Every finding on record at Goshen Healthcare Community

Based on medical record review, resident and staff interview, facility investigation review, and policy review, the facility failed to protect the residents right to be free from physical abuse by another resident for 1 of 3 sample residents (#1) reviewed for abuse. The findings were: 1. Review of the quarterly MDS assessment dated [DATE] showed resident #1 had a BIMS score of 10 out of 15, which indicated moderate cognitive impairment, and had diagnoses which included dementia, coronary artery disease, heart failure, and hypertension. The following concerns were identified:a. Review of the facility incident report dated 8/14/25 and timed 4:45 PM showed resident #1 tapped resident #2 on the shoulder. Resident #2 then grabbed resident #1's arm resulting in a skin tear to his/her right elbow. b. Interview with the MDS coordinator on 10/1/25 at 6:13 PM confirmed resident #1 had a skin tear following the incident; was not fearful, and did not recall if the incident had occurred.c. Interview with Resident #1 on 10/2/25 at 8:50 AM confirmed s/he had some memory of the incident and was not fearful. d. Interview with CNA #1 on 10/2/25 at 10:05 AM revealed she observed resident #2 squeezing resident #1's arm during the incident. e. Interview with LPN #1 on 10/2/25 at 11:22 AM confirmed the incident occurred. She further revealed that resident #1 often approached other residents in this same manner. f. Interview with the NHA on 10/2/25 at 10:10 AM revealed staff were expected to keep resident #2 greater than arm's length away from other resident's, which did not occur that day. 2. Review of resident #2's care plan dated 5/13/25 showed s/he had frequent, unpredictable, and impulsive behaviors and may slap or punch other residents. A goal and intervention in the care plan included adjusting supervision as needed to avoid aggression toward other residents. a. Observation on 10/1/25 at 12:50 PM showed resident #2 was unsupervised in the hall outside of his/her room from 12:50 PM to 1:20PM. 3. Review of the policy titled Abuse Prevention Plan last revised 10/2024 showed .1. All residents will be protected from abuse and interventions would be implemented . Abuse was defined as A.2.Hitting, slapping, scratching, and pinching .

Based on staff interview and policy and procedure review, the facility failed to ensure a system to monitor antibiotic usage. The census was 74. The findings were:1. Interview with the infection preventionist on 7/24/25 at 8:45 AM revealed physicians ordered antibiotics while labs were pending and would change the antibiotic when the results were obtained. He revealed antibiotics were reviewed at the end of the month and not when they were ordered. He confirmed the facility had not implemented an antibiotic stewardship program.2. Review of the facility policy titled Antibiotic Stewardship Program (ASP) dated 2016 showed .5. Tracking a. IP [infection preventionist] will be responsible for infection surveillance and MDRO [multi-drug resistant organisms] tracking b. IP may collect and review data/measurements such as : i. Antibiotic prescription orders for completeness: dose, route, frequency, duration and indication .iv. Whether appropriate tests such as cultures were obtained before ordering antibiotic .

Based on observation, resident and staff interview, and policy and procedure review, the facility failed to ensure personal protective equipment (PPE) was used for 2 of 9 sample residents (#8, #63) reviewed for infection prevention. In addition, the facility failed to report an outbreak of infectious disease involving 13 residents. The census was 74. The findings were: Regarding reporting facility outbreaks: 1. Observation on 7/21/25 at 2:40 PM showed the entrance doors had a sign that indicated the facility was experiencing an outbreak. Interview with the administrator at that time revealed the facility had several residents who were experiencing a respiratory illness. 2. Review of the state licensing agency incident database showed no evidence the facility had reported an infectious disease outbreak. 3. Interview with the infection preventionist on 7/24/2025 at 8:45 AM revealed 13 residents had experienced respiratory symptoms during the outbreak and he confirmed the outbreak was not reported to the licensing agency. Regarding appropriate PPE use: 1. Observation on 7/21/25 at 2:45 PM showed resident #8 had a sign on his/her door which indicated s/he was on droplet precautions and PPE was stored in a plastic container outside the room. a. Observation 7/21/25 at 5:45 PM showed an unidentified staff member entered the room for resident #8 to deliver a meal tray. No PPE was in use or donned prior to entering the resident's room. b. Interview with the infection preventionist on 7/24/25 at 8:45 AM precautions for the facility's outbreak had not been lifted. He confirmed staff should have worn PPE in resident #8's room until 7/23/25. 2. Review of the quarterly MDS assessment dated [DATE] showed resident #63 had a BIMS score of 13 out of 15, which indicated intact cognition and diagnoses which include urinary incontinence. Further review showed the resident had a stage II pressure ulcer. The following concerns were identified: a. Observation on 7/23/25 at 9:53 AM showed the DON and LPN #1 entered the resident's room to perform a dressing change. The DON and LPN #1 applied gloves and performed a dressing change to the residents wound. No other PPE was used. Further observation showed a sign on the back of the resident's door which indicated the resident was on enhanced barrier precautions. b. Interview with the DON on 7/23/25 at 10:15 AM confirmed that no gown was worn by herself or the LPN #1 while changing the resident's dressing. Further interview revealed Enhanced barrier precaution procedures are a new practice to the facility and has not been fully implemented. c. Interview with the infection preventionist on 7/23/25 at 10:45 AM confirmed enhanced barrier precautions were not being performed to the national standard at this time. 3. Review of the policy titled Transmission Based Precautions: Contact, Droplet and Airborne Precautions dated 2014 showed .Droplet Precautions . II. PPE A mask should be worn when entering the resident's room or cubicle. If substantial spraying or respiratory secretions ins [sic] anticipated, gowns ad [sic] gloves as well as goggles or face shield (in place of goggles) should be worn .

Based on observation, staff interview, and medial record review, the facility failed to ensure adequate supervision for 1 of 8 sample residents (#56) reviewed for accident hazards. The findings were:1. Review of the quarterly MDS assessment dated [DATE] showed resident #56 had short-term and long-term memory impairment and diagnoses which included cerebrovascular accident and Alzheimer's dementia. Further review showed the resident had upper extremity impairment on one side, lower extremity impairment on both sides, and was dependent on staff for transfers. The following concerns were identified:a. Observation on 7/23/25 at 9:23 AM showed CNA #1 entered resident #56's room with a sit-to-stand style lift and placed a sling behind the resident. The CNA assisted the resident out of his/her wheelchair and into the bathroom. The CNA removed the resident's pants and brief, lowered the resident onto the toilet, locked the sit-to-stand lift's brakes, and left the bathroom. The resident remained in the bathroom, attached to the lift, without staff supervision. Observation on 7/23/25 at 9:29 AM showed the CNA returned to the resident's room and asked if s/he was done, then performed care and removed the resident from the bathroom, assisted him/her into the wheelchair, and removed the mechanical lift sling.b. Interview with the DON on 7/23/25 at 3:42 PM revealed a resident should not be left in the bathroom attached to a mechanical lift without staff present and the lift sling should be removed while residents were using the bathroom.

Based on medical record review, staff interview, and policy and procedure review, the facility failed to follow the pharmacist's recommendations for 1 of 5 sample residents (#55) reviewed for (MRR) medication review regimen. The findings were:1. Review of a GDR dated 6/6/25 showed the pharmacist recommended a dose reduction of resident #55's trazadone (antidepressant) from 50 milligrams (mg) to 25 mg. Further review showed the recommendation was signed by the physician on 6/13/25, and the DON on 6/19/25. Review of a medication regimen review dated 7/7/25 showed the pharmacist wrote Pharmacy recommendation for decrease in trazadone to 25mg qhs [every day at hours of sleep] was approved by Dr. there [sic] is still an order for 50mg qd [every day] in the chart. Further review showed it was signed and dated by the DON on 7/10/25.2. Review of the resident's MAR showed the resident's trazadone dosage was not decreased until 7/10/25.3. Interview with the DON on 7/24/25 at 9:40 AM revealed she did not know why the change was not implemented and confirmed it should have been performed on 6/19/25.4. Review of the policy and procedure titled Medication Regimen Review provided by the facility showed .7. Facility should encourage Physician/Prescriber or other Responsible Parties receiving the MRR and the Director of Nursing to act upon the recommendations contained in the MRR .

Based on record review, staff interview, and policy and procedure review, the facility failed to provide a bed hold policy for 1 of 3 sample residents (#10) reviewed for discharge. The findings were:1. Review of the Notice of Transfer or discharge date d 7/2/25 showed resident #10 was transferred to the Hospital ER on [DATE]. The Bed Hold Policy box was marked; however there was no evidence a written bed-hold was provided to the resident or resident representative.2. Interview with the DON on 7/24/25 at 9:40 AM revealed the resident or their representative should have received a packet which included a copy of the bed hold policy. Further interview revealed there should have been a note that showed the resident's representative was notified by telephone when s/he was discharged to the ER (emergency room). She reported the policy had been sent with the resident to the ER, and only the first page had been copied by the nurse and put in the resident's chart. The DON confirmed there was no evidence the resident or his/her family received the notice.3. Review of the policy and procedure titled Discharge Plan and Summary and last revised March 2025 showed .14. Written documentation will be given to resident or resident representative about payment needed to hold a bed when readmission/return is expected .

Based on review of the facility's abuse investigations forms, State Survey Agency incident database review, policy and procedure review, and staff interview, the facility failed to implement their policy and procedure for ensuring the reporting of a reasonable suspicion of a crime was made in a timely manner for 4 of 10 abuse allegations reviewed. The findings were: 1. Review of the facility's policy ABUSE PREVENTION PLAN (WY), last revised October 2024, showed .The facility requires that all suspected maltreatment will be reported to the Administrator and the State promptly .All alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made .to the administrator of the facility and to other officials, including the State Survey Agency .The facility will take all necessary corrective actions depending on the results of the investigation and complete and send a final investigative report to the State Agency within 5 business days. The following concerns were identified: a. Review of the facility's investigation report showed an allegation of staff-to-resident abuse occurred on 4/6/25 at 8:30 PM and the administrator was aware of the allegation on 4/8/25 at 8 AM; however, review of the state survey agency incident database showed this allegation was not reported to the agency until 4/10/25 at 3:27 PM. b. Review of the facility's investigation report showed an allegation of staff-to-resident abuse occurred on 4/22/25 at 1:30 PM; staff were aware of the allegation on 4/23/25 at 12 AM; however, the administrator was not made aware of the allegation until 4/24/25 at 8:45 AM. Review of the state survey agency incident database showed this allegation was not reported to the agency until 4/24/25 at 2:10 PM. c. Review of the facility's investigation report showed an allegation of visitor-to-resident abuse occurred on 2/13/25 at 12 PM. Review of the state survey agency incident database showed the final investigative report was not submitted to the agency until 4/14/25. d. Review of the facility's investigation report showed an allegation of resident-to-resident abuse occurred on 1/1/25 at 5 PM. Review of the state survey agency incident database showed the final investigative report was not submitted to the agency until 2/9/25. 2. Interview with the administrator and the DON on 6/17/25 at 2:26 PM confirmed the allegations of abuse were not reported within the required timeframe.

Based on review of facility investigations, review of the state agency facility reported incidents, staff interview, and review of the Wyoming Board of Nursing license verification portal, the facility failed to provide services which met professional standards of practice. The facility census was 69 of which 19 residents resided in the secure unit. The facility implemented corrective action prior to the survey and was determined to be in substantial compliance as of 12/19/24. The findings were: 1. Review of facility incident report filed with the state agency showed on 12/10/24 at 4 PM the facility received a concern from a CNA (identified as CNA #1) a night shift nurse (identified as LPN #1) may be administering medications which had not been prescribed to the residents. The following was the response from the facility: a. On 12/10/24 LPN #1 was suspended prior to clocking in for her shift pending an investigation. b. On 12/11/24 LPN #1 confessed to administering two residents with medications which had not been prescribed to make them sleep on 'crazy nights'. LPN #1 resigned at that time. c. Review of a 12/11/24 letter showed the Board of Nursing was notified and a complaint was filed. d. Review of the Wyoming State Board of Nursing showed LPN #1's license was terminated on 12/19/24. 2. Interview with the NHA on 2/4/25 at 12:09 PM confirmed LPN #1 had resigned immediately after being interviewed, the Wyoming Board of Nursing was notified immediately, and LPN #1's license to practice was suspended.

Based on medical record review, review of the facility's investigation report, review of the state agency incident report, staff interview, and policy and procedure review, the facility failed to ensure residents were free from chemical restraints intentionally imposed for staff convenience for 2 of 8 sample residents (#7, #8). The findings were: 1. Review of the facility's investigation report showed the facility administration received information from CNA #1 on 12/10/24 at approximately 3:45 PM. CNA #1 was concerned LPN #1 was medicating residents on the Alzheimer's unit with meds that are not ordered for them. [LPN #1] was overheard making a statement .I give them a little bit of extra of mine, but not enough so that when I go to the doctor, they won't refill me. CNA #1 stated she heard the statement from LPN #1 approximately 1 week ago and was unsure if it was a joke or serious. Further review of the statement from CNA #1 showed she was concerned last Wednesday and Thursday because three residents who received medications appeared sedated shortly after receiving them .LPN #1 offered to put three residents to bed at an early hour just after supper. 2. Review of the facility's investigation report showed the NHA approached LPN #2, who was on duty in the secure unit on 12/10/24 at approximately 5 PM, who produced a bottle of Tylenol 325 mg tablets (100) with a date written on it in red ink of 12/6/24. LPN #2 confirmed she had opened the bottle and had dated it. Upon opening the bottle on 12/10/24 LPN #2 noted three pink tablets in the bottle with approximately 30 tablets of Tylenol. The NHA took the bottle .as evidence. The count of Tylenol pills inside the newly opened bottle was 29 tablets and 3 Benadryl tablets. 3. On 12/11/24 LPN #1 was questioned by the facility and confessed to administering two residents medications that were not ordered. These residents were resident #7 and resident #8. LPN #1 admitted to administering Tylenol, melatonin (a hormone which plays a role in sleep), and Benadryl (an antihistamine which may have a sedative effect); however, LPN #1 could not remember who all of the residents were that she had given the medications to. In addition, the LPN stated she had been medicating the residents since 11/1/24 when she became a full-time employee. 4. Review of a complaint form submitted to the Wyoming Board of Nursing on 12/11/24 at 12:41 PM showed Information had come to the employer that [LPN #1] may be giving residents medications that are not prescribed to them. The original complaint did not know what kind of medications or if they were prescription medications belonging to [LPN #1]. The report is that residents were complaining of feeling funny after being given medications by this particular nurse. Also, CNA staff reported finding some residents unusually tired or out like a light for the entire night, which raised suspicions. All residents involved have dementia diagnoses and are admitted to a secured memory care unit for their safety. On December 10, 2024 [the NHA and executive director] began investigating the allegations. During the initial investigation, it was discovered that a generic acetaminophen 325 mg bottle in the medication cart contained three pink caplets with the inscription of S4 on one side that was hidden among the tablets of acetaminophen. It was noted that the bottle had been labeled and put into service on December 6, 2024. The bottle contained 100 tablets at opening. There were 61 tablets of acetaminophen missing from the bottle. Only one resident on the unit receives this medication regularly and no more than 9-12 tablets should have been taken from this stock bottle. It should be noted that [facility name] has a strict no Benadryl policy for the patient population and that no resident is ordered this medication in any form. [LPN #2] advised that she had discovered the pink caplets on December 10, 2024, and the caplets were not present the day before. The only other staff member with access to the medication cart at that time was [LPN #1]. On December 11, 2024 [the NHA and executive director] conducted a telephone interview with [LPN #1] regarding the allegations and the unapproved medications located in the medication cart. Immediately upon beginning the interview, [LPN #1] stated I think I am going to pivot away from nursing and just terminate my employment immediately. During that recorded interview, [LPN #1] admitted to giving two residents combinations of Tylenol, Melatonin, and Benadryl that were not ordered or prescribed to these residents. [LPN #1] mentioned that she had done this occasionally when things got crazy over there referring to the Alzheimer's Care Unit. [LPN #1] denied bringing in any outside prescription medications to provide to residents, however, it was noted that her response was delayed and lacked confidence . 5. Interview with the NHA on 2/4/25 at 2:49 PM revealed the facility did not treat the incident as an allegation of chemical restraint because it was just one nurse who had administered unprescribed medications to the residents. The NHA stated she had notified the residents' representatives, physicians, and performed urine drug testing on the residents which could provide a urine sample; however, there was no documentation available. Further, the administrator stated the allegation was dealt with promptly and the appropriate agencies had been contacted; however, education had not been provided to staff on the use of chemical restraints. 6. Telephone interviews were attempted on 2/4/25 with LPN #2, CNA #1 (who was no longer employed at the facility) and LPN #1. These attempts were unsuccessful 7. Review of the ABUSE PREVENTION PLAN (WY) policy, last revised October 2017, showed .CHEMICAL RESTRAINT: Any drug that is used for discipline or convenience and not considered accepted professional practice to treat medical or behavioral symptoms. Examples include but are not inclusive: Attempting to alter the individual's behavior with inappropriate use of drugs .Staff administer a medication to sedate or subdue the resident .

Based on review of the facility's investigation report, medical record review, staff interview, and review of policy and procedure, the facility failed to complete and maintain documentation for 1 of 3 allegations of abuse investigations reviewed. The findings were: 1. Review of the facility's investigation report showed CNA #1 reported to facility administration on 12/10/24 at approximately 3:45 PM an allegation that she suspected LPN #1 was administering medications to residents in the secure unit which were not prescribed for them. The facility immediately suspended LPN #1 and began an investigation. The following concerns were identified: a. Review of the facility's investigation report showed 8 residents were identified which may have been affected; however, review of the residents' medical records failed to show documentation of the allegation or notification of the residents' representatives or primary care providers. b. Review of the facility's investigation report showed the facility performed urine drug testing on the residents in the secure unit; however, there was no evidence the results of the urine drug tests were retained. c. Review of the facility's investigation report showed the medical director and consultant pharmacist had been consulted. Interview with the consultant pharmacist on 2/4/25 at 1:43 PM confirmed she had been consulted; however, there was no documentation in the investigation report related to the consultation. Further interview with the pharmacist revealed there were too many variables present to determine what the side effects, described by the residents and staff, were the result of. The medical director was unavailable. d. Interview with the NHA on 2/4/25 at 12:09 PM revealed she had notified the residents' representatives and primary care providers for the two residents LPN #1 had confessed to administrating unprescribed medications; however, did not document the allegation in the residents' medical record. In addition, the NHA stated she had convened an adhoc QAPI (quality assurance performance improvement) meeting to discuss the allegation; however, the minutes of the meeting were not available. An additional interview on 2/4/25 at 12:45 PM revealed the facility did not treat the incident as an allegation of chemical restraint because it was just one nurse who had administered unprescribed medications to the residents and not a systemic problem. 2. Review of the ABUSE PREVENTION PLAN (WY) policy, last revised October 2017, showed .E. Investigation: 1 .Facility will identify the staff member(s) responsible for: . c. Identifying and interviewing all involved persons, including the alleged victim, alleged perpetrator, witnesses, and others who might have knowledge of the allegations; d. Focusing the investigation on determining if abuse, neglect, exploitation, and/or mistreatment has occurred, the extent and cause; e. Providing complete and thorough documentation of the investigation .

Based on observation, staff interview, and 2022 U.S. Public Health Food Code review, the facility failed to ensure a sanitary equipment and failed to ensure food was stored under safe conditions in 1 of 2 food storage, preparation, and service areas (main kitchen). The census was 62. The findings were: 1. Observation on [DATE] at 2:14 PM showed the ice machine had a plastic piece which was not secured to the machine and a white powdery substance was built-up around the exterior above the door. Further observation showed the white powdery substance moved when the ice machine door was opened and closed and could fall into the ice. 2. Observation of the walk-in refrigerator on [DATE] at 2:17 PM showed a container of tomatoes with no date, a container labeled bell peppers with a use by date of ,d+[DATE], three containers labeled beef base dated with an expiration date of [DATE] and a use by date of [DATE], two containers labeled chicken base with and expiration date of [DATE] and a use by date of [DATE], a bag labeled chili with use by date of ,d+[DATE], a container labeled hardboiled eggs with a use by date of [DATE]. 3. Observation on [DATE] at 10:56 AM showed the ice machine remained with a white powdery substance on the exterior above the door. 4. Observation of the walk-in refrigerator on [DATE] at 10:58 AM showed the bell peppers, beef base, and chicken base remained. 5. Interview with the dietary manager on [DATE] at 11:35 AM revealed expired items or items past use by date should be discarded and the ice machine was cleaned by maintenance; however, she was unsure of the cleaning schedule. She revealed the facility was aware of the damaged part of the ice machine and confirmed the powdered build-up could fall in the machine. Further she confirmed all items in the walk-in refrigerator were available for resident consumption. 6. According to Food Code 22, U.S. Public Health Service: ,d+[DATE].11 .(A) EQUIPMENT FOOD-CONTACT SURFACES and UTENSILS shall be clean to sight and touch. (B) The FOOD-CONTACT SURFACES of cooking EQUIPMENT and pans shall be kept free of encrusted grease deposits and other soil accumulations. (C) NonFOOD-CONTACT SURFACES of EQUIPMENT shall be kept free of an accumulation of dust, dirt, FOOD residue, and other debris . 7. According to Food Code 22, U.S. Public Health Service: XXX,d+[DATE].17 Ready-to-Eat, Time/Temperature Control for Safety Food, Date Marking. (A) Except when PACKAGING FOOD using a REDUCED OXYGEN PACKAGING method as specified under S ,d+[DATE].12, and except as specified in (E) and (F) of this section, refrigerated, READY-TO-EAT, TIME/TEMPERATURE CONTROL FOR SAFETY FOOD prepared and held in a FOOD ESTABLISHMENT for more than 24 hours shall be clearly marked to indicate the date or day by which the FOOD shall be consumed on the PREMISES, sold, or discarded when held at a temperature of 5 C (41 F) or less for a maximum of 7 days. The day of preparation shall be counted as Day 1 .

Based on medical record review, staff interview, and policy and procedure review, the facility failed to ensure target symptoms were identified and monitoring of target symptoms was completed for 3 of 5 sample residents (#14, #20, #32) with psychotropic medication use. The findings were: 1. Review of the quarterly MDS assessment dated [DATE] showed the resident #14 had a brief interview for mental status score of 10 out of 15, which indicated moderate cognitive impairment, and diagnoses which included non-Alzheimer's dementia and depression. Review of the physician orders showed the resident received Abilify (antipsychotic) 5 milligrams (mg) by mouth daily for depression, buspirone (anti-anxiety) 10 mg by mouth three times daily for depression, and sertraline (antidepressant) 50 mg by mouth daily for depression. The following concerns were identified: a. Review of the care plan, last revised on 4/5/24 showed .TARGETED BEHAVIORS: 1) anxiety 2) depressed or withdrawn 3) insomnia . Further review showed no evidence of resident specific or medication specific target symptoms for the identified behaviors. b. Review of the medication administration record for January 2023 through April 2023 showed no evidence resident specific or medication specific target symptoms were identified or monitored for the effectiveness of psychotropic medications. 2. Review of the quarterly MDS assessment dated [DATE] showed resident #20 short-term and long-term memory impairment and diagnoses which included Alzheimer's disease, non-Alzheimer's dementia, and adjustment disorder with mixed anxiety and depressed mood. Review of the physician orders showed the resident received citalopram (antidepressant) 20 mg by mouth daily for depression/agitation, divalproex sodium (anticonvulsant) 250 mg by mouth twice daily for psychotic disturbance, Seroquel 50 mg by mouth twice daily for dementia with aggression towards others, and Seroquel (antipsychotic) 75 mg by mouth daily at bedtime for dementia. The following concerns were identified: a. Review of the care plan, last revised on 1/16/24, showed .TARGETED BEHAVIORS: 1) agitated 2) depressed withdrawn 3) restless . Further review showed no evidence of resident specific or medication specific target symptoms for the identified behaviors. b. Review of the medication administration record for January 2023 through April 2023 showed no evidence resident specific or medication specific target symptoms were identified or monitored for the effectiveness of psychotropic medications. 3. Review of the annual MDS assessment dated [DATE] showed resident #32 had diagnoses which included non-Alzheimer's dementia, anxiety disorder, depression, and post-traumatic stress disorder. Review of the physician orders showed the resident received buspirone (anti-anxiety) 5 mg by mouth twice per day for anxiety disorder and depression, Celexa (antidepressant) 20 mg by mouth once daily for depression, and clonazepam (anticonvulsant) 0.5 mg by mouth twice per day for anxiety. a. Review of the care plan, last revised on 4/4/24, showed no evidence target symptoms were identified for the use of each psychotropic medication. b. Review of the medication administration record for January 2023 through April 2023 showed no evidence resident specific or medication specific target symptoms were identified or monitored for the effectiveness of psychotropic medications. 4. Interview with the DON on 4/18/24 at 11:24 AM confirmed target symptoms were not identified or monitored with the use of psychotropic medication. 5. Review of the policy titled Psychotropic Medication Use last revised on 11/28/16 showed .1.1 The facility should not use psychotropic medications to address behaviors without first determining if there is a medical, physical, functional, psychological, social or environmental cause of the resident's behaviors .4. Psychotropic medications to treat behaviors will be used appropriately to address specific underlying medical or psychiatric causes of behavioral symptoms .7. All medications used to treat behaviors must have a clinical indication and be used in the lowest possible dose to achieve the desired therapeutic effect. All resident's receiving medications used to treat behaviors should be monitored for: 7.1 efficacy, 7.2 Risks, 7.3 Benefits, and 7.4 Harm or adverse consequences .

Based on personnel record review, and staff interview, the facility failed to ensure the CNA abuse registry was verified for 1 of 3 sample CNAs (#1) prior to resident contact. The findings were: Review of the personnel record for CNA #1 showed she had quit on 5/3/23, and was rehired on 11/3/23, indicating 6 months between employment. The review showed the CNA abuse registry was checked on 1/19/23 prior to the CNAs initial employment; however, there was no evidence it was verified upon rehire. Interview with the business office manager and CEO on 4/16/24 at 3:52 PM confirmed the facility did not recheck the abuse registry when the CNA was rehired.

Based on medical record review, staff interview, and review of the resident rights the facility failed to ensure resident advance directives were accurate for 1 of 18 sample residents (#46). The findings were: 1. Review of the WyoPOLST (Providers Orders for Life Sustaining Treatment) dated [DATE] showed resident #46 elected Cardiopulmonary Resuscitation (CPR). 2. Review of the physician orders dated [DATE] showed the resident was Do Not Resuscitate (DNR). 3. Interview with LPN #1 on [DATE] at 10:05 AM revealed I would look at the orders and look for the code status. We do have a binder with the POLST in it. They must not have changed it since she came back. 4. Interview with health information coordinator on [DATE] at 10:10 AM confirmed the WyoPOLST and the physician orders were conflicting between the POLST and the orders. 5. Review of the Resident Rights showed .Get proper medical care To participate in the decisions that affect your care To formulate advance directives, such as a living will or durable power of attorney for health care .

Based on observation, staff interview, and medical record review, the facility failed to ensure residents received oral care per the plan of care for 1 of 2 sample residents (#4), who were unable to independently carry out activities of daily living. The findings were: 1. Review of the annual MDS assessment dated [DATE] showed resident #4 had short-term and long-term memory impairment and diagnoses which included rheumatoid arthritis, non-Alzheimer's dementia, and weakness. Further review showed the resident required partial/moderate assistance to perform oral hygiene. Review of the ADL care plan last revised on 4/15/24 showed the resident had an ADL deficit related to Lewy-Body dementia and severely impaired cognition. Interventions included .ORAL CARE: Provide oral care after each meal. 1-person assist. Encourage [resident name] to participate .ORAL CARE: Requires total assistance for completion. I do not wear dentures or partials . The following concerns were identified: a. Review of a progress note dated 4/13/24 and timed 4:27 PM showed the facility contacted the resident's power of attorney related to oral care and a build of plaque on the resident's teeth. The facility communicated a new plan for oral care and the power of attorney voiced understanding and was okay with the new plan. b. Observation on 4/17/24 at 2:42 PM showed CNA #1 and CNA #2 assisted the resident to the bathroom following the lunch meal. Continued observation showed the staff did not offer or perform oral hygiene. c. Observation on 4/18/24 from 8:05 AM through 10:26 AM showed the resident was assisted to the dining room table for the breakfast meal. Further observation showed the resident finished the meal at 8:35 AM and was assisted to a recliner in the TV area. The resident remained in the recliner until 10:26 AM and staff did not offer or perform oral hygiene during that time. d. Review of the oral care task documentation from 4/13/24 through 4/17/24 showed oral care was documented at 11:34 AM and 9:06 PM on 4/14/24, 2:34 PM on 4/14/24, 2:13 AM and 9:35 AM on 4/15/24, 9:11 AM and 9:15 PM on 4/16/24, and 1:42 PM on 4/17/24; however, there was no evidence the oral care was offered or provided after each meal. e. Interview with the infection preventionist and DON on 4/18/24 at 11:24 AM revealed the resident should receive oral care, within 30 minutes following the completion of each meal.

Based on observation, staff interview, and policy and procedure review, the facility failed to ensure appropriate infection control techniques were implemented to prevent cross contamination during 2 of 4 observations of perineal care. The census was 62. The findings were: 1. Review of the annual MDS assessment dated [DATE] showed resident #15 had short-term and long-term memory impairment and diagnoses which included Alzheimer's dementia, seizure disorder, traumatic brain injury, anxiety disorder, and depression. Further review showed the resident was totally dependent on staff for toileting and personal hygiene. Review of the ADL care plan last revised on 2/7/24 showed the resident required assistance with ADLs related to early onset Alzheimer's dementia and interventions included .INCONTINENT: Check and change q [every] 2-3 hours and prn [as needed]. Toilet upon awakening, before and after meals, and at bedtime and PRN with goal to be as dry as possible during waking hours . The following concerns were identified: a. Observation on 4/17/24 at 2:26 PM showed the resident was assisted by 2 staff members his/her room and transferred into bed. CNA #2 and CNA #1 applied gloves, obtained supplies, and removed the resident's pants and brief. CNA #2 provided perineal care, then without removing her gloves, CNA #2 used her contaminated gloved hand to apply a clean brief, pull up the resident's pants, and touched the resident's shirt. 2. Review of the annual MDS assessment dated [DATE] showed resident #4 had short-term and long-term memory impairment and diagnoses which included rheumatoid arthritis, non-Alzheimer's dementia, and weakness. Further review showed the resident required substantial/maximal assistance with toileting and personal hygiene. Review of the ADL care plan last revised on 4/15/24 showed the resident had an ADL deficit related Lewy-Body dementia and severely impaired cognition. Interventions included .TOILETING: Total dependence with toileting, wears briefs. Frequently incontinent. The following concerns were identified: a. Observation on 4/17/24 02:42 PM showed CNA #1 and CNA #2 assisted the resident out of a chair and ambulated the resident to his/her room. CNA #1 explained to resident she was going to assist her to the bathroom. The staff member applied gloves, removed the resident's pants, and assisted the resident to sit on the toilet. When the resident was finished going to the bathroom, the CNA assisted the resident to stand a performed perineal care; however, without removing her gloves, the CNA used the contaminated gloved hand to reach into the wipe container and obtain additional wipes. CNA #2 stood near the sink while care was provided. CNA #1 began performing care to the resident's buttocks to remove feces from a bowel movement and wiped the resident front to back, clean to dirty; however, during the care, CNA #1 continued to use her contaminated gloved hand to removes wipes from the container and touched the outside of the perineal spray to spray the resident's skin with the solution. During the care, CNA #1 passed the contaminated bottle of perineal spray from one hand to the other, contaminating her clean gloved hand. In addition, CNA #1 placed each of her contaminated gloved hands on the resident's shirt while performing perineal care with the opposite hand. Further observation showed, upon completion of the perineal care and without removing the contaminated gloves, CNA #1 touched the outside of resident's clean brief, the resident's shirt, and the resident's pants. 3. Interview with the infection preventionist and DON on 4/18/24 at 11:24 AM revealed staff should wash their hands before resident care, apply gloves prior to performing perineal care, and change gloves before touching clean areas when they were contaminated. They confirmed gloves should be removed before touching resident clothing. 4. Review of the policy titled Perineal Care last revised February 2023 showed .14. Remove gloves and discard into designated container. Perform hand hygiene. 15. If changing brief or dressing/undressing resident, apply clean gloves before proceeding with these items .

Based on observation, resident and staff interview, and resident rights review, the facility failed to ensure residents received care in accordance with the care plan for 1 of 5 sample residents (#1). The findings were: 1. Review of care plan for resident #1 last revised on 1/7/24 showed ADLs: [residents' name] needs mostly extensive assistance with ADLs. [S/he] has diagnoses of Parkinson's and Tremors. [S/he] has required extensive assistance with bed mobility, transfers, locomotion, dressing, toileting, hygiene and bathing. [S/he] needs total assist with meals/eating. [S/he] has a BIMS [brief interview for mental status] score of 14 (cognitive intact). The following concerns were identified: a. Observation on 1/23/24 at 12:15 PM showed the resident sitting in a wheelchair with an over the bed table in front of him/her and an untouched open lunch meal plate in front of the resident. Interview with resident at that time revealed s/he needed help eating the meal. The plate was a ribbed plate and the utensils had large grips. Further, observation showed CNA #2 was in the room placing a sheet on the resident's bed. The CNA stated at that time someone will come in and feed [him/her.] b. Interview with CNA #2 on 1/23/24 at 12:25 PM revealed the resident refused to eat. Continued observation showed the director of dietary services entered the room and checked the food temperatures. At that time, the temperature of the green beans was 127 degrees Fahrenheit, and the temperature of the macaroni and cheese was 91.9 degrees Fahrenheit. The director of dietary services revealed meal trays were delivered to rooms at noon. c. Interview with the IP on 1/23/24 at 4:15 PM revealed the facility would expect the CNA to assist the resident with the meal instead of making the bed. 2. Review of the Resident [NAME] of Rights showed .You have the right to be treated with dignity and respect . You have the right to decide when you go to bed, rise in the morning, and eat your meals .

Based on grievance log review, staff interview, and policy and procedure review, the facility failed to ensure resident grievances were resolved for 2 of 3 sample residents (#2, #3). The findings were: 1. Review of a Grievance/Concern Report Form dated 12/4/23 at 9:15 AM showed resident #3's representative notified the facility of concerns related to positioning, hydration, and activities of daily living. Further review showed no action or resolution by the facility. 2. Review of a Grievance/Concern Report Form dated 12/26/23 and untimed showed resident #2's representative notified the facility of concerns related to cleanliness and maintenance needs. Further review showed no action or resolution by the facility. 3. Interview with the health information management RN on 1/23/24 at 2:13 PM confirmed the grievances were not addressed, and she would have them addressed right away. 4. Review of the policy and procedure Grievance/Concerns hand delivered on 1/23/24 at 4:40 PM by the Business Office Manger showed .4.b.facility's policy is to complete and review results with resident/resident representative within 72 hours of receipt of concern/grievances .

Based on medical record review, staff and resident representative interviews, and review of incident reports and facility policies, the facility failed to ensure a resident's choice to refuse COVID-19 vaccination was honored for 1 of 6 sample residents (#6). The findings were: 1. Review of the 10/18/23 quarterly Minimum Data Set (MDS) assessment for resident #6 showed the resident had diagnoses which included dementia, COPD, and diabetes and had severely impaired cognition. Review of the resident's immunization record showed the resident was vaccinated for COVID-19 on 9/21/21 and 12/5/23. The two entries prior to 12/5/23 showed consents were refused. Review of the care plan last revised 12/29/22 and initiated 11/25/22 showed my family chooses for me to not have further Covid-19 booster vaccinations and staff will assist in decision making as instructed by my family or resident. Review of the RESIDENT COVID-19 CONSENT OR DECLINATION signed on 8/2/22 by the resident representative showed the vaccine was refused due to a serious reaction in the past. The following concerns were identified: a. Review of a physician's order written on 12/5/23 showed a COVID-19 vaccine was to be administered. b. Review of the 12/6/23 at 4:08 PM nurse progress note showed Resident appears not to be feeling well, she is tense, when [s/he] is touched, [NAME] [sic] well. Not eating well very tired. Review of a 12/7/23 nurse progress note timed at 2:15 PM showed the medication error was discussed with the power of attorney (POA) regarding COVID-19 vaccination. [S/he] is more lethargic than baseline, eyes are open and does respond to DON [director of nursing]. A progress note dated 12/7/23 at 4:36 PM showed the resident was not feeling well, and the spouse visited and was informed the resident was given the COVID-19 vaccine. The spouse stated s/he did not want the resident to receive the vaccine and was upset. c. Review of a medication error incident report showed on 12/5/23 the resident received the COVID-19 vaccine in error as the POA did not wish for the resident to receive the vaccine. The resident had been more lethargic since the vaccine injection. Review of the December treatment administration record (TAR) showed the resident had no pain from 12/1/23 to 12/12/23, except on 12/6, 12/7, and 12/8 after receiving the COVID-19 vaccine. d. Interview with the resident representative on 12/13/23 at 10 AM revealed the staff told him/her they did not totally check the resident paperwork because the resident had a bad reaction to the COVID-19 vaccine in the past. S/he stated the facility never asked him/her to sign anything until after s/he was notified the resident was erroneously given the COVID vaccine. e. Interview with the infection control registered nurse (RN) on 12/13/23 at 10:30 AM revealed the resident was given the COVID-19 vaccine as a result of human error and s/he did become lethargic after the vaccine was given. Interview with the chief operating officer (COO) on 12/13/23 at 2:44 PM revealed it was the facility expectation for nurses to follow the resident or resident representative wishes and to follow the physician ' s orders. 2. Review of the facility's policy Infection Prevention and Control Practices During COVID-19 Pandemic revised May 11, 2023 showed .Upon admission COVID-19 immunization status for residents is recorded. Residents (and their representatives) that are not up-to-date are encouraged to receive the vaccination. They receive information and counselling [sic] regarding the risks and benefits of the vaccine and have an opportunity to ask questions and discuss concerns. A form reviewing the risks and benefits of COVID-19 vaccination including acceptance or declination of the vaccination is completed .

Based on medical record review and resident representative and staff interviews, the facility failed to ensure resident choices were honored for 1 of 5 sample residents (#2) reviewed for resident rights. The findings were: 1. Review of the admission MDS assessment dated [DATE] showed resident #2 had moderate cognitive impairment and diagnoses which included dementia with psychotic disturbance. Further review showed the resident required one person physical assistance for bathing. Review of the baseline care plan showed the resident paces when s/he needs to use the restroom and a bath is an option if a shower isn't working. Review of the 7/7/23 care plan showed the resident wanted staff to approach him/her in a calm manner, use clear and simple instructions, liked showers during the evening hours but enjoyed the whirlpool, approach the resident with a polite attitude, and required one person to assist with bathing. Review of the July 2023 bathing record showed the resident received a shower on 7/15/23. The following concerns were identified: a. Review of a grievance form dated 7/30/23 showed the resident's representative reported concerns related to 4 staff members forcing the resident into the shower on 7/15/23. Interview with the resident's representative on 9/20/23 at 9:47 AM confirmed a grievance was reported to the facility on [DATE]. b. Review of a nurse's progress note dated 7/15/23 at 10:25 AM showed .resident refused to come down for breakfast and was swinging [his/her] arms at staff members; reapproached later on when [s/he] was up moving around to get [him/her] a shower since [s/he] had wet underwear and a bowel movement, resident refused shower staff ended up getting [him/her] into the shower, resident likes to hit, push, and shove. c. Interview with CNA #1 on 9/19/23 at 3:05 PM revealed the CNA was asked to help shower the resident because s/he was dirty with feces and confirmed 4 staff members forced [him/her] into the shower by grabbing his/her arms and not letting him/her out of the shower. Further interview revealed staff could have tried a better approach. d. Interview with the DON on 9/19/23 at 3:30 PM revealed staff should have used a better approach with the resident and confirmed the resident's wishes were not followed.

Based on observation, resident and staff interview. medical record review, and policy review, the facility failed to ensure residents received adequate supervision and assessment for 1 of 1 sample residents (#72) reviewed for accident hazards. The findings were: 1. Review of the admission MDS assessment dated [DATE] showed resident #72 had diagnoses which included acute embolism and thrombosis, cancer, deep vein thrombosis, arthritis, and non-Alzheimer's dementia. Further review showed the resident received an anticoagulant 6 of the 7 days during the look back period. Review of the care plan showed the resident had a risk of falls and required staff assistance of one for transfers to bed, mobility, and toileting. Review of the at risk for further fall careplan last revised on 8/14/22 showed the resident had difficulty maintaining sitting balance, impaired balance during transitions, and had several risk factors for falls which included arthritis, delirium, wandering, cognitive impairment, dementia, depression, incontinence, hearing impairment, and pain. Interventions included staff of 1 to assist to ambulate with a walker to all destinations and therapy services to assist in reaching highest practicable level. Review of the fall risk assessment dated [DATE] showed the resident was at risk for falls and fall prevention protocols included a new admission, ambulated on own, did not wait for assistance, and wandered often. The following concerns were identified: a. Review of a progress note dated 8/4/22 and timed 10:16 PM showed .resident unwitnessed fall .resident fell out of [his/her] recliner chair sideways to the left side onto the floor . Further review showed the resident complained of pain, had a contusion to the left wrist with edema noted in the left hand, had a skin tear to the right hand, and swelling to the forehead and the back of the head. The resident was sent to the emergency department at that time. Review of a fall risk assessment dated [DATE] showed the assessment was initiated; however, it was not completed. Review of the Neurological Assessment Form initiated on 8/4/22 showed the facility performed neurological assessments; however, the assessments stopped on 8/6/23. b. Review of a progress note dated 8/7/22 and timed 7:03 PM showed the resident was found on the floor next to his/her recliner. Further review showed the resident had a .new hematoma to left knee cap and left forearm . There was no evidence a fall risk assessment or neurological assessment was performed after the fall. c. Interview with the resident's representative on 1/25/22 at 4:55 PM revealed the facility did not have fall interventions in place, and the resident had two falls. Further interview revealed the resident was in a hall by his/her self, and there were no staff present on the hall to help the resident. d. Interview with RN #1 and RN #2 on 1/26/23 at 9:31 AM revealed staff from another hall were expected to check on and provide care to residents who lived on the hall resident #72 resided. Further interview revealed the facility's expectation was for staff were to check the residents at frequent intervals. e. Interview with the administrator on 1/25/23 at 3 PM revealed nurse's were expected to perform a fall risk assessment after all falls. 2. Review of the Fall Prevention policy and procedure last revised November 2022, showed .Procedure: 1. A Fall Risk Assessment will be completed at the following times: a. Upon admission/readmission to the facility .d. Change of condition. e. Post fall . 3. Incident report and A fall scene investigation form will be completed after each fall. 4. Falls will automatically be logged through completion of Incident Report in PCC. 5. Initiate Neuro checks if resident hit head or if unwitnessed fall. 47344

Based on medical record review, resident representative interview, staff interview, and policy and procedure review, the facility failed to ensure residents received or were offered [MEDICATION NAME] care visits during a facility outbreak of COVID-19 for 3 of 11 sample residents (#66, #71, #72) reviewed with a change of condition. This failure resulted in harm to residents #71 and #72, who died without receiving a visit with family. The findings were: 1. Review of the medical record for resident #72 showed the resident had [DIAGNOSES REDACTED]. Review of the [DATE] significant change MDS assessment showed the resident had a BIMS score of ,[DATE] (cognitively impaired), required extensive assistance for all ADLs except for bathing and transfers which required the total assistance of two staff members, and did not require supplemental oxygen. The following concerns were identified: a. Review of a progress note dated [DATE] (Saturday) and timed 8:41 PM showed resident observed to have a dry mouth and deep shallow breathing. All medications held this HS (bedtime) due to resident change in status. Further review showed the resident's oxygen saturation level fell to 85% and 2 liters of oxygen was applied. There was no evidence the physician or resident's representative were notified of the change of condition. b. Review of the [DATE] Medication Administration Record [REDACTED]. A corresponding nurse's note stated the resident was unable to open his/her mouth and swallow the medication. There was no evidence the physician or resident's representative were notified of the change of condition. c. Review of a progress note dated [DATE] and timed 1:45 PM showed .less responsive, stares at the wall, does not smile, does not talk, does not open mouth for food or pills . A progress note timed 3:59 PM showed the resident's family and the physician were notified and the resident was placed on comfort care. Further review showed the resident expired on [DATE] at 3:35 AM. d. Interview with the DON on [DATE] at 4 PM revealed she had not anticipated the resident's death to occur so quickly and had set up a [MEDICATION NAME] care visit for [DATE]. In an additional interview on [DATE] at 10:46 AM the DON stated she was unaware of the resident's change of condition until [DATE] (Monday) when she came to work (2 days after the change of condition was first noted). e. Interview with the resident's representative on [DATE] at 8:53 AM revealed the last time she saw the resident in person was [DATE] during a physician office visit outside of the facility. Further, she had FaceTime visits weekly with the resident, but felt the facility should have known the resident was declining longer than the 12 hours notice she received before the resident died . 2. Review of the medical record for resident #71 showed the resident had [DIAGNOSES REDACTED]. The resident was receiving intravenous antibiotics for treatment of [REDACTED]. Further review showed the resident had been transferred to a geriatric psychiatric hospital from [DATE] through [DATE] for behaviors. Review of the [DATE] significant change MDS assessment showed the resident had a BIMS score of ,[DATE] (moderate cognitive impairment) and was coded as being independent with eating. The following concerns were identified: a. Review of a nurse's progress note dated [DATE] showed the resident's representative was notified the resident's foot was not healing, was becoming more necrotic, and the resident had seen an orthopedic surgeon. The surgeon had recommended amputation at this time after MRI (magnetic resonance imaging) to determine how far up the infection has gone and if osteo[DIAGNOSES REDACTED] is present. b. Review of an IDT (interdisciplinary team) progress note dated [DATE] showed the resident had lost 7 pounds and Not doing well related to infection, surgical candidate at this time after seeing surgeon. Resident is not eating well. Resident gets milkshake with juven (a nutritional supplement). Review of a skilled nursing evaluation dated [DATE] showed Resident needs assistance with eating. c. Review of an IDT progress note dated [DATE] showed .Behaviors have declined, but resident is notably ill . There was no evidence the physician or resident's representative was notified of the change of condition. d. Review of a nurse's note dated [DATE] showed the resident expired at 3:15 AM. The resident's representative was notified at 3:20 AM and was devastated and wanted to know what the cause of death was . e. Interview with the resident's representative on [DATE] at 11:23 AM revealed the resident's death was kind of unexpected. In addition, the representative stated he had last seen the resident in person in October of 2020 related to some behavioral problems and had not been contacted by the facility since that time related to a [MEDICATION NAME] care visit. f. Interview with the DON on [DATE] at 10:46 AM revealed the resident's decline should have been discussed during the IDT meeting, however the facility was focused on moving ahead with the resident's surgery. Further, the DON stated the resident's representative had been notified of the surgeon's recommendations, but not the resident's decline. g. Interview with the NHA on [DATE] at 11:16 AM revealed there was a lot of COVID-19 in the building at the time of the resident's decline and death, so the facility could not bring the family members inside and the resident was too sick to be moved. 3. Review of the [DATE] quarterly MDS assessment for resident #66 showed the resident had [DIAGNOSES REDACTED]. The resident had a BIMS score of ,[DATE] (severe cognitive impairment). Review of the medical record showed the resident tested positive for COVID-19 on [DATE] and was moved out of quarantine on [DATE]. The following concerns were identified: a. Review of nurses' progress notes from [DATE] and [DATE] showed the resident was refusing care, was withdrawn, and had mottled skin throughout and was cool to the touch. b. Review of a progress note dated [DATE] and timed 9:30 AM showed talked to (social services) about resident's decline and comfort cares .family will come visit. c. Review of a nurse's note dated [DATE] showed the resident expired at 11:48 AM. d. Interview with the resident's representative on [DATE] at 9:15 AM revealed RN #1 had called to inform him of the resident's decline, however the facility did not offer a [MEDICATION NAME] care visit. Further, he stated he called the facility to initiate the [MEDICATION NAME] care visit for his family which occurred on [DATE]. 4.Interview with the director of social services on [DATE] at 1:03 PM revealed a determination of the necessity of [MEDICATION NAME] care visits was supposed to be made by the IDT and families were typically granted 2 hour time slots with some exceptions if a resident was actively dying. 5. Interview with RN #1 on [DATE] at 3 PM revealed [MEDICATION NAME] care visits were scheduled through the social services department, visitors were screened in through the 400 hallway entrance, and limited to 2 hours. 6. Interview with the DON on [DATE] at 10:46 AM revealed [MEDICATION NAME] care visits were determined on a case-by-case basis. Staff members would inform her if they thought a [MEDICATION NAME] care visit was warranted and she would make a decision. The nurses would then arrange for the visit. 7. Review of an undated policy and procedure entitled Limited COVID-19 Indoor Visitation Policy and Procedure showed .Goshen Healthcare Community acknowledges that it is equally important to consider the quality of life and dignity (sic) our residents, and the critical role of family relationships to overall health. During the pandemic, visitation is permitted for [MEDICATION NAME] care until we reach certain parameters as described by governmental guidelines for broader visitation allowance. At Goshen Healthcare Community, we will define it as allowing in-person visitation for patients for whom prognosis is terminal with a short life expectancy, as well as other extenuating circumstances affecting resident quality of life on a one-to-one basis. All visitation must be cleared with the management team. EG. Administrator, DON, Social Services Director, Medical Director or MD/PA of record who confirm that the resident is terminal or falls under the term [MEDICATION NAME] care.

Based on observation, medical record review, staff interview, and policy and procedure review, the facility failed to ensure pressure ulcer care and treatment were implemented in a timely manner for 1 of 2 residents (#73) with pressure ulcers. This failure resulted in the worsening of a pressure ulcer for resident #73. The findings were: Review of the 12/3/16 quarterly MDS assessment showed resident #73 was not cognitively impaired, was at risk for developing pressure ulcers, required extensive assistance with bed mobility, and was totally dependent with transfers. Review of the care plan, revised on 12/12/16 showed staff were directed to reposition the resident every two hours while in bed and when up in the electric scooter. This review revealed the resident did not have mobility and sensation below the waist including the lower extremities due to paralysis. Review of the care plan and November 2016 to January 2017 daily nursing notes revealed the resident resisted staff efforts to offload him/her with frequent repositioning when up in the electric scooter. This review also revealed the resident refused to take rest periods out of the electric scooter during the day. Review of the Weekly Wound Documentation Form showed a pressure ulcer developed on the right ischium on 12/6/16. This review also showed the following measurements: 2.4 cm (centimeters) x 0.8 cm x 0.3 cm on 12/6/16, 0.9 cm x 3.1 cm x 0.3 cm on 12/20/16, 0.2 cm x 2.4 cm x 0.3 cm on 12/27/16, 0.5 cm x 3.8 cm x 0.4 cm on 1/3/17, and 0.8 cm x 3.0 cm x 0.3 cm on 1/7/17. Review of the wound care nurse's 12/6/16 documentation showed the pressure ulcer was a stage II with no drainage and 100% pink viable tissue wound bed. Review of the wound care nurse's 1/3/16 documentation showed the pressure ulcer had declined to a stage III with serosanguinous drainage, no tunneling, and 75% thin yellow slough with 25% granulation on the wound bed. Interview with the unit manager on 1/11/17 at 5 PM revealed an indwelling urinary catheter was inserted on 12/9/16 to prevent the right ischial pressure ulcer from being saturated with urine during incontinent episodes. She further stated the catheter caused the development of an additional pressure ulcer in the resident's genital area, and the catheter was discontinued on 1/5/17. Review of the Weekly Wound Documentation Form showed the pressure ulcer caused by the catheter was first noted on 12/29/16 and described as an intact blister. This review showed the pressure ulcer measured 0.5 cm x 1.4 cm with no depth on 1/3/17, then progressed to a stage II, measuring 6 cm x 2 cm x 0.3 cm on 1/10/17. The following concerns were identified: a. Observation of both pressure ulcers with LPN #1 on 1/11/17 at 4:10 PM revealed the two areas were as documented on 1/3/17. b. Review of the December 2016 wound care treatment record showed the nurses applied [MEDICATION NAME] (an ointment for minor bruises) to the right ischium pressure ulcer from 12/6/16 until 12/10/16 (4 days). Review of the physician's orders [REDACTED]. Further review showed this treatment was ordered daily and as needed. c. Review of the dietary note showed a dietary assessment regarding nutritional needs to promote pressure ulcer healing was not done until 1/10/16 (35 days after the resident developed the right ischium pressure ulcer). Further review revealed the assessed nutritional needs included adding protein supplements to the resident's diet. d. Interview with the unit manager on 1/11/17 at 5 PM revealed the wound care nurse talked with staff about the positioning non-slip pad that was placed on the pressure-relieving chair cushion. According to the unit manager, the wound care nurse told staff the resident needed a chair cushion that provided pressure redistribution and a support device that did not secure the resident in a non-pressure relief position for prolonged periods of time in the same manner as the non-slip pad did. The unit manager stated she did not remember the exact date of the conversation with the wound care nurse; however, no actions had been taken regarding the wound care nurse's recommendations. e. On 1/11/17 from 11:20 AM to 1:30 PM, the resident was observed in his/her room sitting in the electric scooter on the cushion with the support device. During the observation staff did not offer to reposition the resident. At 1:30 PM the resident went with the activity staff on a shopping trip and returned at 3 PM. Interview with activity assistant #1 on 1/11/17 at 4 PM revealed the resident remained in the electric scooter while on the shopping trip and was not repositioned from 1:30 PM to 3 PM. f. Interview with the DON on 1/12/17 at 1:55 PM revealed she was unable to provide evidence that the Collagen-Hydrogel treatment was initiated earlier than 4 days after the pressure ulcer developed; the nutritional assessment had been done earlier than 35 days; and the pressure relief cushion and support positioning device had been re-evaluated prior to the 1/9/17 to 1/12/17 survey. g. Review of the policy titled, Prevention of Pressure Ulcers, revised February 2014, showed the general guidelines included the following: Pressure ulcers are often made worse by continual pressure, heat, moisture, irritating substances on the resident's skin .decline in nutrition and hydration status, acute illness and/or decline in the resident's physical and/or mental condition. Once a pressure ulcer develops, it can be extremely difficult to heal. Pressure ulcers are a serious skin condition for the resident. The facility should have a system/procedure to assure assessments are timely and appropriate and changes in condition are recognized, evaluated, reported to the practitioner, physician, and family, and addressed.