Every finding on record at Fieser Nursing Center

Based on interview and record review, the facility failed to electronically submit to the Centers for Medicare and Medicaid Services (CMS) complete and accurate direct care staffing information no less frequently than quarterly, for three quarters preceding the annual survey. The census was 38. Review of the fiscal years Payroll Based Journal (PBJ) staffing report, showed the facility triggered for failing to submit data for:-Fiscal year quarter 1, 2025 (October 1 to December 31);-Fiscal year quarter 2, 2025 (January 1 to March 31);-Fiscal year quarter 3, 2025 (April 1 through June 30). During an interview on 9/25/25 at 10:18 A.M., the Administrator said she has not been able to log in to the account to submit the PBJ. The account kept saying it was the incorrect password. The help desk would send a new password, but she still was not able to get in. The PBJs are supposed to be submitted quarterly. The Administrator no longer has an account to submit PBJs.

Based on interview and record review, the facility failed to ensure their facility assessment was reviewed and updated as necessary and at least annually. The census was 38.Review of the facility's Facility Assessment policy, revised 9/18/17, showed:-Requirement: Nursing facilities will conduct, document and annually review a facility-wide assessment, which includes both their resident population and the resources the facility needs to care for their residents;-Purpose: The purpose of the assessment is to determine what resources are necessary to care for residents competently during both day-to-day operations and emergencies. This assessment is used to make decisions about direct care staff needs, as well as the facility's capabilities to provide services to the residents in the facility;-Guidelines for Conducting the Assessment includes:-The facility will review and update this assessment annually or whenever there is/the facility plans for any change that would require a modification to any part of this assessment. Review of the facility's Facility Assessment Tool, dated 1/4/24, showed:-Persons involved in completion of assessment included: -Registered Nurse (RN) G listed as Director of Nurses (DON); -Licensed Practical Nurse (LPN) H listed as Assistant Director of Nurses (ADON); -Physician J listed as Medical Director; -LPN I listed as Infection Preventionist;-Date(s) of assessment or update: 1/4/24;-Date(s) assessment reviewed with quality assessment and assurance (QAA)/quality assurance performance improvement (QAPI) committee: Blank;-Resident Profile: -Indicate the number of residents you are licensed to provide care for: Our community is licensed for 60 beds. During an interview on 9/29/25 at 1:01 P.M., the Administrator said Physician J has not been the facility's Medical Director in over a year. LPN H has not been the ADON for over a year and LPN I has not been the Infection Preventionist in about a year. RN G has not been the DON for months. On 9/1/25, the facility changed their bed count from 60 to 47 beds. The facility assessment should be updated once a year and as needed. She has not met with the involved parties to review and revise the facility assessment this year.

Based on interview and record review, the facility failed to ensure Certified Nursing Assistants (CNA) received a minimum of 12 hours of ongoing education annually for three out of three sampled CNAs (CNA D, CNA C and Certified Medication Technician (CMT) E). The census was 38.Review of the facility's Required In-service Training for Nurse Aides, dated, 1/16/25, showed-Intent: It is the policy of the facility to provide a staff education plan in accordance with state and federal regulations;-Procedure: Required in-service training for nurse aides will: -Be sufficient to ensure the continuing competence of nurse aides, but must be no less than 12 hours per year; -Include dementia management training and resident abused prevention training; -Address areas of weakness as determined in nurse aides' performance review and facility assessment and may address the special needs of residents as determined by the facility staff; -For nurse aides providing services to individuals with cognitive impairments, also address the care of the cognitively impaired.Review of the list of CNA's and CMT's that have worked more than one year at the facility showed only three employees. 1. Review of CNA D's, employee file, showed:-Hire date: 11/23/23;-CNA hours of training completed: six. 2. Review of CNA C's employee file, showed:-Hire date: 1/3/24;-CNA hours of training completed: seven. 3. Review of CMT E's employee file, showed:-Hire Date: 6/12/24;-CNA hours of training completed: two. 4. During an interview on 9/26/25 at approximately 11:00 A.M., the Director of Nursing (DON) said she was not aware the CNAs required 12 hours of training. It is her responsibility, along with the Assistant Director of Nursing (ADON), to provide the education to the CNAs. 5. During an interview on 9/30/25 at 10:51 A.M., the Administrator said she expected the CNA staff to complete the 12 hours of annual training.

Based on observation, interview and record review, the facility failed to follow acceptable infection control standards by not implementing Enhanced Barrier Precautions (EBP, an infection control intervention designed to reduce the transmission of multidrug-resistant organisms (MDROs) that employs targeted gown and glove use during high contact resident care activities) as recommended by the Centers for Disease Control and Prevention (CDC) and required by the Centers for Medicare and Medicaid Services (CMS) and use good infection control practices while providing wound treatments on two residents (Resident #15 and Resident #5). The sample was 12. The census was 38. Review of the facility's Clean Dressing Change policy, dated 1/16/25, showed:-Intent: It is the policy of the facility to change dressing in accordance with state and federal regulations. -Procedure: -Verify and review physician's orders for procedure; -Perform hand hygiene and assemble equipment and supplies for dressing change; -Put on gloves and clean the bedside stand or table with germicidal disposable cloth; Establish a clean field; -Remove gloves and perform hand hygiene; -Set up supplies on barrier; -Position the resident for comfort; -Put on clean gloves; -Remove dressing; -Remove gloves and perform hand hygiene; -Put on clean gloves; -Cleanse wound with gauze and prescribed cleaning solution; -Use a dry gauze to pat the wound dry; -Remove gloves and perform hand hygiene. Review of the CDC recommendations for EBP, show:-Every staff member must clean their hands before entering and leaving the room;-Providers and staff must also wear gloves and gown for the following high contact resident care activities: -Dressing; -Bathing or showering; -Changing linens; -Providing hygiene; -Changing briefs or assisting with toilet care; -Wound care: Any skin opening requiring a dressing. 1. Review of Resident #15's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 9/15/25, showed:-Resident rarely understood or able to understand;-Dependent on staffing for personal hygiene, toilet hygiene and mobility in bed. -Diagnoses included non-Alzheimer's dementia, malnutrition, depression and anxiety; -The resident is at risk for developing pressure ulcer. Review of the resident's care plan, in use at the time of survey, showed:-Problem: The resident has a pressure wound to his/her buttocks measuring 3 centimeters (cm) by 4 cm;-Approach: Cleanse and dry affected area to right buttock; apply Medihoney (an ointment used to remove dead tissue) to the wound bed and cover with dry dressing daily and as needed (PRN);-The care plan did not address EBP. Review of the resident's Physician Order Sheets (POS), dated 9/25/25, showed an order, dated 8/20/25, cleanse and dry affected area to right buttock; apply Medihoney to the wound bed and cover with dry dressing daily and PRN. During observation and interview on 9/26/25 at approximately 9:00 A.M., Licensed Practical Nurse (LPN) F prepared the treatment at the medication cart. LPN F said he/she couldn't log into the computer to look at the treatment order but thought the treatment was cleanse the right buttock with saline and apply a calcium alginate (a specialized dressing) dressing and cover with a dry dressing. LPN F opened a package of small gauze dressings and removed the gauze with ungloved hands and placed it back into the package. LPN F then removed a pair of bandage scissors out of his/her uniform pocket and cut the calcium alginate dressing and placed the scissors back into his/her uniform pocket. The outside of the resident's room showed no EBP sign. LPN F entered the room with treatment supplies and laid the opened dressings directly on the resident's nightstand with no barrier. The resident lay in bed and LPN F positioned the resident to his/her right side. There was no dressing present to the resident's right buttock. The resident's buttock had a dime sized superficial open area with a pink and moist wound bed with no drainage or odor. LPN F said the resident's right buttock wound was a Stage II pressure wound. LPN F performed hand hygiene and applied clean gloves. LPN F placed the calcium alginate on the resident's wound and said the piece of calcium alginate that he/she cut was too big. LPN F then removed his/her bandage scissors out of his/her uniform shirt pocket and cut the piece of calcium alginate to a smaller size and applied the calcium alginate to the resident's right buttock pressure wound. LPN F then covered the resident's right buttock pressure wound with a border gauze (a specialized dressing). LPN F did not clean the bandage scissors prior to cutting the calcium alginate. LPN F did not use a clean barrier to place clean supplies on. LPN F did not use EBP while providing direct care. LPN F did not provide the correctly ordered treatment. 2.Review of Resident #5's quarterly MDS, dated [DATE], showed:-Cognitively intact.-Diagnoses included cancer and diabetes;-One Stage III pressure ulcer (full thickness skin loss in which subcutaneous (under the skin) fat is exposed and may contain non-viable tissue). Review of the resident's care plan, in use at the time of survey, showed:-Problem: Pressure ulcer: The resident is at risk for infection related to chronic (long term) process, impaired mobility, and impaired skin integrity as evidenced by chronic wounds and repeated infections.-The care plan did not address EBP. Review of the resident's POS, dated 9/25/25, showed an order, dated 6/16/25, wound to coccyx (tailbone), cleans with normal saline, apply Santyl (an ointment that removes dead tissue) and Gentamycin (antibiotic) ointment to wound bed, cut calcium alginate to fit wound bed and cover with dry dressing) daily and PRN. Observation on 9/29/25 at 9:02 A.M., showed LPN B gathered the treatment supplies off of the medicine cart and entered the resident's room. The resident's room did not have an EBP sign on the door. The resident lay in bed. Certified Nursing Assistants (CNA) C and D entered the resident's room. CNA C and D assisted the resident in bed by turning the resident side to side and removed the resident's brief. The resident was positioned to his/her left side by CNA D. LPN B placed the treatment supplies and a pair of office paper scissors directly on the resident's bed, without a barrier. LPN B removed the dressing, dated 9/28/25, from the resident's coccyx. A very small, approximately one half of an inch, wound was present to the resident's coccyx. The resident's coccyx wound appeared macerated (wrinkled and softened skin from prolonged moisture) and had a pin hole opening. LPN B performed hand hygiene and changed his/her gloves. LPN B opened a package of small gauze and placed the gauze on top of a peanut butter jar located on the resident's nightstand. LPN B then removed the gauze from the top of peanut butter jar and soaked the gauze with normal saline and cleansed the resident's coccyx wound. LPN B removed another piece of small gauze off the top of the peanut butter jar and dried the resident's coccyx wound. LPN B performed hand hygiene and changed his/her gloves. LPN applied the Santyl and Gentamycin to the resident's coccyx wound. LPN B cut the calcium alginate with the same scissors that were laying directly on the resident's bed. LPN B placed the cut calcium alginate dressing on the resident's wound and covered the wound with a border gauze. LPN B did not utilize a clean barrier to lay the treatment supplies on. LPN B did not clean the scissors prior to cutting the calcium alginate dressing. LPN B, CNA C, and CNA D did not wear isolation gowns while providing direct care to the resident. During an interview on 9/30/25 at 8:20 A.M., Certified Medication Technician (CMT) A said he/she did not know what EBPs were or when they are utilized during resident care. During an interview on 9/30/25 at 8:29 A.M., CNA C said he/she did not know what EBPs were or when they are utilized during resident care. During an interview on 9/30/25 at 8:45 A.M., LPN B said she didn't think there were any type of clean barriers available to use for treatments. LPN B said he/she would normally not clean the treatment scissors prior to use because the nurse who used them before LPN B should have cleaned them. LPN B did not know what EBPs were and when they needed to be used. 3. During an interview on 9/30/25 at 8:00 A.M., the Assistant Director of Nursing (ADON) said she is also the facility Infection Preventionist (IP) and said she was aware of the EBP and when they need to be used. The facility has not implemented EBP with resident care. There is no policy for the EBP. She expected staff to use a disposable barrier pad or a clean towel to lay any treatment supplies on. She expected staff to use bandage scissors and clean them with disinfectant wipes before use. She expected staff to use good infection control practices when providing the residents their treatments. 4. During an interview on 9/30/25 at 10:51 A.M., the Administrator said she was familiar with EBP and expected the facility to implement them during resident care and use good infection control practices when providing the residents their treatments.

Based on interview and record review, the facility failed to ensure quality assessment and assurance (QAA) meetings consisted of the required committee members when the Medical Director failed to attend the facility's QAA meetings. The census was 38.Review of the facility's Quality Assurance Performance Improvement (QAPI) Program policy, dated 1/7/25, showed:-Guiding Values or Principles: The written QAPI plan for the facility will identify and address areas that need improvement in order to ensure the best quality of life for the people in our community;-QAA Committee and oversight of QAPI in our Community:-The Administrator, all department managers, Medical Director, consulting pharmacist, residents, family members or responsible parties, and at least three general staff members (one from each department);-Reporting on QAPI Activities:-The Administrator will discuss our QAPI activities at the quarterly QAA meeting that consists of all the department managers, Medical Director, pharmacy consultant, resident, general staff, etc. During an interview on 9/25/25 at 10:34 A.M., the Assistant Director of Nurses (ADON) and Administrator said QAA meetings are held quarterly. The Medical Director does not attend the QAA meetings. In the QAA meetings, the department heads identify system-wide issues and ways to address them. After the meetings take place, the ADON discusses the QAA meetings with the Medical Director. The Medical Director should be attending the QAA meetings.

Based on interview and record review, the facility failed to document a discharge summary that included a recapitulation of stay, final summary of resident's status at the time of discharge, and reconciliation of medications for one resident sampled for discharges (Resident #38). The sample was 12. The census was 38.Review of the facility's Discharge Summary policy, undated, showed:-Intent: It is the policy of the facility to assure that a discharge summary is completed in accordance to State and Federal requirements;-Procedure:--When the facility anticipates discharge, a resident must have a discharge summary that includes, but is not limited to, the following:-a. A post-discharge plan of care that is developed with the participation of the resident and, with the resident's consent, the resident representative(s), which will assist the resident to adjust to his or her new living environment;--When the facility anticipates discharge, a resident must have a discharge summary that includes, but is not limited to, the following: -a. A recapitulation of the resident's stay that includes, but is not limited to, diagnoses, course of illness/treatment or therapy, and pertinent lab, radiology, and consultation results; -b. A final summary of the resident's status at the time of the discharge that is available for release to authorized persons and agencies, with the consent of the resident or resident's representative; -c. Reconciliation of all pre-discharge medications with the resident's post-discharge medications. Review of the resident's medical record, showed:-admission date 7/7/25;-Diagnoses included dementia with agitation, depression, fracture of unspecified part of neck of left femur (thigh bone), hypertension (high blood pressure), heart failure, mixed hyperlipidemia (high cholesterol), hypoxemia (low levels of oxygen in the blood), sciatica (nerve pain), and unspecified abdominal pain. Review of the resident's progress notes, dated 8/18/25, showed:-On 7/7/25, staff documented the resident admitted to the facility. Resident alert and oriented times two. Resident speaks Bosnian and understands no English. Resident representative in attendance when admitted ;-On 7/18/25, the Social Services Director (SSD) documented assessment review completed. Resident is to remain long term in this facility. Resident and/or representative does not need to be asked about discharging to the community, or only ask on compressive assessments;-On 8/18/25 at 11:23 A.M., the SSD documented the resident discharged home with family today;-On 8/18/25 at 11:44 A.M., Licensed Practical Nurse (LPN) A documented resident discharged home with family today. Belongings were taken by family. All medication was sent with responsible party. Review of the resident's Discharge/Release form, signed 8/18/25, showed:-Date of discharge: [DATE];-Location of discharge and physician documented;-Brief explanation to support this action: Discharge home with spouse and caregiver;-Signed by resident representative and Social Services Director. Review of the resident's medical record, showed:-No recapitulation of the resident's stay;-No final summary of the resident's status at the time of discharge, including nursing assessments;-No reconciliation of the resident's pre-discharge medications with his/her post-discharge medications. During an interview on 9/29/25 at 2:33 P.M., the SSD said the resident was admitted to the facility for long-term care. His/Her spouse kept getting depressed and felt bad about the resident being in a nursing home. The resident's responsible party came to the facility on a Friday and said the resident's spouse was having a hard time and wanted the resident to come home. The family wanted to take the weekend to think about it. The next week, the resident's representative and spouse came to the facility and said they were bringing the resident home. The SSD offered home health and the family declined and left with the resident. The SSD does not think a physician order is required to discharge a resident. When a resident is discharged , the nurse writes a note in the resident's medical record, assesses the resident and gives the resident their medications. During an interview on 9/30/25 at 8:28 A.M., the Assistant Director of Nurses (ADON) said the resident was supposed to be there long-term. She was not aware of any discussion about the resident's discharge. The resident's family showed up one day and said they were taking the resident home. When a resident is discharged , the nurse should obtain a physician order for discharge and to discharge with or without medications. The nurse should obtain a set of vital signs upon discharge and provide the resident with their medications, physician orders, contact information, and ancillaries. The nurse should document a discharge summary in the resident's medical record. During an interview on 9/30/25 at 10:20 A.M., the Administrator said she expects staff to document a resident's discharge plans in their medical record. Staff should document an assessment of the resident upon discharge and a summary of the resident's stay. Documentation should include what the resident left with, their medications and physician orders.

Based on interview and record review, the facility failed to complete a Level I Preadmission Screening and Resident Review (PASARR, a federally required screening for all applicants to a Medicaid-certified nursing facility to help ensure individuals who have a mental disorder or intellectual disabilities are not inappropriately placed in nursing homes for long-term care) for one of two residents sampled for PASARR review (Resident #4). The sample was 12. The census was 38.Review of the facility's Coordination and PASARR Program policy, dated 1/16/25, showed:-Intent: It is the policy of the facility to assure that all residents admitted to the facility receive a PASARR in accordance with State and Federal regulations;-Procedure included:-Preadmission screening for individuals with a mental disorder and individuals with intellectual disability. The facility will not admit, on or after January 1, 1989, any new residents with mental disorder, unless the State mental health authority has determined, based on an independent physical and mental evaluation performed by a person or entity other than the State mental health authority, prior to admission. Review of Resident #4's medical record, showed:-admission date 11/16/21;-Diagnoses included bipolar disorder and anxiety disorder;-No Level I PASARR screening documented. During an interview on 9/26/25 at 9:24 A.M., the Social Services Director (SSD) said a Level I PASARR screening was not completed for the resident because the resident's stay at the facility is private pay. All beds in the facility are Medicaid-certified. The SSD did not know a Level I PASARR screening must be completed on all residents in Medicaid-certified beds, regardless of the resident's payor source. During an interview on 9/26/25 at 9:29 A.M., the Administrator said a Level I PASARR screening is required for all residents admitted to the facility because all beds in the facility are Medicaid-certified.

Based on interview and record review, the facility failed to ensure residents' care plans were updated routinely and accurately reflected residents' code status orders. Do Not Resuscitate (DNR) orders were not accurately reflected in four of 22 sampled residents' care plans (Residents #20, #25, #7 and #37). The census was 38.Review of the facility's Comprehensive Resident Centered Care Plans Policy, revised 1/26/25, showed:-The facility must develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights set forth by state and federal regulation, including measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs identified in the comprehensive assessment;-The resident will have the right to participate in the development and implementation of his or her person-centered care plan, including by not limited to: participation in the planning process, the right to participate in establishing goals and outcomes of care, and the right to receive or deny services included in the plan of care;-Care plans are modified between care plan conferences when appropriate to meet the resident's current needs, problems, and goals;-The care plan will be updated or revised for the following reasons: significant change in condition, a change in planned interventions, new diagnoses, new medications, or abnormal labs. 1. Review of Resident #20's medical record, showed:-Diagnoses included history of cerebral infarction (stroke, an occlusion of one or more blood vessels in the brain), dysphagia (difficulty swallowing), history of seizures, functional incontinence, and metabolic encephalopathy (a condition where the brain does not receive enough oxygen or nutrients, leading to changes in brain function);-A copy of the resident's active DNR order, signed by the resident and physician on 8/27/25. Review of the resident's physician orders at the time of survey, showed an order for Do Not Resuscitate status placed by the physician on 8/27/25. Review of the resident's care plan, in use at the time of survey, showed a focus regarding the resident's active code status, which is listed as full code, and interventions including reviewing the resident's code status quarterly for accuracy. 2. Review of Resident #25's medical record, showed:-Diagnoses included acute cystitis (an inflammation in the bowel, typically caused by bacterial infection, metabolic encephalopathy, acute respiratory failure with hypoxia (a condition where the body's lungs cannot adequately provide oxygen to the tissues, leading to low levels of oxygen in the blood), and unspecified hallucinations (sensory experiences that occur in the absence of external stimuli).-A copy of the resident's active DNR order, signed by the resident on 6/30/25 and by the physician on 7/2/25. Review of the resident's physician orders at the time of survey showed an order for Do Not Resuscitate status placed by the physician on 6/30/25. Review of the resident's care plan, in use at the time of survey, showed no focus regarding the resident's DNR status or section of the care plan addressed the resident's code status. 3. Review of Resident #7's medical record, showed:-Diagnoses included Alzheimer's Disease (a progressive brain disorder that slowly destroys memory, thinking skills, and the ability to carry out everyday tasks), acute pressure ulcer of the left foot (a skin wound resulting from prolonged, unrelieved pressure on the skin, causing tissue damage and loss due to impaired blood flow), and xerotis cutis (a condition characterized by abnormally dry and itchy skin).-A copy of the resident's active DNR order, signed by the resident on 4/9/24. Review of the resident's physician orders at the time of survey, showed an order for Do Not Resuscitate status placed by the physician on 8/18/25. Review of the resident's care plan, in use at the time of survey, showed a focus regarding the resident's active code status, which was listed as full code, and interventions including reviewing the resident's code status quarterly for accuracy. 4. Review of Resident #37's medical record, showed:-Diagnoses included vascular dementia (a type of cognitive decline caused by damage to the blood vessels in the brain), history of falls, generalized muscle weakness, and metabolic encephalopathy.-A copy of the resident's active DNR order, signed by the resident on 7/7/25 and by the physician on 7/9/25. Review of the resident's physician orders at the time of survey, showed an order for Do Not Resuscitate status placed by the physician on 7/7/25. Review of the resident's care plan, in use at the time of survey, showed no focus regarding the resident's DNR status or section of the care plan addressed the resident's code status. 5. During an interview on 9/30/25 at 8:45 A.M., Certified Medication Technician (CMT) A said the facility Minimum Data Set (MDS, a federally mandated assessment instrument completed by facility staff) Coordinator is responsible for creating, revising, and updating resident care plans at the facility. Care plans should include information specific to the resident including care needs, transferring status, wounds, and code status information. Care plans should be updated quarterly and are important because they help drive resident-centered care and inform staff of the resident's care needs. 6. During an interview on 9/30/25 at 8:49 A.M., Certified Nursing Aide (CNA) C said the facility MDS Coordinator and Social Services Coordinator are responsible for developing and updating care plans for residents at the facility. Care plans should include resident-specific care needs such as transferring status, toileting status, dietary needs, and the resident's code status information. Updating care plans routinely is important as care needs including transferring status and code status information can often change over the duration of a resident's admission. 7. During interview on 9/30/25 at 8:52 A.M., Licensed Practical Nurse (LPN) B said the MDS Coordinator and Social Services Coordinator are responsible for developing and updating care plans for residents at the facility. Care plans should include care needs, transfer status, and code status. It is important for code statuses to be accurately reflected in the resident's care plan as all code status information in the resident's record should match in each part of the record. LPN B was aware of the active DNR orders for Residents #20, #25, #7 and #37, and in the event of an emergency staff are instructed to check the facility's dedicated binder containing physical copies of each resident's code status order. 8. During an interview on 9/30/25 at 10:29 A.M., the Director of Nursing (DON) and Administrator said the MDS Coordinator is responsible for developing and updating care plans for the residents. Each resident's care plan should be updated quarterly and should include care needs, transfer status, dietary preferences, frequent behaviors, and the resident's code status. In the event that a code status change occurs, the resident's care plan should be updated to reflect the change given the order is signed and valid. The Administrator said Residents #20, #25, and #7 recently had changes made to their code statuses within the last couple of months. The Administrator expected their care plans to be updated as soon as the validity of the DNR order was confirmed.

Based on interview and record review, the facility failed to ensure residents are free from chemical restraints imposed for purposes of discipline or convenience by not limiting one resident's as needed (PRN) psychotropic (a medication used to treat mental and emotional disorders) to 14 days (Resident #40). The sample was 12. The census was 38. Review of the facility's Pharmacy Services- Drug Regimen Free from Unnecessary Drugs policy, dated 1/16/25, showed:-Intent: The intent of this policy is each resident's entire drug medication regimen is managed and to promote or maintain the residents highest practicable mental, physical, and psychosocial well-being; The facility implements PRN orders for psychotropic medications are used when the medication is necessary and PRN use is limited;-Procedure: PRN orders for psychotropic drugs are limited to 14 days. Review of the facility's Psychotropic Management policy, dated 1/16/25, showed:-Policy statement: The facility will monitor use of psychotropic medications by residents to reduce its effects and achieve their highest practicable level of functioning;-Interpretation and Implementation: -A psychotropic drug is any drug that affects brain activities, associated processes and behavior; These drugs include but are not limited to: Anti-psychotics (medication used to treat mood disorders); Antidepressants; Anti-anxiety; and Hypnotics (medications used to promote sleep); -Staff will monitor for any new behaviors, or ongoing behaviors; -Non-pharmacological interventions will be attempted to reduce behaviors; -If PRN psychotropic medications is prescribed the order will be limited to 14 day or less; To write a new order after 14 days the physician must evaluate the resident to determine if that PRN order is necessary. Review of Resident #40's care plan, in use at the time of survey, showed;-Focus: The resident is on hospice;-Interventions: Administer drugs for palliation (managing symptoms and providing relief to serious medical conditions). Review of the resident's medical record, showed diagnosis that include generalized anxiety. Review of the resident's Physician Order Sheet (POS) dated September 2025, showed;-An order, dated 4/21/25, Haloperidol (medication used to treat restlessness, agitation, and anxiety) 2 milligrams (mg) per one milliliter (ml); Administered 0.5 mls every 2 hours PRN for generalized anxiety. -No stop date for the resident's PRN Haloperidol. Review of the resident's Medication Administration Record (MAR), dated 8/1 through 8/31/25 showed:-An order, dated 4/21/25, Haloperidol 2 mg per one ml; Administered 0.5 mls every 2 hours PRN for generalized anxiety;-On 8/4/25 at 6:56 P.M., Haloperidol was documented as administered. Review of the resident's MAR, dated 9/1 through 9/29/25 showed:-An order, dated 4/21/25, Haloperidol 2 mg per one ml; Administered 0.5 mls every 2 hours PRN for generalized anxiety;-On 9/29/25 at 6:48 A.M., Haloperidol was documented as administered. During an interview on 9/26/25 at 2:50 P.M., Licensed Practical Nurse (LPN) F said the resident has episodes of anxiety and hallucinations at times. The staff will try to check on him/her more frequently and ensure his/her needs are met. The resident does not take the PRN Haloperidol. The resident usually refuses the PRN Haloperidol and it should be discontinued. During an interview on 9/30/25 at 8:00 A.M., the Director of Nurses (DON) and the Assistant Director of Nursing (ADON) said the resident is on hospice and the hospice nurse wrote the orders. They have not been tracking use of psychotropic medications on the residents. The ADON said she was aware that PRN psychotropic medications are expected to have a 14 day stop date and a reassessment needs to be completed to determine if the resident needs the medication. The ADON and DON said they do not expect floor nursing staff to monitor stop dates on psychotropic medications. They expected the pharmacist to make a recommendation related to PRN psychotropic medications. During an interview on 9/30/25 at 10:51 A.M., the Administrator said she expected a stop date on PRN psychotropic medications. A reassessment is expected to be completed to determine if the resident requires an extension of the medication. Wright, [NAME] (42795) - RESIDENT NOTE No Notes

Based on observation, interview, and record review, the facility failed to ensure reports with respect to surveys, certifications and complaint investigations conducted during the preceding three years were available for review by residents, family members and legal representatives of residents. The census was 38.Review of the facility's list of resident rights, undated, showed the right to be fully informed of state survey reports. Observations on four out of four days of survey, showed no reports with respect to surveys, certifications and complaints available for review. There was no notice posted regarding availability of survey results. During a group interview on 9/29/25 at 1:30 P.M., four out of four residents, whom the facility identified as alert and oriented, said they did not know they had the right to review survey results. They would like to be able to review survey results. During an interview on 9/29/25 at 1:16 P.M., the Social Services Director (SSD) said she did not know if survey results were available anywhere for people to review. During an interview on 9/29/25 at 2:51 P.M., the Administrator said she has a binder in her office that used to contain survey results and was out in a common area for people to review, but people used to take things out of it. Survey results should be available for residents and family members to review. Going forward, she will be responsible for ensuring this is done.

Based on observation, interview and record review, the facility failed to ensure residents were assessed to self-administer medications and physician orders were maintained for self-administration of medication for one resident observed with medications left at bedside (Resident #41). The sample was 12. The census was 38.Review of Resident #41's medical record, showed diagnoses included asthma-chronic obstructive pulmonary disease (COPD, lung disease) overlap syndrome (symptoms of both asthma and COPD) and heart failure. Review of the resident's physician order summary (POS), showed:-An order, dated 8/16/25, for albuterol sulfate hydrofluoroalkane (HFA) aerosol inhaler (medication used to treat asthma); 90 microgram (mcg)/actuation (release of a single dose); inhale two puffs by mouth three times a day;-An order, dated 8/16/25, for Incruse Ellipta (umeclidinium, medication used to treat COPD) blister with device; 62.5 mcg/actuation; one puff inhalation; inhale one puff once daily;-An order, dated 9/18/25, for Breo Ellipta (fluticasone furoate-vilanterol, medication used to treat asthma or COPD) blister with device; 100-25 mcg/dose; one puff inhalation; once a day;-An order, dated 9/18/25, for Spiriva with HandiHaler (tiotropium bromide, medication used to treat COPD) capsule with inhalation device; 18 mcg; one cap inhalation; once a day;-An order, dated 8/16/25, discontinued on 9/18/25, for Symbicort (budesonide-formoterol, medication used to treat COPD) HFA aerosol inhaler; 80-4.5 mcg/actuation; two puff inhalation; inhale two puffs by mouth two times a day;-No physician orders for the resident to self-administer the inhaler medications or to keep the medications at bedside. Review of the resident's care plan, in use at the time of survey, showed no documentation related to the resident's use of inhalers, ability to self-administer medications, or ability to keep medications at bedside. Observation on 9/25/25 at 12:54 P.M., showed three inhalers on the resident's bedside table, including Incruse Ellipta, albuterol sulfate HFA, and Symbicort. During an interview, the resident said he/she is able to keep his/her inhalers in his/her room and administer them him/herself. He/She does not need staff assistance or monitoring for inhaler use. Observation on 9/29/25 at 2:24 P.M., showed the resident not in his/her room. An Incruse Ellipta inhaler and albuterol sulfate HFA inhaler on his/her bedside table, in plain view. Observation on 9/30/25 at 9:01 A.M., showed the resident's Incruse Ellipta inhaler and albuterol sulfate HFA inhaler on his/her bedside table. During an interview on 9/30/25 at 9:03 A.M., Certified Medication Technician (CMT) A said the resident keeps his/her inhalers in his/her room. He/She went to the hospital recently and came back with the inhalers and said he/she was going to keep them at bedside. The resident wants to keep the inhalers in his/her room for a sense of independence. He/She can administer his/her inhalers without supervision. Physician orders must be obtained for residents to be able to self-administer their medications and keep them at bedside. Nurses are responsible for obtaining physician orders. During the interview, CMT A reviewed the resident's physician orders for inhalers and said none of the inhalers have orders for the resident to self-administer or keep at bedside. During an interview on 9/30/25 at 9:19 A.M., Licensed Practical Nurse (LPN) B said the resident can administer his/her inhalers and keep them at bedside. He/She has to have physician orders for this. Nurses do not assess residents for their ability to safely and appropriately use their inhalers. The physician is the only person responsible for monitoring self-administration of medication. During an interview on 9/30/25 at 8:50 A.M., the Director of Nurses (DON) said physician orders must be obtained for a resident to be able to self-administer their own medications and keep them at bedside. If a resident has physician orders to self-administer their inhalers, the DON would want to see a demonstration to know they can follow physician orders to administer at the correct times and to use the inhaler properly, including swishing their mouth after using certain inhalers. During an interview on 9/30/25 at 9:25 A.M., the Assistant Director of Nurses (ADON), Director of Nurses (DON) and Administrator said the resident is alert and oriented. He/She has physician orders to self-administer some of his/her other medications, such as creams. During the interview, the DON reviewed the resident's medical record and confirmed there were no physician orders for the resident to self-administer his/her inhalers.

Based on observation, interview and record review, the facility failed to ensure one resident with a pressure wound (skin or soft tissue injury that develops with prolonged periods of pressure over specific areas of the body) received necessary treatments and services to promote healing (Resident #15). The sample size was 12. The census was 38. Review of the facility's Treatment and Services to Prevent and Heal Pressure Ulcers policy, undated, showed:Intent: It is the policy of the facility to ensure it identifies and provides needed care and services that are resident centered, in accordance with the resident's preference, goals for care and professional standards of practice that will meet each resident's physician, mental, and psychosocial needs; -Procedure: The facility will ensure that based on the comprehensive assessment of a resident with pressure ulcers receives necessary treatment and services, consistent, with professional standards of practice, to promote healing, prevent infection, and prevent new ulcers from developing; The pressure sore will be evaluated weekly and the nurse will document the size, location, odor (if any), drainage (if any), and current treatment ordered. Review of Resident #15's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 9/15/25, showed:-The resident is rarely understood or able to understand;-Dependent on staffing for personal hygiene, toilet hygiene and mobility in bed;-Diagnoses included non-Alzheimer's dementia; malnutrition (inadequate nutrition), depression and anxiety; -The resident is at risk for developing pressure ulcer. Review of the resident's care plan, in use at the time of survey, showed:-Problem: The resident has a pressure wound to his/her buttocks measuring 3 centimeters (cm) by 4 cm;-Approach: Cleanse and dry affected area to right buttock; Apply Medihoney (an ointment used to remove dead tissue) to the wound bed and cover with dry dressing daily and as needed (PRN). Review of the resident's Physician Order Sheet (POS), dated 9/25/25, showed;-An order, dated 8/20/25, Cleanse and dry affected area to right buttock; Apply Medihoney to the wound bed and cover with dry dressing daily and PRN;-The order did not reflect what product is to be used to clean the wound. Review of the resident's progress notes, dated 9/23/25 at 2:56 A.M., showed the right buttock wound measured 2 cm by 2.5 cm, treatment done as ordered. During observation and interview on 9/26/25 at approximately 9:00 A.M., Licensed Practical Nurse (LPN) F prepared the treatment at the medication cart. LPN F said he/she couldn't log into the computer to look at the treatment order but thought the treatment was cleanse the right buttock with normal saline (sterile salt water) and apply a calcium alginate (a specialized dressing) dressing and cover with a dry dressing. With ungloved hands, LPN F opened a package of small gauze dressings and removed the gauze and placed it back into the package. LPN F then removed a pair of bandage scissors out of his/her pocket and cut the calcium alginate dressing into a small square piece. LPN F entered the room with treatment supplies and laid the opened dressings directly on the resident's nightstand with no barrier. The resident lay in bed and LPN F positioned the resident to his/her right side. There was no dressing present to the resident's right buttock. The resident's buttock had a dime sized superficial open area with a pink and moist wound bed. The wound had no drainage or odor. LPN F said the resident's right buttock wound was a Stage II (a wound with partial thickness loss, presents as a shallow open ulcer) pressure wound. With gloved hands, LPN F soaked the gauze with normal saline and cleaned the wound, dried the wound, and placed the calcium alginate on the resident's wound. LPN F removed the calcium alginate and said the piece of calcium alginate that he/she cut was too big. LPN F then removed his/her bandage scissors out of his/her uniform shirt pocket and cut the piece of calcium alginate to a smaller size and re-applied the same calcium alginate to the resident's right buttock pressure wound. LPN F placed his/her bandage scissors back into his/her uniform shirt pocket. LPN F did not clean the bandage scissors prior to cutting the calcium alginate. LPN F then covered the resident's right buttock pressure wound with a border gauze (a specialized dressing). LPN F said the wound looked a lot better. Review of the resident's Treatment Administration Record (TAR), dated 9/1 through 9/29/25, showed:-An order, dated 8/20/25, cleanse and dry affected area to right buttock; Apply Medihoney to the wound bed and cover with dry dressing daily and PRN; 6:00 A.M. to 2:00 P.M. shift.-On 9/26/25 6:00 A.M. to 2:00 P.M. shift; the resident's treatment was documented as completed. Review of the resident's progress notes, dated 9/27/25 at 2:25 A.M., showed the right buttock with Stage I pressure wound (intact skin with localized redness), 1.5 cm by 2.5 cm. There is much improvement from last week. MediHoney and dressing applied. Review of the resident's skin observation detailed report, dated 9/27/25 at 3:21 A.M., showed the resident had a pressure ulcer Stage II on buttocks. During an interview on 9/30/25 at 8:45 A.M., LPN B said treatment orders should be checked prior to administering, just like with medicine. The current treatment for the resident's right buttock pressure wound is to apply Medihoney and dry dressing. Calcium alginate is an old order the resident had previously. Normal saline is the only product used to clean wounds. During an interview on 9/30/25 at 8:00 A.M., the Assistant Director of Nursing (ADON) and the Director of Nursing (DON) said the resident is on hospice. The hospice nurse normally writes the orders for wounds and monitors the wounds. The resident is not seen by an outside wound company. The resident's right buttock pressure wound is a Stage II. The ADON does wound rounds and lost her wound tracking documentation due to a recent virus on her computer. The current order for the resident's right buttock pressure wound is to cleanse the wound, dry the wound, apply Medihoney, and cover with a dry dressing. Normal saline is what most wounds are cleaned with unless the order specifies something different. Calcium alginate is not the resident's current order. The ADON and the DON expected staff to follow the orders, provide the correct treatment, and use good infection control practices. During an interview on 9/30/25 at 10:31 A.M., the Administrator said she expected the physician treatment orders to be followed and correctly administered.

Based on observation, interview and record review, the facility failed to ensure medications kept in facility medication rooms were within the date of expiration and failed to remove one of 22 sampled resident's expired hospital discharge medications (Resident #22). Concerns were noted in one of one medication rooms during the survey period. The census was 38.Review of the facility's Storage of Medications policy, revised 1/16/25, showed:-Drug containers that have missing, incomplete, improper, or incorrect labels shall be returned to the pharmacy for proper labeling before storing;-The facility shall not use discontinued, outdated, or deteriorated drugs or biologicals. All such drugs shall be returned to the pharmacy or destroyed;-The nursing staff shall be responsible for maintaining medication storage AND preparation areas in a clean, safe, and sanitary manner. 1. Observation of the facility's only medication room on 9/26/25 at 11:46 A.M., showed:-One bottle of GeriCare Stool Softener Docusate Sodium (a type of laxative used to treat occasional constipation) 100 milligram (mg) oral tablets expired as of 3/25;-Two boxes of Bisacodyl Laxative Supplement (a medication used to treat constipation) 5 mg tablets expired as of 4/25;-Two bottles of cetirizine (an antihistamine used to relieve allergy symptoms) 10 mg tablets expired as of 3/25 prescribed for Resident #22;-One bottle of furosemide (a diuretic used to treat edema and high blood pressure) 20 mg tablets expired as of 4/25 prescribed for Resident #22;-One bottle of aspirin 81 mg tablets expired as of 3/25 prescribed for Resident #22. 2. During an interview on 9/30/25 at 8:45 A.M., Certified Medication Technician (CMT) A said since starting at the facility two months ago, she has taken on some of the responsibility of auditing the medication room for expired medications and biologicals. CMT A reviews the medication room weekly for expired medications, and the facility's pharmacy partner conducts a review of the medication room for expired meds once per month. Expired medications should be removed from the medication room shelves and placed into a bin designated for the facility's pharmacy partner to dispose. 3. During an interview on 9/30/25 at 8:49 A.M. Licensed Practical Nurse (LPN) B said the Assistant Director of Nursing (ADON), Director of Nursing (DON), nursing staff, and facility CMTs are responsible for auditing the medication rooms for expired medications and biologicals. All expired medications should be placed into the designated disposal bin for the facility's pharmacy partner to pick up once per week. 4. During an interview on 9/20/25 at 10:29 A.M., the Administrator and DON said they expected all medications and biologicals in the medication room to be within the date of expiration and removed if they are expired. The facility's pharmacy partner conducts a monthly audit of the medication room and they expected the pharmacy partner to remove expired medications during those audits. The Administrator said Resident #22's expired medications were left over from a stay at the Veteran's Affairs (VA) Hospital earlier in the year and she expected staff to have removed them once expired.

Based on observation and interview, the facility failed to post the nurse staffing information daily in a prominent place readily accessible to residents and visitors. The census was 38.Observations on 9/25/25 at 10:00 A.M., and 12:02 P.M., showed no staffing information posted in a prominent place.Observations on 9/26/25 at 9:00 A.M., and 11:00 A.M., showed no staffing information posted in a prominent place.During an interview on 9/26/25 at 11:15 A.M., the Assistant Director of Nursing (ADON) said the staffing has not been posted for about a month. It usually was posted in the lobby of the facility. The Activities Director was responsible for posting it but that person no longer works at the facility. The ADON did not know who currently was responsible for posting the staffing hours.During an interview on 9/30/25 at 10:51 A.M., the Administrator said she expected staffing information to be posted daily in a prominent place.

Based on observation, interview, and record review, the facility failed to provide services consistent with acceptable standards of practice for one resident when staff failed to accurately assess and document a wounds appearance, odors, the condition of the surrounding skin, resulting in the failure to timely identify the worsening of a left heel wound. The resident was sent to the hospital for evaluation of the wound. The hospital staff assessed the wound and identified the wound to have necrotic (dead) skin, very malodorous (very foul odor), and the surrounding skin erythematous (abnormally red and inflamed). The hospital diagnosed the wound as osteomyelitis (infection of the bone) and gangrene (a serious condition that occurs when tissue dies due to a lack of blood flow or a bacterial infection) (Resident #1). The sample size was four. The census was 38. Review of the facility's undated Wound Management policy, showed: -Purpose: to assist the facility in the care, services and documentation related to the occurrence, treatment, and prevention of pressure wounds; -Process: -all residents admitted to the facility will have a Braden scale (a tool used to predict the development of pressure wounds) observation completed at admission, in conjunction with each quarterly and annual assessment, with any significant change in assessment and as deemed necessary by the interdisciplinary team. The admitting nurse is responsible for completing the form. The admitting nurse will then be responsible for initiating the appropriate interventions such as ensuring treatment orders are in place, pressure reduction devices are ordered and/or requested, i.e. specialty mattress and wheelchair cushion, and that the interim/baseline care plan is initiated; -the admitting nurse will then initiate and complete the initial wound exam for each wound that has been identified; -the admitting nurse will be responsible for informing the unit manager or other designated supervisor of the wound so that the wound can be documented on the appropriate tracking log. The unit manager or other designated supervisor will be responsible for updating the log and every Thursday turning the completed tracking logs to the Director of Nursing (DON), the Minimum Data Set department and the dietary department; -the unit managers will be responsible for the creation of the monthly cumulative report of all wounds on their individual unit and present this report at the monthly risk management/quality assurance meeting; -the facility utilizes an outside wound care specialist, to assist with wound management and treatment, who provides weekly visits to residents with wounds. The wound description information obtained from this provider will be scanned into the electronic medical record and maintained under the documents section; -the unit manager or designee with be responsible for completing the wound exam observation utilizing the information obtained during that week's visit. Review of Resident #1's significant change Minimum Data Set (MDS, a federally mandated assessment instrument completed by facility staff), dated 6/28/24, showed: -Severe cognitive impairment; -Does not reject care; -Dependent on staff for hygiene, toileting, dressing, bathing, bed mobility and transfers; -Diagnoses included diabetes, seizures, anxiety and depression; -Used pressure reducing device for chair; -No pressure reducing device selected for the bed. Review of the resident's care plan, in use at the time of the investigation, showed: -Problem: Resident is at risk for impaired skin integrity related to incontinence of bowel and bladder, impaired mobility and function, and dependence on staff for activities of daily living, transfers, and mobility; -Goal: left heel wound will exhibit structural intactness and normal physiological function; -Approach: provide heel treatment as ordered, monitor wound and surrounding area for deterioration of skin and wound for redness, swelling, blanching and moisture, Review of the resident's podiatry visit note, dated 8/7/24, showed: -Patient presents for diabetic foot care and at risk foot care; -Thickened toe nails. Review of the resident's medical record, showed: -On 8/13/24 at 5:25 P.M., the resident readmitted to the facility. The resident alert and oriented to self and place (A&O 1-2), able to make needs known. Bruising noted to arms from intravenous sites; -No Braden assessment completed. Review of the resident's electronic physician order sheet (ePOS), showed: -An order, dated 8/13/24: wound care consult and treat as needed; -An order, dated 8/13/24: weekly skin assessment every Thursday day shift; -An order, dated 8/13/24: Apply skin prep (protective barrier wipe) to left heel twice a day. Leave open to air. Discontinued 9/25/24. Review of the resident's progress note, showed on 8/14/24 at 11:08 A.M., remains on new admission monitoring. Able to make needs known. Incontinent of bowel and bladder and moisture barrier cream applied. Skin prep applied to left heel. Heel noted with scabbed area. Review of the resident's skin assessment, dated 8/14/24 at 2:36 P.M., showed: -Skin impairments: left heel; -Skin color: within normal limits, pale; -Sign of infection: none; -Treatment: skin prep left heel. Review of the resident's wound care nurse practitioner visit note, dated 8/19/24, showed: -Wound: left foot, heel; -Status: open; -Reported wound cause: diabetic; -Measurements Length: 2.5 centimeter (cm); Width: 2.5 cm; Depth: 01 cm; -Preliminary impression: the ulcer is mixed etiology including pressure. Further workup will determine primary etiology; -Classification: full thickness; -Exudate (drainage): none, dry; -Recommendations: wipe the skin protectant (skin prep or similar product) to stable eschar (black, hard tissue). Ensure edges and surrounding skin are painted. Do not wash off skin protectant between applications. Review of the resident's progress notes, showed on 8/19/24 11:45 A.M., seen by wound care nurse practitioner. Left heel assessed with no changes in treatments. Review of the resident's medical record, showed no weekly skin assessment located for 8/21/24. Review of the resident's skin assessment, dated 8/29/24, showed: -Skin impairments: area to bilateral heels; -Skin color: within normal limits; -Sign of infection: none; -Continue current plan. Review of the resident's skin assessment, dated 9/5/24, showed: -Skin impairments: area to left heel; -Skin color: within normal limits and pale; -Sign of infection: none; -Current treatment: skin prep to left heel; -Continue current plan. Review of the resident's skin assessment, dated 9/12/24, showed: -Skin impairments: area to bilateral heels; -Skin color: within normal limits and pale; -Sign of infection: none; -Current treatment: lotion to dry skin; -Continue current plan. Review of the resident's October 2024 ePOS and Treatment Administration Record (TAR), showed an order dated 9/25/24 and discontinued 10/14/24: Betadine (antiseptic cleansing solution) to left heel daily, leave open to air. Scheduled daily at 6:00 A.M. to 4:00 P.M. All days 10/1/24-10/11/24 documented as completed. The scheduled administration on 10/12 and 10/13/24 documented as not completed due to resident being in the hospital. Review of the resident's skin assessment, dated 9/26/24, showed: -Skin impairments: area to bilateral heels; -Skin color: within normal limits and pale; -Sign of infection: none; -Current treatment: lotion to dry skin, skin prep to heels; -Continue current plan. Review of the resident's skin assessment, dated 10/3/24, showed it did not address the heel. Review of the resident's progress notes, showed on 10/8/24 at 11:40 A.M., the left heel wound noted growth. Measured 6 cm wide x 7 cm length. Redness and warm to touch. Pain noted to area. Hospice provider ordered antibiotic twice a day for 10 days. Next of kin aware. Review of the wound infection event report, dated 10/8/24, showed: -admitted with infection: No; -Infection develop after admission: yes; -What date develop: 10/8/24; -Wound cultured: No; -Necessary to isolate: No; -Infection type: skin; -Orders: Doxycyxline (antibiotic) 100 milligram (mg). Take one capsule twice a day for 10 days for the left heel. Review of the resident's progress notes, showed on 10/8/24 at 8:29 P.M., the resident will begin antibiotic in the morning for left heel wound. Review of the resident's ePOS, showed an order, dated 10/9/24: Doxycycline 100 mg, take one capsule twice a day for six days. Review of the October MAR, dated 10/1/24-10/31/24, showed Doxycycline 100 mg, take one capsule twice a day. Documented as administered as ordered until the resident sent to the hospital on 10/11/24. Review of the resident's skin assessment, dated 10/10/24, showed: -Skin impairments: left heel; -Skin color: within normal limits and pale; -Sign of infection: none; -Current treatment: lotion to dry skin, major wound to left heel and treatment in place; -Continue current plan. Review of the resident's progress note, showed: -On 10/10/24 at 1:18 P.M., resident on antibiotic to the left heel, denies pain but resistive to care provided; -On 10/10/24 at 11:20 P.M., the resident continues on antibiotic for left heel wound and yelled out help me. As needed morphine (narcotic pain medication) given for pain control with positive results. Review of the progress notes, showed on 10/11/24 at 11:17 A.M., facility assistant director of nursing (ADON) and writer, along with hospice nurse assessed the resident's left heel. A growth was noted from previous assessment and odor. The resident continuously complained of pain, and as needed morphine was administered. Family present and after observing the wound, requested the resident to be sent to the hospital. Review of the resident's ePOS, showed an order dated 10/11/24, transfer to local emergency department for left heel wound per family request. Review of the resident's hospital emergency room provider notes, dated 10/11/24 at 1:06 P.M., showed: -Patient presents with a wound to the left heel. Patient was on antibiotics at the nursing home and he/she was sent in due to worsening of the wound; -Medications administered: -Cefepime (antibiotic) 2,000 mg in 0.9% normal saline intravenous (IV) 50 milliliters (ml) IV; -Vancomycin (antibiotic) 1,500 mg in 530 ml IV; -Skin: dry, left heel with necrotic skin, very malodorous, surrounding skin erythematous; -Left foot x-ray findings: demineralization and subtle permeative osteolysis (type of bone destruction characterized by a large number of small holes in the bone). Subtle cortical erosion (bony degeneration that occurs over time) and suspicious for osteomyelitis. Soft tissue thickening and perhaps some adjacent gas within the soft tissues; -Podiatry consult: family stated the left heel wound started a few weeks ago and had grown in size. The patient is on hospice services. The patient was started on Doxycycline at the facility and is presently on morphine for pain. Hospice provided wound care at the facility; -Dermatology: left heel ulceration measured 7.0 cm x 4.0 cm x 0.2 cm. significant surrounding erythema, plus malodor. Wound unable to be palpated or probed due to patient's mental status and pain. Review of the hospital wound nurse assessment, dated 10/15/24, showed: -Left heel: present on admission; -Wound bed: brown, eschar; -Exudate (drainage): scant; -Wound margin: undefined edges; -Length: 8 cm -Width: 6.5 cm; -Depth: 0 cm; -Assessment and plan: left heel osteomyelitis, left heel gangrene with sepsis (life-threatening medical emergency that occurs when the body has an extreme response to an infection). The patient is not a surgical candidate; -Recommendations: cleanse left heel ulcer with Vashe (wound cleanser) and gauze. Paint with betadine. Cover with abdominal pad (large, thick pad) and wrap with gauze daily. Apply bilateral heel boots. During an interview on 10/15/24 at 1:47 P.M., hospital Registered Nurse C said the resident admitted to the hospital a few days ago with a necrotic, infected left heel wound. The resident is not a surgical candidate due to his/her poor general health status. The resident revoked hospice services when admitted to the hospital, but family is considering re-admitting to hospice care. The resident is diagnosed with osteomyelitis and gangrene to the left heel. The resident will be discharged to a different facility with hospice services. During an interview on 10/16/24 at 10:43 A.M., Licensed Practical Nurse (LPN) A said he/she helped care for the resident. The resident had a wound to the left heel. The hospice nurse provided wound care on visits twice a week and the hospice aide provided baths. The other days of the week facility staff should administer the ordered treatments. The facility staff would initial in the TAR when hospice administered the treatments. The facility staff should report changes in a wound to the hospice provider, the physician and next of kin. During an interview on 10/16/24 at 3:04 P.M., the Director of Hospice services said the resident admitted to hospice services on 8/23/24. He/She admitted with a wound to the left heel. Hospice staff visited the resident twice a week and the nurse would provide wound care on visit days. The hospice nurse would obtain wound measurements weekly. The resident's family revoked hospice services and sent the resident to the hospital. During an interview on 10/16/24 at 3:33 P.M., the hospice LPN D said he/she had seen the resident with hospice services for several months. The resident had a wound to the left heel. The treatment was Betadine daily. He/She had administered wound care on visit days. The hospice aide notified him/her of a change in the heel wound around 10/7/24. LPN D ordered antibiotic. He/She visited the resident on 10/9/24 and the facility staff reported the antibiotic was started on 10/9/24. The heel wound appeared inflamed at the edges. He/She visited the resident again on 10/11/24 and the wound was odorous, inflamed, and painful to touch. The resident's family was present and elected to revoke hospice and sent the resident to the hospital. LPN D said he/she was going to order a stronger antibiotic on 10/11/24 and different wound care orders but the resident was sent to the ER. He/She expected staff to administer wound care orders when hospice was not at the facility and to notify hospice if wounds worsen. During an interview on 10/17/24 at 11:38 A.M., Certified Nurse Assistant (CNA) B said he/she took care of the resident occasionally and cared for him/her a few days before he/she went to the hospital. The resident received hospice services and the hospice aides provided bathing. The resident had a wound to his/her left heel. It was black and had some redness around the edge. CNA B did not recall if he/she notified the charge nurse of the wound appearance. The resident was later sent to the hospital. During an interview on 10/17/24 at 11:20 A.M., the DON and ADON said they expected staff to report worsening wounds to the charge nurse. All new wounds should be documented with measurements, a skin event, and wound care orders. Each wound should be documented separately with separate orders. Resident #2's heel wound worsened quickly but the facility staff should have observed it prior to the resident being sent to the hospital. Aides should report any changes in skin or changes in a wound to the charge nurse. The charge nurse should assess, document and notify the physician. Facility staff should provide treatments when hospice does not visit, including assessment of the wound at the time of treatment. The staff should conduct Braden assessments and document in the medical record, if the Braden assessments are not in the record, the assessments were not done. MO00243466

Based on observation, interview, and record review the facility failed to ensure staff followed acceptable standards of nursing when staff failed to accurately assess open areas to the buttock and coccyx (tailbone) for one resident. When the wound was assessed by the wound care provider, the wounds were identified as stage III (full thickness tissue loss. Subcutaneous fat may be visible, but bone, tendon or muscle is not exposed) pressure injuries. New treatment orders were given by the wound care provider, but not transcribed to the resident's physician orders or completed as ordered. (Resident #2). The sample size was four. The census was 38. Review of the facility's undated Treatment/Services to Prevent and Heal Pressure Ulcers policy, showed: -Intent: to ensure it identifies and provides needed care and services that are resident centered, in accordance with the resident's preferences, goals for care and professional standards of practice that will meet each resident's physical, mental and psychosocial needs; -Procedure: The facility will ensure that based on comprehensive assessment of the resident: -A resident received care, consistent with professional standards of practice to prevent pressure ulcers and does not develop pressure ulcers unless the individual's clinical condition demonstrates that they were unavoidable; -A resident with pressure ulcers receives necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing; -Upon admission, the resident will receive a head-to-toe skin check to identify any skin issues; -Interventions will be implemented in the resident's plan of care to prevent pressure sore development, when the resident has no areas of concern; -When the resident is admitted with a pressure sore the admitting nurse will document the size, location, odor if any, drainage if any, and current treatment ordered; -Interventions will be implemented in the resident's plan of care to prevent deterioration and promote healing of the pressure sore; -The admitting nurse will notify the attending physician as well as the resident and/or the resident's representative of the condition of the pressure sore on admission; -The pressure sore will be evaluated weekly and the nurse will document the size, location, odor, drainage and current treatment ordered; -The nurse will notify the physician anytime the pressure sore is showing signs of non-healing or infection and request treatment order changes; -The nurse will notify the resident and/or the resident's representative of any changes related to the improvement, deterioration and/or treatment changes on an on-going basis. Review of the facility's undated Wound Management policy, showed: -Purpose: to assist the facility in the care, services and documentation related to the occurrence, treatment, and prevention of pressure wounds; -Process: -all residents admitted to the facility will have a Braden scale (a tool used to predict the development of pressure wounds) observation completed at admission, in conjunction with each quarterly and annual assessment, with any significant change in assessment and as deemed necessary by the interdisciplinary team. This includes the development of a newly identified pressure ulcer. The admitting nurse is responsible for completing the form. The admitting nurse will then be responsible for initiating the appropriate interventions such as ensuring treatment orders are in place, pressure reduction devices are ordered and/or requested, i.e. specialty mattress and wheelchair cushion, and that the interim/baseline care plan is initiated; -the admitting nurse will then initiate and complete the initial wound exam for each wound that has been identified; -the admitting nurse will be responsible for informing the unit manager or other designated supervisor of the wound so that the wound can be documented on the appropriate tracking log. The unit manager or other designated supervisor will be responsible for updating the log and every Thursday turning the completed tracking logs to the Director of Nursing (DON), the Minimum Data Set department and the dietary department; -the unit managers will be responsible for the creation of the monthly cumulative report of all wounds on their individual unit and present this report at the monthly risk management/quality assurance meeting; -the facility utilizes an outside wound care specialist, to assist with wound management and treatment, who provides weekly visits to residents with wounds. The wound description information obtained from this provider will be scanned into the electronic medical record and maintained under the documents section; -the unit manager or designee with be responsible for completing the wound exam observation utilizing the information obtained during that week's visit. Review of Resident #2's care plan, in use at the time of the investigation, showed: -Problem start date 10/17/22: pressure ulcer/injury; -Goal: skin will remain intact, without breakdown or pressure sores; -Approach: apply skin prep (protective barrier wipe) to both heels twice a day, provide incontinence care, turn and reposition every 2 hours, use barrier product to perineal area (the surface area between the thighs, extending from the pubic bone to tail bone), avoid shearing the skin, keep skin clean and dry, weekly skin assessments every Monday on night shift. Review of the resident's medical record, showed: -readmitted : 6/26/24; -Diagnoses included: protein-calorie malnutrition, history of pressure injury to the sacral region (tailbone, coccyx), cognitive impairment, anxiety, and chronic pain; -No Braden assessments documented. Review of the resident's quarterly Minimum Data Set (MDS, a federally mandated assessment instrument, completed by facility staff), dated 7/5/24, showed: -Moderate cognitive impairment; -No behavior concerns; -Used a wheelchair for mobility; -Dependent on staff for hygiene, dressing, bed mobility, and, transfers; -Always incontinent of bowel; -Uses an indwelling urinary catheter (a flexible tube inserted through the urinary tract and into the bladder to drain urine); -Pressure reducing device for chair; -Received applications of ointments/medications other than to feet. Review of the resident's skin assessment, dated 9/19/24 at 8:29 A.M., showed: -Skin impairments that require preventative care: redness to buttock; -Skin color: within normal limits and pale; -Type of wound or area of concern: moisture associated skin damage (MASD) to buttocks; -Current treatment: -Dry skin: lotion; -Incontinent care: Calmoseptine ([NAME], moisture barier) to the buttock; -Foley (a brand of indwelling urinary catheter) care; -Nystatin (antifungal) powder; -Plan: Continue current plan. Review of the resident's skin assessment, dated 9/21/24 at 3:12 P.M., showed: -Skin impairments that require preventative care: redness to buttocks, a concerned area to the coccyx, purple in color and inside the gluteal (buttock) folds; -Skin color: within normal limits, and pale; -Type of wound: pressure ulcer: stage I pressure ulcer (an observable, pressure-related alteration of intact skin, the ulcer may appear with persistent red, blue, or purple hues), purple in color and MASD; -Current treatment: -Dry skin: lotion; -Incontinent care; -Foley care; -Nystatin powder; -Plan: Continue current plan. Review of the resident's progress notes, dated 9/21/24 at 3:16 P.M., showed: The resident noted to have a stage I area on the inside of the gluteal folds, purple in color and also to the coccyx area. Informed the aides to keep the resident clean and apply barrier ointment to the area. Will notify the night shift nurse of the concerned area and to make sure the resident is rotated off his/her backside at night. Will continue to follow plan of care. Review of the resident's progress note, dated 9/23/24 at 2:35 P.M., showed: new order for [NAME] cream to coccyx/buttock area to prevent breakdown. Apply a quarter size amount to the reddened area on coccyx/buttock. Review of the facility's wound report, dated 9/23/24, showed the resident not listed on the report. Review of the resident's skin assessment, dated 9/26/24 at 9:09 A.M., showed: -Skin impairments that require preventative care: redness to the buttocks, concerned area to coccyx, purple in color, and inside the gluteal folds; -Skin color: within normal limits, and pale; -Type of wound: Pressure ulcer, stage I-purple in color; -MASD; -Current treatment: -Dry skin: lotion -Incontinent care: apply Calmoseptine to buttocks; -Foley care; -Nystatin powder as needed; -Plan: Continue current plan. Review of the resident's progress note, dated 9/28/24 at 4:54 P.M., showed the resident transferred back to bed after meals for comfort and to prevent more breakdown to the coccyx. Staff positioned the resident on his/her side. Review of the facility's wound report, dated 9/30/24, showed the resident not listed on the report. Review of the resident's skin assessment, dated 10/3/24 at 10:24 A.M., showed: -Skin impairment that require preventative care: redness to coccyx, superficial area to coccyx; -Skin color: within normal limits and pale; -Type of wound: MASD; -Current treatment: -Dry skin: lotion; -Incontinent care: apply Calmoseptine; -Foley care; -Plan: Continue current plan. Review of the resident's progress note, dated 10/4/24 at 9:29 A.M., showed the resident noted to have four open areas to coccyx and right buttock. The right buttock 2 areas appeared to be shearing (occurs when tissue layers laterally shift in relation to each other) and current treatment of [NAME]. Distal (area furthest from the center of the body) wound roughly measured 1 centimeter (cm) x 1 cm. The proximal (area closest to the center of the body) area measured 2.0 cm x 2.0 cm. The coccyx has 2 open areas. The distal wound measured 2.5 cm x 1.5 cm with slough (moist dead tissue) noted to the wound bed. The proximal area measured 1 cm x 1 cm with a pink wound bed and continue current order of [NAME]. Physician notified and new orders received to cleanse the wound and apply Santyl (enzyme ointment used remove dead tissue and aide in healing) to distal coccyx wound and cover with dry dressing daily. Continue [NAME] to other areas and refer to the Wound Care providers. Next of kin notified. Review of the resident's physician visit note, dated 10/4/24 at 10:18 A.M., showed the resident identified with 4 open areas. The right buttock 2 open area appeared to be shearing with current treatment of [NAME]. Additional areas consult by wound care specialist. Consider surgery if areas do not improve. Review of the resident's electronic physician order sheet (ePOS), showed: -An order, dated 10/4/24: Calmoseptine ointment, apply to coccyx wound every day and night shift; -An order, dated 10/4/24: Cleanse distal coccyx wound with hypochlorous acid (used to kill bacteria and prevent infections), apply Santyl to the wound bed and cover with absorbent dressing daily and as needed; -An order, dated 10/4/24: Santyl 250 unit/gram. Apply nickel thick to distal coccyx wound, once daily. Scheduled daily at 6:00 A.M. to 10:00 A.M; -An order, dated 10/4/24: Wound care to evaluate and treat; -Weekly skin assessment every Thursday. Review of the resident's October treatment administration record (TAR), dated 10/1/24-10/31/24 and reviewed on 10/16/24 at 12:00 P.M., showed: -An order, dated 10/4/24: Calmoseptine topical every shift. Apply to proximal coccyx wound and right buttocks. Documented as completed as ordered; -An order, dated 10/4/24: Cleanse distal coccyx wound with hypochlorous acid. Apply Santyl to wound bed and cover with absorbent dressing. Change daily and as needed. Diagnosis: Pressure ulcer of sacral region, stage III. Not documented as completed on 10/8/24. Review of the resident's wound care visit note, dated 10/7/24, showed: -Wound 1: Coccyx: -Cause of origin: pressure; -Where was wound created: acquired at facility; -Length: 4.4 cm; -Width: 3.2 cm; -Depth: 0.2 cm; -Granulation (new tissue growth): 10 percent (%); -Slough: 70%; -Pressure injury: Stage III; -Exudate (drainage): moderate, wound is wet and drainage covers 25-75 % of the dressing; -Wound recommendations: Cleanse wound with soap and water. Pat dry. Scrub wound to mechanically debride (remove dead tissue). Apply skin protectant to peri-wound (skin on the edge of wound). Apply calcium alginate (absorbent dressing) to wound base. Cut to fit inside the wound edges, do not place on the skin. Cover with bordered gauze. Change dressing daily and as needed; -Procedure: debridement to remove unhealthy tissue to stimulate wound healing; -Wound 2: Right buttock; -Cause of origin: pressure; -Where was wound created: acquired at facility; -Length: 0.5cm; -Width: 0.5 cm; -Depth: 0.2 cm; -Granulation: 100 %; -Pressure injury: Stage III; -Exudate: moderate, wound is wet and drainage covers 25-75 % of the dressing; -Wound recommendations: Cleanse wound with soap and water. Pat dry. Scrub wound to mechanically debride. Apply skin protectant to peri-wound. Apply calcium alginate to wound base. Cut to fit inside the wound edges, do not place on the skin. Cover with bordered gauze. Change dressing daily and as needed. Review of the resident's skin assessment, dated 10/10/24 at 1:09 P.M., showed: -Skin impairment that required preventative care: coccyx with open area with treatment in place; -Skin color: within normal limits and pale; -Type of wound: pressure ulcer-stage I and MASD; -Current treatment: -Dry skin: lotion; -Incontinent care: calmoseptine; -Foley care; -Plan: continue current plan. Review of the resident's medical record, reviewed on 10/16/24, showed: -No documentation the physician was notified of the wound care provider's recommendation to change the treatment order; -The treatment recommended by the resident's wound care provider on 10/7/24 for the coccyx and right buttocks, cleanse wound with soap and water. Pat dry. Scrub wound to mechanically debride. Apply skin protectant to peri-wound. Apply calcium alginate to wound base. Cut to fit inside the wound edges, do not place on the skin. Cover with bordered gauze. Change dressing daily and as needed, not transcribed onto the TAR or ePOS. Review of the resident's wound care visit note, dated 10/14/24, showed: -Wound 1: Coccyx: -Cause of origin: pressure; -Where was wound created: acquired at facility; -Length: 3.5 cm; -Width: 3.0 cm; -Depth: 0.2 cm; -Granulation: 10%; -Slough: 70%; -Pressure injury: Stage III; -Exudate: moderate, wound is wet and drainage covers 25-75 % of the dressing; -Wound recommendations: Cleanse wound with soap and water. Pat dry. Scrub wound to mechanically debride. Apply skin protectant to peri-wound. Apply calcium alginate to wound base. Cut to fit inside the wound edges, do not place on the skin. Cover with bordered gauze. Change dressing daily and as needed; -Procedure: debridement to remove unhealthy tissue to stimulate wound healing; -Wound 2: Right buttock: resolved. Review of the resident's medical record, reviewed on 10/16/24, showed: -No documentation the physician was notified of the wound care provider's recommendation to change the treatment order; -The treatment recommended by the resident's wound care provider on 10/14/24 for the coccyx and right buttocks, cleanse wound with soap and water. Pat dry. Scrub wound to mechanically debride. Apply skin protectant to peri-wound. Apply calcium alginate to wound base. Cut to fit inside the wound edges, do not place on the skin. Cover with bordered gauze. Change dressing daily and as needed, not transcribed onto the TAR or ePOS. Observation on 10/16/24 at 9:30 A.M. and 10:23 A.M., showed the resident asleep and lay on his/her back in bed. During an observation and interview on 10/16/24 at 1:30 P.M., showed the resident sat upright in bed. His/Her lunch tray on the over bed table and food untouched. He/She said he/she had some sores on his/her buttocks. Staff had been changing the treatment. During an interview on 10/17/24 at 10:23 A.M., the Wound Care Nurse Practitioner (NP) said the resident had a wound to the right buttock that had healed and a current open area to the coccyx. His/Her initial assessment on 10/7/24 he/she determined both wounds were a stage III. The resident is incontinent of bowel and used a catheter that frequently leaked. The resident is dependent on staff for care needs and repositioning. Staff should notify the facility wound care nurse immediately for changes in skin condition, the physician should be notified so orders can be obtained quickly. During an observation and interview on 10/17/24 at 9:34 A.M., the Assistant Director of Nursing (ADON) said he/she is also the facility wound care nurse. The ADON entered the resident's room with wound care supplies. She assisted the resident onto his/her side and exposed the buttocks. The ADON said the resident is seen weekly by the wound care nurse practitioner. The wounds have been improving. An open area noted to the left buttock and to the coccyx. The ADON said the wound care plus NP had combined the left buttock wound and the coccyx wound into one wound. The ADON cleaned both wounds with hypochlorous, applied Santyl and applied cut to size Calcium Alginate to the wounds. She covered both wounds with absorbent pads, dated and labeled the dressings. During an interview on 10/17/24 at 11:48 A.M., the Wound Care NP said he/she was not aware of an open area to the resident's left buttock. All wounds are independent of each other unless the wounds expand into one. All wounds should have orders.

Based on interview and record review, the facility failed to ensure residents were free from significant medication error by not administering the resident's seizure medication when an error resulted in the order being deleted from the physician order sheet, for at least three months, for one resident reviewed for hospitalization . This resulted in the resident having a seizure that resulted in hospitalization (Resident #1). The census was 39. Review of the facility's undated Physician's Services policy, showed: -Intent: It is the policy of the facility to provide Physician Services in accordance with State and Federal regulations: -A physician, physician assistant, nurse practitioner, or clinical nurse specialist must provide orders for the resident's immediate care and needs; -Each resident will remain under the care of a physician; -All physician or other health care professional verbal orders, including telephone orders, will be immediately recorded, dated, and signed by the person receiving the order; -All physician orders will be followed as prescribed and if not followed, the reason shall be recorded on the resident's medical record during that shift. Review of Resident #1's medical record, showed: -admitted [DATE]; -Diagnoses included history of seizures and post traumatic seizures. Review of the resident's care plan, reviewed 8/25/22, showed no interventions or goals regarding the resident's history of seizures and use of seizure medications. Review of the resident's electronic Physician Orders Sheet (ePOS), dated July 2022 through January 2024, showed: -An order dated 7/12/22, for Keppra (levetiracetam, used to treat seizures), 500 milligram (mg), one tablet by mouth, twice a day: -On 8/31/23, Keppra was discontinued; -An order dated 8/22/23, for Keppra 500 mg, one tablet by mouth, twice a day: -On 10/5/23, the Keppra was discontinued. Review of the resident's Medication Administration Record (MAR), dated October 2023 through January 2024, showed no documentation Keppra 500 mg was administered since 10/5/23 through 1/11/24. Review of the resident's progress notes, dated October 2023 through January 2024, showed: -On 1/11/24 at 12:23 A.M., a loud noise was heard, went to two other rooms before entering resident's room to find him/her supine (on his/her back and facing upward) on the floor, with a basketball sized, [NAME] red blood pool at the head area, less than one inch laceration noted on the frontal area of the skull. Resident was having active seizure upon arrival. Unable to arouse with verbal or physical stimuli. At 12:31 A.M., 911 called, seizure ended 12:34 A.M., appearing postictal (a drowsy state that commonly occurs after seizure activity), snoring, still unable to arouse. Emergency Medical Technicians (EMT) arrived 12:39 A.M., oxygen at that time was in the 40's (percentage of oxygen in the blood, normal is 95%-100%), oxygen placed on by facility staff 3 liters (L)\nasal cannula (NC), laceration on forehead pressurized and not bleeding at that time. EMT assessed placed on gurney and taken to hospital. Responsible party called at 12:49 A.M., message left. Responsible party returned call at 12:57 A.M., made aware of above documentation; -No documentation of physician orders to discontinue Keppra or rationale to discontinue Keppra. During an interview on 2/19/24 at 1:30 P.M., Pharmacist Representative J said they contracted with the facility in 12/28/23. The only order they had on file for the resident was an order for Keppra 750 mg, twice a day. It was filled on 1/20/24. During an interview 2/19/24 at 2:09 P.M., Pharmacist Representative K said they were the previous pharmacy for the facility until they switched on 12/28/23. The resident's Keppra was last filled on 9/19/23. During an interview on 2/20/24 at 2:28 P.M., the Director of Nursing (DON) said the resident had a history of seizures. She never observed the resident having a seizure while at the facility; -At 2:56 P.M., the DON said she remembered what happened with the resident's orders. In October 2023, she questioned if they were able to crush Keppra for the resident. The DON removed the order out and ordered the Keppra as a liquid. They found out the Keppra was indeed crushable, but she forgot to put the order back in. There is no system for recapping or reviewing the ePOS with MARs. It was not being done. During an interview on 2/20/24 at 1:39 P.M., the administrator said she would expect physician orders be followed. MO00230147

Based on interview and record review, the facility failed to complete quarterly resident assessments for nine of 12 residents sampled (Residents #55, #101, #104, #102, #51, #54, #151, #53, and #103). The quarterly assessments had not been completed since year 2022 for some sampled residents. The census was 39. Review of the Minimum Data Set (MDS, a federally mandated assessment instrument completed by facility staff) version 3.0 Resident Assessment Instrument (RAI) User's Manual, showed: -For all non-Admission assessments, the MDS completion date must be no later than 14 days after the Assessment Reference Date (ARD). 1. Review of Resident #55's medical record, showed admitted [DATE]. Review of the resident's MDS records, showed a quarterly MDS, dated [DATE], in process. 2. Review of Resident #101's medical record, showed admitted on [DATE]. Review of the resident's MDS records, showed a quarterly MDS dated [DATE], in process. 3. Review of Resident #104's medical record, showed admitted [DATE]. Review of the resident's MDS records, showed: -A quarterly MDS, dated [DATE], in process; -A quarterly MDS, dated [DATE], in process. 4. Review of Resident #102's medical record, showed admitted [DATE]. Review of the resident's MDS records, showed: -A quarterly MDS, dated [DATE], in process; -A quarterly MDS, dated [DATE], in process. 5. Review of Resident #51's medical record, showed admitted [DATE]. Review of the resident's MDS records, showed: -A quarterly MDS, dated [DATE], in process; -A quarterly MDS, dated [DATE], in process; -A quarterly MDS, dated [DATE], in process; -A quarterly MDS, dated [DATE], production batch; -A quarterly MDS, dated [DATE], production batch; -A quarterly MDS, dated [DATE], production batch; -A quarterly MDS, dated [DATE], in process. 6. Review of Resident #54's medical record, showed admitted [DATE]. Review of the resident's MDS records, showed: -A quarterly MDS, dated [DATE], in process; -A quarterly MDS, dated [DATE], in process. 7. Review of Resident #151's medical record, showed admitted [DATE]. Review of the resident's MDS records, showed: -A quarterly MDS, dated [DATE], in process; -A quarterly MDS, dated [DATE], in process. 8. Review of Resident #53's medical record, showed admitted [DATE]. Review of the resident's MDS records, showed: -A quarterly MDS, dated [DATE], in process; -A quarterly MDS, dated [DATE], production batch; -A quarterly MDS, dated [DATE], production batch; -A quarterly MDS, dated [DATE], production batch; -A quarterly MDS, dated [DATE], in process; -A quarterly MDS, dated [DATE], in process; -A quarterly MDS, dated [DATE], in process. 9. Review of Resident #103 medical record, showed admitted [DATE]. Review of the resident's MDS records, showed a quarterly MDS, dated [DATE], in process. 10. During an interview on 2/19/24 at 10:30 A.M., with the MDS Coordinator and Administrator, they said the facility does not have access to transmit MDS assessments to the Centers for Medicare and Medicaid Services (CMS). The MDS Coordinator said she has been the MDS coordinator since June 2023 and has never been able to transmit MDS assessments. She does work on them. The MDS Coordinator before her left several incomplete MDS assessments. If an MDS says in process, that means it is still being worked on and is not yet done. If it says validated, that means it is done, signed by a registered nurse, but not yet ready to be transmitted. If the MDS says production batch, it means it is completed, ready to be transmitted, but not yet transmitted. She is aware she is behind on several of them. Quarterly MDS assessments are completed quarterly, between the comprehensive MDS assessments.

Based on interview and record review, the facility failed to complete and transmit required Minimum Data Sets (MDS, a federally mandated assessment instrument completed by facility staff) as required for 11 of 12 sampled residents (Residents #55, #101, #104, #102, #51, #152, #153, #54, #53, #103, and #151) when the facility failed to ensure staff had the required credentials to submit and transmit MDS data. The facility failed to transmit data since February 2022. This had the potential to affect all residents who reside in the facility. The census was 39. Review of the MDS aversion 3.0 Resident Assessment Instrument (RAI) User's Manual, showed: -For all non-Admission assessments, the MDS completion date must be no later than 14 days after the Assessment Reference Date (ARD); -For the Admission assessment, the MDS Completion Date must be no later than 13 days after the entry date; -Encoding Data: Within 7 days after completing a resident's MDS assessment or tracking record, the provider must encode the MDS data (i.e., enter the information into the facility MDS software). -Assessment Transmission: Comprehensive assessments must be transmitted electronically within 14 days of the Care Plan Completion Date. All other MDS assessments must be submitted within 14 days of the MDS Completion Date. 1. Review of Resident #55's medical record, showed admitted [DATE]. Review of the resident's MDS records, showed: -An admission MDS, dated [DATE], production batch; -A quarterly MDS, dated [DATE], production batch; -A quarterly MDS, dated [DATE], in process. 2. Review of Resident #101's medical record, showed admitted on [DATE]. Review of the resident's MDS records, showed: -An admission MDS, dated [DATE], production batch; -A quarterly MDS, dated [DATE], production batch; -A quarterly MDS, dated [DATE], production batch; -An annual MDS, dated [DATE], in process; -A quarterly MDS, dated [DATE], in process. 3. Review of Resident #104's medical record, showed admitted [DATE]. Review of the resident's MDS records, showed: -An annual MDS, dated [DATE], in process; -A quarterly MDS, dated [DATE], production batch; -A quarterly MDS, dated [DATE], production batch; -A quarterly MDS, dated [DATE], production batch; -An annual MDS, dated [DATE], in process; -A quarterly MDS, dated [DATE], in process; -A quarterly MDS, dated [DATE], in process. 4. Review of Resident #102's medical record, showed admitted [DATE]. Review of the resident's MDS records, showed: -An admission MDS, dated [DATE], in process; -A quarterly MDS, dated [DATE], in process. 5. Review of Resident #51's medical record, showed admitted [DATE]. Review of the resident's MDS records, showed: -A quarterly MDS, dated [DATE], in process; -A quarterly MDS, dated [DATE], in process; -A significant change MDS, dated [DATE], production batch; -A quarterly MDS, dated [DATE], in process; -A quarterly MDS, dated [DATE], production batch; -A quarterly MDS, dated [DATE], production batch; -A quarterly MDS, dated [DATE], production batch; -An annual MDS, dated [DATE], in process; -A quarterly MDS, dated [DATE], in process. 6. Review of Resident #152's medical record, showed admitted [DATE]. Review of the resident's MDS records, showed: -An admission MDS, dated [DATE], validated. 7. Review of Resident #153's medical record, showed admitted [DATE]. Review of the resident's MDS records, showed: -An admission MDS, dated [DATE], validated. 8. Review of Resident #54's medical record, showed admitted [DATE]. Review of the resident's MDS records, showed: -An admission MDS, dated [DATE], production batch; -A quarterly MDS, dated [DATE], in process; -A quarterly MDS, dated [DATE], in process. 9. Review of Resident #53's medical record, showed admitted [DATE]. Review of the resident's MDS records, showed: -A quarterly MDS, dated [DATE], in process; -A significant change MDS, dated [DATE], in process; -A quarterly MDS, dated [DATE], production batch; -A quarterly MDS, dated [DATE], production batch; -A quarterly MDS, dated [DATE], production batch; -An annual MDS, dated [DATE], production batch; -A quarterly MDS, dated [DATE], in process; -A quarterly MDS, dated [DATE], in process. 10. Review of Resident #103 medical record, showed admitted [DATE]. Review of the resident's MDS records, showed: -An admission MDS, dated [DATE], production batch; -A quarterly MDS, dated [DATE], in process; -A quarterly MDS, dated [DATE], production batch; -A quarterly MDS, dated [DATE], production batch; -An annual MDS, dated [DATE], production batch; -A quarter MDS, dated [DATE], production batch; -A quarterly MDS, dated [DATE], production batch; -A quarterly MDS, dated [DATE], production batch. 11. Review of Resident #151's medical record, showed admitted [DATE]. Review of the resident's MDS records, showed: -An admission MDS, dated [DATE], production batch; -A quarterly MDS, dated [DATE], production batch; -A significant change MDS, dated [DATE], production batch; -A quarterly MDS, dated [DATE], in process; -A quarterly MDS, dated [DATE], in process. 12. During the entrance conference on 2/18/24 at 9:50 A.M., the Administrator said the MDS Coordinator has been in his/her role for 6-8 months. She has been doing MDS assessments, but is not able to submit them. She became aware of the issue with MDS assessments during the last annual survey. It is again an issue. The need to complete MDS assessments was discuss during recent quality assurance and performance improvement (QAPI) meetings, but this concern had not been selected as a performance improvement project. The MDS coordinator is trying to get access to submit the MDS assessments. She completes them in the facility's system, but has not been able to submit them. During an interview on 2/19/24 at 10:30 A.M., with the MDS Coordinator and Administrator, they said the facility does not have access to transmit MDS assessments to the Centers for Medicare and Medicaid Services (CMS). The MDS Coordinator said she has been the MDS coordinator since June 2023 and has never been able to transmit MDS assessments. She does work on them. The MDS Coordinator before her left several incomplete MDS assessments. If an MDS says in process, that means it is still being worked on and is not yet done. If it says validated, that means it is done, signed by a registered nurse, but not yet ready to be transmitted. If the MDS says production batch, it means it is completed, ready to be transmitted, but not yet transmitted. She is aware she is behind on several of them. Quarterly MDS assessments are completed quarterly, between the comprehensive MDS assessments. Comprehensive MDS are completed on admission and at least every year. During an interview on 2/19/24 at 1:27 P.M., the Administrator said after calling the help desk, she found out they had the wrong role set up in the system. The facility needed an administrator role set up. They are now working on getting that set up. On 2/20/24 at 10:41 A.M., the Administrator said they are finalizing the facility's access to the MDS system and then will begin submitting the MDS assessments.

Based on interview and record review, the facility failed to complete comprehensive resident assessments on admission and at least annually for six of 12 residents sampled (Residents #101, #104, #102, #51, #52, and #53). The quarterly assessments had not been completed since year 2022 for some sampled residents. The census was 39. Review of the Minimum Data Set (MDS, a federally mandated assessment instrument completed by facility staff) version 3.0 Resident Assessment Instrument (RAI) User's Manual, showed: -For all non-Admission assessments, the MDS completion date must be no later than 14 days after the Assessment Reference Date (ARD); -For the Admission assessment, the MDS Completion Date must be no later than 13 days after the entry date; -Encoding Data: Within 7 days after completing a resident's MDS assessment or tracking record, the provider must encode the MDS data (i.e., enter the information into the facility MDS software). -Assessment Transmission: Comprehensive assessments must be transmitted electronically within 14 days of the Care Plan Completion Date. All other MDS assessments must be submitted within 14 days of the MDS Completion Date. 1. Review of Resident #101's medical record, showed admitted on [DATE]. Review of the resident's MDS records, showed an annual MDS, dated [DATE], in process. 2. Review of Resident #104's medical record, showed admitted [DATE]. Review of the resident's MDS records, showed: -An annual MDS, dated [DATE], in process; -An annual MDS, dated [DATE], in process. 3. Review of Resident #102's medical record, showed admitted [DATE]. Review of the resident's MDS records, showed an admission MDS, dated [DATE], in process. 4. Review of Resident #51's medical record, showed admitted [DATE]. Review of the resident's MDS records, showed an annual MDS, dated [DATE], in process. 5. Review of Resident #52's medical record, showed admitted [DATE]. Review of the resident's MDS records, showed an admission MDS, dated [DATE], in process. 6. Review of Resident #53's medical record, showed admitted [DATE]. Review of the resident's MDS records, showed: -A significant change MDS, dated [DATE], in process; -An annual MDS, dated [DATE], production batch. 7. During an interview on 2/19/24 at 10:30 A.M., with the MDS Coordinator and Administrator, they said the facility does not have access to transmit MDS assessments to the Centers for Medicare and Medicaid Services (CMS). The MDS Coordinator said she has been the MDS coordinator since June 2023 and has never been able to transmit MDS assessments. She does work on them. The MDS Coordinator before her left several incomplete MDS assessments. If an MDS says in process, that means it is still being worked on and is not yet done. If it says validated, that means it is done, signed by a registered nurse, but not yet ready to be transmitted. If the MDS says production batch, it means it is completed, ready to be transmitted, but not yet transmitted. She is aware she is behind on several of them. Comprehensive MDS are completed on admission and at least every year.

Based on interview and record review, the facility failed to fully document physician orders [REDACTED].#1). The facility failed to provide the treatments by properly trained staff. The facility also failed to provide daily monitoring with documentation when a change was identified (chemical burn to the resident's abdomen), and failed to notify the physician promptly. The census was 36. Review of Resident #1's care plan, dated 2/8/18, under the category of pressure ulcers, showed the following: -Problem: At risk of pressure ulcers due to the need for staff assistance with repositioning, incontinence, and wearing of daily TED hose (long, tight fitting stockings that place mild static pressure on the lower legs to decrease lower leg swelling and to prevent the blood from clotting); -Approach: Resident will have skin assessed under TED hose every 4 hours, will have a weekly skin assessment by a licensed nurse, and will be repositioned every two hours; -Problem: Rash in belly button, dated 6/11/18; -Approach: No approach or intervention dated 6/11/18. -Problem: Excoriation to right groin, dated 7/12/18; -Approach: No approach or intervention dated 7/12/18; -Problem: Open area/blister to left medial thigh, dated 8/9/18; -Approach: Dermatology to follow skin issues and nursing to follow orders, dated 8/9/18; -Problem: Blister under left breast, dated 8/13/18; -Approach: No approach or intervention dated 8/13/18; -Approach: Apply [MEDICATION NAME] (an antibiotic that treats fungal infections) to blister under left breast as directed, dated 8/23/18. Review of the resident's Medication Administration Record [REDACTED]. During an interview on 10/1/18 at 3:05 P.M., Certified Medication Technician (CMT) A said when there are two CMTs on duty, one passes all of the residents' medications and the other takes the medication treatment cart, and does all of the residents' treatments according to the treatment administration record (TAR). The licensed nurse on duty does skin conditions/wounds, which require bandages, and those orders are in the Licensed Nurse Administration History record. Review of the resident's physician order [REDACTED]. -Apply two by two gauze dressing into naval ([DIAGNOSES REDACTED]. -8/13/18, Vinegar soak to open areas on navel/stomach, twice daily. Mix one tablespoon of white/yellow vinegar with 8 ounces (oz.) of water. Soak gauze in solution and apply to wound areas twice daily, for 20 minutes. Rinse off and pat dry with gauze. Continue the soaks until next follow up dermatology appointment on 8/20/18 (stop date 8/17/18); -8/17/18, bleach water to open areas on navel/stomach, twice daily. Mix one tablespoon of bleach with 8 oz. of water. Soak gauze in bleach solution and apply to wound area twice daily, for 10 minutes. Rinse off and pat dry with gauze. Continue soaks until follow up appointment on 8/20/18 (stop date 8/20/18); -8/18/18, Apply a thin layer (location of where to apply and [DIAGNOSES REDACTED]. Review of the resident's treatment administration record (TAR), from 8/1/18 to 8/18/18, showed the following: -8/13/18, Vinegar soak to open areas on navel/stomach, twice daily, was initialed as completed by CMT A, on 8/14/18, on the evening shift; -8/17/18, bleach water to open areas on navel/stomach, twice daily, was initialed as completed by CMT A, on the day shift, on 8/18/18, 8/19/18, and 8/20/18; -8/18/18, Apply a thin layer of Mupirocin 2% ointment, twice daily, was initialed as completed on the day shift by CMT B, on 8/18/18, and CMT A on 8/19/18 and 8/20/18. Review of the resident's dermatology consult, dated 8/20/18, showed [DIAGNOSES REDACTED]. Physical findings included the following: -A one centimeter (cm) area of erosion (skin erosion is a loss of some or all of the outer layer of skin, leaving a denuded surface) to the mid-lower abdomen with [DIAGNOSES REDACTED] (redness of the skin); -Three eroded bullae (large blisters containing fluid) on the lower abdomen; -Two eroded bullae on the right groin; -[DIAGNOSES REDACTED]tous patches (redness/inflammation of the skin) on inframammary region (the place where the breast and chest meet); -[DIAGNOSES REDACTED] on umbilicus. The consultation showed the following treatment orders: -Apply Mupirocin ointment, to open sores daily; -Apply [MEDICATION NAME] powder to area under breasts and groin, two to four times daily; -Apply [MEDICATION NAME] ointment (a strong steroid cream indicated for relief of inflammation and itching associated with certain skin disorders) to new blisters twice a day, to prevent blisters; -Apply zinc oxide ointment to eroded areas; -Short daily bleach baths (5-10 minutes) to remove irritants, allergens, germs, and to help moisturize the skin. Add one tablespoon of household bleach to a baby bath or ½ cup of bleach to a big tub; -Use a gentle cleanser to wash the body, such as Dove bar soap. Gently pat skin dry (do not rub) or leave damp and immediately apply a liberal amount of moisturizer (petroleum jelly, plain mineral oil, or [MEDICATION NAME] cream) to the entire body; -[MEDICATION NAME] (a broad spectrum antibiotic) 100 milligrams (mg) twice daily; -[MEDICATION NAME] 500 mg three times daily; -Return in two months. Review of the resident's physician order [REDACTED]. -8/20/18, Daily bath, for 5 to 10 minutes, with ½ cup of bleach added to the bath water, to remove irritants, allergens, and germs. Use Dove bar soap and immediately apply Vaseline to entire body, once daily (stop date 9/12/18); -8/20/18, Apply a dusting of [MEDICATION NAME] powder (location of where to apply and [DIAGNOSES REDACTED]. -8/20/18, Apply a thin layer (location of where to apply and [DIAGNOSES REDACTED]. -8/20/18, Apply a thin layer (location of where to apply and [DIAGNOSES REDACTED]. -8/20/18, [MEDICATION NAME] ointment (a skin protectant/moisture barrier ointment) to eroded skin (skin erosion is a loss of some or all of the outer layer of skin, leaving a denuded surface) areas (location of areas were not identified), twice daily (stop date 8/27/18); -8/21/18, Apply a thin layer of Mupirocin 2% ointment, to open sores (location of sores not documented) daily (stop date 8/22/18); -8/21/18, Apply a thin layer of [MEDICATION NAME] 0.05% ointment to new blisters (location of blisters not documented), twice daily (stop date 9/17/18); -8/21/18, Apply Vaseline to entire body after daily bleach bath (stop date 9/13/18); -8/21/18, Apply a dusting of [MEDICATION NAME] powder, under the breasts and groin ([DIAGNOSES REDACTED]. -8/22/18, Apply a thin layer of [MEDICATION NAME] 0.1% cream, (location of where to apply and [DIAGNOSES REDACTED]. -Additionally, the above topical creams, ointments, and powders, do not specify if they are to be applied before or after the resident's bleach bath. Review of the resident's care plan, showed no additional wounds, or wound treatment, updates. Review of the resident's treatment administration record (TAR), from 8/19/18 to 8/31/18, showed the following: -8/20/18, Daily bath, for 5 to 10 minutes, with ½ cup of bleach added to the bath water, use Dove soap, and immediately apply Vaseline to entire body, once daily, was initialed as completed by CMT A on 8/23/18, 8/24/18, and 8/30/18, by CMT C on 8/25/18, 8/26/16, and 8/29/18, and by CMT D on 8/27; -8/21/18, Apply a thin layer of [MEDICATION NAME] 0.05% ointment to new blisters, twice daily, was initialed as completed on the day shift by CMT A on 8/23/18, 8/28/18, and 8/30/18, by CMT C on 8/25/18, 8/26/18, and 8/29/18, and by CMT D on 8/27; -8/21/18, Apply a thin layer of [MEDICATION NAME] 0.05% ointment to new blisters, twice daily, was initialed as completed on the evening shift by CMT D on 8/26/18, 8/27/18, and 8/30/18, by CMT C on 8/29/18 and 8/31/18; -8/21/18, apply a dusting of [MEDICATION NAME] powder, under the breasts and groin, two to four times a day, three times daily, was initialed as completed on the day shift by CMT A on 8/23/18 and 8/24/18; -8/21/18, apply a dusting of [MEDICATION NAME] powder, under the breasts and groin, two to four times a day, three times daily, was initialed as completed on the evening shift by CMT A on 8/23/18; -8/22/18, Apply a thin layer of [MEDICATION NAME] 0.1% cream, three times daily, was initialed as completed on the day shift by CMT A on 8/24/18, 8/28/18, and 8/30/18, by CMT C on 8/25/18, 8/26/18, and 8/29/18, and by CMT D on 8/27/18; -8/22/18, Apply a thin layer of [MEDICATION NAME] 0.1% cream, three times daily, was initialed as completed in the afternoon (11:00 A.M. to 2:00 P.M.) by CMT A on 8/23/18, 8/24/18, 8/28/18, and 8/30/18, by CMT C on 8/25/18, 8/26/18, and 8/29/18, and by CMT D on 8/27/18; -8/22/18, Apply a thin layer of [MEDICATION NAME] 0.1% cream, three times daily, was initialed as completed on the evening shift by CMT D on 8/26/18, 8/27/18, and 8/30/18, by CMT C on 8/28/18 and 8/31/18. During an interview on 10/1/18 at 2:05 P.M., Nurse F, the 12 hour day shift nurse (6:30 A.M. to 7:00 P.M.), said prior to the resident's bleach baths, his/her wounds were being treated with [MEDICATION NAME] powder and they were not doing so good. Nurse F did not know who was applying the treatments because the resident had so many treatment orders. The resident was sent to a dermatologist and returned with an order for [REDACTED]. The bleach baths were on the day shift and the certified nurse assistants (CNAs) did them. Nurse F said he/she did not get the bleach, or add it to the bath water. The CNAs got the bleach from housekeeping and put the bleach in the bath water. He/she was not sure how much bleach they used and was not sure who told them how much to use. Maybe the other day shift nurse told them. The CNAs automatically knew how to do the bleach baths. Nurse F said he/she did not go into the shower/bath room to look at the resident's wounds every time he/she got the bleach bath. The CNAs kept the resident in the bleach bath for 10 minutes, because they knew this. Nurse F did not time them. When they got the resident out of the tub, they dried him/her off, got him/her dressed, then the CMT put the [MEDICATION NAME] ointment on the resident's right thigh, belly, left inner thigh, and anything else that was open. Review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 8/24/18, showed the following: -Moderate cognitive impairment; -Required assistance of one staff for bed mobility; -Independent with transfers; -Required a walker for walking and utilized a wheelchair; -Required total staff dependence with bathing, but required set up only; -Occasional urinary incontinence; -No bowel incontinence; -No scheduled or as needed (PRN) pain medications; -Open [MEDICAL CONDITION] with applications of ointments/medications; -Height: 65 inches; -Weight: 219 pounds. Review of the resident's licensed nurse weekly skin assessment, dated 9/7/18 at 12:44 A.M., showed the following: -Redness under left breast; -Small, open area to right groin, with some redness/excoriation still present; -Left medial thigh still has areas, which are being treated for [REDACTED]. -Open area to coccyx from shearing (shearing wound is caused by friction plus the force of gravity; gravity pulls the skeleton down, but the person's buttock skin is stuck to the mattress/chair, due to friction. As the person's bones slide down, blood vessels in between the skin and the bone can become compressed, stretched, and/or torn, causing a lack of blood flow to the tissue, leading to ischemia/tissue death and an eventual full thickness pressure ulcer); -No coccyx pressure ulcer measurements or description was documented on the skin assessment form. Review of the resident's medical record, showed: -9/7/18, no nurse's note; -8/1/18 through 9/30/18, no physician's wound treatment order for the resident's coccyx pressure ulcer. Review of the nurse's note, dated 9/11/18 at 8:48 A.M., showed the resident did not receive his/her bleach bath that morning. The resident asked the nurse if he/she was going to have a daily bleach bath forever. Nurse E placed a call to the resident's dermatologist, to ask about a stop date for the bleach baths. The dermatology office said they would call back, after speaking with the physician. Review of the nurse's note, dated 9/11/18 at 9:02 A.M., showed Nurse E spoke to the dermatology office, regarding a stop date for the resident's bleach baths, and was still waiting for a call back. Review of the resident's nurse's notes, showed no notes from 9/11/18 at 9:02 A.M. to 9/12/18 at 10:38 A.M. Review of the nurse's note, dated 9/12/18 at 10:38 A.M., showed the resident's family member asked the nurse how much longer the daily bleach baths were to continue. Nurse F called the dermatologist's office and asked how much longer the bleach baths were to continue. The office called back and changed the bleach baths to bleach soaks. They were to soak gauze in a bleach/water solution, place on open areas for 10 minutes, and apply [MEDICATION NAME] ointment daily. Review of the resident's physician order [REDACTED].M. and 2:00 P.M., and apply [MEDICATION NAME] per order. The order had no bleach to water ratio/dilution strength, exact location(s) of where to apply, instructions following treatment, and duration of the order. During an interview on 10/1/18 at 2:05 P.M., Nurse F said the resident's wounds were getting better, until the bleach baths were changed to the bleach gauze soaks. Nurse E called the dermatology office, on 9/11/18, because the resident's family member wanted to know how long the baths were to continue. The dermatology office did not call back, so he/she called the next day, on 9/12/18, and the office returned the call. They discontinued the bleach baths and added the bleach and water gauze soaks, to the open areas, for 10 minutes. The dermatology office did not specify the amount of bleach to water ratio. He/she should have clarified the order, but he/she thought people would have enough sense not to make the solution too strong because the bleach baths called for only ½ cup of bleach to a whole bathtub of water. The CMTs were doing the bleach gauze soaks. When asked how they, or anyone else, would know how much bleach to put into how much water, Nurse F said they would not know, but they should have asked. It runs downhill and other people should have asked too. Nurse F said he/she worked on 9/12/18 and 9/13/18 but did not look at the resident's wounds because a friend of the family told the Director of Nursing (DON) that he/she was not allowed in the resident's room. The DON texted Nurse F and told him/her, that according to the resident's friend, he/she was not to go into the resident's room. The DON told the resident's friend that Nurse F was the only nurse on duty, in the building, but he/she was told to stay out of the resident's room. There was no reason to go into the resident's room, the resident was fine, and the CMTs were doing the resident's treatments. Nurse F said he/she never did a bleach bath or bleach treatment on the resident. Review of the resident's dermatology physician notes, dated 9/11/12 at 11:21 A.M., showed the resident does not have to do a full bleach bath, that can be discontinued. They should take a basin of water, add one teaspoon (5 ml) of bleach to the water, dampen sterile gauze in the solution, and lay it over the wounds for 10 minutes. Then pat dry with sterile gauze and apply medicated ointments as already ordered. If the wounds worsen, they should follow up with the clinic sooner. Review of the resident's dermatology telephone encounter note, dated 9/12/12 at 10:38 A.M., showed the dermatology nurse called the facility, spoke to Nurse F, and relayed the physician's response. Nurse F had no questions. During an interview on 10/18/18 at 1:48 P.M., Medical Assistant H, with the dermatology clinic, said the dermatology nurse told Nurse F exactly what the MD had written in her notes. He/she was sitting next to the nurse, during the telephone call, and the nurse read verbatim what the MD had ordered. That is their protocol, to read the MD's exact words, as written. During an interview on 10/18/18 at 5:30 P.M., CMT A said he/she did the resident's bleach/gauze soak on 9/13/18 and all of the resident's affected areas were looking very good. The abdominal fold was almost healed, the navel was just a little discolored, and there was a little redness (not bright) to the left thigh. The areas were much better than they had been. CMT A said the treatment order did not specify how much bleach to put into how much water, but he/she thought the previous order had called for 5 ml of bleach to 8 oz. of water, so that was what he/she used. The prior order was actually for 15 ml of bleach to 8 oz. of water, so he/she had used less bleach. CMT A did not ask the nurse for clarification of the order, because the nurse was busy. He/she said it was within the CMTs' job description, to do bleach baths and bleach soaks, because there were no bandages involved. CMTs were allowed to treat skin conditions, with prescription creams, ointments, liquids, and salves, as long as there were no bandages involved. He/she had been carrying out physician's skin treatment orders, at the facility, for the past 12 to [AGE] years. Review of the resident's nurse's notes, showed no notes on 9/13/18. Review of the resident's licensed nurse weekly skin assessment, dated 9/13/18 at 11:42 P.M., showed the following: -Small open area to right groin with some redness/excoriation still present; -Shearing, open area to coccyx; -Dry skin to both lower legs. During an interview on 10/17/18 at 2:05 P.M., Nurse E, the 12-hour day shift nurse (6:30 A.M. to 7:00 P.M.), said all of the resident's wound areas were clear on 9/14/18. There were no areas to apply the bleach gauze soak to, so he/she did not do the bleach soaks, just applied the [MEDICATION NAME] ointment. Nurse E said he/she did not notice the bleach gauze soak order did not have the dilution strength, instructions following treatment, and duration of the order, because he/she never had to do it. During an interview on 10/18/18 at 5:30 P.M., CMT A said Nurse E did the resident's bleach gauze soak, on 9/14/18, because it was documented as completed by Nurse E on the TAR. Review of the resident's TAR, dated 9/14/18, showed the order to soak gauze with bleach/water and apply to open areas for 10 minutes, was initialed as completed by Nurse E. Review of the resident's medical record showed no nurse's notes, dated 9/14/18, documenting the status of the resident's wounds and that the bleach gauze soaks were held. Review of the nurse's note, dated 9/15/18 at 1:06 A.M., by Nurse G, the 12 hour night shift nurse (7:00 P.M. to 7:00 A.M.), showed that evening, on 9/14/18, the resident had new areas of redness to the right abdominal fold, right groin and right medial thigh. The area of redness to the right abdominal fold measured 4.5 centimeters (cm) by 1.5 cm. The area of redness to the right groin measured 6 cm by 2.5 cm. The area of redness to the right medial thigh measured 5 cm by 2.5 cm. All areas appeared at risk of becoming open areas and suggested the facility follow up with the dermatologist on Monday, 9/17/18. During an interview on 10/24/18 at 4:47 P.M., Nurse G said he/she checked the resident's skin areas again, around 4:00 A.M. on 9/15/18, and the areas had not changed. The resident said it was bothering him/her and they did burn a little. Nurse G reported the resident's new skin areas to Nurse E that morning, at change of shift, on 9/15/18. Nurse E told him/her about the resident's bleach baths being changed to bleach gauze soaks. Nurse G said he/she figured the red irritated areas must have happened as a result of that new order. Nurse E said nothing about the probable cause of the worsened skin areas and said nothing about holding the resident's bleach gauze soaks the day before, on 9/14/18, the day the areas went from being all clear to fresh reddened areas. Nurse G said he/she told Nurse E to monitor the resident's red areas throughout the day and call the dermatologist if they worsened. Review of the resident's TAR, dated 9/15/18, showed the order to soak gauze with bleach/water and apply to open areas for 10 minutes, was initialed as completed by CMT A. Review of the nurse's note, dated 9/15/18 at 4:26 P.M., by Nurse E, showed the resident's skin looked worse than the day before, so Nurse E had staff give the resident another bleach bath. The resident's treatment order had recently changed, from bleach baths to bleach gauze soaks, and he/she was not sure if that is what was irritating the resident's skin or not. He/she was monitoring the skin, to let the dermatologist know why the areas may be getting worse. The navel area measured 5 cm by 6 cm, the right abdomen measured 9 cm by 7 cm, and the lower abdomen measured 12 cm by 6 cm. Review of the nurse's note, dated 9/16/18 at 12:05 A.M., by Nurse G, showed the resident was having some sort of skin reaction. There was a large area of redness to the right abdominal fold, right groin area, right and left medial thighs, and the center of all these reddened areas appeared brown in color. The areas were cleansed with soap and water, and yellow drainage appeared on the gauze. The resident said the areas burned quite a bit. Compared to the areas the night before, the areas were larger. The resident's vital signs were obtained and Nurse G called the resident's primary care physician. He/she told the resident's primary care physician that the resident's skin reaction had progressed throughout the day. The physician ordered the resident be sent to the emergency room for evaluation of a severe condition that needs urgent attention, due to the rapid progression and character of the rash. Review of the nurse's note, dated 9/16/18 at 2:41 A.M., by Nurse G, showed the resident left by ambulance to the hospital. During an interview on 10/24/18 at 4:47 P.M., Nurse G said he/she returned to the facility, at 5:00 P.M. on 9/15/18, and heard from CMT A that the resident's skin had worsened. Nurse E also said the resident's skin was worse, but he/she did not describe it or give any detail/specifics about the worsened areas. Nurse G was busy that evening and did not get to see the resident's skin until about midnight. The areas were really bad. The areas were much worse, redder, much larger with brown areas in the middle, and clear drainage coming from the areas. The areas looked [MEDICAL CONDITION] he/she thought they were bleach burns, especially after seeing two perfectly straight red lines leading downward, toward his/her thigh and peri-area. They appeared to be drip lines/burn lines from where the bleach solution had dripped from the gauze. Nurse G thought someone probably got the bleach to water ratio too strong, and burned the resident's skin. He/she could not understand why they let the resident go all day with nothing done. He/she took a picture of the areas, with the resident's permission, and forwarded it to the resident's physician. The physician ordered the resident be sent to the emergency room for evaluation. Observation of the photograph, taken during the early morning hours of 9/16/18, showed large red and brown areas to the resident's right, lower, abdomen and groin. The upper, lower, abdominal reddened area had two areas, on the upper end, in the shape of a four-by-four gauze pad. The lower abdominal and upper-inner thigh area had two reddened streaks, leading downward. Review of the nurse's note, dated 9/16/18 at 1:53 P.M., by Nurse E, showed the nurse called a resident's family member, who was at the hospital with the resident. The family member said the hospital is assuming a possible chemical burn. Review of the resident's hospital record, dated 9/17/18 at 2:26 P.M., showed the resident was sent to the emergency room at 3:00 A.M., on 9/16/18, for worsened [MEDICAL CONDITION]. The resident said the areas were healing, until the day before, when something was applied to the areas that aggravated it. The resident said the areas hurt. The physician's note said the areas appeared to be [MEDICAL CONDITION] the bleach soaks were the suspicious cause. The bleach soaks were discontinued and the resident was admitted with a [DIAGNOSES REDACTED]. The resident's discharge [DIAGNOSES REDACTED]. Review of the nurse's note, dated 9/16/18 at 4:04 P.M., by Nurse G, showed the resident's family member's friend came to the facility and said the resident was being treated for [REDACTED]. He/she also said the resident told them that someone at the facility had poured some kind of liquid on him/her and he/she kept telling them it burned, but they did not listen. Review of the nurse's note, dated 9/17/18 at 9:42 A.M. (after the resident was sent to the emergency room for chemical burns), as a late entry for 9/15/18 at 9:21 A.M., by CMT A, showed that he/she did not apply the bleach gauze soaks to the resident's skin, as he/she had inadvertently documented as completed on 9/15/18. The bleach soaks were not done because the resident had a large reddened area to the right abdominal fold, right groin, and was complaining of a burning sensation. CMT A said he/she read the prior note, from Nurse G, and measured the resident's reddened areas to compare them to Nurse G's measurements. The areas were considerably larger than the night before. CMT A informed Nurse E, and Nurse E came to the resident's room. CMT A told Nurse E he/she cleaned the areas with normal saline, no bleach applied, and applied the [MEDICATION NAME] ointment. They discussed the possible cause of the worsened areas. Nurse E said he/she would have the aide give the resident a bleach bath, because that seemed to be what had helped the resident before. CMT A said on 9/13/18, he/she noticed the new bleach gauze soaks had no ratio, so he/she used 5 ml of bleach to approximately 200 ml of water. During an interview on 10/17/18 at 11:30 A.M., the DON said CMTs should not be working with any wounds. A licensed nurse should have been doing the resident's bleach gauze treatment soaks and the order should have been under the Licensed Nurse TAR, and not the CMT TAR. She was not sure if it was okay for the CNAs to perform the bleach baths, as she was not sure what the facility Administrator had told them. CMTs can apply lotions, creams, ointments, etc., but not to open areas or wounds. A nurse does not need to daily assess the areas the CMTs are treating, they should be [MEDICATION NAME] (treatments used to prevent a disease from occurring). During an interview on 10/24/18 at 2:30 P.M., the resident's primary care physician said the picture of the resident's skin, from the early morning hours of 9/16/18, was very bad, so she sent the resident to the hospital. Nurse G told her about the gauze bleach soaks which had been recently ordered. No one had called her about this new order, or about her worsening skin areas, until this call in the middle of the night. The bleach gauze soak order should have had the specific amount of bleach to water ratio and a stop date. CMTs cannot carry out these kinds of orders, only a licensed nurse. Review of the facility's Healing Wound Policy, updated 3/25/14, showed the following: -A LPN or RN are to take the Event Report with them, during treatment, to ensure all events are monitored daily; -Licensed staff are to evaluate wounds and current treatment for [REDACTED].>-Any wound can be discontinued by the LPN or RN, if no residual of the wound can be seen, except for scarring; -Licensed nurse must then close event and mark sheet as closed. During an interview on 10/17/18 at 11:30 A.M., the DON said in the electronic chart, any abnormal thing that happens, such as a wound or a bruise, was labeled as an event. A treatment order can be the event. MO 7542 MO 397