Every finding on record at Friendly Village Nursing and Rehab Center

Based on observation, interview, and record review, the facility did not ensure unlicensed staff would not administer medications to 1 resident (R27) for 5 residents reviewed for medication administration in a sample of 23 residents.Certified Nursing Assistant (CNA) D was observed by Surveyor applying a Lidocaine external patch 4% to R27's back.Findings include:The facility policy titled Administering Medication, revised 01/22/2024, states, Only licensed staff.may administer or record the administration of medications.certified medication technicians may administer specific medications under the direction of a licensed nurse if competency has been determined.R27 was admitted to the facility on [DATE] and has diagnoses of cerebral palsy and back pain. R27 has a physician's order for Lidocaine external patch 4% - apply to lower back topically two times a day for pain. On in AM and off in the evening. On 04/21/2026 at 9:05 AM, Surveyor observed CNA D apply a Lidocaine external patch to R27's lower back after completion of R27's bed bath. CNA D stated to Surveyor Nurses give to me to put on. Lidocaine patch was observed at R27's bedside prior to application. A facility licensed nurse was not observed by Surveyor in R27's room during application of Lidocaine patch to R27's back by CNA D. Surveyor observed Registered Nurse (RN) C administering medications to other residents on R27's wing. On 04/21/2026, record review of R27's medication administration record (MAR) indicated RN D's initials for administration of Lidocaine external 4% topical patch at AM time. Review of facility's staffing indicated CNA D did not work as a medication administration technician. On 04/22/2026 at 7:03 AM, Surveyor interviewed RN C, and asked which staff were permitted to administer medications within the facility. RN C stated registered nurses, licensed practical nurses and certified medication technicians could administer medications. On 04/22/2026 at 7:05 AM, Surveyor interviewed Director of Nursing (DON) B, and asked which staff were permitted to administer medications to residents at the facility. DON B stated all licensed nurses and certified medication technicians. DON B confirmed CNA D was not a certified medication technician and was not allowed to administer medications to residents. DON B confirmed to Surveyor a Lidocaine external patch was considered a medication as ordered by a physician. DON B stated RN C confirmed to DON B on 04/21/2026 a Lidocaine 4% patch was left by RN C in R27's room for CNA D to apply to R27's back. Certified Nursing Assistant (CNA) D, who is unlicensed, administered a medication (Lidocaine patch) to R27's lower back, which could result in an adverse event causing physical harm.

Based on observation, interview, and record review, the facility did not ensure standard and transmission-based precautions are followed to prevent spread of infections for 2 residents (R27, R25) of 23 residents reviewed for infection control precautions in a sample of 23 residents. The facility failed to prevent possible transmission of infection/disease to R25 and R27 as follows: Staff did not wear personal protective equipment (PPE) during cares performed for R27 who is on enhanced barrier precautions (EBP). Staff did not perform hand hygiene before and after cares performed for R27. Staff used contaminated gloves during application of topical cream to buttock and applying a new dressing to suprapubic catheter site for R27. Urinary catheter drainage bag lying on floor at foot of R25's bed without a protective barrier between drainage bag and floor. Findings include:The facility policies, titled Enhanced Barrier Precautions, dated 03/26/2024, and Hand Hygiene, last revised 05/08/2024, state, Staff will perform hand hygiene.before applying gloves and after removing gloves or other PPE.before moving from a contaminated body site to a clean body site.for residents for whom EBP are indicated, EBP is employed when performing.bathing, providing hygiene, changing briefs, device care including urinary catheter.Example 1R27 was admitted to the facility on [DATE] with diagnoses including cerebral palsy, a suprapubic catheter (indwelling urinary catheter), bowel/bladder incontinence, and history of frequent urinary tract infections. On 04/21/2026 at 9:08 AM, Surveyor observed Certified Nursing Assistant (CNA) D perform bathing/hygiene cares for R27. R27 was lying in bed and incontinent of bowel. R27 has EBP for a healing buttock wound and indwelling urinary catheter device. EBP precautions are posted outside R27's room. PPE is available for staff use inside of R27's room. CNA D did not perform hand hygiene prior to starting cares for R27. CNA D donned gloves but no other PPE including a gown. CNA D was observed cleansing R27's peri-area and buttocks of feces. Without performing hand hygiene or changing gloves, CNA D reached into a jar of Zinc Oxide cream with contaminated gloves and removed a large dollop of cream to apply to R27's right buttock. CNA D was then observed to cleanse around R27's suprapubic catheter insertion site without changing gloves. With same contaminated gloves, CNA D applied a new, clean gauze dressing to R27's suprapubic catheter insertion site. CNA D was observed to change gloves prior to performing personal hygiene to R27's torso but did not do hand hygiene in between. Example 2R25 was admitted to the facility on [DATE] and has an indwelling urinary catheter in place. On 04/21/2026 at 6:53 AM, Surveyor observed R25 lying in bed with indwelling urinary catheter lying on the floor near foot of R25's bed. The urinary catheter did not have a protective bag covering in place, nor was there a barrier device in place between the catheter and floor surface. R25's catheter was facing downward with urine drainage port touching floor. On 04/22/2026 at 7:03 AM, Surveyor asked Director of Nursing (DON) B when staff should wear PPE. DON B stated PPE is to be worn whenever a resident is on EBP. DON B stated staff is expected to perform hand hygiene before and after resident cares and remove contaminated gloves and do hand hygiene between contaminated areas.

Based on observation, record review and interview, the facility did not store resident foods brought in by visitors in a manner to prevent food-borne illness. The facility practice had the potential to affect 59 of 76 residents who reside on the main level of the facility on the 100, 200, 300 and 400 wings. The facility did not ensure the low temperature dishwasher chemical sanitizer maintained the correct concentration per manufacturer's guidelines. The facility practice had the potential to affect all 76 residents who are served foods from the facility's kitchen. Surveyor observed foods and beverages brought in for residents by visitors in 2 refrigerators/freezers in the nurses' station that were not labeled by resident or dated with received by and use by dates. Surveyor observed dish machine logs showing the low temperature dishwasher did not maintain appropriate chemical sanitizer minimal parts per million. This is evidenced by: Example 1 Surveyor requested and reviewed the facility policy titled Resident Food Brought in by Family or Visitors which was not dated. The policy in part read: It is the goal of this facility to maintain safe food practices in accordance with professional standards for food service safety. If bringing food into the facility for a resident, please contact the kitchen or the Dietary Manager to ensure that food will be: ~Covered, labeled, dated and stored in a way that maintains safe storage. ~Leftover foods will be used within 7 days. On [DATE] at 8:14 AM, Surveyor conducted an initial tour with Registered Dietician (RD) C. As part of the initial tour Surveyor and RD C observed 2 refrigerators/freezer units in the nurse station on the main level of the facility. The units are used for resident foods brought by family or visitors. Surveyor observed the units had a variety of foods and beverages stored in them which were not labeled with resident names. The foods and beverages were not dated with received dates and use by dates. Surveyor and RD C were joined by Nursing Home Administrator (NHA) A who indicated some of the foods/beverages may be staff's items. Surveyor asked RD C how the facility would know which foods/beverages are residents' items and how the facility would know the items are not outdated and safe for consumption. RD C responded you cannot tell who the foods/beverages belong to and whether the foods/beverages should be discarded. Surveyor requested a list of foods/beverages stored in the units and if the facility is able to identify resident foods/beverages. RD C expressed the refrigerator/freezers are for storage of foods/beverages for the residents who reside on the main level on 100, 200, 300 and 400 wings. Surveyor confirmed the facility practice had the potential to affect 59 of 76 residents. Surveyor received a list of foods from the refrigerator/freezers confirmed to belong to residents on the main level. With some foods noted as presumably staff as the facility could not confirm who the foods/beverages belonged to. The list noted the following items: ~prune juice ~Gatorade ~Miller Lite ~iced coffee ~carrots ~string cheese ~summer sausage ~Lipton teas ~pie (partially eaten) ~nutritional bars ~gluten-free bread ~Cousins sub sandwich dated [DATE], partially eaten ~chocolate cake ~orange juice ~diet cranberry juice ~apple juice ~pickles ~butter On [DATE] at 9:09 AM, Surveyor spoke with Dietary Manager (DM) D and RD C about food storage for food and beverages brought in for residents. RD C expressed both refrigerators/freezers were cleaned with foods/beverages removed yesterday due to the items not being dated/labeled correctly and not knowing the received by and use by dates. The facility policy indicates to discard foods in 7 days; however, the facility practice is to discard foods in 3 days to err on the side of caution and ensure foods are safe for consumption. The facility will be conducting staff education on the policy and doing audits going forward to ensure foods/beverages are labeled correctly and not expired. Example 2 Surveyor requested and reviewed the facility policy titled Dishwashing Procedure which was not dated. The policy in part read: Scope: The policy is pertinent to all kitchen staff and has the potential to affect all residents. Purpose: It is developed to ensure consistency in dishwashing methods, as well as compliance with temperatures and concentrations of all chemical used for mechanical ware washing .including both hot water sanitizing and chemical sanitizing machines. ~If the dish machine is not operating .including temperature and concentration of sanitizer .process must be stopped immediately and Dietary Manager and/or Maintenance Director must be notified. On [DATE] at 8:14 AM, Surveyor conducted an initial tour with RD C. RD C informed Surveyor the dish machine is a low temperature chemical sanitizing machine. Surveyor observed the dish machine log to be recorded for wash and rinse temperature along with ppm (parts per million) of the chemical sanitizer which had been recorded for February 2025. Surveyor noted the ppm recorded as 40 ppm for the supper meal on February 2, 2025. The log showed a note on bottom of the log stating Sanitizer concentration minimum of 50 ppm. Note: If any temperature or concentration is outside guidelines, notify Dietary Manager and/or maintenance immediately. Surveyor requested the dish machine log for [DATE] and noted the following: [DATE], breakfast: 32 ppm [DATE], breakfast: 40 ppm [DATE], lunch: 30 ppm [DATE], supper: 40 ppm [DATE], breakfast: 30 ppm [DATE], supper: 32 ppm Surveyor requested and received the manufacturer's guide for the dish machine. Surveyor reviewed the guide and noted the guide does not recommend a specific chemical to use or required ppm to ensure proper sanitation of dishes. Surveyor requested and reviewed the product information for the chemical used for the low temperature dish machine. The product information sheet noted the product as Sanitizer Lo Temp with description that read: Effective EPA registered .chlorine sanitizer for use in low temp dish machines. On [DATE] at 2:27 PM, Surveyor spoke with DM D, Assistant Dietary Manager (ADM) E and RD C about the low ppms as recorded on the dish machine logs. DM D expressed she recently returned from a leave of absence, approximately 2 weeks ago. Her expectation is for dietary staff to inform her as directed on the dish machine log when the ppm is low. DM D further expressed she then can check the ppm to determine if staff are correctly checking the ppm or if there are issues with the machine. In her absence the Assistant Dietary Manager should have been notified immediately. Surveyor asked ADM E if she had been notified in DM D's absence of low ppm of the dish machine. ADM E indicated she was not made aware of any low ppm readings in the absence of DM D. On [DATE] at 8:59 AM, Surveyor spoke with [NAME] Brothers Representative (MBR) F, who is responsible for periodic checks and maintenance of dish machine, DM D and RD C regarding the parts per million (ppm) levels of the dish machine and the process of checking the ppms. MBR F indicated the minimal temperature on the low temperature dish machine should be minimally 120 degrees Fahrenheit. The ideal temperatures for both wash and rinse is ,d+[DATE] degrees Fahrenheit as long as the ppm is at least 50 ppm. Lower than 50 ppm would not meet the minimal requirements which could affect the cleaning solution and affect proper cleaning and sanitizing of dishes. Surveyor asked DM D if she was aware of the low ppm readings which were evident on the log and if she or maintenance had checked the dish machine with the low ppms. DM D expressed she has no evidence of staff notifying maintenance or ADM E of the low ppms and there is no evidence the dish machine was checked or serviced. Going forward staff will be educated on the process and audits will be conducted to ensure proper ppm is maintained to ensure proper cleaning and sanitizing of the dishes.

Based on interview and record review, the facility did not ensure the mandatory staffing data that had been submitted from 7/1/24-9/30/24 was complete, accurate, and auditable. This has the potential to affect all 76 residents that reside in the facility. This is evidenced by: The facility policy titled Payroll Based Journal dated as revised on 2/26/22 in part read: Policy: Long-term facilities must electronically submit to CMS (Centers for Medicare and Medicaid Services) complete and accurate direct care staffing information, including information for agency and contracted staff, based on payroll and other verifiable and auditable data in a uniform format according to specifications established by CMS. Procedure: ~The facility must submit to CMS complete and accurate direct care staffing information, including: The category of work for each person on direct care staff (including, but not limited to, whether the individual is a registered nurse, licensed practical nurse, licensed vocational nurse, certified nursing assistant, therapist, other type of medical personnel as specified by CMS). ~Information on direct care .the hours of care provided by each category of staff per resident day. The Payroll Based Journal (PBJ) Staffing Data Reports that were generated quarterly document the facility triggered for Excessively low weekend staffing from 7/1/24-9/30/24 for specified dates. The specified dates are as follows: FY (Fiscal Year) Q4 (Quarter 4) 2024 (July 1-September 30). The facility provided Surveyor with Payroll-Based Journal Quarterly Totals 4th Quarter (7/01/24-9/30/24) report. The data that was submitted during this time frame for the specified dates showed an average daily census of 73.95. The data showed a decrease staffing percents from previous quarter as follows: Total Nurse Staff: (weekend): -2.4% Non-Administrative nurse staff: (weekend) -2.5% Registered Nurse (weekend): -15.7% Nurse Aide (weekend): -2.8% Surveyor reviewed the facility's daily schedule sheets for each date for the last four weeks and all dates had appropriately licensed staff on duty for each shift. Surveyor reviewed the facility's daily schedules for each date from 07/01/24 to 09/30/24 and all dates had appropriately licensed staff on duty for each shift. On 2/05/24 at 10:49 AM, Surveyor spoke with Director of Nursing (DON) B and Nursing Home Administrator (NHA) regarding the facility's process for reporting of nursing staff hours per PBJ. NHA A expressed the Human Resource Director (HRD) is the staff person in-house who usually enters the electronic timekeeping staff hours on a form that is submitted to the corporate office for reporting of staff hours. The facility's HRD is new to the facility and is still working on training in this process. The former HRD is no longer on staff. The corporate office enters the hours submitted by the HRD into the system for PBJ reporting. NHA A and DON B expressed agency staff that are used were not in the facility's system for electronic timekeeping thus their hours were not being accurately reflected in the PBJ hours report. In addition, the facility has medication assistants (MA) that are also Certified Nursing Assistants (CNA). The MAs were not coding CNA hours when working in the capacity of a CNA thus the certified nursing hours on the PBJ were inaccurate. The facility has also identified staff who are working longer than an 8-hour shift are not coding hours correctly, with the facility having several nursing staff on 12 hour shifts. The hours were not being accurately reflected in the PBJ. The facility was not aware of this issue until brought to their attention by Surveyor thus a plan has not yet been developed to correct the issue.

Based on interview and record review, the facility did not provide a notice of transfer to residents or resident representatives. This affected 4 of 4 sampled residents (R8, R9, R20, and R73). -A notice of transfer was not provided prior to a facility-initiated discharge for R8, R9, R20, and R73. -The facility did not inform the residents or their representatives, prior to a transfer, of appeal rights, including the name, address, and telephone number of the entity which receives such requests; and information on how to obtain an appeal form and assistance in completing the form and submitting the appeal hearing request. Findings include: The facility's policy, Policy & Procedure Admission, Readmission, Bed Hold, and Transfer/Discharge, read in part, Transfer/Discharge. Before the facility transfers or discharges a resident, the facility must- -Notify the resident and the resident's representative(s) of the transfer or discharge and the reasons for the move in writing and in a language and manner they understand. -Include in the notice- -The reason for the transfer or discharge -The effective date of the transfer or discharge which must be made at least 30 days before the resident is transferred or discharged . -A statement of the resident's right to appeal including the name, address, and telephone number of the entity which received such requests; information on how to obtain an appeal form and assistance in completing the form and submitting the appeal hearing request. Example 1 R8 was admitted to the facility on [DATE], after a fall which resulted in a fracture of her right ankle. R8's Minimum Data Set (MDS) assessment, dated 12/14/24, confirmed R8 scored 13/15 during Brief Interview for Mental Status, indicating intact cognition. R8 makes her own healthcare decisions. R8 was admitted to the hospital on 11/26/24 related to urinary tract infection (UTI). R8 was readmitted to the facility on [DATE]. On 02/04/25, Surveyor reviewed R8's record and was unable to locate a notice of transfer was provided to R8 prior to her transfer to the hospital. Example 2 R9 admitted to the facility on [DATE], with primary diagnosis of Multiple Sclerosis and paraplegia. R9's MDS assessment, dated 01/29/25, confirmed R9 scored 04/15 during BIMS, indicating severe cognitive impairment. R9 has an activated Power of Attorney (POA) to assist with health care decision-making. R9 was admitted to the hospital on 12/06/24 related to wound infection. R9 was readmitted to the facility on [DATE], with hospice services. On 02/04/25, Surveyor reviewed R9's record and was unable to locate a notice of transfer was provided to R9 prior to her transfer to the hospital. Example 3 R20 was admitted to the facility on [DATE], after a fall resulting in a fractured right lower leg. R20's MDS assessment, dated 01/05/25, confirmed R20 scored 15/15 during BIMS, indicating intact cognition. R20 has an activated POA to assist with health care decision-making. On 12/05/24, R20 was admitted to the hospital for UTI and pneumonia. R20 was readmitted to the facility on [DATE]. On 12/09/24, R20 was admitted to the hospital for respiratory failure. R20 readmitted to the facility on [DATE]. On 02/04/25, Surveyor reviewed R20's record and was unable to locate a notice of transfer was provided to R20 prior to her hospitalization s. Example 4 R73 was admitted to the facility on [DATE], after a fall resulting in a pelvic fracture. R73's MDS assessment, dated 10/22/24, confirmed the facility did not complete BIMS due to R73 not being able to understand or be understood by others. Staff assessment of R73's mental status confirmed R73's cognition was severely impaired. R73 has an activated POA to assist with health care decision-making. On 11/27/24, R73 sustained a fall with injury and was transferred to the emergency room . R73 received stitches for treatment of the injury and returned to the facility on [DATE]. On 02/04/25, Surveyor reviewed R73's record and was unable to locate a notice of transfer was provided to R73 prior to his transfer to the ER. On 02/05/25 at 8:26 AM, Surveyor interviewed Business Office Manager (BOM) I. BOM I and Surveyor reviewed the criteria to be provided at time of transfer, including: an explanation of the right to appeal the transfer or discharge, the name, address (mail and email), and telephone number of the State entity which receives appeal hearing requests, information on how to obtain an appeal form, and information on obtaining assistance in completing and submitting the appeal hearing request. BOM I indicated the facility was not providing residents with this information at the time of transfer. On 02/05/25 at 9:38 AM, Surveyor interviewed Nursing Home Administrator (NHA) A. NHA A provided documentation to support the facility is providing a notification of transfer for resident-initiated discharges. Surveyor requested evidence this notification was provided for facility-initiated discharges, and did not receive this information. Surveyor determined for emergent transfers, discharges with a return anticipated, or facility-initiated discharges, residents or their representatives did not receive a notification of transfer prior to the transfer.

Based on record review and interview, the facility did not accurately code the Minimum Data Set (MDS) for 2 of 2 residents (R) reviewed for Preadmission Screening and Resident Review (PASARR) screen. (R18 and R48) -The MDS assessments are coded in error stating that a PASARR level 2 screen had not been completed when it was completed at the time of assessment for R18. -The MDS assessments are coded in error stating R48 had a serious mental illness when, in fact, the mental illness was a result of progressive dementia. Findings include: Example 1 R18 was admitted to the facility on [DATE] with diagnoses including depression, anxiety, and PTSD. Record review identified R18 had a PASARR level 2 screen completed on 03/03/22. R18's comprehensive MDS assessment, dated 01/13/25, indicated for question A 1500 that No PASARR level 2 had been completed. Example 2 R48 was admitted to the facility on [DATE] with diagnoses that include dementia with severe agitation and delusional disorders. Surveyor was unable to find that a level 2 PASARR was completed for R48. R48's hospital discharge summary, dated 08/04/21, notes delusions were due to progressive dementia which indicates a PASARR level 2 was not necessary. R48's comprehensive MDS assessment, dated 04/24/24, indicated for question A 1500 that No PASARR level 2 had been completed which is correct but conflicts with question I 5950 that Yes R48 has a psychotic disorder (other than schizophrenia) which would require a level 2 PASARR screen. On 02/05/25 at 2:42 PM, Surveyor interviewed MDS Coordinator (MDSC) H and Social Worker (SW) G who completes the PASARR screenings for the facility. Director of Nursing (DON) B was present. Surveyor reviewed R18 and R48 with SW G and MDSC H. Both agreed that R18's MDS section A1500 should have been coded as yes a PASARR level 2 screen was completed. Also agreed that, R48's diagnosis should have been coded as dementia with psychotic disturbances, acknowledging the answer to I 5950 was inaccurate. MDSC H stated she she misinterpreted the guidance.

Based on observation, interview and record review, the facility did not ensure the resident (R) maintained acceptable parameters of nutritional status for 1 out of 3 residents reviewed for nutrition. R5 did not receive the assistance R5 required with eating. Weights were not obtained in over 60 days when R5 had been identified for high risk for altered nutrition. R5 had a recorded significant weight loss, and the facility did not reassess significant weight loss or her ability to feed herself. Findings include: The facility policy titled, Resident Height and Weight last revised 1/7/2025, documents, in part: All residents will be weighed upon admission and subsequently as the policy directs to provide a baseline and ongoing record for monitoring stability of weight as an indicator of nutritional status and medical condition over a period of time. Nursing department staff and Registered Dietitian (RD) will cooperate to prevent. Monitor, and provide intervention for undesirable weight variances for our residents . 8. Any weight change of 5 pounds or greater within 30 days will be retaken within 24 hours for verification, and re-weight will be documented in the EMR (electronic medical record) . 10. Care Plan interventions to be considered include, but are not limited to: a. Implementation of Fortified or Caloric dense foods and snacks b. Review of medical status (e.g. change of condition including chewing/swallowing problems, edema, decline in ADLs (activities of daily living) /self-feeding skills, infections or other acute conditions) . R5 was admitted to the facility on [DATE] with a diagnosis which included primary generalized osteoarthritis, type 2 diabetes mellitus, major depressive disorder, dysphagia, muscle wasting and atrophy, weakness, and chronic pain. On R5's Quarterly Minimum Data Set (MDS) assessment, dated 1/6/2025, the facility assessed R5 as having intact cognition with a Brief Interview for Mental Status (BIMS) score of 14. R5 was assessed as having no impairment with upper extremity range of motion (ROM). R5 requires setup or clean-up assistance; resident completes activity, with eating. No swallowing disorder noted. No or unknown weight loss indicated and is on a therapeutic diet. R5 has an activated Power of Attorney (POA). R5's care plan indicates, in part: R5 has potential for altered nutritional status related to recent hospitalization with low back pain and history including PI (pressure injury) stage 4, ., need for adaptive equipment, medication regimen, and need for SNF (Skilled Nursing Facility) services. Date Initiated: 9/30/2023. Revision on 12/10/2024 by RD C. Target date 3/31/2025. Goals: The resident will accept assistance with meals as needed through review date. The resident will maintain stable nutrition and hydration with no significant weight fluctuations through review date. Date Initiated 10/02/2023. Revision on 10/07/2024 by . (MDS Coordinator H). Target date 03/31/2025. Interventions: Adaptive Devices for meals: Light weight Built up silverware, built up soup spoon, and 2 handled cup with a straw hole in lid DIET TEXTURE - Level 7 - Regular, DIET TYPE - CCHO (Consistent Carbohydrate Diet), EATING - Prefers to eat in room, FLUIDS - Level 0 Thin (Regular), Monitor for s/s (signs and symptoms) of dehydration. Resident needs to be weight shifted on her right side during all meals so she can use LUE (left upper extremity) to feed self d/t (due to) limited ROM in RUE (right upper extremity), with bedside tray table within reach. can be weight shifted as needed between meals. Provide HS (hour of sleep) snack: Provide supplements with med pass as ordered for wound healing and to address malnutrition risk factors. Document and monitor acceptance. Weigh resident per facility policy or as ordered. Notify MD (Medical Doctor)/NP (Nurse Practitioner) per order or with significant changes. On 02/04/25 at 8:50 AM, Surveyor observed R5 awake lying on her side with her breakfast tray set up, lids off, on bedside table directly in front of her, food untouched. Surveyor asked R5 if she required help with eating or if she can feed herself. R5 said, They will come in and help me when they get time. R5 reported to Surveyor, I need help for all my care. 0n 02/04/25 at 9:00 AM, Surveyor interviewed Registered Nurse (RN) J, who reported R5's breakfast tray was not taken from room. RN J stated, She wants to work on it. RN J reported R5 usually will feed herself. Surveyor asked RN J about follow up when R5 does not eat. RN J reported, If she refuses to eat, she has supplements, and we encourage fluids. Record review indicated R5's intake at breakfast on 2/4/2025 at 11:50AM was -0-25%. On 2/04/25 at 12:32 PM, Surveyor observed Certified Nursing Assistant (CNA) K sitting in a chair, next to R5's bed, providing total assistance and feeding R5 lunch. R5 was alert and eating well. A review of R5's electronic medical record indicated on 12/01/2024, the resident weighed 183.5 lbs. On 02/02/2025, 60 days later, the resident weighed 163 pounds which is a -11.17 % loss. Progress note, dated 12/3/2024, stated, Nutrition/Dietary Note, Note Text: RD C update: Resident notes recent weight loss over the past month following prior higher weight status the month before. Per recent observations resident had noted need for greater assistance with feeding following prior ability to consume meals independently. Writer reached out to head of therapy to have team evaluate as needed. Current OT (Occupational Therapist) directions noted as part of resident's care plan to better assist resident to eat independently via proper positioning and placement of meal items and utensils. Therapy to evaluate whether resident's feeding status has shown declines with potential need for additional aides including adaptive equipment or physical assistance upcoming as appropriate. Resident continues on multiple ONS (oral nutritional supplements) at this time to address appetite and wound healing. Will continue encouraging all current interventions at this time. Additional inter-communication documentation was provided to the Surveyor from therapy department, which indicated, in part: TEAMS communication note dated on 11/25/2024 from RD C, reported, in part, When our CNA students were here last Tuesday, one of them was pretty much fully feeding her [R5] and noted that R5 needs that level of assistance for all of her meals . wondering if therapy has been in there to work with her [R5] recently at all . or whether her feeding instructions maybe should be updated if she really is needing that level of assistance. This communication indicated that R5 stated to RD C in response to eating, I can't do it by myself. Surveyor noted no new interventions added to R5's plan of care to address R5's inability to feed herself or documentation that R5's recent weight loss was addressed. There was no documentation found notifying the physician or the POA prior to 2/04/2025. No orders to weigh R5 more frequently to follow up on the weight loss. On 2/05/25 at 8:05 AM, Surveyor interviewed CNA K, who reported usually [R5] would get weighed monthly, because everybody gets weighed at least monthly. CNAs do not document weights but report them to the nurse. CNA K reports that if R5 is in a lot of pain or refuses to get a weight then he would report this to the nurse. Surveyor noted there was no documentation of R5 refusing to be weighed in December 2025. On 2/05/2025 at 10:00 AM, Surveyor interviewed Director of Nursing (DON) B, who reported the facility does not have a documented weight for R5 in January and she is unsure of why a weight was not done. DON B was not able to provide documentation that an attempt was made to reweigh R5 after her last weight. DON B stated, Yes, we need to do better at tracking and documenting weights to follow up with. On 2/06/2025 at 9:28 AM, Surveyor observed R5 in bed lying on her left side with breakfast tray uncovered directly in front of her on bedside table. R5's food appeared to not to have been touched. Staff were not assisting R5. On 2/06/25 at 9:30 AM, Surveyor interviewed RN L, who reported R5's breakfast tray was delivered at approximately 8:10 AM. RN L stated that according to R5's care plan there were no changes made regarding R5's ability to feed herself and R5's care plan indicates assistance with meal set up. RN L stated, I know she requires more assistance with eating lately. On 2/06/25 at 11:10 AM, Surveyor interviewed Speech and Language Pathologist (SLP) M. SLP M confirmed RD C sent communication on 11/25/24 that R5 was not able to feed herself. SLP M reported, They ensured the previous recommendations of range of motion prior to eating and positioning were being followed. Surveyor asked if therapy had reevaluated R5 with the change in R5's status. SLP M replied No, because we had just discharged her from therapy.

Based on meal observations, interviews and record review, the facility failed to distribute food under sanitary conditions, improper glove use, and food handling without proper hand hygiene. This has the potential to affect all 78 residents who reside in the facility. This is evidenced by: The facility policy and procedure entitled: Sanitization and Cleaning Schedule, states in part . 2. All foodservice employees must use one of two acceptable sanitary procedures when handling foods: a. Hands are washed using appropriate procedure and food is handled with tongs, deli paper or other utensils. b. Disposable gloves are used and changed when soiled, torn, or switching tasks. 3. Bare hand contact with ready to eat food is not permitted by dietary staff preparing or serving the food. On 01/08/24 at 7:48 AM, Surveyor observed Dietary Aide (DA) G dishing food onto plates to all residents. During food service process, Surveyor observed DA G resting gloved hands onto steam table and lean up against steam table with scrub top. DA G held the pen and clipboard to write food temps half-way through meal service. DA G then opened a sleeve of plastic bowl covers and removed as needed during serving. DA G would continue serving food by using utensil to place noodles and broccoli onto plate and would then use contaminated gloved hands to spread the food around on plate. No change of gloves or hand hygiene was observed by Surveyor during this process of dishing plates of food for all 78 residents. On 01/08/24 at 11:55 PM, Surveyor observed DA G touch DA G's face mask with left gloved hand, DA G then proceeded to pick up a hamburger bun with the same hand, and place on a resident plate without changing of gloves or conducting hand hygiene. On 01/09/24 at 7:49 AM, Surveyor observed DA G scratch the top of DA G's head prior to starting meal service. Then DA G proceeded to use tongs to place bacon and french toast onto resident plates. DA G used contaminated gloved hands to adjust bacon and french toast on the plate. Surveyor did not observe a change of gloves or hand hygiene during this process. On 01/09/24 at 12:47 PM, Surveyor interviewed Dietary Manager (DM) D, regarding expectation of glove changes, hand hygiene during meal service and utilizing gloved hands to touch food. DM D stated the expectations would be to utilize utensils and when gloves are contaminated, remove them, conduct hand hygiene, and put on a new pair of gloves.

Based on observations, interviews and record reviews, the facility did not maintain an infection prevention and control program according to professional standards of practice when droplet precautions of appropriate Personal Protective Equipment (PPE) were not followed, and improper hand hygiene was performed during cares. This affected 4 of 4 residents (R49, R72, R16, R71) observed for infection control. This is evidenced by: The facility policy entitled: Isolation Precautions under the category Droplet Precautions, states in part .3. Prior to entering the isolation room, the following steps are required: a. Perform hand-hygiene and apply gloves, gown, and mask prior to entering room. The facility policy entitled: Hand Hygiene, states in part, staff are to wash hands with soap or water or use alcohol-based hand gel .Before applying and after removing gloves . before moving from a contaminated body site to a clean body site during resident care; example: after providing peri-care, before applying moisture barrier or other treatments . Example 1 On 01/09/24 at 9:27 AM, Surveyor observed Maintenance Director (MD) E enter room of R49 who was on droplet Transmission Based Precautions (TBP). R49 had a Personal Protective Equipment (PPE) bin outside of the room, along with signage on R49's door directing which PPE is to be worn before entering the room. On 01/09/24 at 1:33 PM, Surveyor interviewed MD E regarding observation of not wearing PPE prior to entering R49's room. MD E stated that education was provided by the facility on wearing appropriate PPE prior to entering a resident's room that is identified as being on precautions. MD E stated he was unaware of the droplet precaution sign on R49's door nor the PPE bins in hallway outside R49's room. On 01/10/24 at 8:12 AM, Surveyor interviewed Director of Nursing (DON) B regarding observation of MD E not wearing PPE when entering R49's room, who was on droplet precautions. DON B stated that the expectation would be for a resident under TBP that all staff put on appropriate PPE as directed prior to entering room. Example 2 On 01/08/24 at 9:21 AM, Surveyor observed Certified Nursing Assistant (CNA) F, provide incontinence care on R72. CNA F conducted hand hygiene and donned a pair of clean gloves, stood R72, removed urine soiled brief, provided incontinence care, and proceeded to pull up R72's clean brief, pants, straighten R72's shirt and assisted R72 to sit down without removing gloves and conducting hand hygiene. On 01/09/24 at 11:22 AM, Surveyor interviewed CNA F regarding observation of not removing gloves and conducting hand hygiene after incontinence care for R72 on 01/08/24. CNA F stated facility educated staff on proper hand hygiene after incontinence care. CNA F was not aware that gloves were not removed or hand hygiene performed before proceeding with task. Example 3 On 01/09/24 at 6:58 AM, Surveyor observed CNA C conduct morning cares on R72. During the process CNA C removed soiled incontinent brief, conducted incontinent care, applied moisture barrier cream on buttocks, pulled up incontinent brief and sweatpants. CNA C placed a gait belt around R72's waist, held R72's right hand and assisted resident to walk to the chair. CNA C proceeded to remove the gait belt and place around CNA C's waist, disposed of dirty basin water in the bathroom, gathered supplies and placed them into the basin. CNA C then placed the basin into R72's closet. Surveyor did not have observation of CNA C removing gloves and conducting hand hygiene after incontinence care, prior to applying moisture barrier cream, touching R72's clean clothing, holding R72's hand, and touching gait belt, bathroom door handle and closet door handle. On 01/09/24 at 11:40 AM, Surveyor interviewed CNA C regarding observation of not removing gloves and conducting hand hygiene after conducting peri care and proceeding to touch a clean incontinent product, sweatpants, and R72's hand to assist him to walk to his chair. CNA C stated that facility provided education to remove gloves and conduct hand hygiene after peri care and confirmed that appropriate glove removal and hand hygiene were not conducted during this observation. 17661 Example 4 On 01/08/24 at 11:41 AM, Surveyor observed CNA I and CNA J assist R16 to the bathroom. CNA I placed a gait belt around R16 and assisted the resident to stand and pivot while holding the gait belt and giving R16 a bear hug, while CNA J pulled R16's pants down and removed a urine soiled incontinent brief. CNA J placed this brief into the garbage can. CNA J removed her gloves and donned a clean pair, without washing or sanitizing her hands. CNA J then exited the bathroom and opened R16's closet door to retrieve a clean incontinent brief. CNA I held on to the gait belt and gave R16 a bear hug to stand, while CNA J wiped R16 with toilet paper. R16 was assisted back to the wheelchair with CNA I continuing to bear hug and pivot R16 and CNA J guiding the wheelchair behind R16, using the handlebars of the chair. CNA J then removed her gloves and sanitized her hands. On 01/08/24 at 12:12 PM, Surveyor interviewed CNA J regarding her knowledge of performing hand hygiene. CNA J stated she was expected to wash or sanitize her hands . before or after cares, whenever touching a resident . all the time . Surveyor pointed out the observation made on R16 in which CNA J did not sanitize her hands after handling a soiled brief. CNA J stated, Oh yeah, I feel like I hit the sanitizer when I came out of the bathroom. Surveyor explained she did after resident was in wheelchair but not after removing soiled brief. CNA J stated, Oh, yeah, that could be. I should have then too. Example 5 On 01/08/24 at 12:06 PM, Surveyor observed CNA I and CNA J assist R71 to the bathroom. CNA I and CNA J donned a pair of gloves and assisted R71 to stand and ambulate approximately 3 feet into the bathroom. The wheelchair seat was saturated and puddled with strong concentrated smelling urine. R71 was assisted to sit on the toilet. CNA I removed the saturated brief and slacks from R71. CNA I then placed a clean brief and slacks on R71. CNA I then removed her gloves and without sanitizing her hands, donned a clean pair of gloves. CNA J sanitized the wheelchair cushion, and CNA J did not remove these now soiled gloves. After R71 was finished on the toilet, R71 was assisted to stand once again. CNA J then provided perineal cleansing for R71, then pulled up the brief and slacks. CNA I removed her soiled gloves but did not sanitize or wash her hands. R71 stood very steady during this time. CNA I and CNA J with contaminated hands assisted R71 to sit in the wheelchair, and in the process, guided R71's upper body and arms and moved the wheelchair, holding onto the arm rest. CNA J then removed the gait belt from around R71's waist and placed it around her own waist. CNA J then removed her gloves but did not yet sanitize her hands. CNA I then sanitized her hands. CNA J took the soiled brief and slacks in a plastic bag to the soiled utility room, opening the door knob of the room with her soiled hands. On 01/09/24 at 1:02 PM, Surveyor interviewed CNA I regarding hand hygiene. CNA I stated she was to wash or sanitize her hands, . every time I change gloves, touch someone, before and after pericare, Basically, all the time . On 01/10/24 at 8:12 AM, Surveyor interviewed DON B regarding the expectations of appropriate hand hygiene of staff and the provision of incontinent care. DON B stated that the expectation would be to remove gloves after incontinence care and conduct hand hygiene before continuing cares per policy.

Based on interview and record review, the facility did not ensure care plans were reviewed and revised based on changed needs and goals for antidepressant medications for 1 of 18 residents (R48) reviewed. This is evidenced by: R48 was admitted to the facility on [DATE]. R48's diagnoses include dementia with behaviors, anxiety disorder, and depression. R48's Minimum Data Set (MDS) dated [DATE] indicates Brief Interview for Mental Status (BIMS) of 10, which means R48 has a moderate cognitive impairment. R48's physician orders dated 01/25/23, includes in part, Citalopram 10mg by mouth once a day until 02/15/23, then give Citalopram 20mg once a day for severe depression. Surveyor reviewed R48's care plan with a target date of 01/09/24 where there is no mention of the antidepressant medication Citalopram which R48 is currently receiving. The care plan did include use of an antianxiety medication lorazepam which was confirmed by physician orders R48 was no longer receiving as of 01/11/23. On 01/11/23 at 8:31 AM, Surveyor interviewed Social Worker (SW) H regarding the care plans not being revised. SW H acknowledged that R48's care plan should have included an antidepressant plan and removed the antianxiety plan. SW H understood the issues and stated plans to correct it immediately.

Based on observations, interview and record review, the facility failed to provide the necessary services to maintain good personal hygiene following urinary incontinence for 1 of 4 residents reviewed (R16) for toileting and hygiene assistance. This is evidenced by: The National Association for Incontinence ([NAME]) states in part, .Urinary incontinence leaves the aging population at risk for impaired skin integrity. Exposure to urine and feces is one of the most common causes of skin breakdown . The [NAME] goes on to state that urinary incontinence makes the skin more susceptible to maceration, incontinent dermatitis, bacterial infections, fungal infections, and exposure to caustic agents, such as ammonia, a prime caustic agent in urine. [NAME] goes on to state, . Timely cleansing of the perineal area by using gentle, but effective, cleansers is essential to maintaining skin integrity, controlling odor, and providing comfort and improved self-esteem . R16 has medical diagnoses that include, but are not limited to severe vascular dementia, diabetes mellitus type II, and chronic kidney disease. A review of R16's Minimum Data Set Assessment (MDSA) was completed. This assessment was a significant change in status with an assessment reference date of 12/27/23 and indicated that R16 was dependent on staff to meet her most basic activities of daily living tasks, including personal and toileting hygiene. R16's cognitive status was severely impaired for both short-term and long-term memory and daily decision-making abilities. R16 is always incontinent of bladder function and frequently incontinent of bowel function. A review of R16's comprehensive care plan indicated the following concerns: 1. At risk for skin impairment related to cognitive deficits, use of assistive devices, decreased mobility, and urinary incontinence. (Date Initiated: 06/29/2023; Revision on: 12/18/2023). Note: R16 has a history of moisture associated skin damage, most recently in November 2023. 2. Has bladder incontinence related to dementia. She needs assist for toileting (initiated 06/06/18). Interventions for this plan include to, . Clean peri-area with each incontinence episode . Surveyor reviewed bladder evaluations completed for R16. The most recent evaluation was completed 08/10/23 and indicated R16 is always incontinent with an absent perception of the need to void. On 01/8/24 at 11:41 AM, Surveyor observed Certified Nursing Assistant (CNA) I and CNA J assist R16 to the bathroom. R16 was incontinent of a large amount of urine and voided on the toilet. Upon completion, CNA I held on to the gait belt and gave R16 a bear hug to stand, while CNA J wiped R16 with toilet paper, but did not cleanse R16's skin of the urine. R16 was assisted back to the wheelchair. On 01/8/24 at 12:12 PM, Surveyor interviewed CNA J and asked what education was received regarding incontinence care and the expectations of providing this care. CNA J stated that she has been a CNA since 2014 and stated that she is to provide perineal cleansing once in the morning with morning cares and each time a resident is incontinent. The observation made above was explained to CNA J by Surveyor and asked why it was not completed at that time. CNA J shrugged her shoulders and stated, Oh, it should have been, I guess I didn't do it. On 01/09/24 at 1:02 PM, Surveyor interviewed CNA I and asked what education was received regarding incontinence care and the expectations of providing this care. CNA I stated pericare was to be completed whenever a resident is incontinent. CNA I was not aware that CNA J did not cleanse R16's skin. On 01/10/24 at 8:12 AM, Surveyor interviewed Director of Nursing (DON) B regarding the expectation of staff related to incontinence care. DON B stated the expectation was to clean resident's skin following each incidence of urinary and/or fecal incontinence to remove bacteria that may cause skin irritation and breakdown, to provide dignity and prevent infections.

Based on observation, interview and record review, the facility did not ensure that a resident with a pressure injury (PI) received correct treatment and services, consistent with professional standards of practice, to promote healing for 1 of 1 resident (R) reviewed for PIs. (R4) Findings include: R4 was admitted to the facility on [DATE] with diagnoses, in part of pressure ulcer of sacral region, stage 4, diabetes, muscle wasting and weakness, and abnormalities of gait and mobility. R4's care plan revised on 12/26/23 indicates that R4 is at risk for PIs and had a PI to right buttocks. Interventions include to administer treatment as ordered. According to R4's Minimum Data Set (MDS) assessment, dated 10/06/23, R4 is cognitively intact. R4 is dependent on staff for all mobility, transfers, and toileting and is unable to stand or walk. R4 uses a Foley catheter and was always incontinent of bowel. R4 was assessed at risk for developing PIs and had one stage 4 unhealed PI at the time of admission. On 01/09/24 at 11:07 AM, Surveyor observed Licensed Practical Nurse (LPN) N provide wound care to R4's right upper buttocks. During the process, Certified Nursing Assistant (CNA) M rolled R4 onto R4's right side. Surveyor noted the area on and surrounding the wound contained a thick white paste substance and no dressing. LPN N cleansed the wound and surrounding area with soap and water. The open area on right side of coccyx area was approximately 1cm long dry slit with no drainage. LPN N mixed zinc oxide 20% with Miconazole Nitrate 2% powder and applied to the wound then applied a clean brief. Surveyor reviewed physician order and noted 2 orders were present: 1. Apply Zinc oxide ointment after application of miconazole powder to coccyx wound BID with cares and PRN with all incontinence cares two times a day for Wound care AND as needed for Wound care. Start date: 10/04/23. 2. Coccyx TX- Cleanse with wound cleanser, pat dry, apply skin prep to peri wound skin then cover with hydrocolloid dressing. Change every three days or prn when soiled, rolled edges or loose. One time a day every 3 day(s) for open area on coccyx. Start date: 12/26/23. On 01/09/24 at 1:20 PM, Surveyor interviewed Director of Nursing (DON) B and Registered Nurse (RN) O who is the facility wound nurse. When Surveyor asked what the current order was for R4, RN O stated that it is supposed to be the order to wash with wound cleaner, apply skin prep surrounding wound, and apply a hydrocolloid dressing. Surveyor informed DON B and RN O that R4 has 2 physician orders in the record. RN O stated RN O made the mistake and forgot to remove the old zinc order. Surveyor explained that during observation, LPN N applied the old treatment order. RN O stated that the practice is to have the physician remove older orders when a new order is received. RN O immediately assessed the wound, updated the physician regarding the error, and obtained a new order.

Based on observations, interviews and record reviews, the facility failed to provide pharmaceutical services related to the accurate administration of steroid inhaler to meet the needs for 1 of 1 resident reviewed (R20). This is evidenced by: Surveyor reviewed manufacturer's instructions for Symbicort on My Symbicort.com, which states, Symbicort may cause serious side effects, including . fungal infection in your mouth or throat (thrush). Rinse your mouth with water without swallowing after using Symbicort to help reduce your chance of getting thrush . On 01/09/24 at 3:09 PM, Surveyor observed Licensed Practical Nurse (LPN) N enter R20's room with eye medication and an inhaler. LPN N educated R20 to take a deep breath in and to exhale and then administered one puff of Symbicort Aerosol 160 MCG/4.5 with a spacer or aero-holding device. LPN N administered a second puff at 3:11 PM. LPN N did not educate or offer oral rinsing following this administration. On 1/10/24 at 1:27 PM, Surveyor interviewed Director of Nursing (DON) B regarding the expectation of staff with the administration of steroidal inhalants. DON B stated staff expectation is to . have the resident rinse their mouth after the inhaler to prevent thrush . Surveyor requested the facility policy for administration of inhalant medications and was informed the facility did not have a policy specific to inhalers. On 01/10/24 at 2:42 PM, Surveyor interviewed R20 regarding her knowledge of taking the inhaler Symbicort. R20 stated that she has no history of oral sores and has never been instructed to rinse her mouth after.

Based on record review and interview, the facility failed to develop and/or implement policies and procedures for ensuring the reporting of a reasonable suspicion of a crime in accordance with section 1150B of the Act. The facility did not report to local authorities when R2 pushed R1 to the ground. The facility reported incident (FRI) indicated R2 pushed R1 and caused her to fall to the floor. R1 experienced pain and required a transfer to the emergency room for evaluation. The facility did not report the incident to local authorities as outlined in the facility policy. This is evidenced by: Example 1 Surveyor requested and reviewed the facility policy titled, Vulnerable Adult Abuse and Neglect Prevention which is most recently dated 10/03/22. The policy reads in part: Purpose: To provide residents a safe environment that is free from harm. Investigation: ~If it appears that maltreatment may involve a crime, immediately notify the police as directed . Reporting of Incidents: ~Call law enforcement officials if suspected concern is criminal in nature (theft, assault, unwanted touch, etc .) ~The local police department will be notified of incidents involving any criminal conduct. Reporting Reasonable Suspicion of a crime: ~If you reasonably suspect a crime has occurred against a resident or person receiving care, you must report that suspicion to police and state survey agency. Surveyor reviewed the FRI from 7/29/23 at 1:50 PM. The FRI noted the following: Briefly describe the Incident: The accused resident [R2] was witnessed leaving the dining room on the 900 wing (memory care) quickly entering the hallway pushing down the affected resident [R1]. The incident was witnessed by the nurse on the wing and occurred unprovoked. After the incident the affected resident [R1] was complaining of hip pain and was sent to the emergency room for evaluation to ensure her safety. The accused resident [R2] was immediately redirected, and a new intervention was put in place to ensure safety of other residents. The new intervention was for staff to provide the accused resident [R2] with activities on the unit and walks off the unit to get out her energy. Law Enforcement Involvement: Was law enforcement contacted or Involved: No. On 8/14/23 at 11:00 am, Surveyor spoke with the Nursing Home Administrator (NHA) A, who conducted the investigation into the resident-to-resident altercation on 7/29/23 involving R2 and R1. NHA A described the facility process for investigating and reporting. NHA expressed the previous NHA had begun conversation with local authorities (police) on what is suspicion of a crime and what should be reported to local authorities. The policy is not clear, and expectations have not yet been developed with local authorities. NHA A expressed the incident was not an accident and it caused R1 pain. The incident should have been reported to local authorities and was not.

Based on observation, interview and record reviews, the facility did not maintain an infection prevention and control program designed to provide a safe, sanitary environment to prevent the transmission of communicable diseases, such as Covid 19 and other infections. This had the potential to affect one resident on the 400 wing, 5 residents on the 100 wing, and the 900 wing of this facility. The facility did not ensure staff wore appropriate PPE (Personal Protection Equipment) when entering rooms designated to have contact/droplet isolation in place for one room on the 400 wing, and 5 residents on the 100 wing. The facility allowed 2 of 7 employees who had been infected with COVID 19 to return to work before the recommended time frame had passed. This affected the 900 wing. Findings include: The facility was in a COVID 19 outbreak with 17 positive COVID 19 residents at the time of entrance. These cases of COVID 19 were spread throughout the facility and this involved all wings. The outbreak began on 3/9/23 with a resident who was sent to the ER. At the time the resident did not have any signs or symptoms of COVID 19 but was tested at the ER and found to be positive. The daughter of the first resident positive with COVID 19 on 03/09/23 called and informed the facility that she was in to visit the resident over the weekend and the daughter is positive with COVID 19. The facility identified the visiting daughter was the source of the spread of COVID 19. On 03/20/23, Surveyor reviewed the facility policy titled, Care of Resident with Suspected or Confirmed COVID-19. Under the subtitle Procedure number 8 states; The following measures will be implemented for residents with known or suspected COVID-19: Transmission based precautions will be instituted. Caregivers will don appropriate PPE-gown, N95, face/eye shield, gloves. On 3/20/23, Surveyor reviewed the Centers for Disease Control and Prevention (CDC) provided signs used to alert people that residents were on Droplet Precautions. It is noted that it states to-make sure eyes, nose and mouth are fully covered before room entry. On 3/20/23, Surveyor did a tour of 400 wing. It was noted that at that time there were 3 rooms with isolation carts outside the rooms and contact/droplet isolation signs on the doors. At 8:42 AM, Surveyor observed the staff passing breakfast trays on 400 wing. At that time Surveyor observed CNA (Certified Nursing Assistant) G deliver a tray to room [ROOM NUMBER]. The room had signage indicating the resident was on isolation/droplet precautions. CNA G donned gown, gloves, and an N95 mask. CNA G had on personal glasses and entered the room without applying goggles or a face shield. This is indicated to be worn on the isolation signs. At 9:05 AM, Surveyor observed the 100 wing. The 100 wing had 5 rooms designated to have contact/droplet precautions and one room that was in contact precautions. Surveyor observed Licensed Practical Nurse (LPN) F in a contact/droplet isolation room speaking with the resident. LPN F had on a gown, N95, and gloves but was wearing personal glasses. Surveyor observed CNA E walk into a room that was designated isolation/contact precautions to pick up a meal tray. CNA E had on a gown, N95 mask, gloves and was not wearing eye protection. At 9:15 AM, Surveyor looked inside the drawers and carts set out to house the PPE on each unit. It was observed that there were no goggles or face shields in these carts/drawers. On 3/20/23 at 9:10 AM, Surveyor interviewed LPN F and CNA E asking them what they did wrong in the isolation rooms. CNA E and LPN F were aware that they had not been wearing proper eye protection. At 9:30 AM, Surveyor interviewed Nursing Home Administrator (NHA) A regarding PPE supplies. Surveyor asked NHA A if they had any problems getting PPE supplies. NHA A stated they had not had any issues. At 12:50 PM, Surveyor interviewed Director of Nursing (DON) B regarding the expectations for what PPE staff should be wearing when entering a resident room with droplet/contact isolation. DON B stated they expected the staff to wear gown, N95 mask, proper eye protection, and gloves. Surveyor asked what proper eye protection was to the DON B who stated goggles, face shields, or side guards on regular glasses. The facility did not ensure staff are wearing appropriate PPE when entering COVID positive rooms. Surveyor reviewed the facility policy titled, COVID-19 Employee Screening, Quarantine and Return to Work. The policy states that HCP (Health Care Personnel) with mild to moderate illness who are not moderately to severely immunocompromised could return to work after the following criteria have been met: At least 7 days have passed since symptoms first appeared if a negative viral test is obtained within 48 hours prior to returning to work or 10 days if testing is not preformed or if a positive test at day 5-7 and again 48 hours later. The CDC memo titled, Interim Guidance for Managing Healthcare Personnel with SARS-CO-V-2 Infection or Exposure to SARS-Co-V-2 states the following: HCP who were asymptomatic throughout their infection and are not moderately to severely immunocompromised could return to work after the following criteria have been met: At least 7 days have passed since the date of their first positive viral test if a negative viral test* is obtained within 48 hours prior to returning to work (or 10 days if testing is not performed or if a positive test at day 5-7). On 3/20/23, Surveyor reviewed the line lists for staff since the last survey which was 2.5 months ago. Noted on the line list that in the month of March there had been 7 staff who had tested positive for COVID 19. Of note was CNA H who had an onset of symptoms on 03/12/19 and returned to work on 03/19/23. Per the CDC guidelines CNA H should have returned to work no sooner than 03/20/23. Also noted was CNA D who had an onset of symptoms on 03/13/23 and returned to work 03/20/23. CNA D should have returned to work no sooner than 03/21/23. The facility started counting the first day of symptoms as day one and staff returned to work one day early. On 03/20/23, the facility already had 17 residents ill with COVID 19 when the two staff returned to work one day early. On 03/20/23, Surveyor interviewed CNA D regarding the COVID 19 infection. CNA D was working that day on the 900 wing of the facility. CNA D indicated only working the 900 wing and did not work on any other wing. CNA D stated that on 03/13/23 they had called in sick with bronchitis, which they stated they got frequently as they had COPD. CNA D stated the next day 03/14/23 they felt better so they called the IC (Infection Control) nurse to see if they could return to work. The IC nurse stated they could but that they should test for COVID before returning. CNA D stated she tested negative for Covid 19 at home yesterday, 3/19/23. Today, 03/20/23, was the first day back. CNA H was not available to interview. On 03/20/23, Surveyor discussed the findings on the surveillance log with IC C. Surveyor pointed out that CNA D and CNA H were both allowed to return to work on day 7. IC C stated that the day on the line list that says onset of symptoms is really the call in day and that she had received a text from CNA H stating their symptoms started the day before, but that she did not update the line list. IC C also stated that CNA H had returned to work on 03/19/23. IC C stated that CNA D had sent a text stating she had symptoms the day before what was listed on the line list. IC C counted the first day of symptoms to determine the return to work day. Surveyor also noted that the line list did not indicate if and when CNA D and CNA H had tested negative in order to return to work after 7 days. Surveyor asked IC C why she had not updated the line list, and why if it was not updated, it was presented to the staff as a current line list. IC C stated they had not had time to go in and update it and had given surveyor what they currently had. The two staff involved did not meet the requirements to return to work, the facility did not have accurate surveillance logs to identify the correct date for staff to return to work.

Based on observation, interview and record review, the facility did not store, prepare, and serve food in a safe and sanitary manner. This has a potential to affect 75 of 76 residents (R). The facility's process for cooling foods was not done in a manner that protected the residents from foodborne illness. The facility did not periodically monitor food temperatures throughout the meal service to ensure proper holding temperatures were maintained. The facility did not ensure unit refrigerators were maintained at proper temperature and that resident food items were dated and labeled. COOLING PROCESS On 1/17/23, at approximately 8:45 AM during initial tour of the kitchen, Surveyor asked Interim Dietary Manager (IDM) C if the facility uses leftover food. IDM C stated the facility does not like to waste food. IDM C reported that cooling logs are not kept for leftover food. Surveyor observed wild rice, beef vegetable, and chicken noodle soups cooling in metal containers on a cart in the kitchen. IDM C stated that she prepared soups this morning for resident alternative meals. IDM C stated that she was not aware of the cooling process. Surveyor reviewed Public Health Service Food and Drug Administration Food Code, which states cooked potentially hazardous foods that are subject to time and temperature control for safety are best cooled rapidly within 2 hours, from 135 to 70 degrees F, and within 4 more hours to the temperature of approximately 41 degrees F. The total time for cooling from 135 to 41 degrees F should not exceed 6 hours. Improper cooling is a major factor in causing foodborne illness. Taking too long to chill foods has been consistently identified as one factor contributing to foodborne illness. FINAL COOKING AND HOT HOLDING TEMPERATURES On 01/18/23 at 11:36 AM, Surveyor observed dietary staff serving residents lunch in the dining room. Cook D reported that she had already taken temperatures of food. Surveyor reviewed food temperature log and noted appropriate food temperature for meal being served, however observed that the temperature log was not complete, missing meal temperatures, holding temperatures, times, and names of staff. Surveyor asked Cook D if she checks temperature of foods any time during the meal service to ensure that foods on the steam table are held at 135 or higher. Cook D indicated that she only takes the final cooking temperature of the food when it is placed in the steam table. Cook D stated that she can visually see that the food remains hot on the steam table. At approximately 12:35 PM, Surveyor asked Cook D to check temperatures of food on the steam table to ensure that holding temperatures were above 135. Temperatures were appropriate. Reviewed one month of temperature logs for food service. Per facility temperature log directions, temperatures should be recorded at the beginning and during meal service, for each meal. No temperatures logged for: 12/26/22: lunch and dinner 12/27/22: dinner 12/29/22: lunch and dinner 12/30/22: dinner 12/31/22: dinner 1/1/23: lunch and dinner 1/2/23: lunch and dinner 1/3/23: dinner 1/4/23: dinner 1/5/23: lunch 1/6/23: lunch and dinner 1/7/23: breakfast, lunch and dinner 1/8/23: lunch and dinner 1/9/23: lunch and dinner 1/10/23: lunch and dinner 1/11/23: dinner 1/12/23: lunch 1/13/23: dinner 1/15/23: dinner Interview with IDM C, she reported that she is aware that dietary staff are not completing temperature logs correctly. UNIT REFRIGERATORS Based on information sheet from facility titled, Information Sheet - Resident Food brought in by family or visitors, stated in part, Food that is prepared at home and brought in must be prepared in a way that maintains food safety. If bringing food into the center for a resident, please contact the kitchen or the nutritional service director to ensure that food will be: Covered, labeled, dated and stored in a way that maintains safe storage temperatures. Stored in a way that distinguishes it from food used or prepared by the Center. Handled using safe food handling practices, such as safe re-heating and hot/cold handling. Handled in a way to prevent contamination from equipment, if prepared/re-heated by the center. Clearly identified when served. Leftover foods will be used within 3 days. On 1/19/23 at 9:02 AM, Surveyor inspected resident refrigerator in main nurses' station. A temperature log was hung on door of refrigerator that was blank except for 1/17/23 temperature of 39 degrees documented. Upon opening refrigerator, the following was observed: -Plastic covered container of spaghetti that was not labeled with name or dates. -Plastic bag with a plastic container of soup, sandwich, orange and pickles with no name or dates. -Plastic bag labeled with resident name and room number (record review indicates no resident currently in building with that name or room number) with miscellaneous food items. -Resident food with name but no date. -Bottom of refrigerator had brownish liquid with 2 plastic bags with miscellaneous food items unlabeled with name or dated sitting on top of the liquid. 1 bag had a container of blueberries that was leaking inside of bag. - On the door of the refrigerator was a 1/4 full squeeze bottle of [NAME] Sour Cream with expiration of 11/2022. At 9:02 AM, interviewed facility staff including Director Social Services (DSS) J, Minimum Data Set (MDS) Coordinator E, and Medication Technician (MT) F and asked for the person responsible for resident refrigerator. SW was not sure. MDS Coordinator E stated Dietary staff. MT F stated charge nurse. At 9:14 AM, interview with IDM C, she reported that on 1/18/23 Registered Dietician (RD) I informed her that resident refrigerators are dietary department's responsibility, prior to that it was the responsibility of housekeeping department. Requested three months of temperature logs for unit refrigerators. MDS Coordinator E indicated that the facility did not have temperature logs for unit refrigerators. Based on the Policy and Procedure Sanitation and Cleaning Schedule provided by the facility with issue date 2/24/20 and revision date of 2/25/21. The facility has set forth the following standard for sanitary conditions in the dietary department, based on compliance with the regulations in the State Operations Manual and the Standards of Practice in the 2017 FDA Food Code, Procedure: Temperature 1. Refrigerator/Freezer temperature log must be completed and reviewed on a daily basis. Any temperatures outside requirements must be reported to maintenance and Dietary Manager and plans made to remove food as needed to an alternate storage area 2. Food, Temperature Record must be completed prior to the service of each meal, in each serving area, to ensure cold and hot foods are served at the proper temperature

Based on observations, interviews and record reviews, the facility did not ensure 1 of 4 residents (R49) reviewed for Pressure Injuries (PI), received care consistent with professional standards of practice to promote healing and prevent infection of existing PIs. R49 has PIs on his feet. A treatment was observed of these two wounds in which improper hand hygiene was observed during the dressing changes. According to the CDC (Centers for Disease control and Prevention), . The Core Infection Prevention and Control Practices for Safe Care Delivery in All Healthcare Settings recommendations of the Healthcare Infection Control Practices Advisory Committee (HICPAC) include the following strong recommendations for hand hygiene in healthcare settings. Healthcare personnel should use an alcohol-based hand rub or wash with soap and water for the following clinical indications: - Immediately before touching a patient . - Before moving from work on a soiled body site to a clean body site on the same patient - After touching a patient or the patient's immediate environment - After contact with blood, body fluids, or contaminated surfaces - Immediately after glove removal . This is evidenced by: R49 has medical diagnoses that include but are not limited to Alzheimer's Disease, Congestive Heart Failure, History of Methicillin-Resistant Staphylococcus Aureus Infection, Stage III PI to the left heel (present on admission) and an unstageable PI to the lateral right foot developed 9/15/22. Both wounds are in the healing phase. According to the most recent Minimum Data Set Assessment, which was a quarterly assessment, dated 10/6/22, R49 required extensive assistance of two staff for bed mobility, transfers and toileting assistance. R49 requires extensive assistance of one staff for dressing, personal hygiene and bathing. R49 was also assessed as being nonambulatory and frequently incontinent of bowel and bladder function. R49's Care Plan was reviewed and Surveyor noted the following: - Skin / Pressure Risk: . He has Moisture Associated Skin Damage, a stage III PU to L heel and a venous ulcer. At risk for impairment with weakness and limited mobility and poor safety awareness with lack of self care knowledge. Staff assist to keep clean and dry and complete treatments as ordered . In place to prevent worsening of his wounds, the facility implemented heel lift boots to be worn at all times, a low air loss mattress and repositioning based on a turning clock. Staff also assist and encourage him to elevate his legs for 20 to 30 minutes approximately every 2 hours. The most recent Braden Scale for Predicting Pressure Sore Risk was dated 1/15/23 and scored R49 a score of 17 (AT RISK 15-18). Treatment orders were reviewed and were: - 10/21/22: Left heel Cleanse with wound cleanser apply skin prep to peri- wound skin then cover with honey fiber dressing then cover with ABD (abdominal) pad and secure with bulky rolled gaze to be changed every other day and PRN (as needed.) - 10/20/22: Right outer foot: Cleanse with wound cleanser apply skin prep to peri- wound skin then cover with honey fiber dressing the cover with ABD pad and secure with bulky rolled gaze to be changed every other day and PRN. On 1/18/23 at 9:53 AM, Surveyor observed RN K (Registered Nurse) complete dressing changes to R49's wounds. RN K was assisted by RN H, who is currently being trained in to assist with wound care in the facility. R49 granted Surveyor permission to observe. Both staff sanitized and gloved prior to start of the treatment. RN H removed the old dressing of rolled gauze and a small 2 inch x 1 inch pad of Manuka Honey dressing, which contained brown drainage from the Left heel wound. RN H disposed of this in the trash canister. RN H did not remove the soiled gloves. Instead, she got out her phone and began to take photos of the wound. In the mean time, RN K sprayed several 4 inch x 4 inch gauze pads with wound cleanser. RN K then cleaned the wound. Once cleaned, RN K removed her gloves, sanitized her hands, then applied a new pair of gloves. RN K then applied skin prep to the area surrounding the wound. Once allowed to dry for about 15 seconds, RN K applied a 1 inch squared piece of Manuka honey pad to the wound. RN K then covered the wound with an ABD pad and Kerlix gauze. While this was being completed by RN K, RN H removed her gloves and without sanitizing her hands, applied a new pair of gloves. She then applied Betadine to a small abrasion on R49's left great toe, opened a strip of tape for RN K to secure Kerlix around foot and toes. RN H then applied the tape to the dressing while RN K held the Kerlix gauze in place. RN H then did not remove her gloves and either wash or sanitize her hands. Instead, she picked up R49's bed remote and her phone. RN K removed her gloves, but did not wash or sanitize her hands and donned a new pair of gloves. RN K proceeded to remove the old dressing from R49's right foot. The dressing adhered to the wound and RN K applied wound cleanser to moisten the area for ease of removing the adhered dressing. She then cleansed the wound with additional wound cleanser. The wound was located on the right lateral foot and was approximately a dime coin size. The old dressing contained brownish red drainage. RN K removed her gloves, and without sanitizing or washing, applied a fresh pair of gloves. She then cleaned the wound again. RN H began to take photos of the wound, still with the same gloves she wore with the application of the Betadine to the toe abrasion. RN K then removed her gloves after washing the wound. RN K then gloved again, without sanitizing and applied Betadine to an abrasion to R49's right great toe. She then removed her gloves, but did not yet sanitize her hands. RN H removed her gloves and applied another fresh pair of gloves without sanitizing or washing her hands. RN H then applied a Manuka Honey pad to the right lateral foot wound and covered it with an ABD pad then wraps the wound with Kerlix gauze. RN K then opened the top drawer of the nightstand to put away supplies. She then sanitized her hands. Once RN H completed wrapping R49's wound, she then applied a sock and boot to the right foot, removed her gloves, closed up the plastic bag with old dressings inside, opened the door to the bathroom, then picked up the bed remote, adjusted resident's hip and head pillow, picked up supply basin, then sanitized her hands prior to exiting room. At 11:22 AM, Surveyor interviewed RN K on her technique with hand hygiene. RN K was able to state the correct procedure in regards to hand sanitizing and/or washing, stating hands should be washed or sanitized before going into the room, after removing old dressings, remove gloves and either wash or sanitize; apply new gloves, clean the wound; remove gloves and sanitize; apply new dressing and make resident comfortable. Wash or sanitize when leaving the room. Surveyor explained the technique observed with RN K omitting sanitizing of her hands between removing gloves and donning new gloves. RN K stated, Yes, I know, I did some but I didn't each time I should have. It got a little confusing with both of us working on him. At 11:33 AM , Surveyor approached RN H and asked her what the correct procedure was related to hand hygiene during a dressing change. RN H stated, I walk into the room, sanitize, set up my stuff, sanitize and glove, remove dressing, sanitize, put on new gloves, and make sure my hands are dry. Then I apply gloves again and wash wound, remove the gloves and sanitize, apply new gloves and apply new dressing. I usually also will glove and then tie the plastic bag closed and then sanitize again before leaving the room. Surveyor explained the technique observed in which she applied Betadine to resident's left great toe and then continued to apply the honey dressing to R49's right wound, wearing the same gloves, then did not wash or sanitize and continued to touch other presumed clean items such as her phone the bed remote and the door knob to the bathroom. RN H stated that she is surprised she did that, it was a little confusing in the room with resident calling out with pain to his hip. Normally I am very careful with hand washing/sanitizing.

Based on observations, interviews and record reviews, the facility did not ensure 2 of 19 residents reviewed for quality of care (R65 and R28), received care and treatment in accordance with the individualized comprehensive assessments, resident preferences and person-centered care plans. - R65 was predominantly on bedrest by the facility choice regarding safety concerns. Observations and interviews reflect no repositioning completed for resident, other than micro-shifts. - The facility failed to treat and monitor non pressure skin openings in a manner that would promote healing for R28. Example 1 R65 has medical diagnoses that include, but are not limited to, Hemiplegia and Hemiparesis following Cerebral Infarction, affecting the Right Dominant Side, Attention-Deficit Hyperactivity Disorder- Predominantly Inattentive Type, Depression, Insomnia and Adult Failure to Thrive. R65 has a history prior to admission of sustaining a fall with Traumatic Brain Injury (TBI). R65 was hospitalized [DATE] - 8/11/22 for Covid-19 and returned to the facility on Hospice Services. According to the most recent Minimum Data Set Assessment (MDSA), which was a quarterly assessment dated [DATE], the following was noted: 1. R65 scored a Brief Interview of Mental Status (BIMS) score of 14/15, indicating she is cognitively intact (alert and oriented.) 2. R65 has no behaviors 3. R65 required extensive assistance of two staff to meet her most basic daily needs of bed mobility and toileting. 4. R65 required extensive assistance of one staff to meet her basic needs of dressing, eating and personal hygiene. 5. R65 is non-ambulatory and transfers have only occurred once or twice. She is frequently incontinent of bowel and bladder function. Care Plan: Not all-inclusive 1. ADL (Activity of Daily Living)/ Self Care and Mobility Deficits: . was admitted for rehab s/p (status post) fall at home with TBI. She understands but has some difficulty making self understood. Weak and unsteady with right hemiparesis from history Cerebrovascular Accident (CVA). Staff assist with ADL's with use of walker and wheel chair for mobility (Initiated 3/31/22 and last revised 11/30/22) Interventions: - check and change approximately every two hours and as needed to keep clean and dry. 2. I have limited physical mobility related to fall with TBI, history CVA with right sided weakness (Initiated 3/31/22 and last revised 11/30/22) Interventions: - bed mobility, assist of one staff 3. I am at risk for alteration in skin integrity related to decrease in mobility Skin / Pressure Risk: was admitted with a surgical wound on her scalp, abrasion to right foot, unstageable p/u (pressure ulcer)right malleolus, and a laceration on her left wrist. She is at risk for impairment with weakness and need for assist with mobility, in bed or wheel chair at most times, incontinence. Staff assist with mobility and hygiene. Wears a brief to wick moisture from skin. Pressure reducing mattress in place along with cushion in wheel chair. (Initiated 3/31/22 and last revised 11/30/22) Interventions: - Float my heels or use heel suspension boots while I am in bed - Keep my skin clean and dry - Toilet seat riser arms padded to prevent further skin injury - Use a draw sheet and 2 people when pulling me up in bed (to prevent shear) - Use a pressure relieving cushion for my wheel chair and pressure reducing mattress in bed (11/21/22, revised 11/30/22) - Use A& D Ointment, BAZA, or other Skin Barrier Cream on my skin as needed Also of note: the facility implemented bolsters on each side of the bed on 5/4/22 and extra pillows available for repositioning on 7/10/22. There is no indication resident is on bedrest or refuses to get up in wheelchair in the care plan devised for R65. There also were no directives given to staff regarding R65's repositioning needs. During the initial screening process on 1/17/23 at 9:08 AM, Surveyor noted R65 to be in her bed with body sized bolsters on each side. She was on her back with her head elevated to 45 degrees, the bed was low and there was a floor mat beside her right side. R65 was asleep with the television on. At 10:06 AM, Surveyor screened R9, who mentioned concerns with R65 , stating, . she's in bed every day all day and night. I am concerned she may develop a bed sore. I was a CNA years ago and worked here back in the 60's-70's. I remember how people developed bed sores, from no changing of their position. She lays there in bed all the time on her back. They should get her up once in a while so she can join in on some activities. There is no stimulation for her . R65 remained on her back alone in the room until 11:06 AM when Surveyor interviewed her. During the interview, R65 stated, she is always in bed, . They don't get me up out of the bed because they think it's too dangerous, they are afraid I will fall . I had a fall at home and had a brain injury from the fall, so my memory isn't always clear, but other times I am sharp. I would like to get up and go to some activities . Once, I was going to go to Bingo, and in the process of getting ready, they came into my room and told me I could not go, it was too dangerous to get me up. I lay here in bed, mostly on my back . Now I am getting a sore on my backside. I feel ignored, that they don't want to take care of me. I have never been anything but kind towards them, I don't know why they ignore me. I would like to eventually go home, but as long as I cannot walk, that isn't possible . At 11:46 AM, CNA L (Certified Nursing Assistant) entered the room with the noon meal tray. CNA L assisted R65 to eat meal and left the room at 12:10 PM. R65 remained alone in her room with no stimulation other than the television until Surveyor ended observation at 2:48 PM. She remained on her back. 1/18/23: At 7:39 AM, R65 was in bed on her back with HOB elevated approximately 30 degrees, asleep. The bed was low with the floor mat to her right and bolster cushions on each side of torso. At 7:52 AM R65 placed her call light on. At 7:58 AM, RN K (Registered Nurse) answered the call light. R65 questioned RN K regarding her laundry. RN K left the room with no offers to reposition R65. At that time, Surveyor entered R65's room and asked when she was offered repositioning by staff. R65 stated that initially staff entered her room at 4:30 AM to give her a bed bath, but she asked to sleep a little longer. R65 stated staff returned at 6:30 and washed her up, but did not offer to position her onto a side. She stated, . they never lay me on a side. My bottom gets sore from laying all the time on my back . - Surveyor continued to observe R65 and there was no activity of staff entering her room until she activated the call light at 8:30 AM and CNA L responded. R65 inquired about when her breakfast would arrive and CNA stated that it should be down in a little while. CNA L then left the room with no offers to reposition resident. - At 8:51 AM, R65's meal arrived at this time by CNA N, who placed the meal on R65's table, then left the room. - At 8:55 AM, CNA L entered R65's room and told her, I need to go and help someone to the bathroom and then I will come back and help you. Ok? She then left the room. - 9:01 AM, CNA L returned and assisted R65 with the meal. CNA L conversed with R65 during the meal. Once finished (9:13 AM), there were no offers to reposition R65 onto a side. Surveyor continued to monitor R65 for repositioning. - At 10:06 AM, no staff yet entered R65's room to offer or encourage repositioning. - At 10:32 AM, R65's roommate (R71) came back to her room and Surveyor interviewed her. R71 is alert and oriented and stated, . I know [R65] wants to get up, but nobody ever offers that for her. I think she would have a more meaningful life if there was something for her to do besides lay in bed and watch television. I never see staff come in and offer her to get up. They do some slight repositioning with her, as she needs to be changed often, you know rolling right and left to change the pad underneath her, but she is never laying on her side, always on her back. It's a miracle she doesn't have a bedsore. If they would get her up, she could go down and watch the birds or attend some activities. She really has no stimulation - At 10:49 resident activated her call light. CNA L responded. R65 was asking when she was going to get a shower. CNA L then began to change pad underneath resident; resident grants permission and Surveyor observed. CNA L stated to Surveyor that R65 does not get out of bed, and hasn't gotten up since she returned from the hospital after having Covid-19. CNA L stated that R65 was unable to get up in a chair because it was unsafe. CNA L also stated that she did not know if various chair options were attempted to create a safer sitting position for R65 and referred Surveyor to a nurse. Surveyor asked CNA L what the procedure is for R65 in regards to repositioning in bed. CNA L responded, . we can only place her on her back. There isn't enough room with the bolsters to lay her on a side. We only do the small changes in position when we change her pad . Once cares were completed, CNA L left the room (11:02 AM). CNA L only completed a micro-shift in the positioning of R65 when she rolled R65 right and left to change the soiled incontinent brief and replace it with a clean one. She then positioned R65 back onto her back. - Surveyor continued to observe R65 until meal service began at 11:58 AM. CNA L assisted R65 with the meal. Once the meal was completed (12:16 PM), there was no repositioning of R65 onto a side. R65 remained on her back until Surveyor ended observation at 2:58 PM. During this time, no staff entered to offer or encourage repositioning. She was left alone in her room with only the television on. 1/19/23: R65 was observed 7:18 AM - 10:20 AM. She was on her back in bed, bed was low with a floor mat beside her right side and body bolsters on each side. CNA L entered the room at 8:46 AM to assist with the meal and left the room at 9:18 AM. Upon leaving the room, no offers or encouragement to reposition were given to R65. At 10:30 AM, Surveyor interviewed DON B (Director of Nursing) on various topics, including the expectation of repositioning R65. DON B stated the expectation for R65 is to be repositioned every two hours. She further stated . repositioning means complete pressure redistribution, side to side positioning. She should be totally offloaded . Surveyor then explained what CNA L stated regarding R65's inability to lay on her sides due to the bolsters. DON B stated, Well then the bolsters are a problem. I did not know she wasn't being repositioned, but with [R65], sometimes its refusals with her head injury. I would need to check into that . At 10:49 AM, Surveyor asked CNA N what the expectation of repositioning R65 was. CNA N stated, We go in every two hours to reposition, roll side to side. We would prefer her to lay on a side, but she refuses. Surveyor then entered R65's room and asked her if staff offer to reposition her and she refuses. Surveyor explained that staff were indicating that she refuses to lay on a side. R65 stated, That is an out right lie. I do not refuse. I would like to lay in a different position. My bottom is sore from always laying on my back . Of note: At 10:51 AM, staff were in the process of getting R65 up into a wheelchair in order to change out the mattress, as Hospice was going to be discontinued and the current mattress belonged to Hospice. R65 remained up in the chair for about an hour before she tired and requested to go back to bed. 41994 R28 was an [AGE] year old resident admitted to the facility on [DATE]. R28 has a BIMS (Brief Interview for Mental Status) score of 15 which indicates she is cognitively intact. She has a PHQ-9 score of 03 which could possibly indicate some mild depression. R28 has a diagnosis of Atrial Fibrillation (fast irregular heartbeat), Type II diabetes, Weakness, Fracture of right shoulder, Osteoarthritis, and Psoriasis. R28 requires assistance with Activities of Daily Living (ADLs). On 1/17/23 at approximately 11:00AM, Surveyor observed open areas to R28's back of right upper arm at shoulder level. There were between 4 and 5, 2cm round open areas each surrounded by approximately 1/4 inch of redness. At that time R28 stated that they had Psoriasis and that it itched. R28 was observed to be picking at the area. On 1/19/23 at approximately 9AM, Surveyor again observed these areas. They now appeared to have a yellow center with a slight increase in redness surrounding each sore. R28 stated at that time that they itched. On 1/18/23, Surveyor reviewed R28's comprehensive medical record. It was noted that on 1/4/23 a nurse had faxed the MD a note: It stated that R28 had a history of psoriasis and has 4-5 scabbed areas to the right shoulder. It itches and she opens them. Requested Hydrocortisone 1% topically prn up to TID to affected areas. This was signed by the MD indicating it was approved. On 1/19/23, Surveyor reviewed R28's MAR (Medication Administration Record) and TAR (Treatment Administration Record) for the 3 months. It was observed that the treatment order was put on the MAR and that there were no signatures from nursing staff indicating that it had not been applied since received. On 1/19/23, Surveyor reviewed R28's progress notes in the Medical Record. On 1/4/23, there is a note that resident states she has a history of psoriasis and scratched open area on back of right shoulder related to psoriasis, area is now dry and scabbed, fax update and hydrocortisone request out to MD/NP. There were no other progress notes following up on the open areas. Surveyor reviewed the care plan; they do note the history of psoriasis but not the recent development of open areas noted on 1/4/23. On 1/19/23, Surveyor reviewed the skin assessments in R28's Medical Record done after 1/4/23. There was a skin assessment done on 1/7/23 that noted no open areas. On 1/14/23 there was a skin assessment done that states no new issues. There was no other mention of the skin openings noted in the chart. On 1/19/23, Surveyor reviewed the facility's policy titled: Pressure Injury Prevention and Wound Care Management. Under the bullet point Risk Identification and Assessment, it states under number 5, Residents skin will be monitored daily during cares by nursing assistant and a skin check will be completed weekly by a licensed nurse. Under number 7 it states: Skin impairments, including pressure injuries, non-pressure injury wounds, surgical wounds, skin tears, abrasions, etc should be assessed and documented weekly by the Wound Nurse, or designee, using the PCC (Point Click Care) Weekly Wound Assessment. On 1/19/23 at approximately 9:51 AM, Surveyor interviewed DON B regarding R28 and the open areas. Surveyor spoke to DON B regarding the order obtained on 1/4/23 for Hydrocortisone not observed on the TAR for January. RN F who was also in the room, looked through the record and found that the order had been placed on the MAR instead of the TAR by mistake. Surveyor, DON B, and RN F noted that no nursing staff had signed for the treatment, which indicates that it had never been applied. Surveyor asked the DON B what expectations there were regarding nursing follow up. DON B stated the expectation is that it gets done. DON would expect charting on the open areas, monitoring, and that it would show up the weekly skin assessments and that these assessments should be signed. On 1/19/23 at approximately 9:09AM, Surveyor spoke with R28 regarding the open areas. Surveyor asked if the areas hurt, and R28 stated they did not but they really itched. At this time R28 stated that they hadn't been putting anything on them.

Based on observations, interviews and record reviews, the facility did not provide an ongoing individualized and meaningful program to support the residents in their choice of activities designed to meet their interests and support their physical, mental and psychosocial well-being. This affected 1 of 2 residents (R65) reviewed for activity programming. R65 stated to Surveyor that there were no engaging activities offered daily and that she is bored with nothing to do to pass time. R65 is on bedrest and indicated that she had requested multiple times to get up so that she could attend activities, but the facility does not do so, stating that it is unsafe for her to be up. Three days of observations were conducted (1/17/23 - 1/19/23) in which there was no activities programming observed for R65. This is evidenced by: R65 has medical diagnoses that include, but are not limited to Hemiplegia and Hemiparesis following Cerebral Infarction, affecting the Right Dominant Side, Attention-Deficit Hyperactivity Disorder- Predominantly Inattentive Type, Depression, Insomnia and Adult Failure to Thrive. R65 has a history prior to admission of sustaining a fall with Traumatic Brain Injury (TBI). R65 was hospitalized [DATE] - 8/11/22 for Covid-19 and returned to the facility on Hospice Services. On 1/17/23 at 9:08 AM during the initial tour, R65 was noted to be in bed on her back asleep. She remained alone in her bed, with the exception of Surveyor interviewing her at 11:06 AM, until 11:46 AM when CNA L (Certified Nursing Assistant) entered the room with meal tray. CNA L assisted R65 to eat meal and left the room at 12:10 PM. R65 remained alone in her room with no stimulation other than the television until Surveyor ended observation at 2:48 PM. On 1/17/22 at 10:06 AM, during the initial screening process, R9 verbalized concerns for R65, stating in part, .I have concerns of my neighbor [R65], she's in bed every day all day and night . She lays there in bed all the time on her back. They should get her up once in a while so she can join in on some activities. There is no stimulation for her. She just lays there in bed all the time . On 1/17/23 at 11:06 AM, Surveyor interviewed R65 regarding activity participation. R65 stated . I did try to go to Bingo once and they were going to get me up to go and while I was getting ready, they came in and said I couldn't go because 'It's too dangerous to get you up.' I don't know how it is dangerous, they think I am going to fall. So I spend the majority of my time laying here in bed, watching television. I really would like to get up and do something. I feel ignored, that they don't want to take care of me. I have never been anything but kind towards them, I don't know why they ignore me. I would like to eventually go home, but as long as I cannot walk, that isn't possible. It gets very boring just laying here . I am losing all my strength and really don't have anything to do except lay here and watch TV . According to the most recent Minimum Data Set Assessment (MDSA), which was a Quarterly assessment dated [DATE], the following was noted: 1. R65 scored a Brief Interview of Mental Status (BIMS) score of 14/15, indicating she is cognitively intact (alert and oriented.) 2. R65 has no behaviors 3. Section D0200 Mood Interview or PHQ-score, was 10/27, coding R65 for the following: - Feeling down, depressed, or hopeless 12-14 days (3) - Trouble falling or staying asleep, or sleeping too much 12-14 days (3) - Feeling tired or having little energy 12-14 days (3) - Moving or speaking so slowly that other people could have noticed. Or the opposite - being so fidgety or restless that you have been moving around a lot more than usual 2-6 days (1) Note: PHQ is a diagnostic tool introduced in 2001 to screen adult patients in a primary care setting for the presence and severity of depression. It rates depression based on the self-administered questionnaire. A PHQ-9 score total of 0-4 points equals normal or minimal depression. Scoring between 5-9 points indicates mild depression, 10-14 points indicates moderate depression, 15-19 points indicates moderately severe depression, and 20 or more points indicates severe depression. 4. Section G (Functional Status) 0300 (Balance During Transitions and Walking) - Surface-to-surface transfer (transfer between bed and chair or wheelchair)- Activity did not occur Note: This also indicates that R65 was not getting up out of bed. The facility completed an Activity assessment dated [DATE]. According to this assessment, the following was noted: R65 has the following interests: - Lifetime Occupation: budget and policy worker for USDA (United States Department of Agriculture) - Activity Interests a. Pets/Animals b. Bingo c. Cards d. Current Events e. Knit/ Crochet f. Movies g. Music h. Reading i. TV -Interest in Life/ Activities (Very Interested) - Attitude (Cooperative, Cheerful) - Motivation (Motivated) - Preferred location of activities (Day/Activity Room) - Preferred time of activities (Afternoon) - Preferred waking time: 9 AM R65's Care Plan was then reviewed and Surveyor noted the following: 1. [Resident Name] is on hospice since her return from the hospital. Staff will visit 3 to 4x's (times) or as needed to offer any type of support or activities that would be of interest to her (Initiated 4/1/22 and last revised 11/28/22): GOAL: I will verbalize satisfaction with self initiated, group or in-room activities that are offered in the facility through the next review. Interventions: - Encourage/assist family involvement in resident's activities. Staff will offer any support as needed. - Inform resident times and channels of local news. Listings of channels will be posted in her room. - Provide 1:1 visits 3 to 4x's per week or as needed. - Provide monthly activity calendar of events/newsletter. One is posted in her room. - Reassess resident as needed for changes in activity preferences. - Respect the resident's right for limited group activity. Surveyor then reviewed the documentation regarding activity participation for R65 and noted the following entries: - 7/5/22: . has some limited movement but does participate in some activities.; [NAME] likes to play bingo, bunco, and a few other dice games. - 8/15/22: no group activity attendance at this time, watches some TV, listens to music; watching TV, visiting, 1x1 (one-on-one) contact, music, movies - 11/15/22: . spends all of her time in her room due to health issues at this time. She is accepting of 1x1 visits.; 1x1 visits, watches TV or listens Surveyor then reviewed R65's activity programming for the past 6 months and noted there was very little activity programs offered to R65. They were: August 2022: 1:1 (one-to-one) August 25 at 1:59 PM. No other times documented. Television (independently in room): 11 documented sessions R65 was in hospital 8/1/22 - 8/11/22 SEPTEMBER 2022: 1:1 charted 5 times, once daily Television charted 18 times Walking/Wheeling one time (9/21) OCTOBER 2022: No 1:1 was charted for the month Television: 7 days Walking/Wheeling: 1 day (10/2/22) NOVEMBER 2022: 1:1 was documented 5 days Television: 24 days DECEMBER 2022: 1:1 was documented 12 days Television: 21 days Crosswords: 9 times JANUARY 1-18, 2023 1:1 was documented 8 times Crossword: 13 times Television: 13 times Note: watching television in the room is not considered an activity, unless it is clearly documented as a preference for an individual rather than joining in other activities within the facility. ________________________ 1/18/23: observation - At 7:39 AM, R65 was in bed on her back with HOB elevated approximately 30 degrees, asleep. - 7:52 AM R65 placed her call light on; 7:58 AM RN K (Registered Nurse) answered call light, no active engagement in an activity was done at this time. - 8:30 AM R65 activated the call light; CNA L responded in which R65 requested her breakfast; CNA stated breakfast should be down in a little while, she then left the room; no offers to reposition or engage in any activity, besides the television being on, at this time. - 8:51 AM Meal arrived at this time by CNA N; CNA N left the meal at the bedside covered and left the room. - 8:55 AM- CNA L entered room and told resident, I need to go and help someone to the bathroom and then I will come back and help you. Ok? Then left the room. - 9:01 AM CNA L entered to assist resident with meal. CNA L did converse with R65 frequently during the meal. - 9:03 AM, AA M (Activity Aide) went room-to-room to inform residents that there will be BUNKO at 10:00. She did not enter R65's room. - 9:13 AM, R65 was finished with the meal eating and drinking 100%. There was no offer for an activity at this time. - 9:31 AM RN K entered R65's room to administer medications to her roommate. There was no offering of any type of engagement given to R65. - 10:06 AM no staff yet enter to offer or encourage repositioning - 10:49 resident activated call light. CNA L responded. R65 was asking when she was going to get a shower. CNA L then began to change pad underneath resident; resident grants permission and Surveyor observed. CNA L stated to Surveyor that R65 does not get out of bed, and hasn't gotten up since she returned from the hospital after having Covid-19. CNA L stated that R65 was unable to get up in a chair because it was unsafe. CNA L also stated that she did not know if various chair options were attempted to create a safer sitting position for R65 and referred Surveyor to a nurse. Once cares were completed, CNA L left the room. There were no activities offered to stimulate resident or engage her in anything other than the television, which was left on in her room. Surveyor continued to observe until 11:15 AM, for any activity engagement for R65 and noted none. At 11:17 AM, Surveyor interviewed AD O (Activity Director) regarding R65's activity involvement. AD O stated R65 . is not coming out of room due to her lack of being able to sit up in chair related to safety concerns. She is on Hospice and was choosing to stay in bed. She is getting stronger and the last care conference she was requesting to get up . we are working with therapy and hospice for options for chairs but continue to do room visits very often, every day . AD O referred Surveyor to the activity aide as she completes all of R65's programming. Surveyor again observed activity engagement/repositioning for R65 from 11:58 AM - 2:58 PM and noted none other than staff entering her room once for incontinent check and meal at 11:58 AM - 12:16 PM. R65 was then left alone in her room with the television on until Surveyor ended this observation at 2:58 PM. 1/19/23: From 7:18 AM - 10:20 AM, R65 was in her room on her back with the television on. R65 was alone with the exception of breakfast meal service in which CNA L entered to serve and assist with the meal at 8:46 AM - 9:18 AM when CNA L left the room. There were no attempts at engaging R65 in any activities or stimulation. At 10:22 AM, Surveyor interviewed AA M regarding R65's activity programming. When asked what 1:1 for R65 is defined as, AA M stated, It usually lasts about 5 minutes and it's generally just talking with her, seeing if she needs anything . sometimes I will ask her if she wants to work the crosswords, which she does on her own. She has a book on her table. She does this independently in her room. I don't sit with her and do them with her. Many times she doesn't want to do them but they are there if she decides to do them. At 10:30 AM, Surveyor interviewed DON B (Director of Nursing) regarding various topics, including R65 and her bedrest. DON B stated that R65 was complicated. DON B stated, I know they were trying to get her up and she would refuse. Or other times they would get her up and she could not maintain body alignment and would fall forward out of the chair. She did have a fall that resulted in hospitalization . I know they have tried different wheelchairs, tray tables and lap buddy, but these were removed because she felt she was restrained even though she could remove them. I don't think they tried a Broda chair, but therapy would have these documented. I know within the last 4 weeks they got her up and within 3 minutes she was calling out to go back to bed. Note: Even though R65 may not have been able to get up in a chair, there are numerous other opportunities to conduct engaging and life enriching activity programming in an individual's room. At 10:51 AM, Surveyor entered R65's room to talk with her on my findings. CNA L was in the room. R65 resident was fully dressed on top of the bed and there was a lipped mattress outside her room. CNA L stated they were going to get her up to change out mattress, and referred Surveyor to the nurse. At that time RN H was coming down the hall with a full body lift, and stated they were going to place a different mattress on R65's bed as Hospice will be discharging resident and the mattress she is using belongs to them. RN H stated that R65 . has a lot of strength so has good potential in therapy. Last week we did get order for an evaluation and plan for Hospice to discharge. [Resident Name] has been saying for a while now that she wants to get up and go to activities, so today we are going to try it. She has improved mentally and physically but prior to hospital and upon return, she was weak and confused. Now, she's eating and gaining weight. So I think she has good potential, even maybe to be one assist instead of two. At 11:03 AM, R65 was up in a tilt-back wheelchair. R65 had a big smile on her face. As RN H propelled R65 past Surveyor in the hall, R65 smiled at Surveyor and stated, Thank you.

Based on interviews and record reviews, the facility did not ensure the environment for 1 of 3 residents (R1) reviewed for falls, remained as free of potential hazards as possible, to prevent further falls from occurring. R1 returned to the facility after a hospitalization under hospice services as he was actively dying. The facility did not implement additional fall prevention strategies for R1 after a change in condition and prior to Hospice recommended interventions being put into place. R1 sustained a fall in which he hit his head on the floor expediting the dying process. This is evidenced by: R1 was admitted to the facility 12/3/21. Medical Diagnoses for R1 included, but were not limited to, Unsteadiness on Feet, Weakness, History of Covid-19, Pulmonary Fibrosis, [CONDITION(S)] of Native Coronary Artery, Diabetes Mellitus-Type II, [CONDITION(S)], [CONDITION(S)], and Hypertension. The admission Minimum Data Set Assessment (MDSA) was dated 12/10/21. At that time, R1 had a Brief Interview of Mental Status of 9/15, indicating moderate cognitive abilities. He had no behavioral indicators and was coded as requiring supervision of one staff for ambulation and limited assistance of one staff for transfers. R1 was also identified on this assessment as requiring limited assistance of one staff to meet his most basic daily activities of bathing, dressing, toilet use, and personal hygiene. On this assessment, R1 was noted to have a prior history of falling. The initial Care Plan was reviewed and was dated 12/5/21. The facility did identify R1 as being a fall risk. Interventions put into place at that time were: - Gripper socks on when up - Physical and Occupational Therapy to evaluate and treat Falls: - 12/9/21 1:30 AM: R1 had ambulated himself to the bathroom in a rush to prevent a diarrhea episode, and fell . No injuries were sustained with this fall. A commode was placed at his bedside to shorten the distance for toileting related to the diarrhea he was experiencing. On 12/20/21, there was facility documentation that R1 was having a change in condition, evidenced by increased confusion and restlessness, increased [CONDITION(S)] and weakness. He was previously up independent but on this date, needed two staff to assist related to being very weak, requiring a sit to stand lift for transfer to the bathroom. 12/20/21 8:00 PM: R1 was found on the floor in his room, in front of the recliner chair. The recliner foot rest was still extended and the recliner was tipped forward. R1 appeared very restless once assisted to bed, and was crawling out of bed, then assisted to the wheelchair, and attempting to get out of wheelchair, as well as the Hoyer lift upon transferring. Related to the extreme restlessness and confusion, facility decided to send R1 to the hospital to be evaluated. R1 was diagnosed with [CONDITION(S)]/Stroke, Acute Kidney Failure, and Hypothermia. Hospital indicated no cause for the Hypothermia, as all vital signs remained within normal limits and speculated that the cause may be related to Central Nervous System malfunction as a result of the stroke. R1 returned to the facility 12/24/21 approximately 1:05 PM, per nursing note dated same. R1 was readmitted under Hospice Services as he had a significant change in condition and was actively dying. Hospice entered the facility to conduct an admission to Hospice assessment. There were two documentation entries reviewed that were written by Hospice RN-D (Registered Nurse): 1. According to RN-D's handwritten entry of 12/24/21 6:15 PM, she ordered a hospital bed with a scoop mattress, a wheelchair, a bed side table and an oxygen concentrator machine. This handwritten documentation would have been conducted at the bedside of R1 at the time of the admission assessment. 2. The second entry, which was dated 12/25/21 at 7:36 AM was a typewritten documentation for the visit date of 12/24/21. According to this 21 page document, RN-D listed orders to the facility. Included in these orders were: - .Initiate fall precautions to minimize incidence of falls. Details/Comments: - Initiated fall precautions with instruction given to staff to minimize incident of falls - low bed with fall mat (Directive #19), and - . Coordinate ordering of necessary adaptive equipment . Details/Comments: Assisted in ordering of necessary equipment. Equipment ordered: Low bed, scoop mattress . (Directive #26) During this admission assessment, R1's son and POA, Family-C was present and elected to follow the Hospice mission of Do Not Resuscitate and no hospitalization s. The facility did not implement fall measures to protect R1 while awaiting the delivery of the Hospice ordered equipment. - 12/25/21 at 11:00 PM: R1 had an unwitnessed fall from bed. According to the documentation, .puddle of blood on the floor . and . wound to back of head with large amounts of blood . The facility activated Emergency Medical Services but after their arrival, Emergency Medical Services left the facility as they informed facility to call Hospice. Hospice RN-D was called and arrived at the facility at 11:50 PM. Upon RN-D's arrival, a comprehensive assessment was completed. RN-D measured R1's wound as being 5 centimeters (cm) length x 0.2 cm width x 0.1 cm deep and linear in shape. Documentation indicated R1 had a fall from bed and sustained a head gash to the left parietal area, causing a large amount of bleeding. The wound was cleansed and a dressing was applied. Ice was also applied to the injury. A Neurological assessment revealed a normal assessment. This documentation also indicates that R1 was not in the bed RN-D ordered, but in his normal double sized bed and there was no floor mat on the floor prior to the fall. [MEDICATION(S)] was administered for pain and RN-D ordered the staff at the facility to conduct neurological assessments at 2:00 AM, 3:00 AM, and then over the next three shifts. RN-D also ordered the staff to check on R1 at least every 30 minutes. The neurological assessments were performed and were within normal limits. R1 passed away 12/26/21 at 10:55 PM according to the phone call made to RN-D by the facility. He was pronounced dead by RN-D on 12/27/21 at 12:20 AM, when she arrived at the facility. The Medical Examiner reported to the scene on 12/27/21 at 12:20 AM. According to the Office of the Medical Examiner report, page 4, Description of Investigation, R1 had a fall . a couple days prior to his death . he had fallen out of bed and hit his head very hard on the floor .Compassus (Hospice) believes that this injury made his health decline very rapidly until death happened . According to the Death Certificate filed 12/30/21, the cause of death was Accident, and, Complications of unwitnessed fall with head injury, and, Victim fell out of bed, hitting head on the floor. On 2/23/22 at 2:13 PM, Surveyor interviewed R1's son/POA (Power of Attorney), Family-C, via telephone. Family-C stated R1 was given a double bed when he first was admitted , as that is what R1 was used to sleeping in at home. When R1's condition changed and was sent to the hospital after the stroke (12/24/21,) he came back to the facility under Hospice. He stated he visited R1 upon his return from the hospital and R1 was very restless, trying to get out of bed. I waited 10 minutes before anyone came into the room, and all they did was move him to the middle of the bed . They didn't do anything different . Family-C stated the Hospice nurse came while he was visiting R1 and ordered a regular twin bed that would be low to the floor. Family-C stated he was agreeable to that intervention if it would prevent R1 from any injuries resulting in a fall. On 2/23/22 at 3:30 PM, Surveyor interviewed the Director of Nursing (DON) of the facility. DON-B stated her expectation when Hospice orders equipment, is that staff implement it upon the equipment arrival. She stated until the equipment arrives, staff should, .do other measures until then for resident safety . A second interview with Family-C was conducted 2/23/22 at 5:50 PM. Family-C stated on Christmas Eve, when he was visiting R1, he noticed R1 was in the double bed, and RN-D met him at the facility. He stated RN-D and he spoke of R1's fall risk and she explained the need for a different bed that sat low to the ground and a floor mat to protect R1 should he fall again. He again stated that he agreed with the orders, I would never have refused a different bed if it was to protect Dad from falling or decrease his injuries from a fall . The double bed was before he declined. But once his health changed and he was getting restless and confused, they should have made changes to protect him .They were still treating him like before the decline .they should have done something more with him, that's why we place our parents in nursing homes, to make sure they're safe . Maybe Dad would still be here if they would have just done what Hospice ordered, a lower bed with a floor mat . but then, he fell again, hitting his head on the floor . DON-B was again interviewed on 2/24/22 at 11:20 AM regarding the fall on 12/25/21 of R1. DON-B stated the equipment arrived to the facility . around 4:00 PM on 12/25/21 . She stated staff did not change out the beds, as R1 was asleep. When asked if the facility implemented further measures to prevent falls, DON-B indicated that staff did not. At 12:18 PM, Surveyor interviewed RN-D regarding her recollection of R1 and the falls. RN-D stated that she did R1's Hospice admission on 12/24/21 beginning at 6-6:30 PM. At that time, RN-D stated she ordered a low framed bed with a scoop mattress and a floor mat to prevent injuries should R1 experience another fall. She stated R1 did have another fall on 12/25/21, in which he hit his head on the floor, and the bed and floor mat were in his room at the time of the fall, but R1 was still in the double bed, and not the bed she ordered. She also stated the floor mat was not in place. RN-D read to Surveyor her Durable Medical Equipment order. She stated, I placed the order on 12/25/21 at 5:47 AM, this would have been after I left the facility, the company acknowledged the order at 8:59 AM, and the equipment was delivered to the facility at 3:44 PM on 12/25/21. RN-D stated the facility did not implement the equipment when it arrived and then just before midnight at 11:44 PM, . I received a call from the facility that R1 had fallen and hit his head and there was a lot of blood. I told them I was on [MEDICATION(S)] . RN-D stated, It was very disturbing . prior to this last fall, he was still in the old bed. If anything at all, a floor mat would have been easy enough to implement. They didn't and he ended up with a head injury . something should have been in place . Disturbing is the fact that my orders of the equipment were in the room, but not being used . The facility had prior knowledge that R1 was a risk for falls. After his return from the hospital on 12/24/21, he was restless and confused, and had a change in his condition. Hospice RN-D ordered fall prevention equipment, but until it's arrival and implementation, the facility did not implement additional fall prevention measures. R1 fell again, and hit his head on the bare flooring. R1 passed away on 12/27/21.

Based upon observation, interview and record review, the facility failed to provide appropriate care and services to promote healing and prevent additional pressure ulcers from developing resulting in serious impairment to 1 of 3 residents (Resident #16). In addition to the resident in immediate jeopardy, the facility failed to provide care meant to promote healing, resulting in actual harm that is not immediate jeopardy to 2 of 7 residents reviewed for pressure ulcers (Resident #3 and Resident #6). Resident #16 was at for Risk for pressure ulcers. From 12/6/11, Resident #16 was being treated for [REDACTED]. Also, there were no clear directions on how the facility was evaluating or monitoring the risk of pressure ulcers. On 1/17/12, the wound care clinic noted that the Posterior Achilles Area has a open ulcer measuring 3.7 x 1.5 x 0.1 cm. and complaining of pain to the area. There was no comprehensive assessment or care plan developed for the Right Stage 4 pressure ulcer on the Achilles area. Subsequent documentation indicated that the ulcer was worsening and a second ulcer had developed. No care plan was developed to address the special needs of Resident #16. Staff did not address the resident's refusal at times to elevate her leg when in bed. When staff did elevate the leg, they placed pillows directly under the calf and achilles area, creating pressure on the achilles. On 3/6/12, the Achilles ulcer was cultured and found to be infected [MEDICAL CONDITIONS]. The facility did not develop interventions/outline precautions staff were to take when caring for the infected wound. On 3/29/12, due to the size and the severity of the wound the tendon was surgically removed. The wound clinic implemented a wound vac dressing to aid in healing. Observations found that Resident #16 was wearing a AFO (ankle foot orthotic) which was applying pressure directly to the wound. The failure to provide care and treatment to prevent the development of a stage 4 pressure ulcer and to provide care to promote the healing of the stage 4 pressure ulcer created a finding of immediate jeopardy. The immediate jeopardy began on 1/17/12 when the facility did not implement changes to Resident #16 plan of care related to treatment for [REDACTED]. The immediate jeopardy was removed on 4/5/12, but noncompliance remained at the lower scope and severity level of G (actual harm that is not immediate jeopardy/isolated), as evidenced by: Resident #3 who is at high risk for pressure ulcers was readmitted to the facility after left hip replacement surgery with a AFO for foot drop - not pressure relief - and a deep tissue injury on her left heel. From 10/26/11 through 11/13/11, Resident #3 continued to use the non pressure relieving AFO for extended periods throughout the day. On 11/16/11, a PRAFO (pressure relieving ankle foot orthotic) was implemented and could be worn all of the time. Resident #3 continued to wear the PRAFO on her left foot even after staff noted that Resident #3's foot was rotating inward and putting more pressure on her plantar area, which resulted in worsening of the pressure areas. Resident #3 continues ongoing treatment of [REDACTED]. Resident #6 was readmitted to the facility after a hospitalization with reddened areas. The facility did not assess for this high risk of further breakdown, did not monitor the areas, did not implement preventative measures to prevent further breakdown until the areas progressed to Stage 2 pressure ulcers. Resident #6 experienced increased pain and requested additional pain medications. This is evidenced by: The National Pressure Ulcer Advisory Panel (NPUAP) addressed the following: ~"Ensure that the heels are free of the surface of the bed...Heel-protection devices should elevate the heel completely (offload them) in such a way as to distribute the weight of the leg along the calf without putting pressure on the Achilles tendon. The knee should be in a slight flexion." (Emphasis added.) ~Stage 3, 4, or unstageable: "Place the leg in a device that elevates the heel from the surface of the bed, completely offloading the pressure ulcer...Ensure that the device is not too tight and does not create additional pressure damage..." Example #1 Resident #16 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The physician noted that Resident #16 always had history of left venous stasis ulcers not the right. The Annual MDS (Minimum Data Set), dated 9/14/11 indicates the following: ~Is alert, oriented and makes own decisions. ~Extensive assistance of 2 for transfers, bed mobility and assist of one with ambulation. ~Risk for pressure ulcers and has no venous stasis and no pressure ulcers. ~Wears an assistive device, AFO (ankle, foot orthotic) to the left lower extremity. ~Upper and lower left sided paralysis and requires staff to balance self. ~No infections The Care Area Assessments (CAAs) dated 9/14/11 indicate no current pressure ulcers, has history of vulvular [MEDICAL CONDITION] and LE (lower extremity) ishcemic ulcers, but these are currently not an issue for her. On 12/6/11, Resident #16 developed 3 open areas to her right shin area. A referral was made to the wound clinic. The wound clinic applied an Unna Boot dressing. An Unna Boot is a compression dressing, usually impregnated with zinc oxide. A Skin Condition template Care Plan dated 12/6/11 indicates a problem: "Skin condition Venous Stasis Ulcers" A handwritten, undated note states, "non-compliant with elevating legs." There is no mention of the Unna Boot treatment or direction for the staff on how they are to monitor for Unna Boot complications such as numbness, change in color of toes, excessive swelling, excessive itching, pain, bad odor, drainage. There are also no approaches related to Resident #16's choice to not elevate her legs. The Certified Nurse Aide assignment sheet under Cares addresses, "...elevate legs every shift...Skin prep to heels. PROM (passive range of motion) to Left upper and lower extremities with cares and splint program. There is no mention on how staff are to care/monitor the use of the Unna Boot. There are no approaches for elevating Resident #16's leg including type of device that was to be used. A nurse's note dated 12/13/11 states, "Pt. (patient) needs to elevate legs. If this cannot be done in wc (wheelchair) please assist her back to bed 2x/day (2 times a day) for 1-2 hours to elevate legs." Weekly documentation in the Wound Team Notes indicates that Resident #16 would not allow facility staff to assess the open areas under the Unna Boot. However, there is no documentation of observable areas including appropriate placement of the dressing, redness, swelling, etc. to the surrounding areas. On 1/17/12, Resident #16 was seen by the wound clinic. The Report of Consultation states, "...Posterior achilles area has open ulcer measuring 3.7 x 1.5 x 1.0 cm (centimeter). Wound bed has 50% red tissue and 50% yellow slough." Recommendations stated, "Encourage her to elevate legs..." There were no approaches added to the care plan to address Resident #16's care needs related to the development of the pressure ulcer on the achilles area. Resident #16's care plan did include a problem of "Potential for Noncompliance..." dated 6/10/10. On the care plan is a hand written, undated note that states, "Non-compliant with elevating legs." There are no approaches to address this issue. The December 2011 treatment sheets include a treatment to ensure Resident #16 elevates her legs by laying down 2 times a day for 1 to 2 hours each time. Documentation indicates 6 dates with refusals. There was no note as to what alternatives were offered or tried. Further review finds no documentation on Resident #16 elevating her legs for 10 days. Review of documentation in December 2011 found no daily assessment of wounds on 12/10/11, 12/11/11, 12/14/11, 12/16/11, 12/19/11, 12/20/11, 12/25/11, 12/26/11, 12/27/11, 12/28/11, and 12/29/11. The first entry in the facility Wound Team Notes after the 1/17/12 wound clinic consultation was dated 1/25/12 which states, "Note for 1-17-12 Unable to assess residents wounds this week as she has an unna boot on and is being followed by local wound clinic. Please refer to (wound clinic) notes." The note did not address the newly developed ulcer on the achilles area. The wound clinic note dated 1/23/12 states, "...Resident #16 has an irregularly shaped open wound on her posterior Achilles measuring 4.5 x 3.5 x 0.1 cm. It has 30% black, necrotic tissue and 70% pink moist tissue...The posterior Achilles area is measuring larger than it did last week..." The facility Wound Team Notes after the 1/23/12 wound clinic consultation was dated 1/27/12 and stated, "Note for 1-24-12 Unable to assess residents wounds this week as she has an unna boot on and is being followed by local wound clinic. Please refer to (wound clinic notes)." The entry does not address the ulcer on Resident #16's Achilles area and does not indicate any new approaches put into place to promote healing. The wound clinic note dated 1/30/12 states, "...She (Resident #16) reports that whenever she is in bed, they (staff) do elevate her heels up off the bed with pillows beneath the calf and Achilles area...(Emphasis added.) The right posterior calf and Achilles area has a stage IV (4) pressure ulcer. The Achilles tendon is exposed. This wound measures 6 x 3.7 x 0.2 cm. Above this area is another open area measuring 0.7 x 2.0 x 0.1 cm...I have instructed her (Resident #16) to not allow staff to put pillows beneath her calves as this is causing pressure. I have also written this out for the nursing home..." The Report of Consultation from the wound clinic from 1/30/12 stated, "*No pillow under calf in achilles area*" The facility Wound Team Notes after the 1/30/12 wound clinic consultation were dated 2/2/12 and stated, "Note for 1/31/12 Unable to assess resident's wounds this week as she has an unna boot on and is being followed by local wound clinic. Please refer to (wound clinic) notes." Again, the facility Wound Team did not address the Stage 4 pressure ulcer to Resident #16 Achilles area with exposed tendon. Review of Resident #16's care plan found no new approaches to address the Stage 4 and/or outline approaches staff should implement to promote healing of the wound. Review of the January 2012 treatment sheet indicates many refusals with elevating lower extremities with no documentation on what to do about this. A nurse's note dated 2/6/12 states, "...odor noted from rt (right) leg when positioning..." The wound clinic Report of Consultation, dated 2/6/12 states: "R achilles area with stage IV pressure ulcer. Change treatment to daily gently cleanse with saline. Apply TMC ([MEDICATION NAME]) oint (ointment) to dry areas not on wounds. Apply wound gel, [MEDICATION NAME], secure with [MEDICATION NAME] "Keep pressure off achilles area. Please elevate the heel suspension boot she is using. Don't want to put pressure on the achilles. "She has 2 open area - Achilles = 5.8 x 3.3 x 0.2 cm. Above achilles = 0.4 x 2.5 x 0.1 with yellow moist wound bed..." On 2/6/12, NP-Q (Nurse Practitioner) saw Resident #16 and noted, "...She (Resident #16) has developed a stage IV pressure ulcer to the right Achilles area...There is a sign of wound infection and did contact me and asked me to start an antibiotic..I am going to start [MEDICATION NAME] 500 (milligrams) once daily for 10 days for the wound infection..." The facility Wound Team Note dated 2/7/12 states, "Resident has stage IV pressure area to her right achilles heel. This was noted on wound clinic consult sheet 1-30-12. No previous mention of stage IV wound prior to this note...Today this wound bed is moist with approx (approximately) 80% of the wound bed having yellow tendon exposed and 20% pink tissue...wound measures 7.5 cm x 3 cm x 0.2 cm..." It should be noted that the wound clinic noted the pressure ulcer to the posterior achilles areas on 1/17/12. Review of Resident #16's care plan found no new interventions to promote healing/prevent worsening of the Stage 4 pressure ulcer. On 2/9/12, NP-Q noted, "Resident #16 has a wound infection...I have the C&S (culture and sensitivity) results back. She does [MEDICAL CONDITION] and start [MEDICATION NAME] 500 mg 1 by mouth three times a day for 10 days..." The nurse's notes state, "[MEDICAL CONDITION] positive to right lower extremity wound..." Resident #16's care plan did not identify [MEDICAL CONDITION] infection and did not outline appropriate interventions to follow, including isolation precautions, to follow when caring for Resident #16. It should be noted that on 2/11/12, the facility did implement contact precautions for Resident #16 related to signs and symptoms of gastrointestinal illness. The contact precautions were lifted on 2/14/12 once Resident #16 was symptom free. A wound clinic Report of Consultation dated 2/14/12 states, "R achilles stage IV pressure ulcer with 70% tendon 30% pink and yellow...Keep pressure off achilles area..." The quarterly MDS, dated [DATE], indicates the following declines: ~Resident is total dependent on two staff for transfers, bed mobility and toilet use. Resident does not ambulate and extensive assistance with locomotion. ~Verbal behaviors directed towards others that occurred the last 1 to 3 days. ~No rejection of care. ~Resident has a unhealed stage IV pressure ulcer measuring 6.5cm (centimeters) x 3.2 cm x 0.2 cm. ~Under infections the MDS identifies a Multi Drug Resistant Organism (MDRO). A 2/17/12 nurse's note states, "Fitted for brace to RLE (right lower extremity) by Prosthetic Orthotics. She may wear brace 24 hrs (hours) at a time, remove for skin checks." There is no indication of what type of brace was obtained. Review of Resident #16's care plan found no mention of a brace for the right lower extremity. The wound clinic Report of Consultation dated 2/22/12 states, "R achilles wound 6.5 x 3.2 x 0.2 cm with 80% tendon exposed. Tendon drying out and has tan and brown dry area on surface...Increase drsg (dressing) change freq (frequency) to BID (twice a day) to keep tendon hydrated..." The wound clinic Report of Consultation dated 2/28/12 states, "...Wound measures 6.5 x 3.3 x 0.2 cm. Wound bed has 30% red moist tissue and 70% exposed tendon." In February 2012, the treatment sheet indicates that no pillow is to be placed under Resident #16's calf at the Achilles area. There were no initials or documentation indicating that licensed nurses monitored this. The wound clinic Report of Consultation dated 3/6/12 states, "...Wound measures 6.1 x 3.5 x 0.2 cm, 70% exposed tendon...measures 5.2 x 2.8 cm..." A nurse's note dated 3/10/12 states, "...change in resident's rt lower extremity wound, increase in drainage, color is red/brown and purulent, very strong odor noted prior to wound care...wound bed next to tendon appears to be separating from tendon with tan slough noted...New order to culture wound and start [MEDICATION NAME] 500 mg tid (three times a day)x 10 days...Drainage red through the dressing and wrap, wound drainage on gauze removed was red with purulent green halo..." Review of Resident #16's care plan found no approaches, including isolation precautions, for staff to follow when caring for the infected pressure ulcer. The wound clinic Report of Consultation dated 3/13/12 states, "...Total wound measures 8 x 3.5 x 0.2 cm. Recommendations: Surgical consult..." The facility Wound Team Note dated 3/21/12 states, "...Stage 4 pressure area to right achilles area measures 9.5 cm x 3.2 cm x 0.2 cm. Wound bed is moist with 70% exposed tendon and 30% pink moist tissue. The pink areas are at the wound edges..." A Report of Consultation completed by the surgeon on 3/23/12 states, "R lower leg posterior wound with exposed tendon and superficial necrotic tissue. Tissue debrided in clinic to tendon depth. Will need excision of the tendon and then vac placement to facilitate closure of wound..." According to the hospital report, Resident #16 underwent surgery to remove the right Achilles tendon on 3/29/12 with placement of a wound vac for healing. The surgeon noted that the tendon, "...was very soft and had signs and symptoms of necrosis..." On 4/5/12 at 11:25 a.m. Surveyor # interviewed LPN-G (Licensed Practical Nurse/Unit Manager) about Resident #16's wound progression. LPN-G stated that that initially Resident #16 showed venous stasis ulcers. There were 3 wounds on her right medial shin, right lateral shin, and right lower mid shin. On 12/6/11 NP-Q was updated and a non-adherent and gauze dressing was ordered to be changed every day and a referral was made to the wound clinic. On 12/13/11 an Unna boot was ordered. LPN-G stated that the boot was to be kept clean and dry and was changed at the wound clinic. LPN-G stated she was not aware of the area until a Stage IV ulcer was noted on the wound consult sheet on 12/30/11. LPN-G stated the open area was on the back of her calf in a linear fashion from the pressure of the Unna boot. After this LPN-G stated that she had requested possible treatment for [REDACTED]. LPN-G submitted a copy of the requests. LPN-G stated that for the next several weeks, she was unable to assess the area as the Unna boot was on. On 2/6/12 the wound clinic record described the wound. On 3/6/12 the tendon was noted to be drying and surgery was done a couple to last week ago. LPN-G continued to state that a wound vac was ordered but there was too much bleeding and not used until later on. The wound clinic Report of Consultation dated 4/3/12 states, "Wound vac placed to R achilles area. Wound measures 10.9 x 4.4 x 1.4 cm. Wound bed has 70% pink/red tissue and 30% yellow/black tissue..." On 4/4/12 at 1:10 p.m., Surveyor # observed Resident #16 sitting up in the wheelchair wearing an AFO (ankle foot orthotic) on the right foot. The AFO has a metal bar that connects the foot piece to the leg piece. The boot does not provide pressure relief to the achilles area. Surveyor # noted that the bar was tightly on the Achilles area. This creates pressure on the Stage 4 pressure ulcer/surgical site. Resident #16 stated that she has had this boot for about a month and that she wears it all the time. "I was told not to put pillows under my legs anymore." Surveyor saw a large foam boot on the floor. When asked if she wears the large gold foam boot at all, she stated the staff put that bootie on my left leg at night. On 4/4/12 at 3:00 p.m., Surveyor # spoke with LPN-G who stated that before receiving the order for the foot device, the facility was using a foam boot. LPN-G confirmed that the AFO was received on 2/17/12 with directions that Resident #16 may keep it on 24 hours a day, with removal for skin checks. On 4/4/12 at 1:00 p.m., Surveyor # spoke with CNA-C (Certified Nursing Assistant) who stated Resident #16 wears a foam boot on the right leg when in bed and if she wants it elevated higher we put a pillow under her calf. There were no approaches on Resident #16's care plan related to use of an AFO or other type of boots. On 4/5/12, Surveyor # received the following information: ~A nurse's note dated 4/4/12 which states, "...assessed wound vac and tubing placement. Found that PRAFO could potentially cause pressure related to tubing placement with this specific PRAFO...Resident very accepting of new foam heel lift boot..." ~physician's orders [REDACTED]. ~A care plan dated 4/4/12 for Resident #16 indicating a problem of "Pressure Ulcer." Approaches in their entirety include: -Assess/record changes in skin status; -Report pertinent changes in skin status to physician; -Complete Skin Alteration Sheet at least weekly with shower/bath; -Educate resident/family about treatment and prevention; -Administer/monitor effectiveness of/response to treatment(s) as ordered; -Monitor the need for and provide consultation as needed to Physical Therapy and Occupational Therapy; -Invite, encourage to attend, remind, escort to activity programs consistent with resident's interests; -Provide diet as ordered and monitor nutritional status and dietary needs; -Turn and reposition with cares, round, and as needed, and "other" which is left blank; -Provide/monitor effectiveness of pressure relieving or reduction device(s), modified heel lift boot. The immediate jeopardy that began on 1/17/12 was removed on 4/5/12 when the facility: 1. Implemented walking rounds by Unit Managers to ensure pressure ulcer prevention/treatment approaches are implemented; 2. Re-educated all nursing staff prior to the start of their next scheduled shift on pressure ulcer prevention and treatment; 3. Re-educated all nursing staff prior to the start of their next scheduled shift on care planning pressure relieving approaches; and, 4. Review of new orders and consultation reports daily during the Interdisciplinary Team Meeting. Example #2: Resident #3's medical record includes the following Diagnoses: [REDACTED]. Further review of Resident #3's medical record reveals that Resident #3 has an activated health care agent (power of attorney for health care). Review of Resident #3's Minimum Data Set Assessment ((MDS) dated [DATE], reveals no pressure ulcers. The record reveals that Resident #3 was hospitalized between 09/23/11 and 10/05/11 for a total left hip replacement surgery. Resident #3's medical record reveals a Braden Pressure Ulcer Risk assessment dated [DATE] with a score of 16, which places Resident #3 at high risk for development of pressure ulcers. Review of Resident #3's Minimum Data Set Assessment dated 10/12/11, reveals the following: ~transfers with extensive assistance of 2 staff. ~extensive assistance of 2 staff for bed mobility. ~range of motion impairment both lower extremities. ~1 unstageable deep tissue injury ([MEDICATION NAME] tissue, new skin growing). Resident #3's Minimum Data Set assessment dated [DATE] indicates the following: ~no rejection of care. ~transfers with extensive assistance of 2 staff. ~extensive assistance of 2 staff for bed mobility. ~range of motion impairment both lower extremities. ~2 unstageable pressure ulcers. Review of Resident #3's current care plan obtained by Surveyor # , from the care plan folder in the nurses station on 04/04/12, indicates the following: "Onset: 07/02/11 Problem: At risk for pressure ulcers due to loss of positioning ability and weight loss, 10/26/11 Actual SDTI (Suspected Deep Tissue Injury) to left heel ...Approaches: Assist Resident out of bed. Body/skin audit at least weekly with showers. Record changes in skin status. Report pertinent changes in skin status to physician. Encourage intake of fluids on all shifts. Encourage resident to turn q (every) 2 hours to relieve pressure points. Evaluate nutritional and circulatory status. Keep linens dry and wrinkle free. Keep skin clean and dry. Wash with soap, rinse and dry. Monitor the need to and provide consultation as needed PT/OT (Physical Therapy/Occupational Therapy). Observe for any repeat signs and symptoms of pressure. Provide/monitor effectiveness of pressure relieving or reduction devices. mattress and w/c cushion. report any red or open areas. AFO (ankle foot orthotic) to LLE (left lower extremity) on at all times. TX (Treatment) SDTI per MD (Medical Doctor) orders. Keep heels off of bed. Barrier cream with every incontinent episode. Supplements as ordered. Avoid skin to skin contact." The Hospital Discharge Summary dated 10/5/11 includes the following: Resident #3 had left total hip arthroplasty on 09/23/11. Resident #3 developed left foot drop and decreased sensation in the foot and was found to have a hematoma at the surgical site. Resident #3 was taken back in surgery on 09/26/11 for evacuation of the hematoma. The report indicates that Resident #3 had evidence of a sciatic nerve compression. A cool foot on the left was noted on 09/27/11 and was found to have an occlusion of the left side of her fem-fem bypass graft, a vascular graft that had been placed years past. Resident #3 received TPA (Tissue Plasminogen Activator) infusion and it opened up the graft to allow reperfusion and flow. The report goes on to state that Resident #3 continued to have foot drop and numbness of the left foot. Resident #3 was fitted with a AFO brace (ankle foot orthotic) to avoid a footdrop. Review of the admission nursing assessment dated [DATE] reveals a bruised area to left heel, and 1+ [MEDICAL CONDITION] to top of left foot and lower ankle. Resident #3's physician's orders [REDACTED]." Nurse's note on 10/6/11 states, "...left leg on pillow to keep left heel off of bed. Res has a purplish area to left heel that is somewhat spongy...AFO is used to L foot due to foot drop..." Entries in the nurse's notes indicate that staff should be floating the heels when Resident #3 is in bed. The AFO continues to be used when the Resident #3 is up in the wheelchair. There is no documentation of an assessment of the the deep tissue injury identified on 10/6/11. A nurse's note on 10/19/11: "...Pressure points: (L) heel has dark area and this is suspended on pillow when in bed, skin prep is applied, and does have AFO on when up in wheelchair..." No additional entries were made regarding the status of Resident #3's heel ulcer. From 10/23/11 through 10/26/11 Resident #3 was rehospitalized due to increased swelling and pain of her left leg and foot. Review of a hospital history and physical dated 10/23/11, reveals that Resident #3 had increased swelling and pain of the left leg at the nursing home. This report indicates that a Doppler venous ultrasound was completed on Resident #3's left lower extremity and it revealed a occlusive or nearly occlusive clot within the proximal and medial femoral vein. The discharge summary dated 10/26/11 reveals that Resident #3 had a vena cava filter placed on 10/25/11 and a left lower extremity [MEDICAL CONDITION]. The Admission Nursing assessment dated [DATE] reveals the following: blackened area left heel and blackened area ball of left foot. The comments section indicates the following: "Pressure ulcer to L heel and outer aspects of ball of L foot." Surveyor # review of Resident #3's overflow purged medical record reveals a two page pressure ulcer care plan dated 10/26/11. The problem, need, strength, potential concern indicates the following: "Pressure ulcer: Suspect Deep Tissue Injury Present on Admit. R/T: Immomobility Disease process/condition: [MEDICAL CONDITIONS], ([MEDICAL CONDITION], [MEDICAL CONDITION]), Post-op Hematoma." The following approaches were included: "Keep heel (L) floated at all times., Heelz up pad, Keep heel (L) floated at all times pillows, skin prep L heel q (every) shift. AFO on at all times." A nurse's note date 11/2/11 states, "...On 11/2/11, the heel measures 10 cm x 4.8 cm. The area remains deep purple to black in color and has extended to cover much of calcaneous heel as well as the achilles heel. The lateral plantar foot measures 1 cm x 1.4 cm both continue same treatment..." Review of Resident #3's record reveals a progress note from Resident #3's primary nursing home physician dated 11/03/11. This note includes the following: "She seems to be doing okay. The nurses are a little bit concerned about her left Achilles area, where she has this AFO brace. This is no skin breakdown, but it seems to be a source of pressure irritation perhaps." The note goes on to state the following: "We will have OT (Occupational Therapy) take a look at her leg and make sure the the padding on the AFO brace is as it should be." The AFO is a rigid device that has some foam padding. However, it is not considered pressure relieving and may in fact create additional pressure. There was no change in the type of device Resident #3 wore on the left foot/leg. The AFO was suspected of causing pressure to Resident #3's achilles area, yet no changes in the device were made. On 04/04/12 at 8:20 a.m., Surveyor # spoke with LPN-G (Licensed Practical Nurse/Unit Manager). LPN-G indicated that Resident #3 was readmitted on [DATE] from the hospital, with an unstageable deep tissue injury on the left heel, and an area on the ball of the left foot after left hip replacement surgery. LPN-G indicated that she thought that Resident #3 had an AFO for her left foot/leg when admitted to the facility in June 2010 for strengthening for the hip replacement. LPN-G said that they were putting skin prep on the heel. LPN-G said that at the end of October or early November 2011 the facility felt that the AFO was not effective for pressure relief. LPN-G said that in the middle of November 2011 the area on Resident #3's left heel had brown eschar but had not yet opened up. LPN-G said that staff were putting the AFO on when Resident #3 was up in her wheelchair and when she was in bed, they were elevating her legs/heels with a heel lift or pillows. LPN-G said that she had contacted OT regarding this AFO brace and the fact that it was not pressure relieving. LPN-G said that she thought that she had contacted OT-X (Occupational Therapist) in mid November regarding this. On 04/04/12 at 12:50 p.m., Surveyor # spoke with LPN-G and RN-U (Registered Nurse/Corporate Consultant). LPN-G and RN-U indicated that Occupational Therapy padded the AFO on 11/14/11 or 11/15/11. LPN-G said that the first AFO was only used for transfers and at other times Resident #3 wore a soft heel protector boot. On 04/04/12 at 1:30 p.m., Surveyor # spoke with OT-X. (Occupational Therapist). OT-X said that the AFO that Resident #3 came from the hospital with in October 2011 was for foot drop and not for pressure relief. OT-X said that they had a schedule for Resident #3 to wear that AFO for 2 hours on and 2 hours off and this was in the nursing plan of care. OT-X said that he added padding to the AFO around 11/14/11 or 11/15/11 in order to take off the pressure from the area. This was 12 or 13 days after it was noted the heel ulcer assessed as progressing to the achilles area. On 4/4/12 at 8:20 a.m., LPN-G said that she also had contacted PO-T from Prosthetic Orthotics in November regarding a new pressure relief orthothic and a new pressure relief orthotic was delivered. LPN-G said that this PRAFO was supposed to be used at all times. On 04/04/12 at 12:35 p.m., Surveyor # spoke with PO-T. PO-T indicated that the first AFO that Resident #3 came from the hospital with was for the drop foot and was not a pressure relieving AFO. PO-T said that he dropped off a pressure relieving orthotic boot for Resident #3 on 11/16/11. PO-T said that this PRAFO was for pressure relief and could be worn all of the time. PO-T said that he was back at the facility on 03/07/12 to adjust the PRAFO. PO-T said that he trimmed the straps to position the foot. PO-T said that there were not a lot of options available for Resident #3. PO-T did not see Resident #3 related to modifications

Based on interview and record review, the facility did not ensure that 1 of 18 sampled residents received the necessary care and services with a significant decline medical condition. Resident #13 had a history of [REDACTED]. Resident #13 also had advanced directives which included that Resident #13 desired aggressive treatment, including CPR, in the event of an acute illness. On [DATE], Resident #13 had acute symptoms of shortness of breath, cyanosis, restlessness, low oxygen saturation, and abnormal lung sounds. Despite the acute change in Resident #13's medical condition, the physician was not consulted. Additionally, there were no interventions initiated aside from raising the head of Resident #13's bed. On [DATE], Resident #13's medical condition further declined. A physician was contacted but only ordered oxygen therapy. On [DATE], a nurse practitioner examined Resident #13 and ordered blood work and a chest x-ray under the direction of Resident #13's primary physician. The chest x-ray showed bilateral pneumonia. There was no consultation with the physician when the results were received by the facility. On [DATE], a fax was sent to the physician with an "FYI" summary of Resident #13's condition over the last few days along with a copy of the x-ray results. The physician responded "noted." On [DATE], Resident #13's medical condition had deteriorated to the point that she was exhibiting signs of [MEDICAL CONDITION], was hypotensive, and was hypoxic. Resident #13 was transported to the emergency room and admitted to the Intensive Care Unit (ICU) and diagnosed with [REDACTED]. On [DATE], Resident #13 expired. Throughout the coarse of Resident #13's significant decline, there was no comprehensive assessment of Resident #13's cardiopulmonary status including vital signs. There was also no timely physician consultation. This is evidenced by: According to the American Medical Directors Association (AMDA) Clinical Practice Guideline Heart Failure in the Long-Term Care Setting, "...Practitioners and nurses should evaluate the patient for signs...and symptoms...of heart failure and should document their findings..." The signs and symptoms included: ~"...Rales (or crackles) on lung exam; ~[MEDICAL CONDITION](fast heart beat); ~Third Heart Sound; ~Weight gain...; ~Acute Confusional state, [MEDICAL CONDITION]; ~Anorexia; ~Decline in functional status; ~Decreased exercise tolerance; ~Decreased food intake; ~Dyspnea at rest; ~Dyspnea on exertion; ~Fatigue; ~Orthopnea; ~[DIAGNOSES REDACTED] noctural dyspnea; ~Unexplained cough, especially at night; ~Weakness..." According to the Nursing Standard Respiratory assessment in adults dated [DATE], a respiratory assessment is necessary to determine if the body is receiving enough oxygen. According to the standard, a respiratory assessment would include the following: ~Inspection or observation of breathing to detect changes; ~Observing the rhythm of breathing to detect changes; ~Observing the quality of breathing noting changes; ~Observing the degree of effort to breath including observing for the use of accessory muscles, pursed lips, or nasal flaring; ~Observing for any deformities; ~Observing for any changes in mental status; ~Assessment of any cough; ~Auscultating lung sounds; ~Assessing skin and mucous membranes for cyanosis or a bluish discoloration indicating low levels of oxygen in the blood; and, ~Pulse oximetry to detect low levels of oxygen in the blood. According to the AMDA guidelines for Physician Notification, confusion associated with abnormal blood work, and acute onset of dyspnea (difficulty breathing) should have immediate physician consultation. Resident #13's most recent admission to the facility was on [DATE]. Resident#13's [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE], indicated Resident #13: ~Had moderately impaired cognitive skills; ~Had no indicators of [MEDICAL CONDITION]; ~Had no mood indicators; ~Had no behaviors including those considered socially inappropriate; ~Required the assistance of 1 staff person for bathing, dressing, grooming, and walking; ~Ate independently; ~Had no infections; and, ~Had no shortness of breath. Resident #13's care plan dated [DATE], under problem identified, "...Potential for Decreased Cardiac Output..." had the approaches of monitoring Resident #13's pulse, assessing and report [MEDICAL CONDITION] and shortness of breath and pain, monitor intake and output, complete a weekly cardiac assessment and update the physician as indicated. Surveyor # completed a review of Resident #13's nursing notes and noted the following: ~ [DATE], "...Cardiac Assessment: LS (lung sounds) clear bilaterally no bruits or murmurs. Heart rate 74 reg (regular) O2 (oxygen) 95% on RA (room air) skin pink, warm and dry, denies SOB (shortness of breath). No cough noted...B/P ,[DATE]..." ~ [DATE], "...22:19 (10:19 p.m.)...Res (Resident) c/o (complaints of) labored resp (respirations) O2 sats (oxygen saturation) ,[DATE]% on RA. Res states had cold sx's (symptoms) for past few days. Put head of bed up for res T - (temperature) 98.7. Lung fields: expiratory wheeze throughout fields. Put res in call book for tomorrow.." This is a significant change in Resident #13's medical condition. There was no physician consulted. There was no comprehensive cardiopulmonary assessment completed. Nursing notes continue: ~ [DATE], "...At 0240, (2:40 a.m.) resident awake sitting on edge of bed, unable to sleep, c/o SOB. Writer checked O2 sats 80% on room air, LS wheezing throughout skin color pink, warm. VS (vital signs) WNL (within normal limits)...new order..Oxygen 2 LPM (liters per minute) via NC (nasal canula) PRN (as needed) for SOB...Let Dr (doctor)...know about resident's status in the morning..." On [DATE], Resident #13 was seen by NP-Q. Surveyor # completed a review of NP-Q's progress note. The progress note indicated, "...Restless and short of breath....developed some restlessness. Looked to be a little cyanotic last night...has been awake and somewhat restless all night...looks a bit tired but acting per her usual behavior...O2 sats via room air 88%...lungs with expiratory wheeze throughout...trace to 1+ [MEDICAL CONDITION] of the lower legs...Assessment: Restless and wheeze with some respiratory distress...did contact Dr..." NP-Q ordered [MEDICATION NAME] for Resident #13 as well as a chest x-ray and blood work. The progress note indicated that she would decide further interventions once the tests were completed. Nurses notes continue: ~ [DATE], "...12:21 (12:21 p.m.)...Resident had removed O2 at 0730 (7:30 a.m.) and O2 sat checked at that time and was 88% O2 reapplied...NP (Nurse Practitioner) here at that time and checked resident. Orders received to do chest x-ray, BMP (basic metabolic panel) and BNP (B-type Natriuretic Peptide). Does continue with O2 on and has left in place. Does have congested sounding cough on and off...Afebrile...Order received also to start [MEDICATION NAME] ~ [DATE], "...17:00 (5:00 p.m.)...N.O. (new order) [MEDICATION NAME] 40 mg (milligrams) bid (two times a day)..." On [DATE] neither the day shift nor the evening shift completed a comprehensive cardiopulmonary assessment to ascertain Resident #13's condition. Surveyor # completed a review of a chest x-ray report dated [DATE]. The faxed report indicates the facility received the report on [DATE] at 1:52 p.m. The chest x-ray indicated Resident #13 had persistent bilateral lung infiltrates. There was no indication that the physician was consulted regarding the chest x-ray results once they were received. Nursing notes continue: ~ [DATE], "...02:48 (2:48 a.m.)...Resident awake at this time, sitting on edge of bed, keeps removing oxygen, O2 sats 92 on room air, temp this shift 99.0. Denies pain or discomfort, denies SOB, respirations 20, even, unlabored, skin color pink...LS faint wheezing bilaterally...continue to monitor..." ~ [DATE], "...13:19 (1:19 p.m.)...O2 sat on room air 87%...Faxes were sent to Dr...offers no complaints...Skin warm and dry. Did have a congested nonproductive cough...Lung sounds faint wheeze noted...Afebrile..." Surveyor # completed a review of a fax dated [DATE] sent to Resident #13's physician at 10:05 a.m. It contained information regarding the new orders from NP-Q. It also referenced that Resident #13 had had low oxygen saturation and was using oxygen. There was however, no information regarding Resident #13's current status including the wheezing, and nonproductive cough. The fax also referenced that a copy of Resident #13's blood work and chest x-ray had been attached in the fax. Nursing notes continue: ~ [DATE], "...22:02 (10:02 p.m.)...T (temperature) 98.1. Resident had to be watched with having O2 in place. Resident had poor intake this shift..." None of the assessments completed on [DATE] included a comprehensive cardiopulmonary assessment. Comprehensive assessments are critical in order for the physician to determine appropriate treatment. In addition to being confused, restless, having low oxygen saturation and abnormal lung sounds, Resident #13 had a temperature, productive cough and poor intake. Despite this continued decline in Resident #13's condition, there was no physician consultation. Nursing notes continue: ~ [DATE], "...04:54 (4:54 a.m.)...sat up in w/c (wheelchair) most of the night..." ~ [DATE], "...15:00 (3:00 p.m.) Resident was disoriented and in hallway undressing...not keeping nasal canula on. Staff continuely (sic) assisted her to put the O2 back on..." This again shows significant changes in Resident #13's medical condition. There was no physician consultation. Nursing notes continue: ~ [DATE], "...17:00 (5:00 p.m.)...she was taken to dining room to eat and she would not swallow her food and kept laying her head on the table...brought her back to the room...checked O2 sat which was 80%. She had labored breathing, diaphortic (sic), B/P ,[DATE], pulse 78, resp. 24, Temp 98.7...sent to ER..." The nursing notes dated [DATE] again did not include a comprehensive assessment. Additionally, there was no documentation during the day shift on [DATE]. Surveyor # completed a review of hospital records dated [DATE]. The records indicated that Resident #13 was admitted to the ICU and diagnosed with [REDACTED]. While hospitalized , Resident #13's advanced directives were changed from a full code to do not resuscitate. On [DATE] at 4:00 a.m., Resident #13 expired. Surveyor # completed a review of Resident #13's death certificate dated [DATE]. The primary cause of death was noted to be Pneumonia. On [DATE] at 4:35 p.m., Surveyor # spoke with CNA-N (Certified Nursing Assistant). CNA-N indicated Resident #13 was alert and oriented. CNA-N indicated that on [DATE], Resident #13's roommate, Resident #12, came up to the nursing station concerned about Resident #13. CNA-N indicated Resident #12 told staff Resident #13 could not process how to play cards which she had in the recent past. On [DATE] at 4:45 p.m., Surveyor # spoke with CNA-O. CNA-O indicated she had cared for Resident #13 prior to her hospitalization . CNA-O stated that during Resident #13's illness, Resident #13 kept wanting to put her feet off of her bed, acted "really funny" and was "really confused" which was not her norm. CNA-O stated she had reported this to a nurse. On [DATE] at 5:15 p.m., Surveyor # spoke with RN-P (Registered Nurse). RN-P indicated that any time a resident had a change in condition, they were put that resident in the physician call book to update the physician the next day. RN-P stated the facility had either a MD or NP in the building Monday through Friday, who would address the issues as noted in the physician call book. RN-P indicated that any time a resident had a change in condition, there should be vital signs as well as an assessment completed. RN-P stated the type of assessment depended on the type of symptoms the resident was exhibiting. RN-P also stated an assessment should be completed every shift. RN-P stated she had cared for Resident #13 1 time during her illness and prior to her going to the hospital. Surveyor # noted that this was on the evening of [DATE]. RN-P described Resident #13 as becoming confused, and not as quick to respond. Surveyor # asked RN-P about the lack of assessment and vital signs for Resident #13. Surveyor # reviewed the documentation with RN-P. RN-P was uncertain about it and couldn't say for sure what was done and what was not done. On [DATE] at 5:30 p.m., Surveyor # reviewed the physician call book and noted the following: ~ On [DATE], staff had indicated Resident #13 had expiratory wheezing throughout all lung fields, had O2 sats 88% to 90%, and had a temperature of 98.7. ~ On [DATE], staff questioned Resident #13's order for [MEDICATION NAME]. There was no evidence that after the nurse practitioner saw Resident #13 on [DATE], that a physician had been consulted about Resident #13's significant change. On [DATE] at 8:00 a.m., Surveyor # spoke with LPN-G (Licensed Practical Nurse). LPN-G indicated she was the unit manager on the unit in which Resident #13 resided. LPN-G indicated they had a physician in-house Monday through Friday. LPN-G indicated changes in residents' condition were taken by which ever physician or nurse practitioner who was in-house that day. LPN-G indicated staff placed concerns in the physician call book and she in turn reviewed this and "triaged" those residents for the nurse practitioner or physician to see. LPN-G also stated that if the physician in-house was unable to address a resident's issue, they would then call the primary physician. Surveyor # asked LPN-G about Resident #13. LPN-G indicated Resident #13 developed signs and symptoms of low oxygen levels, restlessness, Upper Respiratory Illness (URI), shortness of breath, and at night wanted to sit up in bed. LPN-G indicated that staff on the night shift were afraid Resident #13 was going to fall, so they placed Resident #13 into her wheelchair. On [DATE] at 1:45 p.m., Surveyor # spoke with Resident #12. Resident #12 was Resident #13's sister and roommate. Resident #12 indicated she felt Resident #13 "died because of lack of medical care." Resident #12 also stated Resident #13 "should have been taken to the hospital but wasn't until it was too late." Resident #12 indicated Resident #13 had kept telling her she couldn't breath. On [DATE] at 8:55 a.m., Surveyor # again spoke with Resident #12. Resident #12 again reiterated that Resident #13 kept telling her she couldn't breath. Resident #12 stated Resident #13 got confused, restless, and "sometimes so sleepy she wouldn't talk to me." Resident #12 also stated she felt the facility did not place oxygen on timely for Resident #13. Resident #12 also stated she felt the facility was lax in their assessment of Resident #13. On [DATE] at 10:55 a.m., Surveyor # spoke with NP-Q. NP-Q indicated she had seen Resident #13 on [DATE]. NP-Q stated she was concerned about Resident #13's condition as prior to this time, Resident #13 had never had any respiratory problems. NP-Q indicated that because of this, she contacted Resident #13's primary physician and subsequently ordered a chest x-ray and lab work. NP-Q stated Resident #13 had a difficult night with dropping O2 sats associated with some cyanosis and being quite restless. NP-Q indicated that when she saw Resident #13, her oxygenation had improved with the placement of oxygen. Surveyor # asked NP-Q about Resident #13's chest x-ray. NP-Q indicated she did not get the report and heard the facility had called the report to Resident #13's primary physician. NP-Q indicated that had she gotten the report, she would have placed Resident #13 on an antibiotic. On [DATE] at 8:25 p.m., Surveyor # spoke with Family-Z. Family-Z indicated that she was Resident #13's Power of Attorney (POA). Family-Z indicated she had spoken with Resident #13 over the phone on [DATE] and she "was fine." Family -Z stated she got a call from another resident in the facility on [DATE], who told her Resident #13 was "really sick." Family-Z indicated she then talked with Resident #13. Family-Z indicated Resident #13 complained of being really sick and being unable to breath. Family-Z also described Resident #13 as "incoherent" and "confused." Family Member-Z indicated she requested the facility send Resident #13 to the ER, however, was told they were doing a chest x-ray and blood work and were waiting to see the results of these. Family-Z stated Resident #13 did not go to the hospital until Saturday. Family-Z stated Resident #13 was "so bad they couldn't save her. Family-Z also indicated that she went to the hospital when Resident #13 was admitted . Family-Z described Resident #13 as "incoherent" and "unresponsive." Family-Z also indicated the admitting physician told her Resident #13 "didn't look good" and "wasn't sure Resident #13 would make it." On [DATE] at 1:39 p.m., Surveyor # spoke with Physician-EE. Physician-EE described Resident #13 as being stable and without any cardiopulmonary problems prior to her hospitalization . Physician-EE indicated he became aware of Resident #13's condition when NP-Q called him on [DATE]. Physician-EE indicated that because they were uncertain of what the source was of Resident #13's change in condition, they opted to do a chest x-ray as well as blood work. Surveyor # asked Physician-EE if the facility had ever contacted him regarding Resident #13. Physician-EE indicated the facility did send him a fax on [DATE], however the fax alluded that Resident #13 had low oxygen saturation which improved with oxygen. Physician-EE indicated the rest of the information was just information on what NP-Q had ordered. Surveyor # asked Physician-EE if he received a copy of the chest x-ray completed at the facility on [DATE]. Physician-AA indicated he had not. Surveyor # reviewed the results of the chest x-ray with Physician-EE. Physician-EE indicated that had he known the results of the x-ray, he would have placed Resident #13 on an antibiotic. Surveyor # also reviewed the documentation in Resident #13's clinical record on [DATE] and [DATE]. Physician-EE indicated a physician should have been called when Resident #13 showed acute changes in condition. Physician-EE also stated that with Resident #13's continued decline, Resident #13 should have been sent to the ER.

Based on observation, record review, interviews, and policy review, the facility did not ensure that 1 out of 4 sampled residents reviewed for wound care received the necessary care and services to attain or maintain adequate wound healing. Resident #1 had chronic venous ulcers of the right lower leg. Resident #1 was followed by the Wound Clinic every other week as part of the treatment plan for the venous ulcers and pressure ulcer. The facility did not make arrangements for Resident #1 to continue with the Wound Clinic visits beginning on 08/17/11 through 10/06/11. During that time period, the facility did not complete dressing changes as ordered by the physician and did not document wound characteristics with each dressing change. In addition the facility did not assess the wounds at least weekly from 08/17/11 through 09/21/11. On 09/24/11, staff noted maggots in the wound as well as malodorous drainage. Resident #1 was sent to the hospital for emergency room care. Resident #1 experienced an avoidable decline in the ulcers of the right lower leg due to the facility's failure to assess the wound characteristics, carry out the prescribed treatment to the wounds, and evaluate the treatment plan with the aid of the Wound Clinic specialists. This is evidenced by: On 12/15/11, Surveyor # requested and reviewed the facility policy titled "Pressure Ulcers/Skin Breakdown - Clinical Protocol." Noted in the policy was: "Treatment/Management 1. The physician will authorize pertinent orders related to wound treatments... 2. The physician will help identify medical interventions related to wound management; for example, treating a soft tissue infection surrounding an ulcer, removing necrotic tissue...." The policy also noted under Monitoring, "1. During resident visits, the physician will evaluate and document the progress of wound healing-especially for those with complicated, extensive, or non-healing wounds. 2. The physician will help the staff review and modify the care plan as appropriate especially when wound are not healing...." On 12/15/11, Surveyor # requested and reviewed the facility policy titled "Wound Care." The policy read, "The purpose of this procedure is to provide guidelines for the care of wounds to promote healing." The policy noted under Documentation, "The following information should be recorded in the resident's medical record: 1. The type of wound care given. 2. The date and time the wound care was given.... 6. All assessment data (i.e., wound bed color, size, drainage, etc.) obtained when inspecting the wound. 10. The signature and title of the person recording the data." Resident #1 was admitted on [DATE] with [DIAGNOSES REDACTED]. The MDS (Minimum Data Set) assessment on 08/17/11 indicated that Resident #1: ~Was able to make self understood and understand others; ~Has adequate hearing and adequate vision; ~Had deficits in memory recall and orientation; ~Had no mood indicators; ~Required extensive assistance with bed mobility, transfers, dressing, bathing, hygiene, and toilet use; ~Did not walk; ~Experienced rare moderate pain; ~Had 3 venous ulcers present; and, ~Received application of dressings. Resident #1's care plan titled "Impairment of skin integrity...as evidenced by RLE (right lower extremity) wound" dated 05/30/11, noted under Goal was, "Wound will heal." The approaches were "Nurses----assess skin condition daily and note any changes. Treat as ordered, ...measure area change dressing...." Resident #1 went to the Wound Clinic on 06/07/11 with orders to complete a daily dressing change for the ulcers on the right lower leg. There was no follow-up appointments recommended. On 06/30/11, Resident #1's primary physician ordered a referral to the Wound Clinic to treat a pressure ulcer of the right heel. On 07/07/11, Resident #1 returned to the Wound Clinic. The report of consultation noted 2 venous ulcers on the inner aspect of the right ankle and a right heel pressure ulcer. The consultation report included a treatment of [REDACTED]. This dressing should be done every 2 days or daily if increased drainage. Also, a heel lift boot was to be used for the right heel pressure ulcer. The wound measurements completed by the Wound Clinic were as follows: 1. Right inner ankle top/front, 2.0 cm (centimeters) by 0.7 cm by 0.2 cm; 2. Right inner ankle bottom/back, 7 cm by 3 cm by 0.2 cm; 3. Right heel 4 cm by 3.7 cm by 0.3 cm. A return appointment was scheduled for 07/20/11. On 07/20/11, Resident #1 returned to the Wound Clinic. The report of consultation noted an additional venous ulcer present on the right outer ankle and to continue with previous dressing change order. The wound measurements were as follows: 1. Right inner ankle top/front, 1.6 cm by 1.4 cm by 0.4 cm; 2. Right inner ankle bottom/back, 4.2 cm by 3.7 cm by 0.2 cm; 3. Right heel, 3.2 cm by 3.3 cm by 0.3 cm; 4. Right outer ankle (new), 0.5 cm by 0.5 cm by 0.2 cm. A return appointment was scheduled for 08/03/11. On 08/03/11, Resident #1 returned to the Wound Clinic. The report of consultation noted an additional venous ulcer on the right inner ankle. The Wound Clinic specialist ordered to change the dressing to daily due to wound being too moist. The wound measurements were as follows: 1. Right inner ankle top/front, 1.2 cy by 1.0 cm by 0.3 cm; 2. Right inner ankle bottom/back, 4.0 cm by 3.0 cm by 0.3 cm; 3. Right heel, 3.3 cm by 4.0 cm by 0.3 cm; 4. Right outer ankle, 2.0 cm by 1.5 cm by 0.3 cm; 5. Right inner ankle middle (new), 1.5 cm by 1.0 cm by 0.3 cm. The progress note dated for 08/03/11 noted, "Wounds are not healing very well. The legs are quite moist...If the wounds do not seem to be healing at the next dressing change, the dressing will be changed to another treatment at that time." A return appointment was to be scheduled for 08/17/11. Resident #1 did not return to the Wound Clinic on 08/17/11 as scheduled. The facility continued with the same treatment. On 12/15/11 at 3:30 p.m., Surveyor # interviewed the DON (Director of Nurses) and LPN-A (Licensed Practical Nurse) who identified herself as the unit manager for Resident #1. Surveyor # asked why Resident #1 did not follow through with the 08/17/11 Wound Clinic appointment. LPN-A stated the facility never scheduled the appointment. The Surveyor asked why the appointment was not scheduled. LPN-A stated she had no knowledge of Resident #1 during that time period as Resident #1 resided on the rehabilitation wing until 09/12/11 when he moved to the 400 wing. The DON stated the appointment was missed. Surveyor # reviewed Resident #1's nurse's notes from 08/01/11 through 10/07/11 looking for evidence of daily wound documentation. There was no wound documentation on the following days: 08/01/11, 08/10/11, 08/12/11, 08/15/11, 08/22/11, 08/24/11, 08/27/11, 08/28/11, 08/29/11, 09/02/11, 09/03/11, 09/05/11, 09/07/11, 09/08/11, 09/10/11, 09/11/11, 09/12/11, 09/13/11, 09/14/11, 09/15/11, 09/17/11, 09/18/11, 09/19/11, 09/20/11, 09/21/11, 09/22/11, 09/23/11, and 09/28/11. Surveyor # reviewed Resident #1's weekly ulcer record and noted no weekly assessments from 08/10/11 through 09/21/11 for the venous ulcers or the pressure ulcer on the right lower leg. According to the facility's policy and procedure as well as accepted standards of practice, weekly documentation should include wound characteristics and measurements. Surveyor # reviewed the TAR (Treatment Administration Record) for Resident #1 from 06/01/11 through 10/31/11. The treatment record noted multiple days where the dressing change was not done for Resident #1: ~In June there were 6 days where the treatment was not done. ~In July there were 3 days where the treatment was not done. ~In August there were 11 days where the treatment was not done. In addition, the TAR does not reflect the Wound Clinic orders to change the dressing daily. ~In September there were 6 days where the treatment was not done. On 12/15/11 at 3:30 p.m., Surveyor # interviewed the DON regarding additional documentation of weekly ulcer assessments for Resident #1. The DON stated she was conducting weekly wound rounds for Resident #1 during that time frame and stated she did not document any of her findings. The DON stated, "If it was not documented, it was not done. I know that." Surveyor # reviewed the TAR for Resident #1 with the DON and discussed the lack of documentation. The DON stated if there are no nurse initials, the treatment was not done. On 09/24/11 nurse's notes for Resident #1 noted, "Wound was extremely moist with a foul odor and active yellow drainage." Resident #1 was sent to the emergency room accompanied by his wife. Review of the facility transfer form for Resident #1 noted increased drainage and possible maggots to the outer ankle wound. The progress note from the emergency room noted chronic right lower leg venous ulcers. There were no changes in the current treatment plan. On 12/14/11 at 9:41 a.m., Surveyor # interviewed the DON and LPN-A regarding the 09/24/11 emergency room visit for Resident #1. LPN-A stated she was called by the nurse who reported maggots present in the right lower leg wound when the dressing was removed. LPN-A stated she was the last person to change the dressing on 09/22/11 and the wound had a malodorous drainage present, but no maggots. LPN-A stated she instructed the nurse to cover the wound and LPN-A would be in to assess the wound. When LPN-A arrived, she uncovered the wound and noted 4 maggots that were not moving. On 12/15/11 at 9:10 a.m., Surveyor # interviewed RN-B (Registered Nurse) who identified herself as the charge nurse working on 09/24/11 when Resident #1 went to the emergency room . RN-B stated she was called to the bedside of Resident #1 by the nurse because of the presence of maggots in Resident #1's leg wounds. RN-B stated she did not count the maggots, but estimated there to be between 4 and 15 maggots in the wound. RN-B stated some of the maggots were moving, but most of them were not moving. RN-B stated she informed the NHA (Nursing Home Administrator) and the on-call physician. The on-call physician ordered an emergency room evaluation of the wound. RN-B stated Resident #1 and his wife, who was present in the room, were informed of the finding and agreed with the emergency room evaluation. During the investigation, the Surveyor was unable to interview the nurse who initially saw the maggots. On 10/04/11, the primary physician for Resident #1 ordered a referral back to the Wound Clinic. On 10/07/11, Resident #1 returned to the Wound Clinic. The report of consultation noted wounds with mild foul odor and to continue with the same treatment. The wounds' measurements were as follows: 1. Right inner ankle top/front, bottom back and middle wounds had combined to form 1 wound measuring 4.1 cm by 3.4 cm by 0.6 cm; 2. Right heel, 4 cm by 5 cm by 0.5 cm; 3. Right outer ankle (x2), 2.1 cm by 0.5 cm by 0.1 and 1.0 cm 0.3 cm by 0.1 cm. A return appointment was scheduled for 11/01/11. On 12/15/11 at 9:47 a.m., Surveyor # observed wound care for Resident #1. LPN-A and LPN-B completed a complex dressing change using good technique. Resident #1 had 3 wounds that currently measured as follows: 1. right inner ankle 3.8 cm by 3.5 cm by 0.2 cm; 2. right outer ankle 3.5 cm by 2.4 cm by 0.4 cm; 3. right heel 5.2 cm by 7.4 cm by 0.2 cm.