Every finding on record at Dow Rummel Village

Based on South Dakota Department of Health (SD DOH) Facility Reported Incident (FRI), record review, interview, and policy review, the provider failed to ensure an environment free of accident hazards and supervision when the staff did not complete hourly safety checks according to the provider's policy and left a resident's bed in an elevated position for one of one sampled resident (1) who was not checked on for four hours and subsequently fell out of bed onto the floor and sustained a laceration to her left hand that was sutured in an emergency room.Findings include: 1. Review of the provider's 4/17/26 SD DOH FRI, revealed that on 4/16/26, resident 1 was found lying on the floor in her room at approximately 9:00 a.m. There was blood all over the floor, and to her bilateral [both] hands and right arm. She was bleeding from a skin tear to her left hand, a potential head injury, complaints of back pain, and a swollen right knee. She was transferred to the hospital emergency room (ER) for evaluation. Resident 1 returned to the facility on 4/16/26 with the laceration to her left hand sutured and a cock-up wrist splint [a rigid brace designed to hold the wrist in a neutral position] to be applied.The provider's investigation as documented on the SD DOH FRI revealed that the staff last checked on resident 1 on 4/16/26 at 5:00 a.m., and that her bed at the time of the incident was found in an elevated position. The provider's FRI did not indicate why resident 1 was not monitored by staff members for approximately four hours or why her bed was in an elevated position. Following this incident, a scoop mattress (specialized medical or care-facility mattress designed with raised edges and a lower center) was provided to the resident for border definition. Caregiver staff members present during that shift were educated on end-of-shift rounding (checking on residents' status and assistance needs) expectations with the oncoming staff members, and further staff education was to be provided on 4/22/26. There was no documented indication that audits were performed after resident 1's fall.2. Review of resident 1's electronic medical record (EMR) revealed she was admitted to the facility on [DATE]. Her 2/4/26 Brief Interview of Mental Status (BIMS) assessment score was a 5, which indicated she had severe cognitive impairment. Her diagnoses included difficulty in walking, weakness, and osteoarthritis (gradual breakdown of the joint).Resident 1's 2/4/26 Minimum Data Set (MDS) assessment (a tool used to evaluate a resident's health status and to develop an individualized care plan to manage the resident's care needs) indicated she was dependent on staff members for all of her care needs. She used a wheelchair and had impairment (difficulty with moving joints, feeling sensations, or gripping objects) on both sides of her upper body. While in bed, she required substantial assistance to roll from lying on her back to the left and right side.Resident 1's 6/10/26 care plan had a 2/2/26 dated focus area that indicated she had an activities of daily living self-care performance deficit with limited mobility and weakness. The 3/26/26 revised interventions for that focus included that resident 1 needed substantial assistance by one staff member to turn and reposition in bed, needed 2 staff members and a mechanical lift to transfer from one area to another. A 3/26/26 focus area indicated that she was at a low risk for falls related to her being unaware of her safety needs, and her total dependence on staff members for transfers. The 3/26/26 interventions included anticipate and meet my needs.A 4/16/26 nurses' progress note revealed that on 4/16/26 resident 1 had an unwitnessed fall with blood all over the floor, her bilateral hands and right arm. Her left hand was noted to have significant bleeding, open to the top of the hand near the knuckle. Measured the area after cleansing it: 7.1 cm [centimeters] X [by] 1.5cm X 0.5 cm. Resident 1 was sent to the emergency room for treatment and returned to the facility on 4/16/26 at approximately 3:40 p.m. with a black brace on her left hand. The nurse's progress note indicated that she had ten sutures on her left hand.Her 4/20/26 nurses' progress notes revealed the interdisciplinary team reviewed resident 1's fall and implemented a scoop mattress on her bed for her safety.Resident 1's 4/16/26 ER notes included that there was an X-ray of her left hand that did not reveal a fracture. There was a laceration of her left dorsal (back of the) hand that spanned the mid-dorsal hand (over the knuckle joint) to the proximal phalanx (over the base of the finger). Her head and cervical spine were evaluated, and there were no acute findings. Resident 1 was discharged back to the facility at 3:38 p.m. in stable condition with sutures to her left hand laceration and a hand splint.3. Interview on 6/10/26 at 1:41 p.m. with assistant director of nursing (ADON) B regarding resident 1's incident on 4/16/26 revealed she reviewed the 4/16/26 video camera footage from 7:08 a.m. through 9:05 a.m. of the hallway where resident 1's room was located. She confirmed, through video footage and her investigation, that resident 1 was last checked on by a staff member at approximately 5:00 a.m. ADON B indicated resident 1's incident was an unwitnessed fall, her bed was higher than it should have been, and that she did not investigate why the bed was that high at the time of resident 1's fall. ADON B indicated that resident 1 is not one who normally attempted to get out of bed on her own, but she may have rolled over and fell out of her bed. Resident 1 needed the use of a full body lift (a mechanical lift and sling used to lift a person's full body) for getting out of bed at the time of her 4/16/26 fall.ADON B stated that staff members were to visually observe all residents at least once per hour to ensure their safety. She stated that she educated the staff members working on 4/16/26, which included ensuring walking rounds were completed during the staff member's change of shift. She indicated there was no documentation of that education. On 4/22/26, ADON B conducted an all-staff meeting education that included the staff were to ensure walking rounds were completed during the change of shift. The change of shift occurred at approximately 6:00 a.m., when the day staff members were coming on duty and the night shift staff members were going off duty. The day shift staff members and night shift staff members were to visually check on each resident, together, before the off-going staff member left. ADON B expected resident 1 to be checked on at a minimum of two hours. She acknowledged the provider's policy was for each resident to be checked on every hour.4. Interview on 6/10/26 at 2:40 p.m. with registered nurse (RN) C regarding resident 1's unwitnessed fall on 4/16/26 revealed she was working the morning of 4/16/26. After resident 1 was found in her room by certified medication aide (CMA) D, RN C stated that he indicated he was not able to see her at the start of his shift, and had not seen her until he found her on the floor around 9:00 a.m. CMA D did not explain to RN C why he was not able to see resident 1 until 9:00 a.m.RN C stated that when she entered resident 1's room, her bed was waist-high, and moved to the right, away from the window. She was between the wall and bed, [CMA D] had moved her bed, so she wasn't squished in there. Resident 1's left hand had a skin tear, and there was lots of blood. Resident 1 was evaluated by RN C. Her family and physician were notified, and resident 1 was transferred to the ER. RN C was unable to recall any incident or staffing issues that would have resulted in resident 1 not being checked on for approximately four hours.5. Interview on 6/10/26 at 3:42 p.m. with administrator A and ADON B revealed that every Monday morning, the interdisciplinary team (group of people with different skills and specialties who work closely together to solve a complex problem or care for a person] met, reviewed the resident falls that had occurred the previous week, and discussed if any new interventions were needed to be implemented to prevent further falls for those residents.ADON B confirmed that on 4/16/26, resident 1's bed was in an elevated position. She stated that staff members would raise the bed when providing the resident personal care while they remained in bed, and those staff members would often forget to lower the bed when the care provided was completed. Resident 1's scoop mattress was implemented on 4/20/26.ADON B indicated she had completed audits through observation to ensure the beds were maintained at the correct height. She confirmed there were no audits related to staff members completing rounds before leaving their shift.6. CMA D was no longer employed by the provider at the time of the survey and was unavailable for interview.7. Review of the provider's January 2026 Resident Call System and Hourly Safety Checks policy revealed, Staff are required to respond promptly to all call lights and complete required hourly safety checks. Hourly Safety Checks. Visually confirm the resident's presence and safety.Review of the provider's March 2025 Fall Prevention and Post Fall policy revealed, nurse's notes should include the following information: New fall intervention implemented to prevent the recurrence of falls. The healthcare team will discuss the residents' [resident's] fall at the next fall's [fall] review and agree on at least one new intervention for the resident's fall risk care plan.Review of the provider's January 2025 Abuse Prevention, Intervention, Reporting, and Investigation policy revealed, Neglect is defined as failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness. May be intentional[,] such as withholding or omitting care[,] or unintentional where the caregiver should have known that care was needed, but it [was] not provided.

Based on observations, interviews, and policy review, the facility failed to ensure the staff followed infection prevention standards to prevent the spread of infection. * One of two rooms had mechanical lift slings touching the floor when not in use. * One of four dirty linen rooms had used incontinent brief dispose of improperly. * Six of seven dirty linen and trash can lids on west hall were left open. * One of two nebulizer (a device that converts liquid medication into an inhalable mist) tubing observed lying on the floor in a resident's 5 room. * One of one whirlpool (heated pool in which hot water is continuously circulated) belt was touching the floor when not in use. * Two of four EZ stands (mechanical lift device) were improperly cleaned or disinfected after use. * One of four clean linen rooms had linens stored improperly. Findings Include:1. Observation on 1/6/26 at 9:03 a.m. in the west hall in the PPE (Personal Protective Equipment) storage room revealed five slings were hanging from hooks and touching the floor. 2. Observation on 1/6/26 at 9:05 a.m. in the west hall dirty hopper (a specialized sink flushing device used to rinse soiled items and linens of body fluids) room revealed:*There was a used incontinent brief sitting on top of the trash can lid.*Total of three trash bin lids were left open. 3. Observation on 1/6/26 at 9:10 a.m. in resident 5's room revealed nebulizer (a device that converts liquid medication into an inhalable mist) tubing was lying on the floor behind the resident's chair. 4. Observation on 1/6/26 at 9:16 a.m. in the west hall Whirlpool room revealed:* The whirlpool (heated pool in which hot water is continuously circulated) tub seat belt was hanging from the whirlpool and touching the floor.* Total of three dirty linen and trash bin lids were left open. 5. Observation on 1/6/26 at 11:02 a.m. in the west hall revealed an EZ stand (a mechanical lift used to assist from a seated to a standing position) or (a mechanical lift and sling used to lift a person's full body) had food debris on the footplate. 6. Interview on 01/06/2026 11:04 a.m. with certified medication aide (CMA) J revealed:*The EZ stand is to be cleaned after each resident and that would include the knee pad, footplate and arms of the machine.*The whirlpool tub belt should not touch the floor. 7. Observation on 1/6/26 at 11:13 a.m. in the north hall clean linen storage room revealed clean privacy curtains were spilling out of a broken cardboard box onto the floor. 8. Observation on 1/8/26 at 11:45 a.m. in the west hall was an EZ stand noted to have food debris on the footplate. 10. Observation on 1/8/26 at 11:47 a.m. in the north hall was an EZ stand noted to have food debris on the footplate. 11. Interview on 1/8/26 at 11:36 a.m. with CMA I revealed:*Soiled incontinent briefs were to be placed in a trash bag. That bag should be closed and then placed in the garbage bin in the hopper room.*Oxygen and nebulizer tubing should not be touching the floor.*Catheter urine collection bags should be covered at all times for dignity and infection reasons.*She agreed that mechanical lift slings are not clean when touching the floor. 12. Interview on 1/8/26 at 12:29 p.m. with assistant director of nursing (ADON)/infection preventionist (IP) C revealed:*Incontinence briefs should be placed in a garbage bag and disposed of by placing the incontinence brief in a closed bag and then placing it in a trash bin.*Oxygen tubing and nebulizer tubing should not touch the floor.*She agreed that mechanical lift straps should not touch the floor.*EZ stands were to be cleaned after each resident's use. 13. Review of the providers 3/5/13 Restorative Equipment Cleaning policy revealed:* It shall be the policy of Dow [NAME] Village that all restorative equipment and supplies that are used for more than one resident be cleaned and sanitized in between each resident use.* Following resident use of any equipment or supplies, cleaning and disinfecting must be done before the same piece of equipment may be utilized by another resident. 14. Review of the providers 10/4/13 Disposal of Incontinence Products policy revealed:* To ensure a safe environment Dow [NAME] Village has established guidelines for managing and disposing of incontinence products. Incontinence products may include but not limited to disposable diapers (briefs), incontinence pads, panty shield products, sanitary pads, tampons and/or disposable wipes. If appropriate should use reusable products. When disposable items are used, emphasis should be placed upon the use of biodegradable items.- 2. The disposable incontinence products should be placed in a waste receptacle that will be located in the bathroom or toilet area.- 4. If the waste is non-hazardous, and appropriately bagged and sealed, it can be disposed of with normal waste products (regular garbage containers). 15. Review of the providers' November 2023 revised Laundry and Linens policy revealed:* Any clean items that come in contact with soiled items or soiled PPE will be considered contaminated.* All clean laundry and linens will be handled in a manner that prevents contamination. 16. Review of the providers' April 2024 revised Infection Control & Prevention policy revealed:* To provide a safer and healthier community through the prevention of infection.* 9. Maintain equipment in safe and sanitary condition.* b. Follow policy for garbage and laundry handing.* c. How and when to use standard precautions, including proper hand hygiene practices and environmental cleaning and disinfection practices.* f. Proper infection prevention and control practices when performing resident care activities as it pertains to staff roles, responsibilities and situations.

Based on observation, interview, and policy review the provider failed to ensure chemicals were stored safely away from resident' for: *One of one beauty shop.*One of four hopper rooms. *One of four eye-wash rooms. Findings include: 1. Observation on 1/6/26 at 9:16 a.m. of the beauty shop in the west hall revealed: *The room was unattended, and the door was unlocked. *A half bottle of Barbicide (disinfectant concentrate) was sitting on the counter by the sink. *A opened box of Ship shape powder (a multi-purpose cleaning powder) was sitting on counter by sink. *The door was to be locked when not in use. *Several residents are sitting outside the beauty shop watching tv currently. 2. Observation on 1/6/26 at 10:51 a.m. of east hall hopper room revealed: *The door was not locked. *A unlocked cupboard had signage on it that said the cupboard was to be always locked. *That unlocked cupboard had one container of Foamy Q & A acid disinfectant cleaner, one Consume odor eliminator (cleaner used to breakdown organic waste such as urine and feces) bottle, one Difference multipurpose cleaner bottle, and one Lysol disinfectant spray bottle inside of it. *Several residents walk by the door on the way to dining room for meals. 3. Interview on 1/6/26 at 9:41 a.m. with registered nurse (RN) D revealed the beautician was at the facility two to three times a week. RN D was unsure if the beauty shop door should be locked. 4. Interview on 1/6/26 at 9:42 a.m. with assistant director of nursing (ADON)/infection preventionist (IP) C revealed: *The beauty shop door should be locked when no one is in it. *She agreed that the chemicals were sitting on the counter and not locked up and should have been. 5. Interview on 1/6/26 at 10:56 a.m. with housekeeper O revealed: *Housekeeping carts were to be locked when unattended or not in use. *The cupboard in the east hall hopper room was supposed to always be locked. *The cupboard was not locked because the key was bent. *When asked who she notified when something was broken she stated, she would notify ADON/IP C it was not lockable and the key was broken. 6. Follow-up interview on 1/6/26 at 11:00 a.m. with assistant director of nursing (ADON)/infection preventionist (IP) C revealed: *The outside door to the east hall hopper room door was never locked. *The cupboard inside the room where chemicals were stored was to always be locked. *She was unable to get the lock to work. 7. Observation on 1/6/26 at 11:14 a.m. of north hall eye-wash room revealed: *The door was unlocked and a housekeeping cart was inside that room. *That housekeeping cart was unlocked and contained: -A bottle of BNC 15 (a disinfectant). -A bottle of Sparkling glass cleaner. -A spray bottle labeled with 50% bleach [50 percent] and 50% water. -On bottle of Difference brand multipurpose cleaner. -One bottle of Damp mop cleaner. -A bottle of Clean by Peroxy (hydrogen peroxide-based all-purpose cleaner). *A bottle of [NAME] hardwood floor cleaner was sitting on a shelf inside that room. 8. Observation on 1/8/26 at 8:24 a.m. north hall eye-wash room revealed: *The door was unlocked. *The housekeeping cart was still inside, was unlocked and contained the same chemicals as observed on 1/6/26. *Residents pass the room on the way to the dining room. 9. Review of the provider's revised October 2024 Cleaning policy revealed: *To provide a safe, clean, comfortable and homelike environment. -Chemicals on carts must be locked up when the cart is not visible to housekeepers and/or nursing staff at all times. -Carts must be stored in a locked room. 10. Review of the provider's 3/5/13 Restorative Equipment Cleaning Policy revealed Sanitizers and disinfectants will be kept in a secure area out of resident reach and locked up whenever staff is not in attendance.

Based on observation, interview, record review, and policy review the provider failed to ensure the staff followed food safety standards to ensure:*Open perishable food items were discarded once they had surpassed the five-day shelf life according to their policy in one of one walk-in cooler.*Ventilation covers were on a cleaning schedule and maintained to prevent dust and lint buildup from circulating over food preparation and cooking surfaces in one of one main kitchen. Findings include: 1. Observation and interview on 1/6/26 at 9:00 a.m. in the main kitchen with culinary licensed supervisor (CLS) M revealed:*A sign on the walk-in cooler door stated:-Shelf Life.-Leftovers 5 days.-ready to eat 5 days.-Raw foods (after thawed) 5 days.*Inside the walk-in cooler on separate shelves there was:-An open package of American cheese slices wrapped in cling wrap dated with a hand written date of 12/20.-An opened plastic container of fruit cocktail dated 12/03.-Three flats of fresh strawberries dated 12/31/25.--Eight of those containers of strawberries had mold growing on the strawberries.*In the main kitchen four vents had heavy dust built up on the edges of the vents.*The vents were blowing air towards a food preparation (prep) table and the stove top.*CLS M stated that: -There was a 5-day open package policy for leftover foods.-The American Cheese should have been discarded.-She thought the fruit cocktail was mislabeled and should have been 1/03 and not 12/03 but could not prove that.*CLS M confirmed some of the strawberries had mold on them and should have been thrown out.*She agreed the vent covers had dust on them and should have been cleaned because they were blowing air over the food prep table and stove top.*She stated the dietary department staff were to clean food service areas according to weekly cleaning schedules.*She was unsure who was responsible for cleaning the vent covers. 2. Observation of the main kitchen and walk-in cooler on 1/7/26 at 11:19 a.m. revealed:*The American cheese, fruit cocktail, and strawberries had been removed from the walk-in cooler.*The vent covers remained in the same condition observed above with dust and lint on them. 3. Interview on 1/7/26 at 11:26 a.m. with director of building services (DOBS) N regarding the vent covers in the main kitchen revealed he:*Agreed there was dust and lint built up on the vent covers.*Thought the dietary department staff cleaned them.*Confirmed those vent covers were not part of the contracted oven hood cleaning service that was completed twice a year. 4. Interview on 1/8/26 at 11:34 a.m. with certified dietary manager (CDM) K and director of culinary services (DOCS) L revealed they:*Expected staff to remove expired and past use by date food items from the walk-in cooler.*Agreed the cheese slices, fruit cocktail, and strawberries should have been discarded.*Confirmed the vent covers in the kitchen were not on a cleaning schedule. 5. Review of the dietary department's weekly cleaning assignments confirmed the vent covers were not included on the cleaning schedule. 6. Review of the provider's 2013 Food Safety and Sanitation policy revealed:*Perishable ingredients are refrigerated when they are not being used.*All time and temperature controls for safety (TCS) leftovers are labeled, covered and dated when stored. They are used within 72 hours (or discarded).*Note: ServSafe guidelines allow 7 days for food safety with the day of preparation counted as day 1 of the 7 days, and then food is discarded. Check your local and state regulations and determine which guidelines your facility will follow.*Foods with expiration dates are used prior to the use by date on the package. 7. Review of the provider's 2013 Cleaning and Sanitation of Dining and Food Service Areas policy revealed:*The food service staff will maintain the cleanliness and sanitation of the dining and food service areas through compliance with a written, comprehensive cleaning schedule.

Based on review of the South Dakota Department of Health (SD DOH) Facility-Reported-Incident (FRI), interview, record review, observation, and policy review, the provider failed to ensure one of one resident (1) had not received incorrect medications, which led to the resident vomiting, requesting a transfer and evaluation at the local emergency department, and anxiety related to medication administration.Findings include:1. Review of the provider's 10/29/25 final FRI submitted to the SD DOH revealed that on 10/29/25, certified medication aide (CMA) D administered medications to resident 1 that were prescribed for resident 2. CMA D recognized that she had given the medications to the incorrect resident and reported it to licensed practical nurse (LPN) H, who was the charge nurse on duty at the time. The provider contacted their telemedicine service who recommended to monitor resident 1's vital signs and blood sugar levels. Approximately one hour later, a different staff member reported to LPN H that resident 1 had an emesis (vomiting). LPN H contacted the telemedicine service again to report that resident 1 had symptoms of nausea/vomiting, diarrhea, being light-headed, and appeared worked up [and was] worried about receiving the wrong medications. Resident 1 was transferred by ambulance to a local emergency department for evaluation. She returned to the facility later that evening. Assistant director of nursing (ADON) C completed and submitted the final report to the DOH. CMA D was removed from performing medication administration while the investigation was completed. When interviewed by ADON C, CMA D reported that she had prepared the medications for administration for resident 2. She followed resident 2 and another staff member into the dining room. At that time, CMA D mistook resident 1 for resident 2 and gave resident 2's prepared medications to resident 1 by mistake. CMA D recognized her mistake when she looked at the room number and name on the inhaler for resident 2 and reported her error to LPN H. Before CMA D resumed medication administration duties, ADON C reviewed the medication administration policy with her, observed her for four hours while performing medication administration, and completed the Medication Administration Clinical Skills Checklist from the South Dakota Board of Nursing website. After the error occurred, resident 1 requested that the medication aides pop out the medications in front of her so she could verify the medication she was being given, and the facility complied with that request. 2. Review of resident 1's electronic medical record (EMR) revealed that she was admitted on [DATE]. She had the following diagnoses: Left pelvic fracture, Paroxysmal Atrial fibrillation (short episodes of irregular heartbeats), Type 2 Diabetes Mellitus (T2DM) with diabetic chronic kidney disease (a condition involving disruptions in how the body regulates blood sugar, with associated kidney function issues), and Occlusion and stenosis of unspecified carotid artery (arrowing or blockage of one or both carotid arteries in the neck). On the morning of 10/29/25, resident 1 received the following medications in error: Aspirin (a nonsteroidal anti-inflammatory drug), Budesonide (a corticosteroid), Calcium citrate (a calcium supplement), Vitamin D3 supplement, woman's multivitamin supplement, diltiazem (used to relax and widen blood vessels), Jardiance (used to treat diabetes), Metoprolol (used to treat high blood pressure), Miralax (a laxative), Pantoprazole (used to treat acid reflux), Pioglitazone (used to treat diabetes), Pravastatin (used to treat high cholesterol), Senna (a stool softener), Gabapentin (used to treat nerve pain), and Venlafaxine (used to treat anxiety and depression). After receiving the above medications in error, her vital signs were measured, and the on-call provider was notified. The on-call provider ordered for the staff to monitor her vital signs and blood sugar checks every four hours for 24 hours. Resident 1 was assisted back to her room after breakfast and was informed of the medication error. She denied feeling nauseous, dizzy, short of breath, or lightheaded. At around 9:15 a.m. on 10/29/25, resident 1 had an episode of emesis (vomit). Her vital signs were measured again, and resident 1 reported feeling nauseous and lightheaded. Another 10/29/25 nursing note indicated the Resident appeared worked up worried about receiving the wrong medications. Resident 1 requested to go to the local emergency department for evaluation. Another 10/29/25 nursing progress note indicated Received call from [hospital emergency department] Dr. [name redacted] she reported resident is doing much better. [Resident 1's] nausea and dizziness are resolving.Dr. also reported her speech is better resident was [complaining] that she had lost her [voice,] but her speech was clear. Provider [the doctor] said she was possibly having a dissociative reaction. 3. Interview on 11/12/25 at 2:58 p.m. with CMA D revealed that on the morning of 10/29/25, she had prepared resident 2's morning medications. Resident 2 usually ate breakfast in her room, so she prepared the medications and went walking to find the resident. She found resident 2 and another CNA at the ice machine and followed them both to the rehab dining room. Upon entering the rehab dining room, resident 1 was already seated at a table and greeting CMA D good morning. CMA D said that my brain got switched up and she mistakenly administered resident 2's medications to resident 1. She realized her mistake when she looked at resident 2's inhaler label. She did not administer resident 2's inhaler to resident 1. She notified the nurse immediately after she recognized her mistake. After that, she continued to prepare medications for a couple more residents until ADON C moved her from the medication administration duties to certified nursing assistant (CNA) duties. CMA D could not remember which other residents she gave medications to that morning after the medication administration error. CMA D confirmed that ADON C reviewed the medication administration policy with her before she was allowed to pass medications again. CMA D confirmed that ADON C followed her for several hours one morning to observe her passing medications before she could perform medication administration duties independently again. 4. Interview on 11/12/25 at 3:30 p.m. with resident 1 revealed that she admitted to the nursing home due to a fall that resulted in a fractured pelvis. She expressed no concerns with her care but then stated there was a medication problem because she was given another person's medications. She felt bad that she had not asked questions at the time she was given those medications. The staff knew right away that they were not her medications, and she vomited shortly after. She said she was very upset about it and the staff offered to bring the medication cards to her so that she could verify for herself that it was her correct medications before they removed medications from the medication card to administer to her. She said they still did that. 5. Interview on 11/12/25 at 3:38 p.m. with CMA E revealed that she was aware of the medication error that had occurred on 10/29/25 with resident 1. She was not educated about the incident, the medication administration policy, or other medication administration topics after the incident. When asked about the six rights to medication administration as listed in the provider's policy, CMA E was able to list four of the six rights. 6. Interview on 11/12/25 at 5:01 p.m. with ADON C revealed that LPN H informed her immediately of the medication error with resident 1 on the morning of 10/29/25. She went to speak with CMA D to learn about what happened. She reassigned CMA D to work as a CNA while she conducted the investigation of the error. She had CMA D write down exactly what happened with the error for resident 1. She confirmed that they had not educated all the other staff who administered medications about the incident yet, and there was no other monitoring or auditing of medication administration other than the four hours she spent with CMA D on the morning of 11/4/25. The CMAs were scheduled to complete their annual medication administration refresher training by the end of the calendar year. 7. Interviews on 11/12/25 at various times with several residents and family members revealed no concerns with the care that staff provided or medication administration. 8. Observations on 11/13/25 from 7:44 a.m. to 8:34 a.m. of CMAs E and F revealed no concerns with their medication administration practices. 9. Observation and interview on 11/13/25 from 7:45 a.m. to 8:30 a.m. with CMA F revealed that she had heard about the medication error on 10/29/25 from other staff members, but did not work that day. She completed a 20-hour medication aide class and test about two years ago and had received annual education assigned to her online last year. Most information was received through 1:1s (individual meetings) with ADON C. No additional education was received after the 10/29/25 medication error. She learned the six rights of medication administration and was able to list them. 10. Interview on 11/13/25 at 8:38 a.m. with CMA E revealed that there was no formal education regarding medication administration after the 10/29/25 medication error occurred. She learned about the incident because she was working that day but did not hear about much else about it. CMA E indicated that ADON C hovered over us while they were performing medication administration that day on 10/29/25, but there was no formal conversation or discussion about how to administer medications correctly to residents to prevent a medication error. 11. Interview on 11/13/25 at 9:14 a.m. with LPN G and CMA F revealed that they both confirmed that there was no recent education provided regarding the correct procedures for medication administration to prevent medication errors. LPN G was not aware of the 10/29/25 medication error that occurred with resident 1. At times when there was new education, DON B would print out an email or a policy and requested staff to review and sign to indicate they understood the material. There was no education like that recently. 12. Interview on 11/13/25 at 10:06 a.m. with administrator A revealed that he was informed of the medication error for resident 1 on 10/29/25. He confirmed he was not involved in the investigation or corrective actions, but DON B kept him informed of the situation. To protect resident 1, they contacted the telemedicine service provider for assessment and further orders. They sent resident 1 to the emergency department upon her request. To protect the other residents, they removed CMA D from medication administration duties until they could reeducate her and deem her competent to perform medication administration safely. As part of an investigation, he expected all parties to have been interviewed, not only from other staff members, but residents too. He expected that a quick huddle with all staff in charge of medications about protocol on how we do it [medication administration] should have been completed. When asked about his expectations for documenting education and auditing, he stated, I'd prefer more documentation than less. I always remind people that we can say we did all this stuff, but it's hard to prove that we did it. He stated that it probably would be a good idea to go through that [the medication administration education] with everybody. The leadership team had planned on including that information at their next nursing staff meeting. He confirmed that he did not know if the monitoring process was documented, but the nursing management team made more of a presence on the floor after the medication error incident. 13. Interview on 11/13/25 at 10:44 a.m. with DON B revealed that he was notified on the 10/29/25 medication error for resident 1 by ADON C, and he asked ADON C to complete the investigation and follow-up. He did not review the FRI report before it was submitted to the SD DOH, but he thought the investigation was adequate. He stated that CMA D was immediately removed from administering medications and ADON C met with her to get her report on the event. CMA D was required to complete a 4-hour competency review with ADON C accompanying her as she administered medications and successfully completed the South Dakota Board of Nursing Medication Administration Clinical Skills Checklist on 11/4/25. CMA D was then allowed to return to medication aide duties. CMA D was now primarily scheduled to work on the long term care nursing home areas. He explained that during the investigation, they learned that a cultural aspect made it difficult for CMA D to ask people who they were, so they felt it would be better for her to be assigned to the long term care nursing home units because there was less resident turnover than the rehabilitation unit. DON B agreed that the 10/29/25 medication error was a high-risk event and a significant medication error. When asked how all residents were protected, he responded by saying that making sure CMAs aides had an understanding of the correct [medication administration] process. He felt the CMAs did understand that process when they implemented a primary medication aide model in July and extensively interviewed the CMAs to determine their medication administration competency. Because they had done that and were in the process of incorporating additional annual training before the 10/29/25 incident, they did not provide any medication administration education with any staff other than CMA D after that incident. He stated that ADON C had talked to the nurses at the shift-to-shift report, but he did not have any expectations of the charge nurses to monitor medication administration. They had not completed any formal medication administration audits. He said ADON C had talked to some of the CMAs but did not document those conversations or who they were with. The annual online medication administration training was assigned to the CMAs on 11/11/25 with a 30-day completion requirement. They had not considered assigning the education to licensed nursing staff as well. 14. Review of the provider's nursing staff schedule from 10/29/25 to 11/6/25 revealed that CMA D was removed from the CMA schedule on 10/29/25. She was transferred to work as a certified nursing assistant (CNA). She continued to work as a CNA on 10/30/25, 10/31/25, 11/1/25, and 11/3/25. She was reassigned as the medication aide on the morning of 11/4/25, where ADON C was paired with her from 6:00 a.m. to 10:00 a.m. She continued working as a CNA for the rest of her shift on 11/4/25, 11/5/25, and 11/6/25. From 11/8/25 to the current schedule at the time of the survey, she was scheduled in both the CMA and CNA roles. 15. Review of the provider's January 2025 Abuse Prevention, Intervention, Reporting, and Investigation policy revealed appropriate steps were taken for investigation and reporting. The policy contained no directions for staff education or follow-up monitoring. 16. Review of the provider's medication administration policy revised November 2025 revealed that the purpose was to ensure safe, accurate, and documented administration of medications and treatments to residents within our facility. By establishing clear procedures for medication administration records (MARS) and treatment administration records (TARs), this policy aims to safeguard against errors and ensure compliance with physician orders. The oral administration of medications procedure listed steps including Identify resident, and Administer the medication to the resident utilizing the 6 rights that include[d] Right Drug, Right Dose, Right Route, Right Time, and Right Resident and Right Documentation.

Based on the South Dakota Department of Health (SD DOH) facility-reported incident (FRI) review, interview, observation, record review, and policy review, the provider failed to ensure certified medical assistant (CMA) G and certified nursing assistant (CNA) I followed facility policy to provide individualized care for one of one resident (1) and resulted in the resident having to be transferred to the emergency department. Resident 1 received a large laceration to her right lower leg that required sutures. 1. Review of the provider's 10/4/25 submitted FRI to the SD DOH regarding resident 1 revealed on 10/3/25 at around 6:46 p.m., certified medication aide (CMA) G and certified nursing assistant (CNA) did not follow resident 1's comprehensive care plan that indicated the resident was to be assisted with transferring by two staff members with the use of the sit-to-stand (a mechanical lift used to assist from a seated to a standing position) which resulted in the resident receiving a large laceration to her right lower leg that required the resident to be sent to the emergency room (ER) for sutures. On 10/3/25 at 6:46 pm. CMA G and CNA I transferred resident 1 with a stand and pivot (when assisted to a standing position, the resident then turns their body to move to another surface) transfer from her wheelchair to her bed. Interviews with CMA G and CNA I during the provider's investigation revealed the resident was anxious at that time and felt it would have caused the resident to have increased anxiety to use the sit- to -stand mechanical lift .During the stand and pivot transfer, the resident's right leg was positioned next to CNA I's left leg. After the transfer, blood was found on the resident's right pant leg and CNA I's shoe. On 10/3/25 at 6:52 p.m. CNA I informed registered nurse (RN) C of the incident with resident 1. RN C and licensed practical nurse (LPN) F assessed the resident, discovered a large laceration to the resident's right lower leg, and determined the resident needed additional care that they were not able to provide at the facility. A telemedicine service was consulted and determined resident 1 needed to go to the emergency room (ER) for sutures to close the laceration. On 10/3/25 at 7:55 p.m. resident 1 left the facility and was transferred to the ER via ambulance. The resident returned to the facility at 12:51 a.m. on 10/4/25 with sutures to her right lower leg. Wound dressing and treatment orders were received from the ER and orders for the resident to follow up with her primary physician in 10 days for removal of the sutures. Resident 1's daughter was updated of events throughout and expressed an understanding of the treatment plan. After the incident on 10/3/25 resident 1's care plan was updated to indicate the resident was to be assisted with transferring by two staff members and the use of a total body lift (a mechanical life and sling used to lift a person's full body) lift until the resident's leg laceration was healed. It was determined the facility would reevaluate after the laceration healed, the resident's abilities to transfer would be re-evaluated. On 10/6/25 at 6:00 p.m. director of nursing (DON) A interviewed CNA I and educated her that she did not follow resident 1's care plan when she decided to independently transfer the resident using the stand and pivot maneuver rather than the sit-to-stand mechanical lift. CNA, I agreed with DON A that she did not follow the provider's policy for providing care according to the resident's care plan. Formal documentation was completed for CNA I related to the incident that occurred on 10/3/25 with resident 1. CNA I had no previous documentation of resident care concerns prior to that time.2. Review of resident 1's electronic medical record (EMR) revealed resident 1's Brief Mental Status (BIMS) score was 0, which indicated her cognition was severely impaired. Her diagnoses include Alzheimer's disease, dementia (a group of symptoms affecting memory, thinking, and social abilities),anxiety, iron deficiency anemia (low iron in blood), localized edema (tissue swelling), and chronic peripheral vascular disease (narrowed or blocked arteries) and hypertension (high blood pressure). On 10/13/25 orders were received from resident 1's primary physician to apply an Ace elastic bandage wrap to the right lower extremity. Apply the ace wrap distal (away from) the laceration, using 50% overlap and 50% stretch, and make sure the knee is bent and the ankle is at 90 degrees to her right lower extremity. Mepilex (foam absorbent dressing) may be applied over pressure point as needed. Remove the ace wrap every eight hours to assess pressure points and provide skin cares. Notify the provider if pedal pulses are absent or there are pressure concerns prior to application and reapplication of wound. 3. Interview and observation on 10/29/25 at 1:25 p.m. with CMA J and CNA H while transferring resident 2 from her wheelchair to her recliner in her room using the sit-to-stand mechanical lift revealed two staff are required to assist with the use of the sit-to-stand mechanical lift.CNA H and CMA J indicated that the use of the sit-to-stand mechanical lift required two staff members to use it safely. There were no concerns with the transfer observed.4. Interview on 10/29/25 at 3:06 p.m. with CNA I revealed resident 1 was more agitated than usual on the evening of 10/3/25. She stated she had asked CMA G to assist with transferring resident 1. She indicated she knew resident 1 had an order to be transferred with the sit-to-stand mechanical lift as indicated on her care plan but decided to stand and pivot transfer resident 1 rather than following the resident's care plan and use the sit-to-stand mechanical lift. She stated she felt that if she had transferred her with the sit-to-stand mechanical lift, it would have further increased the resident's agitation. She did not discuss that with RN C prior to transferring the resident that day.5. Interview on 10/29/25 at 3:22 p.m. by phone with LPN F regarding the 10/3/25 incidentrevealed she was asked by RN C to look at the skin tear resident 1 received after she was transferred by CMA G and CNA I. She felt RN C wanted reassurance about whether she needed to contact the telemedicine service. LPN F stated the telemedicine service gave orders for the resident to be sent to the ER for sutures. 6. Observation and interview on 10/29/25 at 4:06 p.m. with CNA/team and resource coordinator L and CMA K revealed that resident 1 was now to be transferred by two staff members with the use of a total lift until the laceration on her right lower leg was healed. They indicated that was included in the resident's care plan. 7. Interview on 10/30/25 at 8:30 a.m. with CMA G revealed she assisted with getting resident 1 into bed on the evening of 10/3/25. She stated she and CNA I decided to pivot transfer resident 1 rather than following the resident's care plan and using the sit-to-stand mechanical lift. She stated the resident liked to chicken wing (raise her arms at the elbows) when staff transferred her with the sit-to-stand mechanical lift. She indicated once they had gotten the resident into bed, CNA I noticed she had blood on her shoe. They told RN C and LPN F about the resident's injury, the nurses assessed resident 1 and then consulted a telemedicine service regarding the resident. The resident needed to be sent to the ER for sutures as the laceration was very large with a lot of tissue exposed. She stated, It looked like her leg just exploded. 8. Interview on 10/30/25 at 8:47 a.m. with RN C regarding resident 1 confirmed the resident's laceration to her4 right lower leg was identified after the transfer on 10/3/25. CMA G and CNA I used a stand and pivot transfer with the resident rather than following the resident's care plan and using the sit-to- stand mechanical lift. RN C denied she was aware of resident 1 being more agitated on 10/3/25 than she normally was. 9. Observation and interview on 10/30/25 at 9:10 a.m. with RN D while completing a dressing change for resident 1 revealed that resident 1 had a laceration on her right lower leg. Resident 1's dressing to her right lower leg was to be changed daily until healed as ordered by her physician. Resident 1 did not exhibit indicators of being in pain during the dressing change. 10. Interview on 10/30/25 at 9:39 a.m. with RN/Minimum Data Set (MDS) coordinator E revealed she typically updated the residents' pocket care plans. The pocket care plans were to be updated daily by herself and the nursing staff. The CNAs could access a resident's EMR to find their individualized care plans to know what assistance they required. 11. Review of the provider's April 2024 Safe Patient Handling and Mobility policy revealed:*If nursing is uncertain on how to safely transfer a resident, the healthcare provider should consult nursing leadership and or skilled therapy for guidance. *Nursing can independently decide whether to downgrade a transfer method. *Physical therapy and occupational therapy must be utilized in the instance that an upgrade is necessary. *Residents utilizing the stand aide lift must be able to provide weight bearing assistance through all extremities to utilize the stand aide lift. If a resident is found to be hanging or chicken winging in the stand aide, then a Hoyer lift must be utilized for the resident and the healthcare provider safety. *Healthcare providers are to follow the resident care plan for proper and safe resident transfers.

Based on South Dakota Department of Health (SD DOH) facility-reported incident (FRI), observation, interview, record review, and policy review, the provider failed to ensure resident (1) who had an allergic reaction that required the administration of an antihistamine due to a shellfish allergy was identified by the dietary staff before being served shrimp Alfredo. Findings include: 1. Review of the provider's 8/16/2024 SD DOH FRI revealed: *On 8/16/24, the provider served shrimp [NAME] for lunch. The nurse had looked up residents who had shellfish allergies and reminded the certified nursing assistants (CNA) to be careful of cross-contamination. The nurse then questioned resident 1's meal and confirmed that resident 1 was served the pureed shrimp Alfredo. Resident 1 was then taken to the nurses' station for assessment where she started to develop a rash around the mouth and redness in her mouth and throat. The nurse obtained orders to administer Benadryl. The Benadryl was administered to resident 1 once it had been received. 2. Observation on 8/21/24 at 11:30 a.m. of the lunch service with [NAME] E and [NAME] F revealed: * [NAME] E and [NAME] F referred to the resident's tray ticket for the resident's preferences for each meal. *The food tray ticket included the resident's diet, diet texture, adaptive equipment, allergies, and menu preference. *Cook F referenced the tray tickets and placed food items on the resident's plate. 3. Interview on 8/21/24 at 11:45 a.m. with [NAME] E and [NAME] F revealed: *On 8/16/24 [NAME] F served shrimp [NAME] to resident 1. *Cook F admitted that she had missed the documented shellfish allergy on resident 1's tray ticket on 8/16/24. *Cook F felt that a resident's food allergies should be highlighted on the tray ticket, and stated it would make dietary staff more aware of the resident's food allergies. *Cook F stated that nursing staff should have made dietary staff aware when they had known that shellfish was on the menu, and there were residents with a documented shellfish allergy. *Cook E stated nursing did not communicate with them until the food was already served to resident 1. *When asked about substitutes for residents with food allergies, [NAME] E stated that residents on puree diets did not have a choice because the menu does not offer pureed food and most residents with puree diets cannot communicate their preferences. *Cook E stated that the dietary staff would go to each resident's room and would ask them if the resident wanted the main meal being served or if they would want a substitute food item. However, they would not do this for residents on puree diets because there was not a puree option on the menu. She felt this may have been why they would have not looked at resident 1's tray ticket as closely on 8/16/24. *When asked what she would do if she had realized that resident 1 had a shellfish allergy, [NAME] F stated she would have made something else for her to eat. 4. Interview on 8/21/24 at 12:30 p.m. with Certified Dietary Manager (CDM) C and Director of Culinary Services (DCS) D revealed: *Tray tickets were printed three times a week. There is a specific section where allergies are listed. *It is the responsibility of staff to reference the tray tickets regarding resident's food allergies. *The shrimp [NAME] was permanently taken off the menu and replaced with chicken Alfredo. *Dietary staff should be offering residents on a puree diet an alternative food option when needed. *The menu substitution lists referred to the 5/27/2020 Offering Food Replacements at Meal Times Policy was not currently available to the dietary staff in the kitchen. 5. Review of Resident 1's electronic medical record revealed: *Resident had a documented shellfish allergy. 6. Review of resident 1's 8/16/24 nursing progress note revealed: *Nursing was advised that dietary was serving shellfish (shrimp Alfredo) for lunch. Nursing reviewed which residents with shellfish allergies. Nursing reminded staff the certified nurse aides (CNA) to be careful of cross contamination and residents who have allergies. The resident was recently switched to a puree diet. The nurse observed the table where resident one was being assisted by staff and questioned the meal resident one was provided and was currently eating. It is reported that the dietary cook had given the resident the pureed shrimp Alfredo. Resident was immediately brought to the nurses' station for examination and monitoring. It was noted that the nurse was able to see resident 1 started to develop a rash on the corners of her mouth. It was also noted that resident 1's mouth and throat were red. Resident 1 was able to speak one-word answers during the examination. Orders for Benadryl and an epinephrine injection were obtained. The Benadryl was given when it arrived. It was noted that the Benadryl was effective, and the epinephrine injection was not needed. 7. Review of the provider's 2/2024 job description for a Licensed dietary cook revealed: *Job duties included: -Reviewing menus before food preparation and following recipes. -Inspecting special diet trays for accuracy. -Coordinating dietary services with other departments. -Assuming authority, responsibility, and accountability of the cook. -Processing and following diet changes and new diets received from nursing services. -Preparing food for therapeutic diets in line with planned menus and standardized recipes. 8. Review of the provider's 5/27/2020 Offering Food Replacements at Mealtimes Policy revealed: *If an individual is not eating (or foods) served, the Nursing Associates in responsible for asking why and for verbally offering a suitable food replacement. (Please see the Menu Substitution Lists in the Menus/Therapeutic Diets Section.) The individual is encouraged to give input for his/her choice of substitution. A minimum of three substitutions should be offered. *For those on special diets, be sure the food replacement offered are appropriate for the therapeutic and mechanically altered diet order.

Based on interview, record review, and policy review, the provider failed to develop comprehensive care plans to include interventions for documented food allergies and/or intolerance's for four of four sampled residents (1, 2, 3, 4,) which included one who had been served shrimp [NAME] and developed an allergic reaction. Findings include: 1. Interview on 8/21/24 at 10:05 a.m. with certified nursing assistant (CNA) I revealed: *She had worked for the provider for two years. *She would have referred to the pocket care plan to know how to care for her residents. *She would have assisted residents in the dining room at mealtimes. *The pocket care plan did not list resident 1's shellfish allergy. *She did not know where to find out if a resident had a food allergy or food intolerance. *She would have asked the nurse if she had questions or concerns. 2. Interview on 8/21/24 at 10:10 a.m. with CNA J revealed: *She had worked for the provider for 3 weeks. *She would have referred to the pocket care plan for details of the resident's needs. *She was not aware of where to find a list of resident's food allergies or intolerance. 3. Interview on 8/21/24 at 12:12 p.m. with registered nurse (RN) G and licensed practical nurse (LPN) H revealed: *When asked where nursing staff would find a list of a resident's food allergies, LPN H stated information would be included in their care plan. *LPN H and RN G both agreed that a resident's food allergy should have been on the resident's care plan. *When asked how CNAs would know if a resident had a food allergy, they agreed the CNAs would be expected to ask nursing or refer to the resident's EMR or meal tray ticket. 4. Interview on 8/21/24 at 12:30 p.m. with Certified Dietary Manager (CDM) C and Director of Culinary Services (DCS) D revealed: *Resident food preferences or allergies were not included in the resident care plans because those changed of frequently. In the past, some residents had their dislikes listed in the care plan, and requested that food item, and that raised concerns about not following their care plan. *DCS D agreed that it would be important to have residents' food allergies listed in the residents care plan. *CDM C stated that food preferences and food intolerance's were discussed during the residents admission assessment and reviewed quarterly during their care conferences. Food allergies were communicated from the nursing staff at those meetings. *Resident food preferences, intolerance's, and allergies were not included in the residents care plan. They were located on the residents meal tray ticket and available in the kitchen to all staff. 5. Interview on 8/21/24 at 1:04 p.m. with resident 4 with a Brief Interview for Mental Status (BIMS) of 15 which indicated her cognition was intact revealed: *Resident had an intolerance to onions which gave her a headache. *When asked if she is served onions, she said sometimes and stated, It is sometimes hard to avoid eating onions here because they put onions in everything. 6. Interview on 8/21/24 at 1:19 p.m. with director of nursing (DON) B regarding resident food allergies and intolerance's revealed: *Direct care staff would use the pocket care plans for direction when providing assistance to residents. *He agreed resident food allergies should be included in care plans and on the pocket care plans used by the CNAs. 7. Record review of resident 1's EMR revealed: *The resident had a documented shellfish allergy. *The resident's shellfish allergy was not documented in her care plan. 8. Record review of resident 2's EMR revealed: *The resident had a documented shellfish allergy. *The resident's shellfish allergy was not documented in her care plan. 9. Record review of resident 3's EMR revealed: *The resident had a documented allergy to nuts. *The resident's nut allergy was not documented in her care plan. 10. Record review of resident 4's EMR revealed: *The resident had a documented allergy to chocolate, popcorn, and pork. *The resident's allergy to chocolate, popcorn, and pork was not documented in her care plan. 10. Review of the provider's undated pocket care plans revealed: *Resident 1's shellfish allergy had not been listed *Resident 2's shellfish allergy had not been listed. *Resident 3's nut allergy had not been listed. *Resident 4's chocolate, popcorn, and pork allergies had not been listed. 11. Review of the provider's 3/15/2023 Care Plans Policy revealed: *A comprehensive care plan was developed for each resident that included measurable goals and timetables to meet a resident's medical, nursing, mental and psychosocial needs that were identified in their comprehensive assessment. *The care plan focused on the course of action needed to attain or maintain a resident's highest practicable physical, mental, cognitive, medical, and psychosocial well-being.

Based on Certification and Survey Provider Enhanced Reports (CASPER) reporting data review, interview, and job description review, the provider failed to ensure their Payroll Based Journal (PBJ), (information of the provider's daily staffing hours for the appropriate care of the residents) had been complete and the data had been submitted to the Center for Medicare and Medicaid Services (CMS) for one of two quarters in 2024. Findings include: 1. Review of the provider's CASPER reporting data revealed no PBJ data had been submitted for the time period of January 1, 2024 through March 31, 2024. Interview on 8/15/24 at 12:07 p.m. with executive director (ED) A, ED of support services B, and ED of human resources C regarding submission of PBJ data to CMS revealed: *They submitted the PBJ data on 5/15/24 at 11:23 p.m. central time. *It was due on 5/15/24 by 11:59 p.m. eastern time. *They agreed it was submitted late. Review of provider's undated ED of Human Resources Job Description revealed: *Responsibilities include: -Oversee the payroll department and ensure accurate, compliant, and timely payroll is processed. -Gather data and process Payroll Based Journaling (PBJ) Quarterly Report submission to CMS.

Based on observation, interview, record review, and policy review, the provider failed to ensure: *Refrigerators, and freezer temperatures were monitored and documented for one of one main kitchen. *Food temperatures were monitored and documented prior to meal service. Findings include: 1. Observation on 4/25/23 at 11:29 a.m. of the main kitchen revealed: *The temperatures for the front refrigerator in the main kitchen had not been recorded twice a day for twenty-five days in the month of April 2023. *The temperatures for the second refrigerator in the rear of the main kitchen had not been recorded twice a day for twenty-five days in the month of April 2023. *Both freezer kitchen temperatures had not been recorded for twenty days in the month of April 2023. *A sign on the refrigerator in the main kitchen indicated that both refrigerator temperatures should have been recorded by the dietary staff twice a day. Observation on 4/25/23 at 11:30 a.m. in the main kitchen with cook E revealed there had been no food temperatures written in the temperature log for that days lunch meal after the food temperature's had been obtained. Observation on 4/26/23 at 9:30 a.m. in the main kitchen revealed the daily food temperatures had not been recorded in the log for January, February, March, and April 2023. Interview on 4/26/23 at 9:37 a.m. with dietary director D regarding the refrigerator, freezer, and food temperature logs revealed: *He recognized the temperatures had not been recorded. *His expectation was the staff were to record the freezers, refrigerators, food temperatures, and record them in the temperature logs. Interview on 4/26/23 at 3:55 p.m. with executive director of healthcare services A regarding the temperature logs revealed the expectation was that all refrigerator, freezer, and food temperatures would have been monitored and recorded. Review of the provider's policy 2013 Food Storage policy revealed: 14. Refrigerated Food Storage: . b. PHF/TCS [Potentially Hazardous Food/Time/Temperature Control for Safety] foods must be maintained at or below 41 degrees F [Fahrenheit] unless otherwise specified by law. Periodically take temperatures of refrigerated foods to assure temperatures are maintained at or below 41 F. Temperatures for refrigerators should be between 35 to 39 F. Thermometers should be checked at least two times each day. (See Freezer and Refrigerator Temperature Sample Form in this section.) Check for proper functioning of the unit at the same time.

Based on observation, interview, and policy review, the provider failed to ensure infection prevention and control practices were maintained for: *Hand hygiene and glove use during wound care by one of one licensed practical nurse (LPN) (C) and one of one director of nursing (DON) (B) for one of one sampled resident (25). *Handling of wound care supplies by one of one LPN (C) and one of one DON (B) during one of one observed resident's (25) wound care treatment. Findings include: 1. Observation on 1/12/22 at 8:39 a.m. B during a dressing change for resident 25's right foot involving his 2nd, 3rd, and 4th toes revealed: *LPN C entered resident 25's room with a roll of Coban, two plastic medication cups, and one package of non-stick [MEDICATION(S)]. *She placed those supplies on the nightstand next to other resident belongings. *With gloves on she: -Sanitized the overbed table, retrieved a wash cloth from the bathroom, placed the washcloth down on the overbed table, and transferred the above supplies to that area. -Retrieved a bottle of [MEDICATION(S)], wound wash, and another package of [MEDICATION(S)] out of his top dresser drawer, which also had other items in it including deodorant, unpackaged [MEDICATION(S)] and Kerlix wrap, papers, and another bottle of [MEDICATION(S)]. The drawer had dark stains and debris inside on the bottom. *LPN C then removed those gloves, washed her hands, and put on a new pair of gloves. *She took scissors from her pocket but did not sanitize them before she cut strips of the [MEDICATION(S)] squares. *With the same gloves on, she: -Placed the squares in the medication cups and put [MEDICATION(S)] over them, then used her fingers to ensure the [MEDICATION(S)] had covered the surface of the [MEDICATION(S)]. -Removed resident 25's stocking and the old dressing from his foot. -Sprayed the wound cleanser on his toes and lightly dried them but did not ensure his toes were dried in between. -Placed the [MEDICATION(S)] soaked [MEDICATION(S)] strips on the wounds on his toes. *DON B assisted with holding the resident's foot up with gloves on. Without removing her gloves, she opened his dresser drawer and retrieved an unpackaged roll of Kerlix and handed it to LPN C. *LPN C did not change her gloves or sanitize her hands after she had removed the old dressing. With the same gloves on, she wrapped the resident's foot with the Kerlix and Coban the placed his sock back on. Interview on 1/13/22 at 9:30 a.m. with LPN C revealed she agreed: *The scissors should have been sanitized before she used them. *Her gloves should have been changed and she should have sanitized her hands between removing the old dressing and cleansing and putting on the new dressing. *She was very nervous during the dressing change. Interview on 1/13/22 at 2:45 p.m. with infection control/registered nurse F revealed: *She had not completed any observations of dressing changes since she had been the infection control nurse. *Agreed education was needed to ensure glove use and hand hygiene were completed appropriately. *Agreed the dressing supplies should have been separated from other resident personal items. Interview on 1/13/22 at 4:45 p.m. with DON B revealed: *LPN B should have sanitized the scissors before using them. *She had not noticed the missed opportunities for hand hygiene and glove changes. *She confirmed the dresser drawer where some of his dressing supplies were had many different types of items along with the dressing supplies. *She was not aware she had contaminated the Kerlix when she had retrieved it from the dresser. *She agreed the Kerlix would have been contaminated by her gloves. Review of the provider's 12/14/17 Clean Dressing Change policy revealed: *Multi-use wound care supplies will be dated and initialed when opened. They will be maintained as clean after initial use. *Each wound would be treated individually. *When multiple wounds are being dressed, the dressings will be changed in order of least contaminated to most contaminated. Dressing of infected wounds should be changed last. *The dressing change procedure was to set up a clean field on the over bed table with needed supplies for wound cleansing and dressing applications. Those steps included: -If the table is soiled, wipe clean with sanitizer such as Sani wipes. -Place a disposable cloth [drape] or chux on the over bed table. -Place only the supplies to be used per wound on the clean field at one time to include wound cleanser, gauze for cleansing, disposable measuring guide and pen/pencil, skin protectant products as indicated, dressings, tape, scissors [clean with soap and water and alcohol prep pad]. -Perform hand hygiene and put on clean gloves. -Place a barrier cloth [drape] or pad [chux] next to the resident, under the wound to protect the bed linen and other body sites. -Remove the existing dressing and discard into appropriate receptacle. -Perform hand hygiene and put on clean gloves. -Cleanse the wound as ordered. -Perform hand hygiene and put on clean gloves. -Apply topical ointments or creams and dress the wound as ordered. -Secure dressing. Mark with initials and date. -Discard soiled items, gloves, and perform hand hygiene. -Clean scissors with soap, water and alcohol pad. -Perform hand hygiene.

Based on observation, interview, and policy review, the provider failed to maintain appropriate infection control practices for hand hygiene and glove usage for one of one sampled resident (1) completed by one of one licensed practical nurse (LPN)/charge nurse A and certified nursing assistant/medication aide (CNA/MA) B. Findings include: 1. Observation on 3/3/21 at 12:18 p.m. of LPN/charge nurse A performing personal care with assistance from CNA/MA B for resident 1 revealed: *Resident 1's call light was on outside of her room. *LPN/charge nurse A and CNA/MA B were observed entering the room and closed the door. *This surveyor knocked on the door and LPN/charge nurse A opened the door with gloved hands and permission was requested to observe. *The door to the room was closed by LPN/charge nurse A. *Both staff had gloved hands. *Resident 1 was seated in her wheelchair. *A stand aide mechanical lift was in the room and LPN/charge nurse A had moved it into position in front of her wheelchair. *LPN/charge nurse A and CNA/MA B used the mechanical lift to transfer her from her wheelchair to her bed. *Once seated, both staff assisted her to lie down. *They each maintained their same pair of gloves throughout the transfer process. *LPN/charge nurse A then walked to the bathroom door, opened it with the same gloved hands, grabbed a container of sanitary wipes and a disposable brief. -She exited the bathroom using the same gloved hands, closed the bathroom door, and walked back to the resident's bed with the brief and wipes. -Using the same gloved hands, she lowered resident 1's pants, removed the soiled brief and placed it on the bed next to the resident while CNA/MA B had assisted with positioning. -LPN/charge nurse A used the sanitary wipes to cleanse resident 1's perineal area and put the new brief in place. -When finished, resident 1's pants were put back into place. *CNA/MA B helped the resident to get into a comfortable position while LPN/charge nurse A removed the soiled brief and wipes, opened the bathroom door and placed them into the bathroom garbage. *LPN/charge nurse A removed her gloves, discarded them, walked out of the bathroom, opened the hall door and walked out without performing hand hygiene or washing her hands. *CNA/MA B was observed to exit the room and performed hand hygiene. Interview on 3/4/21 at 12:24 p.m. with LPN/charge nurse A regarding the above observation revealed: *She had not usually been the person to maneuver the mechanical stand lift. *She agreed: -She had missed opportunities to change gloves and perform hand hygiene. -Washing hands after performing personal cares for a resident would be the best practice. -The personal care above had not been completed in a sanitary manner and had potentially placed resident 1 at risk for acquiring an infection. Interview on 3/4/21 at 12:40 p.m. with director of nursing C regarding LPN/charge nurse A assisting resident 1 with personal care revealed: *He agreed the personal care above had not been completed in a sanitary manner and had placed resident 1 at risk of infection. *LPN/charge nurse A had been trained on proper infection control and was up to date on her education. *He would have expected LPN/charge nurse A to remove her gloves and perform hand hygiene any time they had been soiled and to follow proper infection control procedures. Review of LPN/charge nurse A's education record revealed she had completed the following courses: *Infection control on 4/1/20. *CMS Targeted COVID-19 Training for Frontline Nursing Home Staff on 12/17/20. *Handwashing and completed the competency on 1/13/21. Review of the provider's 4/23/20 Handwashing policy revealed: *Indications for Handwashing include, but are not limited to: -When hand are visibly dirty or contaminated, they are to be washed with soap and water. -After using the bathroom or assisting a resident with toileting, wash hands with soap and water. -Before and after direct contact with each resident. -After contact with inanimate objects (Including medical equipment and surfaces in the resident's room. -After removing and disposing of personal protective equipment including gloves, gowns, and masks.

Based on observations, staff interviews, and review of the facility's policy, the facility failed to ensure staff performed adequate hand hygiene while serving room trays to prevent the spread of infection, including COVID-19, in one of four halls. This failure had the potential to affect the nine residents living on the West hall (rooms 721 to 734). Findings include: On 12/29/20 at 10:20 AM, the Administrator stated the facility currently had no residents or staff that were COVID-19 - positive. On 12/29/20 at 11:00 AM, the West hall was observed without any hand sanitizer dispensers affixed to the walls. There was an isolation cart in front of room [ROOM NUMBER] and room [ROOM NUMBER] that each held a bottle of hand sanitizer, but there were no other isolation carts in the West hall. On 12/29/20 at 11:07 AM, Dietary Aide (DA) 1 delivered a room tray to room [ROOM NUMBER] and assisted to set up the meal. At 11:09 AM, DA1 exited room [ROOM NUMBER], walked to the meal cart, and grabbed another tray, which she delivered to room [ROOM NUMBER]. She did not perform hand hygiene before delivering the next tray. At 11:11 AM, DA1 exited room [ROOM NUMBER] and took the empty tray back to the cart. She then grabbed another tray from the cart and delivered to room [ROOM NUMBER] without performing hand hygiene before delivering the tray. On 12/29/20 at 11:21 AM, DA1 stated she had received education on COVID-19 policies and procedures, and stated she was educated to use hand sanitizer between serving each resident's tray, but she had forgotten to take some with her. She stated there was hand sanitizer available on the isolation carts scattered throughout the halls, but there were no dispensers affixed to the walls or placed in a more convenient location. On 12/30/20 at 9:10 AM, the Infection Preventionist (IP) stated dietary staff were expected to perform hand hygiene before going into a resident room to deliver a tray. The IP stated she had not received reports of a lack of hand sanitizer availability from the staff. She added, We discussed this in the past but had concerns with residents with dementia and sanitizer dispensers, and staff felt like they were able to access it when needed. The IP stated she expected staff to keep sanitizer with them or wash their hands in the resident's room. The facility's 04/23/20 Handwashing policy documented, Indications for Handwashing include . before eating and after eating or assisting a resident with meals . Before performing any type of meal preparation, . Before and after having direct contact with each resident, . After contact with inanimate objects (including medical equipment and surfaces) in the resident's room, . (and) After handling soiled linens, equipment, or utensils or leaving a soiled utility room.

Based on interview, observation, record review, and policy review, the provider failed to assess and prevent the development of pressure ulcers for one of three sampled residents (19). Findings include: 1. Observations and interviews of resident 19 on 6/3/19 from 4:45 p.m. until 6:00 p.m. and on 6/4/19 from 7:45 a.m. until 5:00 p.m. revealed: *She came to the dining room for meals. *In between meals she was sitting in her recliner in her room. -She dozed off and on while she was in the recliner. *She was alert and oriented. Interview on 6/4/19 at 8:15 a.m. with hospice aide G regarding resident 19 revealed: *She came five days a week, Monday through Friday at different times of the day. *She had just been informed the resident had developed a spot on her coccyx, the boney area. -She had put a barrier cream on it. Interview on 6/5/19 at 7:50 a.m. with registered nurse (RN) F and review of physician's orders [REDACTED]. *In report she had been informed the resident had an area on her tailbone. -The hospice nurse had put [MEDICATION NAME] on it. *She had not worked since the weekend and had not seen the area yet. *The physician's 6/17/19 order read, Duoderm/Acuderm for Pneumonia. -That was the order, but the reason was not correct. Review of resident 19's 3/21/19 Braden Scale for Predicting Pressure Sore Risk completed 3/21/19 with a score of fifteen (score of eighteen or less was considered higher risk). Review of resident 19's 4/26/19 care plan revealed: *(P) (Problem): I have a potential for pressure ulcers related to See Braden Score. *(G) (Goal): I would like to maintain my skin integrity or have changes in my skin integrity reported to the appropriate provider through my next review. *(A) (Approach): Please complete a Braden assessment on me per facility protocol. -Please monitor my skin daily during cares and bathing, and report any changes to my nurse. -I have a pressure-relieving device mattress and wheelchair cushion in my wheelchair. -Please assist to reposition every 1-3 hours in bed or chair. Review of resident 19's following Skin Evaluation forms revealed: *3/21/19: Initial skin assessment with scattered generalized bruising noted. Large bruise to right antecubital. Small abscess/boil area to right upper thigh. -No other issues noted. *3/30/19: Readmission skin assessment, scattered bruising noted to BUE (bilateral upper extremities) redness noted to sacrum. No open areas noted at this time. *5/17/19: Skin pink, warm and dry. No areas of concern noted. Review of resident 19's 3/20/19 through 6/5/19 interdisciplinary notes revealed: *There had only been one nursing note regarding her skin since her admission on 3/20/19. *On 5/21/19 at 5:01 p.m. the nurse had written: Had c/o (complained of) pain to tailbone. Hospice was here, placed a [MEDICATION NAME] to area. It was red, but not open. Interview on 6/5/19 at 8:18 a.m. with licensed practical nurse (LPN) D regarding resident 19 revealed: *She had an area that had opened and closed repeatedly. *They always did skin assessments that were done weekly when they received their baths. *She had problems with moisture, and thought that was more of a problem related to moisture. -They used a barrier cream on it. Interview on 6/5/19 at 8:18 a.m. with hospice aide I regarding resident 19 revealed: *The resident always sat in her recliner or her wheelchair; she never laid down in bed. *She had complained her bottom hurt. *The last two times she had been here she noted the resident had two little areas on her bottom. *Hospice had provided an air pillow that should have always been in her recliner. -They did not put anything in her wheelchair, because she was not in it for that long, But they probably should. *She had put a barrier cream on the area after she pulled the bandage back to see what was under it. Review of resident 19's 3/21/19 Braden Scale for Predicting Pressure Sore Risk assessment score was fifteen indicating a higher risk for pressure sores. Interview on 6/5/19 at 8:37 a.m. and medical record review with RN staff development/compliance coordinator B regarding resident 19 revealed: *The area on her bottom came and went quite a bit; it was more moisture related. -It was not on a boney prominence. It was in the gluteal fold. *As of two weeks ago she did not have any areas of redness or breakdown. *They did not use Mediplex on it, because it started to roll around, and that eventually lead to skin breakdown. *They always did weekly skin assessments. *In reviewing the medical record he confirmed skin assessments had not been completed weekly as expected. -The last skin assessment had been completed on 5/17/19, and only three assessments had been completed since her admission on 3/20/19. -They had not completed eight of the weekly skin assessments since her admission. Surveyor: Observation and interview on 6/05/19 at 10:08 a.m. during resident 19's wound care done by RN F revealed: *The resident was sitting in her recliner. *RN F brought supplies to the resident's room that included: -A [MEDICATION NAME] foam dressing with silicone. -A washcloth and hand towel. -A wound measuring strip. *She set all the items down on the resident's bedside table without placing a barrier to protect them from potential contamination. *For the dressing change she: -Washed her hands. -Put on gloves. -Got the wash cloth wet with soap and water. -Assisted the resident to stand and pull down her pants. -Removed the undated pink adhesive dressing from the resident's coccyx area. -Attempted to wipe away a large amount of white cream-like substance from the resident's buttocks area. --She stated she thought that was barrier cream, but she was unsure. -Measured the left buttock opened area as 0.5 centimeters (cm) by 0.4 cm. -Did not measure the other opened area on the resident's coccyx area. --That area appeared to be an opened slit in her skin. --The skin around the opened areas was reddened. -Then placed the [MEDICATION NAME] foam dressing over both the areas and dated that dressing with a pen. -Pulled the resident's incontinent brief and pants back up. -Assisted the resident to sit back down in the recliner. *The cushion in her recliner appeared to be a plastic/vinyl aired up type that was covered with a pillow case. *The cushion in her wheelchair felt like rubber and had a waffle-type appearance that was covered with a pillow case. *Upon leaving the room the RN stated: -She was unsure who had put the previous dressing on the opened areas but thought it looked like an [MEDICATION NAME] dressing. -The opened areas could have been caused from friction or pressure. -The resident liked to sit in her recliner or wheelchair most of the time. -She was unsure what type of cushions those were in the resident's recliner and wheelchair. -The resident was occasionally incontinent of urine and would just request help when she needed to go to the bathroom. --She was not on a specific toileting schedule that she was aware of. *She indicated the orders were to put a Duoderm dressing on the opened areas. -She confirmed she had not followed that order when she put the [MEDICATION NAME] dressing on it. *She stated the areas on the resident's buttocks and coccyx were not opened the last time she had assessed her. -That had been on (MONTH) 17 or 19. -She was unsure when the areas had become opened. Interview on 6/05/19 at 10:27 a.m. with RN/staff development/compliance coordinator regarding the above observation and resident 19 revealed: *He thought the resident's wheelchair cushion had been provided by her family. -He was unsure if that cushion was pressure relieving or not. *He was unsure what type of cushion was in the resident's recliner. -He stated hospice staff might have brought one in without telling the staff. -There were no aired up type of cushions in the facility that he was aware of. *He indicated the first and only documentation related to her above skin concerns was on 5/21/19 by hospice staff. -That documentation indicated her buttocks were only red and not opened. Surveyor: Interview on 6/5/19 at 2:04 p.m. with the director of nursing regarding the resident revealed: *There should have been weekly skin assessments completed. *Those assessments were completed after one of their two scheduled baths. -The certified nursing assistants were supposed to call a nurse to do a skin assessment. --Either the nurse did not hear them say it was time for her skin assessment or the bath aide did not tell the nurse. Review of the provider's 12/6/17 Skin Care/Pressure Ulcer policy revealed: *All residents admitted into the Health Care Center will be assessed for pressure ulcer risk using the Braden scale upon admission, readmission to he facility, with change in condition and with each MDS (Minimum Data Set( assessment. A full body skin assessment is completed upon admission and readmission. *Pressure ulcer risk and skin assessment findings are documented in the Resident's chart. *Facility practice is to consider as high risk a Braden score of 18 or less. *Nursing assistants will inspect skin during the bath and will as the Nurse tod a skin check while in the bathing area. *All residents will have a weekly skin check.

Based on interview, record review, and policy review, the provider failed to assess and monitor the status of one of one sampled resident (23) who received [MEDICAL TREATMENT] treatment and accurately reflected his needs related to [MEDICAL TREATMENT] on his care plan. Findings include: 1. Review of resident 23's medical record revealed he: *Was admitted on [DATE]. *Received [MEDICAL TREATMENT] treatment. *Scored a ten on the Brief Interview for Mental Status assessment that indicated he had moderately impaired cognition. *Had a [DIAGNOSES REDACTED]. *Received [MEDICAL TREATMENT] treatment every Monday, Wednesday, and Friday at 12:30 p.m. *Had a physician's orders [REDACTED]. -Monitor the fistula every shift for signs of infection three times daily (TID). *A physician's orders [REDACTED]. -Asculate bruit, palpate thrill to right arm every day. Interview on 6/4/19 at 2:14 p.m. with registered nurse (RN) C regarding resident 23's [MEDICAL TREATMENT] care revealed: *He had a fistula located in the bicep area of his right arm. *The fistula was checked periodically for correct placement and function. *He was type 2 diabetic and had blood sugars check TID. *His physician followed his care closely and ordered it completed more frequently if needed. *On his return from [MEDICAL TREATMENT] the staff had checked his blood sugar and offered him something to eat and administered his insulin. Interview on 6/5/19 at 10:34 a.m. with resident 23 regarding his [MEDICAL TREATMENT] care revealed: *Staff did not look at his fistula site or check on it when he returned from treatments. *The staff offered him food, and then he would go to bed. Review of resident 23's treatment administration record (TAR) from (MONTH) 1, 2019 through (MONTH) 4, 2019 regarding the order to monitor his fistula TID for infection revealed: *April there had been fifty-nine out of ninety opportunities documented. -The 8:00 a.m. time had eighteen out of thirty entries documented. -The 2:00 p.m. time had twelve out of thirty entries documented. -The 8:00 p.m. time had twenty-nine out of thirty entries documented. *May there had been sixty-three out of ninety-three opportunities documented. -The 8:00 a.m. time had twenty out of thirty-one entries documented. -The 2:00 p.m. time had thirteen out of thirty-one entries documented. -The 8:00 p.m. time had thirty out of thirty-one entries documented. *June there had been eleven out of twelve opportunities documented. -The 8:00 a.m. time had three out of four entries documented. -The 2:00 p.m. time had four out of four entries documented. -The 8:00 p.m. time had four out of four entries documented. Review resident 23's TAR from (MONTH) 1, 2019 through (MONTH) 4, 2019 regarding the order to ascultate bruit, and palpate the thrill daily revealed: *April there had been twelve out of twenty-three opportunities documented. *May there had been thirteen out of thirty-one opportunities documented. *June there had been 4 out of 4 opportunities documented. Review of resident 23's 6/5/19 care plan revealed it had not addressed: *The [MEDICAL TREATMENT] treatments. *His specific diet. *Care of the fistula area. *Symptoms of infection. *What to do in an emergency. Interview on 6/5/19 at 3:15 p.m. with the administrator regarding resident 23's [MEDICAL TREATMENT] care revealed: *They had not usually accepted [MEDICAL TREATMENT] residents in their care, so it was a fairly new process to them. *She was not aware staff had not followed the physician's orders [REDACTED]. *She had not been aware the care plan did not reflect details about his care regarding [MEDICAL TREATMENT]. *She would have expected staff to follow their policies. Interview on 6/5/19 at 3:40 p.m. with the Minimum Data Set assessment coordinator regarding resident 23's care plan revealed: *She confirmed the care plan had not gone into detail regarding his [MEDICAL TREATMENT] care. *The staff had referred to the medication administration record and treatment administration record for his [MEDICAL TREATMENT] care. Interview on 6/5/19 at 4:51 p.m. with the director of nursing revealed: *There were missing entries on the TAR regarding his fistula care. *No policy for care planning specific to care of a [MEDICAL TREATMENT] resident before, during, or after treatment. *No separate policy for [MEDICAL TREATMENT] care, beside their policy for emergency care measures for [MEDICAL TREATMENT] residents. Review of the provider's (MONTH) 19, (YEAR) Emergency Care Measures for [MEDICAL TREATMENT] Residents policy and procedure revealed: *Nurses will be responsible for monitoring and implementing of orders each time a resident returns from [MEDICAL TREATMENT]. *Nurses will assess resident's [MEDICAL TREATMENT] daily for bruit/thrill and any signs or symptoms of infection (redness, swelling, pain, and/or drainage) and will notify the physician. Documentation of the access site will be recorded on the MAR. *A comprehensive care plan will be developed by the interdisciplinary teams from both the [MEDICAL TREATMENT] unit and (provider) staff in accordance with the regulatory requirements and the individual resident's needs and preferences.

Based on observation, interview, and policy review, the provider failed to ensure a sanitary and organized area was maintained in one of one medication room. Findings include: 1. Observation and interview on [DATE] at 8:06 a.m. with registered nurse F in the medication room revealed: *The counter top contained multiple different items and had an overall cluttered appearance. *The floor had paper shreds and dust build-up by the door and along the floor trim. *She stated the room looked like that most of the time. -She had been working there for several months. -Housekeeping staff did not clean the room unless requested to do so and was observed by the nurse during the cleaning. -There was no process or routine to keep the room clean and orderly. *The counter by the sink had: -A green plastic bin that was full to the top of medications to return to the pharmacy. -A white plastic bin that was full to the top of medications to be destructed. --There were eye drops, nebulizer unit doses, over-the-counter (OTC) medications, topical medications, and prescription medications for multiple residents. --She stated those would stay there until someone had time to destroy them. --Those medications were either discontinued or expired or were from residents who were no longer in the facility. *Underneath the sink there was an ear washing machine in a plastic tote that was sitting underneath the drain pipe. -She stated that was used to wash out residents' ears and should not have been stored there. *Another counter contained multiple items that were commingled and included: -A large stack of empty medication blister packs for a resident. -A radio. -A box of gloves. -Multiple binders and papers. -Residents' ostomy supplies. -Chargers for staff radio equipment. -Nebulizer equipment.-Multiple prescription medications in blister packs for different residents. --Some had handwritten paper notes on them, some did not. -Opened OTC medications with no pharmacy label. -Unlabeled boxes of denture adhesive. -A bottle of body cleaner. -Two boxes of injectable blood thinning medication for residents. -Chemicals including Sani Cloth wipes and Clean on the Go Smoke and Odor Eliminator that were sitting next to the above items. -Several pieces of candy. -Multiple staff items including purses, drink cups, bottled water, papers, and nursing supplies. -Unlabeled sweat pants. -Recipe books. -An outdoor flag. -A resident's hearing aid box. -Febreze air freshener. -An unlabeled box of [MEDICATION NAME] OTC medication. --The nurse thought that was a staff member's personal medication. -An unlabeled electric razor. -Unlabeled and partially used stick deodorant. --The above items were all cluttered onto the counter with no separation of clean or potentially contaminated items. Observation and interview on [DATE] at 8:48 a.m. with licensed practical nurse/resident care supervisor [NAME] in the medication room revealed:*She confirmed the area was not kept in an orderly and sanitary manner. -The medication room seemed to be a catch all area for items. *She tried to clean and organize it, but it just seemed to get back that way. *There was no routine or process for cleaning and organizing the area. -All nurses should have been responsible to keep the area cleaned and organized. Interview on [DATE] at 10:47 a.m. with the director of nursing confirmed the above concerns with the medication room. The area should have been maintained in an orderly and sanitary manner. All nurses were responsible for keeping the area maintained. Interview on [DATE] at 10:58 a.m. with registerd nurse/staff development/compliance coordinator B regarding the above revealed:*He confirmed the medication room should have been maintained in a clean and orderly manner. *There was no process in place to ensure that was happening. Review of the provider's revised (MONTH) 2011 Medication Storage in the Facility policy revealed: Medication storage areas are kept clean, well-lit, and free of clutter and extreme temperatures and humidity.

Based on observation, interview, record review, and job description review, the provider failed to ensure one of one sampled resident (19) receiving end of life care received social services addressing their psychosocial needs. Findings include: 1. Observations of resident 19 on 6/3/19 from 4:45 p.m. until 6:00 p.m. and on 6/4/19 from 7:45 a.m. until 5:00 p.m. revealed: *She came to the dining room for meals. *In between meals she was sitting in her recliner in her room. -She dozed off and on while she was in the recliner. Observation and interview on 6/4/19 at 10:25 a.m. of resident 19 revealed she: *Was alert and oriented to person, place, and time. *Was able to express her needs without difficulty. *Became very weepy and stated I am so lonely here. All I am doing here is sitting here and waiting to die while she reached for this surveyor's hand and continued to cry. *Had no one to visit with but her daughter who visited often. Review of resident 19's 6/3/19 physician's orders [REDACTED]. Interview on 6/5/19 at 11:35 a.m. with certified nursing assistant A regarding resident 19 revealed: *The resident was occasionally weepy. -She missed her daughter even though she visited all the time. *She always reported to the nurse when the resident was weepy. Review of resident 19's 3/21/19 through 5/7/19 social services (SS) notes revealed: *A care conference was held on 4/24/19. -The resident's family was present at that care conference, but the resident was not. -The family indicated she had been on the antidepressants for about four to five years and needed those medications. *On 4/24/19 she included her Patient Health Questionnaire (PHQ) score was zero suggesting no concern of depression. -There was no further indication her mood had been assessed or the director of social services (DSS) had been made aware of any psychosocial concerns. Review of resident 19's 5/21/19 care plan revealed: *(P) (Problem): I have a potential for decline in mood status related to being new to Dow Rummel via the (wing name), end of life care with hospice enrollment 3/3/19. -PHQ-0/0. -(G) (Goal): I would like to maintain my mood status or have changes in my mood status reported to the appropriate provider. -(A) (action): My baseline mood status is such that I was taking a couple antidepressants. -(A): Collaborate as needed with hospice r/t (related to) comfort. -There was no plan for social services to monitor her mood. *(P): I am receiving Hospice Services with (Hospice provider). -(G) I will continue to receive hospice care until I no longer qualify or myself/family wishes to discontinue hospice services. -(A): Hospice case nurse, hospice aid, SS worker and chaplain will evaluate my frequency needs and wishes for my visits. -There was no plan for SS staff and the DSS to ensure psychosocial needs were being met. Interview on 6/5/19 at 3:06 p.m. with the DSS revealed: *Her PHQ score was very low and had not indicated she was depressed. *While she did as needed visits with residents she based her need for routine visits with residents based on their PHQ score. -Hers had been low. *She confirmed the resident had a high Brief Interview Mental Status (BIMS) assessment score that indicated she was for the most part cognitively intact. *She was unaware the resident was feeling sad at times, because no one had informed her. *She confirmed the resident was receiving hospice services and she had the hospice social worker (SW) visiting. -But agreed the SW only had to visit one time a month. -She understood that even though Hospice was involved the facility was ultimately responsible for the resident. Review of the provider's 5/1/19 DSS job description revealed Essential Duties and Responsibilities included: *Plays a lead role in helping facility evaluate and meet the psychosocial needs of each resident, especially as they relate to adjusting to living in the facility and coping with illness, disability. or other similar circumstances.

Based on observation, interview, record review, and manual review, the provider failed to ensure one of one sampled resident (5) with limited range of motion of her extremities had been accurately assessed and recorded on the Minimum Data Set (MDS) assessment record. Findings include: 1. Observations of resident 5 throughout the survey on 6/3/19 from 4:00 p.m. through 7:00 p.m., on 6/4/19 from 7:30 a.m. through 6:30 p.m., and on 6/5/19 from 7:30 a.m. through 6:30 p.m. revealed: *When she was in her bed she was positioned onto her right side most of the time. -Her body was curled up into the fetal position. *She had a specialty wheelchair with a head rest on it. *She had a special touch-pad type of call light. *When she sat in her wheelchair or recliner she appeared hunched forward and tilted to the side. -The staff placed pillows or cushions to help her sit up straighter. *She kept her arms bent at the elbows and pointed toward herself most of the time. *Staff used a total mechanical lift to transfer her from her wheelchair to her bed or lift chair. -During transfers her legs remained bent at the knees and her arms remained bent at the elbows. Interview on 6/3/19 at 5:03 p.m. with registered nurse (RN) C regarding resident 5 revealed: *The resident had been there for several years. *She had [MEDICAL CONDITION] and her condition had been declining overall over the last few years. *She was currently on hospice services. Observation and interview on 6/4/19 at 11:45 a.m. with certified nursing assistants L and M during resident 5's personal care revealed:*They stated restorative therapy had just gotten done working with her. -Restorative staff did passive range of motion exercises since she had limited ability to move her arms and legs. *Both her arms were bent at the elbows, pointing toward her chest, and crossed over one another. *There were washcloths in the palms of both of her hands that were clenched into fists. *During the transfer her legs remained bent at the knees. *She was unable to straighten out her legs when she was in bed, the lift, or the wheelchair. *Her arms remained bent during the transfer in the lift, while in bed during personal care, and while she was in the wheelchair. *Staff assisted holding her legs during the transfer and care. *Her arms remained bent even when the CNA attempted to adjust her shirt. Review of resident 5's medical record revealed:*She had been admitted on [DATE]. *Her condition and [DIAGNOSES REDACTED]. *Her 3/5/19 physician visit progress note included: - .have consulted with (name) hospice for their care due to her progression of her [MEDICAL CONDITION] and related symptoms . - .is fed, as she is unable to do so herself. -She spends her time either in her wheelchair, her lift chair in her room or her bed. She is not ambulatory. -She is sitting in her wheelchair. She lists to the right. She is very kyphotic in the [MEDICATION NAME] region and she is bent over . - .Her hands are continuing to have less ability to grasp and are stiff and in a semi-clenched state. *Her 6/4/19 physician visit orders and notes included: -Tylenol 650 mg PO Q AM (orally every morning) for stiffness & pain . *Her 6/5/19 care plan indicated: -She had self-care deficits related to her [MEDICAL CONDITION] -She required extensive assistance from staff for all her activities of daily living. -She was on a restorative therapy (RT) program six days a week since (MONTH) (YEAR). --It had not specified what type of RT program or why she was on one. -There was no mention of concerns with her upper or lower extremities. *Her interdisciplinary notes from (MONTH) 2019 through 6/5/19 had no documentation related to her range of motion, stiffness in her extremities, or if there had been changes related to those issues. Review of resident 5's RT notes and reports from (MONTH) (YEAR) through 6/5/19 revealed:*On 8/30/18: .does one-on-one active or passive range of motion exercises, as well as a posture and lower extremity stretches, and finger range of motion .was not able to independently complete the lower body flexibility test of the upper body strengthening test, so we could not take measurement of those tests . *On 12/6/18: Offered one-on-one passive range of motion stretches for both upper and lower body, as well as a posture stretch and finger range of motion. Standing is no longer appropriate for her program, so as of (MONTH) 1 we are no longer offering it and will keep the focus on stretches in Restorative .did complete a passive range of motion assessment, but there is not comparable data as it is an initial assessment . *On 3/14/19 there were similar comments about the passive range of motion and posture stretches. *Notes on her exercise documentation from (MONTH) 2019 through (MONTH) 2019 included: -In (MONTH) she had not been as responsive and had not participated well. -In (MONTH) and May: --Att (attempted) all PROM (passive range of motion) but resident seemed very uncomfortable.: --Att upper - was slightly resisting and arms were crossed. -- .was very resistant would not let me move arms. Review of resident 5's Minimum Data Set (MDS) assessment revealed: *Her 11/14/18 quarterly, 2/13/19 annual, and 3/4/19 significant change MDS assessments coding for section G0400 indicated she had no impairment in the range of motion of her upper or lower extremities. *Her 3/4/19 significant change MDS included:-She had been started on hospice services. -Section G related to her functional status was coded to include she:--Required extensive assistance of two staff persons for bed mobility, transfers, dressing, toileting, and personal hygiene. --Had not walked. --Required total dependence of one staff person for locomotion on and off the unit. --Required extensive assistance of one staff person for eating. --Used a wheelchair. --Her assistance level was similar on the previous two MDS assessments on 11/14/18 and 2/13/19. *The coding of no impairment in her range of motion had not matched the above physician notes, restorative therapy notes, or observations of the resident's arms and legs. Interview on 6/05/19 at 9:27 a.m. with the MDS assessment coordinator regarding resident 5 revealed: *She was the only MDS coordinator and had worked there for several years. -She had completed additional training and certification to complete MDS assessments. *She had not felt the resident had limited range of motion in her extremities until the last few weeks. -She stated the resident had a significant decline in her condition about a week and a half ago and had started curling up more than before. --She thought the documentation in the medical record should have supported that sudden decline. *The resident had been on a restorative exercise program for several months that included passive range of motion exercises. -Passive range of motion exercises were when the staff had completed them versus the resident performing their own. -Passive range of motion was usually implemented when a resident was unable to complete their own active range of motion exercises. *She was the nurse who oversaw the restorative therapy program and had to review the program quarterly. *She stated the resident was now due for another quarterly MDS assessment. -She did not answer when asked if the resident would now meet the assessment criteria as defined in the resident assessment instrument (RAI) manual indicating limited range of motion and code her as such for the current MDS assessment. Interview on 6/05/19 at 11:06 a.m. with RN/staff development/compliance director regarding resident 5 revealed:*The resident had limited range of motion in her arms and legs since he had known her the last few years. *It had recently been getting worse. *He thought she was on a passive range of motion program with restorative therapy for her extremities. *He had completed MDS assessments at a prior job. -Coding should have been completed according to the RAI manual guidelines. Interview on 6/05/19 at 3:00 p.m. with RT aide N regarding resident 5 revealed:*The resident had been receiving the same passive range of motion exercises since she had started working there in (MONTH) (YEAR). *She felt the resident had limitations with both her upper and lower extremities since she had started. -Her hands had been closing into fists for several months. *She had seen her cross her arms tight over her chest for quite awhile. -That had not just happened in the last few weeks. Interview on 6/05/19 at 3:17 p.m. with the physical therapist/rehabilitation director regarding resident 5 revealed: *Therapy staff were not currently working with her, but they had in the past. *She had worked with occupational therapy in (MONTH) (YEAR) related to wheelchair positioning. -At that time they had changed her to the tilt-in-space specialty wheelchair with the head rest due to her limited range of motion and posture concerns. *Her [DIAGNOSES REDACTED]. *The resident's range of motion might have worsened recently, but she had limitation in her upper and lower extremities for several months or years prior to recently. Interview on 6/05/19 at 3:38 p.m. with licensed practical nurse/resident care supervisor [NAME] regarding resident 5 confirmed the above interview with the physical therapist. Interview on 6/05/19 at 3:45 p.m. with the director of nursing regarding resident 5 revealed: *She was aware of the resident's current condition and status. *The resident's [DIAGNOSES REDACTED]. *She expected all residents' MDS assessments to have been coded appropriately to fit their unique needs. *The RAI manual should have been followed to ensure proper coding on the MDS. Interview, record review, observation, and RAI manual review on 6/05/19 from 4:40 p.m. through 5:10 p.m. with the MDS assessment coordinator revealed: *She agreed she should have used the RAI manual as her reference when completing the resident's MDS assessments. *She confirmed the resident had not been coded as having an impairment with her range of motion on her last three MDS assessments on 11/14/18, 2/13/19, and 3/4/19. *There was no documentation or summary from her to support her coding on the last MDS on 3/4/19. *She usually completed an MDS summary note for all MDS assessments. -She was unsure why the documentation was not in the medical record, but it could have been lost with the software problems they had been having. *She felt the resident still had full range of motion to her upper and lower extremities even though she was declining these last few weeks. *She took the surveyor to visit the resident and attempted to demonstrate the resident's movement of her arms. *The resident was in her wheelchair in the dining room and had both arms bent at the elbows resting on a pillow in her lap. *She was not able to demonstrate the resident had full range of motion of both upper arms and hands. *Following that observation the RAI manual was reviewed related to range of motion. -She confirmed the assessment and coding instructions in the manual indicated the resident should have been coded as having an impairment in her upper extremities. Review of the (MONTH) (YEAR) Centers for Medicare and Medicaid Long-term Care Facility Resident Assessment Instrument 3.0 User's Manual, Version 1.16, revealed: *Pages 1 through 5 regarding appropriate assessments in the MDS: - .Providing care to residents with post-hospital and long-term care needs is complex and challenging work. Clinical competence, observational, interviewing and critical thinking skills, and assessment expertise from all disciplines are required to develop individualized care plans. The RAI helps nursing home staff in gathering definitive information on a resident's strengths and needs, which must be addressed in an individualized care plan . *Pages G-36 through G-39 related to section G0400: Functional Limitation in Range of Motion included: -The definition of Functional Limitation in Range of motion was: Limited ability to move a joint that interferes with daily functioning (particularly with activities of daily living) or places the resident at risk of injury.-The intent of G0400 is to determine whether functional limitation in range of motion (ROM) interferes with the resident's activities of daily living or places him or her at risk for injury. When completing this item, staff should refer back to item G0110 and view the limitation in ROM taking into account activities that the resident is able to perform. -Steps for the assessment included: --Coding for functional ROM limitations is a 3 step process: --Test the resident's upper and lower extremities ROM. --If the resident is noted to have limitation of upper and/or lower extremity ROM, review G0110 and/or directly observe the resident to determine if the limitation interferes with function or places the resident at risk for injury. --Code G0400 A/B as appropriate based on the above assessment. --4. Assess the resident's ROM bilaterally at the shoulder, elbow, wrist, hand, hip, knee, ankle, foot, and other joints unless contraindicated (e.g., recent fracture, joint replacement or pain). -Coding instructions included: --Code no impairment if the resident had full functional range of motion of extremities. --Code impairment on one side if the impairment affected one side only. --Code impairment on both sides if the impairment affected both sides.

Based on observation, interview, policy review, and professional reference review, the provider failed to follow professional standards of practice for medication administration when narcotic medications were being given by someone other than the staff person who had prepared them. Findings include: 1. Observation and interview on 6/05/19 at 9:16 a.m. with certified medication aide (CMA) H during audit of the southeast medication cart revealed:*There were a few residents' scheduled and as needed narcotic medications held in a locked drawer of the medication cart. *Only the nurses had keys to those narcotic medications. *If a resident needed a prescribed narcotic medication labeled for them the process was: -To ask the nurse to get it out of the lock box for them. -The nurse would have gotten the medication out and put it into a plastic medication cup, signed it out in the narcotic sign-out book, and then gave that medication to the med aide for them to administer it to the resident. -After the med aide gave the medication to the resident they signed it as administered in the resident's medication record. -That was the usual process for narcotics which was different than all other medications. *The process for all other medications was for the staff who had set up the medication to administer it. *She had been working there for several months, and that was how she had been taught. Observation and interview on 6/05/19 at 10:21 a.m. with registered nurse F during audit of the northeast medication cart revealed: *There were several residents' scheduled and as needed narcotic medications specifically labeled for them held in a locked drawer of that medication cart. *She confirmed the process for narcotic administration was completed as indicated by CMA H. *She was unsure why the process for narcotic administration was different than for all other medications. -She thought it was to maintain accountability of the narcotic medication counts. *She agreed it was not a normal standard of practice for medication administration to have been done when the medication had been set-up or prepared by someone else. -Medication administration should have been completed by the person who set-up the medication to avoid potential errors and ensure it was administered properly. Interview on 6/05/19 at 10:47 a.m. with the director of nursing revealed:*She was aware of the above process for administration of the narcotic medications. -The medication was being given by the medication aide after being set-up by the nurse. *She agreed that was not a normal practice for medication administration. *She was unsure if that process met professional standards of practice and stated she would have to check with their pharmacy consultant. Interview on 6/05/19 at 10:58 a.m. with RN/staff development/compliance coordinator revealed: *He was aware the staff were using the above process for narcotic administration. *He agreed it was not a standard of practice for staff to administer a medication that was set-up by another person. Phone interview on 6/05/19 at 2:30 p.m. with the consultant pharmacist related to the above revealed: *He was not aware staff were administering narcotics in the above manner. *He indicated he would have to research if that was not a correct process or standard of practice for medication administration. Secondary interview on 6/5/19 at 4:12 p.m. with the consultant pharmacist revealed: *He had looked up the nursing standard of practice for medication administration related to the above process. *He confirmed it was not recommended for staff to administer a medication that was set-up or prepared by someone else. Review of [NAME] A. Potter and Ann Griffin Perry, Fundamentals of Nursing, 9th ED., St. Louis, MO, pp. 626-627, revealed: *Page 626, Professional standards such as Nursing: Scope and Standard of Practice (American Nurses Association (ANA), 2010) (see Chapters 1 and 23) apply to the activity of medication administration. To prevent medication errors, follow the six rights of medication administration consistently every time you administer medications. Many medication errors can be linked, in some way, to an inconsistency in adhering to these six rights: -1. The right medication. -2. The right dose. -3. The right patient (resident). -4. The right route. -5. The right time. -6. The right documentation. *Page 627 related to the right medication: -Once you determine that information on the patient's MAR indicated [REDACTED]. -Because the nurse who administers the medication is responsible for any errors related to it, nurses administer only the medications they prepare. You cannot delegate preparation of medication to another person and then administer the medication to the patient. Review of the provider's revised (MONTH) 2011 Administration Procedures for All Medications policy revealed: *The purpose was To administer medications in a safe and effective manner. *There was nothing specific related to the concern identified above or if the person who set up or prepared the medication should have administered it.

Based on observation, interview, record review, and policy review, the provider failed to ensure one on one sampled resident's (12) wheelchair was appropriately sized to promote and maintain his mobility. Findings include: 1. Observations of resident 12 throughout the survey on 6/3/19 from 4:00 p.m. through 7:00 p.m., on 6/4/19 from 7:30 a.m. through 6:30 p.m., and on 6/5/19 from 7:30 a.m. through 6:30 p.m. revealed:*He was a very tall and thin-framed man. *In the morning on 6/4/19 a certified nursing assistant (CNA) assisted him with walking in the hallway using his walker for approximately fifteen minutes. -His walker was height adjusted and appeared to be appropriately sized for him. *Most of the remaining time he spent in a wheelchair in the lounge or hallway areas. *The wheelchair he used appeared to be too small for his height and was an average size. *When he was sitting in it: -The top of the back rest came up to his mid-back area only. -The seat depth was approximately four to six inches too short. -His knees appeared to be approximately four inches higher than his waist when his feet were on the pedals. *When staff would put his feet up on the pedals he would move them back down to the floor soon after. *He would try to propel the wheelchair at times with his feet but would not move far. *He was fidgeting most of the time while sitting in it. Review of resident 12's medical record revealed:*He had been admitted on [DATE]. *His [DIAGNOSES REDACTED]. *He had severe cognitive impairment. *His most recent 3/13/19 annual Minimum Data Set assessment indicated he: -Was seventy-seven inches tall. -Required extensive assistance of one staff person with transfers. -Required limited assistance of one staff person with walking. -Had not used a wheelchair. -Had only used a walker. *His 6/5/19 care plan indicated: -He used a walker for mobility with assistance of one staff person. -A 10/4/18 intervention stated: --I some times become very tired and (am) unable to recongize (recognize) when I need to rest. Occassional (occasional) use of a wheelchair when these times occur. My primary mode to locomote is to walk with my walker. *There was no clear documentation to support when the wheelchair had been started, who had given him the wheelchair, or if it was sized appropriately for him. Observation and interview on 6/03/19 at 5:03 p.m. with registered nurse (RN) C regarding resident 12 revealed:*He was currently sitting in the lounge area in his wheelchair. *She stated he was: -Very tall. -Declining recently. -Using a wheelchair now since he was not appropriate with his walker anymore. Observation and interview on 6/04/19 at 10:03 a.m. with CNA J and certified medication aide K during resident 12's personal care revealed:*The resident was in his wheelchair. *They had tried to get him to stand up so they could help him to the toilet, but he was easily distracted and not able to follow their directions. -They chose to leave him in the wheelchair and would come back later. *Both confirmed his wheelchair seemed to be too small for him since he was so tall. -That was his usual wheelchair, and the one he had been using. *He used to walk by himself with his walker, but he had been using the wheelchair more often in the last few weeks. Interview on 6/04/19 at 4:21 p.m. with RN C regarding resident 12 revealed:*He used the wheelchair at times and his walker at times. *She confirmed his wheelchair did not appear to fit him appropriately due to his height. *She thought that was not the first wheelchair he had used. -Though it was the same one he had been in on 6/3/19. *She was unsure if anyone had evaluated him for the appropriate size of wheelchair. *She confirmed he did not appear comfortable while sitting in the wheelchair. Interview on 6/05/19 at 11:12 a.m. with the RN/staff development/compliance director regarding resident 12 and his wheelchair revealed:*He confirmed the resident was very tall. *The wheelchair should have been the appropriate fit for him to promote his comfort and mobility. *He stated they could have had therapy evaluate his wheelchair positioning or nursing staff could have found him a different wheelchair to use. Interview on 6/05/19 at 11:18 a.m. with the director of social services regarding resident 12 revealed:*She was aware he was using a wheelchair more often now. -Especially in the last few weeks. *She confirmed they should have made an effort to accommodate him and get the appropriate sized wheelchair to meet his needs. Interview on 6/05/19 at 3:17 p.m. with the physical therapist/rehabilitation director regarding resident 12 revealed:*Therapy staff had not been asked to evaluate him for appropriate wheelchair positioning. -That was something they could have assisted with. *She had seen the resident in the wheelchair and agreed it was not the appropriate size for him. *Wheelchairs and assistive devices should have been appropriately sized for each resident to promote their comfort and mobility. *She stated: -The back should have been higher. -The seat should have been deeper. -The pedals and overall height of the chair should not have made his knees higher than his waist when his feet were on the pedals or the floor. Interview on 6/05/19 at 3:53 p.m. with the director of nursing (DON) revealed:*She confirmed the resident had been using a wheelchair for awhile. -She was not aware it was not the appropriate size for him. *She agreed there should have been a process to ensure residents' devices were appropriately sized to meet their needs. Policies on the appropriate sizing of wheelchairs and/or positioning were requested on 6/5/19 at 4:00 p.m. from the DON. They were not received prior to the end of survey. Review of the provider's 12/13/17 Repositioning policy revealed the purpose included to: Maintain body parts in correct alignment and use proper positioning, transferring, and turning techniques to minimize skin injury due to friction and shearing forces.

Based on observation, record review, interview, and policy review, the provider failed to ensure three of four sampled residents (1, 2, and 4) identified at risk for skin breakdown had received the necessary and appropriate care to prevent the development of new pressure injuries or prevent worsening of existing pressure injuries. Findings include: 1. Interview on 11/20/17 with registered nurse (RN) C regarding resident 1's skin treatments revealed: *The floor nurses were responsible for performing dressing changes. *Sometimes the hospice nurse might change the dressings, but the floor nurses were responsible to ensure the dressings were changed. *The November 2017 treatment administration record (TAR) revealed a 10/17/17 physician's orders [REDACTED]. *There were no signatures beside the [MEDICATION NAME] dressing to have indicated the dressing had been changed in November. *She stated: -The [MEDICATION NAME] was an old order. -The nurses were no longer using that dressing. -The new dressing order was not on the TAR. -There were no other skin treatments listed on the TAR. *She had only worked at the facility a few months and was not sure why the treatment orders had not been transcribed to the TAR. Interview on 11/20/17 at 4:00 p.m. with the director of nursing (DON) regarding resident 1's treatments revealed:*Licensed practical nurse (LPN) B had taken over as wound nurse in August. *The wound nurse before her had not been documenting skin wounds appropriately. *She confirmed all skin treatments should have been documented on each resident's TAR. Observation and interview on 11/21/17 at 9:15 a.m. of resident 1's dressing changes by her hospice nurse and LPN/resident care supervisor (RCS) B revealed: *A blackened area to the mid-back over the spine that measured two centimeters (cm) by (X) three cm, was treated with [MEDICATION NAME] barrier skin spray, and dressed with [MEDICATION NAME] Foam dressing. *A reddened spot to her right mid-outer rib area was dressed with a border gauze dressing. *A reddened spot to her left buttock near the coccyx was dressed with a border gauze dressing. *A gray opened area to her right outer ear surrounded by reddened skin. *A sign-out form in the bathroom indicated the resident was to have been checked every hour, and the staff member was to have signed she had been checked. Interview at the above time with LPN B regarding the hourly sign-out sheet for resident 1 revealed: *The staff were to have checked her to see if she was on the laying on the floor or if she needed to toileted. *It was not used to document if the resident had been repositioned. Interview at that time with the hospice nurse revealed: *Resident 1 did not want a dressing on her ear, because she did not want to wear it when she left her room. *The staff had been using lotion or barrier cream to her ear. *When the resident started hospice on 10/23/17 it was discussed that we wanted to address comfort rather than healing. *Her expectation had been the provider's nurses would change all the dressings routinely. *She would change the dressings only if she had been present at the time they needed to be changed. *She was not aware the treatments were not part of the TAR. *The hospice staff had not been given access to the residents' electronic medical records (EMR). Review of resident 1's EMR revealed the 6/21/17 Minimum Data Set (MDS) assessment indicated: *Section K indicated a weight of eighty-two pounds. *Section M (skin section) had indicated: -There was no previous skin breakdown. -There was no repositioning program. -She was always continent of her bladder. Review of resident 1's 6/21/17 Braden Scale for predicting pressure injury risk indicated: *A score of 16. *If the total score was 18 or less she was to be considered at risk for a pressure injury. *A [DIAGNOSES REDACTED]. Review of the Braden Scale of Predicating Pressure Sore Risk, Bergstrom, J, Braden, B et. al., 1987, Vol 36 , pp 205 through 210 revealed the next level of care had included the following interventions: *A dynamic air overlay or low air loss mattress. *Supplemental positional shifts. *A nutritional assessment. *An evaluation on change of condition. Review of resident 1's interdisciplinary (ID) notes from 6/1/17 through 8/16/17 revealed: *On 6/22/17 at 1:10 p.m. LPN B had documented: -She had complained of a her bottom hurting. -There was a small red area on coccyx. -Skin ointment was applied. -There was no notification to the family or the physician. -No treatment had been ordered. -No skin assessment record had been completed. -There was no further documentation of the reddened area until 7/7/17. *On 7/7/17 the dietitian had documented: -She had found a note in the record regarding a red area on her coccyx. -Her Braden score was 17 with a 'poor' nutrition subscore indicating a risk for pressure injuries. -She was at nutritional risk with her significant weight loss. -Her weight was seventy-five pounds at the end of June 2017. -Her weight was down fifteen pounds over a three month period (April through July). -She had a cast removed 0n 5/9/17, but that would only have been a few pounds off her weight. -Her intake was poor. -Extra supplements were provided if she would take them. On 7/24/17 the MDS nurse had documented a quarterly MDS note that indicated:*She was at risk for skin breakdown. *(Resident's name) is assisted to reposition. *There was no documentation of previous skin breakdown. Review of the 7/30/17 care conference note revealed not indication of skin conditions. Review of resident 1's ID notes and skin evaluation forms from 8/16/17 through 11/21/17 revealed: *On 8/16/17 she was found on the floor by her daughter when she entered the room. -There was no documentation of skin concerns at that time. *On 8/17/17 RN B had documented Resident scrape on coccyx area (1 cm x .5 cm) red duoderm applied to area, midback scrape also noted. -RN B had documented a skin evaluation form at that time for treatment of [REDACTED]. -There was no physician notification of skin issues. -That form had not been completed for repositioning or other nursing interventions. -On 8/21/17 the physician was notified of the open area to coccyx and approved the duoderm treatment. -There was no notification regarding the scrape to her back. *On 8/23/17 LPN B had documented on a skin evaluation form: -A partial thickness wound of 2 cm x 2 cm to her coccyx. -Duoderm was applied to the area. -The resident was being repositioned. -There was no frequency for the repositioning. *On 8/23/17 the physician signed the sixty-day order renewal form. Those orders had contained no skin treatment recertification orders. *On 8/29/17 the skin evaluation form indicated a 0.5cm x 0.5cm area to coccyx. *A 9/1/17 skin evaluation form indicated the coccyx partial thickness wound was 0.4 cm x 0.4 cm. *A 9/6/17 skin evaluation form indicated the coccyx partial thickness wound was 0.5 cm x 0.5 cm. *Those last three documentations had not indicated a repositioning schedule for the resident. *There was no further documentation of the coccyx pressure injury in the skin evaluation forms or the ID notes. On 8/24/17 RN F had documented in the ID notes and on a skin evaluation form: *A new 0.7 cm x 0.3 cm scab on her right ear from pressure from laying on her right side. *Her family was informed and would bring a pillow to reduce the pressure. *The physician had not been informed. *No treatment had been added to the TAR. *No other repositioning had been documented. A 9/12/17 skin evaluation form by RN G had indicated she had applied triple antibiotic ointment to a scratch on her right ear. *The area had not been measured. *There was no documentation of repositioning frequency or other interventions. A 9/15/17 ID note by LPN B indicated: *The right ear was scabbed over. *A Band-Aid was applied. *She measured the residents areas of concern at 0.5 cm x 0.5 cm. *She applied Duoderm to the bottom with another reddened area noted. *A 9/15/17 skin evaluation form indicated the resident had a repositioning program, but no indication of the repositioning frequency. Another 9/15/17 skin evaluation form by LPN B: *Identified an abrased area to the left lower buttock. *That area measured 0.5 cm x 0.5 cm. *Duoderm was applied to that area. Review of the medical record revealed there was no documentation of the following: *The physician had been notified of the new areas to the buttock or the ear. *Treatments had been added to the TAR. *The dietitian had been notified of the new areas. A 9/20/17 skin evaluation form by RN C indicated: *The left lower buttock open area measured 0.3 cm x 0.3 cm. *Duoderm had been applied to the area. *There was no documentation regarding: -Physician notification. -Interventions for repositioning. -Any other interventions. A 9/20/17 MDS indicated: *A weight loss of fourteen percent over the past ninety days. *Her bladder continence had declined from always continent to frequently incontinent. *Section M indicated: -0.05 cm x 0.05 cm unstageable pressure injury with black eschar. -Repositioning program was not checked. -Nutrition program was not checked. A 9/23/17 ID note by LPN H indicated: *A reddened area to the resident's mid-back. *She had applied Duoderm to the area. *She would be encouraged to lie on her side. *There was no indication the physician or family had been notified. A 9/27/17 ID note by RN C indicated Area to right ear and right lower buttock are healed. There were no further skin assessments in the electronic record regarding skin conditions of the: *Right ear. *Coccyx. *Left lower buttock. A 9/27/17 skin evaluation form and ID note by RN C indicated: *A 2.0 cm x 2.0 cm red blanchable area to the bony prominence of the mid back. *Small pinpoint scabs within that area. *Sheepskin was applied to the back of her wheelchair. *Enc. (encourage) repo (repositioning) side to side. -There was no indication of the frequency of the repositioning. *Duoderm was applied to the area. *No indication the physician or family had been notified. A 10/4/17 skin evaluation program and ID note by RN C indicated the mid-back: *Was a stage two pressure injury. *It measured 3.0 cm x 3.0 cm with a 0.4 cm x 0.4 cm opened area. *Encourage to reposition, prefers to lay on back, W/C (wheelchair) has sheepskin on back of W/C. *There was no documentation of physician notification of the wound. A 10/12/17 quarterly MDS note by the MDS coordinator revealed: *She had a healing pressure injury to the right ear and an abrased area on her left buttock that had treatment plans. *There was no mention of the pressure injury to her mid-back. *She had a scoop mattress to prevent falls. *She had a pressure-reducing mattress. *A ROHO cushion and sheepskin were added to her wheelchair. *She was assisted with bed mobility. *A significant change comprehensive MDS had not been completed related to pressure injuries and significant weight loss. On 10/17/17 RN A faxed the physician stating: *Open area mid back on her spine. *[MEDICATION NAME] foam dressing applied. *The staff would change the dressing every three to five days and as needed. *The physician signed the fax. That treatment was placed on the October 2017 TAR. A 10/18/17 skin evaluation form and ID note by RN C indicated: *A 2.5 cm x 1.5 cm stage two opened area to her mid-back. *The area Shows no signs of healing. *There was an increased reddened surface around the wound. *She refused to reposition at times. *Duoderm was applied. On 10/24/17 a hospice plan of treatment was signed by the physician. The treatment order for decubitus wound care was Cleanse wound with wound cleanser, covered with Duoderm. An unsigned 10/25/17 skin monitoring form indicated resident 1 had a mid-back bony prominence stage 2 that measured 3 cm x 2.5 cm. Intervention areas on the form had identified hospice. No other skin areas or interventions were identified. A 10/26/17 physician's orders [REDACTED]. *She had an opened area to her mid-back over a bony prominence. *Treatment orders had included: -[MEDICATION NAME] foam dressing change every five days and as needed. -[MEDICATION NAME] spray was to have been applied before applying the dressing. -Border Gauze was to have been applied every five days and as needed to reddened areas on her right mid-back and left gluteal fold. LPN H had documented on 10/31/17: *A mid-back skin evaluation form by LPN H indicated the mid-back partial thickness wound now had two opened areas: -One area was 1 cm x 0.5cm. -One area was 1 cm x 0.8 cm. -The whole area was treated with border gauze and changed every five days and as needed. *An ID note indicated: -She had two red areas and border gauze was applied to those areas. -She had not documented where those areas were located or their measurements. RN C documented a mid-back skin evaluation form on 11/1/17 that indicated:*A stage two pressure ulcer on the mid-back with two areas measuring 1.5 cm x 1.0 cm each. -That area was dressed with a foam adhesive dressing. *A new pink, slow-blanching area to the right back measuring 3.0 cm x 1.0 cm. -That area was dressed with a border gauze. Review of the unsigned 11/1/17 skin monitoring form identified skin areas as above. There were no treatments or skin interventions identified. Review of the unsigned 11/8/17 skin monitoring form identified skin areas: *Mid-back stage two: Applied foam dressing to areas. *Right shoulder area stage one. *Face/Bottom. *The nursing interventions area indicated: -Foam drsg (dressing) applied to areas. -Reposition every two hours. Review of the unsigned 11/15/17 skin monitoring form identified: *Skin areas: -Mid-back. -Right shoulder. *The measurements included 2.5 cm x 2 cm. The form had not indicated which area had been measured. *The pressure injury stage box indicated unstageable. *Interventions included Foam dressings to both. An 11/15/17 ID note by LPN C stated: Unstageable to mid back area boney prominence area, same for rt. shoulder area blancable dressing on for protection. Review of the medical record revealed no dietitian notes were located from 7/8/17 through 11/20/17. Review of resident 1's revised 10/12/17 pressure ulcers care plan revealed: *She was at risk for pressure ulcers. *There was a scabbed pressure ulcer to her right ear. *There was a pressure ulcer to her [MEDICATION NAME] spine. *There was an abrased area to her left buttock. *All areas had treatment plans. *Interventions had included: -A Braden skin assessment was to have been completed. -Please monitor my skin daily during cares and bathing, and report any changes to my nurse. -Pressure-relieving devices included a mattress and a wheelchair cushion. -She was to have been assisted with repositioning. -The treatment plan was to have been followed. -The skin nurse was to have checked the skin weekly and documented any skin conditions. Review of resident 1's August, September, October, and November 2017 through 11/21/17 TARS revealed: *The August and September TARs had no skin treatments identified for: -The Duoderm that was applied to the coccyx on 8/17/17 and ordered on [DATE]. -The pressure injury to the ear that was identified 8/24/17. -The triple antibiotic ointment that was applied to the ear area on 9/12/17. -The Duoderm that was applied to the right lower buttock on 9/15/17. -The Duoderm that was applied to the mid-back on 9/23/17. *The October TAR had a 10/17/17 physician's orders [REDACTED]. That treatment had been signed as given on 10/17/17. -No other signature areas had been documented as given. *The October TAR had no skin treatments identified for the: -10/18/17 Duoderm that was applied to her mid-back. -10/24/17 hospice/physician's orders [REDACTED]. -10/26/17 physician's orders [REDACTED]. -10/26/17 physician's orders [REDACTED]. *The November TAR: -Had a 10/17/17 order for [MEDICATION NAME] foam to open area on spine. -There were no signatures on the TAR to indicate the treatment had been given in November. *The November TAR had no treatments identified for the: -10/26/17 physician's orders [REDACTED]. -10/26/17 physician's orders [REDACTED]. -treatment for [REDACTED]. -Left buttock pressure injury. Interview on 11/21/17 at 10:00 a.m. with RN A regarding certified nursing assistant's (CNA) documentation of repositioning revealed:*The CNAs were to have repositioned resident 1 every two hours. *They would have documented the repositioning in their electronic charting record. *RN A was unable to locate any CNA documentation of repositioning resident 1 in the CNA electronic charting record. Interview on 11/21/17 at 9:30 a.m. with resident 1's daughter regarding her pressure injuries revealed:*She and RN I had found a three-quarter inch scabbed pressure ulcer to her left tailbone when her mother had fallen on 8/16/17. *The nurse had apologized at that time for not having known the pressure injury had not been identified before the fall. *RN G had informed her later that evening she had seen the pressure injury weeks earlier but had not documented it. Interview on 11/21/17 at 10:50 a.m. with the MDS coordinator, DON, administrator, dietitian, certified dietary manager, RN B, and RN C regarding resident 1 revealed: *The MDS coordinator confirmed: -She had not completed a significant change in status MDS at the time of the 9/20/17 quarterly MDS, because she had not picked up on the significant changes in her status. -She confirmed the comprehensive significant change in status assessment should have been completed at that time. -The care plan had not been updated to include all of her skin concerns. -The care plan had not included a specific repositioning program, because all residents were to have been repositioned every two hours. -The CNAs had not documented when she was repositioned. -There was no repositioning policy. -There should have been a daily skin monitor sign-off on the TAR only if the care plan had indicated the skin was to have been monitored, -The care plan had indicated the skin was to have been monitored. -The TAR did not have an area to sign off daily skin monitoring. *RN B confirmed: -Resident 1 had a pressure injury on her coccyx prior to the fall on 8/16/17. -There was no skin documentation of the pressure injury or pressure injury treatment after the reddened area was noted on 6/22/17. *The dietitian confirmed: -She had not completed nutritional assessments from 7/8/17 through 11/20/17. -She would have been more involved with her nutritional status if she had been updated of worsened skin concerns when they had been identified. *The DON confirmed: -RN I was no longer employed with the provider. -The provider had a standing order for some skin treatments to have been used when a skin concern was identified. -Once the treatments had been utilized the nurse should have contacted the physician to notify him of a change in skin condition and approval of the orders to continue. -The physician's orders [REDACTED]. -The wound treatments should have been transcribed onto the TARs at the time the orders were received or changed. -The nurses should have documented skin treatments and dressing changes on the TAR each time the treatment was completed. -The current pressure ulcer policy and care of residents at risk for pressure injuries required revision. *The administrator was not aware the hospice provider was unable to access the electronic medical record. 2. Review of resident 2's medical record revealed: *An admission date of [DATE]. *[DIAGNOSES REDACTED]. *He developed a pressure injury to his right heel in September 2017 that was 3 months after his admission. *The Braden Scale For Predicting Pressure Sore Risk on 9/27/17 revealed a score of eighteen indicating he was at risk for developing a pressure injury. *physician's orders [REDACTED]. Review of the Treatment Administration Record (TAR) from 9/19/17 through 9/30/17 showed documentation for [MEDICATION NAME] to the heel injury had been applied twice out of eleven days. -physician's orders [REDACTED]. *Review of the TAR for 10/3/17 through 10/31/17 showed documentation for [MEDICATION NAME] to the heel injury at 8:00 a.m. had been applied eighteen out of twenty-eight mornings and at 8:00 p.m. had been applied twenty-five out of the twenty-nine evenings. *Review of the TAR for 11/1/17 through 11/19/17 showed documentation for [MEDICATION NAME] to the heel injury at 7:00 a.m. had been applied twice out of nineteen mornings and at 8:00 p.m. had been applied four times out of the nineteen evenings. *Daily report sheet from 11/20/17 through 11/26/17 showed treatment plan for repositioning every two hours. -There was no documentation during that time frame supporting repositioning every two hours. Review of resident 2's interdisciplinary progress notes from 9/20/17 through 11/19/17 revealed: skin assessments had been completed on 9/20/17, 10/1/17, 10/18/17. 10/22/17, 11/01/17, 11/15/17. Review of resident 2's undated care plan revealed: *A stage two pressure ulcer on his right inner heel. *Monitor my skin daily during cares and bathing, and report any changes to my nurse. -There was no documentation in the medical record supporting daily skin monitoring had been done. Observation on 11/20/17 at 2:15 p.m. of resident 2 in his room revealed: *He was in bed on his back. *His bed had been lowered to the floor with a fall mat in place. *He had heel protectors on both feet. Interview and observation during care provided on 11/20/17 at 2:15 p.m. by certified nursing assistant (CNA) E regarding resident 2's skin assessments revealed: *His heel was checked daily but was not documented daily. *He had a solid black area on his right heal. *The area was clean and dry with yellow around the edges from dried [MEDICATION NAME]. *CNA's report observations with care to the charge nurse. Interview on 11/20/17 at 3:00 p.m. with registered nurse (RN) C regarding resident 2's skin assessments revealed she: *Had done a skin assessment daily. *Had charted on the treatment sheet. *Was unaware if that sheet became a part of the resident's medical record. Interview on 11/21/17 at 9:14 a.m. with CNA E regarding resident 2's repositioning revealed: *The daily report sheet stated he was to be repositioned every two hours. *He should have had an hourly check sheet when the repositioning was initiated. *They were to have documented repositioning him every two hours. *She confirmed he did not have an hourly check sheet on the back of his bathroom door. Interview on 11/21/17 at 10:50 a.m. with the director of nursing (DON) regarding resident 2's skin assessment and treatment charting revealed: *The charge nurse was to document skin assessments daily in the interdisciplinary progress notes. *There had been no daily documentation done. *The charge nurse was to document all skin treatments on the TAR. *There had been forty-six treatment dates between 10/3/17 through 11/19/17 with no documentation on the TAR. *She agreed documentation had been a problem. *Her expectations were for staff to document all skin assessments and treatments. Interview on 11/21/17 at 11:00 with the Minimum Data Set (MDS) coordinator regarding resident 2's skin assessment and treatment charting revealed: *The charge nurse was to document: -Daily skin assessments in the interdisciplinary progress notes. -Treatments on the TAR. *There had been forty-six treatment dates between 10/3/17 through 11/19/17 with no documentation on the TAR. *Due to time issues repositioning was not documented every two hours. -That should have been done. *She agreed documentation had been a problem. *Her expectations were for staff to document all skin assessments and treatments. Interview on 11/21/17 at 11:10 a.m. with the registered dietician (RD) regarding resident 2's dietary needs revealed: *His undated care plan stated Promote good sources of protein in my diet as well as good healthy choices and adequate (po) oral fluids. *She had educated him to increase his protein intake and to make good food choices. *She agreed she had not documented all the conversations she had with him. *She only documented if there was a change in his dietary needs. Interview on 11/21/17 at 11:20 a.m. with licensed practical nurse (LPN) B regarding resident 2's skin assessment charting revealed: *Every Wednesday skin assessments were to have been done and documented in the interdisciplinary progress notes. *She agreed documentation was missing. 3. Observation and interview on 11/20/17 at 3:15 p.m. in resident 4's room revealed: *She spent all of her time in the recliner, including sleep time. *There was a pink cast on her right lower leg. *There was not a pressure relieving device behind her back in the recliner. Review of resident 4's medical record revealed: *A 11/6/17 admitted . *[DIAGNOSES REDACTED]. Review of the following ID notes for resident 4 revealed on: *11/8/17: Wound care: has 1.0 cm x 1.0 cm pink slow blanching area to bony prominence on mid back. Duo derm applied, faxed PCP (personal care physician). *11/15/17: Mid back area is good duoderm removed and blances good. Review of the 11/9/17 signed physician's fax order regarding resident 4 revealed the physician agreed with the orders for duoderm, change every 3-5 days and PRN if becomes soiled or no longer lays flat. Review of the 11/6/17 Braden Scale for Predicting Pressure Sore Risk assessment for resident 4 revealed a score of sixteen indicating she was at risk for pressure injury development. Review of resident 4's 11/6/17 care plan revealed: *Category: 12 Nutritional Status: -There were no category, interventions, or goals for pressure injuries. Interview on 11/20/17 at 3:40 p.m. with the MDS coordinator and the administrator regarding resident 4 revealed: *The care plan had not been updated to reflect the current skin issues but should have been. *Both agreed the staff would not have known she had skin concerns, since it had not been on her care plan. Interview on 11/20/17 at 4:10 p.m. with the DON regarding resident 4 revealed: *Weekly skin rounds were done on Wednesdays. *The results of the skin rounds were documented in the ID notes or the skin sheet. *They had hired a physical therapist on 11/17/17 to be the wound consultant. *The current pressure ulcer policy and procedure given to the surveyors was three-fourths of a page. *Her expectations would have been to provide more information on that policy. *She agreed the RD should have been notified when resident 4 had developed the pressure injury. *She would have expected the charge nurse to know where and how to find the care plans. Interview on 11/21/17 at 9:00 a.m. with LPN B revealed she was not the wound nurse. Interview on 11/21/17 at 10:15 a.m. with the DON regarding resident 4 revealed whoever found the pressure injury (charge nurse) was responsible to let the RD and certified dietary manager know. Interview on 11/21/17 at 10:50 a.m. with the DON, administrator, MDS nurse, RD, clinical CDM, LPN B, and RN D regarding resident 4 revealed: *An initial skin assessment had not been completed. *The RD should have been notified regarding the Braden score of sixteen. *They had considered her a risk for skin breakdown due to the Braden score, immobility due to right lower leg fracture, and she spent most of her time in the recliner. *The pressure injury had not been care planned and should have been. *There were no interventions in place to prevent skin breakdown. *There was no place documented regarding the charge nurse being responsible to fill out care plans or skin sheets. *The wound sheet should have been filled out on 11/8/17 when the pressure injury had been discovered. *There was no job description or policy indicating what charge nurses were responsible for with documenting skin injuries. *There was no one designated as the wound nurse. *There was no one designated to follow-up on the charge nurses pressure injury documentation. *The DON agreed the Pressure Ulcer policy needed to be tweaked. 4. Review of the provider's 11/1/09 Pressure Ulcer Risk Assessments policy and procedure revealed: *Any resident having pressure sores will receive the necessary treatment and services to promote healing, prevent infection, and prevent new sores from developing. *Purpose: -1. To recognize and define our at-risk population for development of pressure ulcers. -2. To prevent pressure ulcers from developing by implementing a prevention protocol. *Procedure -1. Upon admission an initial risk assessment will be done by the admitting nurse using the Braden Scale. -2. Individualized protocols will be initiated bases on the results of this tool. -3. Protocls will be included in the individualized care plan and on the resident's MDS. -5. If the resident already has an existing pressure ulcer, or develops a pressure ulcer, the nurse on duty will initiate treatment and contact the resident's primary care provider. The Wound/Skin Care Team will be notified and will follow. Treatment will be added to the care plan and the existence of the ulcer will be added to the MDS. Review of the June 2007 Charge Nurse job description revealed: *Essential Duties and Responsibilities: -Evaluate and/or assesses residents on admission to develop interim care plan and further assesses in depth to contribute to the complete care plan. Updates care plans as warranted and required. -Evaluates and/or assesses residents and analyzes obtained information to develop appropriate interventions to prevent decline per scope of practice; records signs of change in condition; notifies appropriate staff of changes; observes conditions that indicate possible need for other nursing programs and then notifies appropriate staff per facility protocol of the need for evaluation; informs the physician of changes in conditions when appropriate. Review of the undated MDS Coordinator job description revealed: *Essential Duties and Responsibilities: -Perform the initial interview and assess new residents. From this

Based on observation, record review, interview, and policy review, the provider failed to ensure neglect had not occurred for one of four sampled residents (2) with fractures resulting from falls. Findings include: 1a. Observation on 11/29/16 at 8:40 a.m. revealed: *Resident 2 was being wheeled to the dining room in a wheelchair by a staff member. *His face had multiple areas of bruising surrounding his eyes and cheeks. *A back brace had been applied and was surrounding his chest and back. Review of resident 2's medical record revealed a fall had occurred on 11/20/16 at 1:00 p.m. An interdisciplinary note dated 11/20/16 at 3:44 p.m. by RN C indicated:*Resident 2 was attempting to self-transfer from the toilet to the wheelchair and fell forward and down onto the floor. *He had hit his head and had multiple abrasions and skin tears. *His vital signs were obtained and neurological checks were normal. *His abrasions were treated, and the nurse notified the family and physician. Review of an Incident Investigation Tool: Fall/Found on Floor document signed by RN C and certified nursing assistant (CNA) E revealed: *The resident was found on his stomach in the bathroom on 11/20/16 at approximately 1:00 p.m. by CNA E. *She had seen the resident five minutes before the incident. *The last call light reset was 11/20/16 at 12:47 p.m. *The contributing factor to the fall had been the resident not using the call light to ask for assistance. *To reduce the likelihood of another incident the staff would remind the resident to use the call light and wait for assistance. *The resident had multiple skin tears and abrasions. *Regarding whether the incident was serious, a NO was circled. *The assessing nurse had circled NO regarding whether she felt there was suspicion of neglect of abuse. *The care plan had not been updated. *On the bottom of the report the social worker signed the report and indicated: -She met with the resident on 11/21/16 at 10:10 a.m. and reviewed the incident. -He had not recalled the fall. -Signage was placed in the bathroom to remind him to Call Don't Fall. *A narrative report attached to the computer generated incident report and signed by CNA E revealed:-CNA E had responded to resident 2's call light. -She placed him on the toilet to urinate. -She cued him to sit on the toilet. -He was wearing oxygen tubing attached to the wheelchair. -Because of the tubing she had positioned the chair under the sink and locked the brakes. -He had his call pendant and the wall call light accessible beside him. -CNA E left the room to assist another resident in the same hallway. -CNA E heard resident 2 yelling help get me up and returned to his room no more than five minutes after leaving the room. -She found resident 2 on the bathroom floor with his head toward the door, laying on his stomach. His pants were below his kneecaps. -She stated he was usually good to use his call light after toileting. -She then called for assistance. An interdisciplinary note on 11/22/16 at 2:45 a.m. by RN D indicated the resident had increased edema and bruising around the eyes. He reported pain by his left ear and had a slight temperature of 99.5 degrees Fahrenheit. At that time the nurse called the family and physician, and he was sent to the emergency department for evaluation and later admitted for observation. Review of the 11/22/16 hospital history and physical revealed resident 2 presented with neck pain and head trauma after a fall. Injuries included:*A new traumatic T10 compression fracture. *A hematoma and laceration to the front of the head. *Fractures to the left eighth and ninth ribs. *A subacute fracture (not new) to T6. *A five centimeter skin tear to the left elbow. *An abrasion to the left knee. *Multiple areas throughout the body of bruising including bruising around both eyes. *The resident was admitted for observation. Review of the 11/22/16 initial Healthcare Online Self Reporting form documented by the social worker revealed: *The type of event being reported was Suspicion/Allegation of Abuse/Neglect. *Under the Suspicion/Allegation of Abuse/Neglect the social worker had documented We don't find concern of abuse/neglect; rather, an unwitnessed fall with hospitalization .*The incident had occurred on 11/20/16 at 1:00 p.m. *Resident 2 fell while trying to get off the toilet. -He had multiple abrasions and skin tears. -The falls review committee met on 11/21/16 to review the fall. *The social worker followed-up with the resident to discuss Call Don't Fall signage that was posted as a result of the fall. *The allegation had not involved facility personnel. *The report had been completed on 11/22/16, after the resident was transferred to the hospital. *Resident 2 was readmitted to the facility on [DATE]. Review of the unfinished 5-day health facility event report revealed on 11/28/16 the administrator, director of nursing (DON), social worker, and resident care supervisor (RCS) reviewed the incident report again at the Falls Review Committee meeting due to the resident's return on 11/25/16. It was decided at that time to have staff remain with the resident when he was toileted. Interview on 11/29/16 at 7:20 a.m. with the administrator regarding resident 2's 11/20/16 fall revealed: *The resident had returned to the facility on [DATE]. *The decision was made on 11/28/16 to stay with the resident when he toileted. *Staff had not previously stayed in the room with the resident during toileting because He had always been good about using a call light prior to the 11/20/16 fall. *The CNA had remained in the same hall while he toileted. *Event reporting had not been completed at the time of the fall, because the resident had not needed outside medical interventions. *The event reporting was done after he had gone to the emergency room . *The interdisciplinary team reviewed the fall on 11/21/16 and began the Falling Leaf Program. -There was no policy for the program, but the program could stand as a policy. - The program was developed to alert staff and the resident at risk of falls to be mindful of the risk. *Signage was placed in the resident's room, and a falling leaf magnet was attached to the resident's door and wheelchair or walker to alert staff the resident was at risk for falls. *The interdisciplinary team was aware of fall concerns at the facility, and there were plans to bring in a third party next month for an in-service on fall prevention. Review of his updated 11/25/16 care plan revealed:*His cognitive status was Alert and oriented to self and family with some confusion and path-finding issues. *His ADL baseline was extensive assistance. *He no longer walked in his room. *He was not able to use a urinal effectively. *Staff was to offer toileting assistance upon rising, before and after meals, at bedtime, and as needed. *He was a fall risk and had a history of [REDACTED]. *I would like to avoid falls, or if falls occur, I would like interventions to reduce my fall risk. Those interventions included:-Ensuring the call light was within reach and staff to encourage him to use it. -Call Don't Fall signage posted in his bathroom. -Providing assistance with transfers, bed mobility, and other ADLs. -On 11/25/16 he was placed on a Falling Leaf Program to promote personal freedom and safety for residents with impaired mobility. A leaf magnet was placed on the resident's door, and a leaf was placed on the handle of the wheelchair and walker. Interview on 11/29/16 at 2:30 p.m. with CNA/unlicensed assistive personal A revealed: *She was working as a UAP on 11/20/16. *She often worked in resident 2's hallway. *If she needed to know how to take care of a resident she would look at the care plan. *The kiosk where the CNAs did their daily documentation had the resident's care plan on it. Any new information that was added to the care plan popped up as they were documenting their resident's care for the day. *Other areas to look for care changes were the nursing twenty-four hour sheet and the individualized compact care plan. *Resident 2 was to have been assisted with toileting with one staff member. Staff members were not required to stay with him while he toileted until 11/28/16. *She was not comfortable leaving him alone while he toileted because of his confusion, so she usually remained in the room until he was done. She had done that even before his fall on 11/20/16. *He preferred a urinal rather than getting up to toilet, but that had been removed from the room because he spilled urine. CNA E was unavailable for interview during the survey. b. Review of resident 2's medical record revealed a fall had occurred on 8/29/16. Review of the incident report revealed: *The fall was unwitnessed. *He was found at 2:30 a.m. by his bathroom door after he had attempted to walk to the bathroom by himself. *He had a cut on his left lower leg. *He was transported to an emergency department at 3:20 a.m. for treatment of [REDACTED]. *He returned from the emergency department on 8/29/16 after he had been treated. Review of his 9/14/16 annual Minimum Data Set (MDS) assessment revealed he: *Had a fall with a major injury since the 6/15/16 assessment. *Had [DIAGNOSES REDACTED]. *Required extensive assistance of one staff member for bed mobility, transfers, toileting, dressing, and eating. *Had not walked during the 9/14/16 assessment period. *Had a [DIAGNOSES REDACTED]. *His balance was not steady when moving: -On and off the toilet. -From a seated surface to a standing position. *His Brief Interview of Mental Status (BIMS) score was seven, indicating his mental status was severely impaired. Review of the interdisciplinary notes revealed: *A 10/3/16 annual review documented by the social worker had indicated: -A BIMS score was seven, Trending to the poorer as 13 (cognitively intact) a year ago. -His BIMS scores in March 2016 and June 2016 were six. *The provider received an email on 10/1/16 from his son indicating, It seems Dad is having even more trouble with reality as he had been talking as if he is still working on sales business and insurance. A 10/3/16 annual MDS review by the MDS coordinator revealed:*He continued to require extensive assistance with most activities of daily living (ADL) care and with bathing. *On 8/29/16 he fell and received a laceration to his leg and fx (fractures) T6 and L3. *He is a high fall risk. Review of the 6/15/16 Fall Risk Assessment by the MDS coordinator revealed: *He walked and was incontinent. It did not specify what type of incontinence. *He was not able to perform a gait and balance test. *A fall risk score of seventeen. *A score of ten or above indicated a high risk for falls. Review of the 9/14/16 Fall Risk Assessment by the MDS coordinator revealed: *He walked and was incontinent. It did not specify what type of incontinence.*He was not able to perform a gait and balance test. *A fall risk score of twenty. A 10/7/16 Care Conference Check List document signed by the MDS coordinator indicated:*The social worker and MDS coordinator had attended the care conference. *No ambulation since fall on 8/29/16. *The social worker had documented his cognitive screen results suggested severe impairment. The cognitive scoring had declined over time. *The resident's spouse and son reported worsened mental impairment. *High risk for falls - poor safety awareness. c. Interview on 11/29/16 at 4:00 p.m. with the administrator, MDS coordinator, RCS, social worker, and DON revealed:*When asked who was responsible for ensuring the care plan was updated and ensuring the residents received safe care revealed the above interdisciplinary team worked together to ensure care was done. *The nursing care plan was updated by both the MDS coordinator, the RCS, and other nurses performing care to the resident, depending on what care was required. *Other care plan updates were done by the discipline in charge of that area. *The MDS coordinator usually did the fall assessments. *In regard to resident 2 requiring extensive assistance with toileting the administrator, DON, MDS coordinator, and RCS stated staff were not required to remain with resident 2 while he toileted. It was decided on 11/28/16 staff should remain with him. *The social worker stated: - His cognitive decline had occurred recently, especially with increased oxygen requirements. -She was aware the BIMS scores had declined for several months previous to the first fall on 8/29/16 that had resulted in injury. *The RCS stated:-She believed the resident was still safe to remain on the toilet at the time of the second fall. -In hindsight after the two falls it had been decided he was not safe to leave alone. -Some residents with poor BIMS scores were safe to leave unassisted in the bathroom, while some residents with higher scores were not safe alone. -The provider would not have enough staff to remain with every severely cognitively impaired resident while they toileted. *The MDS coordinator had done the 9/14/16 Fall Assessment indicating a score of twenty. She: -Was aware her documentation of the care conference had indicated a high risk of falls and poor safety awareness. -Felt he was still safe to remain alone while he toileted. -Stated the staff could not be available to stay with all cognitively impaired residents while they toileted, because they would never get their work done. *The DON stated she believed CNA E had felt she had done the correct thing to push the wheelchair away from the resident and lock the brakes when she left the room to prevent him from falling. Review of the provider's undated Falling Leaf Program revealed: *The goal was to meet the needs and expectations of the resident while keeping them safe. *The program had indicated: -All associates are to be aware of their responsibility in preventing resident falls from occurring. -Provide assistance to residents who are attempting an unsafe transfer or who are in distress. -If you are unable to assist, request assistance for the resident and say with them until help arrives. -Report unsafe resident situations to the charge nurse. Review of the provider's 2/24/15 Accident Prevention and Investigation policy and procedure revealed the policy was developed for tracking accidents to employees, students, visitors, and volunteers. No fall policy or safe transfer policy had been provided upon request of the administrator. Review of the 1/30/01 Resident Rights in the admission packet revealed: *The Nursing Home Reform Law required the provider to care for its residents In such a manner and environment as will promote maintenance or enhancement of the quality of life of each resident. *The resident had the right to be free from neglect. Review of the 9/22/14 Abuse Prevention, Intervention, Reporting, and Investigation policy and procedure revealed: *Residents were to have been free from neglect. *Neglect is defined as failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness. May be intentional such as withholding or omitting care or unintentional where the caregiver should have known that care was needed, but it was not provided. *If neglect is suspected, a determination is made as to what services were not provided and what physical harm, mental anguish, mental illness, or deterioration in the resident's mental or physical condition resulted. Also, neglect is evaluated as a result of indifference, carelessness, or deliberate negligence.

Based on observation, record review, interview, and policy reviews, the provider failed to ensure nutritional interventions were followed for one of one sampled resident (3) who had significant weight loss. Findings include: 1. Review of resident 3's 2/7/10 physician's admission orders [REDACTED]. Review of resident 3's 2/1/12 hospital admission history and physical and 2/712 transfer sheet revealed she: *Was admitted for a urinary tract infection and a left [MEDICAL CONDITION] sustained from a fall. *had a history of [REDACTED]. *Had returned to the facility on [DATE] to receive skilled physical and occupation therapy. Observation of resident 3 from 3/27/12 through 3/28/12 and random interview with various certified nursing assistants (CNA) during that time revealed: *3/27/12, 1:00 p.m. A family member was pushing her in her wheelchair out to the dining room for her noon meal. The family member stated she needed to get out of bed and eat lunch, and had been uncooperative with the staff when they had attempted to get her out of bed. The resident did not receive a supplement at the noon meal. *3/27/12, 6:00 p.m. The resident was in bed sleeping. CNA F said the staff had attempted multiple times to get her up out of bed. She had refused and had been resistant. They would bring her a meal tray later when she woke up. If the resident was in bed she was often resistant to get up and go to the dining room for meals. *3/28/12, 8:00 a.m. The resident was in bed sleeping. CNA D stated the staff had attempted to get her up for breakfast, and she was resistant. She was going to try to get her up soon for her bath, and then would attempt to assist her with breakfast. She was often resistant with getting out of bed in the morning for breakfast. *3/28/12, 9:30 a.m. The resident was awake and had been assisted with her bath. After her bath at 10:15 a.m. CNA D assisted her with oatmeal and coffee. CNA D stated the resident had voiced she only wanted cereal. The resident was not offered a supplement with her breakfast meal. CNA D stated the resident had been given her bath prior to being assisted with her breakfast since she was so cooperative and would be cooperative for her bath. *3/28/12 11:30 a.m.- The resident was moving away from the table in the dining room prior to the noon meal. CNA C kept returning the resident in her wheelchair to the table. The nurse assisted her with four ounces of Two cal. The resident fell asleep in her wheelchair after drinking the Two cal. No staff member attempted for 20 minutes to awaken resident 3 for her noon meal. CNA C stated they did not bring her meal tray until her wheelchair was up to the table. The resident was often resistant with meals and staff would bring her a food tray later. *3/28/12, 12:00 noon The resident was assisted to eat three bites each of meat, potatoes, and vegetable. She consumed four ounces of supplement with staff assistance. *3/28/12 6:00 p.m. The resident was at a table in the dining room where no staff were providing assistance. She was attempting to use her knife to eat her dessert. She ate a few bites of pureed grilled cheese and soup. She drank coffee, water, and juice on her own (not in nosey cups). She did not receive any supplement with her meal. Observation from 3/28/12 through 3/29/12 of four meals revealed resident 3 sat at four different tables. Review of resident 3's weight record revealed the following weights: *1/10/12- 115.0 pounds (lb). *1/18/12- 111.5 lb. *1/25/12- 109.5 lb. *2/8/12- 109.5 lb. *2/15/12- 101.5 lb. *2/29/12- 97.5 lb. *3/8/12- 98.5 lb. *3/14/12- 97.0 lb. *3/21/12- 98.5 lb. *3/28/12- 96.5 lb. Review of resident 3's 1/19/12 through 2/27/12 dietary manager progress notes revealed: *1/19/12: -"Weight 111.5. -Her meal intake is about 50 percent (%) on a regular diet. -A lot of concerns stem from her leaving the table before she is finished. *She will be moved to a table where she can get extensive assistance if needed or just to stay on task." *2/23/12 -"Supplements offered with snacks. -Staff will look at adding supplements with meals versus with snacks. -Meal intake is about 50 % on average. -Talked with registered dietitian (RD) about changing supplements to three times a day (TID) at meals." *2/27/12 "Supplements are now being offered with meals." Review of resident 3's 1/26/12 through 2/12/12 RD's progress notes revealed: *1/26/12 -"Two cal (drink supplement) TID (three times a day). Magic Cup (supplement) between meals. -Averages 60 % of meals and 6-8 ounces of fluid per meal. Breakfast is her best meal. -Weight 109.5 lb. Weight down 6.8 % in one month, 8.8 % in three months, and 12.4 % in six months (significant weight loss). -We are going to offer her more assistance at meals." *2/9/12 -"Oral intake 25-50%. Needs full assistance to eat. -Weight 109.5. Weights better with recent additions of supplements in January 2012. -Fortified cereal at breakfast." *2/12/12 "Fax received from physician to change to pureed diet with nosey cups. Tray card and care plan updated." Review of resident 3's dietary card on 3/28/12 revealed: *"Four ounces Mighty Shake with breakfast, lunch, and supper. *Nosey cups should be used all three meals. *Eight ounces of 2% milk given with breakfast meal. *Four ounces of 2% milk given with lunch and supper meal." Review of resident 3's 2/27/12 care plan revealed: *Staff should have monitored for anxiety-if anxious she was less likely to follow instructions for completing activities of daily living. *Staff should have provided extensive assistance of one with meal, snacks, and consumption of fluids. Encourage the resident to do what she could for herself. *She received a pureed diet served to enhance intake and independence. *She sat at an assisted table and needed assistance with meals. *She could miss meals when she was very sleepy and day and evening. *She should have received Two cal supplement TID at medication pass. *Nosey cups in addition to a pureed diet should have been used. *Staff should have provided diet/supplement as prescribed by the medical doctor/RD. *Nutritional supplements should have been offered twice a day (BID) at meals. Snacks were to have been given TID per RD's recommendations. *Staff needed to offer encouragement and extensive cueing/assistance if she consumed less than 50%. *Staff should have provided and encouraged good nutrition and adequate oral fluid intake. Review of resident 3's care conference checklists revealed: *1/24/12: -"Significant weight loss. -Appetite fair. -Will now sit at an assisted table with much cueing. Keeping her at this table." *2/27/12: -"Significant weight loss. Weight 101.5 lb. Underweight. -Supplements at meals. Not eating well. -We assist with meals and snacks. -Pureed diet. Encourage fluids." Review of resident 3's March 2012 meal intake record revealed she: *Averaged two to ten ounces of liquids at meals. There was no documentation if she had consumed her supplement or the other liquids offered (milk, juice, water, or coffee). *Had no documentation of any fluids for fifteen meals. *Had room trays (RT) documented for fourteen meals. There was no documentation for those meals the % she had eaten or % of fluids she had drank. *Had no documentation of any food or fluid intake for two meals. *Had 0% food intake for one meal, 25% food intake for three meals, 50% food intake for twenty-two meals, 75% food intake for thirty-three meals, and 100% food intake for five meals. Review of resident 3's March 2012 behavior log documentation revealed: *Two episodes of uncooperativeness. - Day shift on 3/1/12 with improvement in her behavior after redirection. - Evening shift on 3/11/12 with no change in her behavior after redirection and changing her position. - There were no documented occurrences of resistance of getting out of bed to go to meals or of resistance with the staff when they had assisted her with meals. *There were six day shifts the behavior documentation log for uncooperativeness had not been completed. *There were seven evening shifts the behavior documentation log for uncooperativeness had not been completed. Review of resident 3's March 2012 activity of daily living sheet revealed there were fourteen meals there was no documentation she had been assisted with eating. Interview on 3/28/12 at 3:00 p.m. with the dietary manager regarding resident 3 revealed: *Her intake had declined since her return from the hospital on [DATE]. She usually required full staff assistance with meals. *Prior to her hospitalization the main problem was she would leave the table prior to completing her meals. *After the hospitalization she had talked to the RD, and they had initially added a supplement between meals. They were unsure of her acceptance of the supplement and had changed the supplements to be given with all three meals. *Since she had returned from the hospital her food intake was often less than 25 %. *She thought the resident usually took the liquid supplements well at meals, but there was no documentation to support that. The staff would only document the total amount of ounces consumed at each meal (that could either be the supplement, coffee, water, juice, or milk). *They had not placed her on a fortified diet (adding more calories without adding supplement), because she had been eating so poorly. *When she would not get up for a meal, a tray was placed in the refrigerator in the staff break room. She would check that the tray had been taken to the resident's room. If the tray remained in the refrigerator she knew either the resident had refused it altogether, or the staff had just not taken it to the room. *The trays that were taken to the resident's room did not have food or fluid intakes documented. *The resident was on the nutrition-at-risk list and was reviewed monthly by the RD. She would phone the RD in-between with any questions or concerns she had. *She was often in the dining room and monitored the intakes of the residents, especially those with poor intake or weight loss. *She usually reviewed the resident's weight record when she was getting prepared for the monthly Quality of Life meeting. *The bath aide usually weighed the residents weekly on their bath day and recorded the weights on their flow record. If a significant weight discrepancy was noted, the nursing staff would usually re-weigh the resident and record the re-weight. Interview on 3/29/12 at 9:45 a.m. with the RD regarding resident 3 revealed she: *Was aware of her declining weight and intake since her return from the hospital on [DATE]. *Confirmed the above interview with the dietary manager that they had changed her supplements to be given at all three meals instead of in-between meals. She should have been offered the Mighty Shake at all meals. *Had recommended resident 3 receive four ounces of mighty shake at all meals and the four ounces of Two cal TID given by the nurses with medications. *Had recommended a nosey cup be used for all fluids. *Had been working with the dietary manager on developing a plan that room trays would be documented as to the amount of food and fluids consumed. Interview on 3/29/12 at 11:30 a.m. with the director of nursing confirmed: *Staff should have been assisting resident 3 with all her meals at the same table. *Resident 3's behaviors had not been consistently documented related to her resistance with getting up for meals and staff assistance. Review of the provider's 5/21/09 Resident Weight policy revealed "If a variance of five or more pounds is noted, rebalance the scale and re-weigh the resident immediately. Notify the charge nurse of teh gain or loss." Review of the provider's 10/1/10 Nutrition policy revealed: *The RD or DM would include documentation of nutrition supplements in the medical record. *The RD or DM would routinely monitor the continued need, tolerance and/or acceptance of the medical nutrition supplement by the resident.

Based on record review, interview, and policy review, the provider failed to prevent a pressure ulcer and maintain treatment to prevent further breakdown of that ulcer for one of three sampled residents (2), and to notify the physician of the status of the pressure ulcer including the response to the treatment. Findings include: 1. Review of resident 2's weekly pressure ulcer record on the following dates revealed: *On 1/20/12 - A stage 1 pressure ulcer to the right of her coccyx that measured 2 centimeters (cm). Wound bed was white. -Treatment had been to leave the site open to air. -Nutritional status had been marked that her food intake was below 50%, she had been losing weight, and she had been above her ideal body weight. -Preventive measures had been to turn her every two hours, a pressure relieving mattress on her bed, and to administer multivitamins with zinc. -The box to check if a physician had been notified was blank. *On 1/24/12 - A stage I pressure ulcer with the same measurement as 1/20/12, wound bed was red, and wound edges were rolled. -Treatment had been to leave open to air. -Nutritional status had been marked that her food intake was below 50%, skin turgor had been poor, she had been losing weight, and had been below ideal body weight. -Preventive measures had been to turn her every two hours, pressure relieving mattress on her bed, and high protein supplements. -The box to check if a physician had been notified was blank. *On 2/1/12 - A stage II pressure ulcer measuring 1.6 cm x 1.0 cm, at the same location and worsening, wound bed had been described as "slough", and wound edges were rolled. -Treatment had been to leave open to air and turn her on her side. -Nutritional status had been marked as above ideal body weight, losing weight, food intake at 50-75%, and good skin turgor. -Preventive measures had been pressure relieving interventions of mattress, wheelchair cushions, and high protein supplements. -The box to check if a physician had been notified was blank. *On 3/14/12 - A stage II pressure ulcer measuring 1.0 x 1.0 cm., wound bed had been described as "slough", and wound edges were rolled. -Treatment had been application of [MEDICATION NAME] dressing. -Nutritional status had been marked as above ideal weight, losing weight, food intake at 50-75% with good skin turgor. -Preventive measures had been the same as 2/1/12. -The box to check if a physician had been notified was blank. *On 3/21/12 - An unstaged pressure ulcer measuring 1.0 x 1.0 cm., in the same location, wound bed had been described as "slough", and wound edges were not described. -Treatment had been application of [MEDICATION NAME] dressing. -Nutritional status had not been described. -Preventive measures had been the same as 3/14/12. -The box to check if a physician had been notified was blank. *On 3/23/12 - Onset of a stage II pressure ulcer on her coccyx measuring 4 x 4 cms.,wound bed had been described as "sloughed pink", wound edges were rolled, and surrounding tissue was black and gray. -Treatment had not been described. -Nutritional status had not been described. -Preventive measures had not been described. -The box to check if a physician had been notified was blank. Review of resident 2's following monthly summary records revealed: *On 1/21/12-The skin condition had been described as dry and fragile. Pressure ulcer box was not checked. *On 2/29/12-The skin condition had been described as dry and fragile. Pressure ulcer box had not been checked. *On 3/19/12-The skin condition had been described as dry and fragile. Pressure ulcer box had not been checked. Review of resident 2's care conference checklist dated 1/25/12 revealed: *"Stage I pressure ulcer on buttock-will monitor weekly. Has protein supplement but hasn't been eating well. Will get pressure reduction mattress for her bed." Review of resident 2's care area assessment summary dated 1/25/12 revealed *Will proceed to care plan to minimize risk for pressure ulcer or other skin breakdown, treat present ulcer to assist to assure that it does not worsen and heals without complications." Review of resident 2's care plan dated 1/25/12 revealed: *A goal for the stage I pressure ulcer to heal without complications. *Approaches included: good nutrition, adequate fluids, extra protein, assistance from staff to reposition or shift weight in chair and bed every two hours, and skin checked during pericare and baths with problems reported to charge nurse. Review of resident 2's nurses notes revealed: *On 1/23/12 a facsimile (fax) had been received from the physician to increase her antidepressant after the nurses had reported she had been sleeping more, and her appetite had been decreased. -Pressure ulcer had not been addressed. *On 1/31/12 the physician decreased a pain medication, because nurses reported she was more lethargic. -Pressure ulcer had not been addressed. *On 2/14/12 two physicians visited resident 2 and administered cortisone injections for a painful shoulder. -Pressure ulcer had not been addressed. *On 3/17/12 the physician had been notified she had shortness of breath and nausea. -Pressure ulcer had not been addressed. *On 3/19/12 a fax had been sent to the physician requesting a medication. -Pressure ulcer had not been addressed. *On 3/23/12 orders had been received from the physician for a dressing to the coccyx after the physician had received a fax with the message the resident had gotten an open wound on the coccyx that measured 4 x 4 cm. Dressing had been ordered to be changed daily for a week and then reassessed. Interview on 3/29/12 at 9:00 a.m. with the Minimum Data Set (MDS) coordinator revealed: *The skin team met every week for every resident with skin breakdown. *The skin team included the DON, assistant DON, dietary manager, charge nurses, and the MDS coordinator. *The skin team learned about the residents with skin breakdown from the nursing report and/or verbally from staff. *The skin team reported to the committee for quality improvement (CQI) quarterly. *The nurses who made rounds with the skin team reported to the physician. *She agreed there was no documentation the physician had been aware of resident 2's pressure ulcer until 3/23/12, and there had been no nursing documentation of the site. Interview on 3/29/12 at 9:15 a.m. with the assistant DON revealed: *She agreed she did not find documentation the physician had been aware of the pressure ulcer until 3/23/12. *She agreed there had been no nursing documentation describing the pressure ulcer site. Interview on 3/29/12 at 9:30 a.m. with DON revealed she agreed: *There had been no documentation the physician had been aware of the pressure ulcer until 3/23/12 when the dressing for the wound had been ordered. *There had been no documentation the skin team had seen the pressure ulcer from 2/1/12 to 3/14/12. *There had been no nursing documentation describing the pressure ulcer. *That there had been no new approaches for care of the pressure ulcer when there had been no improvement. Review of the provider's 11/1/09 policy and procedure regarding pressure ulcer risk assessments revealed: *"It is the policy of (facility) to assure that a resident who enters the nursing home at (facility) does not develop pressure ulcers unless that individual 's clinical condition demonstrates that they were unavoidable. Any resident having pressure sores will receive the necessary treatment and services to promote healing, prevent infection, and prevent new sores from developing."