Every finding on record at East View Healthcare

Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 12 residents (Resident #1) reviewed for infection control.CNA A failed to use Enhanced Barrier Precautions prior to providing perineal care: a high-contact resident care activity for Resident #1 who had a wound and a dialysis catheter (an indwelling medical device). CNA A failed to change gloves, perform hand hygiene after perineal care, and prior to touching clean items for Resident #1.The failure could place residents who require assistance with toileting needs and Enhanced Barrier Precautions at risk of infection and a decline in health.Findings included:Record review of Resident #1's face sheet revealed a [AGE] year-old admitted to the facility on [DATE] and initially admitted on [DATE]. Resident #1's diagnoses included Acute myeloblastic leukemia (fast-progressing cancer of the bone marrow), ESBL resistance (bacteria that have developed resistance to many common antibiotics, making infections harder to treat), urinary tract infection, cirrhosis of the liver (abnormal liver function), diabetes, dependence on renal dialysis, pneumonia, anemia, heart failure, presence of implantable cardiac defibrillator and dementia.Record review of Resident #1's admission MDS dated [DATE] revealed a BIMS score of 12 out of 15 indicating moderately impaired cognition. Resident #1 required substantial/maximum assistance from staff for toileting hygiene. Resident #1 was always incontinent of bowel and bladder.Record review of Resident #1's undated care plan revealed: Focus - Resident #1 was readmitted with a urinary tract infection/ESBL (date initiated 07/10/26). Interventions included - check for incontinence. Wash rinse and dry soiled areas. Focus - Resident #1 had bowel/bladder incontinence r/t impaired mobility and decreased control. Interventions included: Monitor/document for s/sx UTI: pain, burning, deepening of urine color, foul smelling urine and altered mental status. Place call light in reach and assist with incontinent care as needed. Focus - Resident #1 had a diabetic ulcer to the right heel. Goal - Ulcer will improve by review date. Interventions included - Use Enhanced Barrier Precautions. Focus - Resident #1 needed hemodialysis r/t renal failure. Interventions included - Use Enhanced Barrier Precautions. Observation on 08/11/26 at 11:15 AM, Resident #1's room had a posted sign for Enhanced Barrier Precaution outside the door. The instructions on the sign included: Providers and staff must also: wear gloves and a gown for the following High-Contact Resident Care Activities - dressing, bathing/showering, transferring, changing linens, providing hygiene, changing briefs or assisting with toileting; device care use: central line, urinary catheter, feeding tube, tracheostomy; Wound care: any skin opening requiring a dressing. A cart containing disposable gloves and gowns was in the hallway nearby Resident #1's room. CNA A put on clean gloves and did not put on a gown prior to starting incontinent care for Resident #1. LVN B, who was also in Resident #1's room preparing to perform wound care, donned a gown and gloves. Resident #1 was awake, alert and able to help with bed mobility during incontinent care. CNA A performed hand hygiene, put on clean gloves and unfastened Resident #1's brief. CNA A cleansed Resident #1's penis, right groin, and left groin using clean disposable wipes for each area. Resident #1 rolled to his left side. CNA A cleansed the buttocks and rectal area with clean disposable wipes for each area. CNA A removed the soiled brief then touched the clean brief and positioned it under Resident #1's hips. CNA A secured the clean brief then touched clean shorts and a t-shirt then assisted the resident with dressing. CNA A did not remove the dirty gloves, perform hand hygiene, or put on clean gloves prior to handling clean items. CNA A gathered the trash bag with soiled items, removed the gloves, and took the trash bag to the soiled linen room then performed hand hygiene.In an interview on 08/11/26 at 11:30 AM, LVN B stated she put on gloves and gown prior to wound care because Resident #1 had a wound and a dialysis catheter. LVN B stated that anytime resident care was performed by nursing staff, gowns and gloves were required for infection control purposes.In an interview on 08/11/26 at 11:50 AM, CNA A stated that the signs for Enhanced Barrier Precautions on Resident #1's door meant wearing gloves and proper PPE were needed prior to providing care to prevent the spread of infection. When asked, what the reason was for not wearing a gown when providing perineal care for Resident #1, CNA A stated there was no PPE cart at the door to Resident #1's room and usually there would be one. CNA A stated she should have looked for a gown to put on, but she was nervous and had been busy earlier helping many residents at the same time, that she just forgot and that was not a good excuse.In an interview on 8/11/26 at 1:20 PM, CNA A stated she would change gloves if visibly soiled. CNA A stated for Resident #1 the gloves were dirty after incontinent care and she should have removed them, performed hand hygiene then put on clean gloves. CNA A stated the gloves were dirty after handling the soiled brief and should not be used to touch the clean brief or the residents' bed linen to prevent cross contamination. CNA A stated she did not realize she touched clean items with dirty, used gloves. CNA A stated she had been working for 3 weeks and started at the facility on 07/17/26. CNA A stated in-services on incontinent care was completed during orientation as group in-services and conducted by the DON, nurses and HR personnel.In an interview on 8/11/26 at 2:15 PM, the DON stated she expected the CNA to change gloves after touching a soiled brief during incontinent care to prevent contaminating clean items. The DON stated this was the facility's policy, and moving forward, in-services for incontinent/perineal care will be conducted with CNA A.In an interview on 08/12/26 at 9:50 AM, the DON stated that residents who were placed on EBP were ones who had IV's, dialysis accesses, open wounds, and residents who had a history of MDRO's. The DON stated she expected that when staff provided direct care that gowns and gloves were used. The DON stated she expected CNAs, providing incontinent care, to follow the instructions on the EBP signs. The DON stated she did not expect staff who were delivering meal trays to wear gown and gloves, but when providing direct prolonged resident care, she expected gown and gloves to be put on upon entering the resident's room. The DON stated she had only been in the facility as DON for only one month, but to ensure staff compliance with EBP, she would do walking rounds with the nurses every morning and identify any need to provide further staff in-services. Record review of the facility's policy titled Infection Prevention and Control Program, revised on 12/2023, read in part: The infection prevention and control program is a facility-wide effort involving all disciplines and individuals and is an integral part of quality assurance and performance improvement program.Goals - decrease the risk of infection to residents and personnel. Recognize infection control practices while providing care. Identify and correct problems relating to infection control. Ensure compliance with state and federal regulations relating to infection control. Promote individual resident's rights and well-being while trying to prevent and control the spread of infection.Record review of the facility's policy titled Hand Hygiene revised on 10/2022 read in part: .All personnel shall follow the handwashing/hand hygiene procedure to help prevent the spread of infections to other personnel, residents, and visitors.2. Use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations:.h. Before moving from a contaminated body site to a clean body site during resident care;.m. After removing gloves.Record review of the facility's policy and procedures titled Perineal Care, revised in October 2010, read in part: The purposes of this procedure are to provide cleanliness and comfort to the resident, to prevent infections and skin irritation, and to observe the resident's skin condition. The following equipment and supplies will be necessary when performing this procedure: 1. Wipes, 2. Personal protective equipment (e.g. gowns, gloves, masks, etc., as needed), 3. Hand sanitizer.9. For a male resident:.h. Wash the rectal area thoroughly, including the area under the scrotum and the anus. i. Wash hands or sanitize hands, apply new gloves and apply clean brief if applicable. 10. Discard disposable items into designated containers. 11. Remove gloves and discard into designated container. Wash and dry your hands thoroughly. 12. Reposition the bed covers.

Based on observation, interview, and record review, the facility failed to ensure that the daily staffing was posted and readily accessible for review for 1 of 1 facility reviewed for required postings. - The facility failed to post the facility Direct Care Daily Staffing Numbers on 02/24/26.- The facility failed to post the Direct Care Daily Staffing Numbers in a location visible to all by posting it on the wall in front of the 300 Hall.- The facility failed to include the total hours worked for each type of direct care staff on the Direct Care Daily Staffing Numbers from 01/01/26 to 02/24/26. These failures could affect residents, facility visitors, vendors, and emergency personnel by placing them at risk of not having access to information regarding daily nursing staffing in a timely manner. Findings Include: An observation on 02/24/26 at 10:48 AM revealed, the facility did not post the facility direct care staffing information. The clear placard on the wall on the right side of the building, by the DON's office between the 300 and 400 Hall was empty. In an interview on 02/24/26 at 12:41 PM, the Staffing Coordinator said she was responsible for calculating, updating and posting the direct care staffing numbers daily and she had the responsibility for 1 year. She said the posting was located in a clear placard attached to the wall on the right side of the building, by the DON's office between the 300- 400 Hall. She said she usually updated the posting around 8 AM in the morning, but she was not aware of the time the posting had to be updated per the facility posting. The Staffing Coordinator said she just comes in every morning and posts it. She said the direct care staffing posting included the date, facility census, the number of each type of staff on each shift and it served to announce the staff to resident ratio for the day. The Staffing Coordinator said she did not know if facility policy required the posting had to be placed in a specific location, but the current location would not be visible to anyone going exclusively to the 100/200 & 300 Halls as it was on route to the 300 Hall and only on one side of the building. The Staffing Coordinator said the total number of hours worked for each staff type per shift was easily calculated by multiplying the total number of each staff type by the hours worked of each shift, but since she started her position she never documented the total hours worked for each direct care staff type, she was not trained to document the total hours worked, and she did not know if the total hours worked was required to be documented per the facility policy or per regulations. The Staffing Coordinator said failure to display the Direct Care Daily Staffing Numbers in a central location, timely and complete information left visitors/employees in the building unaware of the staff to resident ratio on a particular day. She said when she arrived on 02/24/26 she started to assist the CNAs with resident transfers, so she was unable to update it. The Staffing coordinator said she updated the direct care posting minutes before the interview with the surveyor. An observation on 02/24/26 at 12:50 PM revealed, the facility Direct Care Daily Staffing Numbers posted on the wall on the right side of the building in a clear placard by the DON's office between the 300- 400 Hall. The posting read [Facility Name], Date, Resident Census #, and the Day of the Week, columns for Shift Category, Staffing Total, Scheduled, Hours Worked for Licensed and Unlicensed Staff. The shift categories were: for licensed staff RN (6AM-6PM, 6PM-6AM) LVN (6AM-6PM, 6PM-6AM), Staffing Coordinator (no shift time documented), DON (no shift time documented), ADON (no shift time documented), MDS Coordinator (no shift time documented); and for Un-licensed Staff- CMA (6AM- 2 PM, 2PM- 10 PM) CNA ( 6AM-2PM, 2PM-10PM, 10 PM- 6AM). The columns with the Staffing Total documented the number of staff but the scheduled and hours worked columns were blank. Record review of the facility Direct Care Daily Staffing Numbers from 01/01/26 to 02/23/26 revealed, The columns with the Staffing Total documented the number of staff but the Scheduled and Hours Worked columns were all blank. Record review of the facility policy titled Posting Direct Care Daily Staffing Numbers revised 08/2006 revealed, Policy Statement: Our facility will post, on a daily basis for each shift, the number of nursing personnel responsible for providing direct care to residents. Policy Interpretation and Implementation: 1. Within two (2) hours of the beginning of each shift, the number of Licensed Nurses (RNs, LPNs, and LVNs) and the number of unlicensed nursing personnel (CNAs) directly responsible for resident care will be posted in a prominent location (accessible to residents and visitors) and in a clear and readable format. 3.Shift staffing information shall be recorded on the Nursing Staff Directly Responsible for Resident Care form for each shift. The information recorded on the form shall include: 1. The name of the facility. 2. The date for which the information is posted. 3. The shift for which the information is posted. 4. Type (RN, LPN, LVN, or CNA) and category (licensed or non-licensed) of nursing staff working during that shift. 5.The actual time worked during that shift for each category and type of nursing staff. 6. Total number of licensed and non-licensed nursing staff working for the posted shift. Completing the Form: 5. Within two (2) hours of the beginning of each shift, the staffing coordinate shall compute the number of direct care staff and complete the Nursing Staff Directly Responsible for Resident Care form. The shift supervisor shall date the form, record the census and post the staffing information in the location(s) designated by the Administrator. Maintaining 24 Hours of Staffing Information in One Location: 7. The previous shift's forms shall be maintained with the current shift form for a total of 24 hours of staffing information in a single location. Once a form is removed, it shall be forwarded to the Medical Records' office and filed as a permanent record.

Based on record review and interview, the facility failed to implement written policies and procedures that prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property for 4 (CMA D, RN L, LVN B, DES G) of 16 staff reviewed for abuse prevention. -The facility failed to check the EMR every twelve months for staff members CMA D by 8/28/2025 and RN L, LVN B and DES G by 8/29/2025.This failure could place residents at risk of abuse and neglect.Record review of the facility's personnel files, the following staff were identified as having EMRs conducted more than 12 months apart:-CMA D was hired on 6/9/2016 and had EMR checks on 8/28/2024 and 12/15/2025. CMA D was employable.-RN L was hired on 02/07/2024 and had EMR checks on 8/29/2024 and 12/17/2025. RN L was employable.-LVN B was hired on 07/11/2023 and had EMR checks on 8/29/2024 and 12/17/2025. LVN B was employable.-DES G was hired on 8/18/2022 and had EMR checks on 8/29/2024 and 12/15/2025. DES G was employable.Interview with HR Manager A on 12/18/2025 at 2:25pm, when HR Manager A said that she conducted yearly checks on staff every August. HR Manager A said she was responsible for 150 staff and that there was an issue with TULIP (the state system for checking EMRs) and that she was running behind on checking for some staff. HR Manager A said not checking staff annually for misconduct could run the risk of them hiring someone with something detrimental on their record. Interview with the Administrator on 12/18/2025 at 2:25pm, who said HR was responsible for checking the EMR and that staff were checked just not in the normal timeframe. The Administrator's expectations were for EMRs to be checked once a year and that she saw no risk in it not being checked in the twelve-month period. There could have been someone who committed a crime that the facility was not aware of but that was not the case. Record review of the facility's policy titled TX Annual DADS Registry last reviewed September 2015, it read in part, To conduct annual checks of the Department of Aging and Disability Services ('DADS') 'Employee Misconduct Registry' and 'Nurse Aide Registry' for current employees .Purpose, To ensure compliance with the Texas Administrative Code of the Department of Aging and Disability Services ('DADS'), as amended on September 1, 2010, regulating Nursing Facility Requirements for Licensure and Medicaid Certification. Scope, applies to all employees in Texas.

Based on observation, interview, and record review the facility failed to provide necessary services to maintain good grooming and personal hygiene for 1 (Resident #51) of 5 residents reviewed for activities of daily living. -The facility failed to remove unwanted facial hair from Resident #51's chin area and above resident's mouth observed on 12/16/2025 and 12/17/2025.This failure placed residents at risk for psychological embarrassment, sadness, and decrease in quality of life. Record review of Resident #51's face sheet dated 12/17/2025, she was a [AGE] year-old female originally admitted on [DATE] and last re-admitted on [DATE] with medical diagnoses included type 2 diabetes mellitus (high blood sugar), dementia (declining brain function related to thinking and judgement that is severe enough to impact daily life), generalized anxiety disorder (prolonged excessive worry), and hypertension (high blood pressure).Record review of Resident #51's care dated 09/01/2023 for ADL self-care performance deficit, with interventions including personal hygiene/oral care requiring staff participation with personal hygiene and oral care. There was no refusal of ADLs and personal grooming or shaving documented in Resident #51's care plan.Record review of Resident #51's November and December 2025 shower sheets, Resident #51 refused a shave on 11/21/2025. Resident #51 refused a shave on 12/01/2025, 12/05/2025, 12/08/2025 and 12/15/2025 and signed by LVN C. CNA A documented on 12/10/2025, Resident #51 received a shower and refused to be shaved. Observation and interview with Resident #51 on 12/16/2025 at 9:23a.m., she was in her room sitting on her wheelchair in her briefs. Resident #51 had a 1 cm length of facial hair on either side of the upper corners of her lips and some facial hair on both sides of her chin. Resident #51 had contractures on both hands. On 12/17/2025 at 9:10a.m., Resident #51 was observed in her room with the facial hair and at 9:47a.m., Resident #51 said that she did not feel good with her beard and that it made her feel like a man. Resident #51 said it had been 6 to 8 months since someone helped her shave. When asked if she talked to any staff about her concern, Resident #51 said she told people but could not remember who or when she last told. On 12/17/2025 at 12:30p.m., Resident #51 was observed in the dining room with no facial hair. Interview with ADON A on 12/17/2025 at 9:47a.m., she said aides shaved residents on Sundays. ADON A said she did not know why aides did not shave Resident #51 since when she looked at Resident #51 she would see the resident and not her beard. Staff do not expect to shave a man. ADON A said Resident #51 did not tell staff how she was feeling or Resident #51's beard. ADON A expected aides to shave residents if residents asked for it or if the aides saw the facial hair. ADON A said she was going to inform the aide to check in on Resident #51 and shave her facial hair.Interview with the DON and Administrator on 12/17/2025 at 3:19p.m., the DON said aides shave residents on Sundays if they were in the facility. Normally, staff would check residents for body hair on shower days. The DON said she would look into if the resident could get an electric razor to shave herself. The DON said not getting shaved could affect a female resident's self-image.Attempted interview with Resident #51's RP on 12/18/2025 at 8:25a.m., no returned calls. Attempted interview with LVN C on 12/18/2025 at 10:00a.m., there were no returned communications. Interview with CNA A on 12/18/2025 at 11:28a.m., CNA A said she never saw Resident #51 with facial hair. If she saw residents including female residents with facial hair, CNA A said she would ask them if they wanted to be shaved, especially if it was their shower day. CNA A said she never documented Resident #51 refusing a shave because CNA A never saw facial hair. Resident #51 never reported wanting a shave but CNA A would ask Resident #51 since CNA A did not think Resident #51 could shave herself. CNA A said the last time she worked with Resident #51 was 1-2 weeks ago.Interview with the WCN on 11/18/2025 at 9:10a.m., the WCN checked off of Resident #51's shower sheets and said that aides reported she was refusing shaves. The WCN told Resident #51's nurse but did not remember the name of the nurse. The WCN said Resident #51's family were aware that she refused shaving. On 11/18/2025 at 11:33a.m., the WCN said she was Resident #51's ambassador (someone assigned to the resident to check in on them) and visited Resident #51's room daily. The WCN said she never heard Resident #51 complain of her facial hair before and she did not know if someone brought it up to the resident or not. Interview with MDS A on 12/18/2025 at 11;18a.m., she said Resident #51 needed staff assistance with other ADLs. MDS A said aides were normally pretty good at doing room rounds and that aides would assist residents with shaving facial hair. MDS A was not aware that Resident #51 refused to shave. Staff would need to ask Resident #51 and provide options, such as having someone else go in to shave and if she still refused then document and care-plan that behavior. MDS A said that Resident #51's facial hair should not have been there and that she would feel the same way as Resident #51. Interview with the DON on 12/17/2025 at 3:19p.m., the DON said normally staff checked residents needing a shave on shower days and Sundays were designated shave days. The DON did not know why staff did not notice Resident #51's facial hair. The [NAME] said having facial hair on a female resident could affect their self-image. The DON staff knew and were educated on checking for facial hair for female residents during shower days. In a later interview on 12/18/2025 at 1:34p.m., the DON said Resident #51 did have a care plan for ADL refusals and should have one. The DON said she would provide it, and as of exit no plan has been provided.Interview with LVN A on 12/18/2025 at 3:14p.m, LVN A said that she did not notice Resident #51's facial hair and the last day she worked was on 12/16/2025. If LVN A saw facial hair on Resident #51 she would have asked the resident if she wanted a shave. Resident #51 never brought it up to her. LVN A reviewed Resident #51's shower sheets and signed off on them and said never reported Resident #51 having facial hair. Record review of the facility's policy on ADL services last revised January 2020, it read in part, It is the policy of this facility that residents are given the appropriate treatment and services to maintain or improve his/her abilities .2. Residents who are unable to carry out activities of daily living (ADL) will receive necessary services to maintain: . Grooming Personal hygiene .

Based on observation, interview and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate administration of all drugs and biologicals) to meet the needs of each resident for 1 (Resident #51) of 5 residents reviewed for pharmacy services. -Resident #51 did not receive Ozempic on 11/12/2025 and 12/17/2025 as ordered by the physician.The deficient practice could place residents at risk of not receiving the therapeutic effects from their medications as intended by the prescribing physician order. Record review of Resident #51's face sheet dated 12/17/2025, she was a [AGE] year-old female originally admitted on [DATE] and last re-admitted on [DATE] with medical diagnoses included type 2 diabetes mellitus (high blood sugar), dementia (declining brain function related to thinking and judgement that is severe enough to impact daily life), generalized anxiety disorder (prolonged excessive worry), and hypertension (high blood pressure).Record review of Resident #51's care plan captured on 12/17/2025, Resident #51 had diabetes mellitus care-planned on 09/16/2024 with interventions including educating regarding medications and importance of compliance, discussing meal times and dietary restrictions and snacks allowed in daily nutritional plan and compliance with nutritional regimen, diabetes medication as ordered by doctor and Ozempic (.25 or .5 MG/Dose) 2 MG/3ML solution pen-injector Inject subcutaneously 0.5 mg 1 time a week on Wed. Record review of Resident #51's MAR for November and December 2025, on 11/12/2025 Ozempic subcutaneous solution pen-injector was parked as a 7, which meant other/see nurse notes. Resident #51's blood sugars were the following: 11/12/2025 at 8am was 98 (normal range) and at 4pm was 261 (elevated), 11/13/2025 at 8am was 98 (normal) and at 4pm was 216 (elevated). Resident #51 had Ozempic administered on 11/05/2025 and 11/19/2025 by LVN B. On 12/17/2025, Ozempic subcutaneous solution pen-injector was parked as a 7, which meant other/see nurse notes. Resident #51's blood sugars for December 2025 were the following: 12/17/2025 at 8am was 138 (elevated) and at 4pm was 143 (elevated), and 12/18/2025 at 8am was 137 (elevated). Resident #51's last dose was 12/10/2025 by LVN A.Record review of Resident #51's Order Summary dated 12/18/2025, she had Ozempic .25 or .5mg/dose subcutaneous (below the skin) solution pen-injector inject 0.5 mg subcutaneously one time a day every Wed for DM with a start date of 09/10/2025.Record review of Resident #51's progress notes, LVN A documented on 11/12/2025 at 9:39am that Ozempic was on order. Resident #51 was not documented as having Ozempic administered for the dose scheduled on 11/12/2025. On 12/17/2025 at 7:28a.m., LVN B wrote that medication not available in house, request for refill sent. On 12/18/2025 at 1:43p.m., LVN B wrote, Resident scheduled for Ozempic weekly. Medication noted to need a refill. Refill requested and delivered. Md notified and order was obtained to administer medication. Medication administered to the abdomen in the right lower quadrant. Resident tolerated well. Record review of Resident #51's physician visit note dated 12/17/2025 and provided by the facility on 12/18/2025, it read in part, Nurse notified me that Ozempic has not been delivered from the pharmacy. Told them it was okay to give when medication arrived. The document did not state who was the physician who wrote the note. It was signed by MD A. Observation and interview with Resident #51 on 12/16/2025 at 9:23a.m., she was in her room sitting on her wheelchair in her briefs. Resident #51 had food on her tray table. Resident #51 appeared comfortable and well-groomed. Resident #51 said she had no concerns with her medications.Attempted interview with Resident #51's RP on 12/18/2025 at 8:25a.m., no returned calls. Attempted interview with LVN C on 12/18/2025 at 10:00a.m., there were no returned communications. Interview with the DON on 12/18/2025 at 1:34p.m., she said that Resident #51's Ozempic was not delivered. The facility received medication from the pharmacy and there was no other system for medication delivery. Ozempic was not in the on-site Pixus machine (a machine that can dispense medication with a pharmacy access code if a resident's medication was not in the facility). The DON said the nurse who administered the Ozempic's final dose was responsible for calling in the new order. The DON was not aware that Resident #51's Ozempic was not in the facility on 12/17/2025 for her scheduled dose. In a later interview on 12/18/2025 at 2:14p.m., the DON said Resident #51 was documented as having a missed dose of Ozempic but the pharmacy said there was a 5-day limit without having to restart Resident #51's medications. The DON said there were no negative effects from Resident #51 missing the dose. The DON said the nurse failed to document medication administration in the notes regarding documentation and she expected nurses to order medications timely and notify the physician if the medication was not available so the physician could hold the medication until it was available or to order the resident be given another medication. Interview with the facility's pharmacist on 12/18/2025 at 1:50p.m., the pharmacist said they delivered Resident #51's medications on 11/12/2025 and 12/17/2025. Each delivery contained a month's supply for Resident #51. The pharmacist said she did not see the resident but did not think there was a risk to Resident #51 not having her Ozempic administered since the medication's instructions stated missed doses should be administered within 5 days and the facility was within the 5 days of Resident #51's scheduled dose. Interview with LVN B on 12/18/2025 at 2:07p.m., she said when nurses used the last of a medication, they were supposed to request a refill. When LVN B noticed there was no Ozempic, she requested the refill then told NP A who worked under MD A. Interview with the MD on 12/18/2025 at 3:00p.m., she said that she was notified Resident #51 did not receive her Ozempic medication yesterday and she told the nurse to give the medication when it arrived. The MD said there were no negative effects and no harm from Resident #51 not getting the Ozempic as scheduled. The MD said LVN B notified her the previous day. The MD was at the facility on 12/18/2025 and was aware that staff administered it. When asked if she was notified of the both missed dose on 11/12/2025 and 12/17/2025, the MD confirmed that she was notified of the last missed dose on 12/17/2025. Interview with LVN A on 12/18/2025 at 3:14p.m., she said that after the dose on 12/10/2025 she reordered Ozempic through the facility portal. If the medication was not delivered, she would call the pharmacy and if she did not get it the medication was still not delivered, she would notify the doctor and report this in the morning meeting. LVN A said if Resident #51 missed the dose she could have seen an increase in her blood sugar and that nurses were already monitoring Resident #51 for high and low blood sugar twice a day. Record review of the facility's policy on medication administration, undated, read in part, .p. Medications are administered within (60 minutes) of scheduled time, except before or after meal orders, which are administered (based on mealtimes). Unless otherwise specified by the prescriber, routine medications are administered according to the established medication administration schedule for the facility .4) Signature or initials of person recording administration and signature or initials of person recording effects, if different from the person administering the medication. aa. If a dose of regularly scheduled medication is withheld, refused, or given at other than the scheduled time (for example, the resident is not in the facility at scheduled dose time, or a starter dose of antibiotic is needed), (the space provided on the front of the MAR for that dosage administration is initialed and circled. An explanatory note is entered on the reverse side of the record provided for PRN documentation) .Record review of the facility's policy on ordering medications last revised 11/13/2018, read in part, Repeat medications (refills) are . ordered as follows: a) Reorder medication (seven) days in advance of need to assure an adequate supply is on hand .

Based on observation and interview and record review, the facility failed to dispose of garbage and refuse properly for 1 of 3 dumpsters (Dumpster #2) reviewed for garbage disposal.-The facility failed to close the facility dumpster when not in use on 12/16/2025 when the outside dumpster #2's right sliding door was left open. This failure could place residents at risk of contact with pests and associated diseases. Observation and interview on 12/16/2025 at 8:45a.m., the right sliding door of Dumpster #2 was open. MS A said the dumpster doors should have been closed. When asked what kind of negative effects it could cause, he did not answer the question. Interview with the Dietary Manager on 12/16/2025 at 10:40a.m., she said that the dumpster doors should have been closed. Animals and rodents could get in the trash.Interview with the DON and Administrator on 12/17/2025 at 3:19pm, the DON said the dumpster doors should not have been open. The Administrator said it was infection control. When asked if there could be any risks to residents, she said no and that she did not see residents in that area. Record review of the facility's policy on waste disposal last revised May 2021, it read in part, .All dumpsters' lids and doors shall be closed or sealed at all times.

Based on observation, interview, and record review, the facility failed to prevent complications of enteral feeding including but not limited to dehydration in one of two residents (Resident #52), in that: - Resident #52's pump history reflected the resident only received 37.5% of his enteral order in the past 24 hours. - Resident #52's pump history reflected the resident's tube feeding was stalled for 3 hours. - LVN B and ADON B were unaware of the resident's inadequate intake. The failures placed all resident on tube feedings at risk of malnutrition and dehydration. Findings included: Record review of Resident #52's face sheet revealed [AGE] year-old male who was admitted into the facility on [DATE] and was diagnosed with dysphagia (difficulty swallowing) following cerebral infarction (heart attack), hemiplegia (paralysis of one side of the body) and hemiparesis (inability to move one side of the body). Record review of Resident #52's MDS, dated [DATE], revealed the resident had a BIMS score of 3, indicating severed cognitive impairment, and the resident had a feeding tube. Record review of Resident #52's care plan, dated 03/01/2023, reflected the resident required tube feeding related to dysphagia, weight loss and malnutrition and the goal was to maintain adequate nutritional and hydration status as evidenced by table weight and no signs of malnutrition or dehydration through review target date of 12/07/2024. Record review of Resident #52's orders revealed, starting on 09/09/2024, the resident was on Isosource HN at 65ml/hr for 22 hours and a 200ml water flush every 6 hours (totaling 1430ml of enteral feed or 1716 kcals and 800ml of free water every 24 hours and). The order also specified that the pump may be off for ADL care. Other general tube enteral feed orders such as checking G-tube placement and water flushes between medication administration were in place since 03/26/2023 reflecting Resident #52's long term use of the G-tube. Record review of Resident #52's weight log revealed the resident had a stable weight ranging from 109.3 - 112.6 lbs in the past 3 months (06/10/2024 - 09/09/2024). Record review of Resident #52's nutrition assessments dated 08/28/2024 revealed the RDN wrote: .TF provides: 1716 kcals, 77 g protein, 1155 mL of H2O, flush provides an additional 800 ml of fluid . Resident at increased risk for dehydration and/or weight fluctuations d/t EN and PMH. Staff provides flushes and EN remains appropriate at this time. Anthro: Ht: 71 Wt 111.2# DBW 172+-10% BMI 15.5, underweight . Est needs based on IBW: 78.2 kg (25-30) ~ 1563-1954 kcal . Recommendations: No new nutrition intervention needed at this time, continue current plan. RD will continue to monitor wt status and EN tolerance . Observations on 09/17/2024 at 10:34AM, revealed Resident #52 was lying in bed asleep. His tube feeding pump was on and documented to be hung up by 6:30AM. Out of the 1000ml bag of enteral feed, approximately 850 ml remained. The pump's screen was seen to have an error message and the feed was on hold. Observations on 09/17/2024 at 11:40AM, revealed Resident #52 was still lying in bed asleep with his tube feeding pump screen still showing an error message while the enteral feed was on hold. Out of the 1000ml bag of enteral feed, approximately 850 ml remained. Observations on 09/17/2024 at 12:10PM, revealed the error on Resident #52's pump was resolved and the feeding was flowing at the ordered rate of 65ml/hr. In an interview with Resident #52 on 09/17/2024 at 2:35PM, when asked if he felt hungrier than usual, he stated Yes. Interview with ADON B and observations of Resident #52's pump on 09/17/2024 at 2:37PM revealed the ADON checked the pump history and stated something was off about it and that she would have to investigate to find what the issue was. She stated Resident #52's pump was ran continuously but was turned off for ADL care. The pump history revealed that the enteral feed was stalled for at least 3 hours during the shift after 130ml was already administered, in the past 24 hours, the resident was only administered 537ml of enteral (equating to only 643kcals) and in the past 48 hours, the resident was only fed 1326ml (equating to only 1591kcals) of enteral feed and 1400ml of free water. In an interview with LVN B on 09/17/2024 at 3:14PM, she stated she was the charge nurse over Resident #52 and worked 6AM to 6PM. She said she did not know about the error message on Resident #52's pump. She stated she normally checked on her residents at 8am towards the beginning of her shift and again around 11AM or 12PM when she was done passing her medications. She stated she was not the one who checked on Resident #52 and fixed his pump but if the pump was noticed to have an error, it should have been brought to her attention so she could resolve it. She stated Resident #52 had been using the same pump and he had not left the facility recently for any reason. She stated nurses use to document the amount of enteral feed administered each shift and clear the history before shift change so they could better keep track of the amount that was administered to the patient, but they no longer did that. She stated that nurses just checked to ensure the flow rate matched the order. When reviewing Resident #52's pump history, she acknowledged that the feed had stalled for three hours and the total amount of 537ml fed in the past 24 hours was too low to meet his needs. She said the only reasons the enteral feed should be paused was when ADL care was being provided. She stated there could be a delay in the aides reporting to nurses when care ADL care was completed, thus causing a delay when resuming the enteral feed. She stated the risk of a resident not getting enough enteral nutrition could include malnutrition and possible weight loss. In an interview with ADON B on 09/18/2024 at 02:27 PM, she stated since the observation of Resident #52's pump, she reported the issue to the RDN and asked her to review the pumps and provide an in-service on how to review administration history on the pumps. She said it seemed like there could have been an issue with the pump but she could not speculate why it was low. She stated she knew that the resident was at risk for dehydration, skin breakdown and malnutrition, especially being on hospice. In an interview with the DON on 09/19/2024 at 9:19AM, she stated a previous dietitian they had as part of staff recommended documenting a resident's enteral feed administered at the end of every shift, but since switching dietitians, they stopped doing so. She stated there could have been a complication with the pump that caused the resident to only get 0% of his needs. She stated she had never audited pumps to ensure they worked properly. She stated the risks of a resident not receiving enough enteral nutrition included skin break down, dehydration and a caloric deficit. In a phone interview with the RDN on 09/19/2024 at 01:09PM, the RDN stated Resident #52 had a continuous enteral feed order to be administered for approximately 22 hours leaving about 2 hours for ADL care throughout the day. She stated she calculated his enteral feed order based on his ideal body weight of 172lbs since he was already underweight. She stated if the resident was only fed 537ml or 644 kcals in the past 24 hours, and 1326ml or 1591 kcals over the past 48 hours, that was too low to meet the resident's nutritional needs. She stated it placed the resident at risk for malnutrition, dehydration, weight loss and instability. She stated she had never noticed any issues with the pumps before and had never had to do an in-service with the nursing staff on how to check pump history. Record review of the facility's policy on enteral nutrition, not dated, reflected, . Intake and output will be recorded every shift on enteral residents .

Based on observation, interview and record review, the facility failed to ensure that drugs and biologicals used in the facility were secured properly for Resident #1 (one of eleven residents) as evidenced by: -Resident #1 had pills in a plastic cup in her right hand and was unattended. This deficient practice could place residents at risk for harm and place the facility at risk for a possible drug diversion. The findings include: Record review of Resident #1's clinical record revealed an [AGE] year-old female admitted to the facility on [DATE] including diagnoses: Alzheimer's disease (a brain disorder that gets worse over time), Rheumatoid Arthritis (is an autoimmune disorder where the immune system mistakenly attacks the joints, causing inflammation, pain, and potential joint damage). Record review of the Minimum Data Set (MDS) dated [DATE] for Resident #1 with a BIMS score 10 (moderate cognitive impairment). Observation and interview on 4/24/24 at 10:45 a.m. revealed in Resident #1's hand a plastic cup with 5 tablets: one large white tablet, 2 medium white tablets, one oblong gray tablet, one small yellow tablet. She stated she fell asleep before she took her medications. LVN #1 observed resident with cup of pills in right hand. LVN#1 stated the resident should not have pills in her room unattended. Interview on 4/24/24 at 10:45 a.m. LVN #1, she stated it is not acceptable for medication to be in resident room unattended. She stated she observed 5 pills in a plastic cup in the residents' right hand. She stated residents should take medication when staff administers medications. This prevents any type of under medicating, over medicating and drug diversion. Interview on 4/24/24 at 11:05 a.m. with the Administrator, she stated residents are not to have medications in their room without a doctor's order, and when licensed staff administer medicine they should assure that the resident takes the medicine that they administer. She states her expectation for medication administration is the medicine makes it into the residence body in the appropriate manner that it is ordered. She states the risk of residents having medication without being observed is- it could cause adverse health reaction or taken by that resident and cause them harm. Interview on 4/24/24 at 11:12 a.m. with Medication Aide (MA), she stated she placed resident's medications on the bedside table, administered eye drops, and as she was leaving she saw Resident #1 drinking water and assumed the resident had taken the pills that were on the bedside table. She stated should have verified the medication was taken prior to leaving the room. She stated the risk of leaving medication in a residents room unattended is stockpiling meds, under medicating, other resident could take medication not ordered for them and cause harm to them. Interview on 4/24/24 at 11:24 a.m. with the Director of Nurse (DON), she stated it is not appropriate to leave medications in residents' room unattended. Resident may be under medicated, over medicated, other resident may get incorrect medication and cause harm to themselves. Her expectations for medication administration is that resident will get medications timely, and medications will be observed being taken by staff who give medication, no pills left at bedside. Interview on 4/24/24 at 11:45 a.m. with RN #1, she stated it is important to observe residents take medications at the time being administered to assure a resident is taking the medication., Her expectation is medication aides will stay until medication is swallowed, perform mouth check to assure medicine is not in their mouth . She stated the risk of a resident not taking medications is under medication, overmedicating, and potentially another resident taking incorrect meds. She stated no medication should be left at bedside unattended. Record review of the facility policy titled Administering Medications, 2001 MED-PASS, Inc. revised April 2010. Policy statement: Medications shall be administered in a safe and timely manner, and as prescribed.

Based on observation, interview, and record review, the facility failed to ensure food was stored, prepared, and served in accordance with professional standards for food service safety in 1 of 1 kitchen, in that: - Food was found unsealed in dry storage - Food was found not labeled and dated in the walk-in cooler - Meals from the kitchen were served without first taking temperatures of the food. - Dietary aide A was touching her face mask and handling ready-to-eat foods without proper hand hygiene. These failures increased residents' risks of consuming contaminated foods and getting a foodborne illness. Findings included: Observations of the kitchen and interview with Dietary Aide A on [DATE] at 8:15 AM revealed Dietary Aide A plating food from the breakfast line. Dietary Aide A was seen wearing gloves, shifting around her mask, and touching ready-to-eat toast to add to the plate. When asked about temperature for their breakfast line, she stated she knew how to use a thermometer, but she did not use it prior to serving breakfast because she did not know where it was. Observations of the kitchen and interview with Dietary Manager on [DATE] at 8:25 AM revealed an open bag of grits dry storage that was not resealed and four trays of tangerines in the walk-in cooler that were not labeled or dated. Dietary Manager stated all food was supposed to be dated and labeled. Record review of the undated temperature log revealed no temperatures were recorded for breakfast on [DATE] In an interview with the Dietary Manager on [DATE] at 8:20 AM, the Dietary Manager stated that Dietary Aide A just started working last week, so she is still in training. She stated Dietary Aide A knew the temperatures were supposed to be recorded before starting the tray line but forgot where the thermometer was. In an interview with the Cluster Dietary Resource on [DATE] at 12:58 PM she stated it was necessary to reseal, date, and label all food, in storage, to prevent service of expired foods. She said it was necessary for Dietary Aide A to perform hand hygiene prior to touching ready to eat food in order to prevent possible spread of infections. She also stated it was necessary to record temperatures of all food prior to meal service to ensure limited risk of foodborne illness due to undercooked food. The facility's policy on food and nutrition services food temperatures, dated [DATE], revealed Holding temperatures should be check prior to meal service to ensure appropriate temperatures have been maintained; document these on the temperature log . The policy provided did not address storage requirements of food of food handling. Record review of the FDA Food Code, dated 2022, revealed, The person in charge shall ensure that . (D) EMPLOYEES are effectively cleaning their hands, by routinely monitoring the EMPLOYEES' handwashing .

Based on observation, interview and record review, the facility failed to implement its infection control policies for 6 of 7 residents (Residents #11, #71, #74, CR #69, CR #1 and CR #2) reviewed for infection control, in that: - The facility failed to ensure Residents #71, #74 and #11's rooms had isolation precautions in place on 08/15/2023 despite their being orders for contact isolation. - The facility failed to prevent CNA F from serving a meal tray to a contact isolation room on 08/15/2023 without using necessary PPE. - The facility failed to ensure there was tracking and trending documentation for Resident #69, CR #1 and CR #2 during the months of January to April 2023. This failure placed residents an increased risk for continued infection and lack of proper treatment. Findings included: Record review of Resident #71's face sheet, dated 08/18/2023, revealed a [AGE] year-old male who was admitted into the facility on [DATE] and was diagnosed with mild vascular dementia and hypertension. Record review of Resident #71's MDS assessment, dated, 07/09/2023, revealed the resident had a BIMS score of 15, indicating that his cognition was intact and the resident was dependent for toileting. Record review of Resident #71's MAR, dated August 2023, revealed the resident was ordered to have strict contact isolation related to Extended Spectrum Beta Lactamase (ESBL) in the urine starting on 08/07/2023 without an end date. It also revealed the resident was ordered to take Bactrim DS oral tablet 800-160mg 2 times a day for 7 days and Ciprofloxacin HCl 500mg tablet 1 table by mouth every 12 hours for 7 days for UTI ESBL Record review of Resident #74's face sheet, dated 08/18/2023, revealed a [AGE] year-old male who was admitted into the facility on [DATE] and was diagnosed with urinary tract infection and hypertension. Record review of Resident #74's MDS, dated , 07/09/2023, revealed the resident had a BIMS score of 15, indicating that his cognition was intact, and the resident needed maximum assistance with toileting. Record review of Resident #74's MAR, dated August 2023, revealed the resident was ordered to have strict contact isolations related to ESBL in the urine started on 08/07/2023, discontinued on 08/14/2023 and restarted on 08/15/2023 again without an end date. It also revealed the resident was ordered to take Tetracycline HCl oral capsule 500mg 4 times a day for 3 days. and Ciprofloxacin HCl 500mg tablet 1 table by mouth two times a day for 5 days for UTI. Record review of Resident #11's face sheet revealed an [AGE] year-old female who was admitted into the facility on [DATE] and diagnosed with dementia and hemiplegia/hemiparesis - paralysis of one side of the body). Record review of Resident #11's MARs revealed the resident had orders for contact isolation for ESBL in the wound starting on 08/02/2023 until 08/17/2023. Observations on 08/15/2023 at 9:30 AM revealed Resident #71 and #74 were roommates. Resident #11, Resident #71 and Resident #74 were observed in their rooms without contact isolation signage on the door and with a PPE station located 5 feet away on the left from the door to Resident #11 and #74's room without any gowns or gloves stocked inside. An observation and interview with CNA F on 08/15/2023 at 9:30 AM, revealed CNA F was asked by the surveyor why the PPE station was there and if any residents on hall 300 were under isolation precautions. She said she believed only Resident #71 and #74's room was under isolation, but she needed to confirm with her charge nurse, LVN R, first. CNA F was observed to go LVN R, then she returned to the surveyor and said Resident's #71 and #74's room was under contact isolation and the PPE station was for their room. When asked where the sign was, CNA F stated she did not know where it was. In an interview with LVN R on 08/15/2023 at 9:40 AM, she revealed that she was a PRN nurse and she had just returned to work with the patients. She stated she referred to a list to know which residents received antibiotic treatments, type of infection they had, as well as orders for isolation precautions if necessary. She stated based on that list, only Residents #71 and #74 had orders for strict contact isolation, both for ESBL in their urine. She stated they are supposed to have PPE stations for their room and a sign on their door; Central Supply Aide was taking care of that at the moment. In an interview with the DON on 08/15/2023 at 10:50 AM, she stated Resident #71 and #74's room was supposed to have signs posted on their door with the PPE station stocked. She stated herself and the ADONs were responsible for rounding to ensure signs were posted and PPE was present for immediate use. The DON said the ADON was late so she did not get the chance to make rounds but that was not an excuse for contact isolation signs and PPE to not be present. She also stated the infections Resident #71 and #74 had, were infections contained to their catheters and in that case, PPE was not required unless a healthcare staff was working directly with the resident, but it was still encouraged for all staff to wear in the rooms. Observations on 08/15/2023 at 2:19 PM revealed Resident #11's room with contact isolation signage on the door and the PPE station right by the resident's door. Observations and interview with CNA F on 08/15/2023 at 2:19 PM, revealed CNA F was asked by the surveyor why the PPE station and sign was put up for Resident #11's room, she stated she needed to confirm with LVN R and could not confirm the isolation precautions was put up for Resident #11's room. In an interview with Resident #71 on 08/15/2023 at 3:34 PM, he stated he had been seeing staff entering his room with masks on but he had not seen staff wearing gowns until today. In an interview with the Central Supply Aide on 08/16/2023 at 1:46 PM, she stated she had initially stocked the PPE station on Tuesday 08/15/2023 around 7AM and even at 8AM. She stated CNA F and other staff used a lot of gowns. She stated that she had been restocking it since last week. She said when she came into work by 7:30 AM, she saw the contact isolation sign was on the door but could not remember if the PPE station was placed for Resident #11, #71 and #74's room. She stated the risk of not having PPE available or signage at the door was spread of infection. In an interview with CNA F on 08/16/2023 at 2:02 PM, she said she believed she knew Resident #71 and 74's room were under precautions but wanted to check with the nurse to be more safe. She stated she did not know how long they have been on contact precautions but the isolation precautions were place for Resident #71 and #74's room throughout the weekend and on Monday, 08/14/2023. She said she was not sure about whether Resident #11's room was under isolation precautions until the sign was placed on the door on Tuesday, 08/15/2023. She stated she generally put a gown on to give Resident #71 and #74 a bed bath or change them. She stated on the morning of 08/15/2023, she was aware the PPE station was empty but served Resident #74 and #71 their breakfast meal tray without PPE because they did not need direct care. She said Central Supply Aide was responsible for restocking the PPE cart. When asked what the risk was for not having isolation precautions in place for residents with infections, she stated there was no risk because she cleaned her hands very well before coming out of their rooms. In an interview with the DON on 08/16/2023 at 3:15 PM, she stated Resident #11 was put under isolation precautions by 08/02/2023 for ESBL without a stop date to have the wound re-cultured first after the completion of antibiotic therapy to determine the need to discontinue or continue isolation. She said that was the likely reason for Resident #11's order being a continuous order without an end date. She stated the antibiotic treatment was completed yesterday on 08/15/2023 but the isolation precautions should have remained in place until the resident's wound doctor gave further instructions after a re-culture. She stated the charge nurses were responsible for giving reports shift to shift on needs regarding isolation precautions, and if the facility failed to ensure isolation precautions were in place when necessary, it increased the risk of spreading infections. In an interview with LVN R on 08/16/2023 at 3:50 PM, she stated she could not explain why Resident #11's room was initially found without an isolation precaution sign in place but she knew the morning of 08/15/2023 that both rooms (Resident's #71 and #74's room as well as Resident #11's room) needed isolation precautions in place. She said she was told Resident #11's roommate had took the sign down inquiring about it. She stated the sign was placed for both room for Resident #11, #71 and #74 and both rooms were recognized by her and her staff to be under isolation precautions. In an interview with a family member on 08/17/2023 at 3:14 PM, revealed the PPE was recently instilled a few days ago and they did not have PPE in place for her to use over the weekend when she visited the resident since last Friday, 08/11/2023. Interview with Resident #74 on 08/17/2023 at 3:14 PM, when asked if gowns were being worn by the staff since last week, he stated that's bullshit, this week. In a phone interview with LVN E on 08/18/2023 at 10:09 AM, LVN E stated Resident #74 came in on isolation precautions upon admission and Resident #71 was positive result for infection after a recent hospital visit. She stated necessary PPE to wear in a room under contact precaution included gloves, gowns, and masks, if appropriate. She said the PPE station was stocked while working the night shift on 08/14/2023 and she only went in the room once to administer medication to either Resident #71 or #74. She stated she had on all necessary PPE while providing care. She stated the risks of not wearing PPE was an increased risk of spreading the infection. She stated a sign was required as well for visitors and staff to be aware. She said there was a sign and isolation cart setup in between both of rooms where Residents #71, #74 and #11 resided and she observed this before leaving her shift at 6:00AM on 08/15/2023. Record review of CR# 1's face sheet, dated 08/18/23, revealed a [AGE] year-old female resident who was admitted to the facility on [DATE]. Her diagnoses included: Acute Kidney Failure, Type 2 Diabetes, Zoster without Complications Record review of CR# 1's Medication Administration Record on 08/17/23 revealed, the resident was prescribed and administered Doxycycline Hyclate Tablet 100MG for Shingles from 02/11/2023-02/20/23. Record review of CR #2's face sheet, dated 08/18/23, revealed a [AGE] year-old male resident who was admitted to the facility on [DATE]. His diagnoses included: Syncope and Collapse (Fainting), Pneumonia, Paranoid Schizophrenia, and Depression Record review of CR #2's Medication Administration Record on 08/17/23 revealed, the resident was prescribed and administered Azithromycin Tablet 250 MG for Pneumonia from 01/20/23-01/23/23. Record review of Resident #69's face sheet, dated 08/18/23, revealed a [AGE] year-old female resident who was admitted to the facility on [DATE]. Her diagnoses included: Cerebral Infarction, Enterocolitis due to Clostridium Difficile, Acute Kidney Failure. Record review of Resident 69's Medication Administration Record on 08/18/23 revealed, the resident was prescribed and administered Vancomycin HCI Oral Capsule 125MG for Enterocolitis due to Clostridium Difficile from 02/23/23-03/03/23 and Vancomycin HCI Oral Solution Reconstituted 25MG/ML from 03/03/23-03/09/23. Record review of the facility's tracking and trending binder on 08.17.2023 revealed, there was no tracking and trending documentation for January 2023 to April 2023. In an interview on 08/17/23 at 3:15 PM with the Corporate DON, she stated the previous DON was responsible for doing tracking and trending. She stated Corporate Clinical Resource began doing tracking and trending in May when she noticed it was not being completed. She stated the risk of tracking and trending not being completed was spread of infection and infections that the facility is not aware of. Interview on 08/18/23 at 11:41 AM with the Administrator, revealed the facility was doing tracking and trending during the months of January 2023 through April 2023, but she did not have the paperwork. She stated the previous DON was doing the tracking and trending, and after the DON left the company, she could not find the documentation. She stated the risk of not completing tracking and trending is spread of infection. Record review of the facilities Infection Control policies dated 01/2022 stated, IP or designee will be responsible for infection surveillance and MDRO tracking. The facility's policy on infection control, dated October 2022, revealed, Contact precautions are used with a known infection that is spread by direct or indirect contact with the resident or the resident's environment . wear a gown and gloves for all interactions that may involve contact with the patient or the patient's environment . the facility will implement a system to alert staff, resident and visitors that a resident is on TBP. 1. Post clear signage on the door or wall outside of the resident room indicating the type of precautions and required PPE . make PPE, including gowns and gloves, available immediately outside of the resident room . 47215 FACILITY Infection Control

Based on observation, interview, and record review, the facility failed to maintain an effective pest control program in the kitchen, in that: The facility failed to ensure 5 live roaches were not observed in the kitchen. This failure placed all residents who consume food prepared in the kitchen at increased risk of illness. Findings included: An observation of the kitchen on 08/15/2023 at 8:15AM, revealed 5 live roaches. In an interview with Resident #244 on 08/15/2023 at 2:37 PM revealed the resident reported she had seen a roach on her plate two days ago and sent the tray back to the kitchen because of it. In an interview with the Dietary Manager on 08/15/2023 at 8:30AM, she stated she was aware the kitchen had roaches but she did not believe it to be a major issue. In an interview with the Cluster Dietary Resource on 08/18/2022 at 12:58PM, she stated it was important to maintain effective pest control to prevent diseases from the kitchen to the residents. The facility's policy on pest control, dated 2013, revealed, . If pests are seen in the kitchen, the food service manager or appropriate staff shall be informed describing where the pest was seen and when. Appropriate action will be taken to eliminate reported pest situation in the department .

Based on observation, interview, and record review, the facility failed to ensure that drugs and biologicals used in the facility were secured properly for Resident #10 reviewed for pharmacy services as evidenced by: The facility failed to ensure Resident #10's liquid intravenous medication bag hanging on the pole at bedside and unattended on top of the bedside table was labeled with the name of nurse, time or date of reconstitution (restoring something dried to its original state by adding water to it). This deficient practice could place residents at risk for harm and place the facility at risk for a possible drug diversion. The findings include: Record review of Resident #10 face sheet, dated 8/15/23, reflected a [AGE] year old male, admitted to the facility on [DATE] with diagnoses Chronic kidney disease (CKD) is a long-term condition where the kidneys do not work as well as they should, Peripheral vascular disease (PVD) is a slow and progressive circulation disorder. Narrowing, blockage, or spasms in a blood vessel. Minimum Data Set (MDS) dated [DATE] reflected Brief Interview of Mental Status (BIMS) of 00, which indicated decreased cognition. Observed on 8/15/23 at 9:34 a.m., on a pole at bedside of Resident #10, a bag of liquid intravenous medicine labeled Cefepime (antibiotic) 1 gram (gm) with 100 milliliter (ml) normal saline (NS) (a solution to supply water and salt (sodium chloride) to the body) attached to the antecubital area (the inner or front surface of the forearm). The bag of liquid intravenous medicine was not labeled with the name of the nurse or the time or date of reconstitution. Observed on 8/15/23 at 9:35 a.m., on top of the Resident #10's bedside cabinet, a bag of liquid intravenous medicine labeled Cefepime 1 gram (gm) with 100 milliliter (ml) normal saline (NS) unattended in residents' room. The bag of liquid intravenous medicine was not labeled with the name of the nurse or the time or date of reconstitution During an interview on 8/15/2023 at 9:44 AM, LVN A denied preparing any IV medications to be hung. LVN A and stated all IV medications prepared and hung for infusion by nursing staff must be signed, dated, timed, and initialed by the nurse. LVN A reported no medications were to be in a resident's room. LVN A stated the reason medications should be locked up or in medication cart is a residents could take too much medication, a confused resident could walk into the room and take medications that are not for them, causing an adverse effect. During an interview on 8/15/2023 at 9:48 am, LVN B stated she did not see any medications on Resident #10's bedside table and stated all IV medications prepared and hung for infusion by nursing staff must be signed, dated, timed, and initialed by nurse. LVN B stated she knows that medications are not allowed in patient rooms as it is dangerous if the resident takes too much, or another resident takes medications that is not theirs. During an interview on 8/15/2023 at 11:10 AM with the Director of Nurses (DON revealed medications should not allowed at bedside unless there is a doctor's order. She stated she does not have any residents, that have a doctor's order for medications to be at bedside. DON stated is not good to have medication at bedside as it can be taken by another resident( drug diversion) or a resident could have adverse effects if they take medication that's not for them. DON stated the policy for intravenous medications is that the nurse should place the time medication is hung, date the medication is hung, and initial of nurse that hung the medication. During an interview on 8/16/2023 at 5:02 pm, LVN C stated she had seen the IV medication attached to Resident #10 on the evening of 8/14/23. She put Resident #10's Cefepime 1 gram (gm) with 100 milliliter (ml) normal saline (NS) on the bedside table for the 9:00 PM dose, she stated she did not date, time, and initial the medication. She stated all IV medications prepared and hung for infusion by nursing staff must be signed, dated, timed, and initialed by nurse. LVN C stated she forgot, and she was aware that medications were not allowed in patient rooms unless there was a doctors' order, as it was dangerous if the resident takes a medicine not ordered for them. Record review of the facility policy titled Policy / Procedure - Nursing Clinical (Revised: 05/2007) read in part: Section: Medication Administration; Subject: IV Administration of Drugs; Policy Number: NCMA 6; Policy: It is the policy of this facility that IV drugs shall be administered by a registered nurse or IV Certified Licensed nurse.; Procedures: 3. IV solutions must be labeled in accordance with established procedures governing all Labeling IV Solutions.

Based on observation, interview, and record review, the facility failed to maintain an infection control program to provide a safe, sanitary, and comfortable environment to help prevent the transmission of infection for 1 of 9 residents (Resident # 1) reviewed for infection control in that: -LVN A did not wash or sanitize hands prior and during dressing change for Resident #1. -LVN A did not dispose soiled wound dressing in a red biohazard bag after changing Resident #1's dressing. -LVN A did not use sterile gloves during dressing change of nephrostomy tube for Resident #1. These failures could place resident (s) at risk for unwanted infections, cross contamination, decline in health, and hospitalization . Findings included: Resident #1 Record review of Resident #1's face sheet revealed an 83year old female admitted to NF on 11/11/2022 and again on 01/26/2023 with the diagnoses that included the following: pulmonary embolism (clump of material most often a blood clot, gets stuck in the lungs blocking the flow of blood), respiratory failure ( serious condition that makes it difficult to breathe on your own), hydronephrosis (excess fluid in a kidney due to backup of urine) with ureteral (tube that carries urine from the kidney to the bladder stricture (restricting the flow of urine from the bladder), and urinary tract infection. Record review of Resident #1's MDS dated [DATE] revealed BIMS score of 11 (cognition intact). Further record review revealed that resident required extensive with ADL's in the following areas (toilet use, bed mobility, transfer, dressing, and personal hygiene). Further review revealed that Resident #1 was frequently incontinent of bowel and bladder. Record review of Resident #'s Physician Orders revealed an order dated 11/12/2022 to cleanse right flank nephrostomy insertion sith with normal saline, pat dry and apply dry tegaderm every 3 days and PRN. Notify MD if any s/s of infection. Record review of Resident #1's MAR for the month of February and March 2023 revealed that Resident #1 's dressing change was being done every 3 days. Record review of Resident #1's Care Plan dated 12/02/2022 revealed that the NF was care planning resident for nephrostomy intervention that included to monitor insertion site for s/s of infection such as skin irritation, pain redness, unusual drainage and too much moisture, notify MD if noted. Observation on 03/01/2023 at 10:30am Resident #1 had a right nephrostomy tube (tube that is put into the kidney to drain urine directly from the kidney) draining cloudy pale yellow color fluids approximately 50 ml of fluid was in the drainage bag. The dressing to nephrostomy tube site was dated 02/26/2023. Further observation of dressing had a small amount drainage (brownish in color). Observation on 03/01/2023 at 10:48am LVN A was changing the dressing to of Resident #1's right nephrostomy tube with the assistance of CNA B. LVN A entered the room with supplies (disposable bed padding, clean gloves, and sterile 2x2's gauze). LVN A placed the clean set of gloves on without first washing or sanitizing her hands positioned resident to her left side with the assistance of CNA B. LVN A removed the soiled dressing with drainage and proceeded to clean the nephrostomy tube site with normal saline without changing her gloves and sanitizing hands. LVN A did not clean nephrostomy site from inner to out in a circular motion moving away from the site instead LVN A cleaned back and forward. When LVN A was done cleaning the site LVN A applied 2x2 gauze to nephrostomy site securing with a border dressing and placed the soiled material in a plastic bag instead of a red biohazard bag. LVN A washed her hands as well as CNA B prior to taking the soiled materials out of the room. Interview on 03/01/2023 at 11:00am LVN A said she had washed her hands prior to entering resident room to change nephrostomy dressing. LVN A said she did not have to use sterile gloves when changing nephrostomy tube dressing and that it was a clean technique. LVN A said she had been a nurse for [AGE] years but had not received any in-services regarding the care for nephrostomy tubes. LVN A said it was important to wash or sanitize hands prior to administering care to resident (s) for infection control. LVN A said when cleaning a wound, one should clean the wound site in a circular motion starting at the site moving away from the site in a circular motion to avoid reintroducing bacteria to the wound site. LVN A said soiled material needed to be placed in a red biohazard bag for infection control purposes. LVN A said she became nervous and began to make mistakes. Interview on 03/01/2023 at 1:14pm, RN C at the Nephrologist Office said when changing the dressing of a nephrostomy tube, the nurse should practice sterile technique by wearing sterile gloves because the tube was connected to the kidneys. RN C said this was done to avoid infections. RN C said if the tube was being irrigated, the nurse did not have to wear sterile gloves but clean gloves. Interview on 03/01/2023 at 2:00pm, the DON said the correct way to clean a wound was to clean away from the wound site to prevent infections. The DON said she could not explain why LVN A cleaned Resident #1 wound site back and forward. The DON said when changing dressing for nephrostomy tubing, the nurse did not have to wear sterile gloves, just clean gloves. Record review of the NF policy regarding Care of Nephrostomy Tube undated revealed in part: .For dressing changes equipment included the following: clean gloves, sterile gloves, sterile drape . Record review of the NF policy Hand Hygiene revised 06/2021 revealed in part: .Hand hygiene is one of the most effective measures to prevent the spread of infection. Studies show that effective had decontamination can significantly reduce the rate of healthcare associated infection .Use an alcohol-based hand rub containing at least 62% alcohol; or alternatively, soap before and after direct contact with residents, before handling clean or soiled dressings, gauze pads, etc .after handling used dressings . Record review of the NF policy on Biohazardous Materials dated 07/2018 revealed in part: . soiled wound dressings are bagged and tied up and disposed properly in red biohazard bags and disposed of appropriately .

Based on observation, interview, and record review the facility failed to assist resident to obtain or provide dental services for 1 of 5 residents (Resident #1) reviewed for dental service in that: -Resident #1 had lots of painful broken and missing teeth and was neither offered nor assisted with dental services since her admission. This failure could cause residents to have dental problems, which could cause pain, complications, and a poor quality of life. Findings include: Record review of Resident #1's Admission Record printed on 12/7/22 revealed a [AGE] year-old female admitted to the facility on [DATE] with a diagnosis of Alzheimer's disease, cardiac arrhythmia (irregular heartbeat), early onset cerebellar ataxia (sudden uncoordinated muscle movement), dysphagia (difficulty swallowing), muscle weakness, cognitive communication deficit, gastro-esophageal reflux disease, abnormal posture, history of falling, mood disorder, due to depression, hyperlipidemia (high cholesterol), hypertension (high blood pressure), arthritis, kyphosis (outward curvature of the spine), major osseous defect (extensive bone loss) and overactive bladder. Record review of Resident #1's Quarterly MDS dated [DATE] revealed she usually understood verbal content, had impaired vision seeing only large print and corrective lenses were not used. Resident #1's BIMS Summary Score was 3 indicating severe cognitive impairment. Resident #1 required extensive assistance with one person physically assisting with bed mobility, walk in corridor, locomotion on and off unit, dressing, eating, and personal hygiene; extensive assistance with two persons physically assisting with transfers and toilet use and walking in room did not occur; she required total dependence with support provided for bathing and she was not steady with transitions and walking and was only able to stabilize with staff assistance. Resident #1 required setup or clean-up assistance with eating, oral hygiene, and toileting hygiene. Record review of Resident #1's Care Plan last updated 11/30/22 revealed she was at risk for impaired skin integrity, she was at risk for impaired cognitive function/dementia or impaired thought processes route of diagnosis of Alzheimer's with interventions as administer medication as ordered, keep routine consistent and social services to provide psychosocial support as needed. She was at risk for impaired visual function route of history of cataracts with the goal is to use appropriate visual devices glasses to promote participation in ADLs and other activities and interventions were to identify/record factors affecting visual function including physiological Crohn's, macular degeneration, cataracts, color discrimination, light eyes); Environmental (poor lighting, monochromatic color scheme), to wear glasses, use mag glass, turn on lights) etc., remind resident to wear glasses when up and review medications for side effects which affect vision. Resident #1 required assistance with Activities of Daily Living self care performance deficit route of decreased mobility and Alzheimer's with interventions with personal hygiene routine requiring staff participation in personal hygiene and oral care. In an interview on 12/6/22 at 3:07 p.m. with Resident #1's Responsible Party he said that on 12/5/22, he came to the facility at 7:30 p.m. and Resident #1's food was still on the tray uneaten, and the residents were usually served between 5 p.m. to 5:30 p.m. He said no one tried to feed Resident #1 and she is losing her teeth. The Responsible Party said when Resident #1 was admitted to the facility she had a full set of teeth and now all of her teeth were broken, and she has missing teeth. The Responsible Party said Resident #1 had never seen the dentist since she had been living at the facility. Resident #1 has been placed on a chopped food plan where all of her food comes chopped up. The Responsible Party feels the facility needed to do a consult for what has taken place with her teeth. He said Resident #1 used to be able to do her own oral care, but she is not able to do it now and the staff are not doing oral care. In an observation and interview on 12/7/22 at 9:40 a.m. with Resident #1 she was observed lying in bed. Resident #1 said she had pain in her teeth and that all her teeth were breaking off all by themselves. Resident #1 said she thought she may have been given pain medicine for her teeth before, but she did not remember seeing a dentist. Observation of Resident #1's teeth revealed they were yellow, there were appeared to be some missing teeth and broken teeth. In an interview on 12/7/22 at 11:40 a.m. with the SW she said Resident #1 was having trouble eating so she was put on Mechanical Soft diet. The Social Worker said Resident #1 had always been a picky eater, so they are always monitoring her eating. The Social worker did call the local dentist office to see if Resident #1 saw a dentist. The Social worker said she did not write any notes that said the resident saw the dentist. In an interview on 12/8/22 at 12:13 p.m. with CNA A she said she allowed Resident #1 to brush her own teeth in the morning. She said the few teeth Resident #1 has in her mouth Resident #1 brushes them. CNA A said she was not aware of any teeth breaking out. In an interview on 12/8/22 at 12:30 p.m. with the SW she said for dental the family will let them know if the resident needs to see a dentist and sometimes they have their own dentist. She went to talk with Resident #1's Responsible Party last night on 12/7/22 and he told her that he noticed that Resident #1 lost 4 or 5 teeth. He never asked her about the dental and no one else told her Resident #1 had any problems with dental. In an interview on 12/8/22 at 1:18 p.m. with the Administrator and DON they said dental is discussed in Care plan meeting, and the SW is present in the clinical meeting daily . The Administrator and DON said they were not aware Resident #1 had not received dental services and that all residents should be receiving dental services. Attempted Record review of Resident #1's dental services revealed there were no notes. Record review of Facility's Policy on Dental Services dated 1/2022 revealed It is the policy of this facility to ensure that its residents who require dental services on a routine or emergency basis have access to such services without barrier. Emergency dental services includes services needed to treat an episode of acute pain in teeth, gums, or palate, broken, or otherwise damaged teeth, or any other problem of the oral cavity that required immediate attention by a dentist . Routine dental services means an annual inspection of the oral cavity for signs of disease, diagnosis of dental disease, dental radiographs as needed, dental cleaning, fillings (new and repairs), minor partial or full denture adjustments, smoothing of broken teeth, and limited prosthodontic procedures, e.g, taking impressions for dentures and fitting dentures.

Based on interview and record review, the facility failed to ensure the resident's right to participate in the development and implementation of his or her person-centered plan of care, for 1 of 5 Residents (Resident #1) reviewed for care plans, in that: -The facility did not have a quarterly care plan meeting to discuss Resident #1's care. This failure caused Resident #1 and her Responsible Party to miss the opportunity to participate in the residents' care planning. The findings were: Record review of Resident #1's Admission Record printed on 12/7/22 revealed a [AGE] year-old female admitted to the facility on [DATE] with a diagnosis of Alzheimer's disease, cardiac arrhythmia (irregular heartbeat), early onset cerebellar ataxia (sudden uncoordinated muscle movement), dysphagia (difficulty swallowing), muscle weakness, cognitive communication deficit, gastro-esophageal reflux disease, abnormal posture, history of falling, mood disorder, due to depression, hyperlipidemia (high cholesterol), hypertension (high blood pressure), arthritis, kyphosis (outward curvature of the spine), major osseous defect (extensive bone loss) and overactive bladder. Record review of Resident #1's IDT-Care Plan Review dated 4/7/22 revealed a quarterly review with Resident #1's responsible party and activity assessment-preferences for customary routine and activities user defined assessment, social services assessment, BIMS, patient Health Questionnaire (PHQ-9), dietary assessment, Braden scale for predicting pressure sore risk, fall risk assessment evaluation, pain risk assessment evaluation, nutrition/hydration risk assessment/evaluation, bowel and bladder evaluation, elopement/wandering evaluation and immunization history. Social services plan of care (cognitive patterns, mood and behavior revealed alert and oriented X2, anxious at times, family supportive, and remains full code. Followed by podiatrist and Optometrist. Social Services Director emailed local company asking if they can repair her broken glasses. Record review of Resident #1's Quarterly MDS dated [DATE] revealed she usually understood verbal content, had impaired vision seeing only large print and corrective lenses were not used. Resident #1's BIMS Summary Score was 3 indicating severe cognitive impairment. Resident #1 required extensive assistance with one person physically assisting with bed mobility, walking in corridor, locomotion on and off unit, dressing, eating, and personal hygiene; extensive assistance with two persons physically assisting with transfers and toilet use and walking in room did not occur; she required total dependence with support provided for bathing and she was not steady with transitions and walking and was only able to stabilize with staff assistance. Resident #1 required setup or clean-up assistance with eating, oral hygiene, and toileting hygiene. Record review of Resident #1's Care Plan last updated 11/30/22 revealed risk for impaired skin integrity was added to the Care Plan, alteration in musculoskeletal status route of diagnosis of Kyphosis and hyper-extension of neck with the goal to remain free from pain or at a level of discomfort acceptable to the resident through the review date, remain free of injuries or complications with the interventions being to anticipate and meet needs, be sure call light is in reach and to use the neck brace as needed for hyper-extension of neck muscles. Resident #1 had a urinary tract infection on 10/19/22 and the interventions were to encourage fluid intake, give antibiotic therapy as ordered, resident/family/caregiver teaching should include good hygiene and cranberry or prune juice to keep urine acidic. She was at risk for impaired cognitive function/dementia or impaired thought processes route of diagnosis of Alzheimer's with interventions as administer medication as ordered, keep routine consistent and social services to provide psychosocial support as needed. She was at risk for impaired visual function route of history of cataracts with the goal is to use appropriate visual devices glasses to promote participation in ADLs and other activities and interventions were to identify/record factors affecting visual function including physiological Crohn's, macular degeneration, cataracts, color discrimination, light eyes); Environmental (poor lighting, monochromatic color scheme), to wear glasses, use mag glass, turn on lights) etc., remind resident to wear glasses when up and review medications for side effects which affect vision. Resident #1 had an actual fall revised on 6/15/22 with the goal being to resume usual activities without further incident and the interventions were that labs, instructed resident to call for assistance, monitor/document/report to MD for pain, bruises, change, confusion, sleepiness, and inability to maintain posture. In an interview on 12/6/22 at 3:07 p.m. with Resident #1's Responsible Party he said he had not had a Care Plan meeting concerning Resident #1 and he does not recall how long ago. The Responsible Party said the facility has not had a Care Plan meeting at all for Resident #1 and there are things that need to be evaluated with Resident #1's care. The Responsible party said Resident #1 had broken teeth and she had never seen the dentist, she needs help with eating her food, she cannot brush her own teeth anymore and he was concerned especially since the incident where she fell on [DATE], and he had lots of concerns. In an observation and interview on 12/7/22 at 9:40 a.m. with Resident #1 she was observed lying in bed. Resident #1 said she could not recall a Care Plan meeting. In an interview on 12/7/22 at 11:40 a.m. with the SW she said Resident #1's last care plan meeting was in April 2022 and at the last meeting she was receiving wound care and she was getting repeat UTI's so they put her on antibiotics . Resident #1's diet was mechanical soft, protein liquid, health shake. The SW said Resident #1's glasses were broken so she emailed the local company about glasses, and the SW said she had to check to see if they got glasses because they were broken. In an interview on 12/8/22 at 12:30 p.m. with the SW she said she tries to do a care plan review every 3 months, but it depends on if the family requests it or if there is change in condition because it would have been more frequent than that. The Social Worker said she was surprised that it was April since the last Care Plan meeting for Resident #1 because her Responsible Party was so good about talking with her. She said the system for Care Plan meeting is when the facility has a skilled patient, they try to do the Care Plan meeting as soon as the residents get to the facility and the long-term residents get MDS to put it on the calendar. She said MDS does a calendar for the ARD dates and that tells them when the ARD is. She said the care plan meeting has to be within 20 days of the MDS ARD. The SW said she did not know what happened for why Resident #1 was not placed on the calendar. She said they discuss Care Plan meetings every morning in clinicals and the resident or the family lets them know if they need any services. In an interview on 12/8/22 at 12:45 p.m. with the ED she said the Care Plan meetings are completed within the first week of the resident moving into the facility and quarterly unless there is a request. She said the IDT will also request a Care Plan meeting, and if there is a change with the resident, a Care Plan meeting may be requested. Record review of Facility's Policy on Comprehensive Person-Centered Care Planning dated 11/2016 revealed It is the policy of this facility that the interdisciplinary team (IDT) shall develop a comprehensive person-centered care plan for each resident that includes measurable objectives and timeframes to meet a resident's medical, nursing, mental and psychosocial needs that are identified in the comprehensive assessment. The IDT team will also develop and implement a baseline care plan for each resident, within 48 hours of admission, that includes minimum healthcare information necessary to properly care for each resident and instructions needed to provide effective and person-centered care that meet professional standards of quality care .The resident's comprehensive plan of care will be reviewed and/or revised by the IDT after each assessment, including both the comprehensive and quarterly review assessments .The facility will provide the resident and resident representative, if applicable, advance notice of care planning conference to encourage resident and/or resident representative participation.

Based on observation, interview, and record review, the facility failed to ensure each resident received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the resident's choices for 1 of 10 residents (Resident #1) reviewed for quality of care. The facility failed to provide Resident #1 with wound care for three days (11/13/2022 - 11/15/2022). This failure placed residents with wounds at risk of worsening wounds, infection, and pain. Findings include: Record review of Resident #1's face sheet revealed he was a [AGE] year-old male who was admitted to the facility on [DATE]. He was diagnosed with bacterial infection, end stage renal disease (when a person's kidneys cease to function on a permanent basis leading to a need for a regular course of long-term dialysis or a kidney transplant to maintain life), diabetes mellitus (too much sugar in the blood) without complications, dependence on renal dialysis (a treatment for people whose kidneys are failing), hypertension (a condition in which the force of the blood against the artery walls is too high), and peripheral vascular disease (a circulatory condition in which narrowed blood vessels reduce blood flow to the limbs). Record review of Resident #1's BIMS (Brief Interview for Mental Status), dated 11/11/2022, revealed a score of 15 (cognitively intact). Record review of Resident #1's electronic clinical records revealed his MDS was incomplete due to his recent admitted . Record review of Resident #1's care plan, revised 11/15/2022, revealed, Resident #1 has end stage renal disease (Goal: Will not have a re-hospitalization within 30 days. Interventions: Assist resident with ADLs and ambulation as needed. Give medications as ordered by physician. Monitor for s/sx of hypovolemia [a condition in which the liquid portion of the blood, plasma, is too low] or hypervolemia [a condition in which the liquid portion of the blood is too high]. Monitor for s/sx of infection, UTI); Resident #1 is on IV medications due to bacterial infection (Goal: Will not have any complications related to IV therapy. Interventions: Check dressing at site daily. Monitor/document/report to MD PRN s/sx of infection at the site: Drainage, Inflammation, Swelling, Redness, Warmth); Resident #1 ha actual impairment to skin integrity due to surgical wound right foot (Goal: Will have no complications due to surgical wound through review date. Interventions: Open wound right lateral foot close to heel. Cleanse with NS, pat dry, pack with packing gauze, apply collagen and wrap with kerlix cover and elastic tape daily. Monitor/document location, size and treatment of skin injury. Report abnormalities, failure to heal, s/sx of infection, maceration, etc. to MD); and Resident #1 has potential for pressure ulcer development due to decreased mobility (Goal: Will have intact skin, free of redness, blisters or discoloration. Interventions: Administer treatments as ordered and monitor for effectiveness. Follow facility policies/protocols for the prevention/treatment of skin breakdown. Notify nurse immediately of any new areas of skin breakdown: Redness, Blisters, Bruises, discoloration noted during bath or daily care). Record review of Resident #1's physician's orders for November 2022 revealed: Open wound right lateral mid foot. Cleanse with NS, pat dry, pack with packing gauze, apply collagen, and cover with dry dressing wrap with kerlix and elastic tape daily every day shift. Discontinued. Order date: 11/11/2022. Date start: 11/12/2022. End date: 11/16/2022. Cleanse surgical wounds x2 to right lateral foot with NS, pat dry, pack tightly with iodoform gauze, cover packing with small amount of alginate, wrap in kerlix and coban daily and as needed (Apply skin prep to scabbed abrasion to Achilles area) as needed and every day shift. Active. Order date: 11/16/2022. Start date: 11/16/2022. Record review of Resident #1's hospital records revealed he was admitted to an acute care hospital on 10/28/2022 and was discharged on [DATE]. The document read in part, . Chief Complaint: Comprehensive rehabilitation related to chronic nonhealing diabetic ulcer, status post amputation. History of Present Illness: This is the case of a pleasant [AGE] year-old male with a noted past medical history of end-stage renal disease, type 2 diabetes, and trans metatarsal amputation. He has multiple nonhealing ulcers to the bilateral lower extremities, who presented to acute hospital setting with complications due to his nonhealing ulcers and underwent an incision and drainage on 10/31/2022, was later transferred to the ICU for close medical management . He has been referred for further acute comprehensive inpatient rehab to optimize his acute postsurgical pain, continue with dialysis, address his impaired mobility, decreased strength and high risk for infection . Record review of Resident #1's, Initial Admission Record dated 11/10/2022 revealed, . admitted from: 8. Acute Care Hospital . 1. Skin Integrity . Site: Right Toe(s), Description: Surgical Incision . Record review of Resident #1's progress notes for November 2022 revealed: On 11/11/2022 at 10:00 p.m., the DON wrote, Provided wound care to right foot; resident has surgical site ~4 cm long below big toe; open wound lateral/mid foot 3x2x0.2 with tunneling 0.8 beefy red; lateral foot closer to heel 1.5x1.1 slough; back of calf 5x4x0 pink dry tissue. Cleansed all with saline, packed foot wounds with packing gauze, covered with collagen; calf applied xerfoam; wrapped foot and calf with kerlix and elastoban. On 11/16/2022 at 10:36 a.m., LVN C wrote, Wound care performed to right lateral foot at this time with surgical puncture noted x2. Both wounds' beds show healthy granulation tissue with no noted odor or slough. Edges of wounds show some maceration and skin surrounding wounds is intact and normal for resident. Scabbed abrasion to Achilles area stable. Per surgeon, orders updated to cleanse surgical sites with NS, pat dry, pack tightly with iodorform gauze, cover with small amount of alginate, wrap foot with kerlix and coban dressing daily. Resident tolerated dressing change well and denied need for pain medication prior to, during or followed wound care. Further review of Resident #1's progress notes for November 2022 revealed no other documentation related to wound care treatments. Record review of Resident #1's electronic TAR for November 2022 (printed copies were also requested from the DON and Administrator on 11/16/2022 at 10:30 a.m.) revealed: Open Wound right lateral mid foot. Cleanse with NS, pat dry, pack with packing gauze apply collagen, and cover with dry dressing wrap with kerlix and elastic tape daily every day shift -Order Date- 11/11/2022 -D/C Date- 11/16/2022. Further review of the TAR revealed there were no entries (the blocks were blank) for 11/13/2022, 11/14/2022, and 11/15/2022, indicating the treatments were not completed. Cleanse surgical wounds x2 to Rt lateral foot with NS, pat dry, pack tightly with iodoform gauze, cover packing with small amount of alginate, wrap in kerlix and coban daily and as needed (Apply skin prep to scabbed abrasion to Achilles area) as needed- Order Date- 11/16/2022. Record review of Resident #1's printed TAR (provided by the DON on 11/16/2022 at approximately 1:15 p.m.) for November 2022 revealed: Open Wound right lateral mid foot. Cleanse with NS, pat dry, pack with packing gauze apply collagen, and cover with dry dressing wrap with kerlix and elastic tape daily every day shift -Order Date- 11/11/2022 -D/C Date- 11/16/2022. Further review of the TAR revealed entries for 11/13/2022 and 11/14/2022 were checked and initialed by the nurse who completed the treatment (indicating that the treatments were completed). There was no entry for 11/15/2022. In a telephone interview with Resident #1 on 11/16/2022 at 9:21 a.m., he stated he had not received wound care at the facility for three days. He said he told somebody he did not get wound care (he could not recall the name of the person). He said he was supposed to get his dressings changed daily but one nurse always said somebody else was going to do it. An interview and observation of Resident #1 on 11/16/2022 at approximately 11:30 a.m. revealed he was alert and oriented. Resident #1 was on a stretcher and was being taken out of the facility by EMS. He stated he unexpectedly got an earlier chair time at the dialysis clinic. No observations of Resident #1's wounds were conducted. Resident #1 stated he had received wound care that morning (11/16/2022). In an interview with the Clinical Market Leader on 11/16/2022 at 12:41 p.m., she said she saw the blanks on Resident #1's TAR when she and the DON were preparing the printed copies. She said they were looking into the blanks on the TAR and several nurses were involved. She said the DON addressed the blanks and contacted the nurses. She stated the wound care was done, but the TAR was not signed to reflect the treatment. She said the ADON was filling in for the wound care nurse, but on weekends, the nurses did their own wound care. She said the nurses who completed Resident #1's wound care should have done the care and signed the electronic TAR immediately, but that did not happen. In a telephone interview with ADON A on 11/16/2022 at 12:59 p.m., she stated she and the other ADON, ADON D, had been splitting wound care duties since the facility did not have a wound care nurse. She said for the past couple of nights, she had been working over night as a charge nurse. She said Resident #1 went to dialysis late (around 3:30 p.m.) on Mondays, Wednesdays, and Fridays, so she would have been the nurse to do his wound care on dialysis days. She said she did Resident #1's wound care since he was admitted to the facility. She said one time, on Monday, 11/14/2022, she did Resident #1's wound care, but she forgot to sign the TAR. ADON A said she got very busy, and it slipped her mind to go back and sign the TAR. She said she did eventually go back and sign the TAR (she did not say when she went back to sign the TAR). She said Resident #1 would definitely tell you if his wound care was not done, but he never mentioned to her that it did not get done, other than 11/14/2022. She said on 11/14/2022 when Resident #1 returned from dialysis, he said he had not received wound care. She said she went to Resident #1's room around 8:30 p.m. on 11/14/2022 and completed his wound care. In an interview with the DON and Administrator on 11/16/2022 at 1:35 p.m., the DON said she did not think ADON B did any of Resident #1's wound care. The Administrator said ADON B could not have done any of Resident #1's wound care based on the staff schedule. The DON said Resident #1 was admitted on Thursday, 11/10/2022 and she (the DON) did his wound care on Friday, 11/11/2022. The DON said RN D should have done Resident #1's wound care on Saturday, 11/12/2022 and Sunday, 11/13/2022. The DON said ADON A should have done Resident #1's wound care on Monday, 11/14/2022 and Tuesday, 11/15/2022. The DON said she initiated an action plan and education of the nurses based on the missed entries. The DON said some care (wound care for Resident #1) was done, but the treatments were just not signed off on. The DON said she planned to audit all MAR/TARs to make sure all wound care had been done. The DON said ADON A went to the facility that day (11/16/2022) and signed Resident #1's TAR for the days of care she did but forgot to sign before. The DON said RN D was the facility's weekend supervisor. The DON said RN D went to the facility that day (11/16/2022) and completed her sign-ins on Resident #1's TAR that she forgot to do before. The DON said RN D was re-educated on signing the TAR when she went in on 11/16/2022. The DON said the expectation was that nurses sign the TAR when they completed the wound care treatment. The DON said she planned to pull the TARs, before the morning meeting on 11/17/2022, to see if there were any holes and ask each nurse why. The DON said she did not find a facility policy regarding physician's orders, and they probably did not have a policy on documentation. In an interview with ADON B on 11/16/2022 at 1:45 p.m., she stated she did wound care in the daytime because the other ADON worked the night shift. She said she did wound care for all of the residents who were in the facility in the daytime. She said some went out to dialysis and the floor nurses or the other ADON did the wounds once the residents return from dialysis. She said she never did Resident #1's wound care because either he was not in his room when she went in, he had company, or he was out at dialysis. She said the normal procedure was for the nurses to sign the TAR immediately after they completed the wound care treatment. In a telephone interview with RN D on 11/16/2022 at 1:55 p.m., she stated she was the facility's weekend supervisor. She said she only worked weekends, usually from 7:30 a.m. until 8:00 p.m. She said she normally did wound care, but sometimes, the nurses did them. She said she did Resident #1's wounds that past weekend (Saturday, 11/12/2022 and Sunday, 11/13/2022). Initially, RN D said she did sign off on Resident #1's TAR after she completed each treatment. RN D then said she went to the facility that day (11/16/2022) and signed Resident #1's TAR because she forgot to sign it on Sunday, 11/13/2022. She said she asked the floor nurse to do Resident #1's wound care treatment on 11/13/2022, but when she saw it was not done, she went and did the treatment herself. She said she typically would sign off on the TAR right after care, but that day (11/13/2022), it was just something that happened. She said she also received an in-service from the DON when she went to the building on 11/16/2022. Record review of facility policy, Nursing Clinical revised May 2007 revealed, . Subject: Charting and Documentation. Definition of Record: The resident's clinical record is a concise account of treatment, care, response to care, signs, symptoms, and progress of the resident's condition. Is also necessary to include data needed for identification and communication with family and friends. Complete history of resident and present illness is required under current law and regulations at the time of admission . Rules For Charting, Notes are to be written on all long-term residents by day and night shifts; frequency is determined by the individual nursing service . Continuous nurse's notes are required on all residents as the necessary arises. Record review of facility policy, Wound Care revised October 2010 revealed, Purpose: The purpose of this procedure is to provide guidelines for the care of wounds to promote healing. Preparation: 1. Verify that there is a physician's order for this procedure . Documentation: The following information should be recorded in the resident's medical record: 1. The type of wound care given. 2. The date and time the wound care was given . 4. The name and title of the individual performing the wound care .

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed for kitchen sanitation. The facility failed to: - properly seal food stored in the refrigerator and pantry, and - label and date food stored in the refrigerator These failures could place residents who eat food prepared in the kitchen at risk of serious complications from foodborne illness. Findings include: Observation of the kitchen's main refrigerator on 07/10/2002 at 10:20 am revealed: - A Tupperware container with jelly in it with a label that read apples and stickers with a date of 5/19 and written on top in sharpie 5-1-22. - About ¼ of a bell pepper wrapped in Plastic wrap on shelf not dated -Jalapenos in a container dated 6-30 with the plastic wrap loose over the top of the container. Observation of the pantry on 07/10/2022 at 10:31 a.m. revealed: - Opened container of grits not sealed closed - Soy sauce less sodium about less than half remaining out of a 2qt bottle states which indicated refrigerate after opening. In an interview with the Dietary Manager on 7/10/2022 at 10:31 am she stated the grits should be wrapped and placed in a plastic bag. In a later interview with the Dietary Manager on 7/13/2022 at 2:37 pm she stated it was important for food to be labeled, dated, and sealed properly in the fridge and pantry so the resident do not get sick from food borne illness. Initially the kitchen staff was responsible for ensuring everything is stored properly in the fridge and the pantry. She was supposed to come behind them to ensure it was done correctly. She checks daily. In an interview with the Administrator on 07/13/2022 at 2:33 pm she stated it was important for food to be labeled, dated, and sealed properly in the fridge and pantry for sanitation and freshness purposes as well as the food quality for the residents. The risks to residents when food was not stored properly was their health was at risk for not receiving food that was of optimum quality. Record Review of the facility's policy titled food storage revised date 8/2007 revealed in part It is the policy of this facility that food storage areas shall be maintained in a clean, safe, and sanitary manner. Policy does not say anything about food needing to be sealed, labeled, or dated. Record review of the Texas Food Establishment Regulations dated 2021 revealed: .Food storage containers, identified with common name of food .

Based on observation, interview and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for all residents in the facility reviewed for infection control. The facility failed to monitor and screen visitors for signs and potential exposure of COVID-19 illness before entering the facility. The facility failed to have signage on front door alerting visitors of recent COVID-19 positivity in building. The facility failed to have proper signage on resident rooms on hall 400 and 300 indicating isolation precautions. The facility failed to have proper PPE available on the isolation and Covid-19 halls. This failure could place residents at risk of acquiring infectious diseases including COVID 19, leading to illness and possible hospitalization . Findings include: Record review of facility policy Infection Control and Prevention Policy revision date 4/12/21 read in part .It is the policy of this facility to include preparatory plans and actions to respond to the threat of the COVID-19, including but not limited to infection prevention and control practices in order to prevent transmission . Educate residents, healthcare personnel, and visitors about [CONDITION(S)]-CoV-2, current precautions being taken in the facility, and actions they should take to protect themselves . Reinforce adherence to standard infection prevention control measures including correct use of PPE . Establish a screening process for symptoms or recent contact with [CONDITION(S)]-CoV-2 infection for all persons entering the building . Plan for staff, equipment, supplies and access to and from the unit to be dedicated whenever possible to reduce likelihood of cross-contamination . Staff should avoid working on both the COVID-19 care unit and other units during the same shift . Visitors should be informed of the outbreak in order to make informed decisions about visitation . Record review of facility policy Infection Prevention and Control Program revised 9/29/2017 read in part . Linens: Contaminated linens should be handled appropriately whether their source was an isolation room or a non-isolation room. All linens should be handled as if it were highly infectious . Anyone who handles soiled laundry must wear protective gloves and other appropriate protective equipment (e.g., gowns if soiling of clothing is likely . An observation on 7/10/22 at 9:09 a.m. the facility entrance door was locked. On the door there were 2 signs alerting visitors and vendors related to COVID-19 signs and symptoms and vendors/ visitors were not to enter if they had any of the listed symptoms. There was no sign alerting of any COVID-19 positive residents in the building. LVN B opened the front door for 3 surveyors to come into the facility. The LVN walked away from the visitors without saying anything. The surveyors stood at the front door entrance for a couple minutes, then the charge nurse , LVN C at the nurses' station flagged the surveyors over. An interview on 7/10/22 beginning at 9:12 a.m. LVN C said she was one of the charge nurses working at the facility. One of the surveyors asked if there was anything the LVN needed to do upon our entrance. LVN A said she would call the administration notifying them the surveyors were in the building. LVN C then guided the surveyors to the conference room. The LVN C said that there were 3 COVID-19 positive residents residing at the end of hall 200. The nurse indicated the front of hall 200 was quarantined residents and at the back of 200 hall was the isolated residents due to COVID1-19 positive. Later in the conversation with LVN C said all visitors should be screened for COVID-19 before entering the facility. She said she did not know why the surveyors were not COVID screened before entering. She said she thought LVN B had screened the surveyors before entering. She said this was LVN B first weekend working at the facility . The Surveyors were never screened on 7/10/22 while at the facility. An interview on 7/10/22 at 9:29 am LVN B said he was new, it was only his second day on the job. It was his first time opening the door. He stated he was supposed to ask visitors to check in on the kiosk. Usually someone is was sitting up front. He didn't remember to ask surveyors to answer screening questions as this was his first time opening the door. An observation and interview on 7/10/22 beginning at 10:22 a.m. revealed 2 washable PPE gowns hanging on each resident bathroom door on hall 300 . No observation of PPE storage anywhere on hall 300, no signage on any resident door indicating isolation precautions and no biohazard boxes or yellow biohazard bags to put the contaminated washable gowns in. An interview with the housekeeper she said she wears a mask and face shield before entering a resident room. Observed of the housekeeper enter resident rooms on hall 300 with no PPE gown use . Further observation of 2 signs posted on the front of hall 300 which read STOP, you are entering a warm zone and warm zone N95 mask, face shield in room, gown in room, gloves in room required. Observed CNA A enter resident room on Hall 300 with N95 and face shield then applied a gown that was hanging on the residents bathroom door. An observation on 7/10/22 at 11:28 a.m. revealed on the front of 400 hall a sign indicating a warm zone. There was no PPE available for use observed stocked anywhere accessible on the hall. There was were no signs on any resident door indicating isolation precautions. Observed reusable gowns hanging on resident bathroom doors. An observation and interview on 7/10/22 at 1:11 p.m. with the DON said all of 300 and 400 halls were the warm zones. She said the front of hall 200 had some warm zone residents and at the back of 200 hall there was 3 COVID-19 positive residents. She said all staff and visitors are instructed to wear full PPE before entering a resident room. She said staff get a gown for each resident room that they go into. She said staff reuse the same gown for the same resident throughout the shift. She said the staff will apply the hanging gown upon entrance of a resident room and take it off and rehang after providing care. The DON explained if a vendor went into several rooms that they needed to change out the gown before entering the next room. She pointed to a biohazard box at the front entrance and said that vendors, family and staff can place their used PPE in the yellow bag/ biohazard box. The DON showed surveyors on the back bottom linen cart where there were about 4 tied bags with reusable gowns. She said there were no biohazard bags or boxes in the resident room because they had the one box at the front entrance of the facility. The DON said that at the end of the shift a housekeeping staff would gather all the reusable PPE gowns and take them to the laundry room. She explained visitors on the COVID unit get screened in the front and offered PPE, then go to the back door of hall 200 to enter to visit COVID-19 positive residents. She said the staff and visitors also are to leave through the back door of 200 hall. She said the staff working on the hot zone (COVID-19 positive residents) was only assigned to that hall. Observation on 7/10/22 at 2:25 p.m.an unidentified housekeeping staff was wearing N95, face shield and gloves (no PPE gown) entering resident rooms on hall 400 with a large clear plastic bag and placing the reusable gowns into the bag. The housekeeper's clothing brushed up against several of the PPE gowns that she had placed into the clear plastic bag. Interview on 7/10/22 at 3:35 p.m. with LVN A said the end of hall 200 was the COVID -19 positive residents. She said her assignment was all of 200 and 300 halls including the COVID-19 positive residents. She said she tried not to go over onto the hot zone often. She said she went at the end of her shift and gave the residents their medications and COVID-19 assessment. She said visitors and staff who enter the COVID-19 unit also leave the COVID unit from the back door of 200 hall. She said the staff will provide visitors with new PPE to apply before entering the building. She said if you go onto the hot zone visitors and staff are not allowed to come back into the other parts of the building and need to leave through the back door. Observation and interview on 7/10/22 at 3:54 p.m. CNA A opened the door to the back of hall 200 and allowed the surveyor into the facility. She was wearing a N95 mask and a face shield. Observed 2 yellow disposable gowns hanging on each of the resident's bathroom doors. The CNA said she was working with the 3 COVID-19 positive. She said she was supposed to put on the disposable gown at the door of the resident room before caring for the resident, then remove the gown and hang back up on the hook before leaving the room. The CNA A left the hot zone into the warm zone on the 200 hall to the clean linen cart and reached for a PPE gown all the way on the bottom back of cart touching the clean linen that was in front of the PPE. She said she did not know why there was no PPE supplies on the hot zone. An interview on 7/10/22 at 4:00 p.m. with a family member visiting a resident on the hot zone. She said she checked in at the front entrance desk then was given her PPE then drove to the back of 200 hall. She said that their there was no box for her to dispose of her PPE on the hot zone when exiting the resident room. The family member said when they left they removed the PPE, carried it up to the front biohazard box and then again walked back down to the back of 200 hall because she was told she could not exit the front door if she was on the hot zone. An observation and interview on 7/10/22 at 4:25 p.m. surveyor questioned CNA B was asked where to dispose of used PPE before exiting facility. CNA B got a black trash bag and told the surveyor to put the used PPE in there and she would dispose of it later. She said the facility did not have biohazard boxes or bags at that time set up on the COVID hot zone. She said she was in-serviced on how to remove PPE and how to dispose of her old PPE in a yellow biohazard bag and trash was to be put in a red biohazard bag. An observation on 7/11/22 at 9:45 a.m. revealed the front door was opened for the surveyor to enter into the building. The Receptionist pointed to a kiosk on the wall and a scan thermometer that was by the entrance door. The receptionist did not say anything about the screening process. She did not offer the surveyor new PPE upon entrance to the facility. An interview on 7/11/22 at 11:44 a.m. with the DON said she was assigned as the infection preventionist for the facility. She said staff and all visitors are were screened for COVID-19 at the front entrance by the receptionist or the staff who answered the doorbell. The DON said she did not know that the surveyors were not screened into the building on 7/10/22. The DON said the staff should have asked if the surveyors had been COVID screened at the entrance, if not redirected to the kiosk for screening before allowed to enter the facility. She said the staff who answered the doorbell was responsible to show the visitors on how to use the kiosk on the wall. She said that most of the families are not first-time visitors and know how to screen themselves in. The DON said visitors will then be provided with PPE and told that it was necessary to wear all PPE while visiting the resident. She said they had plenty of PPE available at the facility. She said they had used reusable PPE gowns because they had never been told to do anything different. She said she was the Infection Preventionist at the facility and did most of the infection control trainings. She said most of the staff are were great about wearing the PPE correctly, but some have had to be reminded and reeducated on the use of PPE. She said there should be a stock of PPE and biohazard bags on the COVID unit for staff and visitors to use and she did not know why there was not enough supplies on the COVID hot unit. She said the supply coordinator was good at making sure that there was enough PPE and also that it was available for staff. She said the staff working with the COVID unit are dedicated to that hall. She said there was a sign on the front door alerting visitors that there was COVID-19 positive residents in the building. She said there was a sign on the front halls of 300 and 400 indicating warm zone. The DON said she did not know why there was no isolation precautions on each resident door on Hall 300 and 400. She said she will have staff post signs on the resident doors. An interview on 7/11/22 at 1:41 p.m. with the corporate nurse and DON, the DON said CNA D was working on all of 200 hall, the COVID -19 positive and new admits on quarantine. The DON said the CNA was not supposed to leave 200 hall to decrease cross contamination, but could care for both the hot zone and warm zone residents with proper use of PPE. The DON and corporate nurse both said proper use of PPE, disposing of PPE correctly and screening at entrance would help decrease the risk of communicable infections including COVID-19.

Based on observation, interview and record review, the facility failed to ensure all alleged violations involving mistreatment, neglect, abuse, or misappropriation of resident property were reported immediately, but not later than 2 hours if the alleged violation involved abuse to the administrator of the facility and to other officials in accordance with state law through established procedures for (including to the State Agency) for one resident (Resident #61) of eight residents reviewed for abuse. The facility failed to immediately report to the Administrator or State Agency (within 2 hours) an allegation of abuse made by Resident #61 on 7/9/2022. These failures could affect residents and result in undetected abuse and/or decline in feelings of safety and well-being. Findings include: Record review of facility policy/ procedure for administration: Abuse: Prevention of and Prohibition Against revised date 11/28/17 read in part .It is the policy of the facility that each resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation. The facility will provide oversight and monitoring to ensure that its staff, wo are agents of the facility, deliver care and services in a way that promotes and respects the rights of the residents to be free from abuse, neglect, misappropriation of resident property, and exploitation . (E). (1). The facility will assist staff in identifying abuse, neglect and exploitation of residents . This includes identifying the different types of abuse-mental// verbal abuse . (F)(1) All identified events are reported to the Administrator immediately . (4.) All allegations of abuse, neglect, misappropriation of resident property, and exploitation will be promptly and thoroughly investigated b the Administrator or his/ her designee . Record review of facility policy/ procedure for Nursing Administration: Reporting Alleged Violations of Abuse, Neglect, Exploitation or Mistreatment revised 11/28/17 read in part . Procedures: In response to allegations of abuse . are reported immediately but: Not later than two hours after the allegation is made if the events that cause the allegation involves abuse . Record Review of Resident #61's face sheet revealed a [AGE] year-old female with an admitted [DATE]. Her diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #61's initial admission record assessment completed on 7/8/22 revealed reason for admission was a history of gastrointestinal bleed. The assessment identified the resident was alert and orientated to person, place, time and able to follow simple commands. Section bowel and abdomen identified the resident had a [CONDITION(S)] (a collection of stool in a bag on the belly) and had often bowel incontinence. Resident #61 had no identified behaviors. Record review of Resident #61's BIMS completed on 7/8/22 revealed a score of 15 indicating the resident was cognitively intact. Record review of Resident #61's care plan read in part .Resident had a [CONDITION(S)] . Interventions: change [CONDITION(S)] bag and or flange (An adhesive plate to secure an ostomy pouch to the body) as needed for leakage. Difficulty to seal, accidental removal, may apply Duoderm . empty [CONDITION(S)] bag every shift and when half full as needed . Monitor and assess appearance of [CONDITION(S)] stoma and peristomal area every shift for signs and symptoms of complications . ADL self-care performance deficit related to generalized weakness . Interventions: Resident #61 requires staff participation to use toilet . Potential for mood problem related to short term admission for [CONDITION(S)] care and rehab services. Resident fidgets with [CONDITION(S)] causing it to be dislodged, either discards it or puts paper towels or other objects around bag, requiring frequent replacement. Gown observed on floor or in trash, resident will make statement she was not provided care . Interventions: Educate resident on potential complications from fidgeting with her [CONDITION(S)] . Monitor and record mood to determine if problems seem to be related to external causes . Observe for side effects and adverse reaction to antianxiety medications . An observation and interview on 7/10/22 at 3:12 p.m. with Resident #61 revealed she was sitting up in bed and appeared upset. The resident said she had been admitted to the facility 2 nights ago and her care has been terrible since she was admitted to the facility. She said the first night she was there a facility staff yelled at her and was rough, pushing her around in bed when she changed her brief. She said she was just mean when she came to care for me and she made me feel degraded. She said it really made her upset that someone could be so mean. Resident #61 said she reported the incident to the day shift nurse, LVN A. The resident began to cry . An interview on 7/10/22 at 3:42 p.m. with LVN A said she had reported to the RN A (weekend supervisor) that Resident #61 reported that the night staff were loud and rough with her. She said when she went to the resident's room on 7/9/22 in the morning the resident was distraught and told her that the night staff were mean to her. LVN A said she had abuse and neglect training a few weeks ago. She said she would report to the DON or the administrator if that a resident was possibly getting abused. LVN A said Resident #61 was very distraught when she told her about the incident with the night staff. An interview on 7/10/22 at 3:45 p.m. with RN A said she had recently started working at the facility. She said LVN A had reported on 7/9/22, unsure of time, that Resident #61 said staff were talking loud to her. RN A said she had talked to the resident for about 20 minutes about the resident concerns. RN A said the resident reported that a staff member was talking loud to her and it made her feel bad . RN A said she had notified the DON who told her to start an in service on customer service/ abuse neglect. RN A said she could not find the training that she initiated on 7/9/22. An interview on 7/10/22 at 3:47 p.m. with DON said RN A notified her on 7/9/22, unsure of time that Resident #61 reported a staff was speaking loud to her. The DON said she had not talked with Resident #61 or the alleged staff about the incident. She said she did not notify the Administrator, or the state agency related to the reported incident because it was not abuse. She said the incident was a misunderstanding and the staff tended to talk loud in general. DON told the RN A to start an in-service on customer service. She said she completed a grievance form in behalf of Resident #61's concern. An observation and interview on 7/11/22 at 1:05 p.m. with Resident #61 appeared distraught and upset. Resident #61 said the [CONDITION(S)] bags that the facility was using wouldn't remain adhesive to her skin and the BM would leak out onto her skin. She said the night nurse came in and told her to stop messing with her [CONDITION(S)] bag because it had opened, and BM was leaking onto her skin. Resident #61 said the night nurse refused to change her [CONDITION(S)] bag and said she was a liar. Resident #61 said she was exhausted because she couldn't sleep because she had to continue to wipe the BM off her stomach to prevent it from burning her skin. She said she did not want to be at the facility because of how the staff have cared for her. She said that morning LVN A applied a new [CONDITION(S)] bag when she came in this morning. Resident #61 moved the bag to show surveyor that it remained adhesive to her skin. The resident said she was concerned that the staff want to drug her up. She said LVN A told her she had an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident said she had never taken [MEDICATION(S)] before. An interview on 7/11/22 at 1:05 p.m . with LVN A said when she started her shift that morning, she saw that Resident #61's [CONDITION(S)] bag was not adhesive to her skin. She said she replaced the [CONDITION(S)] bag with a new brand and Resident #61 had no concerns with the new bag. LVN A said maybe the previous [CONDITION(S)] bags were faulty. LVN A said Resident #61 said a night staff had raised their voice and told the resident she was lying. LVN A said she notified the DON of last nights incident. LVN said she had recent training on abuse and neglect and said she would report to the DON or administrator if a resident alleged abuse. She said the resident was a smoker and could possibly be anxious because she refused to wear a nicotine patch and the resident could not smoke on facility premises. LVN A said she reported Resident #61's concerns to the DON. She said it was discussed possible PRN use of [MEDICATION(S)] to help take the edge off not being able to smoke. An interview on 7/11/22 at 1:41 p.m. with the DON and Corporate Nurse said Resident #61's allegation were being investigated. The DON said she tried to call the night nurse, but she did not answer the phone. The DON said safe surveys were initiated yesterday. The DON said she talked with Resident #61 on 7/10/22; the resident the staff was talking loud to her. DON said the nurse that the resident is talking about is A loud country nurse. An interview and observation on 7/11/22 at 4:26 p.m. the Social Worker said she had not met Resident #61 yet. She said she typically filed grievances for residents. She said she was not involved with filling a grievance log for Resident #61 and was not aware of any concerns. Observed the Social Worker enter Resident #61's room with Surveyor's presence present. Resident #61 reported to the Social Worker all her concerns from staff on Friday night yelling and being rough with her and on Saturday night calling her a liar and not assisting with her care needs. The Social Worker said she would report the incident to the Administrator immediately because that stuff should not be happening and apologized for what the resident had reported. A record review of a Witness Statement, undated, by the Social Worker read in part .State inspector brought me to Resident #61 to hear her grievances . Resident #61 said on the night she admitted on [DATE] around 8:30 and 9:00 p.m . a tall, burly blacked haired aide was very rude to her-talking down to her and she doesn't know why she had to talk to her like that . She said last night the nurse said, I can't give you a [CONDITION(S)] bag tonight because you keep taking it off. She said she didn't get a [CONDITION(S)] bag, diaper, or gown last night because she had already met her quota. Resident said she had to keep wiping off her BM with paper towels all night to keep it off her skin, because it burned her skin . Resident said last night her nurse, and later changed it to nurse aide- tall big lady. said, You're a liar. She was crying and said she doesn't understand why she's being treated like this . I reassured resident that I will report all of this to the Administrator and DON . An interview on 7/12/22 at 12:27 p.m. with Administrator said she was informed by the DON then shortly after the Social Worker reported that Resident #61 said there was a staff talking loudly to her. The Administrator said she called the incident into the State Agency when she was first alerted of the alleged abuse on 7/11/22 around 4:00 p.m. and called the incident into the State Agency the same day around 5:30ish. The Administrator said the social worker had also reported Resident #61's same allegations to her approximately around the same time on 7/11/22. She said when she became aware of the allegation she started [NAME] interviews with residents and staff, training staff on abuse and neglect and initiation of safe surveys. She said the DON said it was reported as a staff member was being loud to a resident and a grievance form had been initiated. The Administrator said she had not spoken to Resident #61 and the resident went home AMA last night around 11:00 p.m . She said that there was no staff who fit the description Resident #61's gave of a staff who worked . The Administrator said she was the abuse coordinator, staff are to report any and all allegations of abuse to her. She said if staff don't report abuse or neglect to her it could be detrimental to the residents. She said that the administration staff, including herself and the DON train on abuse and neglect. She said the DON did a lot of her own training with her staff. A telephone interview on 7/13/22 at 10:28 a.m. with RN A (weekend supervisor) said Resident #61 reported a night staff had raised their voice at the resident. She said she notified the DON of the incident who told her to initiate training on abuse and neglect. RN A identified the Administrator as the abuse coordinator. She said she did not report to the Administrator because RN A did not feel like it was abuse. She said if she did not report allegations of abuse or neglect to the administration staff it could affect other residents or the abuse could get worse.

Based on interview and record review, the facility failed to ensure a Pre-Admission Screening and Resident Review (PASARR) Level I was completed for 1 (Resident #17) of 3 residents reviewed for PASARR assessments, in that: -Resident #17's PASARR Level l did not indicated a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] This failure could place all residents who had a mental illness at risk for not receiving needed assessment, care, and services to meet their needs. Findings include: Record review of Resident #17's face sheet revealed a [AGE] year-old female admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #17's Quarterly MDS, dated [DATE], revealed resident had a BIMS of 15 out 15 indicating no cognitive impairment. Her Active diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Medication received during the last 7 days were Antianxiety and Antidepressant. Record review of Resident #17's PASRR Level I Screening, completed by an outside facility, dated 07/31/2019, revealed Mental Illness is there evidence or an indicator this is an individual that has a Mental Illness? NO. Record Review of Resident #17's care plan revealed Focus: Resident #17's Anti-Anxiety medication use due to anxiety as evidence by irritability date initiated 8/12/2019 revised on 11/19/2021. Goal: Will be from discomfort or adverse reactions related to anti-anxiety therapy through the review date. Focus: Antidepressant medication use due to depression as evidence by tearfulness. Date initiated 1/26/2020 Revised on 11/19/2021. Goal: Will show decreased episodes of signs and symptoms of depression through the review date. Focus: Resident #17 has diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Date initiated 3/19/2021. Goal Will be/remain free of drug related complications, including movement disorder, discomfort, [CONDITION(S)], gait disturbance, constipation/impaction or cognitive/behavioral impairment through review date. Record review of Resident #17's July 2022 Medication Administration revealed an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . [MEDICATION(S)] Tablet .5mg by mouth three times a day related to anxiety disorder unspecified. Record review of Resident #17's Psychological Services Progress Notes dated April 29, 2022 read in part Top target symptoms: Anxiety, depression, tension. Current Rating 4-Moderate Goal for therapy: reduction. Symptoms present Appetite disturbance, depression, fatigue, loss of pleasure/interests, nervous/worried/stressed, anxiety, confusion, grief/loss issues, irritability, memory loss, pain, sleep disturbance, withdrawal. Observation of Resident #17 on 07/10/2022 at 11:29 am Resident was in her room in her bed with g-tube infusing. She appeared to be talking to herself as there was no one else in the room with her and she was moving her mouth as though she was having a conversation. In an interview with MDS Nurse J on 07/12/2022 at 11:25 am she stated if residents mental illness is present upon admission she has been going through their PASARR and making corrections . If Resident #17 had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . She was not sure if Resident #17 had psych diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] In an interview with the Administrator on 7/12/2022 at 12:12 PM she stated the importance of a PASARR Level I being done correctly was for the facility to determine if they need additional services. The impact to the resident if a PASARR is not completed correctly they could be missing out on having that extra oversight that could enrich their lives. Record review of the facility Policy titled PASARR revealed dated 10/2007, It is the policy of this facility to ensure that each resident is properly screened using the PASARR specified by the state. Based upon the assessment, the facility will ensure proper referral to appropriate state agencies for the provision of specialized services to residents with MI/MR.

Based on interview and record review, the facility failed to ensure each resident was free from neglect for three (Resident #5, CR #1 and Resident #6) of eleven residents reviewed for neglect. -The facility failed to prevent the development and worsening of facility acquired pressure ulcers for Resident #5 who was identified at risk to develop pressure sores. The facility failed to implement a Plan of Care when he was identified at risk to develop pressure sores. Resident # 5 developed a facility acquired pressure sore that was first identified as a Stage 3 to his left buttocks. The pressure sore advanced to a stage 4 pressure sore. -The facility failed to follow the MD recommendations to offload Resident #5's Stage 4 pressure ulcer, failed to provide the appropriate treatment and implement preventive measures to avoid the deterioration of Resident #5's stage 4 pressure sore. Resident #5 was found with deep tissue injury on the outside of his stage 4 pressure sore, foul odor on the wound and a large reddened area covering most part of his left buttocks. -The facility failed to prevent the worsening of CR #1's pressure ulcers who was readmitted to the facility with a Stage 4 pressure sore to his Sacrum and Stage 2 pressure sore to his right heel. The facility failed to follow CR #1's Plan of Care to turn/reposition and offload/float heels with pillows. CR #1's Stage 2 pressure sore to his right heel deteriorated to Unstageable within a week, his Sacral pressure sore developed an infection to the bone and increased in size within 18 days of being readmitted to the facility. CR #1's sacral wound developed a Deep Tissue Injury around the pressure sore. Sacral Stage 4 pressure sore required antibiotic therapy and wound debridement by the MD. -In addition, the facility failed to prevent the development of a new pressure injury. CR #1 developed a Deep Tissue Injury when the facility staff placed a boot to his foot that was not ordered by the MD or was on his Plan of Care -The facility failed to follow the MD recommendations to offload Resident #6's Stage 4 pressure ulcer to her sacrum (facility acquired unavoidable). Resident #6 was found soiled with stool and the pressure sore had maceration around the wound. These failures resulted in the identification of an Immediate Jeopardy (IJ) on 10/13/17. While the IJ was lowered on 10/14/17, the facility remained out of compliance at a scope of pattern and severity level of actual harm that was not IJ because all measures for prevention and treatment of [REDACTED]. These deficient practices contributed to the development of new pressure ulcers and the worsening of existing pressure ulcers resulting in harm for Residents #5, #6 and CR#1, with the potential to place the other 99 resident at the facility at risk for neglect. Findings included: TX 709/ Intake # 9, TX 319/ Intake # 2, TX 379/ Intake # 6, TX 457 / Intake # 2 and TX 875/ Intake # 8. Resident #5 Record review of the medical record face sheet revealed Resident #5 was admitted on [DATE] and re-admitted on [DATE]. [DIAGNOSES REDACTED]. He was [AGE] years old. Record review of Resident #5's nurses notes dated 08/18/2017 at 7:15 p.m. revealed in part Resident #5 admitted to the facility. Incontinent of bowel and bladder. No wounds . Record review of Resident #5's Plan of Care initiated 08/25/2017 revealed in part: -Focus: Resident #5 has an ADL (Activity of Daily Living) Self Care Performance Deficit. -Interventions: Bed mobility: Requires (1-2) staff participation to reposition and turn in bed. Transfer: Requires 1-2 physical assistance with transferring. Further record review of Resident #5's Plan of Care revealed no interventions to prevent the development of pressure sores. Record review of Resident #5's admission MDS assessment with 08/28/2017 ARD revealed that he was rarely/never understood and was unable to complete the interview for Mental Status. Resident #5 required extensive assistance for his activities of daily living and he was total dependent for bathing. He had impairment on both sides of his lower extremities. He was always incontinent of bowel and bladder. Further record review revealed that Resident #5 was at risk of developing pressure sores and had no pressure sores during assessment. Further record review of the MDS section that read Skin and Ulcer Treatment revealed that Resident #5 was not checked to be on a turning/repositioning program or on a pressure reducing device for chair or bed. Record review of Resident #5's Braden Scale for Predicting Pressure Sore Risk revealed in part; - 08/29/2017 revealed a score of 14 indicating Moderate risk to develop pressure sores. Record review of Resident #5's nurses notes dated 9/17/2017 at 6:16 p.m. by LVN A (former Wound Care Nurse) revealed in part; Observed new Stage 3 pressure ulcer to the left buttocks which is 25% slough and 25% eschar tissue. Measurements: 3.5x3.0x0.2 (c.m.) (LWD) with moderate serous drainage. Air mattress ordered and orders placed to offload with pillows and turn frequently . Record review of Resident #5's Skin Pressure Ulcer Weekly dated 9/17/2017 revealed in part; -Site: Left buttock. Initial evaluation. -Stage 3 -Description: 25% slough, 25% eschar -Size: 3.5x3x0.2 c.m. (LWD) -Exudate: Serous moderate -Surrounding tissue: [DIAGNOSES REDACTED] -Odor: none Record review of Resident #5's consolidated MD orders revealed in part; -9/17/2017 Air mattress every shift for Stage 3 left buttocks -9/17/2017 Avoid positioning on left buttocks when possible, alternate sides and offload with pillows every shift for Stage 3 (pressure sore). -10/01/2017 [MEDICATION NAME] Acid tablet 500 mg by mouth two time a day for supplement. -10/01/2017 Multiple vitamins-minerals tablet, take one by mouth every day for supplement. -10/01/2017 Zinc Sulfate Capsule 220 mg, one by mouth one time a day for wound healing for 14 days. -10/06/2017 Clean left buttock with Normal Saline, pat dry, apply Santyl ([MEDICATION NAME] oitment) to slough followed by Calcium Alginate (dressing derived from seaweed, highly absorbent) and a dry dressing daily every day shift for Stage 4. Continued record review of Resident #5's Plan of Care initiated 09/17/2017 revealed in part: -Resident #5 has an actual Stage 4 pressure ulcer to the left buttock related to decreased mobility and incontinence. -Goal: Pressure ulcer will show signs of healing by target date 01/10/2018. -Interventions: Air mattress and frequent turns, avoid positioning on left buttocks when possible, alternate sides and offload with pillows. Record review of Resident #5's Braden Scale for Predicting Pressure Sore Risk revealed in part; - 09/18/2017 revealed a score of 11 indicating High risk to develop pressure sores. Record review of Resident #5's Skin Pressure Ulcer Weekly dated 9/22/2017 revealed in part; -Site: Left buttock. Follow up. -Stage 3 -Description: 25% eschar -Size: 3x3x0.2 c.m. (LWD) -Exudate: Serous moderate -Surrounding tissue: [DIAGNOSES REDACTED] -Odor: none Record review of Resident #5's wound care MD evaluation revealed in part; -Date: 9/29/2017 Stage 3 pressure ulcer left buttocks. Facility acquired on 9/18/2017. -Wound measurements: 3.5 x 4.5 x 0.0 c.m. (LxWxD) Area: 15.75 square centimeter. Cubic centimeters: 0 -Exudate (drainage): Moderate serous -Moist Yellow Slough: 76 - 100% -Wound progress: Initial exam -Wound Orders: Cleanse/protect wound. Cleanse wound with Normal Saline. Apply Alginate, cover wound with dry absorptive dressing. Change dressing daily. Additional orders: Pressure relief/Offloading. Off-load wound. Reposition per facility protocol. Record review of Resident #5's wound care MD evaluation revealed in part; -Date: 10/06/2017 Stage 4 pressure injury left buttocks. -Wound measurements: 3.0 x 4.5 x 2.0 c.m. (LxWxD) Area: 13.50 square centimeter. Cubic centimeters: 27 -Exudate (drainage): Moderate serous -Moist Yellow Slough: 76 - 100% -Wound progress: deteriorating -Exposed Muscle Necrosis: Yes -Exposed Adipose Necrosis: Yes Tissue and other material debrided: Muscle, subcutaneous, Slough -Wound Orders: Cleanse/protect wound. Cleanse wound with Normal Saline. Apply Santyl, Alginate, cover wound with dry absorptive dressing. Change dressing daily. Additional orders: Pressure relief/Offloading. Off-load wound. Reposition per facility protocol. Record review of Resident #5's nurses notes dated 10/6/2017 at 4:27 p.m. by LVN A revealed in part; Resident #5 is an [AGE] year old long term resident admitted on [DATE]. He was noted to have new Stage 3 pressure ulcer to the left buttock on 09/18/2017. Wound MD debrided the wound removing all slough, increasing the depth and revealing muscle and subcutaneous tissue. Wound upgraded to a Stage 4. Santyl ([MEDICATION NAME] ointment) resumed for slough along with Calcium Alginate dressing (dressing derived from seaweed, highly absorbent) daily. Air mattress and orders in place to offload with pillows and turn frequently . Observation on 10/12/2017 at 9:10 a.m. revealed that Resident #5 was not on his room. Observation on 10/12/2017 at 10:45 a.m. revealed that Resident #5 was in the dining room seated in a geri-chair. Further observation revealed that he did not have a pressure reducing device in his chair. Resident #5 appeared leaning to his left side when seated in his chair. In an interview on 10/12/2017 at 11:27 a.m. with Wound Care Nurse B, she stated that she was new in the position for wound care. She further said that Resident#5 was not in his room and that he probably was in the dining room area. In a confidential interview on 10/12/2017 at 12:05 p.m., the staff stated that there was only one CNA on the 100, 200 and 400 halls. The staff said that it was difficult to provide incontinent care or provide frequent care to all of the residents and further said we try, but it is hard. Observation on 10/12/2017 at 2:00 p.m. revealed that Resident #5 was still not in his room. Observation on 10/12/2017 at 4:00 p.m. revealed that Resident #5 was seated in a geri-chair in dining room area. Further observation revealed that he still did not have a pressure reducing device in his chair. Resident #5 appeared leaning to his left side when seated in his chair. Observation on 10/12/2017 at 5:00 p.m. revealed that Resident #5 was lying in his bed. There was a strong odor of urine in his room. During observation with Wound Care Nurse B and LVN C revealed that Resident #5's wound to his left buttocks was not protected with a dressing. Open wound was 4.0 c.m. in diameter and 2.0 c.m. in depth. The wound base was black and had a foul odor. The superior surrounding tissue of the wound had a non-blanchable deep red, maroon discoloration that measured 4.0 c.m. in length around top part of wound and 2.6 c.m. wide. There was a large dark reddened area covering most part of the left buttocks that measured 14 c.m. wide and 12 c.m. long. (measurements were taken by Wound Care Nurse B). The brief Resident #5's was wearing had small spots of red blood on it. Interview on 10/12/2017 at 5:05 p.m. with CNA A inside Resident #5's room, she stated that she had just assisted Resident #5 to bed at that time and that his brief was very wet that's why smells urine. She further said that when she helped Resident #5, he did not have his cushion on the chair or dressing on the wound. CNA A then said I did not get him up. I haven't had the time to get to him before. I've been laying people to bed and answering call lights. I have 22 residents under my care. CNA B got him up early today to shower him, I do not know what time she got him up, CNA B dressed him up and put him up on his geri-chair. She told me that Resident #5 did not have a dressing on his wound but I told her to report it to the Wound Care Nurse. Further interview at that time, the Wound Care Nurse B stated Nobody told me that Resident #5 did not have a dressing to his wound. When asked the Wound Care Nurse B about the foul odor and the non-blanchable deep red, maroon discoloration on the superior part of Resident #5's wound, she responded probably because he is being seated on the wound. In an interview on 10/12/2017 at 5:20 p.m. with CNA B, she stated that she was the Shower Tech and that she got up Resident #5 at around 6:00 a.m. or 7:00 a.m. It was early. She then said that when she got him up for shower, she noticed that he did not have a dressing to the open wound to his left buttocks and that she did not know if the dressing had fallen anytime during the night shift. CNA B continued saying I got him up, showered him, dressed him and got him up in his geri-chair and helped him go to the dining room. When asked if she placed any cushion or pressure reducing device on Resident #5's chair before he was seated on it, CNA B responded No, I did not know he needed a cushion. I did let CNA A know that Resident #5 needed a dressing to the wound to his left buttocks. When asked about facility's policy of notification when an open wound did not have a dressing, CNA B responded I was supposed to notify the charge nurse or Wound Care Nurse. When asked if she had checked on Resident #5 any time after she got him up, CNA B stated No, I haven't seen him anymore. He might have a dressing (to his wound) by now. In an interview on 10/12/2017 at 5:25 p.m. with the DON, she stated that charge nurses were supposed to make rounds to make sure residents were turned and repositioned and incontinent care was provided. DON then said that the ADON was supposed to follow up on the nurses to make sure they were making sure that residents were turned or repositioned when they were in bed or up in a chair and that incontinent care was provided as needed. Further interview at that moment, when asked if she had seen Resident #5's wound lately, the DON responded No, I have not seen his wound. Well, yes, I saw it on 9/29/2017. Resident #5 has a Stage 3 pressure sore to his buttocks. When asked about the facility protocol to turn or reposition residents in bed or in chair, the DON stated We encourage the CNA's to turn and reposition residents frequently, every 3 hours. When asked for residents who had Stage 3 pressure sores on their buttocks if it was acceptable to be up on their chair all day from 7:00 a.m. to 5:00 p.m. without being repositioned or incontinent care provided, the DON responded No, it is not acceptable to be up all day from 7:00 a.m. to 5:00 p.m. without being assisted to bed to offload the pressure sore. DON then said that she remembered seeing Resident #5 in the dining room during the day, but in different sites of the dining area and that she believed that he had been already taken care of. When asked DON if she believed having one CNA per hall was enough staffing to provide frequent incontinent care and frequent turning and repositioning of the residents, the DON said Yes, I have staff that had worked on the 200 hall and the other halls and they are able to do the work. Continued interview with the DON, when asked if she was aware that Resident #5 had been up all day in a geri-chair without a pressure reducing cushion on his chair, without a dressing to his Stage 3 pressure sore and without being provided incontinent care, the DON did not respond. At that moment, DON was asked to come to Resident #5's to observe the pressure sore. Observation and interview on 10/12/2017 at 5:30 p.m. inside Resident #5's room with the DON, the DON stated as she observed Resident #5's open wound to his left buttocks and reddened area to his left buttocks Resident #5's wound did not look like this before on 9/29/2017. This does not look like a Stage 3 pressure sore. When pointed the large dark reddened area to his left buttocks and the non-blanchable deep red, maroon discoloration around top part of the wound, the DON stated The CNA's know about the cushion. In an interview on 10/12/2017 at 5:46 p.m. with LVN C, she said she was the charge nurse for Resident #5 and that she was responsible that residents under her care were turned and repositioned as frequently as possible and then said It's kind of hard for the CNA's to do it. There is only 1 CNA per hallway. Each hallway has 22 to 24 residents. It's hard for them to do it. There are floating CNA's but they don't help the CNA's on the floor. The reddened area to Resident #5's left buttocks just blew me away. It's redness from pressure. Resident #5 is really non-verbal, there is only 1 CNA for all those patients, the patients really don't get the care they deserve. It's hard. The CNA's need to get residents up, assist with meals and call lights. It's hard. In an interview on 10/12/2017 at 5:50 p.m. with the ADON, she stated that she was responsible to make sure residents were turned and repositioned every 3 to 4 hours. ADON then said that residents who had pressure sores were supposed to be turned every 2 hours. She then said that the shower tech CNA's were supposed to help the CNA's on the floor on turning/repositioning and incontinent care to residents. ADON further said I know Resident #5 was up for a long time. I told CNA A at around 3:00 p.m. when I saw Resident #5 still in the dining room area, I asked her to help Resident #5 to his room, but CNA A was doing other things then I checked at around 5:00 p.m. and Resident #5 was no longer in the dining room. Record review of facility daily census summary dated 10/12/2017 revealed the following census per hall; 100 Hall 27 residents 1 CNA assigned 200 Hall 24 residents (Hall of Resident #5) 1 CNA assigned (CNA A) 300 Hall 25 residents / Skilled floor. 2 CNA's assigned 400 Hall 24 residents 1 CNA assigned Record review of Resident #5's Plan of Care initiated on 10/12/2017 revealed in part; -Focus: Resident #5 has bowel and bladder incontinence. -Interventions: Check as required for incontinence. -Focus: Resident #5 has limited physical mobility. -Interventions: Mobility: Is totally dependent on staff for locomotion. Record review of Resident #5's Skin/Wound notes dated 10/13/2017 at 6:21 p.m. signed by LVN A (former Wound Care Nurse) revealed in part; Stage 4 to the left buttock noted to have a foul odor and increase in slough. Wound debrided at bedside, removing all slough and dead tissue from wound bed and edges, increasing measurements. Ulcer has exposed ligament, muscle and subcutaneous tissue. Staff educated on proper turning techniques and importance of offloading wounds. Cushion noted for geri-chair and Resident #5 remains on air mattress. Med pass and health shakes added to diet . Record review of Resident #5's wound care MD evaluation revealed in part; -Date: 10/13/2017 Stage 4 pressure injury left buttocks. -Wound measurements: 4.5 x 5.5 x 4.0 c.m. (LxWxD) Area: 24.75 square centimeter. Cubic centimeters: 99 -Exudate (drainage): Moderate serous -Moist Yellow Slough: 76 - 100% -Wound progress: deteriorating -Exposed Ligament Necrosis: Yes -Exposed Muscle Necrosis: Yes -Exposed Adipose Necrosis: Yes Tissue and other material debrided: Ligament, Muscle, subcutaneous, Slough -Wound Orders: Cleanse/protect wound. Cleanse wound with Normal Saline. Apply Santyl, Alginate, cover wound with dry absorptive dressing. Change dressing daily. Additional orders: Pressure relief/Offloading. Off-load wound. Reposition per facility protocol. CR #1 Record review of the medical record face sheet revealed CR #1 was admitted on [DATE] and re-admitted on [DATE]. [DIAGNOSES REDACTED]. He was [AGE] years old. CR #1 was discharged from facility on 9/27/2017 due to [MEDICAL CONDITION] in right jugular neck vein. Record review of CR #1's Braden Scale for Predicting Pressure Sore Risk revealed in part; - 07/27/2017 revealed a score of 15 indicating Low risk to develop pressure sores. Record review of CR #1's MD orders revealed in part; -7/28/2017 Avoid positioning on sacrum when possible, alternate sides and offload sacrum and heels with pillows when in bed every shift for Stage 3 sacrum and right heel Deep Tissue Injury. -7/28/2017 Cleanse right heel with Normal Saline and apply skin prep daily every day shift for Deep Tissue Injury. Ensure heels are floating. -7/28/2017 Cleanse sacral wound with Normal Saline, pat dry, apply calcium alginate and a dry dressing daily every day for Stage 3 pressure sore. Record review of CR #1's Plan of Care initiated 7/28/2017 and revised 8/14/2017 revealed in part; -Focus: CR #1 has an ADL self care deficit related to decreased mobility and generalized weakness. -Interventions: Bed Mobility. Requires 1-2 (staff) assistance. Record review of CR #1's Skin Pressure Ulcer Weekly dated 7/28/2017 revealed in part; -Site: Sacrum (is a large, triangular bone at the base of the spine and at the upper, back part of the pelvic cavity, where it is inserted like a wedge between the two hip bones). Initial evaluation. -Stage 3 -Description: 25% slough -Size: 1.2x1.0x0.1 c.m. (LWD) -Exudate: Serous moderate -Surrounding tissue: Normal for skin -Odor: none -Site: Right heel. Initial evaluation. -Stage SDTI (Suspected Deep Tissue Injury) -Description: deep red/purple discoloration -Size: 5.0x6.0x0.0 c.m. (LWD) -Exudate: none -Surrounding tissue: Normal for skin -Odor: none Record review of CR #1's Braden Scale for Predicting Pressure Sore Risk revealed in part; - 08/01/2017 revealed a score of 14 indicating Moderate risk to develop pressure sores. Further record review of CR #1's Plan of Care initiated 8/03/2017 and revised 9/15/2017 revealed in part; -Focus: CR #1 has actual Stage 4 pressure ulcer to the sacrum with confirmed [DIAGNOSES REDACTED],[MEDICAL CONDITION] and psuedomonas related to decreased mobility. -Interventions with initiated date of 8/3/2017 * Avoid positioning on sacrum when possible, alternate sides and offload with pillows. Needs monitoring/reminding/assistance to turn/reposition at least every 2 hours, more often as needed or requested. * Air mattress as ordered. Initiated 8/14/2017 Record review of CR #1's wound care MD evaluation revealed in part; -Date: 8/04/2017 Stage 3 pressure ulcer Sacrum. Facility acquired: No. -Wound measurements: 1.5 x 1.0 x 0.2 c.m. (LxWxD) Area: 1.5 square centimeter. Cubic centimeters: 0.3 Wound margin: Flat and intact -Exudate (drainage): small serous -Wound progress: Initial exam -Surrounding skin: Normal for skin -Wound Orders: Cleanse/protect wound. Cleanse wound with Normal Saline. Apply Collagen, cover wound with dry absorptive dressing. Change dressing daily. Additional orders: Pressure relief/Offloading. Off-load wound. Reposition per facility protocol. -Date: 8/04/2017 Right heel. Deep Tissue Pressure Injury persistent non-blanchable deep red, maroon or purple descoloration. Facility acquired: No. -Wound measurements: 5.0 x 5.0 x 0.0 c.m. (LxWxD) Area: 25 square centimeter. Cubic centimeters: 0 -Exudate (drainage): none -Wound progress: Initial exam -Wound Orders: Skin prep and leave open to air daily. Float heels with pillows. Record review of CR #1's admission MDS assessment with 08/05/2017 ARD revealed that he had severe cognitive impairment with a BIMS score of 6 out of a possible 15. CR #1 required extensive assistance of two or more person physical assist for bed mobility, transfer and toilet use. He required extensive assistance of one person physical assist for walking, locomotion, eating and personal hygiene. He was always incontinent of bowel and bladder. Further record review revealed that CR #1 was at risk of developing pressure sores. He had one Stage 3 pressure ulcer that was present upon admission to the facility and one unstageable pressure ulcer with suspected deep tissue injury in evolution that was present upon admission to the facility. The dimensions of unhealed Stage 3 or 4 Pressure Ulcers or Eschar were 1.5x1.0x0.2 c.m. (LWD). Continued record review of the MDS section that read Skin and Ulcer Treatment revealed that CR #1 was not checked to be on a turning/repositioning program or on a pressure reducing device for chair or bed. Record review of CR #1's MD orders revealed in part; -8/09/2017 Air Mattress every shift for Stage 3 (pressure sore) sacrum. Record review of CR #1's Braden Scale for Predicting Pressure Sore Risk revealed in part; - 08/10/2017 revealed a score of 13 indicating Moderate risk to develop pressure sores. Record review of CR #1's wound care MD evaluation revealed in part; -Date: 8/11/2017 Stage 3 pressure ulcer Sacrum. Facility acquired: No. -Wound measurements: 2.0 x 1.0 x 0.2 c.m. (LxWxD) Area: 2 square centimeter. Cubic centimeters: 0.4 Wound margin: Flat and intact -Exudate (drainage): moderate serous -Wound progress: Initial exam -Surrounding Skin: Maceration -Wound Orders: Cleanse/protect wound. Cleanse wound with Normal Saline. Apply Alginate, cover wound with dry absorptive dressing. Change dressing daily. Additional orders: Pressure relief/Offloading. Off-load wound. Reposition per facility protocol. -Date: 8/11/2017 Right heel. Deep Tissue Pressure Injury persistent non-blanchable deep red, maroon or purple discoloration. Facility acquired: No. -Wound measurements: 5.0 x 5.0 x 0.0 c.m. (LxWxD) Area: 25 square centimeter. Cubic centimeters: 0 -Exudate (drainage): none -Wound progress: Improving -Wound Orders: Skin prep and leave open to air daily. Float heels with pillows. Record review of CR #1's wound care MD evaluation revealed in part; -Date: 8/18/2017 Stage 3 pressure ulcer Sacrum. Facility acquired: No. -Wound measurements: 2.0 x 1.2 x 0.2 c.m. (LxWxD) Area: 2.4 square centimeter. Cubic centimeters: 0.48 Wound margin: Flat and intact -Exudate (drainage): moderate serous -Wound progress: No change -Surrounding Skin: Maceration -Moist yellow slough: 1-25% -Wound Orders: Cleanse/protect wound. Cleanse wound with Normal Saline. Apply Algunate, cover wound with dry absorptive dressing. Change dressing daily. Additional orders: Pressure relief/Offloading. Off-load wound. Reposition per facility protocol. -Date: 8/18/2017 Right heel. Deep Tissue Pressure Injury persistent non-blanchable deep red, maroon or purple discoloration. Facility acquired: No. -Wound measurements: 5.0 x 5.0 x 0.0 c.m. (LxWxD) Area: 25 square centimeter. Cubic centimeters: 0 -Exudate (drainage): none -Wound progress: Improving -Wound Orders: Skin prep and leave open to air daily. Float heels with pillows. Record review of CR #1's nurses notes dated 08/21/2017 at 5:54 p.m. revealed in part CR #1 having [MEDICAL CONDITION] episode and unresponsive while in rehab. Orders to send to emergency room . Record review of CR #1's nurses notes dated 08/31/2017 at 5:24 p.m. revealed in part CR #1 arrived at facility. Bandage to sacrum area. CR #1 is resting in semi-fowler position . Record review of CR #1's Braden Scale for Predicting Pressure Sore Risk revealed in part; - 08/31/2017 revealed a score of 18 indicating Low risk to develop pressure sores. Record review of CR #1's Skin Evaluation Weekly assessment dated [DATE] and signed by RN A revealed in part; .CR #1 right heel with Stage 2 (pressure sore). 4x4.5x0.1 (c.m.) Cleaned with normal saline, puracol to wound, covered with dry dressing. Sacrum: Stage 4. 3x2.5x0.75 (c.m.) with slough noted. Santyl and dry dressing applied . Record review of CR #1's MD orders dated 9/1/2017 revealed in part; -Cleanse Stage 2 to the right heel with normal saline, pat dry. Apply puracol (Puracol is a primary wound dressing for all drainage types. It is highly absorbent material) and cover with a dry kerlix wrap daily every day. Ensure heels are floating. -Clean sacral wound with Normal Saline, apply Santyl to slough, cover with Calcium Alginate and dry dressing every day shift. Record review of CR #1's nurse notes dated 9/6/2017 at 8:00 p.m. revealed in part; - .CR #1 to be sent out to the hospital due to abnormal KUB abdomen Record review of CR #1's Transfer to Hospital form dated 9/6/2017 revealed under Skin/Wound Care Sacrum Stage 4, Right heel Stage 2. No measurements or description of wounds noted. Record review of CR #1's nurse notes dated 9/7/2017 at 2:30 a.m. revealed that CR #1 returned to facility. No skin assessments noted. Record review of CR #1's Braden Scale for Predicting Pressure Sore Risk revealed in part; - 09/07/2017 revealed a score of 15 indicating Low risk to develop pressure sores. Record review of CR #1's wound care MD evaluation revealed in part; -Date: 9/08/2017 Stage 4 pressure ulcer Sacrum. Facility acquired: No. -Wound measurements: 3.0 x 3.0 x 1.0 c.m. (LxWxD) Area: 9 square centimeter. Cubic centimeters: 9 -No tunneling or undermining Wound margin: Flat and intact -Exudate (drainage): moderate serous -Wound progress: deteriorating -Surrounding Skin: Maceration -Moist yellow slough: 1-25% -Exposed Ligament Necrosis: Yes -Exposed bone necrosis: Yes -Suspected [DIAGNOSES REDACTED]: Awaiting results. -Wound Orders: Cleanse/protect wound. Cleanse wound with Normal Saline. Apply Santyl ([MEDICATION NAME]), apply [MEDICATION NAME], apply Alginate, cover wound with dry absorptive dressing. Change dressing daily. Additional orders: Pressure relief/Offloading. Off-load wound. Reposition per facility protocol. -Plan of Care: Will submit bone fragments from sacral wound to the laboratory for culture for evaluation of osteo[DIAGNOSES REDACTED]. -Date: 9/08/2017 Right heel. Unstageable Pressure Injury Obscured full thickness skin and tissue loss. Facility acquired: No. -Wound measurements: 3.5 x 3.5 x 0.0 c.m. (LxWxD) Area: 12.25 square centimeter. Cubic centimeters: 0 -Exudate (drainage): moderate serous -Dry black eschar: 26 - 50% -Wound Orders: Apply Alginate, cover wound with dry absorptive dressing. Every day. Float heels with pillows. Record review of CR #1's Surgical Pathology report for collection dated 9/8/2017 and report dated 9/12/2017 revealed in part; [DIAGNOSES REDACTED]. Acute. Sacrum fragment of bone with acute osteomyelitits (bone infection). Record review of CR #1's Laboratory report for wound culture to Sacral wound collected on 9/9/2017 and printed on 9/13/2017 revealed results in part; .[MEDICAL CONDITION]. Rare growth . Further record review a hand written note [MEDICATION NAME] (antibiotic)1 gram every 12 hours for 6 weeks. Record review of CR #1's MD orders revealed in part; -9/13/2017 [MEDICATION NAME] (antibiotic) in [MEDICATION NAME] Solution 1 gram/200 ml. Use 1 gram intravenously every 12 hours for osteo (bone) of the sacral wound for 6 weeks. Record review of CR #1's nurse Skin/Wound note dated 9/15/2017 at 11:59 a.m. signed by LVN A revealed in part: .During weekly skin assessment, CR #1 was noted to have non blanchable deep maroon/red discoloration to the right distal lateral foot. MD with orders for daily skin prep and (TRUNCATED)

Based on observation, interview, and record review, the facility failed to ensure a resident who is unable to carry out activities of daily living receives the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for three (Resident #5, CR #1 and Resident #6) of eleven residents reviewed for activities of daily living. The facility failed to provide ADL care as needed for Resident #5, Resident #6 and CR #1, who required incontinent care and repositioning. -The facility failed to provide repositioning and incontinent care to Resident #5 resulting in the development of a deep tissue injury to the outside of his stage 4 pressure sore, foul odor on the wound, increased in size of the wound and a large reddened area covering most part of his left buttocks. -The facility failed to provide repositioning and timely incontinent care to CR #1 resulting in the development of a deep tissue injury around his Sacrum Stage 4 pressure sore. Stage 2 pressure sore to his right heel advanced to a Unstageable pressure sore. -In addition, the facility failed to prevent the development of a new pressure injury. CR #1 developed a Deep Tissue Injury to his right distal lateral foot . -The facility failed to provide repositioning and timely incontinent care to Resident #6, who had a Stage 4 pressure ulcer to her sacrum (facility acquired unavoidable). Resident #6 was found soiled with stool and the pressure sore had maceration around the wound. These failures resulted in the identification of an Immediate Jeopardy (IJ) on 10/13/17. While the IJ was lowered on 10/14/17, the facility remained out of compliance at a scope of pattern and severity level of actual harm that was not IJ because all measures for prevention and treatment of [REDACTED]. These failures affected two residents (Resident #5 and Resident #6) and a former residents (CR #1) and placed an additional 17 residents who were occasionally or frequently incontinent of bladder or bowel and the additional 13 residents who required assistance with bed mobility in the 200 Hall at risk for not receiving care and assistance when needed. Findings included: TX 709/ Intake # 9, TX 319/ Intake # 2, TX 379/ Intake # 6, TX 457 / Intake # 2 and TX 875/ Intake # 8. Resident #5 Record review of the medical record face sheet revealed Resident #5 was admitted on [DATE] and re-admitted on [DATE]. [DIAGNOSES REDACTED]. He was [AGE] years old. Record review of Resident #5's nurses notes dated 08/18/2017 at 7:15 p.m. revealed in part Resident #5 admitted to the facility. Incontinent of bowel and bladder. No wounds . Record review of Resident #5's Plan of Care initiated 08/25/2017 revealed in part: -Focus: Resident #5 has an ADL (Activity of Daily Living) Self Care Performance Deficit. -Interventions: Bed mobility: Requires (1-2) staff participation to reposition and turn in bed. Transfer: Requires 1-2 physical assistance with transferring. Further record review of Resident #5's Plan of Care revealed no interventions to prevent the development of pressure sores. Record review of Resident #5's admission MDS assessment with 08/28/2017 ARD revealed that he was rarely/never understood and was unable to complete the interview for Mental Status. Resident #5 required extensive assistance for his activities of daily living and he was total dependent for bathing. He had impairment on both sides of his lower extremities. He was always incontinent of bowel and bladder. Further record review revealed that Resident #5 was at risk of developing pressure sores and had no pressure sores during assessment. Further record review of the MDS section that read Skin and Ulcer Treatment revealed that Resident #5 was not checked to be on a turning/repositioning program or on a pressure reducing device for chair or bed. Record review of Resident #5's Braden Scale for Predicting Pressure Sore Risk revealed in part; - 08/29/2017 revealed a score of 14 indicating Moderate risk to develop pressure sores. Record review of Resident #5's nurses notes dated 9/17/2017 at 6:16 p.m. by LVN A (former Wound Care Nurse) revealed in part; Observed new Stage 3 pressure ulcer to the left buttocks which is 25% slough and 25% eschar tissue. Measurements: 3.5x3.0x0.2 (c.m.) (LWD) with moderate serous drainage. Air mattress ordered and orders placed to offload with pillows and turn frequently . Record review of Resident #5's Skin Pressure Ulcer Weekly dated 9/17/2017 revealed in part; -Site: Left buttock. Initial evaluation. -Stage 3 -Description: 25% slough, 25% eschar -Size: 3.5x3x0.2 c.m. (LWD) -Exudate: Serous moderate -Surrounding tissue: [DIAGNOSES REDACTED] -Odor: none Record review of Resident #5's consolidated MD orders revealed in part; -9/17/2017 Air mattress every shift for Stage 3 left buttocks -9/17/2017 Avoid positioning on left buttocks when possible, alternate sides and offload with pillows every shift for Stage 3 (pressure sore). -10/01/2017 [MEDICATION NAME] Acid tablet 500 mg by mouth two time a day for supplement. -10/01/2017 Multiple vitamins-minerals tablet, take one by mouth every day for supplement. -10/01/2017 Zinc Sulfate Capsule 220 mg, one by mouth one time a day for wound healing for 14 days. -10/06/2017 Clean left buttock with Normal Saline, pat dry, apply Santyl ([MEDICATION NAME] oitment) to slough followed by Calcium Alginate (dressing derived from seaweed, highly absorbent) and a dry dressing daily every day shift for Stage 4. Continued record review of Resident #5's Plan of Care initiated 09/17/2017 revealed in part: -Resident #5 has an actual Stage 4 pressure ulcer to the left buttock related to decreased mobility and incontinence. -Goal: Pressure ulcer will show signs of healing by target date 01/10/2018. -Interventions: Air mattress and frequent turns, avoid positioning on left buttocks when possible, alternate sides and offload with pillows. Record review of Resident #5's Braden Scale for Predicting Pressure Sore Risk revealed in part; - 09/18/2017 revealed a score of 11 indicating High risk to develop pressure sores. Record review of Resident #5's Skin Pressure Ulcer Weekly dated 9/22/2017 revealed in part; -Site: Left buttock. Follow up. -Stage 3 -Description: 25% eschar -Size: 3x3x0.2 c.m. (LWD) -Exudate: Serous moderate -Surrounding tissue: [DIAGNOSES REDACTED] -Odor: none Record review of Resident #5's wound care MD evaluation revealed in part; -Date: 9/29/2017 Stage 3 pressure ulcer left buttocks. Facility acquired on 9/18/2017. -Wound measurements: 3.5 x 4.5 x 0.0 c.m. (LxWxD) Area: 15.75 square centimeter. Cubic centimeters: 0 -Exudate (drainage): Moderate serous -Moist Yellow Slough: 76 - 100% -Wound progress: Initial exam -Wound Orders: Cleanse/protect wound. Cleanse wound with Normal Saline. Apply Alginate, cover wound with dry absorptive dressing. Change dressing daily. Additional orders: Pressure relief/Offloading. Off-load wound. Reposition per facility protocol. Record review of Resident #5's wound care MD evaluation revealed in part; -Date: 10/06/2017 Stage 4 pressure injury left buttocks. -Wound measurements: 3.0 x 4.5 x 2.0 c.m. (LxWxD) Area: 13.50 square centimeter. Cubic centimeters: 27 -Exudate (drainage): Moderate serous -Moist Yellow Slough: 76 - 100% -Wound progress: deteriorating -Exposed Muscle Necrosis: Yes -Exposed Adipose Necrosis: Yes Tissue and other material debrided: Muscle, subcutaneous, Slough -Wound Orders: Cleanse/protect wound. Cleanse wound with Normal Saline. Apply Santyl, Alginate, cover wound with dry absorptive dressing. Change dressing daily. Additional orders: Pressure relief/Offloading. Off-load wound. Reposition per facility protocol. Record review of Resident #5's nurses notes dated 10/6/2017 at 4:27 p.m. by LVN A revealed in part; Resident #5 is an [AGE] year old long term resident admitted on [DATE]. He was noted to have new Stage 3 pressure ulcer to the left buttock on 09/18/2017. Wound MD debrided the wound removing all slough, increasing the depth and revealing muscle and subcutaneous tissue. Wound upgraded to a Stage 4. Santyl ([MEDICATION NAME] ointment) resumed for slough along with Calcium Alginate dressing (dressing derived from seaweed, highly absorbent) daily. Air mattress and orders in place to offload with pillows and turn frequently . Observation on 10/12/2017 at 9:10 a.m. revealed that Resident #5 was not on his room. Observation on 10/12/2017 at 10:45 a.m. revealed that Resident #5 was in the dining room seated in a geri-chair. Further observation revealed that he did not have a pressure reducing device in his chair. Resident #5 appeared leaning to his left side when seated in his chair. In an interview on 10/12/2017 at 11:27 a.m. with Wound Care Nurse B, she stated that she was new in the position for wound care. She further said that Resident#5 was not in his room and that he probably was in the dining room area. In a confidential interview on 10/12/2017 at 12:05 p.m., the staff stated that there was only one CNA on the 100, 200 and 400 halls. The staff said that it was difficult to provide incontinent care or provide frequent care to all of the residents and further said we try, but it is hard. Observation on 10/12/2017 at 2:00 p.m. revealed that Resident #5 was still not in his room. Observation on 10/12/2017 at 4:00 p.m. revealed that Resident #5 was seated in a geri-chair in dining room area. Further observation revealed that he still did not have a pressure reducing device in his chair. Resident #5 appeared leaning to his left side when seated in his chair. Observation on 10/12/2017 at 5:00 p.m. revealed that Resident #5 was lying in his bed. There was a strong odor of urine in his room. During observation with Wound Care Nurse B and LVN C revealed that Resident #5's wound to his left buttocks was not protected with a dressing. Open wound was 4.0 c.m. in diameter and 2.0 c.m. in depth. The wound base was black and had a foul odor. The superior surrounding tissue of the wound had a non-blanchable deep red, maroon discoloration that measured 4.0 c.m. in length around top part of wound and 2.6 c.m. wide. There was a large dark reddened area covering most part of the left buttocks that measured 14 c.m. wide and 12 c.m. long. (measurements were taken by Wound Care Nurse B). The brief Resident #5's was wearing had small spots of red blood on it. Interview on 10/12/2017 at 5:05 p.m. with CNA A inside Resident #5's room, she stated that she had just assisted Resident #5 to bed at that time and that his brief was very wet that's why smells urine. She further said that when she helped Resident #5, he did not have his cushion on the chair or dressing on the wound. CNA A then said I did not get him up. I haven't had the time to get to him before. I've been laying people to bed and answering call lights. I have 22 residents under my care. CNA B got him up early today to shower him, I do not know what time she got him up, CNA B dressed him up and put him up on his geri-chair. She told me that Resident #5 did not have a dressing on his wound but I told her to report it to the Wound Care Nurse. Further interview at that time, the Wound Care Nurse B stated Nobody told me that Resident #5 did not have a dressing to his wound. When asked the Wound Care Nurse B about the foul odor and the non-blanchable deep red, maroon discoloration on the superior part of Resident #5's wound, she responded probably because he is being seated on the wound. In an interview on 10/12/2017 at 5:20 p.m. with CNA B, she stated that she was the Shower Tech and that she got up Resident #5 at around 6:00 a.m. or 7:00 a.m. It was early. She then said that when she got him up for shower, she noticed that he did not have a dressing to the open wound to his left buttocks and that she did not know if the dressing had fallen anytime during the night shift. CNA B continued saying I got him up, showered him, dressed him and got him up in his geri-chair and helped him go to the dining room. When asked if she placed any cushion or pressure reducing device on Resident #5's chair before he was seated on it, CNA B responded No, I did not know he needed a cushion. I did let CNA A know that Resident #5 needed a dressing to the wound to his left buttocks. When asked about facility's policy of notification when an open wound did not have a dressing, CNA B responded I was supposed to notify the charge nurse or Wound Care Nurse. When asked if she had checked on Resident #5 any time after she got him up, CNA B stated No, I haven't seen him anymore. He might have a dressing (to his wound) by now. In an interview on 10/12/2017 at 5:25 p.m. with the DON, she stated that charge nurses were supposed to make rounds to make sure residents were turned and repositioned and incontinent care was provided. DON then said that the ADON was supposed to follow up on the nurses to make sure they were making sure that residents were turned or repositioned when they were in bed or up in a chair and that incontinent care was provided as needed. Further interview at that moment, when asked if she had seen Resident #5's wound lately, the DON responded No, I have not seen his wound. Well, yes, I saw it on 9/29/2017. Resident #5 has a Stage 3 pressure sore to his buttocks. When asked about the facility protocol to turn or reposition residents in bed or in chair, the DON stated We encourage the CNA's to turn and reposition residents frequently, every 3 hours. When asked for residents who had Stage 3 pressure sores on their buttocks if it was acceptable to be up on their chair all day from 7:00 a.m. to 5:00 p.m. without being repositioned or incontinent care provided, the DON responded No, it is not acceptable to be up all day from 7:00 a.m. to 5:00 p.m. without being assisted to bed to offload the pressure sore. DON then said that she remembered seeing Resident #5 in the dining room during the day, but in different sites of the dining area and that she believed that he had been already taken care of. When asked DON if she believed having one CNA per hall was enough staffing to provide frequent incontinent care and frequent turning and repositioning of the residents, the DON said Yes, I have staff that had worked on the 200 hall and the other halls and they are able to do the work. Continued interview with the DON, when asked if she was aware that Resident #5 had been up all day in a geri-chair without a pressure reducing cushion on his chair, without a dressing to his Stage 3 pressure sore and without being provided incontinent care, the DON did not respond. At that moment, DON was asked to come to Resident #5's to observe the pressure sore. Observation and interview on 10/12/2017 at 5:30 p.m. inside Resident #5's room with the DON, the DON stated as she observed Resident #5's open wound to his left buttocks and reddened area to his left buttocks Resident #5's wound did not look like this before on 9/29/2017. This does not look like a Stage 3 pressure sore. When pointed the large dark reddened area to his left buttocks and the non-blanchable deep red, maroon discoloration around top part of the wound, the DON stated The CNA's know about the cushion. In an interview on 10/12/2017 at 5:46 p.m. with LVN C, she said she was the charge nurse for Resident #5 and that she was responsible that residents under her care were turned and repositioned as frequently as possible and then said It's kind of hard for the CNA's to do it. There is only 1 CNA per hallway. Each hallway has 22 to 24 residents. It's hard for them to do it. There are floating CNA's but they don't help the CNA's on the floor. The reddened area to Resident #5's left buttocks just blew me away. It's redness from pressure. Resident #5 is really non-verbal, there is only 1 CNA for all those patients, the patients really don't get the care they deserve. It's hard. The CNA's need to get residents up, assist with meals and call lights. It's hard. In an interview on 10/12/2017 at 5:50 p.m. with the ADON, she stated that she was responsible to make sure residents were turned and repositioned every 3 to 4 hours. ADON then said that residents who had pressure sores were supposed to be turned every 2 hours. She then said that the shower tech CNA's were supposed to help the CNA's on the floor on turning/repositioning and incontinent care to residents. ADON further said I know Resident #5 was up for a long time. I told CNA A at around 3:00 p.m. when I saw Resident #5 still in the dining room area, I asked her to help Resident #5 to his room, but CNA A was doing other things then I checked at around 5:00 p.m. and Resident #5 was no longer in the dining room. Record review of facility daily census summary dated 10/12/2017 revealed the following census per hall; 100 Hall 27 residents 1 CNA assigned 200 Hall 24 residents (Hall of Resident #5) 1 CNA assigned (CNA A) 300 Hall 25 residents / Skilled floor. 2 CNA's assigned 400 Hall 24 residents 1 CNA assigned Record review of Resident #5's Plan of Care initiated on 10/12/2017 revealed in part; -Focus: Resident #5 has bowel and bladder incontinence. -Interventions: Check as required for incontinence. -Focus: Resident #5 has limited physical mobility. -Interventions: Mobility: Is totally dependent on staff for locomotion. Record review of Resident #5's Skin/Wound notes dated 10/13/2017 at 6:21 p.m. signed by LVN A (former Wound Care Nurse) revealed in part; Stage 4 to the left buttock noted to have a foul odor and increase in slough. Wound debrided at bedside, removing all slough and dead tissue from wound bed and edges, increasing measurements. Ulcer has exposed ligament, muscle and subcutaneous tissue. Staff educated on proper turning techniques and importance of offloading wounds. Cushion noted for geri-chair and Resident #5 remains on air mattress. Med pass and health shakes added to diet . Record review of Resident #5's wound care MD evaluation revealed in part; -Date: 10/13/2017 Stage 4 pressure injury left buttocks. -Wound measurements: 4.5 x 5.5 x 4.0 c.m. (LxWxD) Area: 24.75 square centimeter. Cubic centimeters: 99 -Exudate (drainage): Moderate serous -Moist Yellow Slough: 76 - 100% -Wound progress: deteriorating -Exposed Ligament Necrosis: Yes -Exposed Muscle Necrosis: Yes -Exposed Adipose Necrosis: Yes Tissue and other material debrided: Ligament, Muscle, subcutaneous, Slough -Wound Orders: Cleanse/protect wound. Cleanse wound with Normal Saline. Apply Santyl, Alginate, cover wound with dry absorptive dressing. Change dressing daily. Additional orders: Pressure relief/Offloading. Off-load wound. Reposition per facility protocol. CR #1 Record review of the medical record face sheet revealed CR #1 was admitted on [DATE] and re-admitted on [DATE]. [DIAGNOSES REDACTED]. He was [AGE] years old. CR #1 was discharged from facility on 9/27/2017 due to [MEDICAL CONDITION] in right jugular neck vein. Record review of CR #1's Braden Scale for Predicting Pressure Sore Risk revealed in part; - 07/27/2017 revealed a score of 15 indicating Low risk to develop pressure sores. Record review of CR #1's MD orders revealed in part; -7/28/2017 Avoid positioning on sacrum when possible, alternate sides and offload sacrum and heels with pillows when in bed every shift for Stage 3 sacrum and right heel Deep Tissue Injury. -7/28/2017 Cleanse right heel with Normal Saline and apply skin prep daily every day shift for Deep Tissue Injury. Ensure heels are floating. -7/28/2017 Cleanse sacral wound with Normal Saline, pat dry, apply calcium alginate and a dry dressing daily every day for Stage 3 pressure sore. Record review of CR #1's Plan of Care initiated 7/28/2017 and revised 8/14/2017 revealed in part; -Focus: CR #1 has an ADL self care deficit related to decreased mobility and generalized weakness. -Interventions: Bed Mobility. Requires 1-2 (staff) assistance. Record review of CR #1's Skin Pressure Ulcer Weekly dated 7/28/2017 revealed in part; -Site: Sacrum (is a large, triangular bone at the base of the spine and at the upper, back part of the pelvic cavity, where it is inserted like a wedge between the two hip bones). Initial evaluation. -Stage 3 -Description: 25% slough -Size: 1.2x1.0x0.1 c.m. (LWD) -Exudate: Serous moderate -Surrounding tissue: Normal for skin -Odor: none -Site: Right heel. Initial evaluation. -Stage SDTI (Suspected Deep Tissue Injury) -Description: deep red/purple discoloration -Size: 5.0x6.0x0.0 c.m. (LWD) -Exudate: none -Surrounding tissue: Normal for skin -Odor: none Record review of CR #1's Braden Scale for Predicting Pressure Sore Risk revealed in part; - 08/01/2017 revealed a score of 14 indicating Moderate risk to develop pressure sores. Further record review of CR #1's Plan of Care initiated 8/03/2017 and revised 9/15/2017 revealed in part; -Focus: CR #1 has actual Stage 4 pressure ulcer to the sacrum with confirmed [DIAGNOSES REDACTED],[MEDICAL CONDITION] and psuedomonas related to decreased mobility. -Interventions with initiated date of 8/3/2017 * Avoid positioning on sacrum when possible, alternate sides and offload with pillows. Needs monitoring/reminding/assistance to turn/reposition at least every 2 hours, more often as needed or requested. * Air mattress as ordered. Initiated 8/14/2017 Record review of CR #1's wound care MD evaluation revealed in part; -Date: 8/04/2017 Stage 3 pressure ulcer Sacrum. Facility acquired: No. -Wound measurements: 1.5 x 1.0 x 0.2 c.m. (LxWxD) Area: 1.5 square centimeter. Cubic centimeters: 0.3 Wound margin: Flat and intact -Exudate (drainage): small serous -Wound progress: Initial exam -Surrounding skin: Normal for skin -Wound Orders: Cleanse/protect wound. Cleanse wound with Normal Saline. Apply Collagen, cover wound with dry absorptive dressing. Change dressing daily. Additional orders: Pressure relief/Offloading. Off-load wound. Reposition per facility protocol. -Date: 8/04/2017 Right heel. Deep Tissue Pressure Injury persistent non-blanchable deep red, maroon or purple descoloration. Facility acquired: No. -Wound measurements: 5.0 x 5.0 x 0.0 c.m. (LxWxD) Area: 25 square centimeter. Cubic centimeters: 0 -Exudate (drainage): none -Wound progress: Initial exam -Wound Orders: Skin prep and leave open to air daily. Float heels with pillows. Record review of CR #1's admission MDS assessment with 08/05/2017 ARD revealed that he had severe cognitive impairment with a BIMS score of 6 out of a possible 15. CR #1 required extensive assistance of two or more person physical assist for bed mobility, transfer and toilet use. He required extensive assistance of one person physical assist for walking, locomotion, eating and personal hygiene. He was always incontinent of bowel and bladder. Further record review revealed that CR #1 was at risk of developing pressure sores. He had one Stage 3 pressure ulcer that was present upon admission to the facility and one unstageable pressure ulcer with suspected deep tissue injury in evolution that was present upon admission to the facility. The dimensions of unhealed Stage 3 or 4 Pressure Ulcers or Eschar were 1.5x1.0x0.2 c.m. (LWD). Continued record review of the MDS section that read Skin and Ulcer Treatment revealed that CR #1 was not checked to be on a turning/repositioning program or on a pressure reducing device for chair or bed. Record review of CR #1's MD orders revealed in part; -8/09/2017 Air Mattress every shift for Stage 3 (pressure sore) sacrum. Record review of CR #1's Braden Scale for Predicting Pressure Sore Risk revealed in part; - 08/10/2017 revealed a score of 13 indicating Moderate risk to develop pressure sores. Record review of CR #1's wound care MD evaluation revealed in part; -Date: 8/11/2017 Stage 3 pressure ulcer Sacrum. Facility acquired: No. -Wound measurements: 2.0 x 1.0 x 0.2 c.m. (LxWxD) Area: 2 square centimeter. Cubic centimeters: 0.4 Wound margin: Flat and intact -Exudate (drainage): moderate serous -Wound progress: Initial exam -Surrounding Skin: Maceration -Wound Orders: Cleanse/protect wound. Cleanse wound with Normal Saline. Apply Alginate, cover wound with dry absorptive dressing. Change dressing daily. Additional orders: Pressure relief/Offloading. Off-load wound. Reposition per facility protocol. -Date: 8/11/2017 Right heel. Deep Tissue Pressure Injury persistent non-blanchable deep red, maroon or purple discoloration. Facility acquired: No. -Wound measurements: 5.0 x 5.0 x 0.0 c.m. (LxWxD) Area: 25 square centimeter. Cubic centimeters: 0 -Exudate (drainage): none -Wound progress: Improving -Wound Orders: Skin prep and leave open to air daily. Float heels with pillows. Record review of CR #1's wound care MD evaluation revealed in part; -Date: 8/18/2017 Stage 3 pressure ulcer Sacrum. Facility acquired: No. -Wound measurements: 2.0 x 1.2 x 0.2 c.m. (LxWxD) Area: 2.4 square centimeter. Cubic centimeters: 0.48 Wound margin: Flat and intact -Exudate (drainage): moderate serous -Wound progress: No change -Surrounding Skin: Maceration -Moist yellow slough: 1-25% -Wound Orders: Cleanse/protect wound. Cleanse wound with Normal Saline. Apply Algunate, cover wound with dry absorptive dressing. Change dressing daily. Additional orders: Pressure relief/Offloading. Off-load wound. Reposition per facility protocol. -Date: 8/18/2017 Right heel. Deep Tissue Pressure Injury persistent non-blanchable deep red, maroon or purple discoloration. Facility acquired: No. -Wound measurements: 5.0 x 5.0 x 0.0 c.m. (LxWxD) Area: 25 square centimeter. Cubic centimeters: 0 -Exudate (drainage): none -Wound progress: Improving -Wound Orders: Skin prep and leave open to air daily. Float heels with pillows. Record review of CR #1's nurses notes dated 08/21/2017 at 5:54 p.m. revealed in part CR #1 having [MEDICAL CONDITION] episode and unresponsive while in rehab. Orders to send to emergency room . Record review of CR #1's nurses notes dated 08/31/2017 at 5:24 p.m. revealed in part CR #1 arrived at facility. Bandage to sacrum area. CR #1 is resting in semi-fowler position . Record review of CR #1's Braden Scale for Predicting Pressure Sore Risk revealed in part; - 08/31/2017 revealed a score of 18 indicating Low risk to develop pressure sores. Record review of CR #1's Skin Evaluation Weekly assessment dated [DATE] and signed by RN A revealed in part; .CR #1 right heel with Stage 2 (pressure sore). 4x4.5x0.1 (c.m.) Cleaned with normal saline, puracol to wound, covered with dry dressing. Sacrum: Stage 4. 3x2.5x0.75 (c.m.) with slough noted. Santyl and dry dressing applied . Record review of CR #1's MD orders dated 9/1/2017 revealed in part; -Cleanse Stage 2 to the right heel with normal saline, pat dry. Apply puracol (Puracol is a primary wound dressing for all drainage types. It is highly absorbent material) and cover with a dry kerlix wrap daily every day. Ensure heels are floating. -Clean sacral wound with Normal Saline, apply Santyl to slough, cover with Calcium Alginate and dry dressing every day shift. Record review of CR #1's nurse notes dated 9/6/2017 at 8:00 p.m. revealed in part; - .CR #1 to be sent out to the hospital due to abnormal KUB abdomen Record review of CR #1's Transfer to Hospital form dated 9/6/2017 revealed under Skin/Wound Care Sacrum Stage 4, Right heel Stage 2. No measurements or description of wounds noted. Record review of CR #1's nurse notes dated 9/7/2017 at 2:30 a.m. revealed that CR #1 returned to facility. No skin assessments noted. Record review of CR #1's Braden Scale for Predicting Pressure Sore Risk revealed in part; - 09/07/2017 revealed a score of 15 indicating Low risk to develop pressure sores. Record review of CR #1's wound care MD evaluation revealed in part; -Date: 9/08/2017 Stage 4 pressure ulcer Sacrum. Facility acquired: No. -Wound measurements: 3.0 x 3.0 x 1.0 c.m. (LxWxD) Area: 9 square centimeter. Cubic centimeters: 9 -No tunneling or undermining Wound margin: Flat and intact -Exudate (drainage): moderate serous -Wound progress: deteriorating -Surrounding Skin: Maceration -Moist yellow slough: 1-25% -Exposed Ligament Necrosis: Yes -Exposed bone necrosis: Yes -Suspected [DIAGNOSES REDACTED]: Awaiting results. -Wound Orders: Cleanse/protect wound. Cleanse wound with Normal Saline. Apply Santyl ([MEDICATION NAME]), apply [MEDICATION NAME], apply Alginate, cover wound with dry absorptive dressing. Change dressing daily. Additional orders: Pressure relief/Offloading. Off-load wound. Reposition per facility protocol. -Plan of Care: Will submit bone fragments from sacral wound to the laboratory for culture for evaluation of osteo[DIAGNOSES REDACTED]. -Date: 9/08/2017 Right heel. Unstageable Pressure Injury Obscured full thickness skin and tissue loss. Facility acquired: No. -Wound measurements: 3.5 x 3.5 x 0.0 c.m. (LxWxD) Area: 12.25 square centimeter. Cubic centimeters: 0 -Exudate (drainage): moderate serous -Dry black eschar: 26 - 50% -Wound Orders: Apply Alginate, cover wound with dry absorptive dressing. Every day. Float heels with pillows. Record review of CR #1's Surgical Pathology report for collection dated 9/8/2017 and report dated 9/12/2017 revealed in part; [DIAGNOSES REDACTED]. Acute. Sacrum fragment of bone with acute osteomyelitits (bone infection). Record review of CR #1's Laboratory report for wound culture to Sacral wound collected on 9/9/2017 and printed on 9/13/2017 revealed results in part; .[MEDICAL CONDITION]. Rare growth . Further record review a hand written note [MEDICATION NAME] (antibiotic)1 gram every 12 hours for 6 weeks. Record review of CR #1's MD orders revealed in part; -9/13/2017 [MEDICATION NAME] (antibiotic) in [MEDICATION NAME] Solution 1 gram/200 ml. Use 1 gram intravenously every 12 hours for osteo (bone) of the sacral wound for 6 weeks. Record review of CR #1's nurse Skin/Wound note dated 9/15/2017 at 11:59 a.m. signed by LVN A revealed in part: .During weekly skin assessment, CR #1 was noted to have non blanchable deep maroon/red discoloration to the right distal lateral foot. MD with orders for daily skin prep and offloading. CR #1 wearing a protective boot to the right foot for a right heel wound. Boot adding pressure to foot, contributing to new wound. Boot discontinued per MD and foot offloaded on pillows . Record review of CR #1's MD orders and Plan of Care revealed no orders were found for boot to the right foot. Record review of CR #1's wound care MD evaluation revealed in part; -Date: 9/15/2017 Stage 4 pressure ulcer Sacrum. Facility acquired: No. -Wound measurements: 5.0 x 8.0 x 1.5 c.m. (LxWxD) Area: 40 square centimeter. Cubic centimeters: 60 -Undermining: Yes Starting Position (o'clock) 1 Ending Position ((TRUNCATED)

Based on observation, interview and record review, the facility failed to ensure that based on the comprehensive assessment, residents received care consistent with professional standards of practice to prevent pressure ulcers and residents with pressure ulcers received necessary treatment and services to promote healing, prevent infection and prevent new ulcers from developing for 3 of 11 residents (Resident #5, CR#1 and Resident #6) reviewed for pressure ulcers. -The facility failed to prevent the development and worsening of facility acquired pressure ulcers for Resident #5 who was identified at risk to develop pressure sores. The facility failed to implement a Plan of Care when he was identified at risk to develop pressure sores. Resident # 5 developed a facility acquired pressure sore that was first identified as a Stage 3 to his left buttocks. The pressure sore advanced to a stage 4 pressure sore. -The facility failed to follow the MD recommendations to offload Resident #5's Stage 4 pressure ulcer, failed to provide the appropriate treatment and implement preventive measures to avoid the deterioration of Resident #5's stage 4 pressure sore. Resident #5 was found with deep tissue injury on the outside of his stage 4 pressure sore, foul odor on the wound and a large reddened area covering most part of his left buttocks. -The facility failed to prevent the worsening of CR #1's pressure ulcers who was readmitted to the facility with a Stage 4 pressure sore to his Sacrum and Stage 2 pressure sore to his right heel. The facility failed to follow CR #1's Plan of Care to turn/reposition and offload/float heels with pillows. CR #1's Stage 2 pressure sore to his right heel deteriorated to Unstageable within a week, his Sacral pressure sore developed an infection to the bone and increased in size within 18 days of being readmitted to the facility. CR #1's sacral wound developed a Deep Tissue Injury around the pressure sore. Sacral Stage 4 pressure sore required antibiotic therapy and wound debridement by the MD. -In addition, the facility failed to prevent the development of a new pressure injury. CR #1 developed a Deep Tissue Injury when the facility staff placed a boot to his foot that was not ordered by the MD or was on his Plan of Care -The facility failed to follow the MD recommendations to offload Resident #6's Stage 4 pressure ulcer to her sacrum (facility acquired unavoidable). Resident #6 was found soiled with stool and the pressure sore had maceration around the wound. These failures resulted in the identification of an Immediate Jeopardy (IJ) on 10/13/17. While the IJ was lowered on 10/14/17, the facility remained out of compliance at a scope of pattern and severity level of actual harm that was not IJ because all measures for prevention and treatment of [REDACTED]. These failures affected 2 current residents (Resident #5 and #6), 1 former resident (CR #1) resident and placed 15 residents with pressure sores at risk for developing new or worsening pressure ulcers which could lead [MEDICAL CONDITION], severe pain, hospitalization and even death. The findings include: TX 709/ Intake # 9, TX 319/ Intake # 2, TX 379/ Intake # 6, TX 457 / Intake # 2 and TX 875/ Intake # 8. Resident #5 Record review of the medical record face sheet revealed Resident #5 was admitted on [DATE] and re-admitted on [DATE]. [DIAGNOSES REDACTED]. He was [AGE] years old. Record review of Resident #5's nurses notes dated 08/18/2017 at 7:15 p.m. revealed in part Resident #5 admitted to the facility. Incontinent of bowel and bladder. No wounds . Record review of Resident #5's Plan of Care initiated 08/25/2017 revealed in part: -Focus: Resident #5 has an ADL (Activity of Daily Living) Self Care Performance Deficit. -Interventions: Bed mobility: Requires (1-2) staff participation to reposition and turn in bed. Transfer: Requires 1-2 physical assistance with transferring. Further record review of Resident #5's Plan of Care revealed no interventions to prevent the development of pressure sores. Record review of Resident #5's admission MDS assessment with 08/28/2017 ARD revealed that he was rarely/never understood and was unable to complete the interview for Mental Status. Resident #5 required extensive assistance for his activities of daily living and he was total dependent for bathing. He had impairment on both sides of his lower extremities. He was always incontinent of bowel and bladder. Further record review revealed that Resident #5 was at risk of developing pressure sores and had no pressure sores during assessment. Further record review of the MDS section that read Skin and Ulcer Treatment revealed that Resident #5 was not checked to be on a turning/repositioning program or on a pressure reducing device for chair or bed. Record review of Resident #5's Braden Scale for Predicting Pressure Sore Risk revealed in part; - 08/29/2017 revealed a score of 14 indicating Moderate risk to develop pressure sores. Record review of Resident #5's nurses notes dated 9/17/2017 at 6:16 p.m. by LVN A (former Wound Care Nurse) revealed in part; Observed new Stage 3 pressure ulcer to the left buttocks which is 25% slough and 25% eschar tissue. Measurements: 3.5x3.0x0.2 (c.m.) (LWD) with moderate serous drainage. Air mattress ordered and orders placed to offload with pillows and turn frequently . Record review of Resident #5's Skin Pressure Ulcer Weekly dated 9/17/2017 revealed in part; -Site: Left buttock. Initial evaluation. -Stage 3 -Description: 25% slough, 25% eschar -Size: 3.5x3x0.2 c.m. (LWD) -Exudate: Serous moderate -Surrounding tissue: [DIAGNOSES REDACTED] -Odor: none Record review of Resident #5's consolidated MD orders revealed in part; -9/17/2017 Air mattress every shift for Stage 3 left buttocks -9/17/2017 Avoid positioning on left buttocks when possible, alternate sides and offload with pillows every shift for Stage 3 (pressure sore). -10/01/2017 [MEDICATION NAME] Acid tablet 500 mg by mouth two time a day for supplement. -10/01/2017 Multiple vitamins-minerals tablet, take one by mouth every day for supplement. -10/01/2017 Zinc Sulfate Capsule 220 mg, one by mouth one time a day for wound healing for 14 days. -10/06/2017 Clean left buttock with Normal Saline, pat dry, apply Santyl ([MEDICATION NAME] oitment) to slough followed by Calcium Alginate (dressing derived from seaweed, highly absorbent) and a dry dressing daily every day shift for Stage 4. Continued record review of Resident #5's Plan of Care initiated 09/17/2017 revealed in part: -Resident #5 has an actual Stage 4 pressure ulcer to the left buttock related to decreased mobility and incontinence. -Goal: Pressure ulcer will show signs of healing by target date 01/10/2018. -Interventions: Air mattress and frequent turns, avoid positioning on left buttocks when possible, alternate sides and offload with pillows. Record review of Resident #5's Braden Scale for Predicting Pressure Sore Risk revealed in part; - 09/18/2017 revealed a score of 11 indicating High risk to develop pressure sores. Record review of Resident #5's Skin Pressure Ulcer Weekly dated 9/22/2017 revealed in part; -Site: Left buttock. Follow up. -Stage 3 -Description: 25% eschar -Size: 3x3x0.2 c.m. (LWD) -Exudate: Serous moderate -Surrounding tissue: [DIAGNOSES REDACTED] -Odor: none Record review of Resident #5's wound care MD evaluation revealed in part; -Date: 9/29/2017 Stage 3 pressure ulcer left buttocks. Facility acquired on 9/18/2017. -Wound measurements: 3.5 x 4.5 x 0.0 c.m. (LxWxD) Area: 15.75 square centimeter. Cubic centimeters: 0 -Exudate (drainage): Moderate serous -Moist Yellow Slough: 76 - 100% -Wound progress: Initial exam -Wound Orders: Cleanse/protect wound. Cleanse wound with Normal Saline. Apply Alginate, cover wound with dry absorptive dressing. Change dressing daily. Additional orders: Pressure relief/Offloading. Off-load wound. Reposition per facility protocol. Record review of Resident #5's wound care MD evaluation revealed in part; -Date: 10/06/2017 Stage 4 pressure injury left buttocks. -Wound measurements: 3.0 x 4.5 x 2.0 c.m. (LxWxD) Area: 13.50 square centimeter. Cubic centimeters: 27 -Exudate (drainage): Moderate serous -Moist Yellow Slough: 76 - 100% -Wound progress: deteriorating -Exposed Muscle Necrosis: Yes -Exposed Adipose Necrosis: Yes Tissue and other material debrided: Muscle, subcutaneous, Slough -Wound Orders: Cleanse/protect wound. Cleanse wound with Normal Saline. Apply Santyl, Alginate, cover wound with dry absorptive dressing. Change dressing daily. Additional orders: Pressure relief/Offloading. Off-load wound. Reposition per facility protocol. Record review of Resident #5's nurses notes dated 10/6/2017 at 4:27 p.m. by LVN A revealed in part; Resident #5 is an [AGE] year old long term resident admitted on [DATE]. He was noted to have new Stage 3 pressure ulcer to the left buttock on 09/18/2017. Wound MD debrided the wound removing all slough, increasing the depth and revealing muscle and subcutaneous tissue. Wound upgraded to a Stage 4. Santyl ([MEDICATION NAME] ointment) resumed for slough along with Calcium Alginate dressing (dressing derived from seaweed, highly absorbent) daily. Air mattress and orders in place to offload with pillows and turn frequently . Observation on 10/12/2017 at 9:10 a.m. revealed that Resident #5 was not on his room. Observation on 10/12/2017 at 10:45 a.m. revealed that Resident #5 was in the dining room seated in a geri-chair. Further observation revealed that he did not have a pressure reducing device in his chair. Resident #5 appeared leaning to his left side when seated in his chair. In an interview on 10/12/2017 at 11:27 a.m. with Wound Care Nurse B, she stated that she was new in the position for wound care. She further said that Resident#5 was not in his room and that he probably was in the dining room area. In a confidential interview on 10/12/2017 at 12:05 p.m., the staff stated that there was only one CNA on the 100, 200 and 400 halls. The staff said that it was difficult to provide incontinent care or provide frequent care to all of the residents and further said we try, but it is hard. Observation on 10/12/2017 at 2:00 p.m. revealed that Resident #5 was still not in his room. Observation on 10/12/2017 at 4:00 p.m. revealed that Resident #5 was seated in a geri-chair in dining room area. Further observation revealed that he still did not have a pressure reducing device in his chair. Resident #5 appeared leaning to his left side when seated in his chair. Observation on 10/12/2017 at 5:00 p.m. revealed that Resident #5 was lying in his bed. There was a strong odor of urine in his room. During observation with Wound Care Nurse B and LVN C revealed that Resident #5's wound to his left buttocks was not protected with a dressing. Open wound was 4.0 c.m. in diameter and 2.0 c.m. in depth. The wound base was black and had a foul odor. The superior surrounding tissue of the wound had a non-blanchable deep red, maroon discoloration that measured 4.0 c.m. in length around top part of wound and 2.6 c.m. wide. There was a large dark reddened area covering most part of the left buttocks that measured 14 c.m. wide and 12 c.m. long. (measurements were taken by Wound Care Nurse B). The brief Resident #5's was wearing had small spots of red blood on it. Interview on 10/12/2017 at 5:05 p.m. with CNA A inside Resident #5's room, she stated that she had just assisted Resident #5 to bed at that time and that his brief was very wet that's why smells urine. She further said that when she helped Resident #5, he did not have his cushion on the chair or dressing on the wound. CNA A then said I did not get him up. I haven't had the time to get to him before. I've been laying people to bed and answering call lights. I have 22 residents under my care. CNA B got him up early today to shower him, I do not know what time she got him up, CNA B dressed him up and put him up on his geri-chair. She told me that Resident #5 did not have a dressing on his wound but I told her to report it to the Wound Care Nurse. Further interview at that time, the Wound Care Nurse B stated Nobody told me that Resident #5 did not have a dressing to his wound. When asked the Wound Care Nurse B about the foul odor and the non-blanchable deep red, maroon discoloration on the superior part of Resident #5's wound, she responded probably because he is being seated on the wound. In an interview on 10/12/2017 at 5:20 p.m. with CNA B, she stated that she was the Shower Tech and that she got up Resident #5 at around 6:00 a.m. or 7:00 a.m. It was early. She then said that when she got him up for shower, she noticed that he did not have a dressing to the open wound to his left buttocks and that she did not know if the dressing had fallen anytime during the night shift. CNA B continued saying I got him up, showered him, dressed him and got him up in his geri-chair and helped him go to the dining room. When asked if she placed any cushion or pressure reducing device on Resident #5's chair before he was seated on it, CNA B responded No, I did not know he needed a cushion. I did let CNA A know that Resident #5 needed a dressing to the wound to his left buttocks. When asked about facility's policy of notification when an open wound did not have a dressing, CNA B responded I was supposed to notify the charge nurse or Wound Care Nurse. When asked if she had checked on Resident #5 any time after she got him up, CNA B stated No, I haven't seen him anymore. He might have a dressing (to his wound) by now. In an interview on 10/12/2017 at 5:25 p.m. with the DON, she stated that charge nurses were supposed to make rounds to make sure residents were turned and repositioned and incontinent care was provided. DON then said that the ADON was supposed to follow up on the nurses to make sure they were making sure that residents were turned or repositioned when they were in bed or up in a chair and that incontinent care was provided as needed. Further interview at that moment, when asked if she had seen Resident #5's wound lately, the DON responded No, I have not seen his wound. Well, yes, I saw it on 9/29/2017. Resident #5 has a Stage 3 pressure sore to his buttocks. When asked about the facility protocol to turn or reposition residents in bed or in chair, the DON stated We encourage the CNA's to turn and reposition residents frequently, every 3 hours. When asked for residents who had Stage 3 pressure sores on their buttocks if it was acceptable to be up on their chair all day from 7:00 a.m. to 5:00 p.m. without being repositioned or incontinent care provided, the DON responded No, it is not acceptable to be up all day from 7:00 a.m. to 5:00 p.m. without being assisted to bed to offload the pressure sore. DON then said that she remembered seeing Resident #5 in the dining room during the day, but in different sites of the dining area and that she believed that he had been already taken care of. When asked DON if she believed having one CNA per hall was enough staffing to provide frequent incontinent care and frequent turning and repositioning of the residents, the DON said Yes, I have staff that had worked on the 200 hall and the other halls and they are able to do the work. Continued interview with the DON, when asked if she was aware that Resident #5 had been up all day in a geri-chair without a pressure reducing cushion on his chair, without a dressing to his Stage 3 pressure sore and without being provided incontinent care, the DON did not respond. At that moment, DON was asked to come to Resident #5's to observe the pressure sore. Observation and interview on 10/12/2017 at 5:30 p.m. inside Resident #5's room with the DON, the DON stated as she observed Resident #5's open wound to his left buttocks and reddened area to his left buttocks Resident #5's wound did not look like this before on 9/29/2017. This does not look like a Stage 3 pressure sore. When pointed the large dark reddened area to his left buttocks and the non-blanchable deep red, maroon discoloration around top part of the wound, the DON stated The CNA's know about the cushion. In an interview on 10/12/2017 at 5:46 p.m. with LVN C, she said she was the charge nurse for Resident #5 and that she was responsible that residents under her care were turned and repositioned as frequently as possible and then said It's kind of hard for the CNA's to do it. There is only 1 CNA per hallway. Each hallway has 22 to 24 residents. It's hard for them to do it. There are floating CNA's but they don't help the CNA's on the floor. The reddened area to Resident #5's left buttocks just blew me away. It's redness from pressure. Resident #5 is really non-verbal, there is only 1 CNA for all those patients, the patients really don't get the care they deserve. It's hard. The CNA's need to get residents up, assist with meals and call lights. It's hard. In an interview on 10/12/2017 at 5:50 p.m. with the ADON, she stated that she was responsible to make sure residents were turned and repositioned every 3 to 4 hours. ADON then said that residents who had pressure sores were supposed to be turned every 2 hours. She then said that the shower tech CNA's were supposed to help the CNA's on the floor on turning/repositioning and incontinent care to residents. ADON further said I know Resident #5 was up for a long time. I told CNA A at around 3:00 p.m. when I saw Resident #5 still in the dining room area, I asked her to help Resident #5 to his room, but CNA A was doing other things then I checked at around 5:00 p.m. and Resident #5 was no longer in the dining room. Record review of facility daily census summary dated 10/12/2017 revealed the following census per hall; 100 Hall 27 residents 1 CNA assigned 200 Hall 24 residents (Hall of Resident #5) 1 CNA assigned (CNA A) 300 Hall 25 residents / Skilled floor. 2 CNA's assigned 400 Hall 24 residents 1 CNA assigned Record review of Resident #5's Plan of Care initiated on 10/12/2017 revealed in part; -Focus: Resident #5 has bowel and bladder incontinence. -Interventions: Check as required for incontinence. -Focus: Resident #5 has limited physical mobility. -Interventions: Mobility: Is totally dependent on staff for locomotion. Record review of Resident #5's Skin/Wound notes dated 10/13/2017 at 6:21 p.m. signed by LVN A (former Wound Care Nurse) revealed in part; Stage 4 to the left buttock noted to have a foul odor and increase in slough. Wound debrided at bedside, removing all slough and dead tissue from wound bed and edges, increasing measurements. Ulcer has exposed ligament, muscle and subcutaneous tissue. Staff educated on proper turning techniques and importance of offloading wounds. Cushion noted for geri-chair and Resident #5 remains on air mattress. Med pass and health shakes added to diet . Record review of Resident #5's wound care MD evaluation revealed in part; -Date: 10/13/2017 Stage 4 pressure injury left buttocks. -Wound measurements: 4.5 x 5.5 x 4.0 c.m. (LxWxD) Area: 24.75 square centimeter. Cubic centimeters: 99 -Exudate (drainage): Moderate serous -Moist Yellow Slough: 76 - 100% -Wound progress: deteriorating -Exposed Ligament Necrosis: Yes -Exposed Muscle Necrosis: Yes -Exposed Adipose Necrosis: Yes Tissue and other material debrided: Ligament, Muscle, subcutaneous, Slough -Wound Orders: Cleanse/protect wound. Cleanse wound with Normal Saline. Apply Santyl, Alginate, cover wound with dry absorptive dressing. Change dressing daily. Additional orders: Pressure relief/Offloading. Off-load wound. Reposition per facility protocol. CR #1 Record review of the medical record face sheet revealed CR #1 was admitted on [DATE] and re-admitted on [DATE]. [DIAGNOSES REDACTED]. He was [AGE] years old. CR #1 was discharged from facility on 9/27/2017 due to [MEDICAL CONDITION] in right jugular neck vein. Record review of CR #1's Braden Scale for Predicting Pressure Sore Risk revealed in part; - 07/27/2017 revealed a score of 15 indicating Low risk to develop pressure sores. Record review of CR #1's MD orders revealed in part; -7/28/2017 Avoid positioning on sacrum when possible, alternate sides and offload sacrum and heels with pillows when in bed every shift for Stage 3 sacrum and right heel Deep Tissue Injury. -7/28/2017 Cleanse right heel with Normal Saline and apply skin prep daily every day shift for Deep Tissue Injury. Ensure heels are floating. -7/28/2017 Cleanse sacral wound with Normal Saline, pat dry, apply calcium alginate and a dry dressing daily every day for Stage 3 pressure sore. Record review of CR #1's Plan of Care initiated 7/28/2017 and revised 8/14/2017 revealed in part; -Focus: CR #1 has an ADL self care deficit related to decreased mobility and generalized weakness. -Interventions: Bed Mobility. Requires 1-2 (staff) assistance. Record review of CR #1's Skin Pressure Ulcer Weekly dated 7/28/2017 revealed in part; -Site: Sacrum (is a large, triangular bone at the base of the spine and at the upper, back part of the pelvic cavity, where it is inserted like a wedge between the two hip bones). Initial evaluation. -Stage 3 -Description: 25% slough -Size: 1.2x1.0x0.1 c.m. (LWD) -Exudate: Serous moderate -Surrounding tissue: Normal for skin -Odor: none -Site: Right heel. Initial evaluation. -Stage SDTI (Suspected Deep Tissue Injury) -Description: deep red/purple discoloration -Size: 5.0x6.0x0.0 c.m. (LWD) -Exudate: none -Surrounding tissue: Normal for skin -Odor: none Record review of CR #1's Braden Scale for Predicting Pressure Sore Risk revealed in part; - 08/01/2017 revealed a score of 14 indicating Moderate risk to develop pressure sores. Further record review of CR #1's Plan of Care initiated 8/03/2017 and revised 9/15/2017 revealed in part; -Focus: CR #1 has actual Stage 4 pressure ulcer to the sacrum with confirmed [DIAGNOSES REDACTED],[MEDICAL CONDITION] and psuedomonas related to decreased mobility. -Interventions with initiated date of 8/3/2017 * Avoid positioning on sacrum when possible, alternate sides and offload with pillows. Needs monitoring/reminding/assistance to turn/reposition at least every 2 hours, more often as needed or requested. * Air mattress as ordered. Initiated 8/14/2017 Record review of CR #1's wound care MD evaluation revealed in part; -Date: 8/04/2017 Stage 3 pressure ulcer Sacrum. Facility acquired: No. -Wound measurements: 1.5 x 1.0 x 0.2 c.m. (LxWxD) Area: 1.5 square centimeter. Cubic centimeters: 0.3 Wound margin: Flat and intact -Exudate (drainage): small serous -Wound progress: Initial exam -Surrounding skin: Normal for skin -Wound Orders: Cleanse/protect wound. Cleanse wound with Normal Saline. Apply Collagen, cover wound with dry absorptive dressing. Change dressing daily. Additional orders: Pressure relief/Offloading. Off-load wound. Reposition per facility protocol. -Date: 8/04/2017 Right heel. Deep Tissue Pressure Injury persistent non-blanchable deep red, maroon or purple descoloration. Facility acquired: No. -Wound measurements: 5.0 x 5.0 x 0.0 c.m. (LxWxD) Area: 25 square centimeter. Cubic centimeters: 0 -Exudate (drainage): none -Wound progress: Initial exam -Wound Orders: Skin prep and leave open to air daily. Float heels with pillows. Record review of CR #1's admission MDS assessment with 08/05/2017 ARD revealed that he had severe cognitive impairment with a BIMS score of 6 out of a possible 15. CR #1 required extensive assistance of two or more person physical assist for bed mobility, transfer and toilet use. He required extensive assistance of one person physical assist for walking, locomotion, eating and personal hygiene. He was always incontinent of bowel and bladder. Further record review revealed that CR #1 was at risk of developing pressure sores. He had one Stage 3 pressure ulcer that was present upon admission to the facility and one unstageable pressure ulcer with suspected deep tissue injury in evolution that was present upon admission to the facility. The dimensions of unhealed Stage 3 or 4 Pressure Ulcers or Eschar were 1.5x1.0x0.2 c.m. (LWD). Continued record review of the MDS section that read Skin and Ulcer Treatment revealed that CR #1 was not checked to be on a turning/repositioning program or on a pressure reducing device for chair or bed. Record review of CR #1's MD orders revealed in part; -8/09/2017 Air Mattress every shift for Stage 3 (pressure sore) sacrum. Record review of CR #1's Braden Scale for Predicting Pressure Sore Risk revealed in part; - 08/10/2017 revealed a score of 13 indicating Moderate risk to develop pressure sores. Record review of CR #1's wound care MD evaluation revealed in part; -Date: 8/11/2017 Stage 3 pressure ulcer Sacrum. Facility acquired: No. -Wound measurements: 2.0 x 1.0 x 0.2 c.m. (LxWxD) Area: 2 square centimeter. Cubic centimeters: 0.4 Wound margin: Flat and intact -Exudate (drainage): moderate serous -Wound progress: Initial exam -Surrounding Skin: Maceration -Wound Orders: Cleanse/protect wound. Cleanse wound with Normal Saline. Apply Alginate, cover wound with dry absorptive dressing. Change dressing daily. Additional orders: Pressure relief/Offloading. Off-load wound. Reposition per facility protocol. -Date: 8/11/2017 Right heel. Deep Tissue Pressure Injury persistent non-blanchable deep red, maroon or purple discoloration. Facility acquired: No. -Wound measurements: 5.0 x 5.0 x 0.0 c.m. (LxWxD) Area: 25 square centimeter. Cubic centimeters: 0 -Exudate (drainage): none -Wound progress: Improving -Wound Orders: Skin prep and leave open to air daily. Float heels with pillows. Record review of CR #1's wound care MD evaluation revealed in part; -Date: 8/18/2017 Stage 3 pressure ulcer Sacrum. Facility acquired: No. -Wound measurements: 2.0 x 1.2 x 0.2 c.m. (LxWxD) Area: 2.4 square centimeter. Cubic centimeters: 0.48 Wound margin: Flat and intact -Exudate (drainage): moderate serous -Wound progress: No change -Surrounding Skin: Maceration -Moist yellow slough: 1-25% -Wound Orders: Cleanse/protect wound. Cleanse wound with Normal Saline. Apply Algunate, cover wound with dry absorptive dressing. Change dressing daily. Additional orders: Pressure relief/Offloading. Off-load wound. Reposition per facility protocol. -Date: 8/18/2017 Right heel. Deep Tissue Pressure Injury persistent non-blanchable deep red, maroon or purple discoloration. Facility acquired: No. -Wound measurements: 5.0 x 5.0 x 0.0 c.m. (LxWxD) Area: 25 square centimeter. Cubic centimeters: 0 -Exudate (drainage): none -Wound progress: Improving -Wound Orders: Skin prep and leave open to air daily. Float heels with pillows. Record review of CR #1's nurses notes dated 08/21/2017 at 5:54 p.m. revealed in part CR #1 having [MEDICAL CONDITION] episode and unresponsive while in rehab. Orders to send to emergency room . Record review of CR #1's nurses notes dated 08/31/2017 at 5:24 p.m. revealed in part CR #1 arrived at facility. Bandage to sacrum area. CR #1 is resting in semi-fowler position . Record review of CR #1's Braden Scale for Predicting Pressure Sore Risk revealed in part; - 08/31/2017 revealed a score of 18 indicating Low risk to develop pressure sores. Record review of CR #1's Skin Evaluation Weekly assessment dated [DATE] and signed by RN A revealed in part; .CR #1 right heel with Stage 2 (pressure sore). 4x4.5x0.1 (c.m.) Cleaned with normal saline, puracol to wound, covered with dry dressing. Sacrum: Stage 4. 3x2.5x0.75 (c.m.) with slough noted. Santyl and dry dressing applied . Record review of CR #1's MD orders dated 9/1/2017 revealed in part; -Cleanse Stage 2 to the right heel with normal saline, pat dry. Apply puracol (Puracol is a primary wound dressing for all drainage types. It is highly absorbent material) and cover with a dry kerlix wrap daily every day. Ensure heels are floating. -Clean sacral wound with Normal Saline, apply Santyl to slough, cover with Calcium Alginate and dry dressing every day shift. Record review of CR #1's nurse notes dated 9/6/2017 at 8:00 p.m. revealed in part; - .CR #1 to be sent out to the hospital due to abnormal KUB abdomen Record review of CR #1's Transfer to Hospital form dated 9/6/2017 revealed under Skin/Wound Care Sacrum Stage 4, Right heel Stage 2. No measurements or description of wounds noted. Record review of CR #1's nurse notes dated 9/7/2017 at 2:30 a.m. revealed that CR #1 returned to facility. No skin assessments noted. Record review of CR #1's Braden Scale for Predicting Pressure Sore Risk revealed in part; - 09/07/2017 revealed a score of 15 indicating Low risk to develop pressure sores. Record review of CR #1's wound care MD evaluation revealed in part; -Date: 9/08/2017 Stage 4 pressure ulcer Sacrum. Facility acquired: No. -Wound measurements: 3.0 x 3.0 x 1.0 c.m. (LxWxD) Area: 9 square centimeter. Cubic centimeters: 9 -No tunneling or undermining Wound margin: Flat and intact -Exudate (drainage): moderate serous -Wound progress: deteriorating -Surrounding Skin: Maceration -Moist yellow slough: 1-25% -Exposed Ligament Necrosis: Yes -Exposed bone necrosis: Yes -Suspected [DIAGNOSES REDACTED]: Awaiting results. -Wound Orders: Cleanse/protect wound. Cleanse wound with Normal Saline. Apply Santyl ([MEDICATION NAME]), apply [MEDICATION NAME], apply Alginate, cover wound with dry absorptive dressing. Change dressing daily. Additional orders: Pressure relief/Offloading. Off-load wound. Reposition per facility protocol. -Plan of Care: Will submit bone fragments from sacral wound to the laboratory for culture for evaluation of osteo[DIAGNOSES REDACTED]. -Date: 9/08/2017 Right heel. Unstageable Pressure Injury Obscured full thickness skin and tissue loss. Facility acquired: No. -Wound measurements: 3.5 x 3.5 x 0.0 c.m. (LxWxD) Area: 12.25 square centimeter. Cubic centimeters: 0 -Exudate (drainage): moderate serous -Dry black eschar: 26 - 50% -Wound Orders: Apply Alginate, cover wound with dry absorptive dressing. Every day. Float heels with pillows. Record review of CR #1's Surgical Pathology report for collection dated 9/8/2017 and report dated 9/12/2017 revealed in part; [DIAGNOSES REDACTED]. Acute. Sacrum fragment of bone with acute osteomyelitits (bone infection). Record review of CR #1's Laboratory report for wound culture to Sacral wound collected on 9/9/2017 and printed on 9/13/2017 revealed results in part; .[MEDICAL CONDITION]. Rare growth . Further record review a hand written note [MEDICATION NAME] (antibiotic)1 gram every 12 hours for 6 weeks. Record review of CR #1's MD orders revealed in part; -9/13/2017 [MEDICATION NAME] (antibiotic) in [MEDICATION NAME] Solution 1 gram/200 ml. Use 1 gram intravenously every 12 hours for osteo (bone) of the sacral wound for 6 weeks. Record review

Based on observation, interview, and record review the facility failed to ensure sufficient staffing to provide nursing related services to attain or maintain the highest practicable physical, mental and psychosocial well-being of three of eleven residents (Resident #5, CR #1 and Resident #6) reviewed for nursing services. -The facility failed to have sufficient staffing to provide care to Resident #5 when he was left for 9 hours seated on his geri-chair without being checked for incontinence and without being repositioned or offloaded his pressure sore as ordered by the MD. -The facility failed to provide repositioning and timely incontinent care to CR #1 resulting in the development of a deep tissue injury around his Sacrum Stage 4 pressure sore. Stage 2 pressure sore to his right heel advanced to a Unstageable pressure sore. -In addition, the facility failed to prevent the development of a new pressure injury. CR #1 developed a Deep Tissue Injury to his right distal lateral foot . -The facility failed to provide repositioning and timely incontinent care to Resident #6, who had a Stage 4 pressure ulcer to her sacrum (facility acquired unavoidable). Resident #6 was found soiled with stool and the pressure sore had maceration around the wound. These failures resulted in the identification of an Immediate Jeopardy (IJ) on 10/13/17. While the IJ was lowered on 10/14/17, the facility remained out of compliance at a scope of pattern and severity level of actual harm that was not IJ because all measures for prevention and treatment of [REDACTED]. This failure placed two residents residing in the facility (Resident #5 and Resident #6) and one former resident (CR #1) and placed 99 residents at risk for failure to have sufficient staffing to meet the residents care needs. Findings include: TX 709/ Intake # 9, TX 319/ Intake # 2, TX 379/ Intake # 6, TX 457 / Intake # 2 and TX 875/ Intake # 8. Resident #5 Record review of the medical record face sheet revealed Resident #5 was admitted on [DATE] and re-admitted on [DATE]. [DIAGNOSES REDACTED]. He was [AGE] years old. Record review of Resident #5's nurses notes dated 08/18/2017 at 7:15 p.m. revealed in part Resident #5 admitted to the facility. Incontinent of bowel and bladder. No wounds . Record review of Resident #5's Plan of Care initiated 08/25/2017 revealed in part: -Focus: Resident #5 has an ADL (Activity of Daily Living) Self Care Performance Deficit. -Interventions: Bed mobility: Requires (1-2) staff participation to reposition and turn in bed. Transfer: Requires 1-2 physical assistance with transferring. Further record review of Resident #5's Plan of Care revealed no interventions to prevent the development of pressure sores. Record review of Resident #5's admission MDS assessment with 08/28/2017 ARD revealed that he was rarely/never understood and was unable to complete the interview for Mental Status. Resident #5 required extensive assistance for his activities of daily living and he was total dependent for bathing. He had impairment on both sides of his lower extremities. He was always incontinent of bowel and bladder. Further record review revealed that Resident #5 was at risk of developing pressure sores and had no pressure sores during assessment. Further record review of the MDS section that read Skin and Ulcer Treatment revealed that Resident #5 was not checked to be on a turning/repositioning program or on a pressure reducing device for chair or bed. Record review of Resident #5's Braden Scale for Predicting Pressure Sore Risk revealed in part; - 08/29/2017 revealed a score of 14 indicating Moderate risk to develop pressure sores. Record review of Resident #5's nurses notes dated 9/17/2017 at 6:16 p.m. by LVN A (former Wound Care Nurse) revealed in part; Observed new Stage 3 pressure ulcer to the left buttocks which is 25% slough and 25% eschar tissue. Measurements: 3.5x3.0x0.2 (c.m.) (LWD) with moderate serous drainage. Air mattress ordered and orders placed to offload with pillows and turn frequently . Record review of Resident #5's Skin Pressure Ulcer Weekly dated 9/17/2017 revealed in part; -Site: Left buttock. Initial evaluation. -Stage 3 -Description: 25% slough, 25% eschar -Size: 3.5x3x0.2 c.m. (LWD) -Exudate: Serous moderate -Surrounding tissue: [DIAGNOSES REDACTED] -Odor: none Record review of Resident #5's consolidated MD orders revealed in part; -9/17/2017 Air mattress every shift for Stage 3 left buttocks -9/17/2017 Avoid positioning on left buttocks when possible, alternate sides and offload with pillows every shift for Stage 3 (pressure sore). -10/01/2017 [MEDICATION NAME] Acid tablet 500 mg by mouth two time a day for supplement. -10/01/2017 Multiple vitamins-minerals tablet, take one by mouth every day for supplement. -10/01/2017 Zinc Sulfate Capsule 220 mg, one by mouth one time a day for wound healing for 14 days. -10/06/2017 Clean left buttock with Normal Saline, pat dry, apply Santyl ([MEDICATION NAME] oitment) to slough followed by Calcium Alginate (dressing derived from seaweed, highly absorbent) and a dry dressing daily every day shift for Stage 4. Continued record review of Resident #5's Plan of Care initiated 09/17/2017 revealed in part: -Resident #5 has an actual Stage 4 pressure ulcer to the left buttock related to decreased mobility and incontinence. -Goal: Pressure ulcer will show signs of healing by target date 01/10/2018. -Interventions: Air mattress and frequent turns, avoid positioning on left buttocks when possible, alternate sides and offload with pillows. Record review of Resident #5's Braden Scale for Predicting Pressure Sore Risk revealed in part; - 09/18/2017 revealed a score of 11 indicating High risk to develop pressure sores. Record review of Resident #5's Skin Pressure Ulcer Weekly dated 9/22/2017 revealed in part; -Site: Left buttock. Follow up. -Stage 3 -Description: 25% eschar -Size: 3x3x0.2 c.m. (LWD) -Exudate: Serous moderate -Surrounding tissue: [DIAGNOSES REDACTED] -Odor: none Record review of Resident #5's wound care MD evaluation revealed in part; -Date: 9/29/2017 Stage 3 pressure ulcer left buttocks. Facility acquired on 9/18/2017. -Wound measurements: 3.5 x 4.5 x 0.0 c.m. (LxWxD) Area: 15.75 square centimeter. Cubic centimeters: 0 -Exudate (drainage): Moderate serous -Moist Yellow Slough: 76 - 100% -Wound progress: Initial exam -Wound Orders: Cleanse/protect wound. Cleanse wound with Normal Saline. Apply Alginate, cover wound with dry absorptive dressing. Change dressing daily. Additional orders: Pressure relief/Offloading. Off-load wound. Reposition per facility protocol. Record review of Resident #5's wound care MD evaluation revealed in part; -Date: 10/06/2017 Stage 4 pressure injury left buttocks. -Wound measurements: 3.0 x 4.5 x 2.0 c.m. (LxWxD) Area: 13.50 square centimeter. Cubic centimeters: 27 -Exudate (drainage): Moderate serous -Moist Yellow Slough: 76 - 100% -Wound progress: deteriorating -Exposed Muscle Necrosis: Yes -Exposed Adipose Necrosis: Yes Tissue and other material debrided: Muscle, subcutaneous, Slough -Wound Orders: Cleanse/protect wound. Cleanse wound with Normal Saline. Apply Santyl, Alginate, cover wound with dry absorptive dressing. Change dressing daily. Additional orders: Pressure relief/Offloading. Off-load wound. Reposition per facility protocol. Record review of Resident #5's nurses notes dated 10/6/2017 at 4:27 p.m. by LVN A revealed in part; Resident #5 is an [AGE] year old long term resident admitted on [DATE]. He was noted to have new Stage 3 pressure ulcer to the left buttock on 09/18/2017. Wound MD debrided the wound removing all slough, increasing the depth and revealing muscle and subcutaneous tissue. Wound upgraded to a Stage 4. Santyl ([MEDICATION NAME] ointment) resumed for slough along with Calcium Alginate dressing (dressing derived from seaweed, highly absorbent) daily. Air mattress and orders in place to offload with pillows and turn frequently . Observation on 10/12/2017 at 9:10 a.m. revealed that Resident #5 was not on his room. Observation on 10/12/2017 at 10:45 a.m. revealed that Resident #5 was in the dining room seated in a geri-chair. Further observation revealed that he did not have a pressure reducing device in his chair. Resident #5 appeared leaning to his left side when seated in his chair. In an interview on 10/12/2017 at 11:27 a.m. with Wound Care Nurse B, she stated that she was new in the position for wound care. She further said that Resident#5 was not in his room and that he probably was in the dining room area. In a confidential interview on 10/12/2017 at 12:05 p.m., the staff stated that there was only one CNA on the 100, 200 and 400 halls. The staff said that it was difficult to provide incontinent care or provide frequent care to all of the residents and further said we try, but it is hard. Observation on 10/12/2017 at 2:00 p.m. revealed that Resident #5 was still not in his room. Observation on 10/12/2017 at 4:00 p.m. revealed that Resident #5 was seated in a geri-chair in dining room area. Further observation revealed that he still did not have a pressure reducing device in his chair. Resident #5 appeared leaning to his left side when seated in his chair. Observation on 10/12/2017 at 5:00 p.m. revealed that Resident #5 was lying in his bed. There was a strong odor of urine in his room. During observation with Wound Care Nurse B and LVN C revealed that Resident #5's wound to his left buttocks was not protected with a dressing. Open wound was 4.0 c.m. in diameter and 2.0 c.m. in depth. The wound base was black and had a foul odor. The superior surrounding tissue of the wound had a non-blanchable deep red, maroon discoloration that measured 4.0 c.m. in length around top part of wound and 2.6 c.m. wide. There was a large dark reddened area covering most part of the left buttocks that measured 14 c.m. wide and 12 c.m. long. (measurements were taken by Wound Care Nurse B). The brief Resident #5's was wearing had small spots of red blood on it. Interview on 10/12/2017 at 5:05 p.m. with CNA A inside Resident #5's room, she stated that she had just assisted Resident #5 to bed at that time and that his brief was very wet that's why smells urine. She further said that when she helped Resident #5, he did not have his cushion on the chair or dressing on the wound. CNA A then said I did not get him up. I haven't had the time to get to him before. I've been laying people to bed and answering call lights. I have 22 residents under my care. CNA B got him up early today to shower him, I do not know what time she got him up, CNA B dressed him up and put him up on his geri-chair. She told me that Resident #5 did not have a dressing on his wound but I told her to report it to the Wound Care Nurse. Further interview at that time, the Wound Care Nurse B stated Nobody told me that Resident #5 did not have a dressing to his wound. When asked the Wound Care Nurse B about the foul odor and the non-blanchable deep red, maroon discoloration on the superior part of Resident #5's wound, she responded probably because he is being seated on the wound. In an interview on 10/12/2017 at 5:20 p.m. with CNA B, she stated that she was the Shower Tech and that she got up Resident #5 at around 6:00 a.m. or 7:00 a.m. It was early. She then said that when she got him up for shower, she noticed that he did not have a dressing to the open wound to his left buttocks and that she did not know if the dressing had fallen anytime during the night shift. CNA B continued saying I got him up, showered him, dressed him and got him up in his geri-chair and helped him go to the dining room. When asked if she placed any cushion or pressure reducing device on Resident #5's chair before he was seated on it, CNA B responded No, I did not know he needed a cushion. I did let CNA A know that Resident #5 needed a dressing to the wound to his left buttocks. When asked about facility's policy of notification when an open wound did not have a dressing, CNA B responded I was supposed to notify the charge nurse or Wound Care Nurse. When asked if she had checked on Resident #5 any time after she got him up, CNA B stated No, I haven't seen him anymore. He might have a dressing (to his wound) by now. In an interview on 10/12/2017 at 5:25 p.m. with the DON, she stated that charge nurses were supposed to make rounds to make sure residents were turned and repositioned and incontinent care was provided. DON then said that the ADON was supposed to follow up on the nurses to make sure they were making sure that residents were turned or repositioned when they were in bed or up in a chair and that incontinent care was provided as needed. Further interview at that moment, when asked if she had seen Resident #5's wound lately, the DON responded No, I have not seen his wound. Well, yes, I saw it on 9/29/2017. Resident #5 has a Stage 3 pressure sore to his buttocks. When asked about the facility protocol to turn or reposition residents in bed or in chair, the DON stated We encourage the CNA's to turn and reposition residents frequently, every 3 hours. When asked for residents who had Stage 3 pressure sores on their buttocks if it was acceptable to be up on their chair all day from 7:00 a.m. to 5:00 p.m. without being repositioned or incontinent care provided, the DON responded No, it is not acceptable to be up all day from 7:00 a.m. to 5:00 p.m. without being assisted to bed to offload the pressure sore. DON then said that she remembered seeing Resident #5 in the dining room during the day, but in different sites of the dining area and that she believed that he had been already taken care of. When asked DON if she believed having one CNA per hall was enough staffing to provide frequent incontinent care and frequent turning and repositioning of the residents, the DON said Yes, I have staff that had worked on the 200 hall and the other halls and they are able to do the work. Continued interview with the DON, when asked if she was aware that Resident #5 had been up all day in a geri-chair without a pressure reducing cushion on his chair, without a dressing to his Stage 3 pressure sore and without being provided incontinent care, the DON did not respond. At that moment, DON was asked to come to Resident #5's to observe the pressure sore. Observation and interview on 10/12/2017 at 5:30 p.m. inside Resident #5's room with the DON, the DON stated as she observed Resident #5's open wound to his left buttocks and reddened area to his left buttocks Resident #5's wound did not look like this before on 9/29/2017. This does not look like a Stage 3 pressure sore. When pointed the large dark reddened area to his left buttocks and the non-blanchable deep red, maroon discoloration around top part of the wound, the DON stated The CNA's know about the cushion. In an interview on 10/12/2017 at 5:46 p.m. with LVN C, she said she was the charge nurse for Resident #5 and that she was responsible that residents under her care were turned and repositioned as frequently as possible and then said It's kind of hard for the CNA's to do it. There is only 1 CNA per hallway. Each hallway has 22 to 24 residents. It's hard for them to do it. There are floating CNA's but they don't help the CNA's on the floor. The reddened area to Resident #5's left buttocks just blew me away. It's redness from pressure. Resident #5 is really non-verbal, there is only 1 CNA for all those patients, the patients really don't get the care they deserve. It's hard. The CNA's need to get residents up, assist with meals and call lights. It's hard. In an interview on 10/12/2017 at 5:50 p.m. with the ADON, she stated that she was responsible to make sure residents were turned and repositioned every 3 to 4 hours. ADON then said that residents who had pressure sores were supposed to be turned every 2 hours. She then said that the shower tech CNA's were supposed to help the CNA's on the floor on turning/repositioning and incontinent care to residents. ADON further said I know Resident #5 was up for a long time. I told CNA A at around 3:00 p.m. when I saw Resident #5 still in the dining room area, I asked her to help Resident #5 to his room, but CNA A was doing other things then I checked at around 5:00 p.m. and Resident #5 was no longer in the dining room. Record review of facility daily census summary dated 10/12/2017 revealed the following census per hall; 100 Hall 27 residents 1 CNA assigned 200 Hall 24 residents (Hall of Resident #5) 1 CNA assigned (CNA A) 300 Hall 25 residents / Skilled floor. 2 CNA's assigned 400 Hall 24 residents 1 CNA assigned Record review of Resident #5's Plan of Care initiated on 10/12/2017 revealed in part; -Focus: Resident #5 has bowel and bladder incontinence. -Interventions: Check as required for incontinence. -Focus: Resident #5 has limited physical mobility. -Interventions: Mobility: Is totally dependent on staff for locomotion. Record review of Resident #5's Skin/Wound notes dated 10/13/2017 at 6:21 p.m. signed by LVN A (former Wound Care Nurse) revealed in part; Stage 4 to the left buttock noted to have a foul odor and increase in slough. Wound debrided at bedside, removing all slough and dead tissue from wound bed and edges, increasing measurements. Ulcer has exposed ligament, muscle and subcutaneous tissue. Staff educated on proper turning techniques and importance of offloading wounds. Cushion noted for geri-chair and Resident #5 remains on air mattress. Med pass and health shakes added to diet . Record review of Resident #5's wound care MD evaluation revealed in part; -Date: 10/13/2017 Stage 4 pressure injury left buttocks. -Wound measurements: 4.5 x 5.5 x 4.0 c.m. (LxWxD) Area: 24.75 square centimeter. Cubic centimeters: 99 -Exudate (drainage): Moderate serous -Moist Yellow Slough: 76 - 100% -Wound progress: deteriorating -Exposed Ligament Necrosis: Yes -Exposed Muscle Necrosis: Yes -Exposed Adipose Necrosis: Yes Tissue and other material debrided: Ligament, Muscle, subcutaneous, Slough -Wound Orders: Cleanse/protect wound. Cleanse wound with Normal Saline. Apply Santyl, Alginate, cover wound with dry absorptive dressing. Change dressing daily. Additional orders: Pressure relief/Offloading. Off-load wound. Reposition per facility protocol. CR #1 Record review of the medical record face sheet revealed CR #1 was admitted on [DATE] and re-admitted on [DATE]. [DIAGNOSES REDACTED]. He was [AGE] years old. CR #1 was discharged from facility on 9/27/2017 due to [MEDICAL CONDITION] in right jugular neck vein. Record review of CR #1's Braden Scale for Predicting Pressure Sore Risk revealed in part; - 07/27/2017 revealed a score of 15 indicating Low risk to develop pressure sores. Record review of CR #1's MD orders revealed in part; -7/28/2017 Avoid positioning on sacrum when possible, alternate sides and offload sacrum and heels with pillows when in bed every shift for Stage 3 sacrum and right heel Deep Tissue Injury. -7/28/2017 Cleanse right heel with Normal Saline and apply skin prep daily every day shift for Deep Tissue Injury. Ensure heels are floating. -7/28/2017 Cleanse sacral wound with Normal Saline, pat dry, apply calcium alginate and a dry dressing daily every day for Stage 3 pressure sore. Record review of CR #1's Plan of Care initiated 7/28/2017 and revised 8/14/2017 revealed in part; -Focus: CR #1 has an ADL self care deficit related to decreased mobility and generalized weakness. -Interventions: Bed Mobility. Requires 1-2 (staff) assistance. Record review of CR #1's Skin Pressure Ulcer Weekly dated 7/28/2017 revealed in part; -Site: Sacrum (is a large, triangular bone at the base of the spine and at the upper, back part of the pelvic cavity, where it is inserted like a wedge between the two hip bones). Initial evaluation. -Stage 3 -Description: 25% slough -Size: 1.2x1.0x0.1 c.m. (LWD) -Exudate: Serous moderate -Surrounding tissue: Normal for skin -Odor: none -Site: Right heel. Initial evaluation. -Stage SDTI (Suspected Deep Tissue Injury) -Description: deep red/purple discoloration -Size: 5.0x6.0x0.0 c.m. (LWD) -Exudate: none -Surrounding tissue: Normal for skin -Odor: none Record review of CR #1's Braden Scale for Predicting Pressure Sore Risk revealed in part; - 08/01/2017 revealed a score of 14 indicating Moderate risk to develop pressure sores. Further record review of CR #1's Plan of Care initiated 8/03/2017 and revised 9/15/2017 revealed in part; -Focus: CR #1 has actual Stage 4 pressure ulcer to the sacrum with confirmed [DIAGNOSES REDACTED],[MEDICAL CONDITION] and psuedomonas related to decreased mobility. -Interventions with initiated date of 8/3/2017 * Avoid positioning on sacrum when possible, alternate sides and offload with pillows. Needs monitoring/reminding/assistance to turn/reposition at least every 2 hours, more often as needed or requested. * Air mattress as ordered. Initiated 8/14/2017 Record review of CR #1's wound care MD evaluation revealed in part; -Date: 8/04/2017 Stage 3 pressure ulcer Sacrum. Facility acquired: No. -Wound measurements: 1.5 x 1.0 x 0.2 c.m. (LxWxD) Area: 1.5 square centimeter. Cubic centimeters: 0.3 Wound margin: Flat and intact -Exudate (drainage): small serous -Wound progress: Initial exam -Surrounding skin: Normal for skin -Wound Orders: Cleanse/protect wound. Cleanse wound with Normal Saline. Apply Collagen, cover wound with dry absorptive dressing. Change dressing daily. Additional orders: Pressure relief/Offloading. Off-load wound. Reposition per facility protocol. -Date: 8/04/2017 Right heel. Deep Tissue Pressure Injury persistent non-blanchable deep red, maroon or purple descoloration. Facility acquired: No. -Wound measurements: 5.0 x 5.0 x 0.0 c.m. (LxWxD) Area: 25 square centimeter. Cubic centimeters: 0 -Exudate (drainage): none -Wound progress: Initial exam -Wound Orders: Skin prep and leave open to air daily. Float heels with pillows. Record review of CR #1's admission MDS assessment with 08/05/2017 ARD revealed that he had severe cognitive impairment with a BIMS score of 6 out of a possible 15. CR #1 required extensive assistance of two or more person physical assist for bed mobility, transfer and toilet use. He required extensive assistance of one person physical assist for walking, locomotion, eating and personal hygiene. He was always incontinent of bowel and bladder. Further record review revealed that CR #1 was at risk of developing pressure sores. He had one Stage 3 pressure ulcer that was present upon admission to the facility and one unstageable pressure ulcer with suspected deep tissue injury in evolution that was present upon admission to the facility. The dimensions of unhealed Stage 3 or 4 Pressure Ulcers or Eschar were 1.5x1.0x0.2 c.m. (LWD). Continued record review of the MDS section that read Skin and Ulcer Treatment revealed that CR #1 was not checked to be on a turning/repositioning program or on a pressure reducing device for chair or bed. Record review of CR #1's MD orders revealed in part; -8/09/2017 Air Mattress every shift for Stage 3 (pressure sore) sacrum. Record review of CR #1's Braden Scale for Predicting Pressure Sore Risk revealed in part; - 08/10/2017 revealed a score of 13 indicating Moderate risk to develop pressure sores. Record review of CR #1's wound care MD evaluation revealed in part; -Date: 8/11/2017 Stage 3 pressure ulcer Sacrum. Facility acquired: No. -Wound measurements: 2.0 x 1.0 x 0.2 c.m. (LxWxD) Area: 2 square centimeter. Cubic centimeters: 0.4 Wound margin: Flat and intact -Exudate (drainage): moderate serous -Wound progress: Initial exam -Surrounding Skin: Maceration -Wound Orders: Cleanse/protect wound. Cleanse wound with Normal Saline. Apply Alginate, cover wound with dry absorptive dressing. Change dressing daily. Additional orders: Pressure relief/Offloading. Off-load wound. Reposition per facility protocol. -Date: 8/11/2017 Right heel. Deep Tissue Pressure Injury persistent non-blanchable deep red, maroon or purple discoloration. Facility acquired: No. -Wound measurements: 5.0 x 5.0 x 0.0 c.m. (LxWxD) Area: 25 square centimeter. Cubic centimeters: 0 -Exudate (drainage): none -Wound progress: Improving -Wound Orders: Skin prep and leave open to air daily. Float heels with pillows. Record review of CR #1's wound care MD evaluation revealed in part; -Date: 8/18/2017 Stage 3 pressure ulcer Sacrum. Facility acquired: No. -Wound measurements: 2.0 x 1.2 x 0.2 c.m. (LxWxD) Area: 2.4 square centimeter. Cubic centimeters: 0.48 Wound margin: Flat and intact -Exudate (drainage): moderate serous -Wound progress: No change -Surrounding Skin: Maceration -Moist yellow slough: 1-25% -Wound Orders: Cleanse/protect wound. Cleanse wound with Normal Saline. Apply Algunate, cover wound with dry absorptive dressing. Change dressing daily. Additional orders: Pressure relief/Offloading. Off-load wound. Reposition per facility protocol. -Date: 8/18/2017 Right heel. Deep Tissue Pressure Injury persistent non-blanchable deep red, maroon or purple discoloration. Facility acquired: No. -Wound measurements: 5.0 x 5.0 x 0.0 c.m. (LxWxD) Area: 25 square centimeter. Cubic centimeters: 0 -Exudate (drainage): none -Wound progress: Improving -Wound Orders: Skin prep and leave open to air daily. Float heels with pillows. Record review of CR #1's nurses notes dated 08/21/2017 at 5:54 p.m. revealed in part CR #1 having [MEDICAL CONDITION] episode and unresponsive while in rehab. Orders to send to emergency room . Record review of CR #1's nurses notes dated 08/31/2017 at 5:24 p.m. revealed in part CR #1 arrived at facility. Bandage to sacrum area. CR #1 is resting in semi-fowler position . Record review of CR #1's Braden Scale for Predicting Pressure Sore Risk revealed in part; - 08/31/2017 revealed a score of 18 indicating Low risk to develop pressure sores. Record review of CR #1's Skin Evaluation Weekly assessment dated [DATE] and signed by RN A revealed in part; .CR #1 right heel with Stage 2 (pressure sore). 4x4.5x0.1 (c.m.) Cleaned with normal saline, puracol to wound, covered with dry dressing. Sacrum: Stage 4. 3x2.5x0.75 (c.m.) with slough noted. Santyl and dry dressing applied . Record review of CR #1's MD orders dated 9/1/2017 revealed in part; -Cleanse Stage 2 to the right heel with normal saline, pat dry. Apply puracol (Puracol is a primary wound dressing for all drainage types. It is highly absorbent material) and cover with a dry kerlix wrap daily every day. Ensure heels are floating. -Clean sacral wound with Normal Saline, apply Santyl to slough, cover with Calcium Alginate and dry dressing every day shift. Record review of CR #1's nurse notes dated 9/6/2017 at 8:00 p.m. revealed in part; - .CR #1 to be sent out to the hospital due to abnormal KUB abdomen Record review of CR #1's Transfer to Hospital form dated 9/6/2017 revealed under Skin/Wound Care Sacrum Stage 4, Right heel Stage 2. No measurements or description of wounds noted. Record review of CR #1's nurse notes dated 9/7/2017 at 2:30 a.m. revealed that CR #1 returned to facility. No skin assessments noted. Record review of CR #1's Braden Scale for Predicting Pressure Sore Risk revealed in part; - 09/07/2017 revealed a score of 15 indicating Low risk to develop pressure sores. Record review of CR #1's wound care MD evaluation revealed in part; -Date: 9/08/2017 Stage 4 pressure ulcer Sacrum. Facility acquired: No. -Wound measurements: 3.0 x 3.0 x 1.0 c.m. (LxWxD) Area: 9 square centimeter. Cubic centimeters: 9 -No tunneling or undermining Wound margin: Flat and intact -Exudate (drainage): moderate serous -Wound progress: deteriorating -Surrounding Skin: Maceration -Moist yellow slough: 1-25% -Exposed Ligament Necrosis: Yes -Exposed bone necrosis: Yes -Suspected [DIAGNOSES REDACTED]: Awaiting results. -Wound Orders: Cleanse/protect wound. Cleanse wound with Normal Saline. Apply Santyl ([MEDICATION NAME]), apply [MEDICATION NAME], apply Alginate, cover wound with dry absorptive dressing. Change dressing daily. Additional orders: Pressure relief/Offloading. Off-load wound. Reposition per facility protocol. -Plan of Care: Will submit bone fragments from sacral wound to the laboratory for culture for evaluation of osteo[DIAGNOSES REDACTED]. -Date: 9/08/2017 Right heel. Unstageable Pressure Injury Obscured full thickness skin and tissue loss. Facility acquired: No. -Wound measurements: 3.5 x 3.5 x 0.0 c.m. (LxWxD) Area: 12.25 square centimeter. Cubic centimeters: 0 -Exudate (drainage): moderate serous -Dry black eschar: 26 - 50% -Wound Orders: Apply Alginate, cover wound with dry absorptive dressing. Every day. Float heels with pillows. Record review of CR #1's Surgical Pathology report for collection dated 9/8/2017 and report dated 9/12/2017 revealed in part; [DIAGNOSES REDACTED]. Acute. Sacrum fragment of bone with acute osteomyelitits (bone infection). Record review of CR #1's Laboratory report for wound culture to Sacral wound collected on 9/9/2017 and printed on 9/13/2017 revealed results in part; .[MEDICAL CONDITION]. Rare growth . Further record review a hand written note [MEDICATION NAME] (antibiotic)1 gram every 12 hours for 6 weeks. Record review of CR #1's MD orders revealed in part; -9/13/2017 [MEDICATION NAME] (antibiotic) in [MEDICATION NAME] Solution 1 gram/200 ml. Use 1 gram intravenously every 12 hours for osteo (bone) of the sacral wound for 6 weeks. Record review of CR #1's nurse Skin/Wound note dated 9/15/2017 at 11:59 a.m. signed by LVN A revealed in part: .During weekly skin assessment, CR #1 was noted to have non blanchable deep maroon/red discoloration to the right distal lateral foot. MD with orders for daily skin prep and offloading. CR #1 wearing a protective boot to the right foot for a right heel wound. Boot adding pressure to foot, contributing to new wound. Boot discontinued per MD and foot offloaded on pillows . Record review of CR #1's MD orders and Plan of Care revealed no orders were found for boot to the right foot. Record review of CR #1's wound care MD evaluation revealed in part; -Date: 9/15/2017 Stage 4 pressure ulcer Sacrum. Facility acquired: No. -Wound measurements: 5.0 x 8.0 x 1.5 c.m. (LxWxD) Area: 40 square centimeter. Cubic centimeters: 60 -Undermining: Yes Starting Position (o'clock) 1 Ending Position (o'clock) 5 Maximum Distance: (c.m.) 1.5 -Wound margin: Flat and intact -Exudate (drainage): moderate serous -Wound progress: deteriorating -Surrounding Skin: Maceration -Moist yellow slough: 1-25% -Exposed Ligament Necrosis: Yes -Exposed bone necrosis: Yes -Suspected [DIAGNOSES REDACTED]: diagnosed Positive. -Wound Orders: Cleanse/protect wound(TRUNCATED)

Based on observation, interview and record review, the facility failed to be administered in a manner that enabled it to use its resources effectively to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident for three of eleven residents (Resident #5, CR #1 and Resident #6) reviewed for administration. The Interim Administrator, who was the abuse coordinator, failed to implement the facility's policies and procedures for the prohibition of neglect for Resident #5, CR #1 and Resident #6. The Interim Administrator failed to supervise the DON carried out her responsibilities in the areas of staff monitoring, to provide the appropriate treatment and implement preventive measures to avoid the worsening of pressure sores or the development of new pressure sores. The DON failed to provide sufficient staff to ensure resident care needs were met. These failures resulted in the identification of an Immediate Jeopardy (IJ) on 10/13/17. While the IJ was lowered on 10/14/17, the facility remained out of compliance at a scope of pattern and severity level of actual harm that was not IJ because all measures for prevention and treatment of [REDACTED]. These failures affected 2 current residents (Resident #5 and Resident #6) and 1 former resident (CR #1) and placed the other 15 resident with pressure sores at risk for developing new or worsening pressure ulcers which could lead [MEDICAL CONDITION], severe pain, hospitalization and even death. The findings include: TX 709/ Intake # 9, TX 319/ Intake # 2, TX 379/ Intake # 6, TX 457 / Intake # 2 and TX 875/ Intake # 8. In an interview on 10/13/2017 at 11:18 a.m. with the DON, she stated that staff had received training on turning and repositioning residents including prevention and treatment of [REDACTED]. DON said that charge nurses were responsible to monitor care but that the DON was responsible to make sure care was provided to the residents. When asked how did she think this incident of IJ came about, the DON stated The CNA (A) failed to follow protocol for turning and repositioning the residents, shower Tech (CNA B) got Resident #5 up and was responsible to follow up with the resident. CNA B told me that she forgot, but CNA A who was on the hall should had follow up. The charge nurse failed to follow up and the ADON failed to do her rounds. However, DON is responsible for the overall care. I was there. I gave verbal reminders to make rounds. I do not recall seeing Resident #5 on 3/12/2017. ADON was responsible to go inside of the rooms and make sure residents were repositioned. In an interview on 10/13/2017 at 11:58 a.m. with the Interim Administrator, she stated that she was new in the Corporation, new in the facility and that she was still trying to figure things out. She then said that she had been 2 weeks helping in the facility because the facility's Administration went on a Family Leave. Interim Administrator said that she was not aware that Resident #5's pressure sore was deteriorating, or that residents were not being turned and incontinent care provided timely. Interim Administrator continued saying I am still trying to get my feet wet and learning the facility and about the residents. I know that the facility had a Quality Assurance meeting, that ADL's are monitored thru a computer system and that the Administrator audits the ADL report done by the DON. I am still going thru training myself about operation of the facility. Resident #5 Record review of the medical record face sheet revealed Resident #5 was admitted on [DATE] and re-admitted on [DATE]. [DIAGNOSES REDACTED]. He was [AGE] years old. Record review of Resident #5's nurses notes dated 08/18/2017 at 7:15 p.m. revealed in part Resident #5 admitted to the facility. Incontinent of bowel and bladder. No wounds . Record review of Resident #5's Plan of Care initiated 08/25/2017 revealed in part: -Focus: Resident #5 has an ADL (Activity of Daily Living) Self Care Performance Deficit. -Interventions: Bed mobility: Requires (1-2) staff participation to reposition and turn in bed. Transfer: Requires 1-2 physical assistance with transferring. Further record review of Resident #5's Plan of Care revealed no interventions to prevent the development of pressure sores. Record review of Resident #5's admission MDS assessment with 08/28/2017 ARD revealed that he was rarely/never understood and was unable to complete the interview for Mental Status. Resident #5 required extensive assistance for his activities of daily living and he was total dependent for bathing. He had impairment on both sides of his lower extremities. He was always incontinent of bowel and bladder. Further record review revealed that Resident #5 was at risk of developing pressure sores and had no pressure sores during assessment. Further record review of the MDS section that read Skin and Ulcer Treatment revealed that Resident #5 was not checked to be on a turning/repositioning program or on a pressure reducing device for chair or bed. Record review of Resident #5's Braden Scale for Predicting Pressure Sore Risk revealed in part; - 08/29/2017 revealed a score of 14 indicating Moderate risk to develop pressure sores. Record review of Resident #5's nurses notes dated 9/17/2017 at 6:16 p.m. by LVN A (former Wound Care Nurse) revealed in part; Observed new Stage 3 pressure ulcer to the left buttocks which is 25% slough and 25% eschar tissue. Measurements: 3.5x3.0x0.2 (c.m.) (LWD) with moderate serous drainage. Air mattress ordered and orders placed to offload with pillows and turn frequently . Record review of Resident #5's Skin Pressure Ulcer Weekly dated 9/17/2017 revealed in part; -Site: Left buttock. Initial evaluation. -Stage 3 -Description: 25% slough, 25% eschar -Size: 3.5x3x0.2 c.m. (LWD) -Exudate: Serous moderate -Surrounding tissue: [DIAGNOSES REDACTED] -Odor: none Record review of Resident #5's consolidated MD orders revealed in part; -9/17/2017 Air mattress every shift for Stage 3 left buttocks -9/17/2017 Avoid positioning on left buttocks when possible, alternate sides and offload with pillows every shift for Stage 3 (pressure sore). -10/01/2017 [MEDICATION NAME] Acid tablet 500 mg by mouth two time a day for supplement. -10/01/2017 Multiple vitamins-minerals tablet, take one by mouth every day for supplement. -10/01/2017 Zinc Sulfate Capsule 220 mg, one by mouth one time a day for wound healing for 14 days. -10/06/2017 Clean left buttock with Normal Saline, pat dry, apply Santyl ([MEDICATION NAME] oitment) to slough followed by Calcium Alginate (dressing derived from seaweed, highly absorbent) and a dry dressing daily every day shift for Stage 4. Continued record review of Resident #5's Plan of Care initiated 09/17/2017 revealed in part: -Resident #5 has an actual Stage 4 pressure ulcer to the left buttock related to decreased mobility and incontinence. -Goal: Pressure ulcer will show signs of healing by target date 01/10/2018. -Interventions: Air mattress and frequent turns, avoid positioning on left buttocks when possible, alternate sides and offload with pillows. Record review of Resident #5's Braden Scale for Predicting Pressure Sore Risk revealed in part; - 09/18/2017 revealed a score of 11 indicating High risk to develop pressure sores. Record review of Resident #5's Skin Pressure Ulcer Weekly dated 9/22/2017 revealed in part; -Site: Left buttock. Follow up. -Stage 3 -Description: 25% eschar -Size: 3x3x0.2 c.m. (LWD) -Exudate: Serous moderate -Surrounding tissue: [DIAGNOSES REDACTED] -Odor: none Record review of Resident #5's wound care MD evaluation revealed in part; -Date: 9/29/2017 Stage 3 pressure ulcer left buttocks. Facility acquired on 9/18/2017. -Wound measurements: 3.5 x 4.5 x 0.0 c.m. (LxWxD) Area: 15.75 square centimeter. Cubic centimeters: 0 -Exudate (drainage): Moderate serous -Moist Yellow Slough: 76 - 100% -Wound progress: Initial exam -Wound Orders: Cleanse/protect wound. Cleanse wound with Normal Saline. Apply Alginate, cover wound with dry absorptive dressing. Change dressing daily. Additional orders: Pressure relief/Offloading. Off-load wound. Reposition per facility protocol. Record review of Resident #5's wound care MD evaluation revealed in part; -Date: 10/06/2017 Stage 4 pressure injury left buttocks. -Wound measurements: 3.0 x 4.5 x 2.0 c.m. (LxWxD) Area: 13.50 square centimeter. Cubic centimeters: 27 -Exudate (drainage): Moderate serous -Moist Yellow Slough: 76 - 100% -Wound progress: deteriorating -Exposed Muscle Necrosis: Yes -Exposed Adipose Necrosis: Yes Tissue and other material debrided: Muscle, subcutaneous, Slough -Wound Orders: Cleanse/protect wound. Cleanse wound with Normal Saline. Apply Santyl, Alginate, cover wound with dry absorptive dressing. Change dressing daily. Additional orders: Pressure relief/Offloading. Off-load wound. Reposition per facility protocol. Record review of Resident #5's nurses notes dated 10/6/2017 at 4:27 p.m. by LVN A revealed in part; Resident #5 is an [AGE] year old long term resident admitted on [DATE]. He was noted to have new Stage 3 pressure ulcer to the left buttock on 09/18/2017. Wound MD debrided the wound removing all slough, increasing the depth and revealing muscle and subcutaneous tissue. Wound upgraded to a Stage 4. Santyl ([MEDICATION NAME] ointment) resumed for slough along with Calcium Alginate dressing (dressing derived from seaweed, highly absorbent) daily. Air mattress and orders in place to offload with pillows and turn frequently . Observation on 10/12/2017 at 9:10 a.m. revealed that Resident #5 was not on his room. Observation on 10/12/2017 at 10:45 a.m. revealed that Resident #5 was in the dining room seated in a geri-chair. Further observation revealed that he did not have a pressure reducing device in his chair. Resident #5 appeared leaning to his left side when seated in his chair. In an interview on 10/12/2017 at 11:27 a.m. with Wound Care Nurse B, she stated that she was new in the position for wound care. She further said that Resident#5 was not in his room and that he probably was in the dining room area. In a confidential interview on 10/12/2017 at 12:05 p.m., the staff stated that there was only one CNA on the 100, 200 and 400 halls. The staff said that it was difficult to provide incontinent care or provide frequent care to all of the residents and further said we try, but it is hard. Observation on 10/12/2017 at 2:00 p.m. revealed that Resident #5 was still not in his room. Observation on 10/12/2017 at 4:00 p.m. revealed that Resident #5 was seated in a geri-chair in dining room area. Further observation revealed that he still did not have a pressure reducing device in his chair. Resident #5 appeared leaning to his left side when seated in his chair. Observation on 10/12/2017 at 5:00 p.m. revealed that Resident #5 was lying in his bed. There was a strong odor of urine in his room. During observation with Wound Care Nurse B and LVN C revealed that Resident #5's wound to his left buttocks was not protected with a dressing. Open wound was 4.0 c.m. in diameter and 2.0 c.m. in depth. The wound base was black and had a foul odor. The superior surrounding tissue of the wound had a non-blanchable deep red, maroon discoloration that measured 4.0 c.m. in length around top part of wound and 2.6 c.m. wide. There was a large dark reddened area covering most part of the left buttocks that measured 14 c.m. wide and 12 c.m. long. (measurements were taken by Wound Care Nurse B). The brief Resident #5's was wearing had small spots of red blood on it. Interview on 10/12/2017 at 5:05 p.m. with CNA A inside Resident #5's room, she stated that she had just assisted Resident #5 to bed at that time and that his brief was very wet that's why smells urine. She further said that when she helped Resident #5, he did not have his cushion on the chair or dressing on the wound. CNA A then said I did not get him up. I haven't had the time to get to him before. I've been laying people to bed and answering call lights. I have 22 residents under my care. CNA B got him up early today to shower him, I do not know what time she got him up, CNA B dressed him up and put him up on his geri-chair. She told me that Resident #5 did not have a dressing on his wound but I told her to report it to the Wound Care Nurse. Further interview at that time, the Wound Care Nurse B stated Nobody told me that Resident #5 did not have a dressing to his wound. When asked the Wound Care Nurse B about the foul odor and the non-blanchable deep red, maroon discoloration on the superior part of Resident #5's wound, she responded probably because he is being seated on the wound. In an interview on 10/12/2017 at 5:20 p.m. with CNA B, she stated that she was the Shower Tech and that she got up Resident #5 at around 6:00 a.m. or 7:00 a.m. It was early. She then said that when she got him up for shower, she noticed that he did not have a dressing to the open wound to his left buttocks and that she did not know if the dressing had fallen anytime during the night shift. CNA B continued saying I got him up, showered him, dressed him and got him up in his geri-chair and helped him go to the dining room. When asked if she placed any cushion or pressure reducing device on Resident #5's chair before he was seated on it, CNA B responded No, I did not know he needed a cushion. I did let CNA A know that Resident #5 needed a dressing to the wound to his left buttocks. When asked about facility's policy of notification when an open wound did not have a dressing, CNA B responded I was supposed to notify the charge nurse or Wound Care Nurse. When asked if she had checked on Resident #5 any time after she got him up, CNA B stated No, I haven't seen him anymore. He might have a dressing (to his wound) by now. In an interview on 10/12/2017 at 5:25 p.m. with the DON, she stated that charge nurses were supposed to make rounds to make sure residents were turned and repositioned and incontinent care was provided. DON then said that the ADON was supposed to follow up on the nurses to make sure they were making sure that residents were turned or repositioned when they were in bed or up in a chair and that incontinent care was provided as needed. Further interview at that moment, when asked if she had seen Resident #5's wound lately, the DON responded No, I have not seen his wound. Well, yes, I saw it on 9/29/2017. Resident #5 has a Stage 3 pressure sore to his buttocks. When asked about the facility protocol to turn or reposition residents in bed or in chair, the DON stated We encourage the CNA's to turn and reposition residents frequently, every 3 hours. When asked for residents who had Stage 3 pressure sores on their buttocks if it was acceptable to be up on their chair all day from 7:00 a.m. to 5:00 p.m. without being repositioned or incontinent care provided, the DON responded No, it is not acceptable to be up all day from 7:00 a.m. to 5:00 p.m. without being assisted to bed to offload the pressure sore. DON then said that she remembered seeing Resident #5 in the dining room during the day, but in different sites of the dining area and that she believed that he had been already taken care of. When asked DON if she believed having one CNA per hall was enough staffing to provide frequent incontinent care and frequent turning and repositioning of the residents, the DON said Yes, I have staff that had worked on the 200 hall and the other halls and they are able to do the work. Continued interview with the DON, when asked if she was aware that Resident #5 had been up all day in a geri-chair without a pressure reducing cushion on his chair, without a dressing to his Stage 3 pressure sore and without being provided incontinent care, the DON did not respond. At that moment, DON was asked to come to Resident #5's to observe the pressure sore. Observation and interview on 10/12/2017 at 5:30 p.m. inside Resident #5's room with the DON, the DON stated as she observed Resident #5's open wound to his left buttocks and reddened area to his left buttocks Resident #5's wound did not look like this before on 9/29/2017. This does not look like a Stage 3 pressure sore. When pointed the large dark reddened area to his left buttocks and the non-blanchable deep red, maroon discoloration around top part of the wound, the DON stated The CNA's know about the cushion. In an interview on 10/12/2017 at 5:46 p.m. with LVN C, she said she was the charge nurse for Resident #5 and that she was responsible that residents under her care were turned and repositioned as frequently as possible and then said It's kind of hard for the CNA's to do it. There is only 1 CNA per hallway. Each hallway has 22 to 24 residents. It's hard for them to do it. There are floating CNA's but they don't help the CNA's on the floor. The reddened area to Resident #5's left buttocks just blew me away. It's redness from pressure. Resident #5 is really non-verbal, there is only 1 CNA for all those patients, the patients really don't get the care they deserve. It's hard. The CNA's need to get residents up, assist with meals and call lights. It's hard. In an interview on 10/12/2017 at 5:50 p.m. with the ADON, she stated that she was responsible to make sure residents were turned and repositioned every 3 to 4 hours. ADON then said that residents who had pressure sores were supposed to be turned every 2 hours. She then said that the shower tech CNA's were supposed to help the CNA's on the floor on turning/repositioning and incontinent care to residents. ADON further said I know Resident #5 was up for a long time. I told CNA A at around 3:00 p.m. when I saw Resident #5 still in the dining room area, I asked her to help Resident #5 to his room, but CNA A was doing other things then I checked at around 5:00 p.m. and Resident #5 was no longer in the dining room. Record review of facility daily census summary dated 10/12/2017 revealed the following census per hall; 100 Hall 27 residents 1 CNA assigned 200 Hall 24 residents (Hall of Resident #5) 1 CNA assigned (CNA A) 300 Hall 25 residents / Skilled floor. 2 CNA's assigned 400 Hall 24 residents 1 CNA assigned Record review of Resident #5's Plan of Care initiated on 10/12/2017 revealed in part; -Focus: Resident #5 has bowel and bladder incontinence. -Interventions: Check as required for incontinence. -Focus: Resident #5 has limited physical mobility. -Interventions: Mobility: Is totally dependent on staff for locomotion. Record review of Resident #5's Skin/Wound notes dated 10/13/2017 at 6:21 p.m. signed by LVN A (former Wound Care Nurse) revealed in part; Stage 4 to the left buttock noted to have a foul odor and increase in slough. Wound debrided at bedside, removing all slough and dead tissue from wound bed and edges, increasing measurements. Ulcer has exposed ligament, muscle and subcutaneous tissue. Staff educated on proper turning techniques and importance of offloading wounds. Cushion noted for geri-chair and Resident #5 remains on air mattress. Med pass and health shakes added to diet . Record review of Resident #5's wound care MD evaluation revealed in part; -Date: 10/13/2017 Stage 4 pressure injury left buttocks. -Wound measurements: 4.5 x 5.5 x 4.0 c.m. (LxWxD) Area: 24.75 square centimeter. Cubic centimeters: 99 -Exudate (drainage): Moderate serous -Moist Yellow Slough: 76 - 100% -Wound progress: deteriorating -Exposed Ligament Necrosis: Yes -Exposed Muscle Necrosis: Yes -Exposed Adipose Necrosis: Yes Tissue and other material debrided: Ligament, Muscle, subcutaneous, Slough -Wound Orders: Cleanse/protect wound. Cleanse wound with Normal Saline. Apply Santyl, Alginate, cover wound with dry absorptive dressing. Change dressing daily. Additional orders: Pressure relief/Offloading. Off-load wound. Reposition per facility protocol. CR #1 Record review of the medical record face sheet revealed CR #1 was admitted on [DATE] and re-admitted on [DATE]. [DIAGNOSES REDACTED]. He was [AGE] years old. CR #1 was discharged from facility on 9/27/2017 due to [MEDICAL CONDITION] in right jugular neck vein. Record review of CR #1's Braden Scale for Predicting Pressure Sore Risk revealed in part; - 07/27/2017 revealed a score of 15 indicating Low risk to develop pressure sores. Record review of CR #1's MD orders revealed in part; -7/28/2017 Avoid positioning on sacrum when possible, alternate sides and offload sacrum and heels with pillows when in bed every shift for Stage 3 sacrum and right heel Deep Tissue Injury. -7/28/2017 Cleanse right heel with Normal Saline and apply skin prep daily every day shift for Deep Tissue Injury. Ensure heels are floating. -7/28/2017 Cleanse sacral wound with Normal Saline, pat dry, apply calcium alginate and a dry dressing daily every day for Stage 3 pressure sore. Record review of CR #1's Plan of Care initiated 7/28/2017 and revised 8/14/2017 revealed in part; -Focus: CR #1 has an ADL self care deficit related to decreased mobility and generalized weakness. -Interventions: Bed Mobility. Requires 1-2 (staff) assistance. Record review of CR #1's Skin Pressure Ulcer Weekly dated 7/28/2017 revealed in part; -Site: Sacrum (is a large, triangular bone at the base of the spine and at the upper, back part of the pelvic cavity, where it is inserted like a wedge between the two hip bones). Initial evaluation. -Stage 3 -Description: 25% slough -Size: 1.2x1.0x0.1 c.m. (LWD) -Exudate: Serous moderate -Surrounding tissue: Normal for skin -Odor: none -Site: Right heel. Initial evaluation. -Stage SDTI (Suspected Deep Tissue Injury) -Description: deep red/purple discoloration -Size: 5.0x6.0x0.0 c.m. (LWD) -Exudate: none -Surrounding tissue: Normal for skin -Odor: none Record review of CR #1's Braden Scale for Predicting Pressure Sore Risk revealed in part; - 08/01/2017 revealed a score of 14 indicating Moderate risk to develop pressure sores. Further record review of CR #1's Plan of Care initiated 8/03/2017 and revised 9/15/2017 revealed in part; -Focus: CR #1 has actual Stage 4 pressure ulcer to the sacrum with confirmed [DIAGNOSES REDACTED],[MEDICAL CONDITION] and psuedomonas related to decreased mobility. -Interventions with initiated date of 8/3/2017 * Avoid positioning on sacrum when possible, alternate sides and offload with pillows. Needs monitoring/reminding/assistance to turn/reposition at least every 2 hours, more often as needed or requested. * Air mattress as ordered. Initiated 8/14/2017 Record review of CR #1's wound care MD evaluation revealed in part; -Date: 8/04/2017 Stage 3 pressure ulcer Sacrum. Facility acquired: No. -Wound measurements: 1.5 x 1.0 x 0.2 c.m. (LxWxD) Area: 1.5 square centimeter. Cubic centimeters: 0.3 Wound margin: Flat and intact -Exudate (drainage): small serous -Wound progress: Initial exam -Surrounding skin: Normal for skin -Wound Orders: Cleanse/protect wound. Cleanse wound with Normal Saline. Apply Collagen, cover wound with dry absorptive dressing. Change dressing daily. Additional orders: Pressure relief/Offloading. Off-load wound. Reposition per facility protocol. -Date: 8/04/2017 Right heel. Deep Tissue Pressure Injury persistent non-blanchable deep red, maroon or purple descoloration. Facility acquired: No. -Wound measurements: 5.0 x 5.0 x 0.0 c.m. (LxWxD) Area: 25 square centimeter. Cubic centimeters: 0 -Exudate (drainage): none -Wound progress: Initial exam -Wound Orders: Skin prep and leave open to air daily. Float heels with pillows. Record review of CR #1's admission MDS assessment with 08/05/2017 ARD revealed that he had severe cognitive impairment with a BIMS score of 6 out of a possible 15. CR #1 required extensive assistance of two or more person physical assist for bed mobility, transfer and toilet use. He required extensive assistance of one person physical assist for walking, locomotion, eating and personal hygiene. He was always incontinent of bowel and bladder. Further record review revealed that CR #1 was at risk of developing pressure sores. He had one Stage 3 pressure ulcer that was present upon admission to the facility and one unstageable pressure ulcer with suspected deep tissue injury in evolution that was present upon admission to the facility. The dimensions of unhealed Stage 3 or 4 Pressure Ulcers or Eschar were 1.5x1.0x0.2 c.m. (LWD). Continued record review of the MDS section that read Skin and Ulcer Treatment revealed that CR #1 was not checked to be on a turning/repositioning program or on a pressure reducing device for chair or bed. Record review of CR #1's MD orders revealed in part; -8/09/2017 Air Mattress every shift for Stage 3 (pressure sore) sacrum. Record review of CR #1's Braden Scale for Predicting Pressure Sore Risk revealed in part; - 08/10/2017 revealed a score of 13 indicating Moderate risk to develop pressure sores. Record review of CR #1's wound care MD evaluation revealed in part; -Date: 8/11/2017 Stage 3 pressure ulcer Sacrum. Facility acquired: No. -Wound measurements: 2.0 x 1.0 x 0.2 c.m. (LxWxD) Area: 2 square centimeter. Cubic centimeters: 0.4 Wound margin: Flat and intact -Exudate (drainage): moderate serous -Wound progress: Initial exam -Surrounding Skin: Maceration -Wound Orders: Cleanse/protect wound. Cleanse wound with Normal Saline. Apply Alginate, cover wound with dry absorptive dressing. Change dressing daily. Additional orders: Pressure relief/Offloading. Off-load wound. Reposition per facility protocol. -Date: 8/11/2017 Right heel. Deep Tissue Pressure Injury persistent non-blanchable deep red, maroon or purple discoloration. Facility acquired: No. -Wound measurements: 5.0 x 5.0 x 0.0 c.m. (LxWxD) Area: 25 square centimeter. Cubic centimeters: 0 -Exudate (drainage): none -Wound progress: Improving -Wound Orders: Skin prep and leave open to air daily. Float heels with pillows. Record review of CR #1's wound care MD evaluation revealed in part; -Date: 8/18/2017 Stage 3 pressure ulcer Sacrum. Facility acquired: No. -Wound measurements: 2.0 x 1.2 x 0.2 c.m. (LxWxD) Area: 2.4 square centimeter. Cubic centimeters: 0.48 Wound margin: Flat and intact -Exudate (drainage): moderate serous -Wound progress: No change -Surrounding Skin: Maceration -Moist yellow slough: 1-25% -Wound Orders: Cleanse/protect wound. Cleanse wound with Normal Saline. Apply Algunate, cover wound with dry absorptive dressing. Change dressing daily. Additional orders: Pressure relief/Offloading. Off-load wound. Reposition per facility protocol. -Date: 8/18/2017 Right heel. Deep Tissue Pressure Injury persistent non-blanchable deep red, maroon or purple discoloration. Facility acquired: No. -Wound measurements: 5.0 x 5.0 x 0.0 c.m. (LxWxD) Area: 25 square centimeter. Cubic centimeters: 0 -Exudate (drainage): none -Wound progress: Improving -Wound Orders: Skin prep and leave open to air daily. Float heels with pillows. Record review of CR #1's nurses notes dated 08/21/2017 at 5:54 p.m. revealed in part CR #1 having [MEDICAL CONDITION] episode and unresponsive while in rehab. Orders to send to emergency room . Record review of CR #1's nurses notes dated 08/31/2017 at 5:24 p.m. revealed in part CR #1 arrived at facility. Bandage to sacrum area. CR #1 is resting in semi-fowler position . Record review of CR #1's Braden Scale for Predicting Pressure Sore Risk revealed in part; - 08/31/2017 revealed a score of 18 indicating Low risk to develop pressure sores. Record review of CR #1's Skin Evaluation Weekly assessment dated [DATE] and signed by RN A revealed in part; .CR #1 right heel with Stage 2 (pressure sore). 4x4.5x0.1 (c.m.) Cleaned with normal saline, puracol to wound, covered with dry dressing. Sacrum: Stage 4. 3x2.5x0.75 (c.m.) with slough noted. Santyl and dry dressing applied . Record review of CR #1's MD orders dated 9/1/2017 revealed in part; -Cleanse Stage 2 to the right heel with normal saline, pat dry. Apply puracol (Puracol is a primary wound dressing for all drainage types. It is highly absorbent material) and cover with a dry kerlix wrap daily every day. Ensure heels are floating. -Clean sacral wound with Normal Saline, apply Santyl to slough, cover with Calcium Alginate and dry dressing every day shift. Record review of CR #1's nurse notes dated 9/6/2017 at 8:00 p.m. revealed in part; - .CR #1 to be sent out to the hospital due to abnormal KUB abdomen Record review of CR #1's Transfer to Hospital form dated 9/6/2017 revealed under Skin/Wound Care Sacrum Stage 4, Right heel Stage 2. No measurements or description of wounds noted. Record review of CR #1's nurse notes dated 9/7/2017 at 2:30 a.m. revealed that CR #1 returned to facility. No skin assessments noted. Record review of CR #1's Braden Scale for Predicting Pressure Sore Risk revealed in part; - 09/07/2017 revealed a score of 15 indicating Low risk to develop pressure sores. Record review of CR #1's wound care MD evaluation revealed in part; -Date: 9/08/2017 Stage 4 pressure ulcer Sacrum. Facility acquired: No. -Wound measurements: 3.0 x 3.0 x 1.0 c.m. (LxWxD) Area: 9 square centimeter. Cubic centimeters: 9 -No tunneling or undermining Wound margin: Flat and intact -Exudate (drainage): moderate serous -Wound progress: deteriorating -Surrounding Skin: Maceration -Moist yellow slough: 1-25% -Exposed Ligament Necrosis: Yes -Exposed bone necrosis: Yes -Suspected [DIAGNOSES REDACTED]: Awaiting results. -Wound Orders: Cleanse/protect wound. Cleanse wound with Normal Saline. Apply Santyl ([MEDICATION NAME]), apply [MEDICATION NAME], apply Alginate, cover wound with dry absorptive dressing. Change dressing daily. Additional orders: Pressure relief/Offloading. Off-load wound. Reposition per facility protocol. -Plan of Care: Will submit bone fragments from sacral wound to the laboratory for culture for evaluation of osteo[DIAGNOSES REDACTED]. -Date: 9/08/2017 Right heel. Unstageable Pressure Injury Obscured full thickness skin and tissue loss. Facility acquired: No. -Wound measurements: 3.5 x 3.5 x 0.0 c.m. (LxWxD) Area: 12.25 square centimeter. Cubic centimeters: 0 -Exudate (drainage): moderate serous -Dry black eschar: 26 - 50% -Wound Orders: Apply Alginate, cover wound with dry absorptive dressing. Every day. Float heels with pillows. Record review of CR #1's Surgical Pathology report for collection dated 9/8/2017 and report dated 9/12/2017 revealed in part; [DIAGNOSES REDACTED]. Acute. Sacrum fragment of bone with acute osteomyelitits (bone infection). Record review of CR #1's Laboratory report for wound culture to Sacral wound collected on 9/9/2017 and printed on 9/13/2017 revealed results in part; .[MEDICAL CONDITION] Resistant Staphylococ(TRUNCATED)

Based on observation, record review and interview the facility failed to ensure 1 of 20 residents (Residents # 31) reviewed for services provided for limited range of motion, received appropriate treatment and services to increase range of motion or prevent further decrease in range of motion. Resident # 31 was not provided with physical therapy, restorative services or assistive devices to prevent the decline of range of motion to the right lower extremities. This failure affected 1 resident and placed 12 residents with contractures at risk of their range of motion decreasing. Findings include: Resident # 31 Record review of Resident # 31's face sheet revealed he admitted to the facility on [DATE] and had the following diagnoses; subdural hemorrhage, spinal stenosis, muscle weakness, ataxic, high cholesterol, hypertension and dementia. He was [AGE] years old. Observation of Resident # 31 receiving wound care on 7/31/2013 at 10:00 AM revealed both knees at a 90 degree angle when the covers were pulled down. The resident had a healing pressure sore on his right inner heel. He had a protective boot on his right foot that when removed the foot was resting near the resident ' s buttocks. The foot had to be held away from the body by the CNA assisting with the care when the wound care nurse was completing the care. Observation of Resident # 31 receiving incontinent care on 7/31/2013 at 11:00 AM was conducted. Resident # 31 was observed with both knees contracted, his legs drawn up with his heels near his buttocks in a fetal position. The CNA assisting with the care had to hold the residents legs to keep his feet away from the incontinent care. The resident ' s knees were not observed to be straightened out during the care. Record review of Resident # 31's physical therapy discharge summary for dates of service 10/12/2011-12/9/2011 revealed he was ambulating 100 plus feet with moderate to maximum assistace. Record review of Resident # 31's physician follow up note dated 2/21/2103 read in part, "...ROM knees limited... ROM hips limited... Plan notes: ... physical therapy, occupational therapy..." Record review of Resident # 31's clinical record revealed no documentation that therapy was working with Resident # 31 from 1/2013 through 7/31/2013. Record review of Resident # 31's physician progress notes [REDACTED]. Range of motion hips is limited ... " Record review of Resident # 31's quarterly MDS dated [DATE] revealed he had short and long term memory deficits, required extensive assistance of two persons for bed mobility and was totally dependent with dressing, transfers, toileting and grooming. Continued review of the MDS revealed under ROM limitation, there was no impairment for either of his lower legs. Record review of Resident # 31's plan of care, last review date of 5/31/13, revealed no care plan that addressed range of motion for lower extremities or prevention of lower extremity contractures. Record review of Resident # 31's incident/accident report dated 6/9/13 revealed the resident was found on the floor next to his bed and sent to the hospital. Record review of Resident # 31's hospital discharge record revealed he returned to the facility on [DATE]. Record review of Resident # 31's Monthly Summary dated 6/20/13 under contractures, "none" was checked. Record review of Resident # 31's nurses note dated 6/25/13 at 11:00 AM read in part, " ...noted RLE (right lower extremity) drawn up towards body, difficult to extend RLE ... Referred resident to therapy for possible contracter (sic) management ... " Record review of Resident # 31's July 2013 monthly physician orders [REDACTED]." Record review of Resident # 31's computerized ADL sheet with a start date of July 1, 2013 revealed no documented range of motion for month of July 2013. Record review of Interdisciplinary Therapy Screen dated 8/1/2013 for Resident # 31 read in part, "...Increase or new onset of contractures... decline in lower extremity strength..." Continue review read hand written note which read, "R (right) knee 95 degree extension lag. L (left) knee lacking 20 degree to full knee extension..." An interview was conducted with RN A and LVN C on 8/1/ at 12:40 PM. When they were asked about the resident's contractures RNA A said the resident was starting to be contracted in his hands and right leg was just starting to become contracted. When they were asked if his quarterly MDS assessment dated [DATE] should have identified that the resident had impairment in his range of motion to the lower extremities RN A said, it should be now but not when the assessment was done. She further stated the resident had a fall in June and the contractures started after the fall. In an interview with the DON with the Administrator present on 8/1/2013 AT 1:15 pm she was asked how long Resident # 31 had been in the Geri chair she said possibly a month but not as long as a year. When asked about the contractures she said it had been a while since the resident had upper and lower extremity contractures. She further stated the contracture occurred prior to June 2013. At that time she was told it was not coded on the MDS assessment. In an interview on 8/1/13 at 2:45 PM, LVN E stated she had noticed Resident # 31's lower extremity contractures in June. She stated she referred the resident to therapy for the contractures. In an interview on 8/1/13 at 3:00 PM, the Rehab Manager stated Resident # 31 had been referred to her for contracture management after the residents fall in May or June 2013, but she had missed doing the screen. She stated the last time physical therapy had worked with Resident # 31 (in 2011) he was walking. She stated therapy was screening him today. When asked if the contracture could have been a result of the fall, she stated she did not think so. When asked what could have caused the contracture, she stated lack of activity and being moved. In an interview on 8/1/13 at 3:10 PM, PT A stated she screened Resident # 31 for his contractures on 8/1/13. She stated the resident ' s right knee was lacking about 95 degree extension and the left knee lacked about 20 degrees. She stated she planned to work with the resident using a knee splint to the right knee and stretching to the left knee. When asked if it would be typical to see a contracture of this nature to develop since May 2013, she stated that it was not typical, but she did not know the history of the resident. In an interview on 8/1/13 at 3:40 PM, CNA A stated the contractures to Resident # 31's legs started after his fall in June 2013. She stated his legs started to draw up after the fall, and it was difficult to perform his care due to this. She stated prior it was not difficult to do his care. She stated she would try to move his leg, but it didn ' t move far. When asked if she had let anyone know, she stated she had let the nurses know, but could not be sure of which nurse. In an interview on 8/1/13 at 4:05 PM with the DON and administrator, the DON was asked what interventions had been in place to prevent decreased ROM to Resident # 31's lower extremities. She stated a geri-chair was used, pillows and ROM during care was performed. When asked for documentation of ROM performed for July 2013, she stated it was not documented because there was a new computer system. When asked why therapy did not screen the resident before today, she stated she could not say. When asked if there was a medical cause for the contractures, she stated maybe the spinal stenosis which could affect the right side cause him to be more rigid on that side. When asked if the resident was receiving restorative care, she stated no. The administrator stated it had been brought up a few times in the facility meeting for therapy to screen the resident, and it was the rehab manager who was responsible to make sure that it was carried out. In an interview on 8/1/13 at 4:55 PM, the Rehab Manager stated she messed up on Resident # 31 and should have screened him earlier. Record review of the facility's policy and procedure Range of Motion (ROM) Splints, Braces, Orthotics dated January 2011 read in part, "...Residents identified as a risk for contractures will have a ROM program a minimum of 6 days/week... The ROM included the programs provide to prevent contractures and keep joints as limber as possible... Purpose. To maintain a resident ' ability to move a joint through its normal range of movement and perform activities of daily living (ADL). To prevent pain, discomfort, swelling and stiffness when joint movement is limited or contracted. To prevent contractures and to provide comfort and support for a joint and prevent pain in an already deformed/contracted, weak joint ... Procedure. Range of Motion (ROM) - Passive... 3. Report problems or noted changes immediately to the designated nurse..." According to CMS 672 there were 13 residents in the facility with contractures.

Based on interview and record review, the facility failed to ensure that residents were safe during transfers in the shower room for one of six sampled residents (Resident # 1) who received showers. The facility also failed to identify the risks for subsequent accidents and injuries to residents being transferred. Resident # 1 fell on [DATE] while she was being transferred from her geri-chair to the shower chair by CNA D. The resident received a hematoma (localized swelling filled with blood) to her left forehead and bruise to her left upper arm. Resident # 1 was sent to the hospital and was returned to the facility, after a 7 day hospitalization stay, on 5/04/11. These failures caused one resident harm and placed 56 residents needing staff assistance with transfers at risk for injury from unsafe transfers that could potentially result in the need for hospitalization . Findings include: Complaint # 2 Incident # 8 A review of Resident # 1's medical records was conducted. The face sheet revealed that the original admission was 5/30/08 with a readmission date of [DATE] after her hospitalization . Resident #1's [DIAGNOSES REDACTED]. The MDS dated [DATE] revealed Resident # 1 had severe cognitive impairment. The ADL section revealed that the resident was totally dependent on the staff for bed mobility and transfers with a 2 person physical assist. No contractures to the resident's lower extremities were documented. Resident # 1's care plan was reviewed by the nursing facility on 3/30/11. The resident needed maximum assist with ADLS and Transfers. Resident # 1 was to have assistance with all transfers at all times. A gait belt was to be used with all transfers. Resident # 1 was at risk for falls related to weakness. The resident ' s environment was to be kept free of clutter and wet spots. A review of Resident # 1's May 2011 ADL Flow Record revealed that she had been transferred with only one person on May 5 - 6, 2011. Review of the 4/29/11 Incident/Accident Report on Resident # 1 was conducted. RN H had written that "on entering the shower room, the res was lying on her left side /c 2 towels under her head & a hematoma noted to left forehead. CNA stated that during the transfer her foot slipped & she held onto the res & both went down /c res falling on top of CNA. On her way down res hit her head on edge of whirlpool tub. Nurse in room & assessing res. Res assisted by 2 staff members into gerichair". A review of the 4/29/11 post fall Interdisciplinary Therapy Screen for Resident # 1 was conducted. The document noted that the "Resident should be transferred at all times by 2 CNAs". A review of the Comprehensive Nursing Evaluation for the 5/04/11 admission of Resident # 1 after her hospitalization revealed that the resident had "contractures to R(right) & L(left) legs". A review of Resident # 1's nursing notes on 4/29/11 revealed that after Resident # 1 was placed in the geri-chair and cold compresses continued to be applied. The resident was taken back to her room and placed in bed. Resident # 1's daughter and the doctor were notified. At 5:00 pm Resident # 1 was sent by private ambulance to the hospital. A review of the hospital ER doctor's notes revealed that Resident # 1 had a left frontal hematoma and swollen left upper eyelid. Review of the Resident # 1's hospital history and physical revealed that a CAT scan of the head done on 4/29/11 revealed a left frontal hematoma and a possible 4 mm subdural intracerebral hemorrhage. Resident # 1 was discharged back to the facility on [DATE]. A review of CNA D's employee file revealed that the CNA had been hired on 01/31/11. No skills check-off for transfers was done. She worked the 2 pm to 10 pm shift. A review of the Incident/Accident log for April 2011 was conducted. Seventeen of the 19 falls recorded for the month occurred on the 2 pm to 10 pm shift. A review of inservices revealed that on 4/28/11 an inservice on gait belts and transfers was conducted. The signatures revealed that CNA D had attended. A notation on this inservice training report revealed that one was "never assume that a res is one-one transfer". No other inservices on transfers and gait belts were conducted after the 4/29/11 event. Another inservice on transfers and gait belt use was conducted on 5/05/2011 after the surveyor asked about training. On 5/05/2011 at 9:00 am the ADM told the surveyor that an investigation of this incident and a report to the Texas Department of Aging and Disability Services was now being done. This was after surveyor entered on 5/04/11. An interview with LVN C was conducted on 5/05/11 at 1:00 pm. When asked, LVN C stated that on 4/28/2011 no return demonstration of transfers by the CNAs was done, including CNA D. LVN C stated that the skills check-off in orientation was hand washing, mouth care and perineal/incontinent care/foley catheter care of male and female residents. No transfer skills were checked. An interview with LVN B was conducted on 5/06/11 at 3:00 pm. She stated that a housekeeping staff had heard screams for help from the shower room. LVN B stated that someone, unknown to her, had seen the resident on top of CNA D. When LVN B was called to the shower room, LVN A was assessing Resident # 1 and taking her vital signs before the resident was moved. LVN B stated that Resident # 1 was not clothed and a hematoma was seen on the resident ' s left forehead. LVN B stated that she then took care of CNA D, who was sitting in a chair. CNA D told LVN B that there was " too much water on the floor " and she swept the water off the floor. CNA D then stated that she " took a misstep " . CNA D stated that she had hurt her leg, had hit the steel rack and a steel table as she fell . CNA D left the facility after this event. An interview by phone was attempted with CNA D on 5/06/11 at 9:00 am. CNA D had been injured in the fall on 4/29/11 and had not returned to work. Both phone numbers listed in her employee file were no longer in service. An interview was conducted with CNA E on 5/06/11 at 3:30 pm. This CNA stated that in the past, the CNA had helped CNA D with Residents #1, # 2, and #3 on 3 different occasions. Each time the resident was on the floor after CNA D tried to transfer them. CNA E stated that the charge nurse had been told. A review of the incident/accident log for February, March and April 2011 was conducted. No incidents were recorded for Residents #1, # 2 and # 3 except for the 4/29/11 incident with Resident # 1. An interview with the ADM and DON was conducted on 5/06/11 at 4:00 pm. Both stated that the staff had been told to report all incidents and to fill out an incident/accident report. According to the CMS form 672 there were 57 residents needing one or two staff assistance with transfers.