Every finding on record at Good Samaritan - George

Based on the Center for Medicare and Medicaid Services (CMS) Payroll Based Journal (PBJ) Staffing Data Report from Fiscal Quarter 2, 2025 (January 1 through March 31) review, facility staffing review, and staff interviews, the facility failed to meet staffing requirements in all metrics. The facility reported a census of 31 residents.Findings include:The PBJ Staffing Data Report with a run date of 8/13/25 triggered submitted weekend staffing data excessively low within the quarter.Review of staffing for nurses and Certified Nursing Assistants (CNAs) scheduled similarly for weekdays and weekends. In an interview on 8/21/25 AM at 9:05 AM, the Administrator reported he had no knowledge of how the corporate office submitted staffing data. The Administrator reported the data should reflect that weekend staffing remained the same as during the week. The Administrator reported the facility failed to have a policy regarding PBJ.In an interview on 8/21/25 AM at 9:05 AM, the Director of Nursing (DON) reported the low weekend staffing data error may have occurred when the corporate office supplied staff from a staffing pool during the second quarter. The DON reported the facility staffed the same on the weekdays and weekends. The DON reported insufficient staffing did not occur at any time during the second quarter.

Based on observations, staff interviews and facility policy review the facility staff failed to serve proper serving amounts for residents. The facility identified a census of 31 residents. Findings include:During an ongoing observation on 8/20/2025 at 11:21 a.m., of Staff A, [NAME] completed the puree process for 2 residents in the facility. Staff A added 3 servings of meat, potatoes, roll and gravy into the blender and added a couple spoons full of thickener and pureed the mixture. When the process was completed, Staff A placed the mixture into the measuring cup and had a total of 3 cups of pureed food. According to the chart the residents were to get 2 #8 scoops of the mixture. Staff A then added 3 servings of spinach to the blender, a couple scoops of thickener and added butter and pureed the mixture until smooth. Once the mixture was smooth Staff A poured the mixture into a measuring cup and the amount was over the 1 cup measurement on the cup. Staff A stated the measurement was 1 and 1/4 cup. When asked how Staff A knew for sure there was 1 and 1/4 cup of food in the measuring cup Staff A replied she just knew as she went by the lines. When asked again how Staff A knew there was 1 and 1/4 cup of food in the cup Staff A replied she just knew. When Staff A was asked if Staff A could say for sure there was 1 and 1/4 cup of food in the measuring cup she said no she was going to use a bigger measuring cup. Staff A moved the mixture over to the larger measuring cup Staff A had 1 and 1/2 cups of food. During meal service 2 residents were served a plate of puree meal. Each plate was served one scoop of meat, potato, roll and gravy mixture and one scoop of spinach mixture. These plates were served to the residents. Staff A was asked as to why there was so much of the meat, potato, roll and gravy mixture left in the pan. Staff A replied it was extra due to making 3 portions. When asked how much was left there was approximately 3 and 1/2 scoops of the mixture left. Staff A was asked again how much she started with and how much the residents were to be served. The Dietary Manager (DM) stepped in and asked how much she had made and how much she served. The DM stated Staff A needed to give each of the residents that received pureed meals another scoop of the meat, potato, roll and gravy as they only received half of their meal portion. Staff A continued to service residents in the dining room. Approximately 10 plates were served a smaller portions. Staff A revealed the residents did not want a full portion so the kitchen serves a half portion to them. Staff A used the full serving size scoop and filled the scoops approximately half full. Staff A did not measure out half portions for those 10 plates. During an interview on 8/21/2025 at 12:53 p.m., with the DM and Staff A revealed Staff A was just filling the scoops approximately half full for residents that did not have the full portions and she did not have an exact measurement. Staff A explained residents ask for a half serving as they will not eat the meal if the plate has the full serving. The DM revealed Staff A should have served the correct portions to the puree during meal service and she expected the staff to be serving full portions as only 1 resident is ordered and care planned to have half portions served for meals. Review of the facility policy titled Texture Modified Diets Food and Nutrition dated 5/12/2025 revealed pureed food is not combined or stirred together during dining unless it is requested by the resident and documented in the care plan. Review of the facility policy titled Meal Service dated 11/5/2024 revealed it is the policy to serve well-balanced, attractive meals to all residents and to provide adequate nutrition for the well-being of all residents. Interview on 8/21/2025 at 8:24 a.m., with the Administrator revealed the staff should be serving proper amounts to the residents as ordered.

Based on observations, staff interviews, and facility policy reviews the facility failed to ensure food was stored and prepared under sanitary conditions. The facility identified a census of 31 residents.Findings include: On 8/18/2025 at 10:49 a.m., during the initial walkthrough in the kitchen was conducted and following concerns were noted. The following items were in the kitchen open and ready for use:a. open container of Cheerios with no label and no open dateb. open container of rice cereal with no label and no open datec. open bottle or raspberry syrup with no label and no open dated. open container of oatmeal with no label and no open date e. open box of cornstarch with no label and no open date. The following items were in the refrigerator read for use:a. 32 servings of cake uncovered on a tray b. open carton of liquid egg with no open datec. open carton of heavy whipping cream with no open dated. open gallon of white milk with no open datee. pitcher of orange juice with no open datef. pitcher of apple juice with no open dateg. open carton of thickened water with no open dateh. 2 containers of greek yogurt open with no open date with an expiration date of 8/10/25i. box of oranges sitting on the floorj. open jug of raspberry vinaigrette with no open datek. bottle of honey mustard lacked an open datel. bottle of Italian dressing lacked an open date m. bottle of ranch dressing lacked a label and open daten. bottle of red sauce lacked a label and open date.Review of the facility policy titled Food Supply Storage with a reviewed date of 3/7/2025 revealed foods that have been opened or prepared are placed in an enclosed container, dated, labeled and stored properly. Items being prepared for the next meal do not have to be dated and labeled but must be covered. Interview on 8/21/2025 at 12:53 p.m., with the Dietary Manager revealed she expected the dietary staff to make sure items were dated when they are opened and first in first out. Interview on 8/21/2025 at 8:24 a.m., with the Administrator revealed he expected the kitchen to have things covered and labeled when they are opened.

Based on clinical record review, interviews, and facility policy, the facility failed to ensure bed hold notice was signed by residents and or the resident's responsible person when residents transferred out of the facility for 1 of 1 residents reviewed (Residents #7). The facility reported a census of 31 residents.Findings include: The Minimum Data Set (MDS) assessment dated [DATE] for Resident #7 documented diagnoses of hypertension, anemia and arthritis. The MDS showed the Brief Interview for Mental Status (BIMS) score of 06, indicating severe cognitive impairment. Review of Resident #7's Census tab revealed the following information:11/7/24- no pay hospital leave11/8/24- active12/10/24- no pay hospital leave12/12/24- active Review of Progress Notes revealed the following:On 11/7/24 at 8:47 p.m., resident will be admitted to hospital for observation. On 11/8/24 at 5:07 p.m., resident arrived back at the facility. On 12/10/24 at 9:02 a.m., resident left facility to hospital for hip surgery.On 12/12/24 at 1:13 p.m., returns to facility from hospitalization. Review of Bed Hold dated 11/7/24 revealed verbal authorization from Resident #7's representative but lacked a resident representative signature. Review of Bed Hold dated 12/10/24 revealed verbal authorization from Resident #7's representative but lacked a resident representative signature. Review of facility provided policy titled Bed Hold with revision date of 12/19/24 revealed The Notice of Bed-Hold Policy should be mailed if family or the resident representative does not come to the facility to receive a copy. Interview on 8/21/2025 at 9:50 a.m., with the Social Services revealed the 2 bed holds had been missed and they should have had the signatures obtained from families.

Based on observations, record review, interviews and policy reviews, the facility failed to provide staff with current continuous positive airway pressure (CPAP) machine settings, failed to enter the faxed order into the electronic chart, and failed to enter CPAP information into the care plan for 1 of 12 residents reviewed (Resident #6). The facility reported a census of 31 residents. Findings include:1. The Minimum Data Set (MDS) assessment dated [DATE] for Resident #6 documented diagnoses of renal insufficiency, diabetes and anemia. The MDS failed to indicate Resident #6 used a non-invasive mechanical ventilator. The MDS showed the Brief Interview for Mental Status (BIMS) score of 15, which indicated no cognitive impairment. In an interview on 8/19/2025 at 11:03 AM, Resident #6 reported using a CPAP nightly.Observation on 8/19/25 at 1:48 PM revealed a CPAP on Resident #6's bedside table. The faxed Physician's Order dated 6/19/25 for Resident #6 showed an order for a CPAP.The Order Summary Report with an active order date of 8/21/25 for Resident #6 showed the facility failed to enter the CPAP order and settings into the electronic chart.The Care Plan for Resident #6 failed to show the resident used a CPAP.The Non-Invasive Respiratory Support policy last revised 10/30/24 identified:Provider orders must be obtained stipulating when the device can be removed and how it is to be used while resident is performing activities ofdaily living (bathing, eating, ambulating, etc.).Provider orders stipulating oxygen levels to be maintained when device is not in place or during periods of resident activity shall be recorded in the TAR.Nurse aide observation:1. Immediately report to the licensed nurse any change in resident's condition.2. Directions should be given to the aides based on provider orders for delivering oral care or skin care needs and if the mask/nasal cannula can beremoved for any amount of time if applicable.Start Therapy:1. Connect the breathing circuit to the machine.a. If using a mask, place the mask over the nose and mouth starting at the top and rolling down to the chin to assure that the mask is secure andsealed.b. If using a nasal cannula, ensure that the device is centered, secure and comfortable for the user.c. If using a nasal pillow, insert the nasal pillow into the shell making sure they fit correctly and that there is no air leaking around them.2. Provider orders must be obtained stipulating when the device can be removed and how it is to be used while resident is performing activities ofdaily living (bathing, eating, ambulating, etc.).In an interview on 8/21/25 at 8:50 AM, the MDS Coordinator reported she is responsible for updating and revising care plans. The MDS Coordinator reported the facility failed to enter the orders into the electronic chart and care plan. When asked why, the MDS Coordinator reported the error may have occurred when the responsibility changed from the Director of Nursing (DON) to the MDS Coordinator. In an interview on 8/21/25 at 9:05 AM, the DON confirmed Resident #6 failed to have an electronic order and care plan regarding the CPAP. The DON stated, the CPAP should be in the orders and on the care plan.

Based on clinical record review, facility investigation review, staff and resident interviews, and facility policy review the facility staff failed to report an allegation of abuse to a supervisor and the alleged prepetrator continued to work unattended behind closed doors with other residents. On June 27, 2024, the Director of Nursing Services (DNS) learned of a Certified Nurse Aide (CNA) slapping Resident #12 on his upper arm which occurred on June 19, 2024. This failure resulted in residents living at the facility to be exposed to the potential of abuse therefore causing an Immediate Jeopardy to the health, safety, and security of the resident. The State Agency informed the facility of the Immediate Jeopardy (IJ) that began as of June 19, 2024 on August 27, 2024 at 2:01 p.m The facility staff removed the IJ on June 27, 2024 through the following actions: a. The local police, residents physician and family/responsible party were notified of the allegation on 6/27/24. An initial report was made to DIAL on 6/27/24 within the expected two hour time frame. b. Staff members who failed to report immediately on 6/19/24 received immediate education and re-did the Iowa required Dependent Adult Abuse course online on 6/27/24. Corrective action was completed as well with both staff members. c. The social services manager interviewed all residents to determine if there were any concerns by residents of care and treatment by staff members this began on 6/27/24. None were identified. d. Education on abuse and neglect began 6/27/24 to all staff regarding the treatment of residents and the importance of immediately notifying leadership and/or supervisor of any allegation so steps can be immediately taken to remove/separate suspected staff from residents. A quiz for comprehension was completed by staff. Education was completed with all staff prior to any staff working another shift. e. To ensure deficient practice will not recur, Administrator or designee will implement the following measures: i. Administrator or designee will audit through abuse and neglect questionnaires 5 team members randomly to include all shifts daily X10 days to ensure staff education on abuse and neglect investigation and reporting. ii. Audits will be taken to QAPI for further review and recommendations. f. Center leadership has continued to provide daily reminders to staff on the need to report immediately any suspected abuse and/or neglect. g. Center leadership to include the Director of Nursing, Administrator and Social Services have ensured that their phone numbers have been made available for all staff to place in their phones to ensure ability to call them at all times. h. A Skills Fair was completed on August 6 and 7 where continuing reminders and education was again provided. After ensuring the facility implemented education and their policy and procedures prior to surveyors entrance on August 26, 2024, the deficiency at F610 at a J level will be considered past non-compliance. The facility identified a census of 27 residents. Findings include: The Minimum Data Set (MDS) assessment dated [DATE] for Resident #12 documented diagnoses of stroke, hypertension and depression. The MDS showed the Brief Interview for Mental Status (BIMS) score of 4, indicating severe cognitive impairment. Review of the facility provided Incident report dated 6/27/24 at 5:00 p.m., completed by the Director of Nursing Services (DNS) revealed Certified Nursing Assistant (CNA) staff presented to my office to report that on 6/19/24 while providing bedtime cares one of the other CNA staff was frustrated with Resident #12 when he yelled out as his pericare was being provided and she swatted his upper arm as he yelled out. Review of Resident #12's Progress Notes revealed on 6/27/24 at 10:20 p.m., staff notified DNS that an event had been witnessed on 6/19/24 during bedtime cares that another staff had swatted resident on his arm when he had called out during bedtime cares. Review of written statement by Staff D, CNA dated 6/27/24 revealed last week a CNA confided in me that she witnessed Staff C smack Resident 12's arm after getting frustrated with him. She said they were getting Resident #12 read for bed at 10:00 p.m. and changing his brief. He was turned on his side, facing the wall and holding the other CNA's hand. Staff C got upset that he was holding the CNA's hand and smacked his arm. The CNA told her she had no reason to be upset since he wasn't touching her. Review of facility intake information the facility submitted a self report on 6/27/24 at 9:34 p.m Interview on 8/28/24 at 11:19 a.m., with Staff B revealed she was assisting Staff C, CNA with changing Resident #12. Staff B rolled Resident #12 toward her as he had been touching Staff C and she was getting angry. Resident #12 starting touching Staff B and Staff C slapped him on his upper shoulder area. Resident #12 stated ouch you dumb broad. Staff C responded to Resident #12 by saying he needed to stop touching us. When Staff C left the room Staff B looked at Resident #12's upper shoulder area and did not see any red marks. Staff B revealed she now knows that she should have reported the incident right away but did not trust the charge nurse that was working that night as they worked with Staff C on overnight shift. Interview on 8/26/24 at 11:31 a.m. with Staff D revealed she was working with Staff B on an evening shift. Staff B told Staff D that Staff B witnessed Staff C hit Resident #12. Staff D revealed she told Staff B she needed to report that to the DNS. Staff D revealed she thought Staff B had told the DNS until she worked with Staff B again a couple days later and learned she had not reported it yet. Staff B had asked Staff D to go with her to report it. Staff D revealed she now knows she should have reported the incident as soon as she learned about it. Review of Staff C, CNA's time cards revealed the following information: a. 6/19/24 punch in at 5:49 p.m., and punched out on 6/20/24 at 6:09 a.m b. 6/20/24 punch in at 5:52 p.m., and punched out on 6/21/24 at 6:05 a.m c. 6/25/24 punch in at 5:57 p.m., and punched out on 6/26/24 at 6:05 a.m Review of facility provided policy titled Abuse and Neglect with a reviewed date of 7/22/24 revealed the following information: a. Alleged or suspected violations involving any mistreatment, neglect, exploitation or abuse including injuries of unknown origin will be reported immediately to the administrator. b. If an employee receives an allegation of abuse, neglect, exploitation or misappropriation of resident property or witnesses suspected abuse, neglect or misappropriation of resident property, the employee will take measures to protect the resident, provided the safety of the employee is not jeopardized. The employee will then report the allegation to a supervisor. b. The charge nurse or licensed nurse will be notified immediately, assess the situation to determine whether any emergency treatment or action is required and complete an initial investigation. If this is an injury of unknown origin, he or she also will attempt to determine the cause of the injury. The charge nurse also will ensure that any potential for further abuse is eliminated by taking one of the following actions: If this is an allegation of employee to resident abuse, the employee will be removed from providing direct care to all residents. Additionally, the employee will be placed on suspension pending the results of the internal investigation. Another employee will be assigned to complete the care of the resident. Interview on 8/28/24 at 3:23 p.m., with the Administrator revealed the incident should have been reported right away to the charge nurse or management to be able to separate the staff member from the residents.

Based on review of the menu, observation, and staff interviews the facility failed to serve the full portions of food and failed to consistently fill and empty scoop utensils when preparing meals for residents. The facility identified a census of 27 residents. Findings include: In an interview on 8/28/24 at 11:35 AM, the Dietary Manager (DM) reported the meals for 8/27/24 and today were partially switched due to meat not being completely thawed. The following replacement meal served to residents per the DM: a. 4 ounces (oz.) pork loin b. 2 oz. pork gravy c. 4 oz. mashed potatoes d. 4 oz. corn e. Bun with margarine Residents on a pureed diet received: a. 4 oz. minced pork loin b. 2 oz. pork gravy c. 4 oz. mashed potatoes d. 4 oz. minced buttered broccoli florets e. Bun with margarine pureed During meal service the DM failed to completely fill and empty the scoop when serving corn and minced pork. When asked if scoops should be completely filled and emptied when plating food, the DM reported yes, but thought the scoop used to serve corn looked too big. The DM reviewed the information and determined the scoop size used for corn as correct. Upon further review the DM determined the scoop size used to serve minced pork showed two residents received 1.5 ounces more while the last two residents failed to receive full scoops of pork. The DM also reported the incorrect scoop size used to serve broccoli shorted the resident 2.5 ounces of broccoli. The facility failed to provide a policy specifically related to portion size and usage of food scoops when plating food. In an interview on 8/29/24 at 8:57 AM, the Administrator reported he expected staff to serve the correct amount of food to residents as per the menu.

Based on the Center for Medicare and Medicaid Services (CMS) Payroll Based Journal (PBJ) Staffing Data Report (January 1-March 31) review, facility staffing reports review, and staff interviews, the facility failed to submit accurate staff reports for the PBJ Staffing Data Report. The facility reported a census of 27 residents. Findings include: The PBJ Staffing Data Report run date 8/21/24 triggered for excessively low weekend staffing- submitted weekend staffing data is excessively low and failed to have licensed nursing coverage 24 Hours/Day - four or more days within the Quarter with <24 Hours/Day Licensed Nursing Coverage. Review of staffing for nurses and Certified Nursing Assistants (CNAs) scheduled similarly for weekdays and weekends. No issues for nursing coverage found. In an interview on 8/26/24 at 8:57 AM, the Administrator and Director of Nursing reported incorrect payroll data resulted from the amount of hours the employees were not punched in for breaks and worked to correct the issue. The facility planned to check with CMS to see if the change impacted the most recent data submission.

Based on clinical record review, facility record review, staff interviews and facility policy the facility failed to appropriately implement interventions to protect 1 out of 3 residents reviewed from physical abuse, (Resident #12). The facility reported a census of 27 residents. Findings include: The Minimum Data Set (MDS) assessment dated [DATE] for Resident #12 documented diagnoses of stroke, hypertension and depression. The MDS showed the Brief Interview for Mental Status (BIMS) score of 4, indicating severe cognitive impairment. Review of the facility provided Incident Report dated 6/27/24 at 5:00 p.m., completed by the Director of Nursing Services (DNS) revealed Certified Nursing Assistant (CNA) staff presented to my office to report that on 6/19/24 while providing bedtime cares one of the other CNA staff was frustrated with Resident #12 when he yelled out as his pericare was being provided and she swatted his upper arm as he yelled out. Review of Resident #12 ' s Progress Notes revealed on 6/27/24 at 10:20 p.m., staff notified DNS that an event had been witnessed on 6/19/24 during bedtime cares that another staff had swatted resident on his arm when he had called out during bedtime cares. Review of written statement by Staff B, CNA dated 6/27/24 revealed Staff C, CNA and Staff B were changing Resident #12. The resident was touchy and Staff C was getting angry. I asked the resident to hold my hand because she was getting very mad. Staff C began to hold up her hand in a hitting motion. I had Resident #12 roll toward me. Resident #12 began to yell because the wipes were cold and Staff C slapped Resident #12's arm. Resident #12 said ouch what was that good for. I said he's not even touching you. This was at approximately 8:00 p.m. when he was being changed. Review of written statement by Staff D, CNA dated 6/27/24 revealed last week a CNA confided in me that she witnessed Staff C smack Resident 12's arm after getting frustrated with him. She said they were getting Resident #12 read for bed at 10:00 p.m. and changing his brief. He was turned on his side, facing the wall and holding the other CNA's hand. Staff C got upset that he was holding the CNA's hand and smacked his arm. The CNA told her she had no reason to be upset since he wasn't touching her. Interview on 8/28/24 at 11:19 a.m., with Staff B revealed she was assisting Staff C, CNA with changing Resident #12. Staff B rolled Resident #12 toward her as he had been touching Staff C and she was getting angry. Resident #12 starting touching Staff B and Staff C slapped him on his upper shoulder area. Resident #12 stated ouch you dumb broad. Staff C responded to Resident #12 by saying he needed to stop touching us. When Staff C left the room Staff B looked at Resident #12's upper shoulder area and did not see any red marks. Interview on 8/26/24 at 11:31 a.m. with Staff D revealed she was working with Staff B on an evening shift. Staff B told Staff D that Staff B witnessed Staff C hit Resident #12. Staff D revealed she told Staff B she needed to report that to the DNS. Review of facility provided policy titled Abuse and Neglect with a reviewed date of 7/22/24 revealed the resident has the right to be free from abuse, neglect, misappropriation of resident property and exploitation. Interview on 8/28/24 at 3:23 p.m., with the Administrator revealed the incident should have been reported right away to the charge nurse or management to be able to separate the staff member from the residents.

Based on clinical record review, facility record review, staff interviews and facility policy review the facility failed to report an allegation of abuse to the Iowa Department of Inspections & Appeals and Licensing (DIAL) within 2 hours of an allegation of abuse for 1 of 1 resident reviewed for abuse (Resident #12). The facility reported a census of 27 residents. Findings include: The Minimum Data Set (MDS) assessment dated [DATE] for Resident #12 documented diagnoses of stroke, hypertension and depression. The MDS showed the Brief Interview for Mental Status (BIMS) score of 4, indicating severe cognitive impairment. Review of the facility provided Incident Report dated 6/27/24 at 5:00 p.m., completed by the Director of Nursing Services (DNS) revealed Certified Nursing Assistant (CNA) staff presented to my office to report that on 6/19/24 while providing bedtime cares one of the other CNA staff was frustrated with Resident #12 when he yelled out as his pericare was being provided and she swatted his upper arm as he yelled out. Review of Resident #12's Progress Notes revealed on 6/27/24 at 10:20 p.m., staff notified DNS that an event had been witnessed on 6/19/24 during bedtime cares that another staff had swatted resident on his arm when he had called out during bedtime cares. Review of written statement by Staff D, CNA dated 6/27/24 revealed last week a CNA confided in me that she witnessed Staff C smack Resident 12's arm after getting frustrated with him. She said they were getting Resident #12 read for bed at 10:00 p.m. and changing his brief. He was turned on his side, facing the wall and holding the other CNA's hand. Staff C got upset that he was holding the CNA's hand and smacked his arm. The CNA told her she had no reason to be upset since he wasn't touching her. Review of facility intake information showed the facility submitted a self report on 6/27/24 at 9:34 p.m Review of facility provided policy titled Abuse and Neglect with a reviewed date of 7/22/24 revealed if there is an allegation of abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, and/or there is serious bodily injury, then it will be reported immediately, but not later than two hours after the allegation is made. Interview on 8/27/24 at 1:22 p.m., with the Director of Nursing Services (DNS) revealed all allegations of abuse are to be reported to the state within 2 hours of the allegation of abuse. The DNS further revealed she knew as soon as it was revealed when it happened she knew it was going to be a concern.

Based on observation, facility policy and staff interview, the facility failed to provide proper hand hygiene during urinary catheter care for 1 of 1 resident (Resident #16). The facility reported a total census of 27 residents. Findings include: Observation on 8/28/24 at 1:09 PM, Staff E, Certified Nursing Assistant (CNA) donned personal protective equipment (PPE) then retrieved the urine colander out of the closet. Staff D placed the colander in the bathroom, removed and discarded gloves, failed to complete hand hygiene then donned new gloves. Staff D lowered Resident #16's pants then assisted the resident to sit in the recliner. Staff D removed and discarded gloves, failed to complete hand hygiene then donned new gloves. Staff A cleansed the leg bag urine catheter drainage spout, drained the urine, cleansed the drainage spout then placed the spout back into the holder. Staff D emptied urine from the colander into the toilet, removed and discarded gloves, failed to complete hand hygiene then donned new gloves. Staff D then assisted the resident to pull up and fasten pants. Staff E, Nurse Educator present during observation. The Catheter: Care, Insertion & Removal, Drainage Bags, Irrigation policy last revised on 7/30/24 instructed staff to perform hand hygiene after the removal of gloves. In an interview on 8/28/24 at 1:29 PM, when asked if they would do anything different during the observation, Staff E, Nurse Educator stated, I would have completed hand hygiene after changing gloves. The untitled document dated 8/28/24 at 11:25 AM, showed Staff E, Nurse Educator followed up with Staff D, CNA with written education related to hand hygiene. The documentation noted Staff D stated, I should have sanitized my hands in between changing my gloves, but I forgot to take my hand sanitizer out of my pocket, and I couldn't get to it because of the gown.

Based on clinical record review, staff interviews, facility record review and facility policy review, the facility failed to ensure residents at risk for elopement were unable to exit the facility unattended for 1 of 1 residents reviewed for elopement (Resident #31). The facility failure resulted in an Immediate Jeopardy to the health, safety, and security of the residents. The facility reported a total census of 33 residents. The State Agency informed the facility of the Immediate Jeopardy (IJ) that began as of May 3, 2023 on September 20, 2023 at 2:30 p.m., The Facility Staff removed the Immediate Jeopardy on May 3, 2023 through the following actions: a. Resident #31 ' s wander guard was checked and working. All other residents who wear a wander guard were checked immediately and all were working. b. Maintenance checked that all doors and alarms were functioning. c. Elopement drill was performed that shift on 5/3/2023, Day shift on 5/4/2023 and continued to be performed until all staff are present for at least one drill. d. Resident #31 was placed on 30 min checks for the wake time hours and hourly checks at night while sleeping. e. Social services has called all resident ' s first contact, told them about making sure not to hold the door open for anyone when entering or exiting the building and asked them to please pass this on to anyone who visits the residents in our nursing home. f. Bright colored signs have been placed on all exits reminding visitors to not open the doors or hold the doors for anyone else as it may be unclear if the other person is a staff member or a resident. g. All staff at the facility have been required to review the elopement policy prior to working the next shift. The scope lowered from a J to D at the time of the survey after ensuring the facility implemented education and their policy and procedures. The facility identified a census of 33 residents. Findings Include: The Minimum Data Set (MDS) assessment dated [DATE] for Resident # 31 documented diagnoses of Alzheimer ' s disease, non- Alzheimer ' s dementia and non-traumatic brain dysfunction. The MDS showed the Brief Interview for Mental Status (BIMS) score or 4 indicating severe cognitive impairment. Review of Resident #31 ' s Care Plan with a revision date of 4/6/23 revealed the following information: a. The resident has potential for elopement related to the new environment and diagnosis of dementia. With a goal listed as resident will not leave the facility unattended. b. Interventions in place were to use a wander guard to alert staff to resident's movements and check wander guard functionality every shift to ensure wander guard is in working order. Review of the document titled Elopement Risk dated 3/14/23 revealed Resident #31 is at risk for elopement. Review of May Medication Administration Record revealed a nursing order check wander guard to make sure it is on and working everyday with a start date of 3/19/23. Review of Resident #31 ' s Progress Notes revealed the following: a. On 3/14/2023 at 5:43 p.m., fax sent to the primary care physician informing her that the resident is an elopement risk, and asked for an order for a wander guard. b. On 3/18/2023 at 12:59 p.m., Resident has been exit seeking. Stating she is going to go home and check on her kids. She has told multiple staff members this and has her coat laid out. Nurse has attempted re-orientation, called the daughter and the resident spoke with her. Nurse gave the resident multiple different jobs to distract her. Wander guard in place. Staff have communicated with each other resident is exit seeking and are all monitoring resident. c. On 5/3/2023 at 3:45 p.m., Late Entry entered on 5/4/23 at 2:04 p.m., Resident was noted ambulating outside of the building by a staff member with no alarm having been sounded. Resident does wear a wander guard and was noted to be in the front living room [ROOM NUMBER] minutes prior. Resident was by apartments stated that she was going to the motel to see if her husband was awake yet. Resident came back to the building willingly. Vital signs obtained and assessment completed, was in no apparent distress. Family, administration, Director of Nursing Services and Charge nurse are notified. Review of untitled document provided by the facility dated 5/3/23 at 3:15 p.m., revealed the following information: a. Resident was seen walking on the sidewalk outside of the building by our MDS nurse as she left work. Resident had her coat and shoes on. Just prior to this one of our nurses who is the case manager had set the code in the door for another resident to go outside for a walk. This resident was standing by the door so she waited to make sure the door latched and the wander guard system reset before she walked away. No staff between this time and when the resident was spotted on the sidewalk heard or disarmed the alarm for the wander guard after this. There were many visitors in the building at this time. Staff member reported just prior to this that she had toileted the resident in the resident room and the resident's roommate did have 2 female visitors and they were getting ready to leave as she finished toileting this resident. Resident followed this staff member to the common area and the staff member sat down to chart. b. Resident has repeatedly stated since arriving at the facility that she wants to go to where Her husband has been staying and points to the apartments on our campus that look like a motel. Repeatedly states, he lives in that place that they have for travelers when they get weary. When the staff got to the resident and when she came in she said I just wanted to knock on her husband's door and see if he was up. c. Resident was noted about 3:35 p.m., walking on the sidewalk outside of the building toward the apartments. Resident was in no distress, had on her coat and shoes. Stated that she was going to the motel to see if her husband was up yet. Temperature outside was 70 degrees and sunny, very light breeze. Resident has no soiled or torn parts on her clothing and shows no sign of falling. Walks in with staff who saw her on the sidewalk. Vital signs taken, assessed for injury. Brought to her room. Investigation started. Interview on 9/18/23 at 4:06 p.m., with Staff D, Certified Nursing Assistant (CNA) revealed she was assisting another resident when a staff member told her Resident #31 had left the building. Staff D revealed she had heard the alarm go off and Staff E, CNA reset the alarm without checking other doors. Staff D revealed the alarm system had been weird all day and the door alarms were going off for no reason. Staff D further revealed the staff had received education right away and then had drills until all the staff working in the facility had been through a drill. Interview on 9/19/23 at 2:23 p.m., with Staff F, Registered Nurse (RN) and Staff G, RN revealed they had been working the day Resident #31 left the building. They believe she exited the front door with visitors that day. Staff F, was leaving the facility for the day and when she was driving out of the parking lot she seen Resident #31 walking down the sidewalk to the apartments. Staff F exited her car to get to Resident #31. Staff G was in her office when the Hospice Chaplin told her one of the residents was walking down the sidewalk outside. Staff G immediately went out the front door and met up with Resident #31 and Staff F and assisted Resident #33 in returning to the facility. Staff F and Staff G revealed Resident #33 came back into the building with no problems and the charge nurse on duty assessed her. Interview on 9/19/23 at 2:42 p.m., with Staff E, CNA revealed she was working the day Resident #31 got out of the building. Staff E revealed they were busy and she heard the alarm and saw another resident going out to garden and reset the alarm for him to finish exiting the door. Staff E revealed she saw the wander guard alarm light blinking but thought it was for the other resident's wife standing too close to the door as he was going out to garden. She reset the alarm and did not check any other doors. Staff E revealed she did not know Resident #31 had exited the building until she was asked to come into the office and make a statement. Staff E revealed the facility did a lot of code purple which means missing resident drills until everyone had been through a drill. She revealed all the shifts had the education on code purple and they are still doing them. Interview on 9/19/23 at 3:15 p.m., with the Director of Nursing (DON) revealed the staff was very honest about the situation when she talked to them. The DON revealed during the investigation the facility learned another resident was going out to garden the same time as Resident #31 exited another door of the facility. Staff E reset the door alarms and did not check to see what door it was as she saw the other resident going outside. With the investigation the facility learned the staff was having alarm fatigue and the facility was able to assist with alarm announcements to help decrease the alarm fatigue. The DON revealed the staff did code purple drills until everyone of the staff had participated in one and the drills have continued since the incident. Review of the facility policy titled Elopement with a revision date of 7/11/23 revealed the following information: The purpose of this policy is: a. To assess and identify residents/clients at risk for elopement. b. To clearly define the mechanisms and procedures for monitoring residents/clients at risk for elopement. c. To provide a system of documentation for the prevention of, and in the event of, elopement. d. To minimize risk for elopement through individualized interventions. e. The definition of elopement is when a resident/client who needs supervision leaves the premises or a safe area without authorization. Interview on 9/20/23 at 3:48 p.m., with the DON revealed she has trained all her staff to be checking all doors when the alarms go off. This has helped and they have been continuing to code purple drills in the facility.

Based on clinical record, facility policy, and staff interview, the facility failed to revise care plans with medication changes for 4 of 12 residents reviewed (Residents#6, #11, #2, and #24). The facility reported a census of 33 residents. Findings include: 1. The Minimum Data Set (MDS) dated [DATE] for Resident #6 revealed a Brief Interview of Mental Status (BIMS) score of 15 which indicated intact cognition. The MDS revealed the resident had diagnoses of duchenne or [NAME] muscular dystrophy, chronic pain, pain in right and left toes, and low back pain. The MDS revealed the resident did not receive routine or PRN (as needed) pain medication, reported occasional pain that did not interfere with sleep or daily activities. The Care Plan Intervention revised 2/19/23 revealed: WARNINGS #5: Refer to black boxed warnings in the orders for oxycodone. The Order Summary Report signed by a physician on 8/14/23 lacked an order for oxycodone. The Care Plan- R/S (Rehabilitation and Skilled), LTC (Long Term Care), Therapy & Rehab Policy revised 9/22/22 revealed: a. Residents will receive and be provided the necessary care and services to attain or maintain the highest practicable well-being in accordance with the comprehensive assessment. b. Each resident will have an individualized, person-centered, comprehensive plan of care that will include measurable goals and timetables directed toward achieving and maintaining the resident ' s optimal medical, nursing, physical, functional, spiritual, emotional, psychosocial, and educational needs. Any problems, needs and concerns identified will be addressed through use of departmental assessments, the Resident Assessment Instrument (RAI) and review of the physician ' s orders. c. This plan of care will be modified to reflect the care currently required/provided for the resident. In an interview on 9/19/23 at 3:44 PM, the Director of Nursing (DON) reported that she expected care plans updated with medication changes. 2. The MDS dated [DATE] for Resident #11 revealed that she had short and long term memory problems. The MDS revealed the resident had diagnoses of heart failure (inability of the heart to pump blood effectively), anxiety, depression, and psychotic disorder. The MDS revealed the resident was not administered diuretic medication in the last 7 days, did receive scheduled or PRN (as needed) pain medication in the last 7 days, and did not receive opioid medication in the last 7 days. The Care Plan with a start date of 5/16/19 revealed: a. Intervention dated 4/16/20 revealed monitor/document/report to health care provider PRN (as needed) any s/s signs and symptoms of hypokalemia in residents receiving diuretic therapy: fatigue, muscle, weakness, diminished appetite, nausea and vomiting and dysrhythmias, monitor potassium levels. b. The Care Plan Intervention with no date revealed WARNINGS #4: Refer to boxed warnings in the orders or eMAR (Electronic Medication Administration Record), or medication reference of choice for Levothyroxine & Tramadol. c. No specific side effects for anxiety medication(s) including Ativan (anti anxiety medication). d. No specific side effects for anti depressant medication(s) including duloxetine. e. No specific side effects for Haldol (psychotropic medication). The LTC (Long Term Care) Progress Note signed by a physician on 9/14/23 revealed: a. No order for a diuretic medication. b. Order D.C. (discontinue) tramadol (opioid pain medication). c. Order for Ativan 0.5 milligrams (mg) daily. d. Order for duloxetine 30 mg daily. e. Order for Haldol 0.5 mg in the morning. f. Orders for trazodone 25 mg at bedtime. In an interview on 9/19/23 at 3:47 PM, the DON reported that she expected care plans updated with medication changes and to include specific side effects for psychotropic medications. In an interview on 9/20/23 at 2:06 PM, the DON reported that she did not feel as Certified Nurse Assistants (CNA) need to have specific side effects for psychotropic or high risk medications listed on resident care plans. 44474 3. The MDS assessment dated [DATE] for Resident #2 documented diagnoses of sleep apnea, depression and hypertension. The MDS showed a BIMS score was not assessed. Review of the August 2023 MAR revealed the following orders: Melatonin (sleep aid) Review of the Order Summary Report signed and dated 8/14/23 revealed the following orders: Melatonin tablet at bedtime with an order date of 5/25/22. Review of the care plan with a revision date of 9/18/23 lacked information regarding the usage and side effects of melatonin usage. 4. The MDS assessment dated [DATE] for Resident #24 documented diagnoses of diabetes mellitus, depression, atrial fibrillation and renal insufficiency. The MDS showed a BIMS score of 15 indicating no cognitive impairment. Review of the August 2023 Medication Administration Record (MAR) revealed the following orders: a. Lantus Subcutaneous Solution (Insulin) b. Apixaban Oral Tablet twice daily (anticoagulant medication) c. Bumetanide Oral Tablet (diuretic medication) with a start date of 8/30/23 d. Sertraline HCl Oral Tablet (antidepressant medication) Review of the MDS dated [DATE] revealed insulin injections were given 5 out of the last 7 days in the look back period, anticoagulant medication was taken 5 out of the last 7 days in the look back period, antidepressant medication was taken 4 out of the last 7 days in the look back period. Review of the Admission Orders signed 8/22/23 revealed the following orders: a. Lantus daily with an order date of 8/22/23 b. apixaban twice daily with an order date of 8/22/23 c. sertraline daily with and order date of 8/22/23 Review of the clinical chart lacked a current order for Bumetanide. Review of the Care Plan with a revision date of 8/24/23 lacked information regarding the side effects of insulin, anticoagulant, antidepressant and diuretic medication.

Based on observations, facility policy, Centers for Disease Control and Prevention (CDC), and staff interview, the facility failed to perform hand hygiene when assisting residents during meals and cover clean laundry cart when laundry was delivered and failed to cover a laundry when transporting clean laundry in the facility. The facility reported a census of 33 residents. Findings include: 1. Observation on 9/18/23 at 12:14 PM of Staff A, Certified Nurse Assistant (CNA), assisted Resident #17 eat lunch. After Staff A assisted Resident #17, she assisted Resident #20 without performing hand hygiene. Observation on 9/19/23 at 12:00 PM of Staff A assisted Resident #17 eat lunch. After Staff A assisted Resident #17, she assisted Resident #11 without performing hand hygiene. Observation on 9/19/23 at 12:09 PM of Staff B, CNA assisted Resident #20 eat lunch, she then assisted Resident #5 eat lunch without performing hand hygiene. The CDC Hand Hygiene Guidance last reviewed 1/30/20 accessed 9/19/23 at https://www.cdc.gov/handhygiene/providers/guideline.html revealed: a. 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. b. Healthcare personnel should use an alcohol-based hand rub or wash with soap and water for the following clinical indications: 1. Immediately before touching a patient. 2. After touching a patient or the patient ' s immediate environment. 3. After contact with blood, body fluids, or contaminated surfaces. c. Healthcare facilities should: Require healthcare personnel to perform hand hygiene in accordance with Centers for Disease Control and Prevention (CDC) recommendations. 1. Ensure that healthcare personnel perform hand hygiene with soap and water when hands are visibly soiled. 2. Ensure that supplies necessary for adherence to hand hygiene are readily accessible in all areas where patient care is being delivered. In an interview on 9/20/23 at 2:06 PM, the Director of Nursing (DON) reported that she would expect hand hygiene by performed in between assisting assisting residents with meals. 44474 2. Observation on 9/19/23 at 12:06 p.m., revealed Staff H, Laundry staff pushing the clean laundry cart down the hallway with the cover up around the cart exposing the clean clothing and towels on top of the cart. Staff H pulled the cart to the end of the hallway stopping at each room to deliver clean clothing. Review of the facility provided policy titled Laundry Room with a revision date of 3/29/23 lacked any information regarding covering of laundry carts in the hallways. Interview on 9/20/23 at 1:27 p.m., with the Administrator revealed staff should have had the cover down over the clothing and she would be doing re-education right away. On 9/20/23 at 2:17 p.m., Staff H, revealed she knew as soon as she seen the surveyor she should have had the cover down on the laundry cart. Interview on 9/21/23 at 9:12 a.m., the Director of Nursing revealed in the laundry policy does not state the laundry should be covered as it is going down the hallway.

Based on clinical record review and staff interview the facility failed to notify the Long Term Care (LTC) Ombudsman for 1 of 1 residents reviewed who transferred to the hospital (Resident #23). The facility reported a census of 33 residents. Findings include: The Minimum Data Set (MDS) assessment dated [DATE] for Resident #23 documented diagnoses of heart failure, respiratory failure and lymphoma. The MDS showed the Brief Interview for Mental Status (BIMS) score of 15 indicating no cognitive impairment. Review of Resident #23 ' s Progress Notes revealed the following information: On 7/18/23 at 5:46 p.m., resident being admitted to the hospital. On 7/31/23 at 1:40 p.m., resident returns to facility via private vehicle. Review of Resident #23 ' s Census tab revealed the following: 7/18/23- paid hospital leave The facility lacked documentation that the facility submitted information to the LTC Ombudsman for July 2023. Review of facility provided policy titled Omudsman with a revision date of 12/13/22 revealed the ombudsman is an advocate whose goal is to promote the highest quality of life for residents by serving as a communication bridge between the resident and the location. Interview on 9/21/23 at 9:04 a.m., with the Social Services Director revealed she did not have a report for July.

Based on clinical record review, interviews, and facility policy, the facility failed to ensure bed hold notice was signed by residents and or the resident's responsible person, when residents transferred out of the facility for 1 of 4 residents reviewed (Residents #38). The facility reported a census of 80 residents. Findings include: The Minimum Data Set (MDS) assessment dated [DATE] for Resident #23 documented diagnoses of heart failure, respiratory failure and lymphoma. The MDS showed the Brief Interview for Mental Status (BIMS) score of 15 indicating no cognitive impairment. Review of Resident #23 ' s Progress Notes revealed the following information: On 7/18/23 at 5:46 p.m., resident being admitted to the hospital. On 7/31/23 at 1:40 p.m., resident returns to facility via private vehicle. Review of Resident #23 ' s Census tab revealed the following: 7/18/23- paid hospital leave The clinical record lacked a signed bed hold for the hospitalization for July. Review of the facility provided policy titled Bed hold with a revision date of 12/18/22 revealed the following: To ensure that the resident/resident representative is made aware of the facility ' s bed hold and reserve bed payment policy before and upon transfer to a hospital or when taking a therapeutic leave of absence from the facility. To determine if resident/resident representative wants to hold the bed. In cases of emergency transfer the social worker or designated individual will contact the resident/resident representative to inquire regarding their decision for holding a bed. Interview on 9/21/23 at 8:21 a.m., with the Director of Nursing (DON) revealed the facility does not have a bed hold, the resident was very ill and the facility did not have a contact person to call for the bed hold as the resident has no family. The facility now has an emergency contact listed on his chart

Based on clinical record, facility policy, and staff interview, the facility failed to submit a Preadmission Screening and Resident Review (PASRR) when changes occurred for 2 of 2 residents reviewed (Resident #6 and #11). The facility reported a census of 33 residents. Findings include: 1. The Minimum Data Set (MDS) dated [DATE] for Resident #6 revealed a Brief Interview of Mental Status (BIMS) score of 15 which indicated intact cognition. The MDS revealed the resident had a diagnosis of duchenne or [NAME] muscular dystrophy. The (PASRR) dated 3/22/23 revealed: a. The section to list mental health diagnoses revealed that the resident had no mental health diagnosis was known or suspected. b. The section that listed mental health medications listed Zoloft (anti-depressant medication) 50 milligrams (mg) per day, current status, diagnosis of dysthimia. The Order Summary Report signed by a physician on 8/14/23 revealed an order for Zoloft 50 mg one time daily for dysthimia with a start date of 1/5/23. The Pre-Admission Screening and Resident Review (PASARR)-Rehab/Skilled Policy with a revised date of 12/21/22 revealed: a. Purpose: To ensure that individuals with retardation, serious mental disorder or intellectual disability receive the care and services they need in the most appropriate setting. b. If the resident is diagnosed with a mental disorder while in the location, the social worker will contact the designated state agency for a Level II screening. c. The location will notify the state-designated mental health or intellectual disability authority promptly when a resident with MD or ID experiences a significant change in mental or physical status. A resident whose condition or treatment is or will be significantly different than described in the resident ' s most recent PASARR Level II evaluation and determination. In an interview on 9/19/23 at 3:29 PM, the Social Worker and Director of Nursing (DON) reported that they would expect to submit a PASRR when changes occurred with mental health diagnoses and/or mental health medications. In the same interview, the Social Worker reported that she had training on PASRR in January 2023 with review of PASRRs occurring after this training. 2. The MDS dated [DATE] for Resident #11 revealed that she had short and long term memory problems. The MDS revealed the resident had diagnoses of heart failure (inability of the heart to pump blood effectively), anxiety, depression, and psychotic disorder. The PASRR dated 5/15/19 revealed: a. Mental Illness section: 1. Does the individual have any of the following major mental illnesses? No checked. major depression, psychotic/delusional disorder options 2. Does the individual have any of the following mental disorders? No checked. options are anxiety and depression 3. Does the individual have a diagnosis of a mental disorder that is not listed? No checked. b. Psychotropic Medications section: 1. Has the individual been prescribed psychoactive (mental health) medications now or within the past 6 months? No checked. The LTC (Long Term Care) Progress Note signed by a physician on 9/14/23 revealed: a. Order for Ativan 0.5 mg daily started 7/27/20. b. Order for duloxetine 30 mg daily started 9/12/23. c. Order for Haldol 0.5 mg in the morning 9/12/23. d. Orders for trazodone 25 mg at bedtime started 3/19/21. e. Diagnoses: anxiety, major depressive disorder, recurrent, severe with psychotic symptoms. The Pre-Admission Screening and Resident Review (PASARR)-Rehab/Skilled Policy with a revised date of 12/21/22 revealed: a. Purpose: To ensure that individuals with retardation, serious mental disorder or intellectual disability receive the care and services they need in the most appropriate setting. b. If the resident is diagnosed with a mental disorder while in the location, the social worker will contact the designated state agency for a Level II screening. c. The location will notify the state-designated mental health or intellectual disability authority promptly when a resident with MD or ID experiences a significant change in mental or physical status. A resident whose condition or treatment is or will be significantly different than described in the resident ' s most recent PASARR Level II evaluation and determination. In an interview on 9/19/23 at 3:29 PM, the Social Worker and Director of Nursing (DON) reported that they would expect to submit a PASRR when changes occurred with mental health diagnoses and/or mental health medications. In the same interview, the Social Worker reported that she had training on PASRR in January 2023 with review of PASRRs occurring after this training.

Based on clinical record, facility policy, and staff interview, the facility failed to develop a care plan when a resident had new pressure ulcers for 1 of resident reviewed (Resident #32). The facility reported a census of 33 residents. Findings include: The Minimum Data Set (MDS) dated [DATE] for Resident #32 revealed a Brief Interview of Mental Status score of 8 which indicated moderately impaired cognition. The MDS revealed the resident had diagnoses of essential tremor and hypertension (high blood pressure). The MDS revealed the resident did not have pressure ulcers. The Health Status Note on 8/7/2023 at 2:30 PM revealed Resident found to have unstageable pressure sores to bilateral heels as well as an open area on the back of left leg. Therapy believes the open area may be due to the amount of edema in BLE (bilateral lower extremities). Resident does have 2+ edema in BLE. Fax was sent to provider informing them of skin issues as well as requesting treatment orders. The Care Plan Focus Area with an initiated date of 9/18/23 revealed the resident has an unstageable pressure ulcer to left heel. Sacral area is excoriated and reddened. Right great toe with skin abrasion. The Care Plan- R/S (Rehabilitation/Skilled), LTC (Long Term Care), Therapy & Rehab Policy dated 9/22/22 revealed: 1. Each resident will have an individualized, person-centered, comprehensive plan of care that will include measurable goals and timetables directed toward achieving and maintaining the resident ' s optimal medical, nursing, physical, functional, spiritual, emotional, psychosocial, and educational needs. Any problems, needs and concerns identified will be addressed through use of departmental assessments, the Resident Assessment Instrument (RAI) and review of the physician ' s orders. 2. This plan of care will be modified to reflect the care currently required/provided for the resident. 3. The care plan will emphasize the care and development of the whole person ensuring that the resident will receive appropriate care and services. It will address the relationship of items or services required and facility responsibility for providing these services. In an interview on 9/19/23 at 3:54 PM, the Director of Nursing (DON) reported that it was very interesting that the resident's care plan was not updated when she first developed the bilateral heel pressure ulcers, she expected care plans to be updated as soon as pressure ulcers were found.

Based on record review and staff interviews the facility failed to provide professional standards of care by administering medications without a current physician order for 1 of 6 residents reviewed (Resident #24). The facility reported a census of 33 residents. Findings include: The Minimum Data Set (MDS) assessment dated [DATE] for Resident # 24 documented diagnoses of diabetes mellitus, depression, atrial fibrillation and renal insufficiency. The MDS showed the Brief Interview for Mental Status (BIMS) score of 15, indicating no cognitive impairment. Review of the Admission Orders signed 8/22/23 revealed an order for bumetanide (diuretic medication) daily hold until seen by primary care physician (PCP). Review of the August and September 2023 Medication Administration Record (MAR) revealed an order for bumetanide oral tablet with a start date of 8/30/23. Review of the September MAR revealed bumetanide was administered September 6-20, 2023. Review of the clinical chart lacked a current order for bumetanide. Review of the Progress Notes lacked information about restarting bumetanide. Review of the Care Plan with a revision date of 8/24/23 revealed resident uses bumetanide. Review of fax dated 9/20/23 sent to the PCP the facility wrote, do you have record of when this was restarted? She had an ultrasound on the 27th of August. Thanks. The PCP responded I don' t know. It was not restarted by me. We have no records of restarting. We had it held on our records signed by the PCP undated. Review of the facility provided policy titled Physician or Practitioner orders with a revised date of 3/29/23 revealed the following information: a. It is the policy of the facility to provide individualized care to each resident by obtaining appropriate, accurate and timely physician/practitioner orders. b. Medication orders must include: Diagnosis or medical reason/indication for use.Route (e.g., IV, IM, oral), Dosage (e.g., 1 tablespoon, 2 tablets), Frequency (e.g., once a day, Q4H), Strength (e.g., 500mg, 10meq), Date order was received, If the order is a PRN order, the order must state how often PRN, medication may be given (e.g., Q4H PRN, QD PRN, HS PRN), A stop date may be required for some orders (e.g., stop date is required for antibiotic orders), Signature and date of physician/practitioner. Interview of 9/21/23 at 10:24 a.m., the Director of Nursing (DON) stated she felt the facility had an order but it had not been restarted from the physician yet.

Based on clinical record review and interview, the facility lacked a discharge summary including a recapitulation of a resident's stay for 1 of 1 residents reviewed in the closed record sample (Resident #34). The facility reported a census of 33 residents. Findings Include: The Minimum Data Set (MDS) assessment dated [DATE] for Resident # 34 documented diagnoses of hypertension, arthritis, and anxiety disorder . The MDS showed the Brief Interview for Mental Status (BIMS) score of 9, indicating moderate cognitive impairment. Review of Resident #34 ' s Census tab revealed Resident #34 was discharged on [DATE] at 11:00 a.m. Review of Resident #34 ' s Progress Notes revealed on 9/1/23 at 2:03 p.m., resident was discharged . Review of Resident #34 ' s medical record lacked a completed discharge summary including a recapitulation of the resident ' s stay. Facility later provided a discharge summary dated 9/20/23. Review of the MDS list revealed a MDS completed on 9/1/23 discharge returned not anticipated. Review of facility policy titled Discharge Planning with a revision date of 12/22/22 revealed the purpose of the policy is to ensure a safe and orderly discharge. When discharge is planned from the location to another post-acute provider, assist the resident and representative in selecting a provider by providing them with information such as Nursing Home Compare and 5 Star. Interview on 9/20/23 at 1:52 p.m., with the Director of Nursing (DON) revealed the discharge summary was not completed when the resident was discharged . The DON continued with the facility having just had a COVID outbreak and another nurse told her she had completed the discharge so she didn't think to look at it. The discharge medication list had been completed but not a summary of the resident's stay. The discharging nurse completed the discharge summary today (9/20/23) and we have sent it off to the physician for review.

Based on record review and interviews, the facility failed to ensure a resident who entered the facility without pressure sore did not develop a pressure sore and failed to ensure timely treatment and services to promote healing and prevent infection for 1 of 5 residents reviewed (Resident #4). Resident #4 entered the facility at risk for developing pressure sores (ulcer/wound). The facility failed to protect Resident #4's left heel and he/she developed a pressure sore. The physician ordered wound culture of the ulcer on 1/09/14 due to an odor and the facility did not obtain the culture until 1/14/14 which showed Resident #4 had infection of the ulcer. Resident #4 received the antibiotic for 2 weeks and finished an antibiotic on 1/28/14. The wound showed no improvement and continued with odor and drainage. The facility failed to notify the physician of the condition of the wound until 2/06/14 (9 days after completing the antibiotic). The facility received a fax to re-culture the wound on 2/07/14 and failed to obtain a culture until 2/10/14, further prolonging initiation of treatment. The culture again showed infection and antibiotics started. The wound continued to drain and had a strong odor. The facility failed to keep the physician updated on the condition of the ulcer. The physician was notified on 1/19/14 the ulcer had 20% necrotic tissue. The wound nurse consultant observed the area on 1/20/14 and determined the ulcer had 60% black necrotic tissue. Resident #4 had severe pain unrelieved by narcotic [MEDICATION NAME]. On 2/27/14, Resident #4 had been admitted to the hospital with [REDACTED]. Resident #4 ' s physician reported Resident #4 had osteo[DIAGNOSES REDACTED] of the left heel [MEDICAL CONDITION] related to the left heel ulcers and his/her death was directly related to this. The facility reported a census of 29 residents. Findings include: According to the Minimum Data Set (MDS) assessment dated [DATE], Resident #4 had been unable to complete the Brief Interview for Mental Status (BIMS) cognitive test. Resident #4 demonstrated long and short term memory problems and moderately impaired skills for daily decision making. Resident #4 required two staff assistance with activities of daily living (ADLs) including bed mobility, transfer, ambulation in his/her room, dressing, eating, toilet use and one staff to assist with personal hygiene. Resident #4's [DIAGNOSES REDACTED]. Resident #4 had no pain the previous 5 days. Resident #4 had no pressure ulcer, but at risk for developing pressure ulcers. A History and Physical (H & P) dated 10/31/13 (prior to the nursing home admission) identified Resident #4 could not remember how or why he/she was in the hospital. The resident remembered he/she had knee surgery but was unaware of how that related to being at the hospital. The resident was only oriented to him/her(self). The H & P noted the resident may have developed chronic [MEDICAL CONDITION] which may have been caused by my micro areas of ischemia the watershed areas of the brain circulation, perhaps related to events during the surgery. The [MEDICAL CONDITION] etiology was not from a urinary track infection [MEDICAL CONDITION]. A Hospital discharge date d 11/27/13 documented Resident #4 had recent left knee surgery and needed skilled care. The hospital reported the resident had dementia due to intraoperative [MEDICAL CONDITION]. Resident #4 also had a [DIAGNOSES REDACTED]. An Initial Interdisciplinary Data Collection Tool dated 11/27/13 documented Resident #4 had no pain or pressure areas. The Braden Scale for Predicting Pressure Sore Risk scored Resident #4 at 15 on 11/27/13 and 12/12/13, and 14 on 12/04/13. A score of 15 to 18 indicated a mild risk of developing pressure sores, and a score of 13 to 14 indicated a moderate risk of developing pressure sores. In addition, if other major risk factors were present (including advanced age) to advance to the next level of risk, putting Resident #4 at moderate to high risk. The intervention guide for all risk levels included protecting the heels and managing friction and sheer. Managing friction and sheer included protecting the elbows and heels if being exposed to friction. The assessment indicated Resident #4 had a problem with friction and shear, requiring moderate to maximum assistance in moving. Complete lifting without sliding against the sheets was impossible. Frequently sliding down in the bed or chair, requiring frequent repositioning with maximum assistance. [DIAGNOSES REDACTED], contractures or agitation lead to almost constant friction. An Interdisciplinary Assessment and Summary Review dated 12/05/13 documented Resident #4 at risk for pressure ulcers. A Comprehensive Care Plan dated 12/12/13 identified Resident #4 at risk for pressure ulcers due to decreased mobility. The care plan directed staff to: a. use a pressure relieving device in the resident ' s wheelchair and mattress. b. Observe skin with cares and baths. c. Moisturize as needed. d. The care plan identified Resident #4 was able to reposition him/her (self) in bed. Another care plan for mobility impairment identified due to the resident ' s cognition and post right knee replacement, Resident #4 will be assisted for transfers. Resident #4 would need staff assistance with bed mobility, and used a wheelchair for distances outside his/her room. The care plan dated 12/27/13 identified altered skin integrity related to a pressure ulcer on the left heel. The care plan included the following: a. Treatment as ordered and document on wound sheet. b. Heel boot at all times. c. Float heels off bed with red pillow. d. Wound nurse consultant and follow recommendations. The December 2013 Medication Administration Record [REDACTED]. The Interdisciplinary Progress (IDP) Notes dated 12/21/13 at 6:50 p.m. documented Resident #4 bent over to "fix" his/her sock and rolled out of the wheelchair onto the floor. The IDP notes dated 12/23/13 at 3:00 p.m. documented a follow up to 12/21/13. Resident #4 tried to fix socks and rolled onto the floor with no injuries. Resident #4 often preoccupied with shoes and socks and bending over in the wheelchair. Resident #4 set the alarm off frequently when agitated. The problem was cognition. Staff offered activities and would refer to social services for different shoes. The IDP Notes dated 12/26/13 at 9:30 a.m. documented Resident #4 refused to get up or take a.m. pills. Resident #4 was very belligerent and hitting at staff. Resident #4 remained in bed, and they would continue to monitor. The IDP Notes dated 12/27/13 at 11:00 a.m. documented Resident #4 had a swollen left foot and a large blister on the left heel that burst open. The blister measured 4 by 5 centimeters (cm) with a large amount of serous drainage. Staff sent a fax to the physician asking for a treatment for [REDACTED]. At 4:50 p.m. the physician responded to keep a dressing on the left heel and use heel boots. On 12/27/13 a fax notified the physician Resident #4 had a large blister area on his/her left heel 5 by 4 cm, that burst with a large amount of serous drainage. They placed ABD's to collect the drainage. The fax asked what the physician would like, and heels boots on. The physician responded to keep a dressing on and heel boots. A Medication Administration Record [REDACTED]. On 12/30/13 a fax notified the physician Resident #4 had an open area of the left heel and asked about treating with Calcium Alginate until healed. The physician replied yes. The Wound Flow Sheet dated 1/09/14 documented the pressure ulcer measured 3 by 3 cm with no drainage and no pain. The box regarding odor had a line identifying " yes " there pressure ulcer had an odor. The flow sheet indicated no slough or eschar. The IDP Notes dated 1/09/14 at 6:10 p.m. documented the physician at the facility to see Resident #4 to look at heel. Staff received a new order to culture the wound on the left heel. The physician noted odor. The record lacked a wound culture until 1/14/14. On 1/13/14 a fax notified the physician Resident #4's heel was not healing and asked about changing the treatment. The physician replied okay. A Laboratory final result report dated 1/14/14 at 10:06 a.m. showed a culture of Resident #4's heel with a large amount of Beta-[DIAGNOSES REDACTED] Streptococci group C and a large amount of Staphylococcus aureus,[MEDICAL CONDITION] (Methecillin resistant staph aureus). Culture results from the physician documented Resident #4 needed to start Bactrim DS (antibiotic) for 14 days. On 1/19/14 a fax notified the physician the wound on Resident #4's left heel measured 4 by 4.3 cm by 0.05 cm. Discomfort noted with the dressing change, with 20% eschar (necrotic tissue), black in color. This was an FYI (for your information) and update on status. Odor noted as well. The physician responded " ok " by fax. A wound nurse completed the Wound Care/Skin Integrity/Evaluation form dated 1/20/14. The wound nurse documented Resident #4 had a facility acquired, full thickness, unstageable pressure ulcer of the left heel measuring 3.5 by 5 cm, and unable to determine the depth. The wound had minimal purulent drainage. The wound bed presented with 30% granulation tissue, 10% yellow adherent slough, and 60% black moist necrotic tissue. The peri-wound had macerated tissue with a perimeter of 3 cm. Resident #4 had a PUSH (pressure ulcer scale for healing) score of 14. The IDP Notes dated 1/23/14 at 9:00 a.m. documented the dressing had been changed on the resident ' s left heel, with the continued odor. The note identified they were awaiting new orders per consulting wound nurse who visited on 1/20/14. On 01/24/14 a fax notified the physician they had their wound nurse consultant look at Resident #4's open area to the left heel and she recommended they discontinue the current order and try cleansing with normal saline/wound wash, pat dry, apply skin protectant to peri-wound, apply [MEDICATION NAME] to wound bed, apply thick [MEDICATION NAME] to peri-wound perimeter which [MEDICATION NAME] would lay on, to cover with nonbordered foam, secure with stretch gauze and tape, and change daily. The physician responded okay. The IDP Notes dated 1/25/14 at 4:45 p.m. documented the resident voiced pain in left heel, saying not that ' s bad. " The nursing home Wound Flow Sheet dated 1/27/14 and Wound Status Assessment/Evaluation documented the ulcer showed no progress toward healing, but all measurements remained the same. Resident #4's pain management effective with Tylenol. The ulcer showed no improvement, continued with odor, not worsening either. The physician was not notified. The IDP Notes dated 1/28/14 at 10:00 a.m. documented Resident #4's course of antibiotics completed. Treatments continued daily to Resident #4's heel wound with no improvement. The area was odorous with moderate sanguinous drainage. At 2:10 p.m. Resident #4 request Tylenol for heel pain. The Wound Flow Sheet dated 1/28/14 documented minimum serosanguinous drainage, pain and odor. The flow sheet documented 75% eschar and the wound measured 5 by 6 cm. The clinical record lacked any notification of the physician of the wound showing no improvement and continued drainage and odor. The IDP Notes dated 01/31/14 at 10:10 a.m. documented Resident #4's heel continued odorous with minimal drainage. Resident #4 had pain in the heels and received Tylenol. The Medication Administration Record [REDACTED]. The IDP Notes dated 02/01/14 at 2:40 p.m. documented Resident #4's left heel continued to have minimum drainage and odor. Resident #4 had pain at times in the heel and received Tylenol for pain. The IDP Notes dated 02/02/14 at 10:15 a.m. documented a small amount of bloody drainage from Resident #4's left heel, and very odorous. Resident #4 had pain with the dressing change, but unable to say how much. The Wound Flow Sheet dated 02/02/14 documented Resident #4's pressure ulcer had no drainage, no odor, and no pain (conflicting information documented by same nurse in IDP notes). On 2/04/14 a fax notified the physician Resident #4 had an open area to the left heel with treatments daily. Resident #4 expressed pain with dressing changes and other times related to his/her heel. Resident #4 had an order for [REDACTED]. The IDP Notes dated 2/04/14 at 12:00 p.m. documented a pain interview conducted for the MDS the previous day and Resident #4 denied pain. Staff were interviewed who work with Resident #4 and reported he/she did complain of pain with dressing change to the left heel and at other times. Resident #4 only had Tylenol as needed, but they sent a fax to the physician asking for a scheduled pain medication to give better pain control. Tylenol given for pain. Resident #4 continued to have odor from the left heel. At 3:00 p.m. staff received a fax from the physician for [MEDICATION NAME] 500 mg 2 times a day for pain. The IDP Notes dated 2/06/14 at 10:00 a.m. documented Resident #4's left heel continued odorous with bloody drainage. Staff sent a fax to the physician with update on the condition of the heel, and that the 14 day course of antibiotic completed (actually completed on 1/28/14 ). Resident #4 had [MEDICAL CONDITION] in the left foot. On 2/06/14 a fax notified the Physician the area on resident #4's left heel measured 6 by 5 centimeters, very odorous with bloody drainage. Resident #4 complained of pain with the dressing change. The wound nurse saw on 01/20/14 and a new treatment started. Resident #4 took Bactrim for 14 days, and completed it. The physician responded to reculture the wound. The IDP Notes dated 2/07/14 at 12:20 p.m. documented the facility received a fax from the physician ordering a reculture of Resident #4's left heel. The IDP Notes dated 2/08/14 at 7:30 a.m. documented Resident #4 continued to have odorous and foul smelling left heel with moderate amount of sanguinous drainage. The IDP Notes dated 2/09/14 at 10:00 a.m. documented Resident #4 continued pain with left heel treatment, and foul smelling odor. Resident #4 received Tylenol. An Interdisciplinary Assessment and Summary Review dated 2/10/14 as a dietary addendum noted in January Resident #4 took antibiotic for infected wound and a culture ordered again. Infection would make healing more difficult. The IDP Notes dated 2/10/14 at 9:00 a.m. documented Resident #4's dressing changed, very odorous. Culture obtained at 8:30 a.m. The Director of Nursing present and would contact the wound nurse. At 2:30 p.m. staff received a fax from the wound nurse. An email dated 2/10/14 notified the wound nurse consultant Resident #4's open area of the heel seemed to be worsening. The area measured 4 by 3.5 cm. The black necrotic area was much larger and spongy feeling and measured 3.2 by 3.4 cm. Along the posterior edge of the wound was a moon shaped area of granulation that measured 3.1 by 0.8 cm and did have some sanguinous drainage at times. The whole thing had very putrid, rancid odor to it (what you can smell from a long way away). The wound nurse responded unfortunately things with heels a lot of times have to get worse before they get better. When you start with that dry eschar, you have no idea how deep the tissue damage is. As the necrotic tissue breaks down it gets soggy and smelly... She knew nurses got nervous as it seems to worsen, but it's not (the wound nurse had not seen the wound since 1/20/14, 3 weeks). The clinical record lacked documentation of physician notification. The IDP Notes dated 2/11/14 at 9:00 p.m. documented Resident #4 complained of heel pain and received Tylenol. A Laboratory report dated 2/13/14 showed Resident #4's heel culture had a large amount [MEDICAL CONDITION], and a large amount of [MEDICATION NAME] faecalis, with new orders to [MEDICATION NAME] mg 2 times a day for 14 days. The IDP Notes dated 2/13/14 at 9:00 a.m. documented Resident #4's left foot with less odor and drainage. Tylenol given for slight discomfort in the left heel. At 2:45 p.m. the facility received an order for [REDACTED]. The IDP Notes dated 2/16/14 at 9:30 a.m. documented Resident #4's heel tender and sore to touch, and very odorous. The IDP Notes dated 2/17/14 at 9:00 a.m. documented the skin consultant at the facility for left the heel wound, to continue treatment for 30 days. Resident #4 continued with odor and minimal sanguinous drainage. A Wound Care/Skin Integrity/Evaluation dated 2/18/14 documented the left heel pressure ulcer measured 3.2 by 3.5 cm with minimal serous drainage. The wound bed had 20% granulation tissue and 80% black, necrotic tissue. The peri-wound was macerated with a perimeter of 3 cm. Resident #4 had a PUSH score of 13. The clinical record lacked documentation of physician notification. The Wound Flow Sheet dated 2/18/14 documented Resident #4 had minimum amount of serosanguinous drainage, pain and odor. The Wound Status Assessment/Evaluation documented Resident #4's pain management not effective; physician not notified. The IDP Notes dated 2/19/14 at 9:00 p.m. documented Resident #4's dressing intact and odorous. Resident #4 received Tylenol for complaints of foot pain. The IDP Notes dated 2/20/14 at 9:15 a.m. documented Resident #4 had left foot [MEDICAL CONDITION] due to sock over the foot fitting too tight. They took the sock off and [MEDICAL CONDITION] gone. They would put a towel over the foot instead of a sock. The dressing changed with slight pain noted, and very odorous. At 11:00 a.m. Resident #4 complained of pain unrelieved by Tylenol and [MEDICATION NAME]. Staff faxed the physician and also asked about using a Prafo boot, because the heel boot caused Resident #4 pain. At 6:10 p.m. the facility received a fax from the physician (not the resident's primary) with an order for [REDACTED]. The Wound Flow Sheet dated 2/20/14 documented Resident #4 had a minimum amount of serosanguinous drainage, no pain and no odor (conflicting information in IDP notes). The Wound Status Assessment/Evaluation documented Resident #4's pain management not effective. Staff sent a fax to the physician concerning pain control. Staff received a new order for Tylenol with [MEDICATION NAME] for severe pain from another physician. On 2/20/14 a fax notified the physician Resident #4 complained of severe pain unrelieved by Tylenol as needed and [MEDICATION NAME] 2 times a day. Resident #4 complained pain of the left heel related to a current open wound still being treated. The facility requested something else to help control the pain, and if they could use a Prafo boot, as the heel boot seemed to cause pain as well. The physician (not Resident #4's primary) responded Tylenol with [MEDICATION NAME] every 6 hours as needed for severe pain, and okay to use a Prafo boot. The Wound Flow Sheet dated 2/21/14 documented Resident #4 had a minimum amount of serosanguinous drainage, no pain and no odor. The Wound Flow Sheet dated 2/22/14 documented Resident #4 had a minimum amount of serosanguinous drainage, reported pain and strong odor. The Wound Flow Sheet dated 2/23/14 documented Resident #4 had a minimum amount of serosanguinous drainage, reported pain and strong odor. The Wound Status Assessment/Evaluation documented Resident #4 continued on Cipro, and also received [MEDICATION NAME] 1 gram intramuscular for 2 days for upper respiratory issues. The heel continued very odorous. The Wound Flow Sheet dated 2/24/14 documented Resident #4 had a minimum amount of serosanguinous drainage, no pain with Tylenol with [MEDICATION NAME] given before, and strong odor. The Wound Flow Sheet dated 2/25/14 documented Resident #4 had a minimum amount of serosanguinous drainage, no pain and strong odor. The IDP Notes dated at 2/25/14 at 7:30 a.m. documented Resident #4's left heel wound continued very odorous with sanguinous drainage. Resident #4 received Tylenol at 9:00 a.m. At 2:35 p.m. vital signs registered temp 98.2, pulse 40 (normal 60-100), respirations 20, and blood pressure 88/50 (low). Resident #4 denied pain, but was very loud and anxious. The clinical record lacked a follow up of low pulse and blood pressure. The Wound Flow Sheet dated 2/26/14 documented Resident #4 had a moderate amount of serosanguinous drainage, no pain with treatment, and odor. The IDP Notes dated at 2/26/14 at 10:00 a.m. documented Resident #4's left foot continued with odor and sero-sanguinous drainage from the left heel. Tylenol with [MEDICATION NAME] given at 8:30 a.m. for pain after eating. At 1:00 p.m. Resident #4 complained of severe heel pain and Tylenol with [MEDICATION NAME] already given. Staff sent a fax to the physician. At 4:25 p.m. the physician faxed orders for lab work and heel x-rays to look for bone infection. Appointment scheduled for 02/27/14 a.m. On 2/26/14 a fax notified the physician Resident #4's left heel pain worsened. The Tylenol with [MEDICATION NAME] prescribed every 6 hours provided relief for the first 2 to 3 hours then Resident #4 complained of severe pain again. Resident #4 had only eaten 10% of meals and liquids the past 5 days because he/she stated the heel hurt too bad to eat. The facility requested something else for pain. The physician responded with orders for lab work and wrote Resident #4 needed an x-ray of the heels to make sure no bone infection. The Wound Flow Sheet dated 2/27/14 documented Resident #4 had moderate amount of serosanguinous drainage, no pain with treatment, and odor. The flow sheet documented the wound measured 3.2 by 3.5 cm. The MAR for February 2014 showed Resident #4 started [MEDICATION NAME] 500 mg 2 times a day starting 02/04/14, received Tylenol 650 mg 19 times for heel/foot pain, and Tylenol with [MEDICATION NAME] 15 times. The MAR indicated [REDACTED]. The IDP Notes dated 2/27/14 at 7:35 a.m. documented Resident #4 transferred to the hospital for lab work and x-rays. Staff called to inform nursing of Resident #4's low blood pressure, 84/50 and recheck 75/53. They received a return call for Resident #4 to go to the ER to be seen by the physician. At 9:00 a.m. staff informed family of Resident #4 going to the ER and to call the hospital for information. They informed the family of low blood pressures and x-ray and blood work scheduled. At 12:40 p.m. Resident #4 admitted to the hospital with [REDACTED]. A Hospital Encounter/Consultation dated 2/27/14 at 1:14 p.m. documented Resident #4 seen for pressure ulcer of the heel. The note documented Resident #4 declining because of the pressure ulcer which had become infected and rapidly progressing in stages. Resident #4 responded poorly, staff reported low blood pressure, and he/she was not doing well at that point. The wound had previous culture which [MEDICAL CONDITION]. There had been distinct odor from the ulcer. Resident #4 appeared pale and warm to touch. Resident #4 had a very large pressure ulcer on the inner aspect of the heel measuring 4 by 4 cm, and at the deepest point they were able to probe, 1 cm deep. The ulcer was full of eschar and necrotic tissue with a foul odor. The edges were ragged and macerated with some [DIAGNOSES REDACTED] present. The plan included the physician changing the dressing daily. They hoped by the next week a physician would be able to go in and surgically debride and clean it out. A hospital Daily Discharge Note dated 3/04/14 documented dead tissue [MEDICATION NAME] dissected from Resident #4's heel ulcer, with dead tissue remaining at the base. They would continue chemical debridement, and plan surgery to get a good tissue bed. After an hour long discussion with the family they would stop treatment. Resident #4 would not undergo surgery. A Discharge Summary dated 3/06/14 documented Resident #4's principal [DIAGNOSES REDACTED]. Active problems included an open wound of the left heel, and an infected pressure ulcer. Resident #4 admitted for osteo[DIAGNOSES REDACTED] of the heel. He/she was very hypotensive on arrival. They started Resident #4 on intravenous (IV) fluids and IV [MEDICATION NAME]. After discussion with another physician, they did chemical debridement per recommendation. The family wished for no further treatment. Resident #4 transferred for comfort cares. Hospice would start services on discharge. The IDP Notes dated 3/04/14 documented the social services worker received an e-mail from discharge planner that Resident #4 may need an extended stay at the hospital. The IDP Notes dated 3/05/14 at 3:45 p.m. documented Resident #4's family informed staff Resident #4 would not return as he/she went to hospice. During an interview on 03/26/14 at 12:26 p.m. Staff A Licensed Practical Nurse stated the caregivers discovered the area on Resident #4's heel. When they were putting Resident #4's sock on, they noted the area was wet. They called Staff A in, and she discovered Resident #4 had a popped blister. She said it appeared whitish and had serous, plus maybe a little bloody drainage. During an interview on 03/27/14 at 9:07 a.m. Staff B Registered Nurse (RN) stated Resident #4 got up in the chair during the day or the recliner, and laid down in the afternoon. She said Resident #4 wore slippers or gripper socks. She said Resident #4 didn't like to wear shoes. She said Resident #4 would put his/her heels over the edge of the foot pedals, and he/she had a foot cradle. Resident #4 still put his/her heels over the edge but if they saw it, they would put his/her feet back in the foot cradle. Staff B stated Resident #4 had the foot pedals on pretty much all the time. She said they started the heel boot after they discovered the heel ulcer. She said Resident #4 liked to lean over and mess with his/her pants. She said the foot cradle was padded. She said they did weekly skin checks during baths and which was marked on the Medication Administration Record [REDACTED] The MAR for December 2013 lacked any initials for skin checks. Staff B handed the surveyor an undated typed note that read nurse's at the facility did skin checks during bath time or showers every week. The whole body was accessed. Any other time the CNA's would call the charge nurse if any issues were found during routine cares. Staff B checked Resident #4 on 12/5/13, 12/23/13, and 12/26/13. Resident #4's whole body was accessed during his/her bath. The heels were intact with no blisters or boggy areas. A Bathing Report documented Resident #4 refused a bath on 12/26/13. During an interview on 03/27/14 at 9:21 a.m. Staff C Certified Nursing Assistant (CNA) stated she worked the day they discovered the ulcer on Resident #4's heel. She went to put Resident #4's socks on and it felt wet and oozy. Staff C called for the nurse. She said she had not noticed anything before that. Staff C stated Resident #4 did not wear shoes. She said Resident #4 had slippers that didn't stay on. They did more rubbing than anything, so they used gripper socks. During an interview on 03/27/14 at 9:33 a.m. Staff D CNA stated Resident #4 was up about every 2 hours. She said Resident #4 couldn't keep his/her feet on the foot pedals, and thought that was why he/she had the foot cradle. She said they did not take the foot pedals off the chair. She said Resident #4 did mess with his/her gripper socks, because when he/she moved around they would slip down. She said they did skin checks Monday, Tuesday, and Wednesday during baths. They would call the nurse down. During an interview on 03/27/14 at 9:52 a.m. the MDS Coordinator brought a highlighted IDP note about referring to social services for different shoes for Resident #4 on 12/23/14. She thought Resident #4 needed more proper fitting shoes, but wasn't completely sure. She didn't know enough about the foot cradle to comment. During an interview on 03/27/14 at 10:21 a.m. Staff E CNA stated prior to the pressure ulcer, when in bed, Resident #4 had red pillows under his/her legs and a pillow under his/her legs in the recliner. She said When Resident #4 sat in the wheelchair he/she had a foot cradle on the foot pedals so his/her feet would stay up, and he/she wouldn't drag his/her feet. She said the only time the foot pedals were off the wheelchair was during transfer. Staff E stated Resident #4 had slippers that just kept falling off, so he/she wore gripper socks. She said nurses did skin checks Monday, Tuesday, and Wednesday during baths. During an interview on 03/27/14 at 10:30 a.m. the Medicare Coordinator, Rehab and Infection Control Nurse stated Resident #4 had slippers and he/she would always be bent over trying to tie them, but they didn't have ties. She didn't know if Resident #4 did this because they (slippers) were loose. She said Resident #4 wore gripper socks sometimes, too. They were going to see about different shoes as an intervention to a fall he/she had on 12/21/14. After they discovered the ulcer on Resident #4's heel they didn't pursue it. She thought they had the foot cradle because when pushed, Resident #4 didn't keep his/her feet on the foot pedals. During an interview on 03/26/14 at 3:31 p.m. the Director of Nursing (DON) stated Resident #4 wore gripper socks or slippers, not shoes. She said they were not doing interventions to protect Resident #4's heels prior to the discovery of the pressure ulcer. After the pressure ulcer developed they used heel boots and skin prep to the opposite heel. She said all mattresses were pressure reduction. She said Resident #4 was very restless and fidgety, and would hang his/her ankles over the wheelchair pedals, so they tried a foot cradle and it didn't work. She did not know the start date of the foot cradle. On 03/27/14 at 9:27 a.m. the DON stated the foot cradle was not a pressure reduction device. At 11:53 a.m. the DON stated the information sent to the wound nurse consultant on 02/10/14, did not get reported to the physician. During an interview on 04/03/14 at 9:56 a.m. the RN wound nurse consultant stated when she had a resident to see at the facility she went to the facility every 4 weeks. She had no contact with the physician. She said she collaborated with the staff to come up with interventions and treatment options. The facility then got orders from the physician. She said if the facility thought they had a concern with the ulcer she would hope they would notify the physician. Regarding the odor of the wound, she did tell the facility the breakdown of necrotic tissue could cause odor. She said infection could also cause odor. She said she hoped they would keep the physician updated on the resident and the ulcer. She said she used the PUSH tool when evaluating a wound. She said the number indicates the heal-ability of the wound. She said a number above 6 or 7 usually indicates necrotic tissue and would take longer to heal. She said infection would affect the ability to heal. She said she goes over things to watch for, like increased peri ulcer redness, increased swelling, increased odor and vital signs. She said if they had concerns about infection, they should not wait for the wound nurse. During an interview on 04/01/14 at 9:10 a.m. the Infection Control Nurse (ICN) stated when a culture was ordered on a Friday, they would obtain it, if it were urgent. She said the Friday they got the order for a culture for Resident #4, she didn't know if they had the supplies needed. When asked about the lapse of time between finishing the Bactrim on 01/28/14 and notifying the physician on 02/06/14 of the continued odor and drainage, the ICN said she saw that. She said staff told her the wound didn't get any worse. The ICN stated she knew Resident #4 admitted to the hospital with [REDACTED]. During an interview on 03/31/14 at 12:44 p.m. Resident #4's physician stated she knew Resident #4 had an ulcer to the left heel and she saw it at least once. She ordered a culture in January (2014) and treated for [REDACTED].

Based on observation, record review, staff interviews and facility policy review, the facility failed to ensure staff appropriately assessed and implemented appropriate interventions for wound care with one of four residents reviewed with pressure ulcers and/or skin issues. (Resident #2). The facility identified a census of 38 residents. Findings include: 1. Resident #2 had a Minimum Data Set (MDS) assessment with a reference date of 1/14/2013 which identified the resident had [DIAGNOSES REDACTED]. The MDS assessment indicated the resident had short and long term memory deficits, moderately impaired cognitive skills, required extensive assistance of 2 staff members with bed mobility, transfers, as nonambulatory and at risk for pressure ulcers. The MDS did not have a turning/repositioning program. An MDS assessment with a reference date of 4/1/13 reflected the resident had [DIAGNOSES REDACTED]. The MDS assessment reflected the resident had short and long term memory deficits, moderately impaired cognitive skills, required extensive assistance of 2 staff members with bed mobility and transfers, non-ambulatory, at risk for pressure ulcers, with one unhealed stage IV pressure ulcer which measured 3.0 centimeters (cm) (length) by 3.0 cm (width) and 4.0 cm deep with slough that adhered to the ulcer bed in strings or thick clumps, or had been mucinous. The resident did not have a turning or repositioning program. A Care Plan with a care conference dated 1/24/13, indicated the following problems and interventions with the correlating dates: a. 4/11/13 - Altered mobility related to history of a compression fracture and required assistance with transfers. The Care plan dated February 2/20/2013 identified no problems with pressure ulcers or interventions for staff to follow. The approaches included the following: 1. 2 staff assistance with bed mobility and repositioning. 2. Wheelchair for mobility, able to wheel self around but required assistance to his/her destinations. (Discontinued 4/17/13) 3. Up in chair as tolerated. Observe for condition changes. b. 4/11/13 - Potential for altered skin integrity related to decreased mobility and incontinence of his/her bowel and bladder. The approaches included: Observe skin with cares and bathing Pressure relieving device in wheel chair and mattress. Assist with repositioning at least every 2 hours and keep off open area as much as possible. 4. Encourage the resident to lay down after breakfast and lunch to get off his/her buttocks. c. 4/12/13 - Impaired skin integrity related an open area/pressure ulcer on his/her left buttock related to decreased mobility, poor nutritional intake and incontinency of his/her bowel and bladder. The approaches included: 1. Treat the area with a dressing as ordered. 2. Chart daily on the wound flow sheet. 3. Monitor the open area for infection. 4. Hospice to assist with recommendations for the open area. 5. Keep off open area as much as possible. 6. Had [MEDICATION NAME] Resistant Staphylococcus Aureus (MRSA) in the wound. 7. Low Air Loss Mattress on the bed provided by Hospice. 8. Had a pressure reducing device in the wheel chair and recliner. A Braden Scale for Predicting Pressure Sore Risk form dated 4/1/13, 1/14/13, 10/22/12 and 8/7/12, indicated the resident had a score of 12. (A score of 10 or above indicated a resident at high risk for pressure ulcers). On 4/17/13 at 2:45 p.m., the DON was interviewed and stated the area on the resident's buttock first presented as an abrasion. (Defined as: scraped area of skin: an area on the skin, or some other surface of the body, that has been damaged by scraping or rubbing.) A Wound Flow Sheet form entry dated 2/13/13, indicated the resident had a pressure sore on his her ischium (hip bone) with the following assessment: a. 1 cm (length) x (by)1 cm (width) and 1/16th cm deep. b. [MEDICATION NAME] skin with no percent % documented. c. No drainage. d. Margins/surrounding skin as intact. e. No undermining/tunneling. f. No odor. g. No pain. h. No dressing or treatment had been indicated. An Interdisciplinary Progress Note entry dated 2/14/13 at 10:05 indicated the resident experienced pain when up and positioned directly on the ulcer area. A Wound Flow Sheet form entry dated 2/16/13, indicated the resident had a pressure sore on the ischium with the following assessment: a. No wound measurements had been documented. b. No wound tissue description had been documented. c. No drainage had been documented. d. Margins/surrounding skin as intact. e. No undermining/tunneling. f. No odor. g. Pain with touch h. Dressing/treatment documented as open to air. A Wound Flow Sheet form entry dated 2/17/13, indicated the resident had a pressure sore on his her ischium with the following assessment: a. No wound measurements had been documented. b. No wound tissue description had been documented. c. Clear wound drainage. d. Margins/surrounding skin as intact. e. No undermining/tunneling. f. No odor. g. Pain with touch. h. The dressing as Aqua flow with [MEDICATION NAME]. A Fax Communication To the Physician form dated 2/17/13 indicated the resident had a fluid filled type blister on his/her left lower buttocks that had been slightly weeping. The facility received an order for [REDACTED]. A Wound Flow Sheet form entry dated 2/18/13, reflected the resident had a pressure sore on the ischium with the following assessment: a. No wound measurements had been documented however the area had been described as red. b. No wound tissue description had been documented. c. No wound drainage had been documented. d. Margins/surrounding skin as intact. e. No undermining/tunneling. f. No odor. g. No pain. h. The dressing as Aqua flow with [MEDICATION NAME]. A Physician's Progress Note form dated 2/22/13 indicated the resident had been seen by the physician for routine nursing home rounds and the nurses had reported no problems with the resident. A Fax Communication To Physician form dated 2/25/13 reflected the facility received an order to start Calcium Alginate and [MEDICATION NAME] to the resident's ulcer area to have been changed every day (QD) and PRN. A Fax Communication To Physician form dated 3/12/13 indicated the facility received an order for [REDACTED]. A Wound Flow Sheet form entry dated 3/3/13, indicated a pressure sore on the ischium with the following assessment: a. No wound measurement had been documented. b. The wound with 100% slough tissue. c. No wound drainage had been documented. d. Margins/surrounding skin as intact. e. No undermining/tunneling. f. No odor. g. No pain. h. The dressing as Santyl. An Interdisciplinary Progress Note entry dated 3/4/13 at 11 a.m. indicated the resident had showed signs of discomfort during the treatment. A Wound Flow Sheet form entry dated 3/7/13, indicated the resident had a pressure sore on the ischium with the following assessment: a. No wound measurements had been documented. b. No wound tissue description had been documented. c. A minimum amount of sanguineous and purulent wound drainage. d. Margins/surrounding skin as intact. e. No undermining/tunneling. f. No odor. g. Pain. h. The dressing as Santyl. A Fax Communication To Physician form signed by a PA 3/7/13, indicated the facility received an order for [REDACTED]. A Wound Flow Sheet form entry dated 3/8/13, indicated the resident had a pressure sore on the ischium with the following assessment: a. No wound measurements had been documented. b. No wound tissue description had been documented. c. A minimum amount of sanguineous and purulent wound drainage. d. Macerated wound margins/surrounding skin. e. No undermining/tunneling. f. Odor. g. Pain. h. The dressing as Hydrogel impregnated gauze. A Wound Flow Sheet form entry dated 3/9/13, indicated the resident had a pressure sore on the ischium with the following assessment: a. No wound measurements had been documented. b. No wound tissue description had been documented. c. A minimum amount of sanguineous, purulent and yellow wound drainage. d. [DIAGNOSES REDACTED]tous wound margins/surrounding skin. e. No undermining/tunneling. f. Odor. g. Pain. h. The dressing as Hydrogel impregnated gauze. A Wound Flow Sheet form entry dated 3/10/13, indicated the resident had a pressure sore on the ischium with the following assessment: a. The wound measured 2 cm in diameter with 2 cm of surrounding red skin and 3/8 cm deep. b. No wound tissue description had been documented. c. A minimum amount of sanguineous, purulent and yellow wound drainage. d. [DIAGNOSES REDACTED]tous wound margins/surrounding skin. e. 3/8 cm undermining/tunneling. f. Odor. g. Pain. h. The dressing as Hydrogel impregnated gauze. A Fax Communication To Physician form dated 3/12/13, indicated the facility received an order to switch the dressing to the resident's ulcer area back to Santyl and change QD and PRN. A Fax Communication To Physician form signed by the physician on 3/14/13, reflected the wound had been causing the resident "much pain" with a physician order [REDACTED]. A Bacterial Culture collected on 3/15/13 and verified 3/18/13, indicated the resident had no predominant organism in his/her coccyx ulcer. A Wound Flow Sheet form entry dated 3/16/13, indicated the resident had a pressure sore on his her Ischium with the following assessment: a. No wound measurements had been documented. b. Eschar tissue present in the wound with no % documented. c. A minimum amount of sanguineous and purulent wound drainage. d. [DIAGNOSES REDACTED]tous wound margins/surrounding skin. e. 3/8 cm undermining/tunneling f. Odor. g. Pain. h. The dressing as Santyl. A Wound Flow Sheet form entry dated 3/19/13, indicated the resident had a pressure sore on the ischium with the following assessment: a. No wound measurements had been documented. b. No wound tissue description had been documented. c. A minimum amount of purulent and yellow wound drainage. d. [DIAGNOSES REDACTED]tous wound margins/surrounding skin. e. Undermining/tunneling around the center of the wound. described as 1 cm black area. f. A very foul odor. g. No pain assessment had been documented. h. The dressing as Santyl. A Wound Flow Sheet form entry dated 3/22/13, indicated the resident had a pressure sore on his her Ischium with the following assessment: a. No wound measurements had been documented. b. No wound tissue description had been documented. c. A moderate amount of purulent and yellow wound drainage. * d. [DIAGNOSES REDACTED]tous wound margins/surrounding skin. e. Undermining/tunneling described as 2.5 cm to the upper right side of the wound. f. A more foul odor. g. Increased pain had been documented with the physician notified. h. The dressing as Santyl. An Interdisciplinary Progress Note entry dated 3/22/13 at 9:35 a.m., indicated the resident experienced pain with the dressing changes. A Fax Communication To Physician form dated 3/23/13, indicated the facility received an order for [REDACTED]. An Interdisciplinary Progress Note entry dated 3/23/13 at 9:45 a.m., indicated the resident continued to experience pain with dressing changes and sitting however he/she refused the [MEDICATION NAME] prior to the treatment procedure. A Wound Flow Sheet form entry dated 3/26/13, indicated the resident had a pressure sore on the ischium with the following assessment: a. The area measured 3 cm (length) x 3 cm (width) and 2 cm x 2 cm deep. b. No wound tissue description had been documented. c. No wound drainage had been documented. d. Wound margins as intact. e. No undermining/tunneling documented. f. No odor. g. No pain. h. The dressing as Santyl. A Fax Communication To Physician form dated 3/26/13, indicated the facility received the following orders: a. A treatment order for the ulcer area as Calcium Alginate rope and to over the area with calcium alginate dressing and [MEDICATION NAME]. b. Discontinue the PO (by mouth) [MEDICATION NAME] pain medication due to the resident having not been able to swallow with an order to increase the [MEDICATION NAME] to 25 micrograms. c. [MEDICATION NAME] I gram IM (intramuscular) daily for 1 week. A Wound Flow Sheet form entry dated 3/27/13, indicated the resident had a pressure sore on his her Ischium with the following assessment: a. No wound measurements had been documented. b. No wound tissue description had been documented. c. No wound drainage had been documented. d. Wound margins/surround skin as intact. e. Undermining/tunneling described as 4 cm. f. An odor as present. g. Pain. h. The dressing as Calcium Alginate. An Interdisplinary Progress Note entry dated 3/27/13 at 9:30 a.m., indicated the resident had pain with the dressing change. A Wound Flow Sheet form entry dated 3/31/13, indicated the resident had a pressure sore on the ischium with the following assessment: a. No wound measurements had been documented. b. No wound tissue description had been documented. c. A moderate amount of ensanguines wound drainage. d. Wound margins/surround skin as intact. e. Undermining/tunneling described as 4 cm. f. An odor as present. g. Pain. h. The dressing as Calcium Alginate. A Wound Flow Sheet form entry dated 4/2/13, indicated the resident had a pressure sore on his her Ischium with the following assessment: a. The wound measured 3 cm (length) x 3 cm wide) and 4 cm deep. b. No wound tissue description had been documented. c. A moderate amount of erogenous wound drainage. d. Wound margins/surround skin as intact. e. Undermining/tunneling described as 4 cm. f. An odor as present. g. Pain. h. The dressing as Calcium Alginate. A final Culture Bacterial lab form dated 4/7/13 at 8:48 a.m., collected on 4/3/13 at 10:25 a.m., indicated the resident had a small amount [MEDICAL CONDITION] in his/her buttock wound. An Interdisciplinary Progress Note entry dated 4/3/13 at 9 a.m., indicated the resident's ulcer area as very painful that morning. A Physician's Progress Note dated 4/3/12, indicated the PA was called by the facility with a request to have the resident's decubiti assessed on the left buttock which had been present for some time. The facility staff told the PA the area started out as a pimple on the skin with some undermining and now it had opened up quite a bit and had eschar present. The PA described the area as approximately 1 cm to 1.5 cm open with black eschar and an odor. The area had been described with not a lot of drainage at that point and no real redness around the site and clean edges. The PA documented the resident appeared quite uncomfortable when the area had been palpated but had a [MEDICATION NAME] but additionally had an order for [REDACTED]. A Wound Flow Sheet form entry dated 4/3/13, indicated the resident as hospitalized . A Discharge Summary form dated 4/8/13, indicated the resident as admitted to the hospital on [DATE] with a principal problem of a stage IV decubitus ulcer on the ischium. A History and Physical Report form dated 4/3/13 at 12:23 p.m., indicated the resident as admitted to the hospital with [REDACTED]. a. A 1.5 cm in length x 2 cm wide. b. 4 cm deep. c. The wound bed as yellow/slough, pink and necrotic tissue. d. A small amount of tan drainage. According to an Interdisciplinary Progress Note dated 4/12/13 at 11 a.m., a Hospice nurse documented the resident as hosptalized on [DATE] and discharged back to the facility on [DATE]. At that point, Hospice met with the family with a decision for admission to Hospice services. The Hospice nurse indicated the resident as unable to rate the pain but when the dressing had been changed to the left buttock, the resident flinched and grimaced with the wound repacking. A Hospice progress note printed 4/16/13, identified the resident as admitted to Hospice services on 4/12/13. A Wound Flow Sheet form entry dated 4/12/13, indicated the resident had a ischium pressure sore with the following assessment: a. The wound measured 2 cm (length) x (by) 2.7 cm (wide) and 4 cm deep. b. No wound tissue description had been documented. c. Minimum to moderate amount of purulent green drainage. d. Wound margins/surround skin with 1 cm of hard indurated skin. e. Undermining/tunneling described as 4 cm. f. An odor as present. g. No pain. h. The dressing as [MEDICATION NAME] covered with gauze. A Wound Flow Sheet form entry dated 4/16/13, indicated the resident had a ischium pressure sore with the following assessment: a. The wound measured 3 cm (length) x (by)3 cm (wide) and 4 cm deep. b. No wound tissue description had been documented. c. A moderate to heavy amount of purulent green wound drainage. d. Wound margins/surround skin as intact. e. Undermining/tunneling described as 4 cm. f. An odor as present. g. Pain. h. The dressing as [MEDICATION NAME] covered with gauze. According to a Physician order [REDACTED]. The PA indicated the uncontrollable underlying factors with the resident ' s pressure ulcer had been the resident's dementia and thus the resident ' s immobility and nutritional status related to the lack of cooperation with eating. The PA indicated interventions the staff should have initiated as a means to help in the prevention or reduction of the pressure ulcer as repositioning the resident more often between 2/14/13 and 3/12/13. An additional intervention had been documented as once the area had opened and necrotic tissue noted, a wound consult would have been necessary. An Hourly Flow Sheet dated March 2013, directed the staff to reposition the resident every 2 hours from back to side with documentation that included the following: a. From March 1 to March 12 at 6 a.m. there had been documentation. b. On March 12, the resident had been repositioned at 3 p.m. but not again until 7 p.m. c. On March 13, the resident had been repositioned at 4 p.m. but not again until 7 p.m. d. On March 14 the resident had been repositioned at 3 p.m. but not again until 8 p.m. e. On March 15, the resident had been repositioned at 2 p.m. but not again until 7 p.m. f. On March 17 the resident had been repositioned at 3 p.m. but not again until 7 p.m. g. On March 18 the resident had been repositioned at 2 p.m. but not again until 7 p.m. h. On March 19 the resident had been repositioned at 2 p.m. but not again until 6 p.m. i. On March 20, the resident had been repositioned at 2 p.m. but not again until 7 p.m. j. On March 21, the resident had been repositioned at 3 p.m. but not again until 11 p.m. k. On March 22, the resident had been repositioned at 1 p.m. but not again until 7 p.m. l. On March 23, the resident had been repositioned at 3 p.m. but not again until 7 p.m. m. On March 24, the resident had been repositioned at 11a.m. but not again until 7 p.m. n. On March 25, the resident had been repositioned at 3 p.m. but not again until 7 p.m. o . On March 26, the resident had been repositioned at 3 p.m. but not again until 6 p.m. p. On March 27, the resident had been repositioned at 1 p.m. but not again until 7 p.m. q. On March 28, the resident had been repositioned at 3 p.m. but not again until 7 p.m. r. On March 29, the resident had been repositioned at 1 p.m. but not again until 9 p.m. s. On March 31, the resident had been repositioned at 11 a.m. but not again until 5 p.m. On 4/17/13 at 4:25 p.m., Staff A, Certified Nursing Assistant (CNA) was interviewed and stated the resident required assistance with repositioning every 2 hours before and after the (development of the) pressure ulcer. The staff member confirmed the facility staff may have forgotten to reposition the resident every 2 hours due to other responsibilities and/or forgotten to initial the Hourly Flow Sheet. On 4/17/13 at 4:20 p.m., Staff B, CNA was interviewed and stated the resident required 2 staff assistance with cares prior to the (development of) ulcer area along with having been repositioned every 2 hours. The staff member confirmed she had not assisted the resident to reposition between the hours of 4 p.m. and 7 p.m. but that she felt the resident could have scooted himself/herself around in the wheelchair. On 4/17/13 at 4:50 p.m., the DON (Director of Nursing) was interviewed and confirmed the facility staff should have assessed and documented on (about) the resident's pressure ulcer every week. On 4/17/13 at 3:10 p.m., observation revealed the resident as positioned slightly on his/her left side on an Alternating Pressure with Low Air Loss Mattress #3. The mattress was covered with a fitted sheet, a soaker/washable chux pad and the resident wore a brief with a catheter. On 4/17/13 at 5:15 p.m., observation revealed the resident as positioned on his/her right side on an Alternating Pressure with Low Air Loss Mattress #3 covered by a fitted sheet, a soaker/washable chux pad. The resident wore a brief. An observation 4/18/13 at 8:20 a.m., revealed the resident as positioned on his/her left side on an Alternating Pressure with Low Air Loss Mattress #3 covered by a fitted sheet, a soaker/washable chux pad and as wearing a brief with a catheter. On 4/18/13 at 8:10 a.m., the rotating air loss mattress supplier was interviewed and stated the normal standard of practice when utilizing that type of mattress is the less layering of bedding and/or incontinent products would be better. The supplier confirmed the more barriers between the mattress and the ulcer area would have decreased the effectiveness of the mattress. The Good Samaritan Society Procedure for Pressure Ulcers: Skin Assessment and Prevention form dated 1/12 (January 2012), indicated the purpose had been the following: a. To systematically assess residents with regard to a risk of skin breakdown. b. To accurately document observations and assessments of residents. c. To appropriately use prevention techniques and pressure redistribution surfaces on those residents at risk for pressure ulcers. The procedure included the following: 1. A systematic skin inspection would have been made daily by the nursing assistants assigned to the residents at risk for skin breakdown and documented on the nursing assistant documentation record. The nursing assistant responsible for this would have reported any abnormal findings or signs of skin impairment to the nurse. 2. Residents who were unable to reposition themselves independently should have been repositioned as often as directed by the care plan approaches. Developing an individualized repositioning schedule had been recommended based on observation of the resident's skin over a period of time. 3. If a pressure ulcer had been identified, the registered nurse should have recorded the type of wound and the degree of tissue damage. The licensed nurse records the type of wound, the degree of tissue damage (for a pressure ulcer the stage), location of the area, the measurements and the ulcer/wound characteristics. 4. When a pressure ulcer had been present, daily monitoring (with accompanying documentation when a complication or change had been identified) should have included the following: a. An evaluation of the ulcer, if no dressing had been present. b. An evaluation of the status of the dressing; if present (whether it had been intact and whether draining, if present, and leaking or not leaking). c. The status of the area surrounding the ulcer (that could have been observed without removing the dressing). d. The presence of possible complications, such as signs of an increasing area of the ulceration or soft tissue infection (for example, increased redness or swelling around the wound or increased drainage from the wound) and e. Whether pain, if present, had been adequately controlled. 5. The pressure ulcer should have been assessed/evaluated at least weekly and documented on the Wound Flow Sheet. The documentation would have included: a. Measurements - length, width and depth. b. Characteristics of the ulcer - including the wound bed, undermining, tunneling, exudate, surrounding skin and etc. c. Presence of pain. d. Current treatments.

Based on observation, clinical record review, and staff interviews, the facility failed to plan for and direct nursing services to ensure Resident #1 received adequate supervision against hazards. Resident #1 fell and fractured his/her hip after staff left him/her unattended in the bathroom. Staff interviews determined the level of nursing supervision varied from staff to staff. The facility also failed to provide adequate nursing supervision and interventions determined to keep Residents #3, #5 and #10 safe. The facility reported a census of 36 residents with ten residents reviewed. Findings include: 1. According to Medication Record dated May, 2012, Resident #1's [DIAGNOSES REDACTED]. A Minimum Data Set (MDS) with an assessment reference date of [DATE] identified Resident #1's cognition as severely impaired and had difficulty with short and long term memory. The same MDS revealed the resident required extensive assistance from 2 staff with transfer and toilet use. The MDS indicated the resident required stabilization from staff when moving on and off a toilet, moving from a seated to a standing position and during a surface to surface transfer as he/she demonstrated unsteadiness during the assessment period. Review of a Care Area Assessment record with an assessment reference date of [DATE], indicated the resident's problem areas included: confusion and inability to understand others, inability to comprehend day to day activities and difficulty communicating his/her needs. A Comprehensive Care Plan date [DATE], identified the resident as at risk for falls due to Alzheimer's Disease, diabetes and the use of an antipsychotic medication. The same care plan included approaches for staff to ensure the use of a personal alarm on the resident at all times in order to alert staff if he/she attempted a self transfer. A Falls Data Collection Tool, dated [DATE], identified the resident at high risk for falls. An Incident Detail report dated [DATE] at 5:05 P.M., revealed staff found the resident on the floor on his/her hands and knees. Staff documented the resident received a 0.2 x 0.2 centimeter (cm) skin tear on his/her right knuckle and a 0.4 x 0.2 (cm) carpet burn on his/her knee. During interview on [DATE] at 8:00 A.M., the facility Director of Nursing (DON) stated the resident's personal alarms and pressure alarms were initiated after the above incident. An Incident Details report dated and timed [DATE] at 7:35 P.M., revealed Resident #1 experienced another fall. Staff documented Staff A7, Certified Nurse Aid (CNA) assisted the resident to the bathroom in his/her bedroom. Staff A7, left the resident unattended on the toilet to turn back the resident's bedcovers and tidy up his/her bedroom. Staff A7 (CNA) had her back to the resident, heard a noise, saw the resident attempting to stand, fall to the floor and landed on his/her buttocks with his/her legs out in front of him/her. Review of Interdisciplinary Progress Notes dated and timed [DATE] at 7:35 P.M., revealed staff documented the resident received a 1.25 cm x .75 cm skin tear on his/her right elbow and his/her right elbow seemed to be protruding as well. Staff documented, upon laying the resident on a floor mat, staff observed a notable external rotation of the resident's right knee and foot. Staff documented the resident showed increased signs and symptoms of pain when transfers were attempted. An Interdisciplinary Progress Notes dated [DATE] at 8:23 P.M., revealed after assessing the resident and speaking to the on call medical practitioner at a local hospital, staff called for an ambulance and transported Resident #1 to a local hospital emergency room . Review of emergency room records dated [DATE], revealed the resident suffered a fractured femur (hip) and required transfer to a larger hospital for treatment of [REDACTED]. Review of a History and Physical dated [DATE], revealed a physician documented the resident's X-rays of his/her right hip and femur revealed a displaced comminuted subtrochanteric fracture. The physician documented he discussed the situation with the resident's family members and the family elected surgical hip pinning for comfort reasons. The physician documented the resident as moderate to high risk for perioperative complications based on his/her age, debilitated state and multiple cardiovascular risk factors. An Interagency Transfer Orders form dated [DATE], documented the resident as discharged from a hospital following his/her repair of his/her fractured hip. The orders documented the resident's rehabilitation potential as poor and ordered a hospice referral. A Hospice Certification Of Terminal Illness form dated [DATE], revealed hospice staff documented the resident had a poor post-operative recovery following his/her hip fracture. Hospice staff documented the resident remained un-responsive and unable to take oral nourishment and/or medications. Review of Interdisciplinary Progress Notes dated [DATE] - [DATE] revealed the resident remained under hospice care at the facility until his/her death on [DATE]. During interview on [DATE] at 8:00 A.M., Staff A7 (CNA) reported the following account of Resident #1's fall on [DATE] at 7:35 P.M.: Staff A7 stated she transferred the resident to his/her bathroom in his/her room and transferred the resident to his/her toilet. Staff A7 (CNA) stated she decided to allow the resident to sit on the toilet to allow time for the resident to evacuate his/her bowels. Staff A7 stated she left the resident's bathroom, entered his/her bedroom area, began to tidy his/her room and pull the covers back on his/ her bed. Staff A7 (CNA) confirmed she turned her back on the resident and did not have the resident in her constant eye sight. Staff A7 stated she left the bathroom (door) open to keep observing him/her. Staff A7 (CNA) stated she heard a noise, turned around and saw the resident falling to the floor. Staff A7 (CNA) stated Resident #1 had not attempted to stand on his/her own for a long time and she did not feel any safety concerns by leaving the resident unattended in the bathroom. Staff A7 (CNA) confirmed the resident lacked an alarm while on the bathroom toilet and did not speak. During interview on [DATE] at 11:00 A.M., Staff A4 (CNA) stated she had not worked with Resident #3 for approximately 3 months. Staff A4 (CNA) stated in the past when she did work with the resident she left the resident unattended in his/her bathroom while she completed tasks in the resident bedroom. Staff A4 (CNA) then stated if a resident required the use of personal alarms, it would not be safe to leave that resident unattended in a bathroom. During interview on [DATE] at 9:30 A.M., Staff A (Licensed Practical Nurse (LPN) stated she would not expect a resident who required personal alarms to be left alone in a bathroom unattended. During interview on [DATE] at 11:15 A.M., Staff O (CNA) stated she left Resident #1 in the bathroom alone in the past while she made his/her bed as long as she could the resident. Staff O stated you can view the resident's bed from the bathroom and vice versa and Resident #1 never got up on his/her own. Note: During observation of Resident #1's bed on [DATE] at 9:00 A.M., observation revealed the resident's head of the bed was positioned so, if staff needed to turn down the bed covers, staff ' s back would face the bathroom door. During interview on [DATE] at 11:30 A.M., Staff D1 (CNA) stated she routinely worked with Resident #1. Staff D1 (CNA) stated she never left the resident unattended in the bathroom. During telephone interview on [DATE] at 11:37 A.M., Staff A6 (CNA), confirmed she left Resident #1 alone in the bathroom in the past while she turned down his/her bed. Staff A6 stated she always had her eyes on him/her. During interview on [DATE] at 11:20 P.M., Staff Y (Registered Nurse/Staff Development Coordinator) confirmed no specific training of staff had been done regarding leaving a resident who required alarms or at risk for falling, unattended in a bathroom. However; Staff Y stated she expected staff to be able to see a resident and be able to reach a resident in the case described above. During interview on [DATE] at 11:22 A.M., The DON she expected residents who required an alarm or at risk for falling, to be within staffs eyesight if on a bathroom toilet. The DON stated if staff needed to leave the same resident alone in a bathroom or needed to take their eyes off a resident in the case of turning down a bed, staff needed to place an alarm on the resident. The DON confirmed the facility lacked a policy regarding direction for staff when toileting a resident at risk for falling. Review of a Correction Action Notice dated [DATE], the facility Administrator documented Resident #1's care plan called for the resident to have a personal alarm at all times and could not be left alone without a personal alarm in place. The Administrator documented because staff left the resident alone in a bathroom without an alarm, the resident fell and sustained a major injury. 2. According to the Minimum Data Set with assessment reference date of [DATE] Resident #3 had [DIAGNOSES REDACTED]. The resident required extensive assist of two staff for activities of daily living. Resident #3 had scores of 2 for balance during transitions and walking, not steady, only able to stabilize with staff assistance. Resident #3's Comprehensive Care Plan dated [DATE] included problem: potential for falls related to unaware of safety needs and history of falls. The interventions included chair and bed alarm at all times. An Incident Report form completed on [DATE] at 7:00 p.m. noted Resident #3 had been found in his/her room sitting on the floor in front of wheelchair with a blue mat out in front of him/her. The Incident Report did not include if personal alarm in place or sounded. During interview on [DATE] at 9:30 a.m. the Director of Nursing stated she expected the resident to have alarms on at the time of the fall. The DON stated Resident #3 should have both a TABS alarm and pressure alarm when up in the wheelchair. During interview on [DATE] at 10:15 a.m. Staff A stated she found Resident #3 on the floor on [DATE] when she walked past the resident's room to pass medications. Staff A did not hear an alarm sounding, she stated the resident was to have a personal alarm with a magnetic tab on when up in the wheelchair. 3. According to the Minimum Data Set with assessment reference date of [DATE] Resident #5 had [DIAGNOSES REDACTED]. The resident had moderately impaired cognitive skills for daily decision making, (decisions poor; cues/supervision required). The resident required extensive assist of two staff for transfers. Resident #5 had scored a 2 for balance during moving from a seated to standing position and surface to surface transfer, (not steady, only able to stabilize with staff assistance). Resident #5's Comprehensive Care Plan dated [DATE] included problem: potential for falls related to dementia, impaired mobility and vertigo. The interventions included a personal alarm on at all times at all times and to check to make sure it was working. An Incident Report form completed on [DATE] at 7:10 p.m. noted Resident #5 had been found in his/her room sitting on the floor next to the bed. The Incident Report did not include if personal alarm sounded. Comments included staff heard something hit the resident's door, when investigated found the resident on the floor. The immediate intervention put in place to prevent this incident from happening again was be sure resident's personal alarm is on at all times. During interview on [DATE] at 9:30 a.m. the Director of Nursing stated Resident #5 did not have an alarm on when he/she fell on [DATE]. The Director of Nursing stated she would have expected the resident to have an alarm on. During the investigation of the fall staff questioned if the resident had removed the alarm. Staff monitored the resident for 16 days after the fall, during that time frame the resident made no attempt to remove the alarm. Resident #5's chart review did not reveal any documentation prior to the [DATE] fall of the resident removing the alarm. 4. According to the Minimum Data Set with assessment reference date of [DATE] Resident #10 had [DIAGNOSES REDACTED]. Resident #10 had scores of 2 for balance during moving from a seated to standing position and surface to surface transfer (not steady, only able to stabilize with staff assistance). An Incident Report form completed on [DATE] at 9:00 p.m. noted Resident #10 had been found in his/her room on the floor. The immediate intervention put in place to prevent this incident from happening again included; personal alarm put in place. The form showed the care plan amended [DATE] with personal alarm on at all times and one assist with all transfers and activities of daily living. An Incident Report form completed on [DATE] at 3:00 a.m. noted Resident #10 had been found in his/her room on the floor, lying on back with wheelchair by the resident. The Incident Report did not include if personal alarm was in place or if it sounded. The immediate intervention put in place to prevent this incident from happening again included; placed personal alarm on the resident. During interview on [DATE] at 1:45 p.m. the Director of Nursing stated Resident #10 did not have alarm on when fell on [DATE]. The Director of Nursing stated the resident should have had alarm on because the care plan was amended on [DATE] with intervention added, personal alarm on at all times.