues to have brownish material under the fingernails on both hands and black material on the bottom of his feet. An observation and interview, on 5/23/23 at 2:10 PM, with Certified Nursing Assistant (CNA) #4 revealed that the resident goes to the shower on Tuesday, Thursday, and Saturday. She stated that she took over from his assigned CNA who left early. She stated the CNA told her the resident had his morning care before she left. She stated that his feet do not look like they were washed, and his fingernails are dirty. She stated that she was going to redo his care. An interview, on 05/25/23 at 10:43 AM with the Director of Nursing (DON) confirmed Resident #3 had a care plan in place but was not being followed. Review of the facility Admission Record for Resident #3 revealed an admitted [DATE] with diagnoses that included Atherosclerotic Heart Disease, Epilepsy, and Bipolar Disorder. Review of Section C of the Minimum Data Set (MDS) for Resident #3 with an Assessment Reference Date (ARD) of 3/6/23 revealed a Brief Interview for Mental (BIMS) score of 10 which indicated Resident #3 had moderately impaired cognition. Resident #77 Record review of the care plan for Resident #77 with a focus titled, I require feeding tube for nutrition and hydration r/t (related to) DYSPHAGIA FOLLOWING CEREBRAL INFARCTION. The interventions included: Enteral Feed Order every shift Provide 60 cc (cubic centimeters) H2O (water) ac (before) meds, 30 cc H2O between meds. An observation on 05/24/23 at 10:00 AM, during administration of PEG medications for Resident #77 revealed Licensed Practical Nurse (LPN) #3 drew up approximately 15 ml (milliliters) of water into a 60 ml syringe and placed the syringe into the PEG tube and flushed the water into the tube while listening to the left upper abdomen with a stethoscope. Following this clear fluid and then tan-colored fluid backed up in the tube. She then flushed the tube with approximately 30 cc water and before the water cleared the syringe, she poured the first crushed, undiluted medication into the syringe, then added more water. When the water with the first medication in it was about halfway down the syringe, LPN #3 added more water and then poured in the next undiluted medication and poured in more water, then the next medication. She administered a total of five (5) medications. LPN #3 did not measure water for any of the flushes. An interview on 05/25/23 at 10:18 AM, with the DON revealed LPN #3 did not follow the care plan for flushing during PEG tube medication administration. Review of the facility Admission Record for Resident #77 revealed an admitted [DATE] with diagnoses that included Cerebral Infarction, Systolic (Congestive) Heart Failure, Aphasia, and Dysphagia. 47157 Resident #238 A review of Resident #238's care plan titled,I require tube feeding as my primary nutrition r/t (related to) Dysphagia, revealed Interventions: Enteral Feed order every shift Tube Feeding Continuous: Formula-Jevity 1.5 at 50 cc/hr (cubic centimeters/hour) x 22 hours to allow for ADL care . An observation on 5/22/23 at 11:10 AM, revealed Resident #238 had Jevity 1.5 formula running at 40 cc/hr via PEG tube pump. An observation on 5/23/23 at 10:30 AM, revealed Resident #238 had Jevity 1.5 infusing at 40 cc/hr , directions on the Jevity formula bottle read rate: 50cc/hr. An observation of Resident #238's tube feeding pump and Jevity 1.5 formula bottle hanging on 5/23/23 at 10:35 AM, with the Director of Nursing (DON) confirmed the feeding tube pump read 40 cc/hr infusing and the label on the Jevity bottle read 50 cc/hr. An interview with the DON on 05/23/23 at 11:47 AM, confirmed the staff were not following the care plan and revealed the purpose of the comprehensive care plan is to direct person centered care. Record review of the Admission Record revealed that the facility admitted Resident #238 to the facility on [DATE] with diagnoses of Nontraumatic Intracranial Hemorrhage, Dysphasia following Nontraumatic Intracranial Hemorrhage, and Encounter for Attention to Gastrostomy.

Based on observation, resident and staff interview, record review and facility policy review, the facility failed to properly administer Percutaneous Enteral Gastrostomy (PEG) flushes during medication administration to a resident, failed to assess the pulse rate before administration of a medication, and failed to have resident rinse the mouth after the administration of an inhaler for two (2) of eight (8) resident medication administrations reviewed. Resident #30 and Resident #77 Findings Include Review of the facility policy titled, Administering Medications, revised April 2019, revealed, Policy heading Medications are administered in a safe and timely manner, and as prescribed .Policy Interpretation and Implementation .2. The director of nursing services supervises and directs all personnel who administer medications and /or have related functions .11. The following information is checked /verified for each resident prior to administering medications: b. Vital signs, if necessary . Review of the facility policy titled, Administering Medication through an Enteral Tube with a revision date of January 2023 revealed, Purpose The purpose of this procedure is to provide guidelines for the safe administration of medications through an enteral tube .General Guidelines .3. Administer each medication separately and flush between medications .6. Use warm purified water for diluting medications and for flushing .Steps in the procedure .6. Verify placement of feeding tube .9. Dilute medication: .b. Dilute crushed (powered medication with at least 30 mL purified water (or prescribed amount) .10. Administer each medication separately .12 .c. Begin flush before the tubing drains completely. 13. If administering more than one medication, flush with 15 mL warm purified water (or prescribed amount) between medications. 14. When the last of the medication begins to drain from the tubing, flush the tubing with 15 mL of warm purified water (or prescribed amount) . Review of the facility policy titled, Administering Medications through a Metered Dose Inhaler with a revision date of October 2010 revealed, Purpose The purpose of this procedure is to provide guidelines for the safe administration of inhaled medications .Equipment and Supplies The following equipment and supplies will be necessary when performing this procedure .5. gargling solution; Resident #77 An observation on 05/24/23 at 10:00 AM, during administration of PEG medications for Resident #77 revealed Licensed Practical Nurse (LPN) #3 drew up approximately 15 ml (milliliters) of water into a 60 ml syringe and placed the syringe into the PEG tube and flushed the water into the tube while listening to the left upper abdomen with a stethoscope. Following this clear fluid flush a tan-colored fluid backed up in the tube. She then flushed the tube with approximately 30 cc water and before the water cleared the syringe, she poured the first crushed, undiluted medication into the tube, then added more water. When the water with the first medication in it was about halfway down the syringe, LPN #3 added more water and then poured in the next undiluted medication and poured in more water, then the next medication. She administered a total of five (5) medications. LPN #3 did not measure water for any of the flushes and did not wait for one (1) medication to clear the syringe before adding the next undiluted medication. During the 10:00 AM medication pass, also revealed LPN #3 did not obtain Resident #77's pulse rate prior to the administration of Digoxin 125 micrograms (mcg). An interview on 5/24/23 at 1:10 PM, with LPN #3 revealed she was not sure how much water to use for flush or between medications. She stated that she didn't know why she did not dilute medications prior to administering them. She stated that's usually how I do it. LPN #3 stated that checking tube placement should be with air because water could cause aspiration or could go into the abdomen. LPN #3 stated that she gave the medications how she has always given PEG medications. She confirmed that this way, basically can get the medications mixed together. LPN #3 stated she had a medication in-service on hire. She stated that she should mix each of the medications with water, but she is not sure how much but thinks 10 cc and flush should be 10 to 15 cc. During an interview on 5/24/23 at 1:15 PM with LPN #3, she stated that she doesn't know why she did not count the pulse. She stated that Digoxin can slow the heart rate and should not be given if the pulse rate is below 60. LPN #3 stated she just forgot. An interview, on 05/25/23 at 10:40 AM, with the Director of Nurses (DON) revealed she did not know what to think about how LPN #3 administered the PEG medications. She stated LPN #3 does not need to be giving meds and will be taken off the schedule, in-serviced and worked with one on one. She stated that Resident #77's pulse should have been taken to make sure it was not too low before giving the medication (Digoxin). Review of the Order Summary Report with active orders as of 06/27/2023 for Resident #77, revealed an order dated 3/8/23, Enteral Feed Order every shift Provide 60 cc H2O ac (before) meds, 30 cc H2O between meds. Review of the Order Summary Report with active orders as of 06/27/2023 for Resident #77, dated an order dated 2/13/23, for Digoxin 125 mcg Give 1 tablet by mouth one time a day for heart failure. Review of the PDR.Net Digoxin-drug summary revealed a nurse should assess the apical pulse for one full minute before administering Digoxin. Review of the facility Admission Record for Resident #77 revealed an admitted [DATE], (original admitted [DATE]) with diagnoses that included Cerebral Infarction, Systolic (Congestive) Heart Failure, Aphasia, and Dysphagia. Review of Section C of the Minimum Data Set (MDS) with an Assessment Reference Date (ADR) of 3/10/23, revealed a Brief Interview for Mental Status (BIMS) score of 3 which indicated Resident #77 had severely impaired cognitive skills and never/rarely made decisions. Resident #30 An observation on 5/24/23 at 8:15 AM, revealed LPN #2 administered a Symbicort 160 mg (milligram) /4.5 mg inhaler to Resident #30, and she failed to have the resident rinse her mouth after the resident finished her inhalations. An interview with LPN #2 on 5/24/23 at 8:25 AM, confirmed she did not have Resident #30 rinse her mouth after the inhaler. She stated she guessed she was just nervous. LPN #2 stated not having the resident rinse their mouth could cause irritation. An interview 5/25/23 at 8:20 AM with Resident #30 revealed that she used inhalers when she was at home, and she knows that she is supposed to rinse her mouth. She stated that none of the nurses here get her to rinse her mouth. She denied having any soreness in her mouth. An interview on 5/25/24 at 10:40 AM, with the DON revealed not having a resident rinse their mouth after an inhaler could have negative after side effects occur, like oral cavity problems. Review of the Medication Review Report dated 5/24/2023, for Resident #30 revealed an order dated 4/26/23, for Symbicort Inhalation Aerosol 160-4.5 mcg(micrograms)/act(actuate) two (2) puff inhale orally, two times a day for shortness of breath, related to other Asthma. Review of the Quick Guide to Using Your Symbicort Inhaler revealed after using the Symbicort Inhaler, rinse your mouth with water. Spit out the water. Do not swallow it. Review of the facility Admission Record for Resident #30 revealed an admitted [DATE] with diagnoses that include Asthma, Morbid Obesity, and Anxiety Disorder. Review of Section C of the MDS with an ADR of 5/3/23 revealed a BIMS score of 12 which indicated Resident #30 had moderately impaired cognition.

Based on observation, staff and resident interview, record review and facility policy review, the facility failed to provide nail care, shaving and appropriate bathing to a resident requiring assistance with Activities of Daily Living (ADL's) for one (1) of 86 residents reviewed. Resident #3 Findings Include Review of the facility policy titled, Activities of Daily Living (ADL), Supporting, revised March 2018, revealed residents will be provided with care, treatment, and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADLs). Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming, and oral hygiene. The policy interpretation and implementation revealed under #2. Appropriate care and services will be provided for residents who are unable to carry out ADL's independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with: a. hygiene (bathing, dressing, grooming, and oral care). During an observation and interview on 05/22/23 at 10:40 AM, revealed Resident #3 to have long fingernails on both hands with dirty brownish material under the nails. The nails were past the tips of the fingers. The bottom of both feet had black colored material on them. The resident had a beard that was scraggly. Resident #3 stated that he usually has a beard but does not want it this long. An observation of Resident #3 on 5/23/23 at 9:10 AM revealed he continues to have brownish material under the fingernails on both hands. In an observation and interview on 5/23 23 at 2:10 PM, with Certified Nursing Assistant (CNA) #4 revealed that the resident goes to the shower on Tuesday, Thursday, and Saturday. She stated that she took over from his assigned CNA who left early and the CNA told her the resident had his morning care before she left. She stated that his feet do not look like they were washed, and his fingernails are dirty. She stated that she was going to redo his care. An interview, on 5/23/23 at 2:15 PM, with Resident #3 confirmed he went to the shower this morning. An interview on 5/23/23 at 2:20 PM, with Registered Nurse (RN) #1 confirmed Resident #3's fingernails were long and dirty. An interview on 5/23/23 at 3:45 PM, with the Director of Nursing (DON) revealed that the residents should get better care. She stated that they do not take care of residents like that in this facility. Residents are to be clean and neat and Resident #3 was not taken care of as expected. Review of the facility Admission Record for Resident #3 revealed an admitted [DATE] with diagnoses that included Atherosclerotic Heart Disease, Epilepsy, and Bipolar Disorder. Review of Section C of the Minimum Data Set (MDS) for Resident #3 with an Assessment Reference Date (ARD) of 3/6/23 revealed a Brief Interview for Mental Status (BIMS) score of 10 which indicated Resident #3 had moderately impaired cognition.

Based on observation, staff interview, family interview, record review, and facility policy review, the facility failed to provide goods and services to residents necessary to avoid physical harm, for five (5) of five residents reviewed, Residents #1, #2, #3, #4, and #5. The SA identified an Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) which began on 04/21/2020, as a result of worsening and infection of Resident #1's initial pressure ulcer. The facility ' s failure assess and put preventative measures in place, resulted in nine (9) new pressure ulcers, and the failure to implement an order to increase Resident #1's gastric tube feeding for eleven (11) weeks, to meet his nutritional needs and help heal his significant wounds, resulted in the deterioration of his wounds. The facility's failure to provide preventative measures to residents who were at risk for skin breakdown and to prevent further skin breakdown also affected Residents #2, #3, #4 and #5, which led to further skin breakdown, infections, and hospitalization s. The facility's failure to provide preventative measures to residents at risk for skin breakdown, placed Residents #1, #2, #3, #4, #5 and other residents at risk, in a situation that caused and/or likely to cause serious injury, harm, impairment, or death. On 07/20/2020 at 4:30 PM, the SA informed the Nursing Home Administrator (NHA) of the Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC). The IJ and SQC existed at CFR(s) 483.12(a)(1) - Abuse and Neglect (F600). The facility submitted a Credible Removal Plan on 07/25/2020 at 1:08 PM, in which the facility alleged all corrective actions to remove the IJ were completed and the IJ removed as of 07/25/2020. The SA validated the Removal Plan on 07/25/2020, and determined the IJ was removed, prior to exit. Therefore the scope and severity for CFR(s) 483.12(a)(1) - Abuse and Neglect (F600)was lowered from a L level scope and severity to a F level, while the facility develop a plan of correction to monitor the effectiveness of the systemic changes to ensure the facility sustains compliance with regulatory requirements. Findings include: Review of the facility's Abuse Prohibition Policy, revised on 12/12/2019, revealed, Intent: This protocol was intended to assist in the prevention of abuse, neglect and misappropriation of property. Each resident has the right to be free from abuse, mistreatment, neglect . Policy: 1. The facility will prohibit neglect .Definitions: .Neglect is defined as the failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness . Resident #1 Review of Resident #1's Admission Record, revealed he was admitted on [DATE] with a primary [DIAGNOSES REDACTED]. Review of Resident #1's Minimum Data Set ((MDS) dated [DATE], revealed, he was totally dependent on two (2) + person physical assist for bed mobility (how resident moves to and from lying position, turns side to side, and positions body while in bed). Resident #1 was not able to reposition himself or turn in the bed unassisted. Review of Resident #1's Braden Scale For Predicting Pressure Sore Risk, dated 02/19/2020, revealed his score to be 11 which placed him at High Risk for developing pressure ulcers. Resident #1 was admitted to the facility without any noted pressure ulcers. Since 02/03/2020, he received eleven new, in-house acquired pressure ulcers, (two Unstageable ulcers, two stage IV pressure ulcers, one (1) stage III pressure ulcer, four stage II pressure ulcers, and one stage one pressure ulcer). A lack of turning and repositioning, with proper application of pressure reducing devices was observed, as well as interviews with staff confirming the formation of multiple pressure ulcers due to preventative pressure reducing devices not being consistently used, weekly skin assessments and wound measurements being missed, and orders for enteral tube feedings and supplements, to promote wound healing not being addressed timely. On 07/15/2020 at 10:35 AM, during initial rounds, Resident #1 was observed in bed, lying on his back. On 07/15/2020 at 11:35 AM, Resident #1 was observed in the bed, pillow behind his head, lying on his back, legs drawn up in a fetal position, no positioning devices observed. On 07/15/2020 at 2:10 PM, Resident #1 was observed in the bed, pillow behind his head, lying on his back, legs drawn up in a fetal position, no other positioning devices observed. On 07/15/2020 at 3:45 PM, Resident #1 was observed in the bed, pillow behind his head, lying on his back, legs drawn up in a fetal position, no other positioning devices observed. On 07/16/2020 at 9:00 AM, Resident #1 was observed in the bed, lying on his back, pillow behind his head, a wedge cushion resting in his right axilla, legs pulled into fetal position, with no other positioning devices observed. On 07/16/2020 at 11:40 AM, Resident #1 was observed lying on his right side, with a pillow under his head, and no other positioning devices observed. On 07/16/2020 at 4:15 PM, Resident #1 was observed in the bed on his back, with a pillow behind his head, legs pulled up in the fetal position with no positioning devices observed. On 07/17/2020 at 9:10 AM, Resident #1 was observed in his bed, lying on his back, with a pillow behind his head, legs pulled into the fetal position, and no other positioning devices observed. On 07/17/2020 at 2:00 PM, Resident #1 was observed in the bed, lying on his back, with a pillow behind his head, a wedge cushion in right axilla area, legs pulled into a fetal position, no other positioning devices observed. On 07/16/2020 at 11:40 AM, during an interview with Licensed Practical Nurse (LPN) #1, when asked by the State Agency (SA) about positioning devices/heel cushions for Resident #1, she stated, they usually be in here somewhere, but I don't see them right now .whoever see em' off usually put them back on, but they ain't assigned to nobody .they ain't on the medication or treatment sheets . On 07/17/2020 at 3:30 PM, during an interview with the Director of Nursing (DON), when asked by the SA about a turning and repositioning (TAP) schedule and positioning devices for residents, she stated, .the nurses are supposed to make sure the aides do it, and check for pillows and stuff, but they was moving residents for COVID and didn't know what to put on them . On 07/20/2020 at 10:45 AM, during an interview with Certified Nurse Aide (CNA) #1, concerning positioning devices/heel cushions and a TAP schedule, she stated, We do our charting on iPads (Interactive Personal Application Devices), and it don't talk about heel boots in it. We answer yes or no if we turn them on our shift .the nurse is suppose to check the pillows and stuff .he (Resident #1), supposed to have them boots on right now, and a pillow by his knees, but they was soaked with urine this morning and had to be sent to laundry ain't no extras to put on him right now . there ain't no set schedule for turnin' residents, I just know when, 'cause I been doin' this job for a long time .It ain't written down nowhere to see. On 07/20/2020 at 11:40 AM, during an interview with Registered Nurse (RN) #1, a Minimum Data Set (MDS)/Care Plan Nurse, regarding a TAP program and positioning devices, she stated, .we should put turning and positioning and heel padding on the care plans. No one is assigned the task of checking if the heel padding is in place. The CNA's just answer a yes/no question on whether they did it (TAP) or not, because in order for it to be put on their (the CNA's) Kardex to chart on, we would have to assign exact times to it .we don't want to lock them into a time. On 07/20/2020 at 11:45 AM, during an interview with RN #2, an MDS/Care Plan nurse, regarding heel cushions/floats, and a TAP schedule, and she stated, We should be putting those items on the care plan, if we know they are doing them, but we haven't been doing that recently with COVID in the building . On 07/20/2020 at 11:45 AM, during an interview with CNA #2, regarding positioning devices/heel cushions and a TAP schedule, she stated, We have a Kardex on the iPad for some resident info, and we are supposed to get report from the shift leaving .we tried (to use positioning devices) but couldn't always do it .there aren't always enough wedges to go around .we just know when to turn them, it's not written down. Review of Resident #1's Visual/Bedside Kardex Report revealed Bed Mobility: The resident requires assistance by (x)2 staff to turn and reposition in bed, low air loss mattress to bed . there was no mention of a TAP schedule or preventative positioning devices for him. Review of Resident #1's Skin & Wound Evaluation V5.0 dated 02/03/2020, revealed a new, in-house acquired, stage II (partial thickness loss of skin) pressure ulcer to his Left Trochanter (hip) that measured 1.9 centimeters (cm) Length x 2.2cm Width x 0.2cm Depth with a moderate amount of serosanguineous (serous/bloody) drainage. Additional measures to be put into place were incontinence management, a mattress, moisture barrier,nutrition/dietary supplementation, positioning wedge, repositioning device(s), and a turning/repositioning program. Review of Resident #1's Skin & Wound Evaluation V5.0 dated 03/04/2020 revealed the Left Trochanter wound had worsened and was now a stage III (full thickness loss of skin), and larger in size at 2.3cm Length x 3.4cm Width, and no Depth recorded. Further review of Resident #1's Skin & Wound Evaluation V5.0 for April 2020, revealed no assessment or measurements of the left trochanter wound due on 04/21/2020. Review of Resident #1's Progress Note dated 04/22/2020 revealed, .RP notified of new area noted to resident's right hip . On 07/17/2020 at 3:30 PM, during an interview with the DON, regarding Resident #1's missing skin assessment and measurements of his Left Trochanter wound due on 04/21/2020, and the missing skin assessment and measurements of the new area on his right hip on 04/22/2020, she stated, They weren't done 'cause he was moved to the COVID unit and I don't think they knew about him real good. Further review of Resident #1's wound assessments dated 04/27/2020, revealed, a deterioration in, and the presence of infection to his Left Trochanter (hip) wound, an unstageable (Obscured full thickness loss of skin and tissue loss) wound to his Right Trochanter (hip) identified on 04/22/20, and eight (8) new pressure ulcers with the documented presence of pain. Review of Resident #1's Skin & Wound Evaluation V5.0 dated 04/27/2020 revealed, his stage III (full thickness skin loss) Left Trochanter (hip) wound was larger at 4.7cm Length x 3.9cm Width, no Depth recorded, and Undermining of 4.5cm, with evidence of redness, warmth, increased pain, heavy purulent (pus) drainage, and a moderate odor; a new, in-house acquired, unstageable pressure ulcer to his Right Trochanter (hip), 2.6cm Length x 3.2cm Width, with noted redness and inflammation; a new, in-house acquired, unstageable (obscured full thickness skin and tissue loss) pressure ulcer to his Sacrum measuring 3.8cm Length x 4.2cm Width, no Depth recorded, with redness, inflammation, warmth and bleeding present; a new, in-house acquired, Deep Tissue Injury (DTI) (persistent non-blanchable deep red, maroon or purple discoloration) to his Left Lateral Malleolus (outside ankle) measuring 2.6cm Length x 2.9cm Width; a new, in-house acquired, stage II blister on his nose measuring 0.5cm Length x 0.6cm Width; a new, in-house acquired, stage II blister on his spine measuring 3.6cm Length x 1.4cm Width; a new, in-house acquired, stage II blister to his Right Ischial Tuberosity (buttocks) measuring 1.7cm Length x 1.6cm Width; a new, in-house acquired, stage II blister to his Left Medial Malleolus (inside ankle) measuring 0.6cm Length x 1.6cm Width; a new, in-house acquired, stage II blister to his Right Lateral Calf/Shin measuring 0.6cm Length x 0.9cm Width; and a new, in-house acquired, stage one (non-blanchable redness of intact skin) to his right heel measuring 1.9cm Length x 1.8cm Width. All 10 pressure ulcers rated his pain level at three (3), with noted discomfort during treatment and moving. Review of Resident #1's Progress Note dated 04/28/2020, revealed, a noted deterioration of the wounds to his left hip and right hip. A culture was performed on 04/27/2020. Review of Resident #1's Progress Note dated 05/01/2020, revealed an order for [REDACTED]. Review of Resident #1's Progress Note titled Nutrition/Dietary Note dated 05/04/2020, revealed Resident #1's current gastric tube ([DEVICE]) feeding and oral intake did not meet ENNs (Estimated Nutritional Needs) required to maintain his weight and help heal his extensive wounds. The Registered Dietician (RD), recommended to increase his feeding ([MEDICATION NAME] 1.5) to 60 cc/hr (cubic centimeters/hour) for twenty-two (22) hours a day, from the current order of 50cc/hr for twenty-two hours a day. Review of Resident #1's Order Summary Report .Active Orders as of 07/16/2020 revealed, Enteral Feed Order .Tube Feeding Continuous: Formula [MEDICATION NAME] 1.5 at 50cc/hr x22 hours . On 07/20/2020 at 11:40 AM, standing at Resident #1's bedside, LPN #1 confirmed his [DEVICE] feeding, [MEDICATION NAME] 1.5, was currently running at 50cc/hr. On 07/21/2020 at 11:15 AM, during interview with the Dietary Manager (DM), regarding Resident #1's [DEVICE] feeding rate not being changed to the RD recommendation from 05-04-2020, she stated, When the recommendations come through, I am on the email list . but I only do mighty shakes and magic cups, basically things that would go on their meal tray, double portions etc On 07/21/2020 at 12:00 PM, during an interview with the RD regarding Resident #1's missed feeding increase from 05/04/2020, and the worsening of his wounds, she stated, .I worked remotely and was not in the building .there was no follow-up with the facility for follow through .I was covering six (6) other facilities and don't remember checking follow through of recommendations . Review of Resident #1's Progress Note - Skin/Wound Note dated 07/01/2020 revealed a deterioration with an advancement in staging, and significant size increase of the pressure ulcers to his Left Trochanter (hip), Right Trochanter (hip), Right Calf/shin, and Right Lateral Malleolus (ankle), and two more newly identified in-house acquired wounds. Review of Resident #1's Progress Note - Skin/Wound Note dated 07/01/2020 revealed, a now Stage IV (Full thickness skin and tissue loss) pressure ulcer to his Left Trochanter (hip) measuring 12.2cm Length x 17.0cm Width x 1.5cm Depth with 1.8cm Undermining; an Unstageable (Obscured full-thickness skin and tissue loss) pressure ulcer to his Right Trochanter (hip) measuring 9.0cm Length x 9.0cm Width with 1.5cm Undermining; an Unstageable (Obscured full-thickness skin and tissue loss) pressure ulcer to his Left Lateral Malleolus (outer ankle) measuring 2.4cm Length x 1.5cm Width; an Unstageable (Obscured full-thickness skin and tissue loss) pressure ulcer to his Right Lateral Calf/Shin measuring 4.3cm Length x 2.8cm Width, with a notation of wound edges are red and irritated from pressure of left leg pressing on right shin .; a new, in-house acquired, Unstageable (Obscured full-thickness skin and tissue loss) pressure ulcer to his Right Lateral Malleolus (inner ankle) measuring 2.2cm Length x 1.5cm Width; a new, in-house acquired, Stage III (Full thickness skin loss) pressure ulcer to his Right Great Toe Hallux measuring 1.0cm Length x 1.0cm Width with hyper-granulation due to irritation from toe rubbing mattress . Review of Resident #1's care plan created on 07-08-2020 revealed, Focus: .The resident has unstageable pressure ulcer lt. hip r/t Immobility. Goal: The resident's pressure ulcer will show signs of healing and remain free from infection . Review of the interventions listed, shows no mention of a specialty mattress, moisture barrier use, a positioning wedge, repositioning devices, or a TAP program. Review of Resident #1's care plan created on 07/08/2020 revealed, Focus: .The resident has unstageable pressure ulcer rt. hip r/t Immobility. Goal: The resident's pressure ulcer will show signs of healing and remain free from infection . Review of the interventions listed, shows no mention of a specialty mattress, moisture barrier use, a positioning wedge, repositioning devices, or a TAP program. Review of Resident #1's care plan created on 07/08/2020 revealed, Focus: .The resident has unstageable pressure ulcer to sacral r/t Immobility. Goal: The resident's pressure ulcer will show signs of healing and remain free from infection . Review of the interventions listed, shows no mention of a specialty mattress, moisture barrier use, a positioning wedge, repositioning devices, or a TAP program. Review of Resident #1's care plan created on 07/08/2020 revealed, Focus: .The resident has left lateral ankle-unstageable pressure ulcer development - DTI (Deep Tissue Injury) r/t Immobility. Goal: The resident's pressure ulcer will show signs of healing and remain free from infection . Review of the interventions listed, shows no mention of a specialty mattress, a positioning wedge, repositioning devices, or a TAP program. Review of Resident #1's care plan created on 07/08/2020 revealed, Focus: .The resident has unstageable pressure ulcer-rt lateral ankle r/t Immobility. Goal: The resident's pressure ulcer will show signs of healing and remain free from infection . Review of the interventions listed, shows no mention of a specialty mattress, a positioning wedge, repositioning devices, or a TAP program. Review of Resident #1's care plan created on 07/08/2020 revealed, Focus: .The resident has Stage III pressure ulcer-rt. great toe r/t Immobility. Goal: The resident's pressure ulcer will show signs of healing and remain free from infection . Review of the interventions listed, shows no mention of a specialty mattress, a positioning wedge, repositioning devices, or a TAP program. On 07/21/2020 at 2:05 PM, during an interview with the DON concerning the systemic failure of the wound care program, she confirmed there were multiple issues such as, incomplete documentation, dressings not getting changed timely, orders not being addressed timely, improper staging of wounds, no one monitoring the turning schedule, and checking for positioning devices since the treatment nurse left. She stated, The treatment nurse left on May 1, 2020. Body audits were not done .nothing was done immediately .Another facility's treatment nurse came on 12/09/2019, 12/10/2019, and 12/23/2019 to train her and help her .She was written up on 01/22/2020 for not changing dressings on wounds, and again on 04/29/2020 . The DON confirmed the facility did not have a plan in place to provide over sight after the write ups, to ensure the treatment nurse was providing wound care, and that orders were started timely. When the State Agency (SA) asked the DON Why did you continue to let her work if you knew she wasn't doing her job? and the DON shrugged her shoulders and stated, I don't know. On 07/25/2020 at 2:15 PM, during an interview with Resident #1's wife, she stated, The facility has not been upfront with me concerning my husband's wounds. When I left him the last time in early March, during COVID, he had one small wound on his left hip. It was a little blister. I heard from a staff member I know outside the facility, that his wounds were really bad. I called to get an update on all his wounds and asked for him to get an appointment at a wound clinic. When I went with him to his appointment, I insisted on going into the room with him and saw his wounds myself. I broke down and cried at how large and deep they are. Before COVID, I was there every day because I had noticed some changes in the care. I made sure they changed him and moved him around in the bed. It is heartbreaking to not be allowed in to see my husband, when I know he is in there not being taken care of, and there is nothing I can do about it but pray. He's there because I can't care for him myself. I trusted them to help us and they failed. Resident #2 Review of Resident #2's Admission Record revealed, she was admitted to the facility on [DATE] with the primary [DIAGNOSES REDACTED]. Review of Resident #2's Minimum Data Set ((MDS) dated [DATE], revealed, she was totally dependent on two + person physical assist for bed mobility (how resident moves to and from lying position, turns side to side, and positions body while in bed). She had limited range of motion (ROM) to both of her arms and legs. She was bedridden. Review of Resident #2's Braden Scale For Predicting Pressure Sore Risk dated 03/07/2020 revealed, she scored a 9, which placed her at Very High Risk for pressure sore development. Resident #2 was admitted with a small, Stage IV pressure ulcer to her sacrum. Since 01/21/2020, she has acquired thirteen (13) new pressure ulcers; two Unstageable pressure ulcers, one stage IV pressure ulcer, eight stage III pressure ulcers, and two Stage II pressure ulcers. A lack of turning and repositioning, and proper application of pressure reducing devices was observed, as well as interviews with staff confirming dressings were not being changed timely, preventative pressure reducing devices were not consistently used, and an order for [REDACTED]. On 07/15/2020 at 10:40 AM, during initial rounds, Resident #2 was observed in bed lying on her back, legs drawn into the fetal position, resting. On 07/15/2020 at 11:40 AM, Resident #2 was observed in bed, lying on her back, a pillow behind her head, legs drawn up in the fetal position, and no other positioning devices observed. On 07/15/2020 at 2:15 PM Resident #2 was observed in the bed, on her back, legs drawn into a fetal position, and no other positioning devices observed in the bed. On 07/15/2020 at 3:50 PM, Resident #2 was observed in the bed, on her back, a pillow behind her head, no other positioning devices observed in the bed, resident remains in the fetal position. On 07/16/2020 at 9:05 AM, Resident #2 was observed lying on her back in the bed, pillow behind her head, legs pulled into fetal position, no heel cushions present, no pillows between legs. On 07/16/2020 at 11:45 AM, Resident #2 was observed lying on her back with a pillow under her head, face turned toward the door, no heel cushions or pillow between her legs observed. On 07/16/2020 at 4:20 PM, Resident #2 was observed in the bed, on her back, with a pillow behind her head, face turned toward the door, still in the fetal position with no position devices observed. On 07/17/2020 at 9:15 AM, Resident #2 was observed in her bed, lying on her back, with a pillow behind her head, no positioning devices observed in the bed, and she remains in the fetal position. On 07/17/2020 at 2:05 PM, Resident #2 was observed lying on her back in the bed, pillow behind her head, heel cushions present on both feet, legs drawn into fetal position, and no other positioning devices observed. On 07/20/2020 at 11:45 AM, during an interview with LPN #3 concerning positioning devices/heel cushions, she stated, It is the nurse's responsibility to check if the pads, pillows, and heel boots is on the resident. The aides put them on 'em, but the nurse checks behind 'em. We gotta do med passes in the morning time and have to do treatments too now, it is hard to do it all. On 07/20/2020 at 3:40 PM, during an interview with RN#3 concerning repositioning devices/heel cushions, and the timeliness of wound care, she stated, The nurses are responsible for making sure the residents are padded up. I try to make sure if I do her treatments, that I put her heel cushions and pillows on where they go, but they usually aren't on when I get in here .She has so many wounds it is hard to keep up with. Most of the time the dressings aren't dated or initialed, and her wounds drain so much, it is hard to tell how old they are. The nurses have to pass medications and do all the treatments too since the treatment nurse left a couple months ago. It has been a challenge for them to keep things done. On 07/20/2020 at 4:15 PM, during an interview with Occupational Therapist (OT) #1, regarding her documentation on 05/28/2020, in Resident #2's medical record, she stated, She was on the COVID unit and was part of my rotation. Due to the lack of staff and no treatment nurse, the therapists were trying to help reposition residents when we could, especially [MEDICAL CONDITION] .I overheard her (Resident #2's) CNA telling the nurse her dressings had not been changed on her wounds. I saw the dressings and they were sopping wet with drainage and falling off the wounds. They had not been changed in three (3) days .The CNA took off the old dressings and told the nurse they needed cleaned and redressed When I went back the next day to see her, her wounds still had no dressing on them and had drained all over the bedding . When asked by the SA if she saw dressings not changed often, she stated, I would find this fairly often . Review of Resident #2's Skin & Wound Evaluation V5.0 dated 01/21/2020 revealed, a Stage IV pressure ulcer she was admitted to the facility with, and six (6) new in-house acquired pressure ulcers (five new stage III pressure ulcers, and one new stage II pressure ulcer). Review of Resident #2's Skin & Wound Evaluation V5.0 dated 01/21/2020 revealed a Stage IV (Full thickness skin and tissue loss) pressure ulcer to her Sacrum measuring 2.4cm Length x 2.4cm Width; a new, in-house acquired, unstageable (obscured full thickness skin and tissue loss) pressure ulcer to her Right Trochanter (hip) measuring 2.3cm Length x 3.0cm Width, with moderate serosanguinous (serous/bloody) drainage; a new, in-house acquired, stage III (full thickness skin loss) pressure ulcer to her Left Shoulder measuring 2.9cm Length x 4.1cm Width; a new, in-house acquired, stage III (full thickness skin loss) pressure ulcer to her Left Chest measuring 1.5cm Length x 2.4cm Width x 0.1cm depth; a new, in-house acquired, Stage III (Full thickness skin loss) pressure ulcer to her Right Lateral Malleolus (outer ankle), measuring 1.0cm Length x 0.8cm Width; a new, in-house acquired, Stage III (full thickness skin loss) pressure ulcer to her right ear, measuring 2.0cm Length x 1.5cm Width, with moderate serosanguinous drainage; and a new, in-house acquired, stage II (partial thickness skin loss) pressure ulcer to Left Trochanter (hip) measuring 2.4cm Length x 2.4cm Width. Review of Resident #2's Skin and Wound Evaluation V5.0 dated 04/14/2020, revealed the wounds on her Right Trochanter (hip) and Left Trochanter (hip) had doubled in size from the 01-09-2020 measurements. Review of Resident #2's Skin & Wound Evaluation V5.0 dated 04/14/2020 revealed an Unstageable (Obscured full thickness skin and tissue loss) pressure ulcer to her Right Trochanter (hip) that now measured 6.5cm Length x 3.4cm Width x 1.0cm Depth, with increased drainage; and a Stage II (partial thickness skin loss) pressure ulcer to her Left Trochanter (hip) that now measured 3.6cm Length x 3.9cm Width. Review of Resident #2's Progress Note dated 05/28/2020 revealed, Pt with old bandages on wounds. Aid removed bandages so that nursing could dress wounds. On 05-28-2020 wounds are exposed and uncovered still. Nursing was notified on 05-27-2020 of soiled bandages. Review of Resident #2's Progress Note dated 06/05/2020 revealed, RN Sup attempted to call RP x1 to inform of new areas noted to resident . Review of Resident #2's Skin & Wound Evaluation V5.0 dated 06/05/2020 revealed, two new, in-house acquired, pressure areas; a Stage IV (full thickness loss of skin and tissue loss) pressure ulcer to her Right Ear measuring 2.3cm Length x 1.3cm Width; and a new, in-housed acquired, Unstageable (obscured full thickness skin and tissue loss) pressure ulcer to her right heel measuring 4.8cm Length x 4.4cm Width. Review of Resident #2's Progress Note dated 06/07/2020 revealed, C.N.A. notified this nurse of new pressure areas to both heels and left ear during AM care .wedges applied for positioning . There were no assessments present for either heel wound. The DON confirmed, the assessments had been missed. Review of Resident #2's Order Summary Report dated 07-16-2020, revealed an order dated 06/11/2020, to be started on 06/12/2020 to Cleanse right heel Unstageable pressure ulcer on Mon, Wed, Fri .avoid pressure to area, float heel boots, use padded dressing to off load pressure. This order was put in place five (5) days after the wound was found on 06/07/2020. Review of Resident #2's Skin & Wound Evaluation V5.0 dated 07/08/2020 revealed, a significant increase in size to her stage IV sacral wound now measuring 5.7cm Length x 3.9cm Width, and four (4) new in-house acquired, pressure ulcers; a new, in-house acquired, Unstageable (Obscured full thickness skin and tissue loss) pressure ulcer on her Right Lateral Foot measuring 1.3cm Length x 2.4cm Width; a new, in-house acquired, Stage III (Full thickness loss of skin) pressure ulcer to her Right Ischial Tuberosity (buttock) measuring 1.4cm Length x 0.9cm Width; a new, in-house acquired, Stage III (full thickness skin loss) pressure ulcer to her Right fourth toe, measuring 1.0cm Length x 0.9cm Width; and a new, in-house acquired, Stage II (Partial thickness skin loss) pressure ulcer to her Left Trochanter (hip) measuring 4.8cm Length x 5.2cm Width. There was no assessment of the Stage IV pressure ulcer to Resident #2's Right Ear. The DON confirmed the assessment had been missed. Review of Resident #2's Treatment Administration Record for July 2020 revealed, and order dated 07/13/2020 to Cleanse R lateral Prox foot stage 2 pressure ulcer on M, W, F with NS or WC . The DON confirmed it was another new, in-house acquired, pressure ulcer they had found, and there was no assessment done for it. The SA attempted to reach Resident #2's family/representative multiple times with no answer or return call. Resident #3 Review of Resident #3's Admission Record, revealed she was admitted originally on 01/09/2012 with a primary [DIAGNOSES REDACTED]. Review of Resident #3's Minimum Data Set ((MDS) dated [DATE], revealed, she was totally dependent on two + person physical assist for bed mobility (how resident moves to and from lying position, turns side to side, and positions body while in bed). Resident #3 was not able to reposition herself or turn in the bed unassisted and was bedbound. Review of Resident #3's Braden Scale For Predicting Pressure Sore Risk, dated 12/24/2019, revealed her score to be a nine (9), which placed her at Very High Risk for developing pressure ulcers. Resident #3 was admitted with no pressure ulcers. Since 01-07-2020, she has acquired eight (8) new pressure ulcers; four Unstageable pressure ulcers, Stage III pressure ulcers, and two stage II pressure ulcers. A lack of turning and repositioning, and proper application of pressure reducing devices was observed, as well as interviews with staff confirming preventative pressure reducing devices were not consistently used, and an order for [REDACTED].

Based on staff interview, record review, and facility policy review, the facility failed to revise and update comprehensive care plans with measures to help heal and prevent pressure ulcers for three (3) of five (5) residents, Residents #1, #4, and #5; and dietary recommendations for one (1) of five residents, Residents #4. The facility's failure to revise and update resident's Plan of Care with interventions necessary to treat and prevent pressure ulcers, placed residents at risk for significant harm, up to and including death. The SA identified an Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) which began on [DATE], as a result of worsening and infection of Resident #1 ' s initial pressure ulcer. The facility ' s failure assess and put preventative measures in place, resulted in nine (9) new pressure ulcers, and the failure to implement an order to increase Resident #1's gastric tube feeding for eleven (11) weeks, to meet his nutritional needs and help heal his significant wounds, resulted in the deterioration of his wounds. The facility ' s failure to provide preventative measures to residents who were at risk for skin breakdown and to prevent further skin breakdown also affected Residents #2, #3, #4 and #5, which led to further skin breakdown, infections, and hospitalization s. The facility's failure to revise and update the resident's Plan of Care with interventions necessary to treat and prevent pressure ulcers, placed Residents #1, #4, #5 and other residents at risk, in a situation that caused and/or likely to cause serious injury, harm, impairment, or death. On [DATE] at 4:30 PM, the SA informed the Nursing Home Administrator (NHA) of the Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC). The IJ existed at: CFR(s) 483.21(b)(2)(i)-(iii) - Care Plan Revision (F657) The facility submitted a Credible Removal Plan on [DATE] at 1:08 PM, in which the facility alleged all corrective actions to remove the IJ were completed and the IJ removed as of [DATE]. The SA validated the Removal Plan on [DATE], and determined the IJ was removed, prior to exit. Therefore the scope and severity for CFR(s) 483.21(b)(2)(i)-(iii) - Care Plan Revision (F657), was lowered from a L level scope and severity to a F level, while the facility develop a plan of correction to monitor the effectiveness of the systemic changes to ensure the facility sustains compliance with regulatory requirements. Findings include: Review of the facility's Care Plans, Comprehensive Person-Centered policy, dated ,[DATE], revealed: Policy Statement: A comprehensive, person - centered care plan that includes measurable objectives and timetables to meet the resident's physical psychosocial and functional needs is developed and implemented for each resident. Policy Interpretation and Implementation: 1. The Interdisciplinary Team (IDT) .develops and implements a comprehensive, person-centered care plan for each resident. 2. The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment .8. The comprehensive, person-centered care plan will: .b. Describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being .m. Aid in preventing or reducing decline in the resident's functional status and/or functional levels .13. Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change. 14. The Interdisciplinary Team must review and update the care plan . Resident #1 Review of Resident #1's Admission Record, revealed he was admitted on [DATE] with a primary [DIAGNOSES REDACTED]. On [DATE] at 11:40 AM, during an interview with Registered Nurse (RN) #1, an Minimum Data Set (MDS)/Care Plan Nurse, regarding a TAP (Turning and Positioning) program and positioning devices, she stated, .we should put turning and positioning and heel padding on the care plans . in order for it to be put on their Kardex/Care Plan to chart on, we would have to assign exact times to it .we don't want to lock them into a time. On [DATE] at 11:45 AM, during an interview with RN #2, an MDS/Care Plan nurse, regarding heel cushions/floats, and a TAP schedule, and she stated, We should be putting those items on the care plan, if we know they are doing them, but we haven't been doing that recently with COVID in the building . On [DATE] at 4:15 PM, during an interview with the Director of Nursing (DON), concerning the Kardex/Care Plans not being updated with preventative measures to help heal wounds, and prevent further wounds, she stated, .the Kardex issue goes back to the care plan nurses not putting things on there like they supposed to again. Whether they go on the Kardex for the C.N.A.'s or the regular care plan, the care plan nurses supposed to get the new orders and make sure they are on the care plans, and they supposed to review the care plans real good when the assessments is due, and obviously they aint . Review of Resident #1's MDS dated [DATE], revealed, he was totally dependent on two + person physical assist for bed mobility (how resident moves to and from lying position, turns side to side, and positions body while in bed). Resident #1 was not able to reposition himself or turn in the bed unassisted. Review of Resident #1's Braden Scale For Predicting Pressure Sore Risk, dated [DATE], revealed his score to be eleven (11) which placed him at High Risk for developing pressure ulcers. Review of Resident #1's Order Summary Report dated [DATE], revealed an order for [REDACTED]. Review of Resident #1's Visual/Bedside Kardex Report revealed Bed Mobility: The resident requires assistance by (x) 2 staff to turn and reposition in bed, low air loss mattress to bed . there was no mention of a TAP schedule or preventative positioning devices for him. Review of Resident #1's care plan initiated [DATE], and last revised on [DATE], revealed, Focus: Potential for skin breakdown r/t (related to) impaired mobility & incont of B&B (Bowel and Bladder). Interventions: Incont. Care after each episode, body audit per protocol & PRN, Wheelchair cushion to wheelchair when up in chair for weight redistribution, staff to encourage resident with good nutrition. Review of the interventions indicated no mention of moisture barrier use, repositioning devices, or a TAP program to help prevent pressure ulcer formation. Review of Resident #1's care plan created on [DATE] revealed, Focus: .The resident has unstageable pressure ulcer lt. hip r/t Immobility. Goal: The resident's pressure ulcer will show signs of healing and remain free from infection . Review of the interventions listed, shows no mention of a specialty mattress, moisture barrier use, a positioning wedge, repositioning devices, or a TAP program. Review of Resident #1's care plan created on [DATE] revealed, Focus: .The resident has unstageable pressure ulcer rt. hip r/t Immobility. Goal: The resident's pressure ulcer will show signs of healing and remain free from infection . Review of the interventions listed, shows no mention of a specialty mattress, moisture barrier use, a positioning wedge, repositioning devices, or a TAP program. Review of Resident #1's care plan created on [DATE] revealed, Focus: .The resident has unstageable pressure ulcer to sacral r/t Immobility. Goal: The resident's pressure ulcer will show signs of healing and remain free from infection . Review of the interventions listed, shows no mention of a specialty mattress, moisture barrier use, a positioning wedge, repositioning devices, or a TAP program. Review of Resident #1's care plan created on [DATE] revealed, Focus: .The resident has left lateral ankle-unstageable pressure ulcer development - DTI (Deep Tissue Injury) r/t Immobility. Goal: The resident's pressure ulcer will show signs of healing and remain free from infection . Review of the interventions listed, shows no mention of a specialty mattress, a positioning wedge, repositioning devices, or a TAP program. Review of Resident #1's care plan created on [DATE] revealed, Focus: .The resident has unstageable pressure ulcer-rt lateral ankle r/t Immobility. Goal: The resident's pressure ulcer will show signs of healing and remain free from infection . Review of the interventions listed, shows no mention of a specialty mattress, a positioning wedge, repositioning devices, or a TAP program. Review of Resident #1's care plan created on [DATE] revealed, Focus: .The resident has Stage III pressure ulcer-rt. great toe r/t Immobility. Goal: The resident's pressure ulcer will show signs of healing and remain free from infection . Review of the interventions listed, shows no mention of a specialty mattress, a positioning wedge, repositioning devices, or a TAP program. Resident #1 was admitted to the facility without any noted pressure ulcers, and acquired eleven (11) new pressure ulcers, (two Unstageable ulcers, two Stage IV pressure ulcers, one Stage III pressure ulcer, four Stage II pressure ulcers, and one Stage I pressure ulcer) due to a lack of turning and repositioning, and proper application of pressure reducing devices. Resident #4 Review of Resident #4's Admission Record revealed, she was admitted to the facility on [DATE] with the primary [DIAGNOSES REDACTED]. On [DATE] at 4:50 PM, during a joint interview with the Administrator, and DON regarding concerns of a lack of dietary interventions being put into place and care planned, and interventions not being placed on care plans, the Administrator stated, .there was a changeover of Dieticians in the middle of the COVID crisis, some residents were moved to another room and nurse. They may not have known all the specifics for each resident like they should. The DON had no comment. On [DATE] at 11:40 AM, during an interview with Registered Nurse (RN) #1, an MDS/Care Plan Nurse, regarding dietary interventions no being carried over to the care plans, she stated, .we are to put new orders on the care plans as we are made aware of them. If the recommendations came in, and we were aware of the new orders, they wouldn't get put on the care plan . On [DATE] at 11:45 AM, during an interview with RN #2, an MDS/Care Plan Nurse, regarding dietary recommendations and new orders being placed on the care plan, and she stated, . we've had a changeover in the lady doing recommendations, and they ain't been in the building in a while .we don't always know they (new orders) coming through .We should be putting those items on the care plan, if we know they are doing them, but we haven't been doing that recently with COVID in the building . On [DATE] at 4:15 PM, during an interview with the DON, concerning the Kardex/Care Plans not being updated with preventative measures to help heal wounds, and prevent further wounds, she stated, .the Kardex issue goes back to the care plan nurses not putting things on there like they supposed to again. Whether they go on the Kardex for the C.N.A.'s or the regular care plan, the care plan nurses supposed to get the new orders and make sure they are on the care plans, and they supposed to review the care plans real good when the assessments is due, and obviously they aint . On [DATE] at 2:05 PM, during an interview with the DON she stated, .the flow of dietary recommendations was broken for a while. The recommendations were to be given to the care plan nurses to review, obtain orders, and place on the care plans. There were several months of recommendations missed because of it . Review of Resident #4's MDS dated [DATE], revealed she required extensive assistance of one person for eating, had experienced a significant weight loss of over 5% in 30 days, and over 10% in 6 months, and was at risk for the development of pressure ulcers. Review of Resident #3's Braden Scale For Predicting Pressure Sore Risk, dated [DATE], revealed her score to be a six (6) which placed her at Very High Risk for developing pressure ulcers. Review of Resident #4's Nutrition/Dietary Note, dated [DATE], revealed recommendations to start a Vitamin with minerals. Review of Resident #4's Nutrition/Dietary Note, dated [DATE], revealed a weight loss of 6%, and a recommendation from the RD to add an HS (hour of sleep) snack. Review of Resident #4's Nutrition/Dietary Note, dated [DATE], revealed a significant weight loss of 7.1% in thirty (30) days, and a significant weight loss of 13.4% in ninety (90) days, with a recommendation to add fortified food to her meal trays daily. Review of Resident #4's Nutrition/Dietary Note, dated [DATE], revealed an RD dietary recommendation for an appetite stimulant. Review of Resident #4's care plan, initiated on [DATE], and last revised on [DATE], revealed, Focus: The resident has the potential for nutritional problems r/t mechanically altered diet .Goal: The resident will have gradual weight gain/loss to within 10% of IBW (ideal body weight) for sex and height range by review date .Interventions: .dietary supplement of choice (medpass/ensure) 90 cc bid (twice a day), ensure TID (Three times a day) as ordered, mighty shakes as ordered .provide, serve diet as ordered. Regular diet puree texture thin liquids . There was no mention of a vitamin with minerals, HS snacks, fortified foods, an appetite stimulant, or the significant weight losses at 30 days, 90 days, and 180 days. Review of Resident #4's Progress Note, dated [DATE] revealed, Orders - Cleanse L Hip Stage II pressure ulcer Mon, Wed, Fri with NS or WC, pat dry, apply [MEDICATION NAME], secure with [MEDICATION NAME], pad with gauze tape. One time a day. Avoid pressure to area; Keep skin clean and dry; lift from surfaces during turns, low air loss mattress, turn q 2 hours . Review of Resident #4's care plan Initiated on [DATE], and last revised on [DATE] revealed, Focus: The resident has unstageable pressure ulcer to left hip r/t disease process. Goal: The resident's pressure ulcer will show signs of healing and remain free from infection by/through review date. Interventions: Administer medications as ordered .Administer treatments as ordered .Educate the resident/family/caregivers as to the causes of skin breakdown .monitor dressing to ensure it is intact and adhering .monitor nutritional status .obtain and monitor lab/diagnostic work as ordered . There was no mention of avoiding pressure, keeping skin clean and dry, lifting from surfaces during turns, a low air loss mattress, or a TAP for every two hours. Resident #5 Review of Resident #5's Admission Record revealed, she was admitted to the facility on [DATE], with a primary [DIAGNOSES REDACTED]. She was later [DIAGNOSES REDACTED]. On [DATE] at 11:40 AM, during an interview with Registered Nurse (RN) #1, an MDS/Care Plan Nurse, regarding a TAP program and positioning devices, she stated, .we should put turning and positioning and heel padding on the care plans . in order for it to be put on their Kardex/Care Plan to chart on, we would have to assign exact times to it .we don't want to lock them into a time. On [DATE] at 11:45 AM, during an interview with RN #2, an MDS/Care Plan Nurse, regarding heel cushions/floats, and a TAP schedule, and she stated, We should be putting those items on the care plan, if we know they are doing them, but we haven't been doing that recently with COVID in the building . On [DATE] at 4:15 PM, during an interview with the DON, concerning the Kardex/Care Plans not being updated for Resident #5, she stated, .she had a wound back last year, and should have had a TAP schedule in place, because she didn't have no legs .the issue goes back to the care plan nurses not putting things on there like they supposed to again. Whether they go on the Kardex for the C.N.A.'s or the regular care plan, the care plan nurses supposed to get the new orders and make sure they are on the care plans, and they supposed to review the care plans real good when the assessments is due, and obviously they aint . Review of Resident #5's Wound (Consult) - Consultation Note, dated [DATE] at 9:53 AM, revealed: Reason for Referral - Sacral Ulcer .Chief Complaint/HPI: XXX[AGE] year old female with Stage II sacral ulcer. There is significant maceration. Moderate Pain .Impression and Plan: [AGE] year old female with Stage II sacral ulcer. There is significant maceration. Apply Xeroform and ABD. Patient is a DNR (Do Not Resuscitate). No surgical intervention is needed at this time . Review of Resident #5's MDS/Kardex Report revealed, .Dx: .Acquired Absence of Left Leg Above Knee, Acquired Absence of Right Leg Above Knee, Age-Related Cognitive Decline .Daily Decision Making - Severely Impaired .Bed Mobility: Extensive assistance of One person physical assist .Functional Limitation in Room: Lower Extremity .Bowel: Always Incontinent, Urinary: Always Incontinent .Skin and Ulcer Treatment: .Pressure reducing device for bed .Nonsurgical dressings . A pressure reducing device for chair, Turning/Repositioning program, Nutrition or hydration intervention, and Ulcer care were options present on this form, and were not marked for resident). Review of Resident #5's Progress Note, dated [DATE] revealed, . resident requires total asst. x 1 in bed mobility, toileting and eating at this time . Review of Resident #5's Progress Note dated [DATE], revealed RP (proper name) notified of large area to buttock sacral area (unstageable) . Review of Resident #5's Skin & Wound Evaluation V5.0, dated [DATE], revealed, the wound description section, the location section, and the acquired section to all be blank/unanswered. The only item filled out on this assessment was the Wound Measurements: .8.3cm Length x 8.9cm Width . No other item on the assessment was filled out. Review of Resident #5's Treatment Administration Record, for [DATE], revealed an order for [REDACTED]. Review of Resident #5's care plan, initiated on [DATE], and last revised on [DATE], revealed, Focus: Alteration in Elimination & Skin Integrity r/t cognitive deficits, incont of bladder and bowel daily, and impaired mobility, bil [MEDICAL CONDITION]. Goal: Resident will be clean, dry, and odor free through this 90 day review period; Resident will have no impairment in skin integrity r/t incont. through this 90 day review. Interventions: change pad/briefs after each incont episode, C.N.A. will provide skin checks .nurse will perform weekly skin check, provide me an air mattress to bed, skin barrier to buttocks q shift and prn, wheelchair cushion to wheelchair when up in chair for weight redistribution. There is no mention of staff assisting with a TAP program, or preventative positioning devices on the care plan. Review of Resident #5's care plan, initiated on [DATE] revealed, Focus: The resident has a pressure ulcer development to sacrum r/t immobility. Goal: The resident's pressure ulcer will show signs of healing and remain free from infection by/through review date. Interventions: Administer medications as ordered .Administer treatments as ordered .monitor nutritional status .obtain and monitor lab/diagnostic work as ordered .treat pain as per orders .weekly treatment documentation . There is no mention of a TAP program, an air mattress to the bed, wheelchair cushion to the wheelchair, or preventative positioning devices on the care plan. The facility submitted an acceptable Removal Plan on [DATE] for the Immediate Jeopardy (IJ) and Substandard Quality of Care. Review of the facility's Removal Plan, revealed, the facility took the following corrective actions to remove the IJ prior to exit: On [DATE] at 4:30PM, the State Agency informed Nursing Home Administrator (NHA) of the immediate jeopardy with substandard quality of care due to pressure ulcers, care plans, abuse/neglect and pain. NHA was informed that Resident # One (1), Resident # Two (2), Resident # Three (3), Resident # Four (4), Resident # Five (5) affected. Extensive failure was identified in multiple areas of pressure ulcer care: As a result of the facility's extensive noncompliance in multiple areas of pressure ulcer care, Resident # One (1), Resident # Two (2), Resident # Three (3), Resident # Four (4) developed recurrent and/or multiple, avoidable Stage III or Stage IV pressure ulcers for residents reviewed for facility acquired pressure ulcers. The facility did not have adequate procedures in place to provide preventative measures to residents who are at risk for skin breakdown, in order to prevent further skin breakdown. The facility failed to provide appropriate care to residents with pressure ulcers resulted in further skin breakdown, infections, and hospitalization s (1) Quality Assurance Performance Improvement (QAPI) meeting was conducted on [DATE], at 7:00PM, Medical Director, NHA, Director of Nursing (DON), Social Services Director (SSD), Dietary Manager (DM), Minimum Data Set (MDS) nurses and Corporate Nurse Consultant (acting Infection Prevention Officer) present to determine what systems to evaluate that led to deficient practices. Next actions created from QAPI meeting was to complete body audits on total in-house census of all sixty-seven (67) residents to determine the condition of each resident's skin, comprehensive care plan audit to ensure care plan accurately reflects the care of the resident, new evaluation of each resident by registered dietitian, identify system break in wound care program, and evaluate education needs of staff. On [DATE] at 9:00AM. QAPI meeting was held with Medical Director, NHA, Director of Nursing, Social Services, Dietary Manager, Minimum Data Set nurses and Corporate Nurse Consultant (acting Infection Prevention Officer) present. Meeting agenda items included a review of removal plan, request for recommendations regarding wound care program, and new skin concerns identified. Medical Director recommended locating a provider that employs wound care certified nurse practitioners that could visit center weekly. One new policy change was made related to follow up on dietary recommendations within seventy-two (72) hours instead of seven (7) days. This policy was signed off on by the Medical Director. The facility will now follow up on all dietary recommendations within seventy-two (72) hours as well as update the care plan. The Assistant Director of Nursing (ADON) has assumed responsibility for ensuring that orders are written for dietary recommendations and that the recommendations are updated on the care plan. Assistant Director of Nursing signed in-service regarding new policy of following up on dietary recommendations within seventy-two (72) hours on [DATE]. New measure was implemented and signed off on by Medical Director on [DATE] for physician or Nurse practitioner (NP) providing targeted skin assessments for residents with wounds once a month. **The State Agency (SA) validated through document review, observation, and interview, topics covered in the Quality Assurance (QA) mtg held on [DATE], covering the topics of system deficiencies in the wound care program that led to the Immediate Jeopardy (IJ), complete body audits, care plan review, and dietary recommendation review for all residents, and a secondary QA mtg held on [DATE] to address drafting a removal plan, the results of the body audits, change of the consultant recommendation policy, monthly targeting skin assessments by the Medical Director (MD) or Nurse Practitioner (NP), recruitment of a wound vertified NP, abuse and neglect inservices, and competency based post test for inservices. The new policy for consultant recommendations was signed by the MD, and put into effect. The Assistance Director of Nursing (ADON) was inserviced on responsibility of ensuring dietary recommendations are written, orders received, and care plans are updated within 72 hours of receiving them. The MD of NP providing the targeted skin assessments will sign off on them once a month. (2) Body Audits, to include all residents with wounds, was initiated on [DATE] and completed on [DATE] a total in-house census of sixty-seven (67) residents by Minimum Data Set Coordinator -Registered Nurse (RN), Corporate Nurse Specialist, RN, Corporate Certified Wound Care Specialist, RN, sister facility RN, and Medical Records RN. Resident # Six (6), Resident # Seven (7), and Resident # Eight (8) were noted to have new skin issues identified through audit, new orders for treatment were obtained and implemented. Resident # Six (6) has excoriation to sacrum. The facility reported excoriation on Resident # Six (6) to physician on [DATE], new treatment order obtained, care plan revised to reflect change in condition and treatment and responsible party notified. On [DATE] Physician gave order to evaluate appropriateness of cushion on Resident # Six (6) specialized motorized wheelchair that has cushion to relieve pressure. Wheelchair company visited on [DATE] to assess wheelchair and facility approved order for a new cushion on [DATE]. Resident has suprapubic catheter and [MEDICAL CONDITION] so cause of excoriation is not pressure but moisture caused by sweating. Resident # Seven (7) was assessed and noted Moisture Associated Skin [MEDICAL CONDITION] (MASD) on buttocks. MD was notified and gave order to apply barrier cream after each incontinent episode. Moisture barrier cream order was implemented on [DATE] at 12:08PM by Certified Nursing Assistant (C.N.A). Resident # Seven (7)'s care plan was revised on [DATE] by RN to include every two (2) hour checks by nursing staff to monitor for incontinent care need. **The State Agency (SA) validated through document review, observation, and interview, the facility completed body audits on all 67 residents present in the building between [DATE] and [DATE]. Audit sheets were verified, alert residents interviewed on receiving a body audit, the three residents with new areas identified were reviewed by the physician, orders given were verified in the medical records and care plans were verified to have been updated. Responsible Party was notified of change of status of MASD to sacrum, new order and revision to plan of care on [DATE] by Administrator. Resident # Eight (8) was assessed and noted to have two (2) new areas presenting as stage II on left lateral foot and a stage III on left lateral 5th toe on [DATE]. The Nurse Practitioner was notified and new order obtained for treatment of [REDACTED]. New treatment orders with Xeroform implemented by Licensed Practical Nurse (LPN) under the supervision of an RN on [DATE]. Bilateral lower extremity venous and doppler studies were performed on [DATE] per NP orders which resulted in [DIAGNOSES REDACTED]. **The State Agency (SA) validated through document review, and interview, the facility notified Resident #8's Responsible Party concerning his skin areas, treatments were obtained, doppler study was scheduled and completed with a new [DIAGNOSES REDACTED]. The orders were verified as changed to [MEDICATION NAME] on [DATE]. (3) The following measures for impacted residents were implemented: Resident # One (1) was evaluated by Registered Dietician (RD) on [DATE], and nine (9) new dietary recommendations were given, implemented, and care plan updated. Pain evaluation performed on [DATE] by DON with no changes to pain medication regimen. Nurse Practitioner assessed Resident # One (1) on [DATE] with no new orders given. MD assessed Resident # One (1) on [DATE], and new orders were given for bilateral venous and arterial Doppler studies. Vendor performed doppler on [DATE] and results pending. Sister facility RN reviewed current treatment orders for effectiveness on [DATE] and deemed orders as appropriate due to current treatments are ordered once a day. Resident # One (1) treatment orders have been implemented. Therapy reviewed current positioning devices for Resident # One (1), and ordered full body wedge, palm guards, and knee separator for Resident # One (1) from supply vendor on [DATE]. New orders will be implemented upon delivery of these special-order devices. Resident # Two (2) was evaluated by RD on [DATE] with three (3) new recommendations which were implemented and care planned by Corporate Regional Nurse; responsible party notified during care conference held on [DATE]. NP assessed Resident # Two (2) on [DATE] with no new orders given. MD assessed Resident # Two (2) on [DATE] with no new orders given. Treatment review for effectiveness completed on [DATE] by sister facility RN and a new order was given by NP to change frequency of treatment order to once a day. Therapy reviewed current positioning devices and deemed current devices as appropriate for care. Resident # Three (3) was evaluated by RD on [DATE] with two (2) new recommendations that were implemented and added to the care plan by Corporate Regional Nurse. Sister facility RN reviewed current treatment orders on [DATE] to determine effectiveness of treatments and deemed current treatments as effective. Therapy reviewed positioning devices for Resident # Three (3) and ordered a full body wedge and abductor contracture cushion from a supply vendor on [DATE]. Resident # Three (3) orders are being followed for devices currently in place. New orders will be implemented upon delivery of special-order devices. Resident # Three's (3) care plan was reviewed and revised by MDS RN on [DATE] to reflect current status and new orders. Responsible party for Resident # Three (3) was notified of assessment findings, care plan revision and new orders on [DATE] by MDS RN during care conference. Resident # Four (4) was evaluated by RD on [DATE] with one (1) new recommendation given, implemented, and added to care plan by (who). NP assessed Resident # Four (4) on [DATE] with no new orders given. MD assessed Resident # Four (4) on [DATE] with no new orders given. Corporate Wound Consultant reviewed treatments of Resident # Four (4) wounds and made recommendations which were reviewed and ordered by NP on [DATE]. Devices reviewed by therapy for Resident # Four (4) and elbow splint, boots, and full body wedge were ordered on [DATE] from supply vendor. Resident # Four's (4) orders are being followed for devices currently in place. New special-order device orders will be implemented upon delivery of devices. Resident # Five (5) was hospitalized on [DATE] and subsequently expired due to [MEDICAL CONDITION]. **The State Agency (SA) validated through document review, observation, and interview, the facility ensured Re (TRUNCATED)

Based on observation, staff interview, record review, and facility policy review, the facility failed to prevent the development of pressure ulcers and the worsening of existing pressure ulcers for five (5) of 5 residents, Residents #1, #2, #3, #4 and #5. The SA identified an Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) which began on 04/21/2020, as a result of worsening and infection of Resident #1's initial pressure ulcer. The facility's failure to assess and put preventative measures in place, resulted in Resident #1 developing nine (9) new pressure ulcers. The failure to implement an order to increase Resident #1's gastric tube feeding for eleven (11) weeks to meet his nutritional needs and help heal his significant wounds, resulted in the deterioration of his wounds. The facility's failure to provide preventative measures to residents who were at risk for skin breakdown and to prevent further skin breakdown also affected Residents #2, #3, #4 and #5. The facility's failure to provide goods and services necessary to treat and prevent pressure ulcers caused significant harm to Residents #1, #2, #3, #4, #5 and placed other residents at risk for skin breakdown, in a situation that caused and/or likely to cause serious injury, harm, impairment, or death. On 07/20/2020 at 4:30 PM, the SA informed the Nursing Home Administrator (NHA) of the Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC). The IJ and SQC existed at: CFR(s) 483.25(b)(1)(i)(ii) - Treatment/Services to Prevent/Heal Pressure Ulcers (F686) The facility submitted a Credible Removal Plan on 07/25/2020 at 1:08 PM, in which the facility alleged all corrective actions to remove the IJ were completed and the IJ removed as of 07/25/2020. The SA validated the Removal Plan on 07/26/2020, and determined the IJ was removed, prior to exit. Therefore the scope and severity for CFR(s) 483.25(b)(1)(i)(ii) - Treatment/Services to Prevent/Heal Pressure Ulcers (F686) was lowered from a L level scope and severity to a F level, while the facility develop a plan of correction to monitor the effectiveness of the systemic changes to ensure the facility sustains compliance with regulatory requirements. Findings include: Review of the facility's Pressure Ulcer Prevention Program policy, revised 07/2018, revealed: Standard: All resident will be assessed for the risk of pressure ulcer development. Based on the results of this assessment, specific interventions will be implemented to prevent the development of avoidable pressure ulcers, or, to treat existing ulcers. Procedure: 1. All residents will be screened for risk of pressure ulcer development utilizing the Braden Scale/Norton Scale .2. Residents identified as being at risk will have interventions identified in their plan of care to prevent the occurrence of pressure ulcers. 3. The following is a list of commonly used interventions to prevent the development of pressure ulcers - Frequent turning and positioning .monitor resident's nutritional intake, pad between bony prominences .utilize pressure relieving devices as needed . 4. All resident will have a head to toe assessment completed on a weekly basis by a licensed nurse to identify any skin breakdown. The results of this assessment will be documented in the resident's medical record. 5. If a pressure ulcer/skin breakdown is identified, the following will be done - The licensed nurse will complete a thorough assessment of the affected area . include size, stage, location, drainage and odor. The licensed nurse will notify the physician and the family. Treatment will be initiated per physicians' orders. The resident's plan of care will be updated to reflect interventions. The interdisciplinary team will be notified so that appropriate referrals may be made to the dietician, therapy etc .The Director of Nursing (DON) or designee will track and monitor pressure ulcers weekly. In the event the primary assessing nurse is not by state practice act allowed to stage a PrU (Pressure Ulcer), then the DON/Designee must view and stage the PrU weekly. The DON/designee will report results to the Quality Assurance/Improvement Committee on a quarterly basis. Review of the facility's document titled, Pressure Ulcer Prevention and Treatment Toolkit, dated 07/2018, revealed: This toolkit is intended to assist the resident's care team in assessing, developing the plan of care, monitoring the plan implementation and effectiveness, and revising the plan of care as indicated, to meet the individual resident's needs .the team is more likely to reduce the development of new pressure ulcers and promote healing of existing ulcers .A comprehensive assessment should address risk factors that had been identified as having an impact on the development, treatment and healing of pressure ulcers, such as pressure points, and under nutrition . Skin Assessment: Regularly conduct thorough skin assessments on each resident who is at risk of developing pressure ulcers. Such skin assessments allow early detection of developing or existing skin breakdown or to verify the integrity of the skin. When conducting skin assessments: evaluate all areas at risk of constant pressure, positioning in bed, positioning in chair, presence of contractures or deformities . Examine all pressure points. The most common include: sacrum, heel, greater trochanter, ischial tuberosity, fibular head, scapula, ankle, and elbow. Repositioning: Repositioning should occur at least every two hours, but more frequent repositioning may be warranted for individuals who are at higher risk for pressure ulcer development . If feasible, use pillows to raise heels off the bed .Nutrition: .An Interdisciplinary Team should develop nutritional goals. Unless contraindicated, goal for a resident with nutritional compromise who has a PU (pressure ulcer) or is at risk of developing one should include protein intake of approximately 1.2-1.5gm/kg body weight daily (higher end of the range if larger, more extensive or multiple wounds) . Review of facility's document titled, Nutrition Support for Pressure Ulcers - Nutritional Information From The Role of Nutrition in Pressure Ulcer Prevention And Treatment - National Pressure Ulcer Advisory Panel White Paper revised 07/2018, revealed, Important Nutritional Support For Pressure Ulcers: 1. Calories - the most important Factor in healing pressure ulcers is adequate calories . glucose is the major fuel source for collagen synthesis. Collagen is the matrix, or base for repairing tissue. So without adequate glucose, there is not adequate healing .Every day the resident has calorie intake below the desired amount, there is no wound healing .and may be actual decline .it is our policy that all new wounds be reviewed by the dietitian within 72 hours .there must be a combined effort to make sure that the dietitian is contacted, and her recommendations are presented to the physician and carried out . Delay in this process can mean a delayed healing process .2. Protein - protein is also required for healing .all stages of wound healing require adequate protein .Team work is essential for healing wounds. A break in the system will mean poor outcome. Review of the facility's Consultant Recommendations and Follow Up policy, undated, revealed, Consultants will visit the facility at a time scheduled with the pertinent department head and Administrator/DON. 2. A list of recommendations will be left with the Administrator and Director of Nurses with copies distributed to other disciplines as necessary .4. The recommendations will be followed up on within seven (7) days .5. Documentation will include physicians' orders, nurses' notes, and care plan revision where necessary & appropriate .8. The consultant will review the consultant report book during his/her visit to the facility to assure follow up has occurred. Resident #1 Review of Resident #1's Admission Record, revealed, he was admitted on [DATE] with a primary [DIAGNOSES REDACTED]. Review of Resident #1's Minimum Data Set ((MDS) dated [DATE], revealed, he was totally dependent on two + person physical assist for bed mobility (how resident moves to and from lying position, turns side to side, and positions body while in bed). Resident #1 was not able to reposition himself or turn in the bed unassisted. Review of Resident #1's Braden Scale For Predicting Pressure Sore Risk, dated 02-19-2020, revealed his score to be eleven (11), which placed him at High Risk for developing pressure ulcers. Resident #1 was admitted to the facility without any noted pressure ulcers. Since 02/03/2020, Resident #1 has eleven new in-house acquired pressure ulcers, (two Unstageable ulcers, two Stage IV pressure ulcers, one Stage III pressure ulcer, four Stage II pressure ulcers, and one Stage I pressure ulcer). A lack of turning and repositioning, with proper application of pressure reducing devices was observed, as well as interviews with staff confirming the formation of multiple pressure ulcers, an increase in Resident #1's pain level, preventative pressure reducing devices were not consistently used, weekly skin assessments and wound measurements were missed, and an order for [REDACTED]. On 07/15/2020 at 10:35 AM, during initial rounds, Resident #1 was observed in bed, lying on his back. On 07/15/2020 at 11:35 AM, Resident #1 was observed in the bed, pillow behind his head, lying on his back, wedge triangle behind resident's head on left side, legs drawn up in a fetal position, no other positioning devices observed. On 07/15/2020 at 2:10 PM, Resident #1 was observed in the bed, on his back, legs pulled up in the fetal position, no heel pillows present, triangle wedge was on the floor near his window, no other positioning devices observed. On 07/15/2020 at 3:45 PM, Resident #1 was observed in the bed, pillow behind his head, lying on his back, legs drawn up in a fetal position, no other positioning devices observed. On 07/15/2020 at 3:45 PM, Resident #1 was observed in the bed, on his back, in the same position as prior rounds, legs in fetal position, wedge triangle remains on the floor near window, no other positioning devices observed. On 07/16/2020 at 9:00 AM, Resident #1 was observed in the bed, lying on his back, pillow behind his head, a wedge cushion resting in his right axilla, legs pulled into fetal position, with no other positioning devices observed. On 07/16/2020 at 11:40 AM, Resident #1 was observed lying on his right side, with a pillow under his head, and no other positioning devices observed, just prior to him receiving wound care. Wound care was observed by State Agency (SA), as completed by Licensed Practical Nurse (LPN) #1, without concerns or breach in infection control. Wounds were observed to be a Stage IV, full thickness wound to Resident #1's Left Trochanter (hip), with exposed muscle in the wound bed; an unstageable pressure ulcer to Resident #1's Right Trochanter (hip), with wound bed covered in a large, hard, dark black eschar; an unstageable pressure ulcer to Resident #1's Left Lateral Malleolus (outer ankle), the wound bed was bleeding, covered in a large amount of loose slough, with bone exposed in the center of the wound bed; an unstageable pressure ulcer to Resident #1's Right Calf/Shin, covered in a large, hard, dark eschar, with a small area of slough present; an unstageable pressure ulcer to Resident #1's Right Lateral Malleolus (outer ankle), with half of the wound bed covered in slough; and a Stage III pressure ulcer, with full thickness loss of skin, on Resident #1's Right Great Toe (Hallux), with muscle exposed in the center of the wound bed. On 07/16/2020 at 4:15 PM, Resident # 1 was observed in the bed on his back, with a pillow behind his head, legs pulled up in the fetal position with no positioning devices observed. On 07/17/2020 at 9:10 AM, Resident # 1 was observed in his bed, lying on his back, with a pillow behind his head, legs pulled into the fetal position, and no other positioning devices observed. On 07/17/2020 at 2:00 PM, Resident #1 was observed in the bed, lying on his back, with a pillow behind his head, a wedge cushion in right axilla area, legs pulled into a fetal position, no other positioning devices observed. On 07/16/2020 at 11:40 AM, during an interview with Licensed Practical Nurse (LPN) #1, when asked by the State Agency (SA) about positioning devices/heel cushions for Resident #1, she stated, they usually be in here somewhere, but I don't see them right now .whoever see em' off usually put them back on, but they ain't assigned to nobody .they ain't on the medication or treatment sheets . On 07/17/2020 at 3:30 PM, during an interview with the DON, when asked by the SA about a turning and repositioning (TAP) schedule and positioning devices for residents, she stated, .the nurses are supposed to make sure the aides do it, and check for pillows and stuff, but they was moving residents for COVID and didn't know what to put on them, that's why wounds is a mess right now. On 07/20/2020 at 10:45 AM, during an interview with Certified Nurse Aide (C.N.A.) #1, concerning positioning devices/heel cushions and a TAP schedule, she stated, We do our charting on iPads (Interactive Personal Application Devices), and it don't talk about heel boots in it. We answer yes or no if we turn them on our shift .the nurse is supposed to check the pillows and stuff .he (Resident #1), supposed to have them boots on right now, and a pillow by his knees, but they was soaked with urine this morning and had to be sent to laundry ain't no extras to put on him right now . there ain't no set schedule for turnin' residents, I just know when, 'cause I been doin' this job for a long time .It ain't written down nowhere to see. On 07/20/2020 at 11:45 AM, during an interview with C.N.A. #2, regarding positioning devices/heel cushions and a TAP schedule, she stated, We have a Kardex on the iPad for some resident info, and we are supposed to get report from the shift leaving .we tried (to use positioning devices) but couldn't always do it .there aren't always enough wedges to go around .we just know when to turn them, it's not written down. On 07/20/2020 at 11:40 AM, during an interview with Registered Nurse (RN) #1, a Minimum Data Set (MDS)/Care Plan Nurse, regarding a TAP program and positioning devices, she stated, .we should put turning and positioning and heel padding on the care plans. No one is assigned the task of checking if the heel padding is in place. The C.N.A.'s just answer a yes/no question on whether they did it (TAP) or not, because in order for it to be put on their (the C.N.A.'s) Kardex to chart on, we would have to assign exact times to it .we don't want to lock them into a time. On 07/20/2020 at 11:45 AM, during an interview with RN #2, an MDS/Care Plan nurse, regarding heel cushions/floats, and a TAP schedule, and she stated, We should be putting those items on the care plan, if we know they are doing them, but we haven't been doing that recently with COVID in the building . On 07/20/2020 at 11:40 AM, during an interview with the DON, she confirmed she oversaw the wound program, and the treatment nurse had Left abruptly on 05/01/2020. She found issues with incomplete documentation, staging of wounds, and Certified Nurse Aides (C.N.A.'s) were coming to tell her about their concerns with the wounds and lack of care. Review of Resident #1's Visual/Bedside Kardex Report revealed Bed Mobility: The resident requires assistance by (x)2 staff to turn and reposition in bed, low air loss mattress to bed . there was no mention of a TAP schedule or preventative positioning devices for him. Review of Resident #1's Skin & Wound Evaluation V5.0, dated 02/03/2020, revealed a new, in-house acquired, Stage II (partial thickness loss of skin) pressure ulcer to his Left Trochanter (hip) that measured 1.9 centimeters (cm) Length x 2.2cm Width x 0.2cm Depth with a moderate amount on serosanguineous (serous/bloody) drainage. Additional measures to be put into place were incontinence management, a mattress, moisture barrier, nutrition/dietary supplementation, positioning wedge, repositioning device(s), and a turning/repositioning program. Review of Resident #1's Skin & Wound Evaluation V5.0, dated 03/04/2020 revealed the Left Trochanter wound had worsened and was now a Stage III (full thickness loss of skin), and larger in size at 2.3cm Length x 3.4cm Width, and no Depth recorded. Further review of Resident #1's Skin & Wound Evaluation V5.0, for April 2020, revealed no assessment or measurements of the left trochanter wound due on 04/21/2020. Review of Resident #1's Progress Note, dated 04/22/2020 revealed, .RP notified of new area noted to resident's right hip . On 07/17/2020 at 3:30 PM, during an interview with the DON, regarding Resident #1's missing skin assessment and measurements of his Left Trochanter wound due on 04-21-2020, and the missing skin assessment and measurements of the new area on his right hip on 04/22/2020, she stated, They weren't done 'cause he was moved to the COVID unit and I don't think they knew about him real good. Further review of Resident #1's Skin & Wound Evaluation V5.0, dated 04/27/2020, revealed, a deterioration in, and the presence of infection to his Left Trochanter (hip) wound, an unstageable (Obscured full thickness loss of skin and tissue loss) wound to his Right Trochanter (hip) identified on 04/22/2020, and eight (8) new pressure ulcers with the documented presence of pain. Review of Resident #1's Skin & Wound Evaluation V5.0 dated 04/27/2020 revealed, his Stage III (full thickness skin loss) Left Trochanter (hip) wound was larger at 4.7cm Length x 3.9cm Width, no Depth recorded, and Undermining of 4.5cm, with evidence of redness, warmth, increased pain, heavy purulent (pus) drainage, and a moderate odor; a new, in-house acquired, unstageable pressure ulcer to his Right Trochanter (hip), 2.6cm Length x 3.2cm Width, with noted redness and inflammation; a new, in-house acquired, unstageable (obscured full thickness skin and tissue loss) pressure ulcer to his Sacrum measuring 3.8cm Length x 4.2cm Width, no Depth recorded, with redness, inflammation, warmth and bleeding present; a new, in-house acquired, Deep Tissue Injury (DTI) (persistent non-blanchable deep red, maroon or purple discoloration) to his Left Lateral Malleolus (outside ankle) measuring 2.6cm Length x 2.9cm Width; a new, in-house acquired, Stage II blister on his nose measuring 0.5cm Length x 0.6cm Width; a new, in-house acquired, Stage II blister on his spine measuring 3.6cm Length x 1.4cm Width; a new, in-house acquired, Stage II blister to his Right Ischial Tuberosity (buttocks) measuring 1.7cm Length x 1.6cm Width; a new, in-house acquired, Stage II blister to his Left Medial Malleolus (inside ankle) measuring 0.6cm Length x 1.6cm Width; a new, in-house acquired, Stage II blister to his Right Lateral Calf/Shin measuring 0.6cm Length x 0.9cm Width; and a new, in-house acquired, stage one (non-blanchable redness of intact skin) to his right heel measuring 1.9cm Length x 1.8cm Width. All 10 pressure ulcers rated his pain level at three (3), with noted discomfort during treatment and moving. Review of Resident #1's Progress Note dated 04/28/2020, revealed, Contacted RP (Formal Name) regarding blisters on nose, back, Lt Med ankle, Rt lateral calf and Rt lower buttock, also informed of wounds to Rt heel, Lt lateral ankle (not open yet), sacrum, Rt hip and Lt hip (deteriorating and culture performed yesterday) . Review of Resident #1's Progress Note dated 04/29/2020, revealed, .Resident's wound on lt. hip malodorous . Review of Resident #1's Progress Note dated 05/01/2020, revealed, New order noted per NP (Nurse Practitioner) to begin resident on [MEDICATION NAME] 1gram IV (Intraveneously) via midline (to be inserted per nursePro) x 14 days r/t infection noted to left hip . On 07/21/2020 at 3:45 PM, during an interview with RN #2, regarding the decline in Resident #1's wounds, his infected wound, and the large increase in his number of wounds, she stated, .I don't know what's going on, we changed everybody's wound treatment orders to Monday, Wednesday, and Friday because of COVID, which should have give them more time to be checking on folks . When asked by the SA if assessments were done on residents with wounds, to see if it was appropriate to change the frequency of their dressing changes, which would make them go three days, over the weekend, without a dressing change, she stated, No, we didn't do any assessments, we don't have anybody in the facility it should affect too bad . Review of Resident #1's Progress Note, titled Nutrition/Dietary Note, dated 05/04/2020, revealed Resident #1's current gastric tube ([DEVICE]) feeding and oral intake did not meet ENNs (Estimated Nutritional Needs) required to maintain his weight and help heal his extensive wounds. The Registered Dietician (RD), recommended to increase his feeding ([MEDICATION NAME] 1.5) to 60 cc/hr (cubic centimeters/hour) for twenty-two (22) hours a day, from the current order of 50cc/hr for twenty-two hours a day. Review of Resident #1's Order Summary Report .Active Orders As of 07/16/2020 revealed, Enteral Feed Order .Tube Feeding Continuous: Formula [MEDICATION NAME] 1.5 at 50cc/hr x 22 hours . On 07/20/2020 at 11:40 AM, standing at Resident #1's bedside, LPN #1 confirmed his [DEVICE] feeding, [MEDICATION NAME] 1.5, was currently running at 50cc/hr. On 07/21/2020 at 11:15 AM, during an interview, with the Dietary Manager (DM), regarding Resident #1's [DEVICE] feeding rate not being changed to the RD's recommendation from 05/04/2020, she stated, When the recommendations come through, I am on the email list . but I only do Mighty Shakes and Magic Cups, basically things that would go on their meal tray, double portions etc On 07/21/2020 at 12:00 PM, during an interview with the RD regarding Resident #1's missed feeding increase from 05-04-2020, and the worsening of his wounds, she stated, .I worked remotely and was not in the building .there was no follow-up with the facility for follow through .I was covering six (6) other facilities and don't remember checking follow through of recommendations . Review of Resident #1's Progress Note - Skin/Wound Note, dated 07/01/2020, revealed, a deterioration with an advancement in staging, and significant size increase of the pressure ulcers to his Left Trochanter (hip), Right Trochanter (hip), Right Calf/shin, and Right Lateral Malleolus (ankle), and two more newly identified in-house acquired wounds. Review of Resident #1's Progress Note - Skin/Wound Note dated 07/01/2020 revealed, a now Stage IV (Full thickness skin and tissue loss) pressure ulcer to his Left Trochanter (hip) measuring 12.2cm Length x 17.0cm Width x 1.5cm Depth with 1.8cm Undermining; an Unstageable (Obscured full-thickness skin and tissue loss) pressure ulcer to his Right Trochanter (hip) measuring 9.0cm Length x 9.0cm Width with 1.5cm Undermining; an Unstageable (Obscured full-thickness skin and tissue loss) pressure ulcer to his Left Lateral Malleolus (outer ankle) measuring 2.4cm Length x 1.5cm Width; an Unstageable (Obscured full-thickness skin and tissue loss) pressure ulcer to his Right Lateral Calf/Shin measuring 4.3cm Length x 2.8cm Width, with a notation of wound edges are red and irritated from pressure of left leg pressing on right shin .; a new, in-house acquired, Unstageable (Obscured full-thickness skin and tissue loss) pressure ulcer to his Right Lateral Malleolus (inner ankle) measuring 2.2cm Length x 1.5cm Width; a new, in-house acquired, Stage III (Full thickness skin loss) pressure ulcer to his Right Great Toe Hallux measuring 1.0cm Length x 1.0cm Width with hyper-granulation due to irritation from toe rubbing mattress . On 07/21/2020 at 2:05 PM, during an interview, with the DON, concerning the systemic failure of the wound care program, she confirmed there were multiple issues with the wound program, such as, incomplete documentation, dressings not getting changed timely, orders not being addressed timely, improper staging of wounds, no one monitoring the turning schedule, and checking for positioning devices since the treatment nurse left. She stated, The Treatment Nurse left on May 1st, 2020. Body audits were not done . nothing was done immediately .She was written up on 01/22/2020 for not changing dressings on wounds, and again on 04/29/2020 . The DON confirmed the facility did not have a plan in place to provide over sight after the write ups, to ensure the Treatment Nurse was providing wound care, and that orders were started timely. When the State Agency (SA) asked the DON Why did you continue to let her work if you knew she wasn't doing her job? and the DON shrugged her shoulders and stated, I don't know. On 07/25/2020 at 2:15 PM, during an interview with Resident #1's wife, she stated, The facility has not been upfront with me concerning my husband's wounds. When I left him the last time in early March, during COVID, he had one small wound on his left hip. It was a little blister. I heard from a staff member I know outside the facility, that his wounds were really bad. I called to get an update on all his wounds and asked for him to get an appointment at a wound clinic. When I went with him to his appointment, I insisted on going into the room with him and saw his wounds myself. I broke down and cried at how large and deep they are. Before COVID, I was there every day because I had noticed some changes in the care. I made sure they changed him and moved him around in the bed. It is heartbreaking to not be allowed in to see my husband, when I know he is in there not being taken care of, and there is nothing I can do about it but pray. He's there because I can't care for him myself. I trusted them to help us and they failed. Resident #2 Review of Resident #2's Admission Record revealed, she was admitted to the facility on [DATE] with the primary [DIAGNOSES REDACTED]. Review of Resident #2's Minimum Data Set ((MDS) dated [DATE], revealed, she was totally dependent on two + person physical assist for bed mobility (how resident moves to and from lying position, turns side to side, and positions body while in bed). She had limited range of motion (ROM) to both of her arms and legs. She was bedridden. Review of Resident #2's Braden Scale For Predicting Pressure Sore Risk, dated 03/07/2020 revealed, she scored a nine (9), which placed her at Very High Risk for pressure sore development. Resident #2 was admitted with a small, Stage IV pressure ulcer to her Sacrum. Since 01/21/2020, Resident #2 has acquired thirteen (13) new pressure ulcers; two Unstageable pressure ulcers, one Stage IV pressure ulcer, eight Stage III pressure ulcers, and two Stage II pressure ulcers. A lack of turning and repositioning, and proper application of pressure reducing devices was observed, as well as interviews with staff confirming dressings were not being changed timely, preventative pressure reducing devices were not consistently used, and an order for [REDACTED]. On 07/15/2020 at 10:40 AM, during initial rounds, Resident #2 was observed in bed lying on her back, legs drawn into the fetal position, resting. On 07/15/2020 at 11:40 AM, Resident #2 was observed in bed, lying on her back, a pillow behind her head, legs drawn up in the fetal position, and no other positioning devices observed. On 07/15/2020 at 2:15 PM Resident #2 was observed in the bed, on her back, legs drawn into a fetal position, and no other positioning devices observed in the bed. On 07/15/2020 at 3:50 PM, Resident #2 was observed in the bed, on her back, a pillow behind her head, no other positioning devices observed in the bed, resident remains in the fetal position. On 07/16/2020 at 9:05 AM, Resident #2 was observed lying on her back in the bed, pillow behind her head, legs pulled into fetal position, no heel cushions present, no pillows between legs. On 07/16/2020 at 11:45 AM, Resident #2 was observed lying on her back with a pillow under her head, face turned toward the door, no heel cushions or pillow between her legs observed. On 07/16/2020 at 4:20 PM, Resident #2 was observed in the bed, on her back, with a pillow behind her head, face turned toward the door, still in the fetal position with no position devices observed. On 07/17/2020 at 9:15 AM, Resident #2 was observed in her bed, lying on her back, with a pillow behind her head, no positioning devices observed in the bed, and she remains in the fetal position. On 07/17/2020 at 2:05 PM, Resident #2 was observed lying on her back in the bed, pillow behind her head, heel cushions present on both feet, legs drawn into fetal position, and no other positioning devices observed. On 07/20/2020 at 3:30 PM, the State Agency (SA) surveyor observed wound care for Resident #2, performed by RN #3 without any concerns regarding infection control or technique. Resident #2's wounds were observed to be as follows: Right Trochanter (hip), Stage IV pressure ulcer with muscle exposed in center of wound bed, bleeding; a Stage III pressure ulcer to Resident #2's right Ischium, with full skin loss to wound bed; a Stage III pressure ulcer with full loss of skin on Resident #2's coccyx; an unstageable pressure ulcer to Resident #2's right lateral foot with a small area of slough to the wound bed; a Stage III pressure ulcer with full thickness loss of skin on Resident #2's right fourth toe, between the 4th toe and small toe, with a clean wound bed; an unstageable pressure ulcer to Resident #2's right heel covered in slough; a Stage IV pressure ulcer to Resident #2's Left Shoulder, with a large amount of slough to wound bed and bone exposed in the center; a large Stage II pressure ulcer to Resident #2's Left Trochanter with a clean wound bed. On 07/20/2020 at 11:45 AM, during an interview, with LPN #3, concerning positioning devices/heel cushions, she stated, It is the nurse's responsibility to check if the pads, pillows, and heel boots is on the resident. The aides put them on 'em, but the nurse checks behind 'em. We gotta do med passes in the morning time and have to do treatments too now, it is hard to do it all. On 07/20/2020 at 3:40 PM, during an interview with RN #3 concerning repositioning devices/heel cushions, and the timeliness of wound care, she stated, The nurses are responsible for making sure the residents are padded up. I try to make sure if I do her treatments, that I put her heel cushions and pillows on where they go, but they usually aren't on when I get in here .She has so many wounds it is hard to keep up with. Most of the time the dressings aren't dated or initialed, and her wounds drain so much, it is hard to tell how old they are. The nurses have to pass medications and do all the treatments too since the treatment nurse left a couple months ago. It has been a challenge for them to keep things done. Review of Resident #2's Skin & Wound Evaluation V5.0, dated 01/21/2020 revealed, a Stage IV pressure ulcer she was admitted to the facility with, and six (6) new in-house acquired pressure ulcers (five new Stage III pressure ulcers, and one new Stage II pressure ulcer). Review of Resident #2's Skin & Wound Evaluation V5.0, dated 01/21/2020, revealed a Stage IV (Full thickness skin and tissue loss) pressure ulcer to her Sacrum measuring 2.4cm Length x 2.4cm Width; a new, in-house acquired, unstageable (obscured full thickness skin and tissue loss) press (TRUNCATED)

Based on record review, staff interview and policy review, the facility failed to implement effective specific fall prevention measures to prevent falls for three (3) of six (6) residents' reviewed (Residents #1, #4, and #5). The facility failed to implement corrective measures to ensure that one (1) of six (6) resident's reviewed, Resident #3, bruises were thoroughly investigated to implement measures to prevent further bruising. Resident #1 had a fall on 9-2-10 and sustained a laceration to the head requiring sutures. On 10-7-10 Resident #1 had another fall and sustained a laceration also requiring sutures. Resident #3 had bruising noted to her right hand and forearm. The facility staff witnessed a family member striking Resident #3 on the hand. The facility did not implement any additional protective measures for Resident #3. Resident #4 had a skin tear to the chest area where an Exelon patch was removed. Resident #4 also had red spots on cheeks and multiple red discolorations to the upper chest and shoulder areas. Resident #5 was found on the floor beside the bed on 10-3-10, 10-31-10, and 11-5-10. Findings Include: Resident #1 Record review revealed that Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. An interview and observation on 11-9-10 at 11:20 a.m. revealed that Resident #1 was alert to self and spoke in a very low tone. Resident #1 was wheelchair (w/c) confined. Review of a Minimum Data Set (MDS) with a return admitted d 10-15-10 revealed that Resident #1 had short and long term memory impairment with modified independence in cognitive skills for daily decision-making. Resident #1 required extensive assistance of one (1) person for transfers and was non-ambulatory, using the w/c as the primary means of locomotion. Review of a fall risk assessment dated [DATE] revealed that Resident #1 scored a "37%" meaning that she was a moderate risk for falls. Review of the October 2010 printed "Physician Orders" revealed an order for [REDACTED]. The original order was dated 7-1-10. Review of recent falls for Resident #1 revealed that on 9-2-10 that the resident self propelled to the dining room, staff responded to a chair alarm and found Resident #1 face down on the floor. Resident #1 was unable to explain what happened. Resident #1 received a laceration to the right side of the forehead and right elbow. On 9-7-10, Resident #1 was found sitting on the floor with with a right elbow skin tear. On 9-23-10 Resident #1 was found sitting on the landing strip. Resident was trying to transfer from w/c to her bed. On 10-7-10 Resident #1 was found on floor. Resident stated that she fell forward striking her head. Resident #1 received a laceration to the right forehead and was sent to the emergency room . Resident #1 returned to the hospital for an unrelated condition on 10-12-10 and returned to the facility on [DATE] with seven (7) sutures to the laceration of the right forehead. Review of the resident care plan updated on 7-13-10 and 9-30-10 revealed a problem stating "fall: moderate fall risk r/t (related to) hx (history) of falls, generalized muscle weakness and taking psychotropic medications." Some of the approaches listed stated: "Observe resident for any adverse effects of psychotropic medications; provide safe clutter free environment; encourage in wellness activities of self care and self initiated exercises; maintain a lift free environment; consider PT and OT (physical and occupational therapy) screen for fall education; remove clothing items to ensure foot wear is slip resistant; review for restorative program on ambulation/transfers; and address specific causes of risk to eliminate cause." Review of the care plan revealed the following revisions: "9-2-10 send to ER for evaluation; neuro checks initiated; steri-strips to right forehead; and observe for any cognitive decline/altered LOC (level of consciousness). On "9-7-10 refer to OT and PT for eval of multiple falls; positioning in w/c; and w/c safety. On "9-23-10 assist to bed to rest". on "10-7-10 send to ER, will conference with family regarding a seat belt." There was no documented evidence that there were effective interventions to prevent further avoidable falls. Resident #3. Record review revealed that Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Observation on 11-9-10 at 10:00 a.m. revealed that Resident #3 was sitting in her wheelchair (w/c) in her room. Resident #3 was oriented to name. Observation revealed a bluish/purple bruise to the top of Resident #3's right hand and the lower forearm. Resident #3 was unable to relate the cause of the bruising. Review of the nurse's notes revealed that there was no documented evidence of the bruising. An interview on 11-9-10 at 3:15 p.m. with the Director of Nurses (DON) revealed that she was unaware of the bruising to the right hand and forearm that was observed on Resident #3. The DON stated that no there was no documented evidence of an investigation regarding the bruising. The facility provided a lab sheet documenting that the site of the blood draw was from the left hand. The blood had been drawn two (2) times. Review of a nurse's note dated 9-7-10 revealed "Summoned to the side by housekeeping she observed resident's (family member) hitting residents hand while attempting to make resident go to bed. This was also witnessed by another family member. " Review of a Social Worker (SW) note dated 9-7-10 revealed: "SW received a call that housekeeping staff observed (name) Resident #3's family member hitting her on the hand. Nursing staff observed her being verbally abusive to her." The SW had documentation of anger, defensive and aggressive behaviors exhibited by the family member. An interview on 11-11-10 at 11:20 a.m. with the SW revealed that she had received a phone call stating that a housekeeping staff member had witnessed a family member hitting the resident on the hand. The SW stated that she spoke with Administration about the allegation and was told it would be looked into. The SW stated that there have been problems with the family member behaviors of being aggressive, angry and defensive. Review of a nurse's note dated 10-28-10 at 4:50 a.m. revealed: "CNA reports resident with circular reddish/purplish area to ? (right) upper arm at upper bicep region approx (approximately) 25 cent coin size in diameter. Similar in appearance to a VP (venipuncture) mark. Resident unable to relate what occurred." Review of Resident #3's care plan updated on 9-16-10 revealed that there was no documented evidence that the resident's care plan was revised to address the bruises or a care plan to address the behaviors and protection of the resident during family member visits. Resident #4 Record review revealed that Resident #4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Observation on 11-9-10 at 10:00 a.m. revealed that Resident #4 was sitting on the side of the bed and was alert to name. A w/c was located by the bed. There was a body alarm lying on the bedside stand behind the resident. Multiple bruises were observed across the upper chest of Resident #4. Resident #4 also had a skin tear to his upper right chest which he related was caused from removing pain patches. Review of an admission/return MDS assessment completed on 9-13-10 revealed that Resident #4 had long and short term memory impairment with moderately impaired cognitive skills for daily decision-making. Resident #4 required one (1) person to assist with transfers. Resident #4 used the w/c for locomotion. Resident #4 was coded for behaviors of resisting care. Review of the November 2010 printed Physician Orders revealed a bed alarm to bed when in bed and chair alarm to chair when up in chair. The original order was dated 7-21-10. Review of a nurse's note dated 10-10-10 revealed: "Requested to exam resident upper left chest during removal of Exelon patch. Noted 2.5 cm (centimeters) x 1 cm half moon shaped skin tear." Review of a nurse's note dated 10-12-10 at 1:30 p.m. revealed: "Resident up in w/c at nurse's desk in his w/c. He is agitated. Resident wants to leave facility. Went into another resident's room and refused to leave the room. Raised his cane and acted as if he wanted to strike this nurse." A nurse's note at 10:15 p.m. revealed "cont. (continues) to be agitated but able to talk to resident and assure him his is ok. Felt as if someone was trying to kill him tonight." Review of a nurse's note dated 10-13-10 at 10:50 p.m. revealed: "Very combative these hours. Hit CNA (Certified Nursing Assistant). Threatened this nurse if I woke him up again to give him a pain pill he does not want. Refused vs (vital signs), refused to place pajamas on earlier, refused to apply lotion to perineal area and threatened this nurse if she tried." Review of a nurse's note dated 10-14-10 at 6:45 p.m. revealed: "cont. (continues) to be agitated but not combative. Wants to go home and someone needs to tell him how to get out of this place because he is a old man. Up in w/c demanding staff show him how to get out." A nurse's note for 10-17-10 at 6:00 revealed: "Resident lying in the bed most of the time wanting to go home." A nurse's note dated 10-29-10 at 5:00 p.m. revealed: "Res. (resident) has been very confused and combative these hours. States someone came to his house and took him away telling him about a minical and now he wanted to go back home. Unable to reorient res. into reality. Res. mobility via w/c going around facility trying to get out. And res. told roommate he had to get out because it was his fault he was here. Res. raised his cane up at resident. At 5:10 p.m. resident received Haldol 2 mg (milligrams) IM. At 5:55 p.m. Res. refuses to go to bed or dining room for meals. Res. found on floor." Review of a nurse's note dated 11-2-10 at 11:20 a.m. revealed: "CNA responded to resident calling out. CNA noted this resident's roommate standing over him in his bed with clinched fists." A body audit was done and revealed that Resident #4 had several red spots on his right cheek and multiple blue-red discolored areas on upper chest and shoulder area. A nurse's note dated 11-4-10 at 9:00 a.m. revealed "removing duragesic patch from upper right chest and the skin came off with the patch." A note dated 11-5-10 at 1:55 p.m. revealed: "Resident has told staff repeatedly." "I want to get home and get my house warmed up." He keeps stating: "You are holding me against my will." Review of the nursing care plan that was last updated on 8-26-10 revealed that the care plan for fall potential was not revised after the fall on 10-29-10 for fall measures implemented to prevent another fall. There was no documented evidence that the care plan addresses the resident behaviors of agitation, combativeness, non-compliance with bed/chair alarm. There was no documented care plan for wandering/elopement risk for Resident #4. Interview on 11-11-10 at 12:30 p.m. with Licensed Practical Nurse (LPN) #2 revealed that Resident #4 does have combative and agitated behaviors and talks about leaving and needing to go home. LPN #2 stated that Resident #4 removes his alarm all the time. Resident #5 Record review revealed that Resident #5 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Observation on 11-10-10 at 10:00 a.m. revealed that Resident #5 was in bed. The height of the bed was elevated to approximately 33 inches from the floor. There was a blue floor pad by the right side of the bed, and two (2) upper ? side rails in the up position and had a bed alarm in place. Resident #5 was alert to name and yelled and cursed at the during conversation. Review of an annual MDS completed on 8-30-10 revealed that Resident #5 had short memory impairment with modified independence in cognitive skills for daily decision-making. Resident #5 was coded for verbally and physically abusive behaviors, non-ambulatory and bedfast most of the time. Review of the falls for Resident #5 revealed that on 10-3-10, 10-31-10, and 11-5-10, Resident #5 was found on the floor mat by the bed with no injury noted. Review of Resident #5's care plan that was updated on 8-30-10 revealed: "moderate fall risk r/t immobility." "Approaches listed: provide safe clutter free environment. Maintain the lift free environment; consider rehab screen; encourage resident not to get up unasst (unassisted). On "1-18-10 landing strips to bedside, and 7-15-10 turn from back to rt (right) side. Ensure call light is in easy reach of resident." On "10-28-09 bed alarm check function q (every) shift. "On 1-16-10 bed in lowest position." On "7-22-10 concave mattress." On 7-28-10 frequent checks per staff." Review of the 10-5-10 care plan revision documents stated: "Continue to make frequent checks." There was no documented care plan revision for the 10-31-10 and 11-5-10 falls. There was no documented evidence of specific fall measures to prevent further falls from the bed. Review of the facility policy for falls, (with a revision date of 7-07) revealed: "It is the policy of this facility to assess residents for the potential for falls and identify factors that might contribute to falls. The facility will address those factors identified in order to reduce the risk for falls. The care plan should be updated after a fall to address the most recent cause of the fall." An interview on 11-9-10 at 3:15 p.m. with the Director of Nursing (DON) revealed that she understood that the care plan revisions should be specific for the cause of the fall as per facility policy. The DON indicated that the MDS nurse's are responsible for updating resident care plans. Review of the care plan policy revealed: "Each resident will have an individualized care plan that is developed by the interdisciplinary team." "Goal - progress is evaluated by the appropriate discipline at least quarterly or in response to a resident change in condition." Review of the facility "Fall" policy revealed: "It is the policy of this facility to assess residents for the potential for falls and identify factors that might contribute to falls. The care plan should be updated after a fall to address the most recent cause of the fall." Review of the facility policy on behaviors revealed: "It is the policy of this facility to identify and address individual resident behavior problems. When behavior problems are identified, the resident will be referred to the PAR committee for interventions/approaches to address the individual needs. Implementation of interventions/approaches will be documented including the results in order to determine if they are effective. Problems and interventions for the individual needs of the residents will be addressed on the MAR (medication administration record) and care plan as indicated. Changes will be made as needed when a resident's behavior changes. These changes should be addressed timely."