Every finding on record at Diamond Care Center

Based on Certification and Survey Provider Enhanced Reports (CASPER) data review, staff timecard and pay stub review, facility assessment review, and interview, the provider failed to ensure a registered nurse (RN) was in the facility for eight consecutive hours daily for four of four federal fiscal quarters (Quarter 1, 2024, Quarter 2, 2025, Quarter 3, 2024, and Quarter 4, 2024).Findings include:1. Review of the Payroll Based Journal (PBJ) (information of the provider's daily staffing hours for the appropriate care of the residents) data for Quarter 1 (October 2024 - December 2024) revealed:*There was no eight-hour nurse coverage documented for seven days (October 12, 13, 19, 20, 25, 26, and 27) in October 2024.*There was no eight-hour nurse coverage documented for thirteen days (November 2, 3, 8, 9, 10, 16, 24, 25, 26, 27, 28, 29, and 30) in November 2024.*There was no eight-hour nurse coverage documented for eleven days (December 1, 7, 8, 15, 21, 22, 23, 24, 27, 28, and 29) in December 2024. 2. Review of the PBJ data for Quarter 2 (January 1 2024- March 31 2025) revealed:*There was no eight-hour nurse coverage documented for seven days (January 1, 4, 12, 18, 19, 25, and 26) in January 2025.*There was no eight-hour nurse coverage documented for seven days (February 2, 6, 7, 8, 9, 16, and 23) in February 2025.*There was no eight-hour nurse coverage documented for six days (March 2, 15, 19, 22, 23, and 29) in March 2025. 3. Review of the PBJ data for Quarter 3 (April 1 2024- June 30 2024) revealed the provider failed to submit data for the quarter. 4. Review of the PBJ data for Quarter 4 (July 1 2024 - September 30 2024) revealed:*There was no eight-hour nurse coverage documented for five days (July 5, 6, 19, 20, and 21) in July 2024.*There was no eight-hour nurse coverage documented for three days (August 2, 18, and 31) in August 2024.*There was no eight-hour nurse coverage documented for six days (September 1, 14, 19, 20, 21, and 22) in September 2024. Review of the provider's staff timecards and pay stubs revealed that registered nurse (RN) coverage for eight consecutive hours a day for seven days a week could not be verified. Review of the provider's updated January 2025 facility assessment regarding RN coverage revealed:*One to three licensed nurses providing direct care were needed for each shift.*An RN or LPN (licensed practical nurse) was needed for each shift.*The director of nursing (DON) RN was to work full time day shifts. Interview on 9/11/25 at 2:08 p.m. with administrator A revealed:*She had applied for an RN waiver, but it had been denied.*She was responsible for submitting the PBJ data report.*She had not submitted the PBJ data for the third quarter. *She could not verify that there was RN coverage eight consecutive hours a day for seven days a week during the dates triggered.*The DON was a fulltime interim (temporary) employee.

Based on Certification and Survey Provider Enhanced Reports (CASPER) data review, staff timecard and pay stub review, facility assessment review, and interview, the provider failed to have licensed nursing coverage for 24-hours per day in the facility for four of four federal fiscal quarters (Quarter 1, 2024, Quarter 2, 2025, Quarter 3, 2024, and Quarter 4, 2024).Findings include:1. Review of the Payroll Based Journal (PBJ) (information of the provider's daily staffing hours for the appropriate care of the residents) data for Quarter 1 (October, November, and December 2024) revealed:*There was no 24-hour nursing coverage documented for seventeen days (October 1, 3, 4, 5, 6, 7, 8, 12, 13, 16, 17, 21, 22, 25, 26, 27, and 31) in October 2024.*There was no 24-hour nursing coverage documented for twenty days (November 4, 5, 8, 9, 10, 11, 14, 15, 16, 18, 19, 21, 23, 24, 25, 26, 27, 28, 29, and 30) in November 2024.*There was no 24-hour nursing coverage documented for eighteen days (December 1, 3, 4, 6, 7, 8, 12, 13, 14, 17, 19, 21, 23, 24, 26, 27, 28, and 29) in December 2024. 2. Review of the PBJ data for Quarter 2 (January, February, and March 2025) revealed:*There was no 24-hour nursing coverage documented for sixteen days (January 1, 4, 5, 6, 10, 11, 14, 17, 18, 19, 21, 22, 23, 28, 30, and 31) in January 2025.*There was no 24-hour nursing coverage documented for twelve days (February 2, 6, 7, 8, 15, 16, 18, 20, 25, 26, 27, and 28) in February 2025.*There was no 24-hour nursing coverage documented for seventeen days (March 1, 2, 6, 10, 11, 12, 15, 16, 19, 21, 22, 23, 25, 28, 29, 30, and 31) in March 2025. 3. Review of the PBJ data for Quarter 3 (April, May, and June 2024) revealed the provider failed to submit data for the quarter. 4. Review of the PBJ data for Quarter 4 (July, August, and September 2024) revealed:*There was no 24-hour nursing coverage documented for sixteen days (July 4, 5, 6, 7, 10, 11, 12, 13, 14, 16, 19, 20, 21, 22, 30, and 31) in July 2024.*There was no 24-hour nursing coverage documented for fifteen days (August 2, 3, 4, 10, 13, 14, 18, 19, 20, 21, 22, 23, 24, 29, and 31) in August 2024.*There was no 24-hour nursing coverage documented for eighteen days (September 1, 4, 5, 6, 10, 13, 14, 15, 19, 20, 21, 22, 23, 24, 25, 26, 27, and 28) in September 2024. Review of the provider's staff timecards and pay stubs revealed licensed nursing coverage for 24-hours per day could not be verified for Quarter 1, 2024, Quarter 2, 2025, Quarter 3, 2024, and Quarter 4, 2024. Review of the provider's updated January 2025 facility assessment regarding licensed nursing coverage revealed:*One to three licensed nurses providing direct care were needed for each shift.*An RN (registered nurse) or LPN (licensed practical nurse) was needed for each shift.*The director of nursing (DON) RN was to work full time day shifts. Interview on 9/11/25 at 2:08 p.m. with administrator A revealed:*She was responsible for submitting the PBJ information.*She had not submitted the PBJ data for the third quarter.*The DON was a full-time interim (temporary) employee.*She could not verify that there was licensed nursing coverage for 24-hours a day for the dates listed in the PBJ report.

Based on Certification and Survey Provider Enhanced Reports (CASPER) data review, staff timecard and pay stub review, and interview, the provider failed to ensure Payroll Based Journal (PBJ) (information of the provider's daily staffing hours for the appropriate care of the residents) data was submitted to the Centers for Medicare and Medicaid (CMS) for one of four federal fiscal quarters (Quarter 3, 2024). Findings include: 1. Review of the PBJ data submitted to CMS for Quarter 3, 2024 revealed no PBJ data had been submitted to CMS for the time period of April 1, 2024 through June 30, 2024.*The following metrics were suppressed for invalid data:-Excessively Low Weekend Staffing.-No registered nurse (RN) hours.-Failed to have licensed nursing coverage 24 hours per day. Review of the staff timecards and pay stubs revealed licensed nursing coverage for 24-hours a day and RN coverage for seven days a week could not be verified. Interview on 9/11/25 at 2:08 p.m. with administrator A revealed:*She was responsible for submitting the PBJ data report to CMS.*She had not submitted the PBJ data for the third quarter.*She could not verify that there was licensed nursing coverage for 24-hours a day for Quarter 3, 2024.*She could not verify that there was RN coverage eight consecutive hours a day for seven days a week during Quarter 3, 2024.

Based on observation, interview, and policy review, the provider failed to monitor refrigerator temperatures to ensure safe food storage for six of six sampled residents (13, 14, 20, 29, 30, and 31) with refrigerators in their rooms.Findings include: 1. Observation and interview on 9/9/25 at 2:55 p.m. with resident 31 in her room revealed:*She had a refrigerator in her room.*She stated she had not had it for very long, but there is nothing in it that could spoil.*There was no temperature gauge inside the refrigerator or a temperature monitor log to record its temperatures. 2. Observation on 9/9/25 at 8:33 a.m. in resident 29's room revealed his refrigerator did not have a temperature gauge inside it or a temperature monitor log to record its temperatures. 3. Observation on 9/9/25 at 8:44 a.m. in resident 14 and 30's shared room revealed their refrigerators did not have a temperature gauge inside them or a temperature monitor log to record their temperatures. 4. Observation on 9/11/25 at 6:35 p.m. in resident 20 and 13's shared room revealed their refrigerators did not have a temperature gauge inside them or a temperature monitor log to record their temperatures. 5. Interview on 9/11/25 at 9:53 a.m. with environmental services supervisor L revealed:*She was the head of housekeeping and laundry.*She checked the residents' refrigerators on Mondays and Thursdays for cleanliness and outdated items.*She confirmed that none of the resident refrigerators had temperature gauges to monitor their temperatures. 6. Interview on 9/11/25 at 10:17 a.m. with dietary manager E revealed:*She checked the residents' refrigerators for outdated items twice a week.*She was not aware that the refrigerators did not have temperature gauges, but thought they should have. 7. Review of the provider's revised 7/2025 Refrigerator policy revealed:* This policy will ensure proper handling, serving, and storage of any food items brought into our community from all outside sources.* 4. Food or beverage items may be stored in facility pantries, refrigerators or freezers, or [the] resident's personal room refrigerators, if applicable.* All cooked or prepared food brought in for a resident and stored in the facility's refrigerator or [a resident's] personal room refrigerator will be dated when accepted for storage and discarded after 72 hours/3 days. No home-prepared food items that are canned or preserved will be permitted.* 5. Facility refrigerators will have a temp log completed daily.* a. Refrigerator temps should be between 36-46 degrees and freezer temperatures should be 0 or below.* b. If the temperature is out of range adjust the fridge or freezer, recheck the temp in 4 hours and document action taken at the bottom of the page and log in maintenance service requests.

Based on observation, record review, interview, and policy review, the provider failed to ensure the safety of:*Two of two sampled residents (1 and 4) who used motorized wheelchairs had been assessed for their ability to safely use motorized wheelchairs according to the provider's policy and ensure the safety of other residents.Findings include: 1. Observation and interview on 9/9/25 at 3:35 p.m. with resident 1 in her room revealed: *Certified Nursing Assistants (CNAs) N and O were dressing her and were getting her up in her electric wheelchair. *They used a total-body lift (a mechanical lift and sling used to lift a person's full body) to transfer the resident into her electric wheelchair. *She had been in the hospital recently and was placed on hospice services due to her decline. Review of Resident 1's electronic medical record (EMR) revealed: *She was admitted on [DATE]. *She had diagnoses of anxiety (anticipation of future danger or misfortune with feelings of distress and/or sadness and symptoms such as restlessness or irritability), unspecified encephalopathy (a brain disease that alters the brain function or structure), and paralytic syndrome (a condition that causes the loss of muscle control). *Her 7/28/25 BIMS was 15, which indicated her cognition was intact. *She had a recent hospitalization on 7/17/25 for a urinary tract infection. *Her Minimum Data Set (MDS) assessment indicated she had a significant change in her health status on 7/28/25, due to having been admitted to hospice. *An 8/15/25 at 2:16 p.m. hospice progress note indicated the hospice nurse talked with MDS coordinator B, and MDS coordinator B who told the hospice nurse that the resident's confusion had been getting noticeably worse. *A 9/10/25 at 4:11 p.m. progress note stated that the resident got stuck in her bathroom in her electric wheelchair. The resident reported to the CNA that she had forgotten how to use the joystick on the wheelchair. The CNA had to steer the electric wheelchair out of the bathroom. *She did not have an assistive device assessment completed to assess her ability to safely use her electric wheelchair. Interview on 9/10/25 at 3:15 p.m. with CNA F revealed resident 1 had been more confused lately. Interview on 9/11/25 at 2:20 p.m. with certified occupational therapy assistant (COTA) M revealed: *She had not completed an assistive device safety assessment for Resident 1's electric wheelchair, but indicated she would have if she had received an order to do so. 2. Observation and interview on 9/10/25 at 8:35 a.m. with resident 4 while operating her motorized wheelchair revealed: *She was driving into the bathroom and ran into the bathroom door while entering the bathroom. *While she was exiting the bathroom in her motorized wheelchair she ran into the bathroom door again. 3. Observation on 9/10/25 at 2:00 p.m. of resident 4 while operating her motorized wheelchair revealed she had required her daughter's assistance to operate her motorized wheelchair safely around other residents. Review of resident 4's electronic medical record (EMR) revealed:*She was admitted on [DATE] and had diagnoses of Parkinson's disease with dyskinesia (involuntary, uncontrolled, and repetitive muscle movements). *Her 7/28/25 BIMS score was 15 which indicated her cognitively intact.*An assessment of her use motorized wheelchair had been completed on 1/2/25.-Results of that assessment indicated resident 4 could operate her motorized wheelchair independent (no assistance) for routine use with occasional assist (assistance) with excessive congestion.*Her current care plan indicated Focus: Resident has selfcare deficit related to Parkinson's, limited mobility, and musculoskeletal impairment.-And Intervention/Task: Mobility Devices: wheelchair or electric wheelchair depending on alertness.*Resident 4's Task: Electric scooter documentation revealed: -from 8/31/25 through 9/11/25 resident 4 had been observed running into objects (all, tables, chairs, doors, etc.) fourteen times. Interview on 9/11/25 at 11:07 a.m. with social service designee (SSD) D regarding resident 4's motorized mobility device revealed: *She had been aware that she had completed resident 4's assessment on 1/25/25.*She had not been aware resident 4 had been observed running into objects.*SSD D was not aware per their policy an assessment needed to be completed quarterly. Interview on 9/11/25 at 2:53 p.m. with certified nursing assistant (CNA) F if she observed regarding resident 4's operation of her motorized wheelchair revealed:*She observed resident 4 run into the medication cart and pushed it down the hall.*She had observed resident 4's unsafe use of a motorized wheelchair and documented that in the EMR. Interview on 9/11/25 at 2:57 p.m. with registered nurse (RN) G regarding resident 4's operation of her motorized wheelchair in the facility revealed:*RN G was unsure of how many times resident 4 had run into the medication cart.*RN G had observed her resident 4 running into doorways with her motorized wheelchair at times.*She had noticed a progression of resident 4's involuntary arm and leg movement related to resident 4's Parkinson's diagnosis. Review of the provider's November 2024 Resident Use of Motorized Wheelchairs and Scooters policy revealed:*The therapy assessment (to determine safe operation of motorized devices) will be completed according to physician orders.*A new therapy assessment will be done quarterly and if the resident at any has an acute change in condition or exhibits poor safety awareness.

Based on record review, interview, review the providers dialysis agreement, and policy review, the provider failed to ensure the resident's chosen advance directive (a document that expresses a person's health care wishes if they become unable to speak for themselves) was accurately reflected in the resident's medical record and communicated to the dialysis center for one of one sampled resident (7) who received dialysis services.Findings include:1. Review of resident 7's electronic medical record (EMR) revealed:*He was admitted on [DATE]*His Brief Interview for Mental Status (BIMS) score was 6, which indicated he had severe cognitive impairment.*He had diagnoses of unspecified encephalopathy (disease that alters brain function), end-stage renal disease, dependence on renal dialysis (mechanical cleaning of blood), acute kidney failure with acute cortical necrosis (death of the tissue in the outer part of the kidney), unspecified dementia (a group of symptoms affecting memory, thinking, and social abilities), dysphagia following cerebral infarctions (difficulty swallowing after a stroke), hypertension, chronic obstructive pulmonary disease (COPD)(lung disease that blocks airflow), anxiety disorder (anticipation of future danger or misfortune with feelings of distress and/or sadness and symptoms such as restlessness or irritability), weakness, and a history of malignant neoplasm (cancer) of the prostate.*His code status was do not resuscitate and do not intubate (DNR/DNI) (no life-sustaining measures when one's heart or breathing stops).*He received hemodialysis (a treatment that removes waste products and excess fluid from blood when the kidneys are unable to) twice a week.2. Review of resident 7's Diamond Care Center Directives to Define Scope of Medical Care form revealed:*Resident 7 and his power of attorney (POA) chose his code status as DNR, which was signed on 3/22/25 by his POA.3. Interview on 9/10/25 at 4:28 p.m. and 9/11/25 at 12:05 p.m. with registered nurse (RN) G revealed:*Based on her report sheet, resident 7 was a full code (life-sustaining measures if one's heart or breathing stops).*She reviewed the resident's current orders and stated he had DNR/DNI code status orders.*When reviewing his signed advanced directive, she stated his code status was DNR.*She verified his code status on her report sheet, and in the EMR was not what his advance directive indicated.*Communication sheets were sent with the resident when he went to receive dialysis, in a folder inside his bag that was on his wheelchair.*RN G reviewed his communication sheets and verified that his advance directive was not included on those sheets sent with him to receive dialysis. 4. Interview on 9/11/25 at 12:24 p.m. with the Minimum Data Set (MDS)/ infection preventionist/RN B, and the interim director of nursing (IDON) C revealed:*They expected a resident's code status order entered in the resident's EMR and on the report sheet to indicate what the resident's signed advance directive indicated. They reported that resident 7's code status was DNR.*MDS RN B updated the nursing report sheets, which had indicated the resident was a full code.* They explained resident 7's daughter had visited him while he was receiving dialysis in March. She filled out the advance directive form while he was at the dialysis center and sent the document back to the nursing home.*They assumed resident 7's daughter would have given a copy to the dialysis center.*They would not document when they would provide a resident's advance directives to the dialysis center. 5. Interview on 9/11/25 at 12:36 p.m. with a nurse at the dialysis center where resident 7 received dialysis, revealed they did not have an advance directive on file for resident 7, and indicated that without an advance directive on file, he would be a full code while he was there. 6. Interview on 9/11/25 at 12:46 p.m. with administrator A and IDON C revealed:*They reviewed the contract with resident 7's dialysis center, signed by administrator A on 9/24/24, and verified that they were to have provided the dialysis center with any advance directive executed by the resident.7. Review of the provider's 9/24/24 Nursing Home Dialysis Transfer Agreement revealed:*.the facility [nursing home] shall ensure that all appropriate medical, social, administrative, and other information accompany all Designated Residents at the time of transfer to [the dialysis] Center. This information shall include, but is not limited to, where appropriate, the following:. (g.) Any advance directive executed by the Designated Resident.8. Review of the provider's 7/14/25 Dialysis Policy revealed, pertinent health information and vital signs will be communicated to the dialysis center.9. Review of the provider's 2/11/25 Advance Directive Policy and Procedure policy revealed: It is the policy of the facility to establish, implement and maintain written policies and procedures for advance directive. Resident wishes will be communicated to the staff via the care plan and (identify facility protocol for communication of advance directives, either in written or oral format) and to the resident physician. Changes to the resident choices for advance directives will be documented, included in the resident plan of care,. physician orders will be obtained to reflect new choices as applicable and all items will be communicated to staff providing resident care.

Based on observation, record review, interview, and policy review, the provider failed to ensure resident care plans had been revised to reflect their current needs for fall prevention for two of two sampled residents (25 and 3) who were identified to have a risk for falling and had fallen.Findings include:1. Observation and interview on 9/10/25 at 8:56 a.m. with resident 25 revealed: *She had been sitting in a recliner at the nurse's station with her walker in front of her. *Her glasses were missing the earpiece on the right side of the frames and were just resting on her nose. *She stated that she could get around well but could not remember if she had fallen recently or what happened to her glasses. Review of resident 25's electronic medical record (EMR) revealed: *She was admitted on [DATE]. *She had a Brief Interview of Mental Status (BIMS) assessment score of 6, which indicated she had severe cognitive impairment. *She had a diagnosis of dementia (a group of symptoms affecting memory, thinking, and social abilities). *She used a walker for ambulating (to move/walk) independently. *Her Morse Fall assessments (an evaluation of one's risk level for falling) revealed: -On 10/24/24 and 1/11/25 she had a high risk for falling. -On 3/31/25 and 6/18/25 she had a moderate risk for falling. *The nursing progress notes indicated she had fallen on 3/28/25 and 8/31/25. *She had post-fall assessments completed on 3/31/25 and 9/1/25 which indicated her care plan had been reviewed. *Her care plan did not indicate she had a risk for falling. Interview on 9/11/25 at 9:53 a.m. with registered nurse (RN) G revealed: *When resident 25 last fell, she and her roommate were unsure of who had fallen first and were trying to help one another get up off of their bathroom floor. *She had never updated a care plan because she did not have access to do that. *She thought Minimum Data Set (MDS) coordinator B updated the residents' care plans. Interview on 9/11/25 at 1:30 p.m. with MDS coordinator B revealed: *She was responsible for updating the residents' care plans. *She tried to update residents' care plans as soon as something occurred that needed to be updated on the care plan such as fall prevention interventions for residents who had fallen or changes in residents' mental status. *She confirmed that resident 25's risk for falling and fall prevention interventions had not been included in her care plan. *She agreed that resident 25's Morse fall assessments were filled out incorrectly as she had not marked on those assessments that the resident used a walker to ambulate. *She stated resident 25 should have been considered as having a high risk for falling. Interview on 9/11/25 at 6:00 p.m. with interim director of nursing (IDON) C revealed: *She would update residents' care plans regarding wounds and MDS coordinator B would update the care plans everything else. *She expected a residents' care plan to be updated when there was a new order or when an assessment had been completed. *The provider's fall protocol was to update the resident's care plan with new interventions after a resident fell. 2. Observation and interview with resident 3 on 9/9/25 at 3:25 p.m. and again on 9/10/25 at 9:34 a.m. revealed: *He was lying in bed. *He mumbled when he talked and was hard to understand. *He did not answer most of the questions during the conversation. *He had abrasions on both of his knees that were covered with a Tegaderm (a clear dressing). Review of resident 3's EMR revealed: *He was admitted on [DATE]. *His 6/14/25 BIMS score was 7, which indicated he had severe cognitive impairment. *He had diagnoses of anxiety (anticipation of future danger or misfortune with feelings of distress and/or sadness and symptoms such as restlessness or irritability), bronchitis (respiratory infection), neuromuscular dysfunction of the bladder (nerve damage to the bladder that can lead to problems with the bladder filling and emptying), difficulty walking, hypotension (low blood pressure), atrial fibrillation (irregular heart beat), and long-term use of anticoagulants (medication used to thin the blood to help prevent blood clots). *His 8/19/25 Morse Fall Scale assessment indicated he had a high risk of falling. *His care plan indicated he had a high risk for falls related to his deconditioning, gait (walking)/balance problems, and he had no safety awareness. *His care plan indicated he had fallen and had minor injury on 5/17/25, 8/19/25, 9/2/25, 9/4/25, and had fallen with no injury on 8/30/25. *Fall interventions listed on his care plan included: -Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance. Date Initiated: 07/27/2024 -Educate the resident/family/caregivers about safety reminders and what to do if a fall occurs. Date Initiated: 07/27/2024 -Follow facility fall protocol. Date Initiated: 07/24/2024 -PT [physical therapy] to eval [evaluate] and treat if indicated. Date Initiated: 09/04/2025 -Review information on past falls and attempt to determine cause of falls. Record possible root causes. Alter [and/or] remove any potential causes if possible. Educate resident/family/caregivers/IDT [interdisciplinary team] as to causes. Date Initiated: 07/24/2024 *A progress note on 9/4/25 indicated that a PT staff member had been at the door after his fall, and they requested PT orders to evaluate and treat. *Besides the intervention of PT orders to evaluate and treat on 9/4/25, his care plan regarding his fall interventions had not been reviewed or revised since 7/27/24. *His care plan did not include interventions to keep his wheelchair away from him in his room, that he was to transfer with shoes on or with the use of a gait belt, or that his bed was to be kept in a lower position, but not too low to not cause anxiety. Interview on 9/10/25 at 9:34 a.m. with certified nursing assistant (CNA) F in resident 3's room revealed: *Resident 3 had sores on both knees from having fallen. *He fell out of bed because he was in a hurry, and he did not turn his call light on for staff assistance. *He was not supposed to transfer himself. *His fall precautions included his bed was to be in a low position and his wheelchair was to be placed out of his reach while he was in bed to help deter him from transferring without assistance, which he still self-transfers. Interview on 9/11/25 at 12:08 p.m. with RN G revealed: *Resident 3 was not supposed to transfer himself. *He was to have shoes and a gait belt (a waist strap gripped as support for safe mobility and transfers) on for transferring. *He did not have a fall mat by his bed, but they would implement that if he were sliding or falling out of his bed. *He did not walk by himself. *His wheelchair was to be kept right by his bed, so he did not walk by himself to get the wheelchair. *She did not expect the CNA to move the wheelchair away from his bed to keep it out of his reach. Interview on 9/11/25 with the interim director of nursing (IDON) C and MDS coordinator B revealed: *Resident 3's fall interventions included reminding him to use his call light, physical therapy to evaluate, placing the bed in a low position but not too low as that may increase his anxiety, no fall mat as that may increase his anxiety and he might stand up on it and fall, and to keep his wheelchair away from him so he would not transfer himself. *They stated he had a respiratory infection in the last few weeks, so they felt he was weaker. *They reviewed all resident falls at an interdisciplinary (a group of professionals with diverse expertise who collaborate to address problems) meeting and discussed fall interventions. Review of the provider's reviewed 7/2025 Fall Policy revealed: *To provide a safe living environment for the residents and to protect them from injury. *A licensed nurse will update the care plan to reflect interventions instituted to prevent further falls. *The resident's fall will be discussed with interdisciplinary team (IDT) as soon as possible after the falls to determine new interventions to try. Review of the provider's revised 1/1/25 Care Plan Policy revealed: *Facility staff must develop the comprehensive care plan within seven days of the completion of the comprehensive assessment and review and revise the care plan after each assessment. *The resident's care plan must be reviewed after each assessment, as required by 483.20, except discharge assessments, and revised based on changing goals, preferences, and needs of the resident and in response to current interventions.

Based on policy review, record review, and interview the provider failed to follow nursing professional standards of practice to ensure nursing staff:*Followed physician orders, and provider's policy for one of two sampled residents (5) with orders for insulin administration and blood sugar level monitoring, and to ensure low blood sugars were reported to the physician per the provider's policy.*Assessed one of one sampled resident (25) for risk of falling, fall prevention interventions had been in place.Findings Include:1. Review of the provider's 6/7/22 Blood Sugar Monitoring policy revealed:*1. Check physicians [physician's] order for blood sugar testing frequency.2. Notify provider if 2 glucose checks are <70 [less than 70] or >400 [greater than 400] in 24 hours and/or change in condition. If no change in condition, notify the PCP [primary care provider] the next day.Hypoglycemia1. If patient is symptomatic, conscious, and able to swallow.2. Administer 6oz of fruit juice, milk, regular soda, or other high calorie carbohydrate.3. Repeat BG [blood glucose] after 15 minutes: If <70; repeat above interventions4. if patient can swallow; give a high protein snack with drink5. If after 2 attempts to treat and BG is still <70; notify PCPIf patient is unresponsive or unable to swallow.1. Administer Glucagon 1mg IM.6. Communicate occurrence of any hypoglycemic event to PCP the next business day Review of resident 5's electronic medical record (EMR) revealed:*She was admitted on [DATE].*She had diagnoses of type 2 diabetes (a condition involving disruptions in how the body regulates blood sugar) with chronic kidney disease, senile degeneration of the brain (a progressive decline in cognitive function), unspecified dementia (a group of symptoms affecting memory, thinking, and social abilities), legal blindness, and long-term use of insulin.*Her 6/30/24 Brief Interview for Mental Status (BIMS) assessment score was a 4, which indicated she had severe cognitive impairment.*She had current physician's orders for:-A FreeStyle Libre (a continuous glucose monitoring device), and the sensor was to be changed every 14 days and as needed.-Blood sugars to be checked if she displayed signs of hypoglycemia (low blood sugar) or had an altered mental status.-If her blood sugar was more than 400, staff were to recheck it in one hour.-Staff were to document all of her hypoglycemic episodes and treatments provided.-She had physician's orders to have her blood sugar checked before meals, two hours after every meal three times per day (at 10 p.m., 2 p.m., and 8 p.m.), and as needed.-To receive 20 units of Novolog insulin in the morning.-To receive 18 units of Novolog insulin twice daily at lunch and supper.-To receive 50 units of Lantus (long-acting insulin) at bedtime.-To receive 0.5mg of Ozempic weekly at bedtime, and she had received all doses. Resident 5's July 2025 through September 2025 medication administration records (MARs), progress notes, and glucose logs indicated:*Her blood sugar level was not checked before breakfast on 7/8/25, before lunch on 7/8/25, 7/12/25, 7/13/25, 7/14/25, 7/15/25, 7/16/25, 7/21/25, 7/22/25, 7/23/25, 7/28/25, and 7/29/25, or before supper on 7/1/25, 7/11/25, 7/20/25, and 7/26/25.*Her Novolog morning dose was held (not given) on 7/3/25 as she did not eat breakfast, 7/7/25 as she did not eat much breakfast, and her blood sugar was 106, and 7/23/25 as her blood sugar was 101; her lunch doses were held on 7/9/25 as she only ate bites of her lunch, 7/12/25 as her blood sugar was 118, 7/13/25 no reason was indicated, 7/15/25 no reason was indicated, 7/16/25 as her blood sugar was low and she did not eat much, 7/21/25 no reason was indicated, 7/25/25 for poor intake, and 7/26/25 as she was sleeping; Her supper dose was held on 7/10/25 for poor intake, 7/11/25, 7/18/25 as she refused to eat, and 7/20/25 as she did not eat much and her blood sugar was 81.*She refused her Novolog morning dose on 7/22/25 and 7/29/25; her lunch dose on 7/22/25, 7/23/25, and 7/29/25; her supper dose on 7/1/25, 7/7/25, 7/26/25, 7/27/25, and 7/31/25.*Her Lantus was held on 7/7/25 as her blood sugar was 119 and she did not eat supper, 7/9/25 as her blood sugar was low, 7/10/25 no reason was indicated, 7/14/25 as her blood sugar was low, 7/23/25 as her blood sugar was low, 7/24/25 as she did not eat much supper or her snack, 7/25/25 as her blood sugar was low, and 7/30/25 as her blood sugar was low.*She refused the Lantus on 7/17/25, 7/18/25 (a note indicated she had refused supper on 7/18/25), and 7/22/25.*A progress note on 7/1/25 at 5:25 a.m. indicated the resident's phone alarmed due to a low blood sugar of 62 at 1:00 a.m. She had been given a granola bar and a boost, her blood sugar was rechecked and was 119.-Her glucose log indicated her blood sugar was 62 at 1:27 a.m. and it was 119 when it was rechecked at 2:08 a.m.-The nurse did not follow the provider's policy to recheck her blood sugar 15 minutes after the intervention.*A progress note on 7/19/25 at 4:26 p.m. indicated her blood sugar at 2:00 p.m. was 85. She did not have signs of hypoglycemia noted at that time. She was given a glass of orange juice. At 3:00 p.m. the certified nursing assistant (CNA) reported to the nurse that the resident's blood sugar was 58. She did not have any signs of hypoglycemia. She was given another glass of orange juice with sugar mixed in it. Her blood sugar was rechecked at 4:00 p.m., and was 102.-Her glucose log indicated her blood sugar was 82 at 1:31 p.m. and 1:41 p.m.-Her blood sugar of 58 at 3:00 p.m. was not documented on the blood glucose log.-Her blood sugar of 102 at 4:00 p.m. was not documented on the blood glucose log.-The nurse did not follow the provider's policy to recheck her blood sugar 15 minutes after intervention. *A progress note on 7/30/25 at 10:19 p.m. indicated the resident was sleeping and did not wake for supper. Her blood sugar was 115, and Novolog was given. The resident was not arousable and unable to swallow her bedtime medications. Her glucose monitor was alarming and indicated her blood sugar had been 52. The resident was given orange juice, and she did not open her eyes. The resident's bedtime dose of Lantus was held. After an hour, her blood sugar had increased to 106, and she was not in distress.-The resident's glucose log indicated her blood sugar was 52 at 9:35 p.m. Her other blood sugar checks documented in the nurse's note had not been documented in the resident's glucose log.-The resident was unable to swallow medications and was not arousable, and the nurse had her drink orange juice, placing her at risk for aspiration (when fluid enters the lungs).- The nurse did not follow the provider's policy to, if unresponsive and unable to swallow, the resident was to have glucagon 1mg IM (intramuscular)(a shot given in the muscle) administered.- The nurse did not follow the provider's policy to recheck the resident's glucose 15 minutes after interventions.-The nurses did not follow the provider's policy to notify the resident's physician of her hypoglycemic event.*Her morning blood sugars were not checked on 8/5/25, 8/7/25, 8/8/25, 8/9/25, 8/11/25, 8/14/25, 8/19/25, 8/21/25, 8/22/25, 8/23/25, 8/25/25, 8/26/25; before lunch on 8/5/25, 8/7/25, 8/8/25, 8/10/25, 8/11/25, 8/21/25,8/22/25, 8/23/25, 8/25/25, 8/26/25, 8/27/25; before supper on 8/7/25, 8/11/25, 8/13/25, and 8/22/25.*Her morning Novolog dose was held on 8/4/25 for having low blood sugar, 8/5/25 due to poor intake, and 8/19/25 for poor intake.*She refused the morning Novolog dose on 8/7/25, 8/8/25, 8/9/25, 8/11/25, 8/14/25, 8/21/25, 8/22/25, 8/23/25, 8/25/25, 8/26/25, and 8/30/25- a nurse note indicated the resident refused breakfast.*Her lunch Novolog dose was held on 8/5/25 for poor intake and 8/27/25 as she did not eat.*She refused the lunch Novolog dose on: 8/9/25, 8/11/25, 8/21/25, 8/22/25, 8/23/25, 8/25/25, and 8/26/25.*Her supper Novolog dose was held on: 8/7/25 due to poor intake, 8/8/25 for poor intake, and 8/12/25 for poor intake and low blood sugar.*She refused the supper Novolog doses on: 8/4/25, 8/5/25, 8/9/25, 8/10/25, 8/11/25-a nurse note indicated she did not eat supper, 8/13/25, 8/14/25, 8/18/25, 8/22/25, 8/24/25-A nurse's note indicated she did not eat much and her blood sugar had been 135, 8/26/25, 8/27/25, 8/28/25, and 8/31/25.*Her bedtime Lantus insulin dose was held on 8/6/25 for low blood sugar, 8/8/25 no indication was given, 8/12/25 for poor intake, 8/21/25 for low blood sugar, and 8/23/25 for poor intake.*She refused the Lantus bedtime dose on 8/4/25, 8/5/25, 8/10/25, 8/13/25, 8/14/25, 8/18/25, 8/22/25, 8/28/25, and 8/31/25.*A progress note on 8/3/25 at 1:52 a.m. indicated the resident's phone alarmed due to a low blood sugar of 68. She was given orange juice, and her blood sugar increased to 86.- According to her glucose log, the resident's blood sugar was 68 at 12:15 a.m. and 86 at 12:45 a.m.-The nurse did not follow the provider's policy and recheck her blood sugar 15 minutes after the intervention. *On 8/4/25 at 8:36 a.m., her glucose log indicated her blood sugar was 57.-There was no nurse's note documented regarding interventions that were done to bring her blood sugar up.-Her blood sugar was checked again at 9:57 a.m. and was 126.-The nurse did not follow the provider's policy to recheck blood sugars 15 minutes after intervention. *A progress note on 8/7/25 at 12:09 a.m. indicated the resident's blood sugar was 66. Orange juice and peanut butter crackers were given. Her blood sugar was rechecked and was 77.- Those blood sugars were not documented in the glucose log.*A progress note on 8/20/25 at 1:25 a.m. indicated the resident had been having low blood sugars that evening. She was given granola bars and orange juice, and her blood sugar recheck was 83. At 1:10 a.m., her blood sugar was 71, and she was given a boost, and her blood sugar recheck was 91.-Resident's glucose log indicated: -Her blood sugar on 8/19/25 at 9:51 p.m. was 68. -Her blood sugar on 8/19/25 at 10:18 p.m. was 74. -Her blood sugar on 8/20/25 at 12:29 a.m. was 67. -Her blood sugar on 8/20/25 at 1:08 a.m. was 71. -Her blood sugar on 8/20/25 at 1:52 a.m. was 91.-The nurse did not notify the physician of the resident's two blood sugars that were less than 70 in a 24 hour period of time.*According to the glucose log, on 8/21/25 at 8:47 p.m., the resident had a blood sugar of 59.-The nurse held her Lantus, according to the MAR. -There was no documentation of interventions taken to correct the hypoglycemia. -Her blood sugar was not rechecked until 8/22/25 at 10:42 a.m., 13 hours and 55 minutes later. *A progress note on 8/25/25 at 11:00 p.m. indicated the resident's phone alarmed due to a low blood sugar, which was 69. The resident was given a bar, and her blood sugar recheck on 8/26 at 12:02 a.m. was 72.-The nurse did not follow the provider's policy to recheck blood sugars 15 minutes after intervention.-The nurses did not follow the provider's policy to notify the resident's physician of her hypoglycemic events.*Her morning blood sugars were not checked on 9/4/25 or 9/9/25; before lunch on 9/4/25; before supper on 9/1/25; and her 2 hour after mealtime on 9/7/25.*Her morning Novolog dose was held on 9/2/25 for poor intake, 9/4/25 as her blood sugar was 135, 9/5/25 as her blood sugar was 111, 9/8/25 as she did not eat, and 9/9/25 for poor intake.*Her lunch Novolog dose was held on 9/1/25 due to low blood sugar and poor intake, 9/4/25 as she did not eat, and 9/8/25 as she did not eat.*Her supper Novolog dose was held on 9/1/25 because the nurse missed that dose.*Her bedtime Lantus insulin dose was held on 9/6/25, and no indication was given and 9/11/25 as her blood sugar was low.*She refused the Lantus bedtime dose on 9/3/25, 9/4/25, 9/7/25, 9/8/25, and 9/9/25.*The resident did not have a physician's orders to hold any of her insulin doses.*Staff failed to notify her physician that her insulin had been held or refused.*A progress note on 9/1/25 at 10:15 a.m. indicated she had a blood sugar of 69 and was given orange juice. Her blood sugar recheck at 1:02 p.m. was 161.-The nurse did not follow the provider's policy to recheck glucose within 15 minutes of intervention.-The nurse failed to notify the resident's physician of her hypoglycemic event.*A progress note on 9/1/25 at 8:18 p.m. indicated her insulin dose had not been given as the nurse missed it.-Missed doses are considered a medication error. -Her physician was not notified. Interview on 09/11/2025 8:56 AM with registered nurse (RN) G revealed:*She verified there were no orders by the physician for if or when to hold resident 5's insulin.*She would expect there would be a progress note in the resident's EMR that the resident's physician was notified. *If she had a resident with a blood sugar level in the 50's, she would not administer the resident's insulin, give glucose gel, and would call the physician. Interview on 9/11/25 at 9:01 a.m. with the interim director of nursing (IDON) C and Minimum Data Set (MDS) coordinator/infection preventionist/RN B revealed:* They expected the nurse to give a resident who had low blood sugar something to bring the blood sugar up.* They expected the nurse to recheck a resident's blood sugar every 15 minutes until the resident's blood sugar was within normal range.*They expected a note to be documented and the physician to be notified by the nurse. *If the hypoglycemic episode occurred during a night shift, they expected the physician to be notified by fax; unless the blood sugar remained low, then it would need to be done sooner. *She would expect the nurse to hold the resident's insulin for low blood sugars and the physician to be notified that the insulin was held. *Resident 5's physician was not available on 9/11/25 for an interview. 2. Observation and interview on 9/10/25 at 8:56 a.m. with resident 25 revealed:*She had been sitting in a recliner at the nurse's station with her walker in front of her.*Her glasses were missing the earpiece on the right side of the frames and were just resting on her nose.*She stated that she could get around well but could not remember if she had fallen recently or what happened to her glasses. Review of resident 25's electronic medical record (EMR) revealed:*She was admitted on [DATE].*She had a Brief Interview of Mental Status (BIMS) assessment score of 6, which indicated she had severe cognitive impairment.*She had a diagnosis of dementia (a group of symptoms affecting memory, thinking, and social abilities).*She used a walker for ambulating (to move/walk) independently.*Her Morse Fall assessments (an evaluation of one's risk level for falling) revealed:-On 10/24/24 and 1/11/25 she had a high risk for falling.-On 3/31/25 and 6/18/25 she had a moderate risk for falling.*The nursing progress notes indicated she had fallen on 3/28/25 and 8/31/25.*The nursing progress notes indicated she had a bruise from her fall on 8/31/25 but did not indicate where.*Her care plan did not indicate she was a risk for falling. Interview on 9/11/25 at 9:53 a.m. with registered nurse (RN) G revealed:*She was a travel nurse but had worked at the facility for the past five years and felt she knew resident 25 well.*She stated resident 25 is usually steady on her feet and had used a walker.*When resident 25 last fell, she and her roommate were unsure of who had fallen first and were trying to help one another get up off of their bathroom floor. Review of the provider's reviewed July 2025 Fall Policy revealed:*To provide a safe living environment for the residents and to protect them from injury.*A licensed nurse will update the care plan to reflect interventions instituted to prevent further falls.*The resident's fall will be discussed with interdisciplinary team (IDT) as soon as possible after the falls to determine new interventions to try.

Based on observation, interview, and policy review, the provider to maintain the supply of controlled medication (medication at risk for abuse and addiction) according to the provider's policy to ensure:*Oral and injectable lorazepam (controlled anti-anxiety medication) stored in one of one medication storage room had been accounted for with each shift change.*One of one bottle of oral liquid morphine sulfate (pain medication) observed in a drawer at the nurses' station had been stored in a secure area.Findings include: 1. Observation and interview on 9/11/25 at 10:32 a.m. of the medication refrigerator in the medication storage room with registered nurse (RN) G revealed:*A small locked black box which contained one lorazepam oral liquid and one lorazepam injectable for emergency use.*Staff did not count those medications at each shift change.*She was unsure why they had not been counting those medications but agreed that they should have been counted at shift change.*RN G agreed those medications should have had the amount counted like the medications locked in the medication cart.*Nurses are the only people who would have had access to the keys to open the medication storage room and the locked box.*RN G had been aware there was one set of keys to open the medication storage room and the locked box. 2. Observation on 9/11/25 at 11:00 a.m. of a lab draw supply drawer in the nurses' station revealed: *An opened bottle of morphine sulfate (pain medication) liquid. *The drawer had been unlocked and did not have a lock.Interview immediately after the above observation with RN G regarding the morphine sulfate that had been in the unlocked drawer in the nurses' station revealed:*She had removed that bottle of morphine sulfate liquid from the locked compartment in the medication cart and placed that medication bottle in that drawer this morning.*She had been waiting for another nurse to destroy the medication with her and had forgotten it was in that drawer. Interview on 9/11/25 at 3:55 p.m. with Minimum Data Set (MDS) coordinator/infection preventionist RN regarding the counting of the lorazepam in the medication storage room refrigerator revealed:*They had not been counting the lorazepam in the medication refrigerator.*She agreed those medication amounts should had been counted at each shift change with each act of exchanging of keys.*She commented she thought that it had been a case of out of sight, out of mind but staff should have counted those medications the same way the medications in the locked medication cart are counted.Review of the provider's February 2025 Medication Storage in the Facility policy revealed:*Scheduled two through five medications and other medications subject to abuse or diversion are stored in a permanently affixed double-locked compartment separate from all other medications per state regulation.*At each shift change, or when keys are transferred, a physical inventory of all controlled substances, including refrigerator items is conducted by two licensed nurses and is documented on the shift verification of controlled substances count.*Controlled substances remaining in the facility after the order has been discontinued or the resident has been discharged are retained in the facility in securely locked area with restricted access until destroyed.

Based on observation, interview, record review, and policy review, the provider failed to follow infection control practices to ensure:*Two of two sampled residents (29 and 9) oxygen and nebulizer tubing was dated to identify when the tubing had been placed in the residents' room for use according to the provider's process. *One of one sampled resident (1) with an open wound caused by prolonged pressure (pressure ulcer) had been placed on enhanced barrier precautions according to the provider's policy. Findings include: 1. Observation and interview on 9/9/25 at 2:44 p.m. with resident 29 while seated in his recliner in his room revealed:*He was wearing a nasal cannula (flexible tubing with prongs that delivers oxygen through the nose) and received oxygen at a flowrate of two liters via oxygen concentrator.*The nasal cannula tubing had not been dated to indicate when it was put in use. *Resident 29 had a portable oxygen tank attached to his wheelchair which also had an undated nasal cannula attached to it.*The nebulizer machine (converts liquid medication into an inhalable mist) had tubing that was dated 8/25/25 at 5:00 a.m. Review of the resident 29's treatment administration record (TAR) revealed:*Nebulizer Set Up Change Routine:-Change set up and tubing weekly.-Be sure to date it.-Every night shift every Sunday of weekly duty.*Oxygen-Tubing Change Routine:-Change O2 (oxygen) tubing and set up weekly. -Record date and time on the tubing N.O. (nursing order).-Every night shift every Sunday for weekly duty.*His oxygen tubing and nebulizer setup had been signed off as changed on 9/7/25. 2. Observation and interview on 9/11/25 at 2:05 p.m. with Minimum Data Set (MDS)/infection preventionist (IP) registered nurse (RN) B regarding the date on resident 29's nebulizer tubing revealed:*She agreed the date on the tubing was 8/25/25.*She agreed the oxygen tubing for the concentrator and the portable oxygen tank had not been dated.*MDS/IP RN B stated the tubing should have been dated and timed when it had been changed according to their care practice.*She had not been aware the tubing had been signed off as having been changed on 9/7/25. The provider did not have a policy specific for oxygen and nebulizer set up tubing changes. Observation on 9/9/25 at 4:30 p.m. in resident 9's room revealed she had been receiving oxygen by nasal cannula tubing that was not dated. Interview on 9/11/25 at 2:39 p.m. with certified nursing assistant (CNA) I revealed: *He sometimes would see oxygen tubing dated. *The night shift nurses would replace the residents' oxygen tubing weekly. Review of Resident 9's electronic medical record (EMR) revealed: *She was admitted on [DATE]. *She had diagnoses of chronic obstructive pulmonary disease (COPD) (a group of lung diseases that block airflow and make it difficult to breathe), congestive heart failure (CHF) (a disease where the heart does not pump blood well), dependence on supplemental oxygen, hypoxia (when the body does not get enough oxygen), and anxiety. *She had orders for her oxygen tubing changing to be changed every Sunday night shift, and the date and the time that was done was to be labeled on the oxygen tubing. Observation and interview on 9/9/25 at 3:35 p.m. in Resident 1's room revealed: *CNAs N and O were not wearing gowns while assisting the resident with getting dressed. *CNA N applied Calmoseptine skin protectant cream to the resident's groin folds. *CNA N removed his gloves, did not perform hand hygiene (hand washing), then put on a new pair of gloves. *Resident 1 had a foam dressing on her coccyx (tailbone), that was dated 9/9/25. *The CNAs were not sure if she had an open wound to her coccyx. *After assisting the resident to dress, both of the CNAs removed their gloves and did not perform hand hygiene. *They then, without wearing gloves, moved her up in bed using the slide sheet. *CNA O, without gloves on, removed the dirty garbage bag and replaced it with a new one, and did not perform hand hygiene. *CNA O then maneuvered the resident's electric wheelchair, using the joystick, into position to prepare to transfer the resident. *Without wearing gloves, CNA N and O used a full body lift (mechanical lift and sling used to lift a person's full body), and transferred the resident into her electric wheelchair. *CNA O picked up the garbage bag, exited the room with it, did not perform hand hygiene, and entered the dirty utility room. *CNA N performed hand hygiene using alcohol sanitizer before leaving the resident's room. Review of resident 1's electronic medical record (EMR) revealed: *She was admitted on [DATE]. *She had a 9/2/25 physician's orders for daily skin and wound monitoring. *She was found to have a pressure ulcer on her coccyx on 9/2/25 and received physician's orders to clean her pressure ulcer on her coccyx with wound cleanser, apply collagen powder, and cover with Mepilex (a type of foam dressing). Change every three days and as needed. Interview on 9/10/25 at 9:22 a.m. with registered nurse (RN) G revealed: *Because resident 1 had a pressure ulcer on her coccyx, she should have been on EBP. Interview on 9/11/25 at 9:01 a.m. with Minimum Data Set (MDS) coordinator B revealed she did not think resident 1 needed to be on EBP until her wound became chronic, and explained chronic as it having been open for 3 weeks. She stated that this was what their policy stated. Review of the providers' 7/2025 Enhanced Barrier Precautions policy revealed: *Policy: It is the policy of this facility to implement enhanced barrier precautions for prevention of transmission of multidrug-resistant organisms (MDROs). CMS notes that facilities have some discretion when implementing EBP and balancing the need to maintain a homelike environment for residents. Definitions: -EBP are an infection control intervention designed to reduce transmission of multidrug-resistant organisms (MDROs) in nursing homes. Enhanced Barrier Precautions involve gown and glove use during high-contact resident care activities for residents known to be colonized or infected with a MDRO as well as those at increased risk of MDRO acquisition (e.g., residents with wounds or indwelling medical devices). -High-contact resident activities include: -Dressing -Bathing/showering -Transferring -Providing hygiene -Changing linens -Changing briefs or assisting with toileting -Device care or use: central line, urinary catheter, feeding tube, tracheostomy/ventilator -Wound care: any skin opening requiring a dressing *Enhanced barrier precautions are recommended for residents with indwelling medical devices or wounds, who do not otherwise meet the criteria for contract precautions, even if they have no history of MDRO colonization or infection.This is because devices and wounds are risk factors that place these residents at higher risk for carrying or acquiring a MDRO, and many residents colonized with a MDRO are asymptomatic.

Based on observation, interview, record review, and policy review, the provider failed to ensure certified nursing assistants (CNAs) did not administer a resident's topical (applied to the body) medications and self-administered medications were documented for one of (one) sampled resident (1) who self-administered medications and, at times, requested CNAs to administer her topical medications stored in her room.Findings include:1. Observation and interview on 9/9/25 at 3:35 p.m. in resident 1's room revealed:*The resident had two bottles of eye drops in a plastic container on her bedside table. She reported she administered them herself after naptime.* She had a Tinactin antifungal spay on her nightstand and stated the certified nursing assistants (CNAs) would spray it on her toes every night when they get her ready for bed.*She had Voltaren gel (for joint pain) on her nightstand, and she reported the CNAs applied it a few times a day for her when she asked.*She had antifungal cream, Calmoseptine cream (for skin protection and wound healing), and Nystatin antifungal powder in her nightstand drawer. They were identified with the resident's permission. Review of resident 1's electronic medical record (EMR) revealed:*She was admitted on [DATE].*She had diagnoses of a history of blood clots, obesity (overweight), anxiety (anticipation of future danger or misfortune with feelings of distress and/or sadness and symptoms such as restlessness or irritability), unspecified encephalopathy (a brain disease that alters the brain function or structure), and paralytic syndrome (a condition that causes the loss of muscle control). *She was hospitalized on [DATE] for treatment of a urinary tract infection and was readmitted to the nursing home on 7/22/25 with hospice services.*Her 7/28/25 Brief Interview for Mental Status (BIMS) was 15, which indicated her cognition was intact.*Resident 1's 7/28/25 Medication Self-Administration Self-Assessment stated the resident had occasional confusion and altered mental status. It indicated the resident was able to self-administer eye drops, nasal spray, and to maintain creams safely in her room.*An 8/15/25 hospice progress note at 2:16 p.m. indicated the hospice nurse talked with Minimum Data Set (MDS) coordinator B, who told the hospice nurse that the resident's confusion had been getting noticeably worse.*She had physician orders for the following medications to be kept at bedside and for her to self-administer:- Olopatadine HCL Solutions 0.2%, instill one drop in both eyes daily for allergic conjunctivitis [irritation].- Systane Ultra Solution 0.4-.03%, instill one drop in both eyes as needed for dry eyes.- Biotene Moisturizing Mouth (Dry Mouth Agents and Artificial Saliva) Solution PRN [as needed for dry mouth].- Fluticasone Propionate Suspension 50MCG/ACT 2 spray[s] in both nostrils daily as needed for one time a day [for allergies].- Preparation H Cream 1-0.25-14.1-15% (Pramox-PE-Glycerin-Petrolatum), insert 1 application rectally as needed for itching QID [four times a day].- Tinactin Aerosol Powder 1% (Tolnaftate), apply to toes/feet topically as needed for fungal infection BID [twice daily] PRN.- Voltaren Gel 1% (Diclofenac Sodium), apply 2 gram[s] transdermally [on skin] as needed for pain QID PRN.- Biofreeze Gel 4% (Menthol (Topical Analgesic)), apply to rt [right] upper back, shoulders topically as needed for pain. up to 4x/day [four times per day].- Calmoseptine [a skin protectant]: Apply to any redness or excoriation [damaged skin] PRN when providing pericare. CNA's may apply as needed.-Her orders for Nystatin powder and Lotrisone External Cream 1-0.05%; did not indicate she could self-administer those medications or that they could be left at the bedside.*Nursing did not document Tinactin and Volataren Gel as self-administered on the eMAR, and monthly checks on all the self-administered medications were not completed, as indicated in the provider's policy.Interview on 9/10/25 at 3:15 p.m. with CNA F revealed:*Tinactin fungal spray was applied by the CNA under resident 1's armpits every day and on her toes after her bath.*The CNAs applied that for her as she is unable to do it herself.*The CNAs applied her Voltaren gel, creams, and powders if resident 1 asked them to.*CNA F reported she did not administer resident 1's eye drops, and resident 1 was not able to self-administer those medications, as she was unable to twist the caps off, because her hands shook, and she was more confused.Interview on 9/10/35 at 3:18 p.m. with registered nurse (RN) G revealed:*Resident 1 had not asked her to assist her with her medications that were in her room, but the resident would tell RN G when they needed to be reordered.*Her self-administered medications were not documented when she took them.*She was not aware that CNAs were applying those medications for her and agreed they should not have been.Interview on 9/11/25 at 10:05 a.m. with MDS coordinator B and interim director of nursing (IDON) C revealed:*She was not aware that the CNAs were administering resident 1's topical medications for her, per the resident's request, and they should not have been.*She acknowledged that resident 1's self-administered medications had not been documented when the resident self-administered them.Review of the provider's 7/8/25 Self-Administration of Medications Policy Revealed:*Self-administration of medications will be evaluated at least quarterly.Screenings may take place more frequently if it is determined that the resident's status has changed and there is a question as to whether self-administration should continue. *Indicate on eMAR in 'Administration Notes' that medications are self-administered by the resident. Monthly checks will be done on all self-administered medications.

Based on the South Dakota Department of Health (SD DOH) Facility Reported Incident (FRI), observations, interviews, and record review, the provider failed to ensure: *One of one sampled resident (10) who was mentally incapable of identifying safety risks was free from the potential of abuse and neglect by one of one sampled resident (37). *One of one sampled resident (1) received necessary care related to pressure ulcers. Findings include: 1. Review of the provider's 6/14/24 submitted SD DOH FRI revealed: *On 6/13/2024 at 12:58 p.m. a suspicion/allegation of abuse/neglect regarding resident-to-resident inappropriate sexual behavior involving resident 10 and resident 37. *At 9:01 p.m. licensed practical nurse (LPN) O contacted administrator (ADM) A and informed her of the incident between resident 10 and resident 37. *Resident 10 was found in resident 37's room in her wheelchair next to resident 37 when certified nursing assistant (CNA) E walked by his room and saw resident 10 sitting in there. *CNA E: -Removed resident 10 from resident 37's room and brought her to her room -Noticed that resident 10's blouse was unbuttoned, and her breasts were exposed. *Notified LPN O At 8:58 p.m. of what he had seen. *LPN O contacted administrator A for guidance. *Administrator A advised LPN O to monitor resident 10 through the night. Further information on the SD DOH FRI revealed: *Administrator A had not notified law enforcement or the Department of Human Services (DHS) until after the surveyors had entered the building on 6/18/24. *Both entities were to have been notified if there was reasonable cause to suspect abuse or neglect of any resident by any person. *A conclusion summary indicated resident 37 had been monitored throughout the night of 6/13/24. *Administrator A provided education to all staff on 6/14/24 to monitor residents 10 and 37 and move resident 10 if any interaction between her and resident 37 was happening. *Administrator A instructed CNA E and LPN O to document on 6/13/24 what between residents 10 and 37. *CNA E documentation revealed: -I noticed [resident 37] door was almost completely closed besides a crack. -He knocked on the door and entered to find resident 10 by resident 37. -He (resident 37) was sitting in his recliner with his feet down, leaning and facing toward resident 10 and she was also facing resident 37. -They were about one foot apart from each other while chatting a little bit. -CNA E decided to take resident 10 out of resident 37's room to the hallway, then decided to take her to her room. -[I] noticed her shirt was on weird and completely unbuttoned with both her breasts exposed. -With notice, resident 10 has a crippled arm and is not able to unbutton her shirt herself. *LPN O was called to resident 10's room by CNA E at 8:58 p.m. -LPN O's documentation confirmed CNA E's documentation. -LPN O added that resident 10 was not able to tell her or CNA E what or if anything had happened. *LPN O completed resident 10's 6/13/24 incident report indicating: -On 6/13/24 at 11:15 p.m. LPN O checked on resident 10. -She was restless, wide awake, legs hanging out of bed, and had her arms crossed over her chest. -When asked if she (resident 10) is ok, she quickly states ?no? [no] -LPN O assisted her in getting her legs back in bed and covered up. -Resident keeps trying to say something to [the] nurse but is unable to get the words out. -Nurse sat with resident for about 5 minutes. She was able to relax some and close her eyes. -At 1:45 p.m., She was awake in bed. She appeared to be calm and comfortable. 2. Interview on 6/18/24 at 3:45 p.m. with ADM A regarding the FRI report regarding residents 10 and 37 revealed: *They had notified the SD DOH of the event on 6/14/24. *They had not notified law enforcement or the Department of Human Services (DHS) because they were waiting for SD DOH to tell them what to do. -They were not done with their investigation. *ADM A confirmed: -Resident 37 had a Brief Interview for Mental Status (BIMS) score of 13, indicating he was cognitively intact. -Resident 10 had a BIMS score of 99, indicating the resident chose not to participate for four or more items, or gave nonsensical responses. -Resident 10 liked to go into residents 37 and 5's room and sit with them often. -It occurred mostly after meals. *Administrator A said resident 37 had a history of calling resident 10 inappropriate names and expressed not wanting her in his room at different times. -She confirmed during the above 6/18/24 at 3:45 p.m. interview that resident 37 was being moved to another on 6/18/24 to put space between resident 10 and resident 37. The following surveyor interviews were completed to support the above staff interviews regarding the resident-to-resident allegation: 3. Interview on 6/20/24 at 4:25 p.m. with CNA E revealed: *He had not seen resident 37 touch resident 10 on 6/13/24, but he (resident 37) quickly jolted back when CNA E walked into his room, so CNA E removed resident 10 from resident 37's room. *CNA E attempted to ask resident 10 questions. -She was cognitively impaired with dementia. -CNA E asked her if resident 37 had touched her, and she said yes. *LPN O had entered resident 37's room and asked him if he had a visitor. -He denied having a visitor and then he became frantic/hesitant after she asked him if resident 10 was in his room with him, and he admitted she was in his room. *CNA E stated: -She could have been in resident 37's room for a while because [LPN O and CNA E] had been busy putting other residents to bed. -He did not remember the exact time, but thought it was between 9:00 p.m. and 10:00 p.m. -Resident 10 was one of the last people to go to bed. -Resident 10 would go into the room shared by residents 37 and 5 often because she thought resident 5 was her son. -He had never seen resident 10 on resident 37's side of the room before 6/13/24. -Resident 5 was in the room at the time of the event but was not facing the same way as the other two residents. -Resident 37 was sitting in a recliner/lift chair tilted forward and fully lifted. --He was facing her, and she was facing him, and they were about one foot apart. *After he had taken resident 10 to her room across the hall he realized: -Her shirt was unbuttoned all the way, and she was not able to unbutton it herself. -She was not wearing a bra or an undershirt. *CNA E stated: CNAs charted when residents had behaviors. -He had never heard resident 10 and resident 37 talk to each other. -Resident 37 had not used inappropriate verbal sexual remarks with other residents. -He heard younger female staff state resident 37 had used inappropriate sexual remarks with younger female staff. -On that night one of the female staff members had said resident 37 used inappropriate verbal remarks toward her. -Another CNA also had inappropriate remarks made to her from resident 37 a few days before the event. --He did not know the names of those female staff members. 4. Interview on 6/21/24 at 8:14 a.m. with LPN O revealed: *She worked on the evening of 6/13/24. *Around 9:00 p.m. CNA E came to get her and told her what he had seen. *She was just told resident 10 required full assistance with unbuttoning of her clothes. -She had never seen her unbutton her shirt. *She was not told about resident 10's shoes being off. - She had seen her take her shoes off before. *CNA E had brought resident 10 to her room and pulled her shirt closed. *LPN O texted administrator A and asked her to call her. -She called back right away, and LPN O explained what had happened. -Administrator A said to make sure she checked on resident 10, documented, and to keep residents 10 and 37 separated. *LPN O stated resident 10 wandered in her wheelchair often, most days going into resident 37's room, even when he was not there. -She had documented that resident 37 had told resident 10 to get the hell out of there (his room) before. -She had educated him to call for help to get her out of his room. *LPN O had not seen resident 37 be inappropriate, but other staff had documented that he has made comments about slapping their butts but not that he had ever done it. -She stated, (Resident 37) had a side that can be inappropriate, not all the time but he has his moments. -He had not been inappropriate with other residents that she was aware of. *She did not know if she had access to the SD DOH reporting system. She would report to administrator A. 5. An interview on 6/21/24 at 10:00 a.m. was attempted with resident 5 (resident 37's roommate) regarding the event that took place on 6/13/24 in his room. Resident 5 was unable to participate in that interview. 6. Interview on 06/20/24 at 4:57 p.m. with resident 37 revealed: *He was moved to a new, private room at the end of the 100 wing on 6/18/24 after an incident with resident 10. *He saw resident 10 wheel herself past his room just before the surveyors entered his room for an interview. -He was afraid she would see him here. -He thought she would have seen him and would have wheeled into his room when she saw him, and he was glad she did not. *She would come into his room when they both lived in the 200 hall, two or three times a week and stare out the window. *She would sometimes go in the bathroom or remove his roommate's socks from his drawer. *She would sometimes go through his refrigerator and try to take his pop. -He would kick the refrigerator door and tell her to Put that back. *On 6/13/24 she came into his room in her wheelchair and tried take a Mountain Dew from his refrigerator. -He would ring my buzzer and she came to get her, referring last week when resident 10 came into his room. -He had not recalled who came into the room to get her on that day. -One time CNA R came to get her. *He stated on the evening of 6/13/24: -Resident 10 was in his room in front of his refrigerator taking off her shoes. -She took off both of her shoes but not her socks. -He helped her put her shoes back on. -He lowered his chair down and reached forward to put her shoes on. -He thought she must have had a sore foot because she said, Oh that hurts. -He said, Her shirt was unbuttoned at the bottom, and she had started unbutton her shirt from the bottom up. *He put his call light on a minute after taking the pop from her. *She was in the room for about 5 minutes. *Her shirt was not unbuttoned at that time. *He did not try to help her button her shirt. *He had not known if she had anything else under her shirt. *He denied touching her. *He denied she touched him. *He denied that she was exposed. *He denied calling resident 10 any names. *He did not enjoy resident 10's visits. *He felt roommate (resident 5) hardly knew she was there. *He stated he was given a new room because resident 10 used to come into his room all the time and he was glad to have his new room. *He stated resident 10 had not been in his room since he moved. 7. Interview on 6/21/24 at 9:22 a.m. with business office (BO)/social services designee (SSD) D regarding residents 10 and 37 revealed: *Resident 10 wanders everywhere in a wheelchair. *If you keep your door shut, she is pretty good. *She did go into resident 5's room a lot because he looks like her son. *There has never been a problem between her and resident 5, they both fall asleep in their chairs and seldom talk. *On 6/20/24 resident 37 was worried that resident 10 was going to come into his new room as she had just wheeled herself past his room. *BO/SSD D had not been aware of an incident of resident 37 calling resident 10 inappropriate names. -She could see that might happen. -His use and choice of words were 'crass'. *Resident 37 sees a behavioral health services counselor. *He can be very defensive. *BO/SSD D had never heard him say anything sexual near residents but can be inappropriate with staff. *BO/SSD D's social service (SS) consultant was not called regarding the 6/13/24 event. *Administer A did the investigation, so BO/SSD had not done anything. *BO/SSD D had not checked resident 10 the next day to monitor her emotional status. *BO/SSD D had the SS consultant information and could call her if I needed help. -The SS consultant visited the provider quarterly, and if BO/SSD D needed her she would be able to come. Review of the SSD job description included: *Essential duties: -Work with an interdisciplinary team to provide psychosocial support to residents, families, and or vulnerable populations so they can cope. -Counsel residents, advise family, and assist in the development of their needs and concerns by means of visits, interviews, and care planning. -Assess resident's needs throughout their stay at the facility to maintain a care plan that addresses social, emotional, and psychosocial needs. Continually assess resident needs while they are adjusting to their new home. -Continually maintain contact with residents, and families, concerning all aspects of their residency. -Be firm and be able to take responsibility and take charge of situations. *BO/SSD D stated, I had never visited with anyone about things like that. 8. On 6/20/24 at 4:50 p.m. resident 10 was observed as she wheeled herself up the 100 hall, unsupervised. *Resident 10 had been at the end of that hall, where resident 37 had been moved to separate them. *The surveyors voiced concern to administrator A as resident 10 was wheeling herself down the 100 hall where resident 37 had been moved. *Administrator A asked if the provider must take away resident 10's rights to be down the 100 hall. *Education was provided to her to ensure resident 10's safety, rather than take away her rights. Review of resident 37's 5/23/24 Long Term Care Progress Note by his attending physician indicated resident 37 had inappropriate sexual behaviors. There was an incident where he spoke in a way that was inappropriate to high school CNA. 43844 9. Review of the provider's 6/10/24 SD DOH FRI revealed: *On 6/10/24 at 12:36 p.m. hospice registered nurse (RN) L contacted interim director of nursing (IDON) G and informed her that resident 1 had open sores on her buttocks. -Dressings had been provided on 6/7/24 by hospice to the provider's staff. -The provider's staff did not use the dressings for resident 1 as they just put her in wheelchair and applied cream to buttocks. -Hospice RN H spoke with the provider's licensed practical nurse(LPN) I and stated to apply the dressing once resident 1 was placed back into her bed. *On 6/10/24 after the conversation between hospice RN L and IDON G, IDON G notified resident 1's family that she had developed pressure sores to her bilateral buttocks likely over the weekend. -IDON G then had LPN J place the standing order dressings on the wounds. Review of resident 1's medical record revealed: *She was admitted on [DATE]. *She was admitted to hospice on 1/9/24. *On 6/6/24 two reddened areas were identified on her buttocks. -On 6/7/24 hospice provided Optifoam (foam dressing with adhesive borders) dressings for the reddened area. *Her family was notified on 6/10/24 of the pressure ulcers and their condition. *On 6/11/24 a Wound Documentation assessment was completed which indicated the onset date as 6/6/24. -The 6/11/24 Wound Documentation indicated there were currently six areas identified as pressure wounds. -Areas identified and the measurements of each were: --Two on her left buttock measured 6.0 centimeters (cm) by 8.0 cm. and the other measuring 2.5 cm by 2.0 cm. --Two on her right buttock measured 7.0 cm by 7.0 cm and the other measuring 1.5 cm by 1.5 cm. --One on her coccyx (tailbone) measured 1.7 cm by 0.8 cm. --One on her left heel measured 2.9 cm by 2.0 cm. *Her family requested an air mattress be placed on her bed. -Hospice ordered that mattress. *Wound care orders included: Applied cavilon advanced [skin protectant] to peri wound area due to erythema [redness]. Applied heel mepilex [absorbent foam] dressing to buttocks to cover the entire area of the wound. Also applied a 4x4 mepilex to the middle of the dressing to ensure it was sealed. Applied betadine to left heel. -Her primary care physician was notified. *On 6/11/24 a hospice standing order for Optifoam Gentle Heel Foam Dressing 9 x 9. Apply to buttock/coccyx area daily. Apply 4 x 4 foam dressing over coccyx area to seal. was entered in her orders. -On 6/12/24 was the first time that order was documented in her treatment administration record as completed for the first time. *She passed away on 6/14/24. Interviews conducted during the survey dates of 6/18/24 through 6/21/24 confirmed resident 1 had developed pressure ulcers and had not received appropriate and timely treatment for those pressure ulcers. Interview on 6/21/24 at 11:25 a.m. with administrator A regarding resident 1's pressure ulcer revealed: *Resident 1 was on hospice. *Two licensed practical nurses had been terminated due to this incident. *Education on abuse and neglect had been provided to all staff. *Her expectation would have been for the pressure ulcer to be checked on daily and documented in the resident's EMR. Interim IDON G was unable to be contacted for an interview. Refer to F686.

Based on a review of the South Dakota Department of Health (SD DOH) Facility Reported Incident (FRI), record review, interview, and observation, the provider failed to ensure two of two sampled residents (1 and 4) received necessary care and treatment in a timely manner for the prevention of pressure ulcers. Findings include: 1. Review of the provider's 6/10/24 SD DOH FRI revealed: *On 6/10/24 at 12:36 p.m. hospice registered nurse (RN) L contacted interim director of nursing (IDON) G and informed her that resident 1 had open sores on her buttocks. -Dressings had been provided on 6/7/24 by hospice to the provider's staff. -The provider's staff did not use the dressings for resident 1 as they just put her in wheelchair and applied cream to buttocks. -Hospice RN H spoke with the provider's licensed practical nurse(LPN) I and stated to apply the dressing once resident 1 was placed back into her bed. *On 6/10/24 after the conversation between hospice RN L and IDON G, IDON G notified resident 1's family that she had developed pressure sores to her bilateral buttocks likely over the weekend. -IDON G then had LPN J place the standing order dressings on the wounds. Review of resident 1's medical record revealed: *She was admitted on [DATE]. *She was admitted to hospice on 1/9/24. *On 6/6/24 two reddened areas were identified on her buttocks. -On 6/7/24 hospice provided Optifoam (foam dressing with adhesive borders) dressings for the reddened area. *Her family was notified on 6/10/24 of the pressure ulcers and their condition. *On 6/11/24 a Wound Documentation assessment was completed which indicated the onset date as 6/6/24. -The 6/11/24 Wound Documentation indicated there were currently six areas identified as pressure wounds. -Areas identified and the measurements of each were: --Two on her left buttock measured 6.0 centimeters (cm) by 8.0 cm. and the other measured 2.5 cm by 2.0 cm. --Two on her right buttock measured 7.0 cm by 7.0 cm and the other measured 1.5 cm by 1.5 cm. --One on her coccyx (tailbone) measured 1.7 cm by 0.8 cm. --One on her left heel measured 2.9 cm by 2.0 cm. *Her family requested an air mattress be placed on her bed. -Hospice ordered that mattress. *Wound care orders included: Applied cavilon advanced [skin protectant] to peri wound area due to erythema [redness]. Applied heel mepilex [absorbent foam] dressing to buttocks to cover the entire area of the wound. Also applied a 4x4 mepilex to the middle of the dressing to ensure it was sealed. Applied betadine to left heel. -Her primary care physician was notified. *On 6/11/24 a hospice standing order for Optifoam Gentle Heel Foam Dressing 9 x 9. Apply to buttock/coccyx area daily. Apply 4 x 4 foam dressing over coccyx area to seal. was entered in her orders. -On 6/12/24 was the first time that order was documented in her treatment administration record as completed for the first time. *She passed away on 6/14/24. Interview on 6/19/24 at 1:14 p.m. with hospice registered nurse (RN) H regarding resident 1 revealed: *The hospice certified nursing assistant (CNA) K had notified her on 6/7/24 that she was concerned about resident 1's bottom. *She kept wound dressings in her car and went to gather them. *When she returned with the dressings, the facility staff had already assisted resident 1 from her bed to her wheelchair. *Hospice RN H asked licensed practical nurse (LPN) I to evaluate resident 1's bottom after lunch that day. *When hospice RN H returned on 6/10/24 she was informed the dressings were not applied over the weekend. -Hospice did not inform the family of the wound as the provider was the primary caregiver. *The provider managed routine and regular dressing changes of wounds and completed measurements. -Hospice would record those measurements in their notes. *During a hospice nurse visit, contact would be made with the provider's nurse on duty and information would be shared by verbal reports. Interview on 6/19/24 at 2:10 p.m. with hospice RN L regarding resident 1 revealed: *Resident 1 previously had skin breakdown off and on for a few months but was healed before she started to decline. *On 6/6/24 hospice CNA K had provided her pictures of resident 1's skin breakdown of her upper right hip area and her bottom. -Hospice RN L had informed hospice CNA K by telephone to have the facility use Optifoam and reposition her often. *On 6/7/24 hospice RN H was notified there was no Optifoam at the facility. -Hospice RN H brought Optifoam dressings to the facility and gave them to LPN I. *Hospice RN K came to the facility on [DATE] and LPN J reported to her that resident 1's buttocks were much worse. -LPN J told her that the Optifoam was not applied over the weekend and did not think that resident 1 had been repositioned. *Hospice RN L notified IDON G and requested that she call resident 1's family and notify them that the recommendations hospice made on 6/7/24 had not been followed. *Resident 1's daughter then came to facility and took pictures resident 1's buttocks, sent them to hospice RN L and she identified an area as a Stage III pressure ulcer. *Hospice RN L stated that the hospice agency does not manage pressure ulcer care. -They would make recommendations and assist the provider's licensed nurses with changing of the dressings when they were at the facility. -The hospice agency had not required physician orders for Optifoam. *An order on 6/12/24 Optifoam heel dressing order was by the provider's consulting wound nurse. *RN L stated the typical hospice communication with the provider's nurses included verbal contact when the hospice nurse arrived, the hospice nurse would visit the resident, and discuss with the provider's nurse again regarding any concerns they had found. *She thought the communication between the provider and the hospice agency was poor. -The hospice agency would find information regarding the hospice resident through review of the provider's medical records for that resident. *Hospice RN L stated, She [resident 1] had a history of just being pushed to the side and she was very disappointed in the provider's management of her pressure ulcers. Interview on 6/19/24 at 3:49 p.m. with hospice CNA K regarding resident 1's pressure ulcer revealed: *On 6/6/24, in the afternoon, she had provided hospice care to resident 1. -During this visit, she found resident 1 in her bed soaking wet with urine although she had a catheter in place. --The catheter was removed from underneath of her leg, and it stopped leaking. -While providing cares, she identified that resident 1 had redness to her buttocks. --There had been two areas on the right buttock, about as long as her thumb and the other one higher up by her butt crack and a little longer than the first one. -She notified hospice RN L at that time and was instructed to notify the facility nurse on duty. *On 6/10/24 hospice CNA K has shown by LPN J resident 1's buttocks. -CNA K stated she was disturbed and astounded by the change in the appearance of her buttocks. -She had notified hospice RN L of that change. *On 6/11/24 IDON G and administrator (ADM) A had called her and asked her who had seen resident 1's pressure ulcer and what had happened, she provided them with same information as above. Interview on 6/19/24 at 10:26 a.m. with CNA R regarding resident 1 revealed: *She had assisted hospice CNA K in repositioning her on 6/9/24. *She had been told that resident 1 had sores and to reposition her more often. -Resident 1 had refused a couple of times. Interview on 6/21/24 at 11:25 a.m. with ADM A regarding resident 1's pressure ulcer revealed: *Resident 1 was on hospice. *Two licensed practical nurses had been terminated due to this incident. *Education on abuse and neglect had been provided to all staff. *Her expectation would have been for the pressure ulcer to be checked on daily and documented in the resident's EMR. Interim IDON G was unable to be contacted for an interview. 32332 2. Observation on 6/19/24 at 10:30 a.m. of resident 4 revealed: *She had been in the hallway sitting in a wheelchair (w/c). *Her feet had been resting on the foot pedals and were covered with small foam boots. *She was alert, answered only when spoken to, and had denied any foot pain. Observation on 6/20/24 at 2:00 p.m. of resident 4 revealed she had been: *Sitting in a recliner with legs elevated and with her feet crossed at the calf. *Wearing small foam boots. Observation on 6/18/24 at 1:30 p.m. of resident 4 revealed: *She had been lying in bed on her left side with foam boots on. *No other pressure-relieving measures were in place. 3. Review of resident 4's 8/20/23 through 6/21/24 electronic medical record (EMR) revealed: *She was admitted on [DATE]. *Her diagnoses included the following: Alzheimer's disease and dementia (forgetfulness), psychotic disturbance, major depression with mood disturbance, Type 2 diabetes with neurological complication, degenerative joint disease, and malnutrition. *She had poor memory recall and was unable to participate in decision-making for her care. *She was dependent upon the staff for: -The development of her plan of care and to ensure the interventions were implemented for quality of care. -Assistance with all activities of daily living (ADLs) to include bed mobility, repositioning, and positioning pressure relieving devices. *On 2/10/24 she was admitted to Hospice for end-of-life care. *While under the care of the provider she had acquired seven pressure ulcers. *She had: -One stage 2 pressure ulcer (partial thickness loss) located on her right lateral ankle had worsened to a stage 3 (full thickness skin loss). That wound had been identified on 12/28/23. -A callous formation on her right mid-lateral foot that was identified on 2/21/24 and had worsened to a stage 3 pressure injury. -A deep tissue pressure injury was identified on 3/4/24 to the right lateral foot. It was a deep purple/brown color and unstageable. -Two large intact blisters on her left lateral foot that were identified on 4/14/24. -An unstageable pressure ulcer located by her right little toe that was black in color and was identified on 5/30/24. -An open pressure area to her left buttock/sacrum was identified on 4/11/24. *Hospice and a wound nurse had been involved with the care and treatment of her wounds. -The wound nurse was not available for an interview. Review of resident 4's 8/20/23 through 6/21/24 progress notes revealed: *On 12/3/23 at 9:38 p.m. the nurse documented, Nurse was at the nurses station when a loud noise was heard and resident began yelling. Nurse went to room and found resident sitting on the floor of her room near her sink. She was incontinent of stool and had some blood coming from a spot on her R [right] outer ankle. *On 12/28/23 the director of nursing (DON) B documented, During bath skin assessment, it was noted that resident has a new pressure injury to her right ankle. See wound assessment for details. *Her Braden score fluctuated between 16 and 18 and indicated she was at risk for skin breakdown. -She had a potential problem with friction and shearing due to moving feebly and/or requires minimal assistance. *She had pressure-reducing devices for her chair and bed. -There was no documentation of a repositioning plan. *On 1/23/24 the Minimum Data Set coordinator (MDS)/RN C documented, Charge nurse reported that resident's ankle wound looks worse today and has eschar [dead tissue that sloughs off healthy skin after an injury] in the wound bed. FNP [practitioner's name] saw resident today to evaluate the wound. Orders received If no improvement in wound bed by Thursday afternoon, schedule appointment with [practitioners name] on Friday for the area to be debrided. *On 1/24/24 it was decided with the help of hospice to change the treatment and not debride the wound. *On 2/21/24 DON B spoke with the hospice nurse and confirmed the wound appeared to be larger based on the measurements completed the day before. -There was no documentation to support the callous formation on the lateral side of her right foot had been identified. *On 3/4/24 MDS/RN C documented, Wound to right lateral ankle dressing change noted. Slough covers 95% of the wound bed, edges are round, and wound appears to be larger. Resident also has a DTI [deep tissue injury] to lateral edge of right foot. It is dark purple in color. It is pea-size. Resident shoes were removed and gripper socks applied. -On 3/8/24 the wound had worsened, and MDS/RN C documented: Dressing change completed to right lateral ankle. Wound appears larger and now measures 3.1 x [by] 2.5 x 0.4. There is a small necrotic dark are [area] at 12 o'clock that measures 0.4 x 0.6. -On 3/9/24 both of the wounds had worsened, and MDS/RN C documented: Wound care provided to right lateral ankle this morning because resident had the dressing off. The wound appears swollen and red and warm to the touch. The wound base is 100% green/yellow slough, there is a necrotic area at 12 o'clock that appears larger than yesterday and then redness and the skin is boggy just above and to the right of necrotic area. Swelling noted to distal end of wound when leg is elevated. Hospice nurse updated this morning. TED hose left off the foot so no pressure is applied to area. New wound care orders received from Hospice. *On 3/17/24 the charge nurse documented: Wound dressing changed to R [right] lateral ankle per orders. Peri-wound has increased redness and inflammation. Fax sent to PCP [primary care provider] requesting to consider ABX [antibiotic] tx [treatment]. -The physician ordered an antibiotic to be given every 6 hours for 10 days due to right lateral ankle inflammation. *On 4/11/24 DON B documented: Upon assisting resident to the bathroom, it was noted that resident has an open pressure area to her left buttock/sacrum. Applied a thick layer of calmoseptine over it. -Twelve days later, on 4/23/24, DON B documented that the wound on the left buttocks had closed. -There was no other documentation in the EMR to support the size, appearance, drainage, and pressure relieving measures put in place to promote healing of that wound. *She had a care conference review on 4/11/24. -She had started to decline further and was sleeping more. *On 4/14/24 the nurse documented: Resident has a large fluid filled blister to lateral left heel and a medium sized blister to the medial left heel, both intact. Right ankle is larger in size, with foul smelling drainage. Peri-wound bright red, swollen and warm to touch. Wound to lateral right foot open with slough and necrotic tissue. Per-wound bright red, swollen and warm to touch. -The physician was called, and orders were given to start another antibiotic. *On 4/15/24 the nurse and DON consulted with the Hospice nurse regarding the resident's wounds. -They had decided to discontinue all wound care and provide comfort care for wounds due to poor circulation. *On 4/18/24 the physician was notified of the current status of wound care and the physician advised to continue the wound care to the right ankle to maintain current status. They were to paint the left lateral and medial heel wounds with betadine. -These orders were received three days after the discontinuation of wound care had been decided. *On 4/28/24: -Was the first documentation to support a comprehensive skin and positioning evaluation had been completed for her. -Her Braden score had dropped to 12 and identified her as high risk for skin breakdown. --That was the first Braden score that supported her at high risk due to her gradual failing condition that was identified when she was admitted to Hospice care on 2/10/24. -That was the first documentation that indicated: --Pressure-relieving approaches and interventions were implemented. --A turning and repositioning program had been implemented. Review of resident 4's weekly wound documentation revealed there were five separate wounds assessed and documented on weekly versus the seven that had been identified in the progress notes from 12/28/23 through 4/28/24. Review of resident 4's closet care plan revealed: *Those care plans were placed in the residents' closets for the certified nursing assistants and temporary staff use for providing care. *On 1/3/24 a closet care plan was placed in her closet. -She needed the assistance of one staff member with a walker and transfers. -Her only indicated special need was oxygen. *The closet care plan was not updated until 5 months later on 6/4/24. -She was non-ambulatory and needed the assistance of two staff members with transfers. -She was to be repositioned on rounds and was to be provided with offloading. --There was no documentation on what should have been should have been offloaded. -Pressure ulcer was marked. -Special needs included: Heel boots/gripper sock at all times. O2 [oxygen] at night - HOSPICE. Review of resident 4's ongoing comprehensive care plan revealed: *Focus area: ADL [activities of daily living] Self Care Performance Deficit . -Was created on 1/25/23 and revised on 2/10/23. *Goals: Will maintain current level of function through the review date. Will not develop complications of immobility. With a target date of 7/27/24. *Interventions: -Dressing: [Resident name] requires assistance of 1 with cue with dressing/undressing. -Oral Care: Independent after set up. *A 1/25/23 focus area that was revised on 11/28/23 indicated: has limited physical mobility as e/b [evidenced by] shuffling gait r/t dementia and Alzheimer's. will participate in restorative program. *Goals: Will maintain current level of mobility through review date. -Will remain free of complications related to immobility including skin-breakdown. --Was created on 2/10/23 and has a target date of 7/27/24. *Interventions: -Ambulation: requires walker and 1 assist. -Ambulatory status: 1 assist with gait belt and walker for ambulation. When not walking with staff must use a wheelchair. --Encourage reposition/position changes during rounds. --Transfer: Can transfer independently with walker in room and with supervision when on the unit. *Focus area: [Resident's name] has the potential for a Nutritional problem r/t dementia and Alzheimer's, and episodes of dysphagia needing nectar thick liquids. -Was created on 1/25/23 and revised on 2/10/23. -The focus area had not been updated to include her declining condition and wound care nutritional support requirements. *Focus area: [Resident's name] has potential for impairment to skin integrity r/t cardiac history, fall risk and dementia. -Was created on 2/10/23 and revised on 4/25/23. *Goal: Will be free from skin alteration/injury through the review date. -Target date was 7/27/24. *Interventions: -Reposition frequently. No documentation on how frequently she was to have been repositioned. -Required a pressure-relieving mattress when in bed/chair. -No documentation on other pressure relieving measures to promote the health of her skin. *Focus area: [Resident's name] has Pressure injury to Right Lateral Ankle, Right Lateral foot and Bilateral heels r/t Braden score of 10 - 12 (high risk), immobility, terminal diagnosis, -Was initiated on 4/28/24 and created/revised on 5/5/24. That had been four months after the identification of her first pressure ulcer. -It did not include all seven of her pressure ulcers. *Goals: Will participate with repositioning. Pressure injury will show signs of healing and will remain free from infection by/through review date. Will have intact skin, free from redness, blisters or discoloration by/through review date. -These goals were created on 5/5/24 and had a target date of 7/27/24. -Interventions: Pressure relieving support surfaces in bed and chair: Standard reduction necessary to reduce pressure and to improve comfort level in relation to positioning/repositioning in bed and chair. 4. Interview on 6/20/24 at 2:44 p.m. with MDS/RN C regarding resident 4's pressure ulcers, pressure ulcer care, and the documentation of the pressure ulcer care was difficult to follow revealed: -She stated she would bring the timeline and care provided together so the surveyor could review it. -She stated resident 4's physician would be visiting resident 4 on 6/20/24 and she would discuss the pressure ulcers and possible changes in her pressure ulcer care and the two pressure ulcers on her right lateral foot had worsened and were red in color. 5. Interview on 6/21/24 at 11:30 a.m. with MDS/RN C regarding the pressure ulcers revealed: -She had not put together the documentation of the timeline of the pressure ulcer care. -She had discussed with resident 4's physician and was told he was not going to change her ulcer orders. -She stated the new director of nurses (DON) was wound certified and MDS/RN C felt that the wound care would be changing for the better. *She stated: -Hospice cannot provide an air bed because she did not meet the hospice guidelines. -The provider could provide an air bed, but she was scared the resident would break a hip because she moved in bed. -Resident 4 had used her own mattress when the pressure ulcers started. -She accepted a provider pressure relief mattress, and it did provide better relief than her mattress. -She had long pressure relief boots, but she was too hot in them, and she would take them off. --She had accepted the small foam boots. -The first thing resident 4 would do when she would lie in bed was to place her feet sideways, so they are lateral to the mattress, and she felt that caused pressure ulcers. Review of the provider's undated Charting Expectations policy revealed: *Rounds: -The night CNA and the night nurse are expected to do rounds on residents at 1:00 a.m. AND 4:00 a.m. You cannot skip a round as that can be considered neglect Review of the provider's 10/01/21 Pressure Ulcer Prevention policy revealed: *Purpose: -To promote the prevention of pressure ulcer development. -To promote the healing of pressure ulcers that are present including prevention of infection to the extent possible. -To prevent the development of additional pressure ulcer. *Policy: -It is the policy of [facility name] to prevent a resident who enters the facility without pressure sores from developing pressure sores unless the individual's clinical condition demonstrates that they were unavoidable and to provide necessary treatment and services to a resident having pressure sores to promote healing, prevent infection and prevent new sores from developing. Review of the provider's 9/18/19 Care Plan Policy and Procedure revealed: *Purpose: -Care plans will be developed by an interdisciplinary team with participation of the resident, family, and/or representative . -Care plans include active and historical diagnoses, goals and/or expected outcomes, specific nursing interventions so that any nursing staff member is able to quickly identify a resident's individual needs and to decrease the risk of incomplete, incorrect, or inaccurate care, and to enhance continuity of nursing care. *General instructions: -Care Plans will be reviewed quarterly, annually, and with any significant change in resident condition.

Based on Payroll Based Journal (PBJ) reports, interview, and record review, the provider failed to ensure there was a registered nurse (RN) working for eight consecutive hours per day for 36 days in Federal Fiscal Quarters 1 (October, November, and December 2023) and Quarter 2 (January, February, and March 2024), and one day from June 6th, 2024, through June 14, 2024. Findings include: 1. Review of the provider's Federal Fiscal Quarter 1 (October, November, and December 2023) PBJ Certification and Survey Provider Enhanced Reporting (CASPER) report revealed the following: *There were no eight consecutive hours worked by an RN on the following days: -October 14th, 22nd, and 28th. -November 10th, 11th, 12th, 14th, 24th, 25th, and 26th. -December 3rd, 9th, 10th, 14th, 15th, 17th, 18th, 22nd, 23rd, 24th, 25th, and 31st. Review of the provider's Federal Fiscal Quarter 2 (January, February, and March 2024) PBJ CASPER report revealed the following: *There were no eight consecutive hours worked by an RN on the following days: -January 1st, 6th, 7th, 8th, 13th, 20th, and 27th. -February 1st, 3rd, 4th, 11th, 17th, 18th, 24th, and 25th. -March 1st, 2nd, 3rd, 16th, 17th, 23rd, 24th, 25th, 30th and 31st. Review of provider's timecards and nurse schedules for the time frames above revealed: *There were no eight consecutive hours worked by an RN on the following days: -October 14th, 18th, 22nd, and 28th. -November 4th, 10th, 11th, 12th, 25th, and 26th. -December 3rd, 8th, 9th, 21st, 23rd, 24th, 27th, 29th, and 31st. -January 13th, 14th, and 20th. -February 1st, 2nd, 3rd, 4th, 18th, 23rd, and 24th. -March 2nd, 16th, 17th, 23rd, 24th, 30th, and 31st. Additional review of the provider's time cards and nurse schedules from 6/6/24 through 6/14/24 revealed the were no eight-hour consecutive hours worked by an RN on 6/8/24. Interview on 6/21/24 at 11:30 a.m. with administrator (ADM) A confirmed there were 37 days that had no eight consecutive hours worked by an RN. Interview on 6/21/24 at 11:35 a.m. with Minimum Data Set coordinator (MDS)/registered nurse (RN) C regarding the PBJ revealed: *She had been responsible for submitting PBJ data to the Centers for Medicare and Medicaid Services (CMS) until January 1, 2024, ADM A was then responsible to submit the data. -The information was entered manually, as their time clock system information did not carry over into the PBJ system. *She had not been able to access those Reports online. Continued interview on 6/21/24 at 2:07 p.m. with ADM A regarding having an RN work for eight consecutive hours each day revealed: *The provider was licensed to provide skilled nursing care and did not have a nurse waiver. *She confirmed there was not always a registered nurse for eight consecutive hours each day at the facility. -When an RN was not in the facility, a physician and an RN were available by phone. *She stated there were no residents in the facility that required an RN for care. -She stated, If that were needed [an RN], we would have RNs available, the Hospice nurse is also an RN and available when she is here. *The provider was advertising with online employment companies, Facebook, local television stations, and the local newspaper. *The staffing for weekends was Based upon residents we have and acuity level [of the residents].

Based on interview, Arbitration Agreement review, and record review, the provider failed to ensure the Arbitration Agreement: *Included the arbitration organizations name and how to contact that organization. *Provided for a location that was convenient for both parties for an arbitration dispute. Findings include: 1. Interview on 6/18/24 at 11:14 a.m. with administrator A revealed the provider had an Arbitration Agreement that was reviewed and requested to be signed by newly admitted residents or their representative. Review of the provider's Arbitration Agreement revealed the following: *Location of Arbitration - The Arbitration will be conducted at a site selected by [provider] which shall be either at [the provider] or somewhere within a reasonable distance of [the provider]. *Time limitation for Arbitration - any request to arbitrate a Dispute must be submitted to [initials of the arbitration agency] (2) years from the date the event giving rising to the dispute occurred. *The agreement provided the initials of the name of the arbitration agency, but did not specify what those initials meant. *The agreement did not provide for a way to contact that arbitration agency. Interview on 6/20/24 at 9:28 a.m. with administrator A regarding the Arbitration Agreement revealed: *All current residents or their representative had signed an arbitration agreement. *She was not aware of who had developed and approved the agreement. *Business office/social service designee (BO/SSD) D was responsible for having residents sign the agreement. Interview on 6/20/24 at 10:32 a.m. with BO/SSD D revealed: *She was responsible to have new residents sign the arbitration agreement. *She was not aware of who had developed and approved the agreement. *She confirmed: -The location for a dispute was for the provider to determine and not both parties. -The agreement provided the initials of the name of the arbitration agency, but did not specify what those initials meant. -The agreement did not provide for a way to contact that arbitration agency. *She stated the resident or resident's representative could search the Internet on their phone to obtain the name and how to contact that arbitration agency. Interview on 6/21/24 at 7:55 a.m. with administrator A regarding the Arbitration Agreement revealed she: *Agreed agreement should have had the arbitration agency name spelled out and a way to contact them. *Agreed facility should not have been independent in selecting the location for an arbitration dispute. *Stated not all residents had signed the arbitration agreement, and was not sure why some had not. *To her knowledge, no disputes had occurred. Review of the provider's listing of residents revealed 26 of 34 of the current residents had signed an Arbitration Agreement.

Review of the provider's PBJ CASPER reports revealed the following items triggered: *Federal Fiscal Quarter 1 and Federal Fiscal Quarter 2: -No registered nurse (RN) hours for eight consecutive hours each day for more than four days. -No 24-hour nurse coverage each day for more than four days. -The weekend staffing metric was suppressed, meaning the data submitted was excessively low. Interview on 6/21/24 at 11:30 a.m. with administrator A regarding PBJ reporting revealed: *Minimum Data Set Coordinator(MDS)/registered nurse (RN) C had been responsible to submit the PBJ data to CMS. *The time clock system was not able to automatically upload the payroll data to the PBJ system. -The information had to be entered manually. *Administrator A had recently gained access to the PBJ online reporting site, and the time clock had uploaded the data successfully. *She confirmed the data for Federal Fiscal Year 2024 for Quarter's 1 and 2 had not been submitted accurately. Interview on 6/21/24 at 11:35 a.m. with MDS/RN C regarding PBJ reporting revealed: *She had been responsible to submit PBJ data to CMS until January 1, 2024, administrator A was then responsible to submit the data. -The information was entered manually, as their time clock system information did not automatically transfer into the PBJ system. *She had not been able to access the validation reports after submission. Continued interview on 6/21/24 at 2:07 p.m. with administrator A regarding PBJ Data submission revealed: *She confirmed there was not always an RN for eight consecutive hours each day at the facility. *She confirmed there was no nurse waiver. *She stated there were no residents in the facility that required a RN for care, if that were needed (an RN), we would have RNs available, the Hospice nurse is also an RN and available when she is here. *She confirmed there had been a licensed nurse in the facility at least 24 hours each day and that the PBJ submitted was inaccurate. *When asked about how staff were scheduled for the weekend hours she stated, Based upon residents we have and acuity level [of the residents]. *When asked if the PBJ data was accurate for low weekend staffing, she declined to answer. Refer to F727.

49958 Based on observation, interview, record review, and policy review, the provider failed to review and revise comprehensive care plans to ensure care needs were accurately reflected for six of twelve sampled residents (3, 10, 16, 23, 26, and 37). Findings include: 1. Interview on 6/18/24 at 11:14 a.m. with administrator (ADM) A during the entrance conference revealed there was one resident (16) who received dialysis treatments and one resident who smoked cigarettes (26). Review of resident 16's medical record revealed: *He received dialysis treatments two days a week. *His care plan indicated Fluids as ordered. Restrict or give as ordered. Interview on 6/19/24 at 10:26 a.m. with certified nursing assistant (CNA) R regarding resident 16 and care plans revealed: *If she observed any bleeding at resident 16's dialysis site on his arm, she would report it to the nurse. *He had been on a fluid restriction, and she thought they took it [the fluid restriction] away but she was not sure. -She had seen him have a glass of water in his room, so she had given him water during a routine water pass. *She stated CNAs received information about changes in resident's care through the use of a communication book, verbal report at change of shift, and other CNAs tell me. *She stated she had memorized what care the residents needed and would review a new resident's care plan when they were admitted . Interview on 6/19/24 at 3:48 p.m. with registered nurse (RN) N regarding resident 16's fluid restriction revealed: *She thought he was on a fluid restriction. *She was not sure what the fluid restriction amount was. *She did not monitor or document his fluid restriction. *She stated, He doesn't drink all of what is put in front of him, so I don't worry about it. Interview on 6/20/24 at 10:54 a.m. with minimum data set coordinator/registered nurse (MDS/RN) C regarding resident 16 revealed: *He was not on fluid restrictions or a specialized diet as the dialysis provider had discontinued it on 10/10/23. *She confirmed his care plan indicated his fluids were as ordered or restricted as ordered. *She agreed his care plan for fluids was not individualized to reflect his current needs. 2. Review of resident 26's medical record revealed: *His smoking safety screen was completed on 4/16/24 and indicated: -He had or shown signs of dementia or other cognitive impairment. -He smoked 10 or more cigarettes each day. -He was able to demonstrate safety with smoking. Interview on 6/19/24 at 10:26 a.m. with CNA R regarding resident 26 revealed he smoked independently. Review of his 6/20/24 care plan included: *A 4/16/24 revised focus area that he smoked cigarettes and was at risk for injury related to smoking. *Staff were to assist him outside to smoke and ensure clothing was appropriate for weather. *The charge nurse was to provide him 8 cigarettes each day in the morning, and he was allowed to smoke independently as long as maintained his safety awareness. *Staff were to ensure resident 26 was aware/compliant with the facility's smoking policy and his plan. *Staff were to report burns to himself or his clothing. *A smoking assessment would be completed quarterly and PRN (as needed) for any changes in his condition. Interview on 6/20/24 at 11:25 a.m. with MDS/RN C regarding resident 26's smoking and his care plan revealed: *He was assessed and was determined to be safe to smoke on his own on 4/16/24. *She confirmed his care plan indicated he was not safe to smoke on his own. *She stated his care plan was not supposed to be that way. *She was responsible for ensuring his care plan was accurate. 3. Observation and interview on 6/18/24 at 2:31 p.m. with CNA P regarding resident 23 and care plans revealed: *Her bed was positioned low to the floor. *A fall mat was in the room but had not been placed at her bedside. *CNA P stated resident 23 was mostly non verbal, had several falls recently, and the fall mat was used only when she is sleeping. *She used the residents' care plans to know what care the residents need. Observation of an index card dated 6/4/24 located on resident 23's closet door revealed: *The resident was independent with transfers. *Fall risk interventions included bed to floor and fall mat @ NOC [at night]. Review of resident 23's electronic medical record (EMR) revealed: *Her Morse Fall Scale assessment completed on 3/29/24 indicated she was at high risk for falls and she had at least 14 documented falls in the past 90 days. *Her current care plan included: -TRANSFER: Supervision to limited assist of 1 with walker. *It did not include her bed was to have been positioned low to the floor or the use of a fall mat at night. Interview on 6/20/24 at 9:44 a.m. with MDS/RN C regarding resident 23's care plans revealed: *She had been aware of resident 23's frequent falls and stated, Interventions tried included redirection. *Most of the falls were with wandering and could be due to discomfort or anxiety. *She had experienced a gradual decline since hospice started 10/23/23. Her family wanted her to continue to walk despite falls as it limited her anxiety and reduced her need for medication. *Her bed was kept in the lowered position close to the floor with a fall mat during the night or when she is sleepy and may roll out of bed. During the day the fall mat was not always used due to the increased fall risk associated with the mat if she wanted to get up. *She would have expected staff to know what interventions had been in place because they would be in the care plan that is kept on the closet door. Those closet care plans were updated monthly to reflect the information that was on residents' care plans. *It was her responsibility to update care plans. 4. Observation and interview on 6/18/24 at 4:42 p.m. with resident 3 revealed: *She was seated in her wheelchair with a seat belt around her waist and connected to the wheelchair. *She stated the seat belt was to keep her in the chair, I fall easily. She was able to unclasp the seat belt. *Her closet care plan did not include she used a seat belt. Review of resident 3's current care plan revealed it did not include she had used a seat belt. Interview on 6/19/24 at 11:25 a.m. with MDS/RN C regarding resident 3's seat belt confirmed the use of the seat belt was not included on her care plan. 5. Review of resident 10's EMR including her updated 6/18/24 care plan revealed resident 10: *Was considered a vulnerable adult due to a limited mobility. *She wandered the halls in her wheelchair, entering other resident's room. *Staff were to remove her physically from any potentially harmful situations while reassuring her. *A new intervention in her care plan was to ensure she would be observed hourly, and she stayed out of resident 37's room and other rooms for her safety. Review of resident 10's closet care plan on 10/21/24 at 10:30 a.m. revealed: *It was last updated on 6/4/24 before the event. *The closet care plan had not been updated to include caregivers were to ensure she would be observed hourly, and she stayed out of resident 37's room and other rooms for her safety. 6. Review of resident 37's EMR including his updated 6/18/24 care plan revealed resident 37: *Was considered a vulnerable adult due to recent declines in ADL function, seizures, and ataxia (impaired balance or coordination). *Staff were to remove him physically from anything potentially harmful. *A new intervention in his care plan was to ensure he would be observed hourly and redirected. Review of resident 37's closet care plan on 6/21/24 at 10:30 a.m. revealed: *It was last updated on 6/4/24. *It had not been updated to include staff were to ensure he would be observed hourly and redirected. 7. Interview on 6/20/24 at 11:25 a.m. with MDS/RN C revealed: *Any staff member could update a resident's care plan. *She was responsible for ensuring all care plans were updated with the resident's current care needs. 8. Interview on 6/20/24 at 1:30 p.m. and again at 2:00 p.m. with MDS/RN C regarding care plans revealed: *The nurses had access to the care plan. *The CNAs and temporary staff could look at the closet care plans located on each resident's closet door. *The closet care plans were index cards with the necessary information for caregivers to provide care to the residents. *The closet care plans were updated monthly. The documentation in the care plans did not reflect or support the information provided by MDS/RN C, as the care plans had not been updated. Review of the provider's reviewed 9/18/19 Care Plan Policy and Procedure revealed: *The care plan was the basic responsibly of the MDS/RN or designee. *Care plans included goals and/or expected outcomes, specific nursing interventions so that any nursing staff member is able to quickly identify a residents individual needs and to decrease the risk of incomplete, incorrect, or inaccurate care, and to enhance continuity of nursing care. *Care plans will be reviewed quarterly, annually, and with any significant change in resident condition. *Short term changes to the care plan would be added as necessary to the Short Term Care Plan. *Each discipline will update the care plan as changes occur between assessments and scheduled care conferences. *Care plans were to be written by exception for Resident Centered Care Plan Facility Standards and Short Term Care Plans. They include measurable outcomes and identify interventions that were specific to the individual resident with defined time frames and parameters. Target dates are through next review period unless otherwise specified. Review of the providers' April 3, 2023 Comprehensive Care Plan policy revealed Each Resident's care plan will be updated if a goal has been met or if a new focus arises. If a change is made on a paper copy of a resident's care plan you must date and initial by the change. Review of the provider's undated Fall Policy revealed: The team will discuss root causes for any fall, formulate a plan to prevent further falls, and ensure care plan and staff are updated on all plans to prevent falls.

Based on plan of correction review for survey date 6/21/24, staff member listing, record review and interview, the provider failed to ensure the plan of correction (PoC) review from the 6/21/24 with a completion date of 7/23/24, staff member listing review, record review, and interview, the provider failed to ensure the PoC was followed regarding staff education for the previously cited following citations: F554, F686, F761, and F880. Findings include: 1. Review of the provider's PoC for the above citations revealed education related to F554, F686, F761, and F880 was to be provided to staff with a completion date of 7/23/24. The provider's 7/25/24 staff listing indicated there were a total of 47 staff members. -Of those, 25 were nursing staff members. -An agency registered nurse (RN) was not listed. Review of the provider's documented staff education as stated in the provider's PoC for the above citations revealed: *The provider's PoC for citation F554, Resident Self-Administration of Medications, indicated, All nursing staff are required to complete medication education with post test. All new hired nurses/CMAs [certified medication aides] will be required to complete medication storage training. -There were 17 employees who had completed the training. --Those staff included seven nursing staff members, four dietary staff members, two housekeeping staff members, one laundry staff member, one maintenance staff member, one activity staff member, and the administrator. *The provider's PoC for citation F686, Treatment/Services to Prevent/Heal Pressure Ulcer, indicated, Education on repositioning and offloading including techniques to prevent pressure injuries implement for nursing staff on 7/5/24. Education to be reviewed and quiz to be completed for Nurses, CMAS [medication aides] and CNA's [Certified Nurse Aides]. New hires for nursing staff will be required to complete the quiz as part of the new hire orientation. -There were 19 staff members who had completed the training. --Those staff included one dietary staff member and 18 were nursing staff members. *The provider's PoC for citation F761, Label/Store Drugs and Biologicals, indicated, All nursing staff are required to complete medication storage education with a post test. All new hire nurses/CMA's [CMAs] will be required to complete medication storage training. -There were 11 staff members who had completed the training. --Those staff included one dietary staff member, one RN, three licensed practical nurses (LPN's), and six CNA's. *The provider's PoC for citation F880, Infection Prevention and Control, indicated, Nursing staff are required to complete hand hygiene education with post test. All new hires will be required to complete hand hygiene training. -The provider's staff member listing indicated there were 25 nursing staff that included RN's, LPN's, and CNA's. --There was one agency nurse not listed. -There were 17 nursing staff members who had completed the hand hygiene training, which included the agency nurse. Interview on 7/25/24 at 12:10 p.m. with director of nursing (DON) B regarding education for staff members revealed: -She created a PowerPoint presentation, staff reviewed the presentation, and signed electronically that they had completed the training. -Staff members who had not completed that education would have been educated on a one-to-one basis. Interview on 7/25/24 at 3:09 p.m. with administrator A and DON B confirmed the PoC education was not completed by 7/23/24 as stated in the PoC's.

Based on plan of correction review for survey date 6/21/24, staff member listing, record review and interview, the provider failed to ensure the plan of correction (PoC) review from the 6/21/24 with a completion date of 7/23/24, staff member listing review, record review, and interview, the provider failed to ensure the PoC was followed regarding staff education for the previously cited following citations: F554, F686, F761, and F880. Findings include: 1. Review of the provider's PoC for the above citations revealed education related to F554, F686, F761, and F880 was to be provided to staff with a completion date of 7/23/24. The provider's 7/25/24 staff listing indicated there were a total of 47 staff members. -Of those, 25 were nursing staff members. -An agency registered nurse (RN) was not listed. Review of the provider's documented staff education as stated in the provider's PoC for the above citations revealed: *The provider's PoC for citation F554, Resident Self-Administration of Medications, indicated, All nursing staff are required to complete medication education with post test. All new hired nurses/CMAs [certified medication aides] will be required to complete medication storage training. -There were 17 employees who had completed the training. --Those staff included seven nursing staff members, four dietary staff members, two housekeeping staff members, one laundry staff member, one maintenance staff member, one activity staff member, and the administrator. *The provider's PoC for citation F686, Treatment/Services to Prevent/Heal Pressure Ulcer, indicated, Education on repositioning and offloading including techniques to prevent pressure injuries implement for nursing staff on 7/5/24. Education to be reviewed and quiz to be completed for Nurses, CMAS [medication aides] and CNA's [Certified Nurse Aides]. New hires for nursing staff will be required to complete the quiz as part of the new hire orientation. -There were 19 staff members who had completed the training. --Those staff included one dietary staff member and 18 were nursing staff members. *The provider's PoC for citation F761, Label/Store Drugs and Biologicals, indicated, All nursing staff are required to complete medication storage education with a post test. All new hire nurses/CMA's [CMAs] will be required to complete medication storage training. -There were 11 staff members who had completed the training. --Those staff included one dietary staff member, one RN, three licensed practical nurses (LPN's), and six CNA's. *The provider's PoC for citation F880, Infection Prevention and Control, indicated, Nursing staff are required to complete hand hygiene education with post test. All new hires will be required to complete hand hygiene training. -The provider's staff member listing indicated there were 25 nursing staff that included RN's, LPN's, and CNA's. --There was one agency nurse not listed. -There were 17 nursing staff members who had completed the hand hygiene training, which included the agency nurse. Interview on 7/25/24 at 12:10 p.m. with director of nursing (DON) B regarding education for staff members revealed: -She created a PowerPoint presentation, staff reviewed the presentation, and signed electronically that they had completed the training. -Staff members who had not completed that education would have been educated on a one-to-one basis. Interview on 7/25/24 at 3:09 p.m. with administrator A and DON B confirmed the PoC education was not completed by 7/23/24 as stated in the PoC's.

A. Based on observation, interview, and policy review, the provider failed to ensure: *As needed (PRN) medications stored in blister pack cards with pharmacist-determined expiration dates had been monitored for expiration and removed for destruction for three of three sampled residents (14, 22, and 31) in one of one medication cart. *Four of four medications had opened or expiration dates indicated, for three of three sampled residents (7, 15, and 33) in one of one medication cart. Findings include: 1. Observation, medication review, and interview on 6/20/24 at 11:38 a.m. with registered nurse (RN) N of one of one medication cart revealed: *PRN blister pack cards (medication cards) with expired medications for three residents (14, 22, and 31): -Resident 14's acetaminophen was dispensed from the pharmacy on 6/10/23 and expired on 6/8/24. -Resident 22's loperamide caplets were dispensed from the pharmacy on 9/14/23 and expired on 4/30/24. -Resident 31's acetaminophen was dispensed from the pharmacy on 4/5/23 and expired on 4/4/24. *Four of four medications had no opened date or expiration date stickers, for three of three sampled residents (7, 15, and 33): -Resident 7's two bottles of fluticasone propionate (nasal spray) were dispensed on 11/16/23. The bottles had no opened date or expiration date indicated. -Resident 15's Ozempic injection pen (for diabetes) had no opened date or expiration date indicated. -Resident 33's bottle of PRN fluticasone propionate was dispensed on 12/26/22. --The bottle had no opened date or expiration date indicated. Interview during the above observations with RN N revealed she confirmed: *Those medications were outdated and should have been removed from the medication cart. *The provider normally would mark the medications with an opened date. Review of the provider's undated Medication Storage In The Facility policy revealed: *Expiration dates of dispensed medications should be determined by the pharmacist at the time of dispensing. *Certain medications or package types, once opened, require an expiration date shorter than the manufacturer's expiration date to insure medication purity an potency. *Drugs re-packaged by the pharmacy staff would generally carry an expiration date as follows: -The pharmacist determines the exact date based upon a number of factors as well as applicable law or regulation. -Blister pack cards six months from the date of dispensing (when the manufacturer's expiration date is longer than six months). If the manufactures expiration date on the label will be the manufacturer's date. *When the original seal of the a manufacturers's is initially broken the container or vial would be dated. -The nurse should place a date opened sticker on the medication and enter the date opened and the new date of expiration '(note: the best stickers to affix containers both a date opened and expiration notation line) The expiration date of the container would be 30 days unless the manufacturer recommended another date or regulations/guidelines. *No expired medication would be administered to a resident. *All expired medications would be removed from the active supply and destroyed in the facility, regardless of amount remaining. *Disposal of any medications prior to the expiration dating would be required if contamination or decomposition is apparent. Nursing staff should consult with the dispensing pharmacist of any questions related to medication expiration dates. 49958 B. Based on observation, interview, and policy review, the provider failed to ensure prescription personal care products in one of one resident tub rooms were: *Securely stored in accordance with accepted professional principles. *Discarded when expired. Findings include: Observation on 06/20/24 at 8:34 a.m. of the cabinets in the tub room revealed they contained the following prescription products: *Two bottles of Selsun Blue shampoo with prescription labels. -One was resident 2's bottle and was dated 5/8/23. -One was a resident's who had been discharged from the facility on 1/16/24 and was dated 12/28/23. *One bottle of resident 11's prescription anti-itch lotion was dated 8/23/22 and had a manufacturer's expiration date of 3/24. *Two tubes of resident 16's prescription labeled Desitin (skin protectant). -One was dated 3/23/23, one was dated 3/2/24. *A bottle of resident 11's prescription labeled Nystatin (antifungal) powder dated 12/30/21 and had a manufacturer's expiration date of 3/23. Interview on 6/21/24 at 9:57 a.m. with MDS coordinator/RN C revealed: *She confirmed no staff worked that day who completed baths. *The items stored in the tub room were used during resident baths. *She was unaware that prescription items and expired items had been stored in the tub room. *She would have expected: -Prescription items to have been stored in the locked medication cart or the locked medication room. -Expiration dates on prescription products to have been monitored by the nurse on duty and discarded when expired.

Based on observation, interview, record review, and policy review, the provider failed to ensure three of three sampled residents (14, 23, and 174) who had developed pressure ulcers had been assessed, received care, on-going assessments, and interventions to prevent new ulcers from developing or prevent wounds from worsening. Findings include: 1. Observation and interview on 12/20/21 at 8:07 a.m. with resident 174 revealed: *He was lying on a pressure-reducing alternating air mattress in his room. *When asked if he had any skin problems, he replied he had sores on his bottom. Review of resident 174's electronic medical record (EMR) revealed: *He had been admitted to the facility on [DATE]. *His diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] -Cerebral infarction. -Unspecified disturbances of skin sensation. -Other Reduced Mobility. *An 11/30/21 nursing admission assessment indicated no pressure ulcer was present. *A 12/6/21 comprehensive skin and positioning evaluation did not identify a pressure ulcer. -No other skin evaluation had been completed. -The evaluation was locked and signed on 12/20/21 at 10:01 a.m. *A 12/6/21 Braden scale assessment revealed he was at moderate risk for skin breakdown. *A 12/11/21 Nursing Order identified an open area to coccyx [tail bone] measuring 9 centimeters (cm) by 8 cm. -Order summary for every day and night shift monitor every shift for dressing, drainage, wound bed, periwound area, pain, and status. *A progress note to the above order entered on 12/14/21 at 11:26 p.m. by licensed practical nurse (LPN) D clean, dry and intact. *A fax information sheet dated 12/16/21 at 2:49 p.m. to resident 14's physician. -Information: Resident has had a decline in overall function, he has developed an unstageable pressure wound to his coccyx, he has started to complain of more pain, and his wife feels like he is giving up. Wife and I discussed a hospice consult and she would like to proceed. -Request: OK to consult [hospice provider]. -It had been signed by director of nursing (DON) B. -Physician's Response: OK for Hospice. --It was signed by medical doctor (MD) on 12/17/21. *A Braden scale assessment dated for 12/17/21 had not been started. *A Fax Order Request - hospice in LTC [Long Term Care] standing orders. -He had been admitted to hospice on 12/17/21. -Skin care products/interventions of choice to prevent or treat skin care problems. -MD Signature was signed on 12/20/21. *Active physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . *No initial skin wound assessment was found. *No weekly skin or wound assessments were found. Review of resident 174's treatment administration records (TAR) revealed: *There had been many gaps with treatments related to the resident's 9 cm by 8 cm pressure wound since the identified start date of 12/11/21 at 6:00 p.m. *A current treatment plan for care was not identified. Interview with on 12/20/21 at 2:04 p.m. with DON B revealed: *She had worked for the provider for five years and had been in the DON position for the past two years. *She had monitored resident skin/wounds every week, but stated, I don't always get the paperwork done. *Resident 174's pressure ulcer was first noticed on 12/11/21 with his complaint of pain. -It had appeared suddenly. *She confirmed the 12/11/21 order was a nursing order. Interview on 12/21/21 at 8:27 a.m. with LPN D revealed: *The current treatment plan for resident 174's pressure ulcer was an Opti foam dressing. -It was part of out standing orders. *Resident 174's pressure ulcer was not healing but getting worse. *She was not sure if his physician was aware of his pressure ulcer. Interview with administrator A and DON B on 12/21/21 at 2:47 p.m. revealed and and confirmed: *DON B was the provider's wound care nurse. -Resident 174 did not have weekly skin assessments documented. -She had not been able to get to the weekly wound/skin assessments. -The nurse(s) working the floor was to communicate resident conditions to the residents' primary physician. *She could not confirm if resident 174's physician had been notified of his pressure ulcer. *Resident 174 did not have an initial wound assessment. -His pressure ulcer was not on his care plan. 2. Observation and interview on 12/20/21 at 9:59 a.m. with resident 14 in her room revealed: *She was sitting in her wheelchair in her room. *When asked if she had any skin problems, she replied she had a sore on her bottom that hurts a little at times. -The staff told her, it was getting better. Review of resident 14's electronic medical record (EMR) revealed: *She had been admitted to the facility on [DATE] on hospice care. *Her diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] -Cerebral Vascular Accident -[CONDITION(S)] -Immobility/Contractures -Urinary Incontinence *A 6/20/21 comprehensive skin and positioning evaluation did not identify a pressure ulcer. -The Braden scale assessment revealed she was at risk for skin breakdown. *An 8/30/21 comprehensive skin and positioning evaluation identified a pressure ulcer. - Stage 1 or greater. -The Braden scale assessment revealed she continued at risk for skin breakdown. *A Braden scale assessment dated [DATE] revealed she was at high risk. *A 12/11/21 nursing order identified a red/open area to the coccyx. -Red area measured 7 cm by 7 cm. -Open area to the center measured 4 cm by 4 cm. -Order summary for every day and night shift Monitor every shift for dressing, drainage, wound bed, periwound area, pain, and status. *A 12/12/21 skin/wound progress note by LPN F revealed: -Resident has open area to coccyx. -Dressing is soiled with yellow/tan drainage. -Wound measures 1.5 cm X 1 cm sacrum dressing applied. *A 12/14/21 Hospice communication at 6:30 p.m. by hospice registered nurse (RN) H revealed: -Pressure ulcer area to coccyx is now stage 2, shallow, deep purple around edges. -LPN D states they will start using [MEDICATION(S)] and continue to cover with [MEDICATION(S)] dressing. -Wound measured 1 cm by 1 cm. *A 12/17/21 hospice communication at 4:17 p.m. by hospice RN H revealed: -Cleansed coccyx wound with sterile saline, did not have wound cleanser, applied [MEDICATION(S)] and covered with [MEDICATION(S)]. -Wound measured 1.5 cm by 0.8 cm, oblong shape. *Active physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . *No initial wound assessment was found. *No weekly skin or wound assessments were found. Review of resident 14's TAR revealed: *There were three shifts with no documented treatments related to the resident's red/open area to coccyx since the start date of 12/11/21 at 6:00 p.m. *A current treatment plan was not identified. 3. Interview on 12/19/21 at 4:51 p.m. with resident 23 revealed: *She had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] *She tended to get sores on the back of her legs. *She currently had a sore on the back side of her right thigh that was caused by rubbing against a metal piece on her wheelchair. *She could not remember when the area had opened, but thought that it had been sometime in September 2021. *The provider had added padding and adjusted her wheelchair to eliminate further issues. *Nursing put bandages on the area every day. *The facility had recommended she get a new wheelchair but she wanted to keep the one she had. Review of resident 23's medical record revealed: *An admitted [DATE]. *Her diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . *She had a Brief Interview Mental Status (BIMS) score of fifteen indicating her cognition was intact. *A 12/1/21 Braden Scale assessment score of 14 which put her at moderate risk of skin integrity issues. *A 12/10/21 MDS nursing summary had not identified the open area on her thigh. *A 12/16/21 care conference review note that mentioned she had an open area on the back of her right thigh. *There had been no documentation to support: -Her physician had been notified of the pressure ulcer she had developed. -When that pressure ulcer had been discovered or by whom. Review of resident 23's 12/1/21 Minimum Data Set (MDS) assessment revealed: *She had been at risk for developing pressure ulcers. *No pressure ulcers had been identified. Review of resident 23's 12/10/21 revised care plan revealed: *A focus area for skin impairment potential due to immobility and diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . *Interventions for: *4 inch x 4 inch [MEDICATION(S)] dressings placement to bilateral thighs where the wheelchair meets thighs at her request to provide cushioning. *Observe skin during cares. Report any changes to nurse. Surveyor 4. Observation on 12/21/21 at 10:41 a.m. with certified nurse practitioner (CNP) G assessing resident 23's skin revealed: *CNP G had been nearby and able to come to the facility if the need to assess a resident came up and the primary physician was not available. *This had been the first time she had been made aware of the need to assess resident 23 for a pressure ulcer. *The resident had an open area on the back side of her right thigh that measured 2 centimeters in length through the epidermis (outer layer of skin) . Interview on 12/21/21 at 1:33 p.m. with bath aide H regarding resident skin assessment with bathing revealed she: *Had just returned from a three week absence. *Was the person that had completed most of the baths for the residents. *Checked the residents closely for any skin concerns. *Reported any skin concerns to the nursing staff. *Had not been required to document any skin findings. *Was not sure when resident 23's sore had opened up but it had been there prior to her absence. Interview on 12/21/21 at 2:00 p.m. with licensed practical nurse (LPN) C and LPN D regarding skin documentation revealed: *They had been aware of the above resident skin concerns. *Due to scope of practice concerns they had not assessed the wounds. *They had reported any resident skin concerns to DON B for further assessment. *Confirmed they had not documented skin findings. Surveyor Interview on 12/21/21 at 2:48 p.m. with DON B and administrator A regarding resident skin and wound assessment revealed: *DON B stated she: -Had been responsible for the wound care for all residents. -Had not ensured weekly skin assessments or wound assessments for the above residents had taken place. -Had not considered resident 23's wound to be a pressure ulcer. -Thought her skin injury had been cause by sheering and not pressure at the time. -Agreed that rubbing from a metal piece on her wheelchair had caused the injury. -Would expect: --Newly admitted residents to have a comprehensive skin assessment and then on a quarterly basis. --All residents' skin was to be assessed during weekly bathing by the bath aide. --Any concerns discovered by the bath aide were to be reported to the nurses. --The nurses would report any skin concerns to the resident's primary physician for further instruction. --Agreed that documentation had been lacking regarding weekly skin assessments and wound assessments. --Confirmed they had not followed their policy for skin and wound care. *This surveyor asked for any documentation that would support skin assessment or wound assessments had taken place for resident 23. No further documentation had been provided prior to the survey exit. Review of the provider's 10/15/21 Pressure Ulcer Prevention policy revealed: It is the policy of [facility name] to prevent a resident who enters the facility without pressure sores from developing pressure sores unless the individual's clinical condition demonstrates that they were unavoidable and to provide necessary treatment and services to a resident having pressure sores to promote healing, prevent infection and prevent new sores from developing. Procedure: 1. Skin checks/assessments to be completed weekly (likely following bath schedule) for each resident within the skilled nursing facility. Initial skin assessment to be completed and documented upon admission, with skin assessments continuing weekly thereafter. 2. Any identified new skin injury/wound shall be reported to the charge nurse on duty. Nursing will then complete an evaluation of the injury inclusive of wound measurements. Nursing staff will report the skin injury/wound to the designated wound nurse. An initial wound assessment (UDA) [user defined assessment] will be started in [name of facility computer program] under the assessment tab by the wound nurse (charge nurse to complete if wound nurse unavailable) and continue weekly until healed. A nurse progress note should accompany each wound UDA completed. 3. Charge nurse will notify the physician of skin injury/wound when discovered and obtain any treatment orders recommended. The skin injury/wound will be treated according to physician orders. If there is no order, the skin injury/wound will be placed on the ETAR [electronic treatment administration record] to be monitored daily until healed. 4. If the cause of the skin injury is unknown at the time of the occurrence, an incident report (risk management) shall be completed by the nurse completing the skin assessment. Nursing management or DNS [director of nursing services] will complete an investigation within facility to determine the cause of the skin injury. If the cause of the skin injury is not determined, the proper course of action will be taken by guidelines of Reporting of Injuries of Unknown Source and Reasonable Suspicion of a Crime form. 5. Document in the nurse's notes the following information: *Mechanism of skin injury/wound if known or applicable [if determined after investigation, complete a follow up note with unknown cause found]. *Size of injury. *Treatment if applicable. *Notification of family and physician. 6. Include new skin injury in daily nursing report. 5. A review of the provider's undated Director of Nursing job description revealed: *Essential duties included: -Assures that there is compliance with the regulations pertaining to care plans and resident assessments. -This person monitors the quality of care provided and assists in the assessment process for admission to and exit from all units.