Every finding on record at Hanover Health and Rehabilitation Center

Based on observations, policy review, and interviews, the facility failed to discard six two-pound cartons of liquid eggs located in the walk-in cooler that were beyond the manufacturer's use by date of 02/09/26.Findings include: During the initial tour of the kitchen with the Dietary Manager (DM) on 02/23/26 at 10:30 AM revealed six two-pound cartons of liquid eggs that displayed manufacturer's use by date of 02/09/26 located in the walk-in cooler. The DM confirmed that all six cartons were beyond the use by date displayed and should have been discarded.Review of the facility's policy titled, Cold Food Storage with an effective date of 02/19/25 revealed that it is the center policy to ensure all Time/Temperature Control for Safety (TCS), frozen and refrigerated food items, will be appropriately stored following guidelines of the FDA Food Code.

Based on staff interviews, record reviews and the Virginia Board of Nursing guidance, the facility failed to ensure competent nursing staff with the appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of all 110 residents. This failure had the potential to affect the completion of nursing duties, including incident management, assessments, and fall monitoring and prevention, infection prevention and control, and medication administration.Findings include:Review of a personnel file provided by the facility revealed Registered Nurse Applicant (RNA) 1 was hired as a Graduated Nurse on 09/24/25 Further review of the file revealed RNA1 took her National Counsel Licensing Exam (NCLEX) on 10/13/25 and failed the exam. RNA1 did not notify the facility and continued to work as an RN until the facility received an anonymous email indicating she did not pass her exam and was not an RN. RNA1's personnel file revealed she was terminated on 12/19/25 when the administrator was made aware she could not work as an RN according to the Virginia board of nursing. RNA1's timesheets were reviewed and revealed she had worked 50 shifts at the facility including 42 after she failed her exam to become an RN. During an interview on 02/26/26 at 11:15 AM the Administrator revealed he had received an anonymous complaint on 12/19/25 that RNA1 failed her NCLEX on 10/13/25 and did not notify the facility. The Administrator confirmed RNA1 worked as a nurse from 10/02/25 to12/19/25 before she was terminated from her employment. The Administrator said he had a plan of correction in place to prevent any further incidents from happening again. Review of an undated document titled, Licenses and Letters to Test indicated, Upon hiring Licensed Practical Nurses applicants (LPN) and RN applicants were to inform the facility when they were testing for the board and report whether they passed the board immediately and HR (Human Resources) would follow up to ensure if applicants did not pass the board they would be removed immediately.Review of the reference from the Virginia Board of Nursing included the following: 1. A graduate who has filed a completed application for licensure in Virginia and has received an authorization letter issued by the board may practice nursing in Virginia from the date of the authorization letter. The period of practice shall not exceed 90 days between the date of successful completion of the nursing education program, as documented on the applicant's transcript, and the publication of the results of the candidate's first licensing examination. 3. The designations R.N. Applicant and L.P.N. Applicant shall not be used by applicants beyond the 90-day period of authorized practice or by applicants who have failed the examination. G. Applicants who fail the examination. 1. An applicant who fails the licensing examination shall not be licensed or be authorized to practice nursing in Virginia.

Based on observation, interview, record review, and review of the facility's policy, the facility failed to use appropriate infection control practices, specifically, to ensure Personal Protective Equipment (PPE) was utilized appropriately by housekeeping staff while providing environmental cleaning and disinfecting objects and surfaces in the resident rooms with contact precautions and when moving between resident rooms . who was on Enhanced Barrier Precautions (EBP) for two of two residents (Resident (R) 115) and in room [ROOM NUMBER] reviewed for EBP of 25 sample residents. This failure had the potential to cause the spread of infection to other residents who resided on the hall. Findings include:Review of R115's admission Record, located in the resident's electronic medical record (EMR) under the Resident Profile tab revealed the resident was admitted to the facility on [DATE].Review of R115's nursing Progress Note, dated 02/22/26 and located in the resident's EMR under the Progress Notes tab, revealed R115 was placed on contact precautions related to E. coli in the urine. Observations revealed on 02/23/26 at 11:20 AM a sign on the door of R115's room that indicated Contact Precautions and a cart with the required PPE was available outside the doorway.Continued observation revealed Housekeeping Staff (HK) 1 entered R115's room to provide mopping, environmental cleaning and disinfecting objects and surfaces in the resident's rooms without donning the required PPE before entry. Observation on 02/23/26 at 11:35 AM revealed HK1 exit R115's room carrying what appeared to be two spray bottles and immediately entered room [ROOM NUMBER], exited room [ROOM NUMBER] and immediately re-entered R115's room. As HK1 resumed mopping the floor, the Housekeeping Supervisor (HKS) walking down the hallway, stopped at the doorway of R115's room and told HK1 to put on a gown. The HKS told HK1 the gowns were in the cart. HK1 donned a gown and resumed mopping the floor in R115's room. HK1 did not wear any other PPE as required. During an interview on 02/23/26 at 12:10 PM with HKS, surveyor asked what her expectations were of her housekeeping staff. HKS said she expected her staff to wear the required PPE when entering resident rooms.During an interview on 02/24/26 at 2:20 PM, the Infection Preventionist (IP) stated it was her expectation that all facility department staff, including the housekeeping staff, use appropriate infection control practices, specifically, to ensure Personal Protective Equipment (PPE) was utilized appropriately.During an interview on 02/25/26 at 2:47 PM, the Administrator stated it was her expectation that all staff, including housekeeping, staff use appropriate infection control practice and utilize PPE appropriately when required.Review of the facility's policy titled, Transmission Based Precautions-General Practice, effective date 12/21 revealed, Transmission Based Precautions were initiated to protect other residents, employees, and visitors from the spread of a confirmed or suspected infection or contagious disease. 1. Standard Precautions combine the major features of universal precautions and body substance isolations and 2. are based on residents known or suspected of being infected with highly transmissible pathogens and instituted if there is a risk of spreading infection which are spread by direct or indirect contact with the patient or the patient's environment. 3. Donning PPE before entry and discarding before exiting the patient room is done to contain pathogens, especially those that have been implicated in transmission through environmental contamination.

Based on record review, interview, and policy review, the facility failed to ensure that each resident's medication regimen was free from unnecessary medications through monthly pharmacist review, physician oversight, and monitoring for adverse effects, and implementation of gradual dose reductions when appropriate for four of four residents, Resident (R)2, R4, R68, and R128, reviewed in the sampleFindings include:1. Review of R2's admission Record, located in the resident's electronic medical record (EMR) under the Resident Profile tab revealed the resident was admitted to the facility on [DATE] with diagnosis' to include but not limited to anxiety disorder, depression, chronic kidney disease, and personal history of other mental and behavioral disorders, unspecified dementia and unspecified severity behavioral disturbance, and psychotic disturbance.Review of R2's Orders, located in the resident's Electronic Medical Record (EMR) under the Orders tab, revealed the resident was prescribed Mirtazapine oral Tablet 15 milligram (MG), one tablet by mouth at bedtime for depression, and Fluoxetine Hydrochloride (HCI) Oral Tablet 20 (G), one tablet by mouth one time a day for depression.Review of R2's Medication Regimen Review (MRR) revealed there were no pharmacy reviews for 04/25, 06/25, 09/25, and 10/25. 2. Review of R4's admission Record, located in the residents' EMR under the Resident Profile tab revealed the resident was admitted to the facility on [DATE] with diagnoses to include but not limited to depression, stress disorder, and altered mental status.Review of R4's Orders located in the resident's EMR under the Orders tab revealed the resident was prescribed antidepressant, Buspar.5 MG twice daily.Review of R4's MMRs revealed there were no pharmacy reviews for 04/25, 06/25, 07/25, or 11/25.3. Review of R68's admission Record, located in the resident's EMR under the Resident Profile tab revealed the resident was admitted to the facility on [DATE] with diagnosis' to include but not limited to hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, type 2 diabetes without complications, and other disorder involving the immune mechanism, muscle weakness.Review of R68's Orders, located in the resident's EMR under the Orders tab revealed the resident was prescribed an antipsychotic., aripiprazole 10 MG every day.Review of R68's MMR's revealed pharmacy reviews for 12/25 and 02/26 with no reviews conducted 11/25 or 01/26. 4. Review of R128's admission Record, located in the resident's EMR under the Resident Profile tab revealed the resident was admitted to the facility on [DATE] with diagnoses to include but not limited to depressive disorder, and anxiety disorder, Review of R128's Orders located in the resident's EMR under the Orders tab revealed the resident was prescribed antidepressant, sertraline 200 MG, every day.Review of R128's MMR's revealed there were no pharmacy no reviews for 07/25, 08/25, 10/25, 11/25.During an interview on 02/26/26 at 11:30 AM, the Administrator and the Regional Nurse stated that the previous Director of Nursing (DON) had misplaced the binder that contained all pharmacy reviews for the past 12 months. The facility could not provide documentation that the attending physician responded to GDR's or that he provided a rationale not to reduce R2's medication. Review of the facility's policy titled, Medication Regimen Review, effective date 01/29/24 revealed .the drug regimen of each patient will be reviewed at least once per month by a licensed pharmacist. 1. The consultant pharmacist will provide Medication Regimen Review (MMR) reports to provider and Director of Nursing (DON), within 72 hours of completion.

Based on observation, interview, clinical record review, and facility documentation review, the facility staff failed to ensure that staff have the appropriate competencies and skill sets to provide adequate nursing care for one (1) Resident #1 in a survey sample of 5 residents, resulting in immediate jeopardy and harm to Resident #1.The findings include:For Resident #1, the facility failed to ensure all nurses were competent in the care and use of LVAD (Left Ventricular Assistive Device, an implanted cardiac pump) which resulted in Immediate Jeopardy past non-compliance with harm for Resident #1. Resident #1 was re-admitted to the facility on [DATE] with diagnoses that included but were not limited to chronic systolic heart failure, hypertension, presence of LVAD (Left Ventricular Assist Device), stage 3 chronic kidney disease, diabetes type 2, history of traumatic brain injury related to frequent falls, and history of subdural hematoma. Resident #1's most recent MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of [DATE] scored the resident as having a BIMS score of 8 out of 15 indicating moderate cognitive impairment.On [DATE] at interview was conducted with the Administrator who stated, I filed the incident report on [DATE] when I got a phone call from [MD name redacted] from [Hospital name redacted]. He said the hospital was filing a complaint to the state for neglect but did not want to give me details until we meet face to face. He came to facility on the 1st of oct. In the meeting he told me that the Social Worker and the Emergency Dept. physician filed the initial complaint that they were concerned when he [Resident #1] arrived at the hospital because the LVAD was disconnected. The controller for the device was sent to manufacturer to recover the recording. We were not given the information from the device as there was an active investigation going on at [Hospital name redacted] regarding the LVAD and the Resident. [MD name redacted] that the drive line was disconnected, and the alarm had been silenced 44 times and the stopped recording altogether 12:45 am.A review of the facility documentation revealed the following nurses note dated [DATE] stated that at 7:47 a.m. a Code Blue was called and staff responded, CPR initiated at 7:49 am, Emergency services was called, as was the on -call physician, and the resident's family. The resident was transported to the hospital via rescue squad at 7:56 a.m.A review of the hospital emergency room record revealed the following note: [DATE] 8:41 a.m. - The ED Triage note does not agree with what EMS told me at bedside. Medic reported patient had LVAD turned off and no CPR for 10 minutes prior to EMS arrival. LVAD was still not running. He has been in asystole with no cardiac activity. Pt's skin tone is gray with unreactive pupils. Further resuscitation not indicated.On [DATE] at 2:15 pm, an interview with LPN #3 in Resident #2's room (Resident #2 also has an LVAD). LPN #3 demonstrated care of the LVAD - checking settings, connection, battery charges, and the purpose of the LVAD, and actions if alarms. On [DATE] at 3:03 pm, an interview with LPN #2 was conducted regarding her knowledge of care of a resident with an LVAD. LPN #2 explained the purpose of the LVAD and demonstrated checking device settings with other nurses at the beginning of the shift, ensuring the batteries were functioning. On [DATE] at 4:16 pm, Resident #2 was up in w/c and had recently returned from therapy, LVAD at side; settings noted; battery charge station green lights indicating charging successfully. On [DATE] at 5:15 a.m., an interview was conducted with LPN #5, who stated that she had worked at the facility for a couple of years now. She stated that she was trained on the LVAD when the first patient arrived at the facility with an LVAD, and then last October and last week.On [DATE] at 6:45 a.m. CNA #5 was interviewed, and she stated that CNAs are supposed to make sure the alarms are not ringing and that the batteries are plugged in. She said that she was trained before she started working on the unit.On [DATE] at 7:00 a.m. CNA #'s 4 and #7 both were able to verbalize the training they received regarding the LVAD. They both stated that CNAs are supposed to ensure the batteries are plugged into the red outlet and that the alarms are not sounding. If alarms sound, they are to notify the nurse immediately. [DATE], a review of Resident #1's care plan stated LVAD care as ordered. [DATE] - Monitor Q shift- LVAD Alarm- Document if it sounded Yes or No. If YES, document if LVAD Coordinator was notified and instructions given Observe for signs and symptoms of cardiac complications dizziness, shortness of breath. A review of the MAR / TAR for [DATE] revealed the following: VAD Care Battery - Check battery level and change to new set of batteries. Place old batteries on the charger for next use. Instructions : Change one Battery at a time. 1 Hold battery in one hand and cip in other. 2. Press battery release button and withdraw battery. 3. Insert fully charged battery into battery clip and push until the battery clicks into place. 4. Repeat steps 1-3 as needed for connection. Monitor Q Shift [every shift] LVAD Alarm - Document if it sounded yes or no. If YES document if LVAD coordinator was notified and instructions given every day and night shift for monitoring.On [DATE] a review of LPN #1's employee file revealed the following Corrective Action form dated [DATE] read: LPN #1 [Name redacted] The company reserves the right to bypass any step in the corrective action process depending on the nature and severity of the infraction. [Box checked for employee termination.]DETAILS:LPN #1 [Name redacted] worked a 7:00 p.m. to 7:00 a.m. shift on [DATE]. It has been determined after investigation and interviews with LPN #1 that she knowingly accepted care for a patient without competency in caring for his (sic). The acceptance of the assignment for this patient occurred on three separate instances. Accepting responsibility of a patient that she was not competent in caring for, directly impacted the welfare of the patient in a negative manner. LPN #1 knowingly accepted assignment without making other available competent nursing staff aware in order for patient to be properly cared for.On [DATE], the Administrator provided the survey team with a quality assurance performance improvement (QAPI) Action Plan in response to Resident #1's incident. The facility recorded the incident, obtained statements, identified other residents with an LVAD, educated in-house staff, and had LVAD TEAM from the local teaching hospital come in to train staff as well. The facility then initiated audits to ensure ongoing compliance. All nursing staff are required to complete LVAD patient care training before the next shift (the content of the training depends on the clinical role). The survey team verified the staff training and the audits the facility had conducted. The training records for all nursing staff working at the facility at the time of the survey were verified, and staff were interviewed. The nurses working with Resident #2 (the only resident in the facility with an LVAD) were observed changing the batteries and ensuring they were charging correctly. The CNAs working with Resident #2 were also observed during rounding and were able to verbalize understanding of what they should be looking for (battery lights being on, plugs being in the proper outlet, and why being in the emergency red outlet was imperative). The survey team determined that the facility had completed its plan and that there were no further incidents involving the care of a resident with an LVAD since the incident of [DATE] and thus accepted the past non-compliance as of its stated AOC date of [DATE].

Based on staff interview, clinical record review, and facility documentation review, the facility staff failed to provide influenza vaccines for 3 residents, Residents #2, #3, and #5, out of 5 residents reviewed for influenza immunization and facility staff failed to provide a pneumococcal vaccine for 1 resident, Resident #5, out of 5 residents reviewed for pneumococcal immunization. The findings included: 1. The facility staff failed to provide influenza immunization, to include education of risks/benefits about influenza immunization, for Residents #2, #3, and #5. On 6/30/23 at approximately 2:30 PM, clinical record reviews were performed and revealed the following: A. For Resident #2, the clinical record review revealed Resident #2, who was admitted to the facility on [DATE], had received influenza immunization on 10/26/21. There was no documentation of the flu vaccine being offered, refused, contraindicated, or administered for the current year, 2022. B. For Resident #3, the clinical record review revealed Resident #3 was admitted to the facility on [DATE]. Resident #3 refused to have a flu vaccine on 10/20/22, however there was no evidence of education regarding the risks/benefits for influenza immunization. C. For Resident #5, the clinical record review revealed Resident #5 was admitted to the facility on [DATE]. Resident #5 refused to have a flu vaccine on 10/20/22, however there was no evidence of education regarding the risks/benefits for influenza immunization. On 6/30/23 at approximately 2:45 PM, a group interview was conducted with the Director of Nursing (DON) who accessed the clinical records for the residents sampled and verified the findings. The Infection Preventionist (IP) confirmed there was no additional information and stated, it [no offer to vaccinate and/or educate] appears to be an oversight. Both the DON and IP acknowledged that providing immunization education to residents who may be unsure, or refuse the initial offer to vaccinate, may be beneficial for them to be able to make a fully informed decision. A facility policy was requested and received. On 6/30/23 at approximately 3:00 PM, a review of the facility policy entitled, Influenza Vaccination, effective date 5/01/23, was conducted. It stated under the subtitle, Procedure, item 1a, Influenza vaccine should be offered annually .optimal time to administer influenza vaccine is in late September or early October of each year. The vaccine can be given after the flu season begins .Those who have not had a flu vaccine will be offered one upon admission and item 1, e, 1 read, Educate the patient and or RP [Responsible Party] .document education in the electronic medical record. On 6/30/23 at approximately 3:15 PM, the Facility Administrator and Director of Nursing were made aware of the findings. No further information was provided. 2. The facility staff failed to include education of risks/benefits about pneumococcal immunization, for Resident #5. On 6/30/23 at approximately 2:30 PM, a clinical record review was performed for Resident #5 and revealed Resident #5 refused to have a pneumococcal vaccine on 3/6/23, however there was no evidence of education regarding the risks/benefits for pneumococcal immunization. On 6/30/23 at approximately 2:45 PM, a group interview was conducted with the Director of Nursing (DON) who accessed the clinical records for the residents sampled and verified the findings. The Infection Preventionist (IP) confirmed there was no additional information and stated, it [no vaccine education] appears to be an oversight. Both the DON and IP acknowledged that providing immunization education to residents who may be unsure, or refuse the initial offer to vaccinate, may be beneficial for them to be able to make a fully informed decision. A facility policy was requested and received. On 6/30/23 at approximately 3:00 PM, a review of the facility policy entitled, Pneumococcal Vaccinations, effective date 5/01/23, was conducted. It stated under the subtitle, Procedure, item 1, e, 1 read, Educate the patient and or RP [Responsible Party] .document education in the electronic medical record. On 6/30/23 at approximately 3:15 PM, the Facility Administrator and Director of Nursing were made aware of the findings. No further information was provided.

Based on staff interview, clinical record review, and facility documentation review, the facility staff failed to provide COVID-19 bivalent education for 2 residents, Residents #1, and #5, out of 5 residents reviewed for COVID-19 bivalent immunization. The findings included: The facility staff failed to provide education of risks/benefits about COVID-19 immunization, for Residents #1, and #5. On 6/30/23 at approximately 2:30 PM, clinical record reviews were performed and revealed the following: A. For Resident #1, the clinical record review revealed Resident #1 refused to have a COVID-19 bivalent vaccine on 3/3/23, however there was no evidence of education regarding the risks/benefits for COVID-19 immunization. B. For Resident #5, the clinical record review revealed Resident #5 refused to have a COVID-19 bivalent vaccine on 3/6/23, however there was no evidence of education regarding the risks/benefits for COVID-19 immunization. On 6/30/23 at approximately 2:45 PM, a group interview was conducted with the Director of Nursing (DON) who accessed the clinical records for the residents sampled and verified the findings. The Infection Preventionist (IP) confirmed there was no additional information and stated, it [no vaccine education] appears to be an oversight. Both the DON and IP acknowledged that providing immunization education to residents who may be unsure, or refuse the initial offer to vaccinate, may be beneficial for them to be able to make a fully informed decision. A facility policy was requested and received. On 6/30/23 at approximately 3:00 PM, a review of the facility policy entitled, COVID-19 Vaccinations, effective date 5/01/23, was conducted. It stated under the subtitle, Procedure, item 1, CDC [Centers for Disease Control and Prevention] recommends that everyone stay up to date with COVID-19 vaccination and item 2c read, If contraindicated or refused, document in the patient's immunization record, including that the patient and/or RP [Responsible Party] was provided education regarding the benefits and potential risks associated with the COVID-19 vaccine. The CDC (Centers for Disease Control and Prevention) document titled, Interim Clinical Considerations for Use of COVID-19 Vaccines in the United States, updated May 12, 2023, page 2, Recommendations for the use of COVID-19 vaccines, read, COVID-19 vaccination is recommended for everyone ages 6 months and older in the United States for the prevention of COVID-19 and CDC recommends that people ages 6 months and older receive at least 1 bivalent mRNA COVID-19 vaccine. On 6/30/23 at approximately 3:15 PM, the Facility Administrator and Director of Nursing were made aware of the findings. No further information was provided.

Based on observation, staff interview, clinical record review, and facility documentation review, the facility staff failed to ensure an environment free from accident hazards for one Resident (Resident #2) in a survey sample of 5 Residents. This resulted in harm, past non-compliance. The findings included: For Resident #2 the facility staff failed to safely transfer a resident who had a known fall risk and had recently suffered bilateral leg fractures, causing a deep tissue leg laceration requiring sutures. Resident #2 was admitted to the facility on [DATE] from the hospital after acute surgery to repair multiple broken bones, with diagnoses including; Right femur fracture from a fall, Left tibia/fibula fracture from the same fall, spinal stenosis, Cervical Disk spinal fusion C-4 through C-7 after the fall, post hemorrhagic anemia from bleeding after the trauma of the broken bones, with a history of bilateral arm weakness, falls, osteo arthritis, and numbness in both of the lower extremities due to the long standing spinal stenosis which caused repeated falls and injury. The Resident was also diagnosed with morbid obesity, with a current weight of 258.9 pounds and 56 inches tall. On 10-12-22 at 9:00 a.m. Resident #2 was observed by 2 surveyors alone in her room. The Resident was preparing to go to a doctor's appointment with the Orthopedic Doctor who was treating her. The Resident was found to be alert and oriented to person, place, time, and situation. The Resident was sitting in a wheel chair covered in a sheet, wearing a dress with dressings on her legs exposed to view. The Resident was asked if she could get into her wheel chair without assistance, and she stated, No, I can't walk. She was asked how she got from her bed to the chair, and she stated They put me in that lift, (pointing to a Hoyer Mechanical lift). I have 2 broken legs, and I can't feel my legs because of my neck. The Resident was asked how her lower leg was injured, and she stated A man that works here lifted me to put me in my chair and he couldn't hold me, so I got cut on the wheel chair. I told him to use the lift, but he was in a hurry, and didn't have anyone to help him, and he didn't use the lift like everyone else does, I guess he thought he could hold me, but that's how accidents happen. The Resident further stated, I didn't know I was cut at first, until I saw all the blood. I can't really feel my legs much. The Resident was asked when the injury happened, and she responded About a month ago. The actual date of the injury was 9-8-22. The review Resident #2's MDS (Minimum Data Set) assessment dated [DATE] revealed that the Resident was cognitively intact, and required 2 staff members to transfer her. Physical Therapy notes were reviewed, and indicated the Resident required Hoyer (mechanical) lift transfers. Resident #2's care plan was reviewed, and revealed that the Resident required a mechanical lift for transfers with 2 staff to assist. A review of hospital records revealed that the Resident had sustained a deep laceration to her left calf exposing adipose tissue (fat), which required sutures, following an accident that occurred while the Resident was being transferred to a wheel chair. The facility policy on mechanical lift technique was reviewed and indicated 2 staff members are required to perform this exercise. An investigation of the accident was conducted by the facility after the incident, and before the current survey. The details of the incident were documented by the staff member involved (CNA [certified nursing assistant] B), who transferred the Resident, and closely resembled what the Resident recounted. The investigation revealed statements by staff, training conducted by the facility, and a plan of correction which was self-identified by the facility prior to this investigation. On 9-8-22 a single staff member created a hazard by attempting to stand, and transfer, an obese Resident with known weakness and numbness to lower extremities causing a serious injury and resulting in harm. The Resident's left calf was deeply lacerated causing adipose (fat) tissue to be exposed requiring sutures in the hospital emergency department. The Resident had known current surgical interventions for multiple fractures due to falls. The clinical record denoted in all areas that a mechanical lift and 2 staff members were required for transferring the Resident. The Resident was a known risk for falls and accidents because of known hazards. The facility staff self-identified the deficient practice on 9-8-22, and started an investigation. The investigation led to a five-point plan of correction that was delivered to surveyors while onsite. The documents included text of the actual training performed, investigation, audits, corrections to the clinical record, and QAPI documents. Those are as follows; 1. Address how correction action will be accomplished for those residents found to have been affected by the deficient practice. The investigation included written statements from the Resident, Resident's daughter, and the staff members involved in the incident. The Resident's nursing care plan, and CNA Kardex care plans were reviewed and updated with the involved Resident's transfer needs, completed by the facility staff. 2. Address how the facility will identify other residents having the potential to be affected by the same deficient practice. The facility then audited 100% of the Residents in the facility to ascertain their transfer needs. The facility staff reviewed residents care plans and Kardex documents to assure correct transfer activities were documented in the records, and were able to be utilized by base line staff. 3. Address what measures will be put into place or systemic changes made to ensure that the deficient practice will not recur. On 9-12-22 education of all clinical staff was begun, and continued through 9-20-22, as staff were not allowed to work until all had received education on the following; Transfers, Falls, Prevention of Injuries, and ensure staff knowledge of where to find transfers in the clinical record, Kardex, and understand different types of transfers. 4. Indicate how the facility plans to monitor its performance to make sure that solutions are sustained. On 9-12-22 the facility staff held a QAPI meeting to discuss the incident, and action plan, to prevent reoccurrence. The QA committee agreed to the plan and documented that the Allegation of returning to compliance (AOC) date would be 9-13-22 as no staff would work with residents until training was completed by them. The QA committee met again on 9-20-22, and found that the measures had been successful and sustained. 5. Include dates when corrective action will be completed. AOC 9-13-22. On 10-12-22 at the end of day debrief, the Administrator and DON were notified of the above findings. The DON stated there was no further evidence to present. The facility staff were made aware that the complaint regarding this Resident would be substantiated with a deficiency cited at a level (3) harm, however, it would be cited at Past non-compliance (PNC) as the facility self-identified the deficient practice and corrected it prior to this survey. The facility Administrator expressed understanding. No further information was provided prior to exit.

Based on staff interview and clinical record review, the facility staff failed for 1 resident (Resident #1) of 5 residents in the survey sample to ensure medications were available for administration. The findings included: For Resident #1, several physician-ordered medications were unavailable for administration. Resident # 1's most recent MDS (minimum data set) (an assessment tool) with an ARD (assessment reference date) of 05/12/2022, was Quarterly assessment. Resident # 1 was coded as having a BIMS (brief interview for mental status) score of 15 out of a possible 15, indicating no cognitive impairment. Review of the closed clinical record was conducted on 10/11/2022 and 10/12/2022. The following nursing notes were documented in the clinical record: 5/3/2022 08:06 Ceftriaxone Sodium solution Reconstituted 2 GM (grams) Use 2 gram intravenously at bedtime for Septic arthritis of Right Knee Awaiting for order from pharmacy 5/3/2022 08:07 Insulin Glargine Solution Pen-injector 100 UNIT/ML Inject 10 unit subcutaneously at bedtime for DM Awaiting order from pharmacy Review of the OMNICELL STAT box (emergency facility medication supply) revealed the following medications were not available in the box for administration to Resident #1: Ceftriaxone 2 Grams IV (intravenous); and Glipizide ER Tablet Extended Release 24 Hour 2.5 MG Give 1 tablet by mouth one time a day for DM Order Date-05/02/2022. A review of the May 2022 MAR (Medication Administration Record) also revealed Ceftriaxone and Glargine Insulin were not available for administration. On 10/12/2022at 12 noon, during the meeting with the Administrator, Corporate Nurse Consultant, Assistant Director of Nursing and Director of Nursing (DON), the findings were discussed. They all stated medications should be available for administration. According to the May 2022 MAR (Medication Administration Record), the medications were not available for administration in the morning on 5/3/22. On 10/12/2022 at 1:00 p.m., the Assistant Director of Nursing (ADON) was interviewed. The ADON stated the nurses should administer medications as ordered. The ADON stated the pharmacy was located in Maryland. He stated the facility received Pharmacy deliveries twice a day at 7 a.m. and 7 p.m. and STAT (Emergency deliveries) when needed. The ADON also stated the facility had a contract with a local pharmacy from which medications could be received in an emergency. The Administrator, Corporate Nurse Consultant, ADON and DON were notified of the issue during the end of day meeting on 10/12/2022. No further information was provided. COMPLAINT Deficiency

Based on staff interview, facility documentation review and clinical record review during the course of a complaint investigation, the facility staff failed to ensure one Resident (Resident # 1) in a survey sample of 5 residents was free of significant medication errors. The findings include: For Resident # 1, the facility staff failed to administer insulin and antibiotic (ceftriaxone), both significant medications, as ordered by a physician. Resident # 1 was admitted to the facility on [DATE], and discharged on [DATE]. Resident # 1's most recent MDS (minimum data set) (an assessment tool) with an ARD (assessment reference date) of 05/12/2022, was Quarterly assessment. Resident # 1 was coded as having a BIMS (brief interview for mental status) score of 15 out of a possible 15, indicating no cognitive impairment. Review of the closed clinical record was conducted on 10/11/2022 and 10/12/2022. The following nursing note was documented in the clinical record: 5/3/2022 08:04 (8:04 a.m.) Insulin Lispro [NAME] KwikPen Solution Pen-injector 100 UNIT/ML Inject as per sliding scale: if 140 - 199 = 2; 200 - 249 = 3; 250 - 299 = 5; 300 - 349 = 7, 350 or greater, call MD, subcutaneously three times a day for DM (Diabetes Mellitus) Awaiting order from pharmacy. Further review of the May 2022 MAR (medication administration record) revealed neither the resident's blood sugar level nor the Insulin Lispro Sliding scale was documented 5/6/2022 at 4 pm and 5/24/2022 at 4 p.m. Further review of the May 2022 MAR revealed the Cephalexin Capsule 500 MG Give 1 capsule by mouth four times a day for right knee septic arthritis for 14 Days was not documented as given on 5/16/2022 at 9:00 pm, and 5/24/2022 at 5:00 p.m. Those dates were blank. According to the May 2022 MAR (Medication Administration Record), the medications were not available for administration. However, a review of the OMNICELL STAT box (emergency medication supply available to facility nurses) revealed the following medications were available in the box for administration: Cephalexin Capsule 500 MG, Quantity 10 capsules; and Insulin Lispro 100 unit/1 mil 3 ml Pen, Quantity 4 pens. The ADON (assistant director of nursing) stated the medications should have been administered from the STAT box. On 10/12/2022 at 12 noon, during the meeting with the Administrator, Corporate Nurse Consultant, Assistant Director of Nursing and Director of Nursing (DON), the findings were discussed. On 10/12/2022 at 1:00 p.m., the Assistant Director of Nursing (ADON) was interviewed. He stated the nurses should administer medications as ordered. He also stated the expectation was for medications to be given as ordered by the Physician. The Assistant Director of Nursing stated it was important to administer the medications (including insulin and the antibiotic) as ordered. He stated correct administration of Insulin would help keep the blood sugar in control and reduce the adverse consequences of a high blood sugar or uncontrolled blood sugar. Proper administration of antibiotics would help to make sure the bacteria did not continue to grow or become drug resistant. When interviewed on 10/12/22 at 4:00 p.m., the Administrator stated that she had identified the failure of the staff to ensure medications and treatments were documented as being administered. The DON stated her expectation was for staff to administer medications and treatments per physician's orders and to document them as having been administered, immediately following administration. The administrator and DON were informed of the failure of the staff to ensure significant medications were administered and documented during the end of day debriefing on 10/12/2022. During the end of day debriefing on 10/12/2022, the Administrator, Corporate Nurse Consultant, ADON and DON were informed of the failure of the staff to ensure significant medications were administered and documented. The Director of Nursing stated it was important to administer the medications (including insulin and the antibiotic) as ordered. It is important to follow the doctor's orders. Review of the facility's policy entitled, Medication Administration revealed that all medications are to be given according to the prescriber's order and signed/documented by the administering individual as soon as the medication is given. No further information was provided. COMPLAINT Deficiency

Based on staff interview, clinical record review, facility documentation review, and in the course of a complaint investigation, the facility staff failed to provide bathing care for one dependent Resident, (Resident #1) in a survey sample of 5 residents. The findings included: For Resident #1, the facility staff failed to provide baths and or showers twice weekly as per facility policy and Resident preference. On 10-22-2022 at 12:48 p.m., a CNA (Certified Nursing Assistant) (C) on Resident #1's unit was interviewed and asked if she had given care to Resident #1. She stated she was not sure if she had ever taken care of Resident # 1. She stated that whenever she showered or bathed any Residents, she would document the Full Bath or Shower in the clinical record. CNA C stated she was from an outside agency and could not remember is she had ever given care to Resident # 1. The Administrator was asked if the facility was experiencing a staffing shortage, and she stated that the facility occasionally had staffing challenges but that was the reason for outside agency staff being utilized. The Administrator stated she made sure there were adequate staff members working each day to provide care to the residents. A full review of the Resident's clinical record was conducted, and revealed that the Resident was incontinent of bowel and bladder, and dependent on staff for all bathing and incontinence care. The Care plan for Resident #1 was reviewed and revealed no care planning for bathing. On 10/12/22 at approximately 1:00 p.m., an end of day meeting was held with the Administrator, Director of Nursing (DON), and the Corporate Regional Registered Nurse Consultant. When asked where the hygiene and bathing records could be found, they responded that CNAs document in the computerized point of care software program, located in cabinets on each hallway. The surveyor requested bathing records for Resident #1 for the month of May 2022. When asked her expectation of how often Residents should be bathed each week, the DON responded, Twice weekly, with hygiene and incontinence care after each incontinent episode. The staff present at the meeting were asked if the documents reflected care had been given to the resident, and responded that if it's not documented it's not done. They confirmed that the documentation showed there were 11 bed baths given to Resident # 1 during the entire stay of 5/2/22-6/10/2022. There were no documented showers or full baths given. They stated bed baths should be given daily, in between the full bath or shower days. The Corporate Nurse Consultant provided a copy of the Resident's point of care documentation completed by CNAs (certified nursing assistants) for ADL (activities of daily living) care for bathing. The documents revealed that the Resident # 1 received a Bed Bath 11 times during the stay at the facility from 5/2/2022-6/10/2022. There were a total of 13 entries, with one listed as non applicable and one as Resident refused. The documentation in its entirety was as follows: 5/5/22 17:00 (5:00 p.m.) Type of Skin Hygiene- Bed Bath 5/9/22 18:59 (6:59 p.m.) Type of Skin Hygiene- Bed Bath 5/12/22 18:59 (6:59 p.m.) Type of Skin Hygiene- Bed Bath 5/14/22 16:40 (4:40 p.m.) Type of Skin Hygiene- Bed Bath Not Applicable 5/16/22 16:00 (4:00 p.m.) Type of Skin Hygiene- Bed Bath 5/19/22 11:17 11:17 a.m.) Type of Skin Hygiene- Bed Bath Resident Refused 5/23/22 16:20 (4:20 p.m.) Type of Skin Hygiene- Bed Bath 5/26/22 12:08 (12:08 p.m.) Type of Skin Hygiene- Bed Bath 5/30/22 08:05 (8:05 a.m.) Type of Skin Hygiene- Bed Bath 6/1/22 18:36 (6:36 p.m.) Type of Skin Hygiene- Bed Bath 6/2/22 18:59 (6:59 p.m.) Type of Skin Hygiene- Bed Bath 6/6/22 12:58 (12:58 p.m.) Type of Skin Hygiene- Bed Bath 6/9/22 10:03 (10:03 a.m.) Type of Skin Hygiene- Bed Bath No Full baths or showers were documented as given for the entire 39 day period that Resident # 1 resided in the facility from [DATE] through discharge on 6/10/22. When the DON was asked what the facility policy was for bathing and incontinence care, she stated, Baths or showers twice weekly, and incontinence care after each incontinence episode. A bathing and incontinence care facility policy was requested. On 10/12/2022 at 1:00 p.m., the Assistant Director of Nursing provided a copy of the facility's policy on Responsibilities for CNAs, effective date 11/01/20219, which included the following excerpts: 2.Obtain patient assignment at the beginning of each shift from/a licensed nurse. Examples of general report information includes but is not limited to the patient's name, room and bed, scheduled appointments, bathing needs, special health care needs, etc 4. Perform shift responsibilities/assignments that promote quality of care; make rounds, identify and address any immediate patient needs, promptly respond to calls lights and notify the licensed nurse of any pertinent patient findings. The Director of Nursing stated she was not employed at the facility at the time Resident # 1 resided at the facility. On 10/12/22 during the end of day debriefing, the facility Administrator, Corporate Nurse Consultant and Director of Nursing were made aware of the above findings. No further information was provided. COMPLAINT related deficiency.

Based on staff interview, facility documentation review, clinical record review, and in the course of a complaint investigation, the facility staff failed to implement a pain management program for one Resident (Resident # 1) in a survey sample of 5 residents. The findings include: For Resident # 1, the facility staff failed to provide Pain Medication as ordered by the physician and requested by the resident. Resident # 1 was admitted to the facility on [DATE], and discharged on [DATE]. On the resident's most recent MDS (minimum data set) (an assessment tool), a quarterly assessment, with an ARD (assessment reference date) of 05/12/2022, Resident # 1 was coded as having a BIMS (brief interview for mental status) score of 15 out of a possible 15, indicating no cognitive impairment. Resident # 1 was also coded as requiring extensive to total assistance of one to two staff persons for Activities of Daily Living (ADLs). Review of the closed clinical record was conducted on 10/11/2/2022 and 10/12022. Review of the Physicians orders and the May 2022 Medication Administration Record (MAR) revealed an order for Oxycodone -Acetaminophen Tablet 5-325 MG (milligrams) Give 1 tablet by mouth every 4 hours as needed for Pain ordered 5/2/2022 at 12:15 pm. Review of the Progress Notes revealed documentation that Resident # 1 arrived at the facility on 5/2/22 at 4:40 p.m. for strengthening following recent hospitalization related to infection of right knee surgical incision. A review of the initial skilled note dated 5/2/2022 at 18:42 (6:42 p.m.) revealed: Pain: yes. Non pharmacological interventions: pharmacological interventions Skilled nursing focus- patient refused to be touched again. Further documentation on 5/2/2022 at 10:05 p.m. showed the nurse was unable to finish the admission skin assessment due to Patient refused to have her skin checked again due the fact she does not have a Cath [catheter] and she do[sic]not have pain medications. I was not able to finish her assessment of the skin. A review of the Admission/Readmission Collection tool revealed, in part: Resident cognitively intact .reported moderate pain to R (Right) knee. Ice therapy effective. (There was no number documented for the moderate pain rate. However, according to the scale using 1-10, moderate pain is rated as 4-6). Review of the clinical record revealed the following orders and records of administration of medications: The May 2022 Medication Administration Record (MAR) revealed an order for Oxycodone Acetaminophen Tablet 5-325 MG (milligrams) Give 1 tablet by mouth every 4 hours as needed for Pain, ordered 5/2/2022 at 12:15 pm was first administered on 5/3/2022 at 1530 (3:30) for a pain level of 8, despite being available for administration in the facility emergency medication supply box (stat box). The next two doses were given on 5/3/2022 at 2223 (10:23 p.m.) for a pain level of 8 and 5/4/2022 at 0954 (9:54 a.m.) for a pain level of 10/10. Review of the Physicians Progress Note on 5/16/2022 revealed an excerpt: She notes that the pain still bothers her significantly with movement similar to when she went to the emergency room for her right knee. An interview was conducted with Licensed Practical Nurse B on 10/11/2022 at approximately 1:45 p.m. She stated that residents were expected to be assessed for pain and interventions provided to alleviate the pain. LPN B stated they use a pain scale of 1-10. Moderate pain is considered 4-6. Severe pain is 7-9. Pain rated at 8 out of 10 is considered severe pain. On 10/12/2022 at 1:00 p.m., the surveyor interviewed the Assistant Director of Nursing (ADON) who stated the nurses should assess the residents for pain, administer medications and inform the physician of pain and requests for pain medication. He also stated the expectation was for medications to be given as ordered by the Physician. During the end of day debriefing on 10/12/2022, the facility Administrator, Director of Nursing and Corporate Nurse Consultant were informed of the findings. No further information was provided. COMPLAINT DEFICIENCY

Based on observation, facility documentation review, and staff interview the facility staff failed to adhere to infection control measures in accordance with the Centers for Medicare & Medicaid Services (CMS) and the Centers for Disease Control and Prevention (CDC) recommendations to prevent the spread of COVID-19 for 2 out of 11 staff members. The findings included: For the two staff members Staff G, and Staff H the facility staff failed to screen them prior to entry to the facility on [DATE]. On 5/19/22 at approximately 9:45 a.m. while surveyors B and C were standing at the East Wing nursing station conducting an interview, Surveyor B heard a door bell ring. Resultantly, noted two individuals to the outside of the facility attempting to gain entrance directly to the interior of the facility through a corridor containing resident's rooms. In response to the doorbell ignition, Surveyor C observed a facility staff go to the door and grant entrance to Staff G and Staff H. Staff G and Staff H were wearing were not wearing N95 masks. Instead, Staff G and Staff H each wore surgical masks. Upon entrance of Staff G and Staff H, Surveyor C interviewed Staff G. Staff G made the following responses: as to the protocol for entering the facility. Staff G made known that for transportation staff the facility had directed them to come to the ambulance entrance door versus the main entrance to the front of the building. For the record, Staff G confirmed that the ambulance entrance door is the door which Surveyor B noted Staff G and Staff H to enter the facility. The ambulance entrance door was not equipped with screening materials. Staff G further expressed that the administrator stated that the transportation team was to come directly the ambulance door for entrance versus entering through the front door and screening at the kiosk. Staff G and Staff H proceeded to the East Wing's nursing station. From the East Wing's nursing station Staff G and Staff H proceeded to the West Wing (COVID-19 Unit). On 5/19/22 at approximately 10:00 a.m. an interview was conducted with the Assistant Administrator. The Assistant administrator declined to confirm or deny that the transportation staff were directed to enter directly into the facility through the ambulance door without being screened. The Assistant Administrator deferred to the Administrator. On 5/19/22 at approximately 12:45 p.m. in an interview with Administrator, the Administrator denied having given a directive to circumvent screening at the front door via the kiosk to gain entry to the facility. On 5/20/22 upon review of COVID-19 Screening Kiosk data for staff who entered the building via the front door, Staff G and Staff H were not present on the list.

Based on observation, staff interview, clinical record review, and facility document review, the facility staff failed to notify the physician that medications were not available for administration for four of 30 residents, Resident #303, Resident #304, Resident #306, and Resident #307. Findings were: 1. Resident #303 was recently admitted to the facility with the following diagnoses, including but not limited to: Hypertension, heart failure, [CONDITION(S)], and anxiety. A full MDS (minimum data set) had not been completed at the time of the survey, but an admission nursing assessment from 04/15/2022, described Resident #303 as oriented to person, place, and time. The clinical record was reviewed on 04/26/2022 at approximately 2:00 p.m. The MAR (medication administration record) for April 2022 documented that Resident #303 did not receive the following medications as ordered by the physician: Sertaline 50 mg at 9:00 p.m. on 04/17/2022. [MEDICATION(S)] 100 mg at 9:00 a.m. on 04/17/2022 and 04/18/2022, and at 5:00 p.m. on 04/17/2022. The medications were coded on the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Documentation from the EMAR (Electronic medication administration record) indicated the medications were on order. There was no documentation in the clinical record of physician notification that the medications were not available for administration. 2. Resident #304 was admitted to the facility with the following diagnoses, including but not limited to: diabetes mellitus, [CONDITION(S)], [CONDITION(S)], and anxiety. A full MDS (minimum data set) had not been completed at the time of the survey, but an admission nursing assessment from 04/15/2022, described Resident #304 as oriented to person, place, time, and situation. On 04/26/2022 at approximately 11:45 a.m., Resident #304 and her son were interviewed about life at the facility and her care. The son stated, I don't think she or her roommate are getting their medicines right .I heard one of nurses telling her (pointing to roommate) that they didn't have her medicine here to give . Resident #304's clinical record was reviewed at approximately 12:30 p.m. The MAR (medication administration record) for April 2022, documented that Resident #304 did not receive the following medication as ordered by the physician: [MEDICATION(S)] 50 mcg at 6:00 a.m. on 04/17/2022 and 04/18/2022. The medications were coded on the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . The EMAR documented Awaiting medication from the pharmacy. There was no documentation in the clinical record that the medications were not available for administration. 3. Resident #306 was admitted to the facility with the following diagnoses, including but not limited to: heart failure, respiratory failure, stage III sacral pressure ulcer, and adult failure to thrive. A full MDS (minimum data set) had not been completed at the time of the survey, but an admission nursing assessment from 04/13/2022, described Resident #306 as oriented to person, place, and time. Review of the clinical record was conducted on 04/27/2022 at approximately 9:30 a.m. The MAR (medication administration record) for April 2022 documented that Resident #306 did not receive the following medication per physician orders: [MEDICATION(S)] 400 mg at 9:00 a.m. on 04/17/2022 and 04/18/2022, and at 2:00 p.m. on 04/17/2022 and 04/18/2022. The medications were coded on the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Documentation from the EMAR (Electronic medication administration record) indicated the medications were on order or not available. There was no documentation in the clinical record that the medications were not available for administration. 4. Resident #307 was admitted to the facility with the following diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A full MDS (minimum data set) had not been completed at the time of the survey, but an admission nursing assessment from 04/20/2022, described Resident #303 as oriented to person, place, and time. The clinical record was reviewed on 04/27/2022 at approximately 11:30 a.m The MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] [MEDICATION(S)] 40 mg QD (every day) on 04/23/2022, 04/24/2022 or 04/26/2022. [MEDICATION(S)] 100 mg HS (hour of sleep) not given from 04/20/2022 through 04/26/2022; a total of seven missed doses. Clopidrogel 75 mg QD (once a day) on 04/21/2022 and 04/22/2022. Nicotine patch QD not applied from 04/20/2022 through 04/27/2022; a total of 8 missed doses. [MEDICATION(S)] 10 mg QD on 04/21/2022 and 04/22/2022. [MEDICATION(S)] 2.5 mg twice a day not given 04/20/2022 through 04/26/2022; a total of 13 missed doses. The EMAR notes contained information that the above medications were not available, on order, awaiting order from pharmacy. There was no documentation in the clinical record that the medications were not available for administration. The above information for all four residents was discussed during an end of the day meeting on 04/27/2022 at approximately 5:15 p.m. with the DON (director of nursing), the administrator, the corporate nurse consultant, and the ADON (assistant director of nursing). The administrator stated that they had identified a problem with medications being unavailable and had been working on it over the last quarter. They were asked if the physician should be notified when medications are not available for administration. The corporate nurse consultant stated, Yes. The policy for Medication Unavailability contained the following: If medications are determined to be unavailable for administration, licensed nurse will notify the provider of unavailability will document notification to the provider .in the medical record will notify the provider .and request an alternate treatment if possible. If alternate treatment is not available, then licensed nurse will activate backup pharmacy process and procedures . On 04/28/2022 at 8:30 a.m., the administrator presented an inservice/education record. She stated, We started inservicing the nurses last night about what to do when medications aren't available. The objectives listed on the inservice record included but were not limited to: Notifying the provider to obtain a hold order or alternate treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] No further information was obtained prior to the exit conference on 04/28/2022.

Based on resident interview, staff interview, clinical record review, and facility document review, the facility failed to develop a baseline care plan and provide a summary of the care plan to the resident responsible party for four of 30 resident's, Resident's #202, #207, #349, and #249. The findings Include: 1. Resident #202 was admitted with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The most current MDS (minimum data set) was an entry assessment with an ARD (assessment reference date) of 4/21/22. Resident #202's cognitive score had not been assessed at time of survey. On 4/27/22 Resident #202's medical record was reviewed and evidenced a baseline care plan was created for Falls on 4/23/22, but no additional care areas. On 04/27/22 at 11:20 a.m. the director of nursing (DON) was asked about the he components that make up a baseline care plan. The nurse consultant who was also present, looked at Resident #202's care plan and stated the baseline care plan should be made up of any services and treatments for a resident's immediate care and agreed that the care plan was not complete. On 04/27/22 at 6:11 p.m. during a meeting with the administrator, DON, and nurse consultant, the above information was presented. When asked about the timeliness of a baseline care plan the nurse consultant said it should be completed within 48 hours of admission. On 04/28/22 at 9:00 a.m. the administrator stated an audit of baseline care plans had been reviewed and indicated that the facility is in the process of completing all baseline care plans. No other information was presented prior to exit conference on 4/28/22. 2. Resident #207 was admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The most current MDS (minimum data set) was an entry assessment with an ARD (assessment reference date) of 4/18/22. Resident #207's cognitive score had not been assessed at time of survey. On 4/27/22 Resident #207's medical record was reviewed evidenced a baseline care plan was created for Nutrition Risk on 4/20/22, with the rest of the baseline care plan created on 4/26/22 (eight days after admission). On 04/27/22 at 2:20 p.m. the administrator was asked where documentation of a baseline care plan would be found in the medical record for a newly admitted resident. The administrator stated all care plans were completely electronic and said the facility does not do a paper form of a baseline care plan. On 04/27/22 at 6:11 p.m. during a meeting with the administrator, DON, and nurse consultant, the above information was presented. When asked about the timeliness of a baseline care plan the nurse consultant said it should be completed within 48 hours of admission. On 04/28/22 at 9:00 a.m. the administrator stated an audit of baseline care plans had been reviewed and indicated that the facility is in the process of completing all baseline care plans. No other information was presented prior to exit conference on 4/28/22. 3. Resident # 249 was admitted to the facility after a ground level fall in the community. The admission MDS (minimum data set) assessment dated [DATE] had Resident # 249 as cognitively intact with a score of 15 out of 15. On 4/26/22 at approximately 3:30 p.m. clinical record review evidenced that Resident # 249's baseline care plan was not completed until 3 days after admission. On 4/27/22 at 10:34 a.m. the discharge planner, identified as other staff (OS) # 1 was interviewed about the care plan. She stated she did the initial care plans, but the care plan was not done within the 48 hour timeframe, and residents were not given a handwritten or computerized copy of the baseline care plan. OS # 1 stated the care plan is done electronically, not hand written, but again, no copy given to the residents. The administrator, DON (director of nursing), ADON (assistant director of nursing, nurse consultant, and vice president of clinical operations were informed of the above findings during a meeting with facility staff 4/28/22 beginning at 10:55 a.m. No further information was provided prior to the exit conference. 4. Resident #349 was admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The most recent minimum data set (MDS) dated [DATE] was the 5-day admission assessment and assessed Resident #349 as severely impaired for daily decision making with a score of 4 out of 15. Resident #349 was interviewed on 04/27/2022 at 8:30 a.m. regarding quality of life and care stay since being admitted to the facility. Resident #349 was asked if she had received a copy of her baseline care plan. Resident #349 stated, I don't know about that. My daughter takes care of all the paperwork. Resident #349's electronic care plans were reviewed. According to the electronic care plan tab the care plans were created on 04/19/2022. On 04/27/2022 at 9:45 a.m., the facility's director of nursing (DON) was asked where the baseline care plans were located. The DON stated all care plans were completed electronically and were located under the care plan tab in the electronic record. The DON was asked if the facility reviewed the baseline care with the resident and/or responsible party and provided them a summary. The DON stated the discharge planner was responsible for this task and would have additional information. On 04/27/2022 at 10:34 a.m., the discharge planner (OS #1) was interviewed regarding the baseline care plans. OS #1 stated the resident and/or the responsible party were not provided a copy of the baseline care plans. OS #1 stated, I've been working by myself for awhile and just got an assistant; so no that hasn't been done. On 04/27/2022 at 2:37 p.m., the DON was interviewed again about the baseline care plans. The DON was asked if the baseline care plans were handwritten and stored somewhere other than the electronic record. The DON stated, The facility is totally electronic and the care plans in the electronic record are all we have. We don't handwrite any care plans. The DON was advised Resident #349's baseline care plan was not created until four days after admission. The DON was advised the baseline careplans should be completed within 48 hours of admission. The DON stated again, Our baseline care plans are in the computer, we don't have anything else. The above findings were reviewed with the administrator, DON, ADON, and corporate nurse consultant during a meeting on 04/27/2022 at 5:16 p.m. The corporate nurse consultant stated the expectation was for the baseline care plan to be completed within 48 hours of admission and to include provision of care needs. A review of the facility's Care Planning policy (11/01/2019) documented the following: 1. The computerized baseline Care Plan is initiated and activated within 48 hours. 2. The Center will provide the patient and the representative(s) with a summary of the baseline care plan that includes, but is not limited to: the initial goals of the patient, a summary of the patient's medications list, the patient's dietary instructions; any services and treatments to be administered by the Center and personnel acting on the behalf of the Center; and any updated information based on the details of the comprehensive care plan .

Based on a medication pass and pour observation, staff interview, clinical record review, and facility document review, the facility staff failed to follow professional standards of practice for one of 30 residents in the survey sample, Resident # 210. Resident # 210 was administered the incorrect dose of a medication. Findings include: Resident # 210 was admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The most recent MDS (minimum data set) was the admission assessment dated [DATE]. Resident # 210 was coded with moderate impairment in cognition with a score of 12 out of 15. A medication pass and pour observation was conducted on 4/27/22 beginning at 8:00 a.m. with LPN (licensed practical nurse) # 1. LPN # 1 was observed administering a heart medication, Carvidilol 3.125 mg to Resident # 210. On 4/27/22 at approximately 9:30 a.m. the medications were reconciled with the physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . One order with a start date of 4/7/22, directed Carvidilol 3.125 mg Give one tablet twice per day. That order included a discontinuation date of 4/9/22. The second order, dated 4/9/22, had the medication changed to 6.25 mg twice a day. On 4/27/22 at approximately 9:50 a.m. LPN # 1 was interviewed about the dose given, and asked if she would pull the medication card. LPN # 1 pulled the medication cards. There were three cards rubberbanded together; 2 cards of Carvidilol 3.125, and 1 card of 6.25. The card of the 6.25 dosage had 2 pills missing. The cards with 3.125 dosage had multiple pills missing. LPN # 1 then pulled up Resident # 210's MAR (medication administration record) and stated, Yes, I did give 1 of the 3.125; that's my mistake .they were all 3 rubber-banded together, and I gave the first one in the stack. Looks like the order changed on 4/9/22 . On the MAR, the 3.125 mg was discontinued on 4/9/22, and the new order for 6.25 mg was included. Staff documented the medication was picked up on the 10th, but there was only two of the 6.25 mg pills missing. LPN # 1 stated I think he must have been given the 3.125 . On 4/27/22 at approximately 10:15 a.m. the administrator was asked for the facility policy for discontinuation of medications. The policy, Discontinued Medications included: Procedures: 1. The nurse documents the order to discontinue the medication in the resident's record. The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Medications are removed from the medication cart or active supply immediately upon receipt of an order to discontinue (to avoid inadvertent administration. The administrator was informed of the findings 4/27/22 at approximately 10:15 a.m. when the policy was requested. No further information was provided prior to the exit conference.

Based on observation, staff interview, clinical record review, and facility document review, the facility staff failed to follow physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility also failed to do an admission skin assessment and provide treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . Findings were: 1. Resident #303 was recently admitted to the facility with the following diagnoses, including but not limited to: Hypertension, heart failure, [CONDITION(S)], and anxiety. A full MDS (minimum data set) had not been completed at the time of the survey, but an admission nursing assessment from 04/15/2022, described Resident #303 as oriented to person, place, and time. The clinical record was reviewed on 04/26/2022 at approximately 2:00 p.m. The MAR (medication administration record) for April 2022, was reviewed. Resident #303 did not receive the following medications as ordered by the physician: * Sertaline 50 mg at 9:00 p.m. on 04/17/2022 * Gabapenting 100 mg at 9:00 a.m. on 04/17/2022 and 04/18/2022, 5:00 p.m. on 04/17/2022 The medications were coded on the MAR with the numbers 9- Other see progress notes or 15-no coverage required. The progress notes section was reviewed, the documentation from the EMAR (Electronic medication administration record) provided information that the medications were on order. 2. Resident #304 was admitted to the facility with the following diagnoses, including but not limited to: diabetes mellitus, [CONDITION(S)], [CONDITION(S)], and anxiety. A full MDS (minimum data set) had not been completed at the time of the survey, but an admission nursing assessment from 04/15/2022, described Resident #304 as oriented to person, place, time, and situation. On 04/26/2022 at approximately 11:45 a.m., Resident #304 and her son were interviewed about life at the facility and her care. The son stated, I don't think she or her roommate are getting their medicines right .I heard one of nurses telling her (pointing to roommate) that they didn't have her medicine here to give . Resident #304's clinical record was reviewed at approximately 12:30 p.m. The MAR (medication administration record) for April 2022, was reviewed. Resident #304 did not receive the following medication as ordered by the physician: * [MEDICATION(S)] 50 mcg at 6:00 a.m. on 04/17/2022 and 04/18/2022 The medications were coded on the MAR with the numbers 9- Other see progress notes The progress notes section was reviewed, the documentation from the EMAR was Awaiting medication from the pharmacy. 3. Resident #306 was admitted to the facility with the following diagnoses, including but not limited to: heart failure, respiratory failure, stage III sacral pressure ulcer, and adult failure to thrive. A full MDS (minimum data set) had not been completed at the time of the survey, but an admission nursing assessment from 04/13/2022, described Resident #306 as oriented to person, place, and time. Review of the clinical record was conducted on 04/27/2022 at approximately 9:30 a.m. The MAR (medication administration record) for April 2022 was reviewed. Resident #306 did not receive the following medication per physician orders: * [MEDICATION(S)] 400 mg at 9:00 a.m. on 04/17/2022 and 04/18/2022, or at 2:00 p.m. on 04/17/2022 and 04/18/2022. The medications were coded on the MAR with the numbers 9- Other see progress notes or 15-no coverage required. The progress notes section was reviewed, the documentation from the EMAR provided information that the medications were on order or not available. 4. Resident #307 was admitted to the facility with the following diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A full MDS (minimum data set) had not been completed at the time of the survey, but an admission nursing assessment from 04/20/2022, described Resident #303 as oriented to person, place, and time. The clinical record was reviewed on 04/27/2022 at approximately 11:30 a.m., the MAR was reviewed. The following medications were not given per physician orders: * [MEDICATION(S)] 40 mg QD (every day) not given 04/23/2022, 04/24/2022 or 04/26/2022 * [MEDICATION(S)] 100 mg HS (hour of sleep) not given from 04/20/2022 through 04/26/2022, total of seven missed doses. * Clopidrogel 75 mg QD not given 04/21/2022 or 04/22/2022 * Nicotine patch QD not applied from 04/20/2022 through 04/27/2022, total of 8 missed doses. * [MEDICATION(S)] 10 mg QD not given 04/21/2022 or 04/22/2022 * [MEDICATION(S)] 2.5 mg twice a day- not given 04/20/2022 - 04/26/2022- total of 13 missed doses. The EMAR notes contained information that the above medications were not available, on order, awaiting order from pharmacy. At approximately 12;30 p.m., the corporate nurse consultant and the DON were asked if they could ascertain why Resident #307 was not receiving his [MEDICATION(S)] at night or his [MEDICATION(S)]. At approximately 4:45 p.m., the medication cart containing Resident #307's medication was observed with RN (registered nurse) #3. The following medications ordered for Resident #307 were not on the medication cart: * [MEDICATION(S)] * [MEDICATION(S)] * Nicotine patch * [MEDICATION(S)] RN #3 looked at Resident #307's medication list and stated, The nicotine patch is stock, I don't know why he hasn't been getting that it looks like his meds were ordered on 04/20/2022 .I don't know why they aren't here it looks like he got his [MEDICATION(S)] earlier today but it isn't in the narc box. LPN (licensed practical nurse) # at the nurse's station and had given medications to Resident #307 earlier in the day. She stated, That is kept in the refrigerator. She went to the refrigerator and returned with a medication card for [MEDICATION(S)]. One pill was missing from the card. She stated, I gave the one that's missing earlier today. She was asked when the medication had been delivered to the facility. She looked at the label and stated, It looks like it was dispensed on 04/22/2022. She and RN #4 were asked why if the medication was in house it had not been given as ordered. LPN #4 stated I don't know, maybe they didn't know to look in the refrigerator. The above four resident information was discussed during an end of the day meeting on 04/27/2022 at approximately 5:15 p.m. with the DON (director of nursing), the administrator, the corporate nurse consultant, and the ADON (assistant director of nursing). The administrator stated that they had identified a problem with medications being unavailable and had been working on it over the last quarter. The DON stated that a report was run every morning regarding medication availability, it was discussed in morning meetings and the unit manager followed up by checking the medication carts. She was asked how medications were obtained at the time of admission. She stated, Once we know we are getting an admission the pharmacy is notified. Once the resident arrives, the medications are verified with the physician and then the pharmacy fills the prescriptions and delivers them here. The administrator stated, If the medication isn't here the nurses can go to the (name of machine) and get what they need .we are working to make sure there is a wide variety of medications available for them to choose from as needed. The corporate nurse consultant stated, We called the pharmacy .when the medications were ordered on 04/22/2022, the pharmacy was told to deliver all medication except the house stock meds. The person at the pharmacy abbreviated house stock as HS .this was miscommunicated as HS- hour of sleep and the evening medications were not delivered. That's why the [MEDICATION(S)] isn't here. The policy for Medication Unavailability was obtained and contained the following: If medications are determined to be unavailable for administration, licensed nurse will notify the provider of unavailability will document notification to the provider .in the medical record will notify the provider .and request an alternate treatment if possible. If alternate treatment is not available, then licensed nurse will activate backup pharmacy process and procedures . On 04/28/2022 at 8:30 a.m., the administrator presented an inservice/education record. She stated, We started inservicing the nurses last night about what to do when medications aren't available. The objectives listed on the inservice record were: .steps for obtaining unavailable medication for patients. The purpose of the (name of machine) to deliver patient's medications. Notifying the supervisor of medication being unavailable. Notifying the provider to obtain a hold order or alternate treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] .there is never a time that someone in house doesn't have access we are moving to a 100% MAR and TAR audit to get this resolved. No further information was obtained prior to the exit conference on 04/28/2022. 5. Failed to complete an admission skin audit and provide treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . The Findings Include: diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The most current MDS (minimum data set) was a 5 day assessment with an ARD (assessment reference date) of 4/18/22. Resident #210's was assessed with [MEDICAL RECORD OR PHYSICIAN ORDER] . On 04/26/22 at 1:07 PM during an interview, Resident #210 verbalized that the facility has not been taking care of the wounds on his left foot, is having pain at times and can make it difficult to do physical therapy. Observation of Resident #210's wounds evidenced dark nacrotic/scabbed tissue from the great toe to the ball of the foot approximately 3 inches long by 1 inch width and also a dime size nacrotic/scabbed area to the heal of the foot. When asked how long has he had the wounds, Resident #210 verbalized the wounds have been there for a long time before coming to the facility and said he had peripheral arterial disease which resulted in a right leg amputation. Review of Resident #210'S medical record documented admission on 4/7/22 a skin observation audit was completed on 4/8/22 and did not indicated Resident #210 had any wounds. review of the physicians admission assessment also did not indicate Resident #210 had any skin wounds. And a hospital discharge summary dated 4/7/22 did not indicate any wounds. Review of the facilities contracted wound agencies skin assessment dated [DATE] documented Resident #210's foot wounds were present on admission indicating a wound to the left medial foot was 8.05 centimeters (cm) in length and 2.85 cm in with and without depth and also a wound to the left heel 2.23 cm in length 2.74 cm wide and without depth. Resident #210's physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . On 04/27/22 at 9:57 AM the facilities nurse consultant was interviewed regarding responsibility for skin audits. The nurse consultant verbalized the admitting nurses should be doing a head to toe body audit and documenting their findings a contracting agency also comes in and does an assessment on new admissions weekly. The nurse consultant reviewed the admission skin audit for Resident #210 and verbalized that the form wasn't completed. On 04/27/22 at 10:23 AM the wound care agencies nurse practitioner (other staff, OS #3) was interviewed. When asked about Resident #210's wounds being present on admission versus acquired in house, OS #3 said Resident #201 came from another facility were OS #3 was taking care of the wounds in that facility. OS #3 then pulled out her cell phone and provided pictures, assessments and dates of Resident #210's foot wounds prior to the admission to the facility. On 04/27/22 at 6:11 PM the above information was presented to the administrator, director of nurses, and nurse consultant. The administrator verbalized in regards to skin assessments, when a new admission comes in the nurses are supposed to do an initial skin assessment, the resident is also put on a list to be seen when the agency wound clinic comes in. If wounds are present the agency will put them on a list to be seen weekly and weekly skin assessments are done by the agency. If wounds are not present then the nursing staff will do a weekly assessment. On 04/28/22 at 8:39 AM OS #2 (facilities nurse practitioner) was interviewed. OS #2 said when a new admission comes into the facility they are seen by the physician within 72 hours and a physical assessment is performed based on diagnoses, history, hospital discharge summary and admission assessments and what the resident is saying. When asked about Resident #210's foot wounds, OS #2 verbalized review of the hospital discharge summary did not indicate any wounds and the nurses body audit did not indicate any wounds. OS #2 said if Resident #210 had verbalized a problem with wounds it would have certainly been looked at and treatment would have been started, but the physician was unaware of any concerns to the foot. No other information was provided prior to exit conference on 4/28/22.

Based on clinical record review, staff interview, and facility document review, the facility staff failed to develop a comprehensive care plan (CCP) for 1 of 30 residents in the survey sample, Resident #5. Resident #5's CCP did not include a focus area with goals and interventions for the use of anticoagulants. The findings include: Resident #5 was admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The most recent minimum data set (MDS) dated [DATE] was a quarterly assessment and assessed Resident #5 as moderately impaired for daily decision making with a score of 10 out of 15. Under Section N - Medications, the MDS documented Resident #5 received anticoagulants. Resident #5's clinical record was reviewed on 04/27/2022. Observed on the order summary report was the following order: [MEDICATION(S)] ([MEDICATION(S)]) Tablet 5mg. Give 1 tablet by mouth every 12 hours for pe (pulmonary embolism). Order Date: 05/15/2021. Start Date: 05/19/2021. Resident #5's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #5's CCP was reviewed and did not include a focus area with goals and interventions for the use of the anticoagulant medication, [MEDICATION(S)] ([MEDICATION(S)]). On 04/27/2022 at 3:30 p.m. the MDS coordinator, registered nurse (RN) #2 was interviewed regarding Resident #5's CCP. RN #2 reviewed Resident #5's electronic health record and stated a care plan should have been developed for the use of the anticoagulant medication. The above findings were reviewed with the administrator, DON, ADON, and corporate nurse consultant during a meeting on 04/27/2022 at 5:16 p.m. A review of the facility's Care Planning policy (11/01/2019) documented the following: 6. Computerized care plans will be updated by each discipline on an ongoing basis as changes in the patient occur, and reviewed quarterly with the quarterly assessment

Based on resident interview, staff interview, clinical record review, and facility document review, the facility staff failed to review and revise a comprehensive care plan (CCP) for 1 of 30 in the survey sample, Resident #15. Resident #15's CCP was not reviewed and revised for the discontinuation of enteral feedings (tube feedings). The findings include: Resident #15 was admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The most recent minimum data set (MDS) dated [DATE] was a quarterly assessment and assessed Resident #15 as cognitively intact for daily decision making with a score of 15 out of 15. Resident #15 was interviewed on 04/26/2022 at 4:30 p.m regarding her quality of care and quality of life at the facility. Resident #15 stated, I'm doing do better now that the tube feeding has been stopped and removed this month. I'm just glad I can eat 100% by mouth now. Resident #15's clinical record was reviewed on 04/26/2022. The clinical record documented the tube feeding was removed by the nurse practitioner on 04/01/2022. A review of Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #15's CCP was reviewed. Observed was the following focus area including goals and interventions: The resident requires tube feeding r/t (related to) Dysphasia. Created/Revision on 07/02/2020 . On 04/27/2022 at 3:30 p.m. the MDS coordinator (RN #2) was interviewed regarding Resident #15's CCP. RN #2 reviewed Resident #15's clinical record and stated, I know she was eating and receiving her medications PO (by mouth). The care plan should have been updated when the tube feeding was removed. The above findings were reviewed with the administrator, DON, ADON, and corporate nurse consultant during a meeting on 04/27/2022 at 5:16 p.m. A review of the facility's Care Planning policy (11/01/2019) documented the following: 6. Computerized care plans will be updated by each discipline on an ongoing basis as changes in the patient occur, and reviewed quarterly with the quarterly assessment

Based on observation, staff interview, and resident interview, the facility staff failed to ensure a dressing was in place for a Stage III pressure ulcer for one of 30 residents, Resident #306. Findings were: Resident #306 was admitted to the facility with the following diagnoses, including but not limited to: heart failure, respiratory failure, stage III sacral pressure ulcer, and adult failure to thrive. A full MDS (minimum data set) had not been completed at the time of the survey, but an admission nursing assessment from 04/13/2022, described Resident #306 as oriented to person, place, and time. On 04/26/2022 at approximately 3:45 p.m., Resident #306 was interviewed about life at the facility and her care. She stated, Things aren't going so well today. She was asked to explain. Resident #306 stated she had a wound on her backside. The dressing had come off earlier in the day due to two episodes of diarrhea. She stated that when she had been cleaned up from that, her patch had come off because it was dirty. She stated therapy had been in and because she told them the wound was open they didn't get her up in her wheelchair for therapy. She stated she had her therapy in the bed. She was asked how she normally had therapy. She stated, They usually get me up in the wheelchair and we do it in here, but they didn't want to get me up since that patch is off. She was asked if the nurses were aware that her wound was not covered, She stated, I don't know, I don't feel like that's my responsibility to tell them but I also don't want it to get infected because the patch isn't over it. The staff at the nurse's station were asked who was providing care to Resident #306. LPN (licensed practical nurse) #4 stated she was taking care of Resident #306. She was asked if she was aware that Resident #306's wound did not have a dressing in place. She stated, No, I'm not doing wound care. (Name of LPN #5) is doing that today. LPN #5 was came to the nurse's station and she was asked if she was aware that Resident #306 did not have a dressing in place over her sacral wound. She stated, No, I didn't know that. I have been up the hall in another room. I'll do it now. She went to the computer and looked at the physician orders. She stated, That's normally done at night .I would have gone down there if I had known. She gathered her supplies and stated, There's a lack of communication around here. LPN #5 went to Resident #306's room. The dressing change was done per the physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . She stated, I've never seen it before. The wound was observed on Resident #306's sacrum, it was clean, without drainage, and LPN #5 described it as a Stage III. Resident #306 stated, I got that place from laying in pee and poop, I want it to get better .I'm sure they told my nurse it was off I know the therapist did. At 4:05 p.m., Other staff #3 was interviewed. She stated, that she had been in Resident #306's room to provide therapy before lunch. She did not get Resident #306 up to her wheelchair since the resident had reported that her dressing was off of her wound. She stated that when she finished the session she told Resident #306's nurse that the dressing was off. She was asked who she told. She pointed down the hall and identified LPN #4. LPN #4 was interviewed and asked if the therapist had told her Resident #306's wound was not covered. She stated, I don't know, maybe I already told you I'm not doing wound care today (Name of LPN #5) is doing it .I figured she would get to it. The above information was discussed during an end of the day meeting on 04/27/2022 at approximately 5:15 p.m. with the DON (director of nursing), the administrator, the corporate nurse consultant, and the ADON (assistant director of nursing). On 04/28/2022 at approximately 10:30 a.m. Resident #306 was sitting in bed. She stated, I wasn't trying to get anybody in trouble the other day about that patch being off .but I'll tell you it is off again today it came off while (Name of certified nursing assistant (CNA) #1) was cleaning me up earlier. CNA #1 was interviewed at approximately 10:40 a.m. She was asked if she had told the nurse that Resident #306's dressing was off of her wound. She stated, No, I forgot, I'll tell her now. The above information was discussed with the corporate nurse consultant at approximately 10:55 a.m. She agreed that the nurses should be informed when the dressing was off a wound so it could be replaced as soon as possible. No further information was obtained prior to the exit conference on 04/28/2022.

Based on staff interview, facility documentation review and clinical record review the facility staff failed to honor one Resident's desires on an Advance directive for one Resident (Resident 4) in a survey sample of 7 Residents. The findings include: For Resident # 4, the facility staff failed to verify and honor the signed Advance Directive and Do not Resuscitate paperwork documented in the clinical record. Because the nurse did not see proper documentation of a DNR, the order was changed to a Full Code. Resident # 4 was admitted to the facility on [DATE], and expired on [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #4's most recent MDS (minimum data set) (an assessment tool) with an ARD (assessment reference date) of [DATE], was coded as an Admission assessment. Resident # 4 was coded as having a BIMS (brief interview for mental status) score of 15 out of a possible 15, indicating no cognitive impairment. Resident # 4 was also coded as requiring extensive assistance of one staff person for Activities of Daily Living (ADLs) to include dressing, bed mobility, toileting and personal hygiene. For eating, Resident # 4 was coded as requiring supervision and assistance of one staff person. Review of the closed clinical record was conducted on 4/ ,d+[DATE] and [DATE]. Review of the Facesheet revealed that Resident # 4 was her own responsible party and had FULL CODE listed for code status. Review of the valid active Physicians Orders revealed an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review of the orders revealed the Full Code order was written by a nurse and signed by the Physician on [DATE]. Review of the Nurses Progress Notes revealed the following documentation: [DATE] 16:46 [4;46 PM] Change of Condition Note Text: ADDENENDUM- TIME CORRECTION: SEE NOTE WRITTEN ON [DATE] 0050: At time time, 0050, Resident is now expired. Events leading up to this event go as follows: This nurse was called into residents room by other House Supervisor, she stated the resident was not acting herself and was cold to touch. I asked the CNAs [Certified Nursing Assistants] to begin checking her VS [vital signs] while I was heading to the room. Upon entering the room, this nurse observed resident to be unresponsive to command and touch. Her VS at this time were BP [blood pressure] ,d+[DATE] P [pulse]54 SPO2 [saturation of oxygen] 63. I immediately retrieved a manual cuff and rechecked residents BP and obtained a reading of ,d+[DATE] with a manual pulse of 32. This was at 0045. I had the RN House Supervisor double check me and I placed a Pulse Ox on her Left Index Finger. A few moments later, her heart had stopped and her SPO2 went blank according to the Pulse Ox. The Rn House Supervisor and I both immediately begin to manually check the resident for any signs of life, both a radial and corroded (sic) pulse, regular or shallow breaths, but there was nothing. So, at 0046 I delegated to the CNAs to run and get the crash cart and at 0047 this nurse began CPR/BLS. Two mins (minutes) into compressions, the resident began to foam blood at the mouth. I asked a CNA that is CPR Certified the take over compressions for me so I could obtain the suction machine. At this time, the RN House Supervisor came back from calling 911, and her I both noticed that the resident had became completely and totally unresponsive and there was a significant amount of blood coming out of her mouth. The RN House Supervisor made the decision to call the Time of Death at 0050 and all form of life saving and sustaining measures were ceased. The resident was then cleaned up. At approx 0108 the ambulance arrived at the facility and declared (sic) the residents body expired. The MD/NP on call was notified at 0106, (Employee H's name redacted) ACNP. This nurse notified the residents RP and EC, both, but neither would give me a name of a funeral home they wanted the body to be sent to. They said they would let me know in the morning. Administration is aware. Other nurses notes stated: [DATE] 00:50 Change of Condition Note Text: At time time, 0050, Resident is now expired. Events leading up to this event go as follows: This nurse was called into residents room by other House Supervisor, she stated the resident was not acting herself and was cold to touch. I asked the CNAs to begin checking her VS while I was heading to the room. Upon entering the room, this nurse observed resident to be unresponsive to command and touch. Her VS at this time were BP ,d+[DATE] P 54 SPO2 63. I immediately retrieved a manual cuff and rechecked residents BP and obtained a reading of ,d+[DATE] with a manual pulse of 32. This was at 0145. I had the RN House Supervisor double check me and I placed a Pulse Ox on her Left Index Finger. A few moments later, her heart had stopped and her SPO2 went blank according to the Pulse Ox. The Rn House Supervisor and I both immediately (sic) begin to manually check the resident for any signs of life, both a radial and corroded pulse, regular or shallow breaths, but there was nothing. So, at 0146 I delegated to the CNAs to run and get the crash cart and at 0147 this nurse began CPR/BLS. Two mins into compressions, the resident began to foam blood at the mouth. I asked a CNA that is CPR Certified the take over compressions for me so I could obtain the suction machine. At this time, the RN House Supervisor came back from calling 911, and her I both noticed that the resident had became completely and totally unresponsive and there was a significant amount of blood coming out of her mouth. The RN House Supervisor made the decision to call the Time of Death at 0050 [12:50 AM] and all form of life saving and sustaining measures were ceased. The resident was then cleaned up. At approx 0108 [1:08 AM] the ambulance arrived at the facility and declared the residents body expired. The MD/NP on call was notified at 0106 [1:06 AM], [Nurse Practitioner name redacted ]ACNP. This nurse notified the residents RP and EC, both, but neither would give me a name of a funeral home they wanted the body to be sent to. They said they would let me know in the morning. Administration is aware. The Nurses Note written by (RN) Registered Nurse A read: [DATE] 00:20 Change of Condition Late Entry: Note Text: Upon entering patients room at 0017 [12:17 AM], this writer observed resident lying in bed with eyes open pupils dilated and fixed, skin cold & clammy touch, weak pulse, and breath sounds with rales and crackles. Resident was unresponsive to her name being called out and physical touch of sternum rub. At 0020 [12:20 AM], called out for CNA obtain a set of vitals and O2sats reading. In addition, this writer requested the LPN to assist she obtain oxygen concentrator for the patient. Vitals taken at 0024 [12:24 AM] showed BP,d+[DATE], P54, O2satss@63. Resident at that time was place on O2NC3l [oxygen via nasal cannula at 3 liters per min] Once resident was placed on oxygen this writer went to call 911 emergency services. While this writer speaking with emergency services at 0026. CPR had already been initiated on patient by LPN & CNA.CPR was allow to continue and maintain until patient start pouring out blood from oral cavity with each chest compression. On account of the excessive amount of blood and lungs fluid build up this writer requested heroic measure to stop and call the time of death as of 0050, [DATE]. EMS arrived at this time same 0050. LPN made on call physician aware of patient death and residents family made aware as well. This above note was documented as written on [DATE]- one week after Resident # 4 expired. Further review of the Nurses Progress Notes revealed the following documentation: Licensed Practical Nurse C documented ------- [DATE] 00:40 Skilled Note Note Text: resident is on skilled services for admitting dx.(diagnosis) of acute resp. failure and secondary dxs of [CONDITION(S)] and [CONDITION(S)]. code status DNR. A&O x 4 (Alert and oriented times four) and able to make needs known. resident shows agitation to staff. resident takes medication whole in applesauce. resident is incontinent of bowel and bladder. resident is a 1 person assist with ADLs and transfers. resident is a left AKA(above the knee amputation). resident is on ongoing monitoring for s/s of covid- 19. enhanced precautions, PPE (personal protective equipment) and handwashing maintained per CDC (Center for Disease Control) regulations. no c/o (complaints of ) pain or discomfort. No noted signs of distress or SOB. resident is in bed with call bell in reach. will continue to monitor. [DATE] 22:44 Skilled Note Note Text: Patient under skilled nursing for acute resp. failure with PMH of [CONDITION(S)], [CONDITION(S)], [CONDITION(S)], DM2, and right above knee amputation. Alert and oriented x3. Full code status. Patient remained in bed this shift. Refused most care provided today. Refused evening p.o. medications despite education , [name of Nurse Practitioner J redacted] DNP aware. Patient had trend of fevers so Rapid covid testing performed per NP, results came back negative [DATE] 17:49 LPN D wrote Patient under skilled nursing for acute resp. failure with PMH of [CONDITION(S)], [CONDITION(S)], [CONDITION(S)], DM2, and right above knee amputation. Alert and oriented x3. Full code status. Patient remained in bed this shift. Refused most care provided today. Refused evening p.o. medications despite education , [Nurse Practitioner, Employee J] DNP aware. Patient had trend of fevers so Rapid covid testing performed per NP, results came back negative. Followed up with Chest x-ray which patient complied with. New c/o diarrhea, sample collected per NP orders to check for c-diff ( awaiting results ). Noncompliant with full lung assessment, writer was able to auscultate lateral left and right aspect of lungs which present clear. [Nurse Practitioner-Employee J] aware. Enhanced precautions in place for monitoring s/s of covid 19. PPE and handwashing techniques practiced per CDC recommendations. Call light in reach. Staff will continue to monitor. Review of Admission History & Physical by the Medical Director dated [DATE] revealed the documentation of Code Status DNR. Review of the Care Plan revealed no documentation of Code Status or Advance Directives documented. Review of the Miscellaneous documents uploaded in the Electronic Record revealed a DNR signed and dated [DATE], uploaded in the record on [DATE]. (the form was from the hospital admission) Review of discontinued Physicians Orders revealed documentation of a discontinue order for DNR order on [DATE] with the explanation of No hard copy of DNR on file. The order was written on [DATE] and discontinued on [DATE]. There was an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Face Sheet had Full Code on front and was listed as Full Code during the survey. On [DATE] at 3:13 PM, an interview was conducted with the Director of Nursing and Regional Nurse Consultant. The Director of of Nursing stated she was hired in her role approximately 2 weeks ago and was unaware of the incident involving Resident # 4. The Regional Nurse consultant stated she was not aware of the incident when it first happened but was informed later. The Regional Consultant stated she instructed the previous Director of Nursing to investigate the allegations regarding the issues with Cardiopulmonary Resuscitation (CPR). The Regional Nurse stated she was not aware of the results of any investigation done. The Regional Nurse stated the expectation was that CPR should be continued until the paramedics arrived and took over. The Regional Nurse stated when she read the nurses notes written by RN (Registered Nurse) A, and those by Licensed Practical Nurse B, it was not clear of the exact time CPR was stopped, but that CPR should have been continued until the paramedics took over. The Regional Nurse Consultant stated she was going to look around the office to see if she could find any documentation of the investigation of what happened during the code. The Regional Nurse looked Electronic Clinical Record and at the Facesheet and stated Resident # 4 was a Full Code. She was a Full Code. When Surveyor D asked about the DNR form in the miscellaneous section of the electronic clinical record, the Regional Nurse Consultant looked at the record and stated she was going to have to look into it. When asked to review the signature and describe what was seen, the Regional Nurse Consultant stated there was a DNR form with Resident # 4's name printed on the top of it and signed on [DATE]. Surveyor D reiterated that the form was signed while Resident # 4 was in the hospital and asked if the facility staff reviewed the form with the Resident # 4 on admission to the facility. Further review of the DNR form revealed that the signature was a long last name, while Resident # 4 had fewer letters in the last name. The Regional Nurse Consultant stated she would check to see what documentation she could find. On [DATE] at 12:38 PM, an interview was conducted with the Regional Nurse Consultant, Director of Nursing, the Assistant Director of Nursing and the Administrator. The Regional Nurse Consultant stated she would submit a copy of a written statement from the Nurse Practitioner who was on call that night. The Regional Nurse Consultant stated the statement was being faxed over now and would be submitted right away. The telephone number for the Medical Director was requested and received from the Administrator. The Assistant Director of Nursing (ADON) stated that on Admission the nursing staff would discuss procedures,time for meals, preferences, and do include information about the code status. The ADON stated Initially she was a DNR. When asked when that code status changed, the ADON stated That ended up changing because we did not have the proper documentation to support her DNR code status. We did not have the official DNR for her. The ADON also stated Sometimes what will happen is that patient will go to the hospital and they will have that conversation there for code status, they may choose DNR. Instead of doing the official DNR, they will do a hospital DNR which does not transfer to the facility. When the receiving nurse looks at the discharge paperwork, it will say DNR but you don't have any paperwork on it. At that time, you would put the patient as a Full Code because you don't have the paperwork. But then that's when you would have the conversations with the Responsible Party and the Physician about what the patient's code status is going to be. On [DATE] at 1:02 PM, and interview was conducted with the Administrator who stated that he was alerted to the situation the next morning. The Administrator stated he was told that the staff thought the patient was a Full Code and the patient was a DNR. They did not get the information corrected and uploaded and was not corrected in the system. CPR should have never been started because the patient was a DNR. The Administrator also stated: Basically we did not dig far enough to find the appropriate paperwork to keep it as a DNR. That is exactly what happened on the audit. If they had looked back and found the information that originally came in and documented, then they would not have started CPR in the first place. The original document was scanned in on [DATE] and that's where the communication The Regional Nurse Consultant could be heard stating that's where the lack of communication happened. When asked if there should have been a conversation with the resident about her desires regarding her code status, the Administrator stated when that happens, the conversation is generally with nursing who should have asked if the DNR wishes are correct. Initially when she came in, it should have been asked by the nursing staff. Are you still a DNR, do you want those wishes granted. When the doctor visited the patient for the Progress Note, he should have elaborated more about the visit in the note. On [DATE] at 1:42 PM, an interview was conducted with the Medical Director who stated that the admission process was that he completes the admission assessments and usually documents what is written on the admission forms from the hospital. The Medical Director stated that if he does not see a Do Not Resuscitate Form on the computer, he would look to see what was written on the discharge papers and the order sheet entered by the nurses. The Medical Director stated it would be redundant to go through that again. The Medical Director stated he usually would do the admissions and the Nurse Practitioner follows the patients. He stated I usually do not address code status with Rehab patients. For the Long Term Care Patients we do address it. Most of the people who come there are Full Code unless there is a DNR order from the hospital. The Medical Director again stated: Usually we do not address code status with Rehab patients. For the Long Term Care Patients, we do address code status with the families. Rehab patients come for only one or two weeks and unless we see a reason to address it, we don't. The Medical Director stated he did not discuss code status with Resident # 4 during her stay at the facility. The Medical Director stated he was surprised to hear what happened with Resident # 4 because she had been there for about more than 10 days and it should have been straightened out by then. Surveyor D asked the Medical Director what he meant when he stated that he was aware of what happened with Resident # 4. The Medical Director stated he was informed that CPR was initiated and the nurse called the time of death prior to the EMS arrival at the facility. The Medical Director stated the Nurse Practitioner told the nurse that she should not have stopped CPR until the EMS arrived. The Medical Director stated the nurses later found that the resident was a DNR and should not have been coded (should not have administered CPR). The Medical Director stated the staff did not find the DNR paperwork until later. The Medical Director provided the telephone number for the Nurse Practitioner. On [DATE] at 3:08 PM, an interview was conducted with the Nurse Practitioner (Employee G) who stated Nurse Practitioner (Employee H) was on call for their practice on the night Resident # 4 expired. Employee G Stated Nurse Practitioner-Employee H called her the next morning, told her that the nursing staff had called her and telling her that they had started CPR on the resident, then they said they called 911 and they had stopped CPR. Employee G stated [Nurse Practitioner Employee H] stated they should verify the code status, at that time in our system it said FULL CODE, she said the nursing staff said to her 'Could you Hold please, EMS is coming in.' They told the nurse Practitioner that they would call her back. They hung up. They later called the Nurse Practitioner back stating that EMS was there and they shouldn't have stopped CPR. My coworker also has a statement about it and would have more details. Employee G also stated: My colleague told them that they should not have stopped CPR. The resident was actually found to be a DNR later. The hospital sent over the DNR and that is in our system. Regarding any discussion with the resident about the code status, when the nursing staff did that audit they did not see the paperwork so they labeled her a Full Code. When asked about any discussion of code status with Resident # 4, Employee G stated she did not see any evidence of a discussion either. Employee G stated The resident did come in. From my recollection, myself, the doctor and the other nurse practitioner, nobody had a conversation for the reversal of the DNR either. We should discuss code status. But, the woman had a abrupt, acute change. Prior to that, she had been relatively stable during her stay. Typically, code status is updated on admission. We proceed with the admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Typically when they come from the hospital, we go by the packet of paper work from the hospital. Regarding their code status, if we see in the packet of paperwork that the resident is DNR., the nursing staff is supposed to confirm that we have the paperwork through the DNR audit. If they come in as a Full Code, then we normally keep Full Code status unless per say something is happening with the resident , they have change in condition, a decline, myself ,or the doctor or the leadership step in we have a conversation or a care plan meeting to discuss that. I'm not sure if the resident had had an opportunity yet to have that care plan meeting That's typically the trend , we go with the code status from the hospital If they are a Full Code, they stay as a Full code, they proceed as a Full Code, If they are a DNR, they are supposed to ensure the paperwork is in place. Then as they progress through their stay, if there are changes we continue that conversation or have an updated care plan meeting. The Nurse Practitioner stated she wanted to clarify that When nursing staff puts in the orders, providers sign the orders, placed by the staff, So I presume the paperwork was just not here. The Nurse Practitioner stated she I saw for myself that the Discharge paperwork said DNR. I am assuming they did some type of audit and did not find the DNR paperwork and subsequently was updated to Full Code But at which point, they should have checked with her They should have checked On [DATE], a copy of the EMS report was provided by the facility's Administrator and Regional Nurse Consultant. Review of the EMS report supplied by the facility revealed documentation that the ambulance arrived at the facility on [DATE] at 01:05:58 AM-. According to the EMS report, the resident was in the room alone when the EMS arrived. There was no staff member in the room with the resident. The report listed DOA (Dead on Arrival) No resuscitation attempted Upon arrival, no staff was in the room. Pt was found laying bed Apneic and pulseless. Getting ready to start CPR. Staff finally came into the room saying We called it. When asked staff stated that they had done CPR for about 30 minutes. CPR was not performed by EMS due to the extent of time CPR being performed with no ROSC. Nurse also stated that Pt was a cull code and the on call Nurse Practitioner was ok with them calling it (stoping (sic) resuscitation efforts). While gathering more information from Nurse info there seemed to be some confusion. Nurse began to explain that they had found Pt laying in bed with some blood coming from her mouth. nurse discovered Pt heart rate to be 32 bpm (beats per minute) before becoming pulses (sic) so Nurse started CPR. Nurse/staff performed CPR for 3 min before calling Nurse Practitioner who advised to stop resuscitation efforts. On [DATE] during the end of day debriefing, the Administrator, Regional Nurse Consultant and Director of Nursing were asked to provide copies of the investigation of the death of Resident # 4, copies of CPR certifications of nursing staff and the copy of the Nurse Practitioner statement. On [DATE] at 9:00 AM, a copy of the on Call Nurse Practitioner's (Employee H)statement was received from the Regional Nurse Consultant. The Statement from Employee H contained two entries of documentation regarding conversations with facility staff (LPN B) regarding Resident # 4 which read: Statement of events on overnight call ,d+[DATE] page 0057 Called by nurse to notify of resident death. Nursing indicated that upon entry to residents room this evening, she was noted by staff to be unresponsive, pale and cool. Per their report, CPR was initiated but after several minutes was stopped during phone call EMS had arrived and was entering building. Call ended. Page 0121 by [redacted- Licensed Practical Nurse C's initials] Nurse called once again to discuss stopping CPR on the above resident that was supposed to have been unresponsive and likely already expired prior to CPR initiation. Discussed that CPR is to continued (on a patient that is Full Code) until EMS arrival and ED physician has communicated orders/plan. Review of the nurses notes revealed documentation from the Licensed Practical Nurse (LPN B) who stated she was instructed by the Registered Nurse Supervisor (RN A) to stop the code (CPR resuscitation efforts) . The Nurse Practitioner (Employee H) was not notified of the Resident's change in condition until after CPR was stopped. The documentation revealed Resident # 4 had a pulse rate of 32 beats per minute upon assessment- Review of RN A's documentation revealed she did instruct the LPN to stop CPR. The Nurse Practitioner statement revealed the facility staff failed to provide an accurate description of Resident # 4's change in condition, failed to continue the delivery of CPR and Code Status information. The Clinical Record had conflicting information about the Code Status that had not been verified by the facility staff prior to declaration of a Full Code status when the proper paperwork for DNR was not found in the clinical record. The Facesheet and physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . On all of the days of survey, the clinical record still had the code status listed as Full Code. The Regional Nurse Consultant stated the resident was a Full Code when she looked at the clinical record. After the surveyor questioned the DNR form found in the miscellaneous portion of the record, the Regional Consultant stated she would have to search for any records of investigation of the incident. The next day of survey, [DATE], the Regional Consultant stated she did not find any information in the files from the previous Director of Nursing. The Regional Consultant stated after reviewing the record, it was noted that Resident # 4 was a DNR (Do Not Resuscitate) and should not have had CPR performed. The Regional Consultant stated that during the routine audit after Resident # 4 was admitted , the facility staff did not find the appropriate DNR paperwork and changed the code status to Full Code as per policy. Review of the DNR policy revealed statements: CPR will not be initiated when there is a valid Do Not Resuscitate (DNR) located on the patient's permanent medical record. 3. If upon admission the patient provides advanced medical directive documents, such as a Durable Health Care Power of Attorney, or a Living Will that specifies the withholding of CPR, a license nurse must immediately notify the attending physician and secure a written DNR for the medical record. 4. A Virginia Department of Health Durable Do Not Resuscitate Form is a valid order. A licensed nurse verifies that the individual in question is the patient for whom the order is issued, and that the document if the original or a legible copy of the DDNR form, that it has not been altered, that the form has been filled out completely and that no signatures are missing. If the said DDNR form is not intact, or has been altered, or has not been filled out completely, it is not considered valid for withholding CPR. If there is any question about the validity of the DDNR Order form, resuscitative measures should be administered until the validity of the order is established. The Regional Consultant stated the facility staff should have confirmed the resident's desires prior to changing the status to Full Code. Once the appropriate DNR paperwork was located and uploaded in the system, the physician should have been notified, an order should have been obtained to change the code status back to DNR, face sheet should have been updated. A copy of the DNR list for [DATE] was requested but not received by the end of survey. On [DATE] at 9:15 AM, an interview was conducted with the Regional Nurse Consultant who stated the facility staff should have had a conversation with Resident # 4 to determine her desires about her Code Status and Advance Directives, Resident # 4 had a BIMS (brief interview for mental status) score of 15 out of a possible 15, indicating no cognitive impairment. She was capable of expressing her desires. She was her own responsible party. Review of the clinical record revealed no documentation of any facility staff member having a conversation with Resident # 4 about her Advance Directives or Code Status after admission to the facility. The documentation of the signed DNR in the clinical record was from the hospital from which she had been discharged on [DATE] and admitted into the facility on that same day. The findings were discussed with the Office of Licensure and Certification supervisor. During the end of day debriefing on [DATE], the facility Administrator, Director of Nursing, Assistant Director of Nursing and Regional Nurse Consultant were advised of the findings. The facility staff members started CPR based on the documentation of Full Code in the Physicians Orders and on the Face sheet. There was no definitive documentation of Resident # 4's desires when admitted to the facility. Also, the Code Status was changed from DNR to Full Code without any discussion with Resident # 4 when the appropriate DNR paperwork was not seen in the clinical record. No further information was provided. COMPLAINT DEFICIENCY

Based on observation, staff interview, clinical record review, and facility documentation review, the facility staff neglected to provide goods and services to prevent and promote the healing of pressure ulcers for one resident (Resident #5) in a survey sample of 46 Residents, resulting in harm for Resident #5. Immediate Jeopardy was identified on 8/6/19 at 6:17pm and the facility was notified. After verification, Immediate Jeopardy was abated on 8/7/19 at 6:55pm and the scope and severity was lowered to level three, isolated. The findings included; 1. For Resident #5, the facility staff neglected to provide treatments, including a working air mattress for pressure a pressure ulcer. The pressure ulcer worsened from a stage 2 ulcer to a stage 4 ulcer which was identified by surveyors while onsite, resulting in harm. Resident #5 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. and chronic Foley catheter. Resident #5's most recent Minimum Data Set (MDS) assessment was a quarterly assessment with an Assessment Reference Date (ARD) of 4-26-19. The Resident was coded with mild cognitive impairment, and no aberrant behaviors. Resident #5 required extensive assistance to total dependence on one to two staff members, for activities of daily living care. The Resident was coded as not having any pressure ulcers at the assessment time, nor on admission. The Resident had a long standing Foley catheter (urine drainage) due to an obstruction, and was incontinent of bowel. The Resident was coded as at risk for pressure sores. On 7-14-19, at 3:30 p.m., the first observation and interview of Resident #5 was conducted during initial tour of the facility. The Resident was found laying on a specialty mattress (Genesis II, a low air loss mattress), and the air motor was bogging down and humming, and not infusing air into the mattress. The mattress was flat, hard, and solid, with no air in it. The Resident was laying partially on his left side, and a Foley catheter was noted to be draining dark yellow urine with white sediment in it. The Resident was able to speak and make his needs known, and was found to be oriented to person, time, place and situation. The Resident stated he was thirsty and wanted water. There were 6 water Sippie non-spillable cups on the over-bed table which were all empty. The bedside table was 3 feet from the bed and the Resident could not reach it. Staff were notified. A second observation of Resident #5 was conducted on 7-15-19 at 4:30 p.m., and the Resident was sleeping in bed on his back. The over-bed table was found to be exactly as the last observation, and the bed was deflated with the motor still humming, but not infusing air. The air mattress was replaced on 7-16-19. A third observation occurred on 7-16-19 at 11:30 a.m., with Licensed practical nurse C (LPN C), and Certified nursing assistant N (CNA N). The nurse removed the bandage from the Resident's coccyx. The 4 inch by 4 inch single bandage had a solid center in it which was a tan [MEDICATION NAME] like non-adherent 2 inch by 2 inch square. The outer circumference of the square bandage was surrounded by a boarder of adherent malleable stretchy tape, reminiscent of Band-Aid fabric. There was no packing or medicated cream in the hollow wound. Immediately after removing the dressing a green purulent discharge was seen. The wound was circular, and deep with full muscle tissue loss and bone protrusion clearly visualized and palpated by the nurse. The wound had undermined and tunneled circumferentially around, only under the circular rolled wound edges. There was also noted yellow tan slough and black necrotic tissue inside the wound, and silvery white fascia could be seen covering the coccygeal bone protrusion. The LPN measured the wound with a long cotton swab and a wound measuring disposable paper tape. She measured the cotton swab after it was laid on the wound, and placed in the wound for an accurate measurement. The wound measured 2 centimeters (cm) long, 1.5 cm wide, and 1.5 cm deep. The exterior wound edges were rolled (epibole). The Resident was pre-medicated with pain medication and stated he felt no pain as the wound was measured. Review of the weekly skin assessment sheets since admission PCC Skin & Wound - Total Body Skin Assessment documents revealed all (including the initial) were completed by LPN's. The findings showed from 1-29-19 until 6-24-19 staff document that the resident had no new wounds however, on 4-29-19, another type of assessment document was initiated and performed by all LPN staff, Skin and Wound Evaluation V 5.0. These documents were started for a new Pressure wound stage 2 on the Resident's sacrum and was described as being treated with [MEDICATION NAME] iodine after cleaning with normal saline, and no dressing. The wound measured 3 cm long x 1.3 cm wide, no depth, and healable. None of these documents were completed after this initial one until 1 month later, on 5-27-19. On 5-27-19 the next Skin and Wound Evaluation V 5.0 document occurred one month after the first one on 4-29-19. The document describes the sacrum wound as stage 2 unchanged, healable, and documents the measurements of the wound as 1.1 cm long x 0.5 cm wide, and no depth. The treatment remains the same. No eschar, no debridement, no dressing. On 6-24-19 staff pin pointed and documented the Coccyx portion of the sacrum, instead of just stating sacrum, stage 2 pressure ulcer 1.3 cm long x 0.9 cm wide, no depth, Normal saline, and now, cover with foam dressing. Healable. No eschar, No debridement. A Left buttock and a right buttock were found as New areas on 6-24-19, however, had nothing to do with the continuing Sacrum/Coccyx wound according to nursing staff. No assessments by staff described a stage 4 pressure ulcer, and no assessments were completed from 7-14-19. through 7-16-19, until the surveyor found the stage 4 pressure ulcer on 7-16-19. All of the assessments, including the initial assessment, were completed by LPN's. physician's orders [REDACTED]. reviewed and revealed no physicians order for prevention of pressure sores from bowel incontinent episodes such as an incontinence barrier cream. Only the following 4 orders appeared after the pressure sore developed for the sacral coccyx acquired pressure ulcer treatment; 1. Ordered 4-29-19 start 4-29-19 discontinued 7-8-19 Clean open area to sacrum with normal saline and apply [MEDICATION NAME] twice per day at morning and bedtime. No dressing. No change to this order occurred after 2.5 months without healing. 2. Ordered 6-3-19 start 6-4-19 discontinued 7-9-19 Clean wound with normal saline & apply [MEDICATION NAME] ointment to coccyx wound topically once per day & as needed with allevyn dressing. 3. Ordered 7-10-19 start 7-10-19 discontinued 7-16-19 Cleanse sacrum/coccyx with normal saline apply [MEDICATION NAME] gel (hydrogel water gel to keep wound bed moist) and cover with coversite once every day. 4. Ordered 7-16-19 start 7-17-19 Cleanse sacral wound with saline, apply [MEDICATION NAME] (iodine impregnated gauze for packing into a hole) and cover area with coversite one time per day, after the examination by surveyors and an LPN, and was not ordered to be administered until the following day (7-17-19) further delaying care. Review of the MAR/TAR's revealed that the pressure sore treatments that were ordered as above, were not administered on 5/18, 5/24, 6/4, 6/10, 6/20, 6/26, 7/8, and 7/9/19. No nursing notes reveal the reason for the omissions. It is of note to mention that the [MEDICATION NAME] ointment ordered on 6-3-19 was a debridement agent. Debridement is the removal of dead and damaged tissue from a wound. This can be completed by surgical/cutting out removal, or chemical enzyme/liquefying of dead tissue to remove it. Resident #5's skin wound evaluation documents on that date show no necrotic/dead tissue in need of debridement. An interview was conducted via telephone with the Resident's physician and all surveyors present on 7-16-19 at 6:45 p.m. The doctor stated he had seen the Resident on 7-15-19 between the hours of 7:00 a.m., to 8:00 a.m. He stated that he was aware the Resident had a wound, and had reviewed the recent nursing notes which stated the Resident had a stage 2 pressure sore, and so in his progress note dated 7-15-19, he wrote a stage 2 sacral decubitus. The nursing notes were reviewed from the doctor's previous visit of 6-22-19, none stated the Resident had a stage 2 decubitus ulcer. The doctor was informed that an RN surveyor had assessed the wound this morning (7-16-19), and he was asked if he had been made aware of the findings. He stated No. The doctor was asked if he evaluated the wound, and he stated it looked like a stage 2 when I saw him, but I was interested in the shingles, my focus was not the wound. The surveyors asked if he could describe the wound, and he stated it was on his coccyx area. The doctor was asked if a debridement agent would be used for a stage 2 decubitus ulcer which had no eschar, and he stated No., The doctor went on to say, but he has been in failing health for several months with [MEDICAL CONDITION] which is an obvious factor for skin integrity, and we don't need to aggressively treat as the prognosis is poor. The doctor stated that the Resident was also losing weight and nutrition was an issue, with mineral loss. The doctor was asked why minerals and supplements had not been ordered as a replacement to mitigate this, and if that would be of value. The doctor stated yes it would be of value, but due to his age and failing health the Resident was supportive care at this stage and his overall prognosis was poor. The physician was asked why a Resident, regardless of age, who was ambulatory and recovering from a hospitalization and receiving aggressive occupational and physical therapy within the past few months would not be treated for [REDACTED]. The doctor was asked why none of his progress notes discuss evaluation of the wound until this last note yesterday, and he responded that the Resident's prognosis was poor, and I thought he had shingles, but probably just heat rash, I was not there to see the decubitus. The DON was requested to supply surveyors with all policies for skin assessments and pressure ulcers. The DON, and Corporate RN supplied 2 facility policies on skin assessments and pressure ulcers. They are as follows; 1. Pressure ulcers Manual - Skin Assessment Skin assessments will be completed for all patients. A licensed nurse will ensure that the skin risk assessment is done upon admission, and quarterly thereafter. A skin assessment will also be completed upon re-entry to the center (i.e., after ER visit, [MEDICAL TREATMENT], etc.) The weekly skin assessment will be completed thereafter. Care plan specific interventions will be developed based on skin risk assessment outcomes and individual patient needs. 2. Pressure ulcers Manual - Pressure Ulcer monitoring & A licensed nurse will assess patients for the presence of pressure ulcers: if a pressure ulcer is present, the nurse will evaluate for complications. Provide pain management prior to pressure ulcer treatment as indicated. The wound record will be completed weekly by a licensed nurse for any patient with pressure ulcers. There will be a wound record for each site. Guidance is provided for the staging of pressure ulcers by the National Pressure Ulcer Advisory Panel (NPUAP), and is as follows; NPUAP announces a change in terminology from pressure ulcer to pressure injury and updates the stages of pressure injury FOR IMMEDIATE RELEASE (MONTH) 13, (YEAR). Stage 2 Pressure Injury: Partial-thickness skin loss with exposed dermis Partial-thickness loss of skin with exposed dermis. The wound bed is viable, pink or red, moist, and may also present as an intact or ruptured serum-filled blister. Adipose (fat) is not visible and deeper tissues are not visible. Granulation tissue, slough and eschar are not present. These injuries commonly result from adverse microclimate and shear in the skin over the pelvis and shear in the heel. This stage should not be used to describe moisture associated skin damage (MASD) including incontinence associated [MEDICAL CONDITION] (IAD), intertriginous [MEDICAL CONDITION] (ITD), medical adhesive related skin injury (MARSI), or traumatic wounds (skin tears, burns, abrasions). Stage 4 Pressure Injury: If necrotic tissue, subcutaneous tissue, granulation tissue, fascia, muscle or other underlying structures are visible, this indicates a full thickness stage 4 pressure injury. Do not use (deep tissue pressure injury) DTPI to describe vascular, traumatic, neuropathic, or dermatologic conditions. In summary, for Resident #5, the physician ordered treatments were not administered, assessments of skin, and the wound were not completed for 1 month, and the wound was identified by surveyors as a stage 4 pressure ulcer, when staff were still documenting a stage 2 wound. Orders were received for debridement of the wound on 6-3-19, when documents say there was nothing to debride. No supplements were ordered for wound healing. The physician did not evaluate the wound. The air mattress that was being used was not in working order for 3 days. The wound was initially identified as a stage 2 wound which progressed to a stage 4 wound, without staff identifying it. The Administrator, DON, and the Registered Nurse (RN) Regional Consultant were made aware of the harm level deficiency at the end of day debrief on 7-16-19. No further information was supplied by the facility. The facility presented the following plan to remove the Immediate Jeopardy: F600 Identification of those residents in which the center staff was negligent in providing care and treatment to a wound resulting in deterioration, and harm to resident. 1) Resident #5 is currently out of center. Dr. (name redacted) notified on 8.6.19 of negligence related to assessment, improper treatment, delay in initiating and implementing orders, and deterioration of wound resulting in hospitalization . 2) All patients admitted to center will have Skin and Wound Assessment completed by Registered Nurse How corrective action will be accomplished for those resident having potential to be affected by the same deficient practice: [NAME] Education provided to registered nursing staff concerning wound identification on admission, assessment of wounds related to staging, appropriate treatment and/or intervention needed to prevent further deterioration. All Registered nurses will have education prior to next scheduled shift. This is validated through return demonstration utilizing the Skills Validation for Skin and Pressure ulcer prevention and management. B. Weekly wound rounds will be completed by DON, UM , MD and/ or MD extender will document in clinical record in physician notes and nursing wound evaluation .

Based on observation, staff interview, facility documentation review, clinical record review, and during the course of a complaint investigation the facility staff failed to ensure professional standards of quality were met for eight Residents (Resident #5, #72, #63, #503, #87, #203, #74, #54) in a survey sample of 46 residents. This resulted in harm for Resident #5. The findings included: Immediate Jeopardy was identified on 8/6/19 at 6:17pm and the facility was notified. After verification, Immediate Jeopardy was abated on 8/7/19 at 6:55pm and the scope and severity was lowered to level three, isolated. The findings included; 1. For Resident #5, the facility staff failed to identify wounds, accurately assess wounds, obtain and implement appropriate treatment orders. Resident #5 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. and chronic Foley catheter. Resident #5's most recent Minimum Data Set (MDS) assessment was a quarterly assessment with an Assessment Reference Date (ARD) of 4-26-19. The Resident was coded with mild cognitive impairment, and no aberrant behaviors. Resident #5 required extensive assistance to total dependence on one to two staff members, for activities of daily living care. The Resident was coded as not having any pressure ulcers at the assessment time, nor on admission. The Resident had a long standing Foley catheter (urine drainage) due to an obstruction, and was incontinent of bowel. The Resident was coded as at risk for pressure sores. At area M-0100 through M-1200 under the MDS skin conditions section of the assessment, the Resident was coded to be at risk for pressure ulcers, had no pressure ulcers, and had no other skin problems such as rashes, and or moisture associated skin damage. On 7-16-19 at 11:30 a.m., an observation of wound treatment for [REDACTED]. The nurse removed the bandage from the Resident's coccyx. The 4 inch by 4 inch single bandage had a solid center in it which was a tan [MEDICATION NAME] like non-adherent 2 inch by 2 inch square. The outer circumference of the square bandage was surrounded by a boarder of adherent malleable stretchy tape, reminiscent of Band-Aid fabric. There was no packing or medicated cream in the hollow wound. Immediately after removing the dressing a green purulent discharge was seen. The wound was circular, and deep with full muscle tissue loss and bone protrusion clearly visualized and palpated by the nurse. The wound had undermined and tunneled circumferentially around, only under the circular rolled wound edges. There was also noted yellow tan slough and black necrotic tissue inside the wound, and silvery white fascia could be seen covering the coccygeal bone protrusion. The LPN measured the wound with a long cotton swab and a wound measuring disposable paper tape. She measured the cotton swab after it was laid on the wound, and placed in the wound for an accurate measurement. The wound measured 2 centimeters (cm) long, 1.5 cm wide, and 1.5 cm deep. The exterior wound edges were rolled (epibole). The Resident was pre-medicated with pain medication and stated he felt no pain as the wound was measured. Nursing progress notes were reviewed from wound identification to the time of survey. No notes describe any pressure ulcer identification, treatments, assessments for pressure ulcers, or changes to the care plan for Resident #5 after the first identification of the wound on 4-29-19. The initial note described the pressure injury as a red bruise with open skin, and the skin evaluation document of 4-29-19 gave further measurements. Review of the weekly skin assessment sheets since admission PCC Skin & Wound - Total Body Skin Assessment documents revealed all (including the initial) were completed by LPN's. The findings were as follows; 1-29-19 - no new wounds 2-5-19 - no new wounds 2-12-19 - no new wounds 2-19-19 - no new wounds 2-26-19 - no new wounds 3-5-19 - no new wounds 3-13-19 - no new wounds 3-25-19 -no new wounds 4-1-19 - no new wounds 4-8-19 -no new wounds 4-15-19 -no new wounds 4-22-19 -no new wounds From 4-22-19 through 5-26-19, no weekly skin checks were completed. 5-27-19 -no new wounds 6-3-19 -no new wounds 6-10-19 -no new wounds 6-17-19 - no new wounds 6-24-19 - 2 new wounds (left and right buttocks) 7-1-19 -no new wounds 7-8-19 -no new wounds 7-15-19 -no new wounds. On 4-29-19, another type of assessment document was initiated and performed by all LPN staff, Skin and Wound Evaluation V 5.0. These documents were started for a new Pressure wound stage 2 on the Resident's sacrum and was described as being treated with [MEDICATION NAME] iodine after cleaning with normal saline, and no dressing. The wound measured 3 cm long x 1.3 cm wide, no depth, and healable. None of these documents were completed after this initial one until 1 month later, on 5-27-19. The Rest of these particular assessment documents follow below in chronological order: On 5-27-19 the next Skin and Wound Evaluation V 5.0 document occurred one month after the first one on 4-29-19. The document describes the sacrum wound as stage 2 unchanged, healable, and documents the measurements of the wound as 1.1 cm long x 0.5 cm wide, and no depth. The treatment remains the same. No eschar, no debridement, no dressing. On 6-3-19 Sacrum stage 2 pressure ulcer 1.7 cm long x 0.5 cm wide, no depth, same treatment. Healable. No eschar, No debridement, no dressing. On 6-10-19 sacrum stage 2 pressure ulcer 1.9 cm long x 0.5 cm wide, no depth, same treatment. Healable. No eschar, No debridement, no dressing. On 6-17-19 sacrum stage 2 pressure ulcer 1.2 cm long x 0.6 cm wide, no depth, same treatment. Healable. No eschar, No debridement, no dressing. On 6-24-19 staff pin pointed and documented the Coccyx portion of the sacrum, instead of just stating sacrum, stage 2 pressure ulcer 1.3 cm long x 0.9 cm wide, no depth, Normal saline, and now, cover with foam dressing. Healable. No eschar, No debridement. A Left buttock and a right buttock were found as New areas on 6-24-19, however, had nothing to do with the continuing Sacrum/Coccyx wound according to nursing staff. On 7-2-19 coccyx stage 2 pressure ulcer 1.4 cm long x 0.2 cm wide, no depth, same treatment. Healable. No debridement, No eschar. On 7-8-19 coccyx stage 2 pressure ulcer 1.5 cm long x 0.5 cm wide, no depth, same treatment. Healable, Deteriorating. No debridement, No eschar. On 7-9-19 (one day later) the last assessment documented coccyx stage 2 pressure ulcer 1.2 cm long x 0.6 cm wide, no depth, Eschar 20%, deteriorating, healable, treatment; normal saline and enzymatic debridement (ordered 6-3-19). It is notable to mention that [MEDICATION NAME] (2 times per day) and [MEDICATION NAME] (1 time per day) were ordered to be completed simultaneously and were signed as administered simultaneously, however, the dressing would have to be removed twice daily for this to occur. No assessments by staff described a stage 4 pressure ulcer, and no assessments were completed from 7-14-19. through 7-16-19, until the surveyor found the stage 4 pressure ulcer on 7-16-19. All of the assessments, including the initial assessment, were completed by LPN's. physician's orders [REDACTED]. reviewed and revealed no physicians order for prevention of pressure sores from bowel incontinent episodes such as an incontinence barrier cream. Only the following 4 orders appeared after the pressure sore developed for the sacral coccyx acquired pressure ulcer treatment; 1. Ordered 4-29-19 start 4-29-19 discontinued 7-8-19 Clean open area to sacrum with normal saline and apply [MEDICATION NAME] twice per day at morning and bedtime. No dressing. No change to this order occurred after 2.5 months without healing. 2. Ordered 6-3-19 start 6-4-19 discontinued 7-9-19 Clean wound with normal saline & apply [MEDICATION NAME] ointment to coccyx wound topically once per day & as needed with allevyn dressing. 3. Ordered 7-10-19 start 7-10-19 discontinued 7-16-19 Cleanse sacrum/coccyx with normal saline apply [MEDICATION NAME] gel (hydrogel water gel to keep wound bed moist) and cover with coversite once every day. 4. Ordered 7-16-19 start 7-17-19 Cleanse sacral wound with saline, apply [MEDICATION NAME] (iodine impregnated gauze for packing into a hole) and cover area with coversite one time per day, after the examination by surveyors and an LPN, and was not ordered to be administered until the following day (7-17-19) further delaying care. Review of the MAR/TAR's revealed that the pressure sore treatments that were ordered as above, were not administered on 5/18, 5/24, 6/4, 6/10, 6/20, 6/26, 7/8, and 7/9/19. No nursing notes reveal the reason for the omissions. The DON was requested to supply surveyors with all policies for skin assessments and pressure ulcers. The DON, and Corporate RN supplied 2 facility policies on skin assessments and pressure ulcers. They are as follows; 1. Pressure ulcers Manual - Skin Assessment Skin assessments will be completed for all patients. A licensed nurse will ensure that the skin risk assessment is done upon admission, and quarterly thereafter. A skin assessment will also be completed upon re-entry to the center (i.e., after ER visit, [MEDICAL TREATMENT], etc.) The weekly skin assessment will be completed thereafter. Care plan specific interventions will be developed based on skin risk assessment outcomes and individual patient needs. 2. Pressure ulcers Manual - Pressure Ulcer monitoring & A licensed nurse will assess patients for the presence of pressure ulcers: if a pressure ulcer is present, the nurse will evaluate for complications. Provide pain management prior to pressure ulcer treatment as indicated. The wound record will be completed weekly by a licensed nurse for any patient with pressure ulcers. There will be a wound record for each site. Guidance is provided for the staging of pressure ulcers by the National Pressure Ulcer Advisory Panel (NPUAP), and is as follows; NPUAP announces a change in terminology from pressure ulcer to pressure injury and updates the stages of pressure injury FOR IMMEDIATE RELEASE (MONTH) 13, (YEAR). Stage 2 Pressure Injury: Partial-thickness skin loss with exposed dermis Partial-thickness loss of skin with exposed dermis. The wound bed is viable, pink or red, moist, and may also present as an intact or ruptured serum-filled blister. Adipose (fat) is not visible and deeper tissues are not visible. Granulation tissue, slough and eschar are not present. These injuries commonly result from adverse microclimate and shear in the skin over the pelvis and shear in the heel. This stage should not be used to describe moisture associated skin damage (MASD) including incontinence associated [MEDICAL CONDITION] (IAD), intertriginous [MEDICAL CONDITION] (ITD), medical adhesive related skin injury (MARSI), or traumatic wounds (skin tears, burns, abrasions). Stage 3 Pressure Injury: Full-thickness loss of skin, in which adipose (fat) is visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. Slough and/or eschar may be visible. The depth of tissue damage varies by anatomical location; areas of significant (fat) adiposity can develop deep wounds. Undermining and tunneling may occur. Fascia, muscle, tendon, ligament, cartilage and/or bone are not exposed. If slough or eschar obscures the extent of tissue loss this is an Unstageable Pressure Injury. The wound may evolve rapidly to reveal the actual extent of tissue injury, or may resolve without tissue loss. Stage 4 Pressure Injury: If necrotic tissue, subcutaneous tissue, granulation tissue, fascia, muscle or other underlying structures are visible, this indicates a full thickness stage 4 pressure injury. Do not use (deep tissue pressure injury) DTPI to describe vascular, traumatic, neuropathic, or dermatologic conditions. On 7-16-19, Resident #5's care plan was reviewed and revealed the following 2 entries of importance; 1. Resistive to care, and 2. Skin care plan. 1. F[NAME]US Resident and wife are resistive to care. instituted 5-7-19, with an intervention for Explain to (Resident spouse name) some interventions she is using may be harmful and cause more problems with skin integrity continues to use own equipment and use of sheepskin which will add moisture. The Corporate RN (corp RN) was asked how a woman who walks with a cane could apply sheepskin to a hospital bed with her husband in it. The Corp RN replied yes, we put it on the bed, but the wife insisted. No nursing progress notes, physician progress notes [REDACTED]. 2. On 5-1-19, and 5-2-19 new focuses were added with no additions after that date. A planned focus area included; the Resident has a pressure ulcer with potential for pressure ulcer development, administer treatments as ordered, and monitor for effectiveness ., Per Lippincott Manual of Nursing Practice, 11th edition, page 150 the nursing standard reads, assess for risk factors for pressure ulcer development and alter those factors, 2. Assess skin of the older adult frequently for the development of pressure ulcers. 3. Stage the ulcer so appropriate treatment can be started. In summary, for Resident #5, the physician ordered treatments were not administered, assessments of skin, and the wound were not completed for 1 month, and the wound was identified by surveyors as a stage 4 pressure ulcer, when staff were still documenting a stage 2 wound. Staff signed that they completed 2 conflicting wound treatment orders simultaneously. The wound was initially identified as a stage 2 wound which progressed to a stage 4 wound, without staff identifying it. The Administrator, DON, and the Registered Nurse (RN) Regional Consultant were made aware of the harm level deficiency at the end of day debrief on 7-16-19. No further information was supplied by the facility. 2. For Resident #72, the facility staff failed to administer insulin as scheduled. Resident #72, an [AGE] year old female, was admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. On 7/15/19 at approximately 10:20, Resident #72 expressed concerns stating, the nurses can be slow giving me my scheduled medicines, I take insulin for my diabetes. On 7/15/19, clinical record review was conducted for Resident #72 and an excerpt from the care plan read, The resident has Diabetes Mellitus, the resident will have no complications related to diabetes .diabetes medication as ordered by doctor. The signed physician orders [REDACTED]. Her dose was scheduled to be given at 9:00 AM each morning. A Medication Administration Audit Report for the previous week was requested and provided by facility staff. Resident #72 received Insulin [MEDICATION NAME] as follows: 7/9/19, time scheduled 9:00 AM, time administered 10:49 AM 7/11/19, time scheduled 9:00 AM, time administered 10:42 AM 7/12/19, time scheduled 9:00 AM, time administered 11:46 AM 7/13/19, time scheduled 9:00 AM, time administered 11:44 AM 7/14/19, time scheduled 9:00 AM, time administered 10:56 AM 7/15/19, time scheduled 9:00 AM, time administered 10:14 AM On 7/16/19 at approximately 9:50 AM, the Director of Nursing (DON, Employee B) was interviewed and stated, the facility expectations for med pass include (medication to be given) one hour before and one hour after (the) scheduled time. When asked about the possible outcomes if insulin is not given as ordered at the scheduled time, she stated, if the resident does not receive the ordered insulin as scheduled at the correct times, it could cause an elevation in the blood sugar levels and that could cause ketoacidosis (a diabetic emergency). Review of the facility's policy entitled, 6.0 General Dose Preparation and Medication Administration (revision date 01/01/13), under subheading Procedure, item 5.4 read, Administer medications within timeframes specified by facility policy. COMPLAINT DEFICIENCY 3. For Resident # 63, the facility staff failed to document the administration of medications as ordered by the physician. Resident #63, an [AGE] year old, was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. The most current Minimum Data Set (MDS) assessment was a 30 day Admission assessment with an assessment reference date (ARD) of 6/23/2019. Resident # 63 was coded with a Brief Interview of Mental Status score of 7 out of 15 indicating severe cognitive impairment. She required extensive to total assistance of one to two staff persons with activities of daily living. Review of the (MONTH) 2019 Medication Administration Record [REDACTED] [MEDICATION NAME] 10 milligrams give one tablet via PEG (Percutaneous Endoscopic Gastrostomy) tube one time per day 7/13/19 at 9 a.m. Aspirin 325 milligrams give one tablet via PEG (Percutaneous Endoscopic Gastrostomy) tube one time per day 7/13/19 at 9 a.m. [MEDICATION NAME] 5 milligrams give one tablet via PEG (Percutaneous Endoscopic Gastrostomy) tube one time per day 7/13/19 at 9 a.m. [MEDICATION NAME] 100 milligrams give one tablet via PEG (Percutaneous Endoscopic Gastrostomy) tube three times per day 7/13/19 at 8 a.m. and 7/13/19 at 2 p.m. Losartan 100 milligrams give one tablet via PEG (Percutaneous Endoscopic Gastrostomy) tube one time per day 7/13/19 at 9 a.m. Enteral Feed Order every shift Check and record residuals every shift 7/6/19-day shift, 7/9/19-day shift, 7/13/19- day shift Enteral Feed Order every shift flush tube with 20-30 milliliters of water before and after administration of medication pass 7/6/19-day shift, 7/9/19-day shift, 7/13/19- day shift Review of the (MONTH) 2019 Treatment Administration Record revealed missing documentation of administration including: Enteral Feed Order every evening shift Check and record residuals every shift 7/5/19-evening shift, 7/10/19 evening shift Anchor Feeding tube every shift 7/5/19-evening shift, 7/9/19-day shift, 7/10/19- evening shift The facility policy General Dose Preparation and Medication Administration stated: 4.1.1 Verify each a medication is administered that it is the correct medication, at the correct dose, at the correct route, at the correct rate, at the correct time, for the correct resident, as set forth in Appendix 17: Facility Medication Administration Times Schedule. 4.1.2 Confirm that the MAR indicated [REDACTED] 5.4 Administer medications within timeframe specified by Facility policy 6.1 Document necessary medication administration/treatment information (e.g. (example) when medications are opened, when medications are given, injection site of a medication, if medications are refused, PRN medications, application sight) on appropriate forms. The Director of Nursing (DON) cited Lippincott as its Nursing professional guidance used by the facility. The DON stated the expectation was that medications should be administered within one hour before or after the scheduled time. Fundamentals of Nursing, by Lippincottcited as the facility nursing practice reference stated The physician is responsible for directing medical treatment. Nurses follow physicians' orders unless they believe the orders are in error or harm clients. Guidance is given from Lippincott Solutions, Safe Medication Administration Practices, General 10/02/2015. Document all medications administered in the patient's MAR indicated [REDACTED]. If a medication wasn't administered, document the reason why, any interventions taken, practitioner notification, and the patient's response to interventions. Additional Guidance from Lippincott's Nursing Center.com (www.nursingcenter.com) Rights of Medication Administration . 5. Right time Check the frequency of the ordered medication. Double-check that you are giving the ordered dose at the correct time. Confirm when the last dose was given. 6. Right documentation Document administration AFTER giving the ordered medication. Chart the time, route, and any other specific information as necessary. For example, the site of an injection or any laboratory value or vital sign that needed to be checked before giving the drug Reference: Nursing 2012 Drug Handbook. (2012). Lippincott[NAME] & Wilkins: Philadelphia, Pennsylvania. www.nursingcenter.com Accessed online 7/16/2019. The Administrator and DON were notified of the issue at the end of day meeting on 7/15/19. The Director of Nursing (DON) stated the expectation was that nurses would administer medications as ordered by the physician. The DON (director of nursing) stated that she was newly employed since 7/1/2019 and had identified the failure of the staff to ensure medications were documented as being administered. The DON stated her expectation was for staff to administer medications and treatments per physician's orders [REDACTED]. No further information was provided. 4. For Resident # 503, the facility staff failed to administer medications timely as ordered by the physician. Resident # 503 was a [AGE] year old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident # 503's most recent (Minimum Data Set) MDS was an Admission Assessment with an (Assessment Reference Date) ARD of 7/12/2019. The MDS coded her has having a (Brief Interview of Mental Status ) BIMS Score of 15 out of 15, indicating no cognitive impairment. During the initial tour of the facility on 7/14/2019 at 3:40 p.m., Resident # 503 complained that her breathing treatments and medications often were given late. Also, Resident # 503 stated medications scheduled for 7/13/2019 at 9 a.m. were not administered until 11 a.m. Review of the (MONTH) 2019 MAR (Medication Administration Record) revealed documentation that all of the medications were administered on time. Review of the nurses notes revealed no documentation that any medications were administered late. On 7/15/2019 at 2:15 p.m., an interview was conducted with the Director of Nursing and the Corporate Consultant (Employee I) who both stated copy of the Medication Administration Audit Report was requested from the Corporate Consultant (Employee I) who stated he would try to obtain the report. Review of the Medication Admin Audit Report confirmed the 9:00 a.m. medications scheduled for 7/13/2019 at 9:00 a.m. were administered at 11:08 a.m. as Resident # 503 stated. Those medications were: [MEDICATION NAME] 5 milligrams give 5 milligrams by mouth one time a day [MEDICATION NAME] HandiHaler Capsule 18 micrograms one capsule inhale orally one time a day Potassium Chloride ER (Extended Release) Tablet 20 milliequivalents give one tablet by mouth one time a day [MEDICATION NAME] Delayed Release 20 milligrams give one capsule by mouth one time a day [MEDICATION NAME]-[MEDICATION NAME] Solution 0.5-2.5 (3) milligrams/3 milliliters one vial inhale orally two times a day Further review of the Medication Admin Audit report revealed other medications administered late: [MEDICATION NAME]-[MEDICATION NAME] Solution 0.5-2.5 (3) milligrams/3 milliliters one vial inhale orally two times a day Scheduled 7/8/2019 at 9:00 p.m., Administered 7/8/19 at 10:26 p.m. [MEDICATION NAME]-[MEDICATION NAME] Solution 0.5-2.5 (3) milligrams/3 milliliters one vial inhale orally two times a day Scheduled 7/11/2019 at 9 p.m., Administered 7/11/19 at 10:43 p.m. The facility policy General Dose Preparation and Medication Administration stated: 4.1.1 Verify each a medication is administered that it is the correct medication, at the correct dose, at the correct route, at the correct rate, at the correct time, for the correct resident, as set forth in Appendix 17: Facility Medication Administration Times Schedule. 4.1.2 Confirm that the MAR indicated [REDACTED] 5.4 Administer medications within timeframe specified by Facility policy 6.1 Document necessary medication administration/treatment information (e.g. (example) when medications are opened, when medications are given, injection site of a medication, if medications are refused, PRN medications, application sight) on appropriate forms. The Director of Nursing (DON) cited Lippincott as its Nursing professional guidance used by the facility. The DON stated the expectation was that medications should be administered within one hour before or after the scheduled time. Fundamentals of Nursing, by Lippincottcited as the facility nursing practice reference stated The physician is responsible for directing medical treatment. Nurses follow physicians' orders unless they believe the orders are in error or harm clients. Guidance is given from Lippincott Solutions, Safe Medication Administration Practices, General 10/02/2015. Document all medications administered in the patient's MAR indicated [REDACTED]. If a medication wasn't administered, document the reason why, any interventions taken, practitioner notification, and the patient's response to interventions. Additional Guidance from Lippincott's Nursing Center.com (www.nursingcenter.com) Rights of Medication Administration . 5. Right time Check the frequency of the ordered medication. Double-check that you are giving the ordered dose at the correct time. Confirm when the last dose was given. 6. Right documentation Document administration AFTER giving the ordered medication. Chart the time, route, and any other specific information as necessary. For example, the site of an injection or any laboratory value or vital sign that needed to be checked before giving the drug Reference: Nursing 2012 Drug Handbook. (2012). Lippincott[NAME] & Wilkins: Philadelphia, Pennsylvania. www.nursingcenter.com Accessed online 7/16/2019. The Administrator and DON were notified of the issue at the end of day meeting on 7/15/19. The Director of Nursing (DON) stated the expectation was that nurses would administer medications as ordered by the physician. The DON (director of nursing) stated that she was newly employed since 7/1/2019 and had identified the failure of the staff to ensure medications were documented as being administered. The DON stated her expectation was for staff to administer medications and treatments per physician's orders [REDACTED]. No further information was provided. 5. For Resident # 87, the facility staff failed to ensure the administration of medications timely as ordered by the physician. Resident # 87's original date of admission was 6/3/2019 and readmitted on [DATE] with [DIAGNOSES REDACTED]. Resident #87's most recent MDS (Minimum Data Set) Assessment was a 30 day Assessment with an ARD (Assessment Reference Date) of 7/1/2019 from the original admission. The MDS coded Resident # 87 with a BIMS (Brief Interview for Mental Status) score of 15 out of 15, indicating no cognitive impairment. During the initial tour of the facility on 7/14/2019 at 3:40 p.m., Resident # 87 complained that her medications often were given late. Also, Resident # 87 stated medications scheduled for 7/13/2019 at 9 a.m. were not administered until after 10 a.m. Review of the (MONTH) 2019 MAR (Medication Administration Record) revealed documentation that all of the medications were administered on time. Review of the nurses notes revealed no documentation that any medications were administered late. On 7/15/2019 at 2:15 p.m., an interview was conducted with the Director of Nursing and the Corporate Consultant (Employee I) who both stated copy of the Medication Administration Audit Report was requested from the Corporate Consultant (Employee I) who stated he would try to obtain the report. Review of the Medication Admin Audit Report confirmed the 9:00 a.m. medications scheduled for 7/13/2019 at 9:00 a.m. were administered between 10:11 and 10:21 a.m. as Resident # 87 stated. Further review revealed other medications administered late: [MEDICATION NAME] 500 milligrams give two tablets by mouth for pain-Scheduled 7/13/19 at 8 a.m., administered at 10:18 a.m. [MEDICATION NAME] 500 milligrams give two tablets by mouth for pain-Scheduled 7/14/19 at 8 a.m., administered at 9:39 a.m. [MEDICATION NAME] Sodium 100 milligrams give one capsule by mouth -scheduled 7/15/19 at 9:00 am, administered at 11:25 a.m. Fish Oil 500 milligrams one capsule by mouth-scheduled 7/15/19 at 9:00 am, administered at 11:25 a.m. [MEDICATION NAME] Extended Release 200 milligrams give one tablet by mouth-scheduled 7/15/19 at 9:00 am, administered at 11:25 a.m. Olmesartan 40 milligrams give one tablet by mouth-scheduled 7/15/19 at 9:00 am, administered at 11:25 a.m. [MEDICATION NAME] 50 milligrams give two tablets by mouth -scheduled 7/15/19 at 9:00 am, administered at 11:25 a.m. Apixaban 5 milligrams give one tablet by mouth -scheduled 7/15/19 at 9:00 am, administered at 11:25 a.m. [MEDICATION NAME] 10 milligrams give one tablet by mouth-scheduled 7/15/19 at 9:00 am, administered at 11:25 a.m. [MEDICATION NAME] 100 milligrams give one tablet by mouth-scheduled 7/15/19 at 9:00 am, administered at 11:25 a.m. [MEDICATION NAME] 20 milligrams give one tablet by mouth-scheduled 7/15/19 at 9:00 am, administered at 11:25 a.m. [MEDICATION NAME] 50 milligrams give 2 tablets by mouth -scheduled 7/9/19 at 9 p.m., administered 7/10/19 at 11:53 p.m. Apixaban 5 milligrams give one tablet by mouth -scheduled 7/10/19 at 5:00 p.m., administered 7/10/19 at 9:52 p.m. [MEDICATION NAME] 500 milligrams give two tablets by mouth-scheduled 7/11/19 at 4:00 p.m., administered at 5:59 p.m. [MEDICATION NAME] 50 milligrams give 2 tablets by mouth -scheduled 7/11/19 at 9:00 p.m., administered at 10:40 p.m. [MEDICATION NAME] 500 milligrams give two tablets by mouth-scheduled 7/13/19 at 4:00 p.m., administered at 5:38 p.m. [MEDICATION NAME] 500 milligrams give two tablets by mouth-scheduled 7/14/19 at 4:00 p.m., administered at 5:24 p.m. The facility policy General Dose Preparation and Medication Administration stated: 4.1.1 Verify each a medication is administered that it is the correct medication, at the correct dose, at the correct route, at the correct rate, at the correct time, for the correct resident, as set forth in Appendix 17: Facility Medication Administration Times Schedule. 4.1.2 Confirm that the MAR indicated [REDACTED] 5.4 Administer medications within timeframe specified by Facility policy 6.1 Document necessary medication administration/treatment information (e.g. (example) when medications are opened, when medications are given, injection site of a medication, if medications are refused, PRN medications, application sight) on appropriate forms. The Director of Nursing (DON) cited Lippincott as its Nursing professional guidance used by the facility. The DON st

Based on observation, Resident interview, spouse interview, staff interview, clinical record review, and facility documentation review, the facility staff failed to perform services to prevent and promote the healing of pressure ulcers for six residents (Resident #5, #19, #155, #156, #62, #79) in a survey sample of 46 Residents, resulting in harm for Resident #5. Immediate Jeopardy was identified on 8/6/19 at 6:17pm and the facility was notified. After verification, Immediate Jeopardy was abated on 8/7/19 at 6:55pm and the scope and severity was lowered to level three, isolated. The findings included; 1. For Resident #5, the facility staff failed to provide ordered treatments, monitoring for worsening of the ulcer for an acquired potentially avoidable stage 4 pressure ulcer. The staff then failed to change the treatment of [REDACTED]. Resident #5 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. and chronic Foley catheter. Resident #5's most recent Minimum Data Set (MDS) assessment was a quarterly assessment with an Assessment Reference Date (ARD) of 4-26-19. The Resident was coded with mild cognitive impairment, and no aberrant behaviors. Resident #5 required extensive assistance to total dependence on one to two staff members, for activities of daily living care. The Resident was coded as not having any pressure ulcers at the assessment time, nor on admission. The Resident had a long standing Foley catheter (urine drainage) due to an obstruction, and was incontinent of bowel. The Resident was coded as at risk for pressure sores. At area M-0100 through M-1200 under the MDS skin conditions section of the assessment, the Resident was coded to be at risk for pressure ulcers, had no pressure ulcers, and had no other skin problems such as rashes, and or moisture associated skin damage. The only preventative measure for skin breakdown ordered by a physician, for the Resident, was a ROHO wheel chair cushion ordered 4-21-19 (3 months after admission) and the day before PT was discontinued. The cushion was signed as administered, and was observed in the Resident room in his wheel chair. On 7-14-19, at 3:30 p.m., the first observation and interview of Resident #5 was conducted during initial tour of the facility. The Resident was found laying on a specialty mattress (Genesis II, a low air loss mattress), and the air motor was bogging down and humming, and not infusing air into the mattress. The mattress was flat, hard, and solid, with no air in it. The Resident was laying partially on his left side, and a Foley catheter was noted to be draining dark yellow urine with white sediment in it. The Resident was able to speak and make his needs known, and was found to be oriented to person, time, place and situation. The Resident stated he was thirsty and wanted water. There were 6 water Sippie non-spillable cups on the over-bed table which were all empty. The bedside table was 3 feet from the bed and the Resident could not reach it. Staff were notified. A second observation of Resident #5 was conducted on 7-15-19 at 4:30 p.m., and the Resident was sleeping in bed on his back. The over-bed table was found to be exactly as the last observation, and the bed was deflated with the motor still humming, but not infusing air. The air mattress was replaced on 7-16-19. A third observation occurred on 7-16-19 at 11:30 a.m., with Licensed practical nurse C (LPN C), and Certified nursing assistant N (CNA N). The nurse removed the bandage from the Resident's coccyx. The 4 inch by 4 inch single bandage had a solid center in it which was a tan [MEDICATION NAME] like non-adherent 2 inch by 2 inch square. The outer circumference of the square bandage was surrounded by a boarder of adherent malleable stretchy tape, reminiscent of Band-Aid fabric. There was no packing or medicated cream in the hollow wound. Immediately after removing the dressing a green purulent discharge was seen. The wound was circular, and deep with full muscle tissue loss and bone protrusion clearly visualized and palpated by the nurse. The wound had undermined and tunneled circumferentially around, only under the circular rolled wound edges. There was also noted yellow tan slough and black necrotic tissue inside the wound, and silvery white fascia could be seen covering the coccygeal bone protrusion. The LPN measured the wound with a long cotton swab and a wound measuring disposable paper tape. She measured the cotton swab after it was laid on the wound, and placed in the wound for an accurate measurement. The wound measured 2 centimeters (cm) long, 1.5 cm wide, and 1.5 cm deep. The exterior wound edges were rolled (epibole). The Resident was pre-medicated with pain medication and stated he felt no pain as the wound was measured. Nursing progress notes were reviewed from wound identification to the time of survey. No notes describe any pressure ulcer identification, treatments, assessments for pressure ulcers, or changes to the care plan for Resident #5 after the first identification of the wound on 4-29-19. The initial note described the pressure injury as a red bruise with open skin, and the skin evaluation document of 4-29-19 gave further measurements. On 5-3-19 a care plan meeting was held and the Resident's spouse asked that the Resident be frequently changed and cleaned for bowel incontinence to prevent skin breakdown as her only concern. The Resident had a Foley catheter for urination. No other nursing progress notes document the pressure ulcer until 5-30-19 (one month later) which was documented by the Registered dietician because of weight loss. Review of the weekly skin assessment sheets since admission PCC Skin & Wound - Total Body Skin Assessment documents revealed all (including the initial) were completed by LPN's. The findings were as follows; 1-29-19 - no new wounds 2-5-19 - no new wounds 2-12-19 - no new wounds 2-19-19 - no new wounds 2-26-19 - no new wounds 3-5-19 - no new wounds 3-13-19 - no new wounds 3-25-19 -no new wounds 4-1-19 - no new wounds 4-8-19 -no new wounds 4-15-19 -no new wounds 4-22-19 -no new wounds From 4-22-19 through 5-26-19, no weekly skin checks were completed. 5-27-19 -no new wounds 6-3-19 -no new wounds 6-10-19 -no new wounds 6-17-19 - no new wounds 6-24-19 - 2 new wounds (left and right buttocks) 7-1-19 -no new wounds 7-8-19 -no new wounds 7-15-19 -no new wounds. On 4-29-19, another type of assessment document was initiated and performed by all LPN staff, Skin and Wound Evaluation V 5.0. These documents were started for a new Pressure wound stage 2 on the Resident's sacrum and was described as being treated with [MEDICATION NAME] iodine after cleaning with normal saline, and no dressing. The wound measured 3 cm long x 1.3 cm wide, no depth, and healable. None of these documents were completed after this initial one until 1 month later, on 5-27-19. The Rest of these particular assessment documents follow below in chronological order: On 5-27-19 the next Skin and Wound Evaluation V 5.0 document occurred one month after the first one on 4-29-19. The document describes the sacrum wound as stage 2 unchanged, healable, and documents the measurements of the wound as 1.1 cm long x 0.5 cm wide, and no depth. The treatment remains the same. No eschar, no debridement, no dressing. On 6-3-19 Sacrum stage 2 pressure ulcer 1.7 cm long x 0.5 cm wide, no depth, same treatment. Healable. No eschar, No debridement, no dressing. On 6-10-19 sacrum stage 2 pressure ulcer 1.9 cm long x 0.5 cm wide, no depth, same treatment. Healable. No eschar, No debridement, no dressing. On 6-17-19 sacrum stage 2 pressure ulcer 1.2 cm long x 0.6 cm wide, no depth, same treatment. Healable. No eschar, No debridement, no dressing. On 6-24-19 staff pin pointed and documented the Coccyx portion of the sacrum, instead of just stating sacrum, stage 2 pressure ulcer 1.3 cm long x 0.9 cm wide, no depth, Normal saline, and now, cover with foam dressing. Healable. No eschar, No debridement. A Left buttock and a right buttock were found as New areas on 6-24-19, however, had nothing to do with the continuing Sacrum/Coccyx wound according to nursing staff. On 7-2-19 coccyx stage 2 pressure ulcer 1.4 cm long x 0.2 cm wide, no depth, same treatment. Healable. No debridement, No eschar. On 7-8-19 coccyx stage 2 pressure ulcer 1.5 cm long x 0.5 cm wide, no depth, same treatment. Healable, Deteriorating. No debridement, No eschar. On 7-9-19 (one day later) the last assessment documented coccyx stage 2 pressure ulcer 1.2 cm long x 0.6 cm wide, no depth, Eschar 20%, deteriorating, healable, treatment; normal saline and enzymatic debridement (ordered 6-3-19). It is notable to mention that [MEDICATION NAME] (2 times per day) and [MEDICATION NAME] (1 time per day) were ordered to be completed simultaneously and were signed as administered simultaneously, however, the dressing would have to be removed twice daily for this to occur. No assessments by staff described a stage 4 pressure ulcer, and no assessments were completed from 7-14-19. through 7-16-19, until the surveyor found the stage 4 pressure ulcer on 7-16-19. All of the assessments, including the initial assessment, were completed by LPN's. physician's orders [REDACTED]. reviewed and revealed no physicians order for prevention of pressure sores from bowel incontinent episodes such as an incontinence barrier cream. Only the following 4 orders appeared after the pressure sore developed for the sacral coccyx acquired pressure ulcer treatment; 1. Ordered 4-29-19 start 4-29-19 discontinued 7-8-19 Clean open area to sacrum with normal saline and apply [MEDICATION NAME] twice per day at morning and bedtime. No dressing. No change to this order occurred after 2.5 months without healing. 2. Ordered 6-3-19 start 6-4-19 discontinued 7-9-19 Clean wound with normal saline & apply [MEDICATION NAME] ointment to coccyx wound topically once per day & as needed with allevyn dressing. 3. Ordered 7-10-19 start 7-10-19 discontinued 7-16-19 Cleanse sacrum/coccyx with normal saline apply [MEDICATION NAME] gel (hydrogel water gel to keep wound bed moist) and cover with coversite once every day. 4. Ordered 7-16-19 start 7-17-19 Cleanse sacral wound with saline, apply [MEDICATION NAME] (iodine impregnated gauze for packing into a hole) and cover area with coversite one time per day, after the examination by surveyors and an LPN, and was not ordered to be administered until the following day (7-17-19) further delaying care. Review of the MAR/TAR's revealed that the pressure sore treatments that were ordered as above, were not administered on 5/18, 5/24, 6/4, 6/10, 6/20, 6/26, 7/8, and 7/9/19. No nursing notes reveal the reason for the omissions. It is of note to mention that the [MEDICATION NAME] ointment ordered on 6-3-19 was a debridement agent. Debridement is the removal of dead and damaged tissue from a wound. This can be completed by surgical/cutting out removal, or chemical enzyme/liquefying of dead tissue to remove it. Resident #5's skin wound evaluation documents on that date show no necrotic/dead tissue in need of debridement. An interview was conducted via telephone with the Resident's physician and all surveyors present on 7-16-19 at 6:45 p.m. The doctor stated he had seen the Resident on 7-15-19 between the hours of 7:00 a.m., to 8:00 a.m. He stated that he was aware the Resident had a wound, and had reviewed the recent nursing notes which stated the Resident had a stage 2 pressure sore, and so in his progress note dated 7-15-19, he wrote a stage 2 sacral decubitus. The nursing notes were reviewed from the doctor's previous visit of 6-22-19, none stated the Resident had a stage 2 decubitus ulcer. The doctor was informed that an RN surveyor had assessed the wound this morning (7-16-19), and he was asked if he had been made aware of the findings. He stated No. The doctor was asked if he evaluated the wound, and he stated it looked like a stage 2 when I saw him, but I was interested in the shingles, my focus was not the wound. The surveyors asked if he could describe the wound, and he stated it was on his coccyx area. The doctor was asked if a debridement agent would be used for a stage 2 decubitus ulcer which had no eschar, and he stated No., The doctor went on to say, but he has been in failing health for several months with [MEDICAL CONDITION] which is an obvious factor for skin integrity, and we don't need to aggressively treat as the prognosis is poor. The doctor stated that the Resident was also losing weight and nutrition was an issue, with mineral loss. The doctor was asked why minerals and supplements had not been ordered as a replacement to mitigate this, and if that would be of value. The doctor stated yes it would be of value, but due to his age and failing health the Resident was supportive care at this stage and his overall prognosis was poor. The physician was asked why a Resident, regardless of age, who was ambulatory and recovering from a hospitalization and receiving aggressive occupational and physical therapy within the past few months would not be treated for [REDACTED]. The doctor was asked why none of his progress notes discuss evaluation of the wound until this last note yesterday, and he responded that the Resident's prognosis was poor, and I thought he had shingles, but probably just heat rash, I was not there to see the decubitus. No changes to the Resident's diet were ever ordered from the time of admission. No dietary supplements, minerals, or protein for pressure ulcer formation, wound healing, was ever added or ordered for the Resident after admission, for the 6 month period. Registered Dietician (RD) notes were reviewed and revealed that the RD evaluated the Resident twice in 6+ months. Those evaluations were on 5-16-19, and 5-30-19, and she made no recommendations. The DON was requested to supply surveyors with all policies for skin assessments and pressure ulcers. The DON, and Corporate RN supplied 2 facility policies on skin assessments and pressure ulcers. They are as follows; 1. Pressure ulcers Manual - Skin Assessment Skin assessments will be completed for all patients. A licensed nurse will ensure that the skin risk assessment is done upon admission, and quarterly thereafter. A skin assessment will also be completed upon re-entry to the center (i.e., after ER visit, [MEDICAL TREATMENT], etc.) The weekly skin assessment will be completed thereafter. Care plan specific interventions will be developed based on skin risk assessment outcomes and individual patient needs. 2. Pressure ulcers Manual - Pressure Ulcer monitoring & A licensed nurse will assess patients for the presence of pressure ulcers: if a pressure ulcer is present, the nurse will evaluate for complications. Provide pain management prior to pressure ulcer treatment as indicated. The wound record will be completed weekly by a licensed nurse for any patient with pressure ulcers. There will be a wound record for each site. Guidance is provided for the staging of pressure ulcers by the National Pressure Ulcer Advisory Panel (NPUAP), and is as follows; NPUAP announces a change in terminology from pressure ulcer to pressure injury and updates the stages of pressure injury FOR IMMEDIATE RELEASE (MONTH) 13, (YEAR). Stage 2 Pressure Injury: Partial-thickness skin loss with exposed dermis Partial-thickness loss of skin with exposed dermis. The wound bed is viable, pink or red, moist, and may also present as an intact or ruptured serum-filled blister. Adipose (fat) is not visible and deeper tissues are not visible. Granulation tissue, slough and eschar are not present. These injuries commonly result from adverse microclimate and shear in the skin over the pelvis and shear in the heel. This stage should not be used to describe moisture associated skin damage (MASD) including incontinence associated [MEDICAL CONDITION] (IAD), intertriginous [MEDICAL CONDITION] (ITD), medical adhesive related skin injury (MARSI), or traumatic wounds (skin tears, burns, abrasions). Stage 3 Pressure Injury: Full-thickness loss of skin, in which adipose (fat) is visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. Slough and/or eschar may be visible. The depth of tissue damage varies by anatomical location; areas of significant (fat) adiposity can develop deep wounds. Undermining and tunneling may occur. Fascia, muscle, tendon, ligament, cartilage and/or bone are not exposed. If slough or eschar obscures the extent of tissue loss this is an Unstageable Pressure Injury. The wound may evolve rapidly to reveal the actual extent of tissue injury, or may resolve without tissue loss. Stage 4 Pressure Injury: If necrotic tissue, subcutaneous tissue, granulation tissue, fascia, muscle or other underlying structures are visible, this indicates a full thickness stage 4 pressure injury. Do not use (deep tissue pressure injury) DTPI to describe vascular, traumatic, neuropathic, or dermatologic conditions. On 7-16-19, Resident #5's care plan was reviewed and revealed the following 2 entries of importance; 1. Resistive to care, and 2. Skin care plan. 1. F[NAME]US Resident and wife are resistive to care. instituted 5-7-19, with an intervention for Explain to (Resident spouse name) some interventions she is using may be harmful and cause more problems with skin integrity continues to use own equipment and use of sheepskin which will add moisture. The Corporate RN (corp RN) was asked how a woman who walks with a cane could apply sheepskin to a hospital bed with her husband in it. The Corp RN replied yes, we put it on the bed, but the wife insisted. No nursing progress notes, physician progress notes [REDACTED]. 2. On 5-1-19, and 5-2-19 new focuses were added with no additions after that date. All planned focuses are included as follows; Focuses-Potential for further skin impairment, and the interventions were: Keep skin clean and dry, lotion to dry skin, peri care with incontinence episodes, pressure reduction mattress, Roho cushion in wheel chair, [NAME] hose as ordered (none were worn on the legs of the Resident during observations), weekly skin assessment, the Resident has a pressure ulcer with potential for pressure ulcer development, administer treatments as ordered, and monitor for effectiveness, devices ATMOS 9000 air mattress (the only 9000 air bed) & (the Resident was on a Genesis II mattress, which is a low air loss mattress while the ATMOS 9000 is an alternating pressure mattress), educate resident and family as to causes of skin breakdown (the Resident is a doctor) monitor nutritional status, provide supplements as ordered (none were ordered), position resident as needed, treat pain prior to treatment as needed to ensure the resident's comfort. On 7-16-19 at the end of day meeting, facility staff were asked to show evidence of how Resident #5's wounds were unavoidable. They stated they had no further evidence to provide. In summary, for Resident #5, the physician ordered treatments were not administered, assessments of skin, and the wound were not completed for 1 month, and the wound was identified by surveyors as a stage 4 pressure ulcer, when staff were still documenting a stage 2 wound. Orders were received for debridement of the wound on 6-3-19, when documents say there was nothing to debride. No supplements were ordered for wound healing. The physician did not evaluate the wound, and staff signed that they completed 2 conflicting wound treatment orders simultaneously. The air mattress that was care planned was not the one in use, and mattress which was being used was not in working order for 3 days. The wound was initially identified as a stage 2 wound which progressed to a stage 4 wound, without staff identifying it. The Administrator, DON, and the Registered Nurse (RN) Regional Consultant were made aware of the harm level deficiency at the end of day debrief on 7-16-19. No further information was supplied by the facility. 2. For Resident #19, facility staff failed to carry over wound treatment orders from the hospital, resulting in a delay in treatment. In addition, the wound worsened. Resident #19 was admitted to the facility from the hospital on [DATE]. Resident #19's [DIAGNOSES REDACTED]. Resident #19's most recent Minimum Data Set (MDS) Assessment was a Quarterly Assessment with an Assessment Reference Date (ARD) of 05/14/2019. The Brief Interview for Mental Status (BIMS) scored Resident #19 at a 9, indicating moderate impairment. Resident #19 was coded as requiring total assistance of 1 person for toileting, and requiring extensive assistance of 1 person for other Activities of Daily Life (ADLs). A review of Resident #19's medial record was conducted beginning on 08/05/2019. Resident #19 was admitted to the facility from the hospital on [DATE]. A review of Resident #19's Hospital Discharge Summary revealed the following: .Stage 3 Sacral (on the sacrum) ulcer POA (Present on admission) c/w (continue with) wound care. A review of the Hospital discharge document entitled DISCHARGE MEDICATIONS revealed the following: .iodine-sodium (IODINE) 2% external solution: Apply to affected area three (3) times daily. To left buttocks and sacral area. The Assessment entitled Admission Assessment/Screening V.1.2 dated 05/08/2019 at 1:49p.m. entered by Licensed Practical Nurse (LPN) B does not contain a section reviewing the skin. No documentation of a skin issue is noted in the section entitled Other Concerns. The Assessment entitled PCC Skin and Wound - Total Body Skin assessment dated [DATE] reveals no documentation of a wound. A review of Resident #19's Physician order [REDACTED]. Apply [MEDICATION NAME] to left buttock every day shift - start date 07/05/2019 Apply EPC (cream) to buttocks every shift and with incontinent episodes every shift for skin protection - start date 07/23/2019 Clean left and right buttocks with NS (normal saline) apply [MEDICATION NAME] every shift for left and right buttocks open area - start date 07/29/2019 A discontinued order for Santyl(4) was noted as being initiated on 06/12/2019 and continuing until 07/01/2019. A progress note entitled Health Status Note dated 06/10/2019 at 3:40p.m. by LPN G reads: Resident was found to have an open area one(sic) the left buttock. In the same area that he usually does. Picture taken of area and RP (Responsible Party) [NAME] notified. N.O. (new orders) for prostat(5) and [MEDICATION NAME]. (RP NAME) is aware of the new orders as well. [MEDICATION NAME] applied. Wedge cushion in placed(sic) and resident repositioned at q2h (every 2 hours). Temp 97.1, Resident remains on abt (antibiotic) therapy, 600cc (cubic centimeter) output noted yellow urine. A progress note entitled Skin/Wound Note dated 06/10/2019 at 8:30p.m. by LPN A reads: Skin Assessment Complete. Findings: Turgor: Good Elasticity Skin Color: Temperature: Warm (normal) Moisture: Normal Condition: Extremely Dry New Wounds: 1 An Assessment entitled Skin & Wound Evaluation V5.0 dated 07/08/2019 at 8:47p.m. describes the following: The form contains several sections, where the staff member may select an option for each section from multiple choices. In the section entitled Describe, the option 15. Pressure is selected. In the section Stage, the option 2. Stage 2: Partial thickness skin loss with exposed dermis is selected. In the Location, a free text box, contained the words Left Buttock. In the section Measurements, the following measurements are documented: Area: 1.2 cm2, Length: 0.9cm, Width: 2.1cm, Depth: Not Applicable, Undermining: Not applicable, Tunneling: Not applicable. No description of the wound bed is made. On the morning of 08/06/2019, an observation of Resident #19's wound was made by this surveyor and Employee B, the Director of Nursing (DON). The wound stretched horizontally across both buttocks, roughly midway down the buttock. No dressing was in place. On the left buttock, the wound bed was obscured by tan/yellow slough (dead tissue, usually cream or yellow in color). The portion of the wound on the right buttock consisted of red, moist, abraded looking skin. Employee B documented her assessment of the wound in a Skin/Wound note dated 08/06/2019 at 4:59p.m.: skin assessment of wound to right and left buttock. Left buttock noted to be UTS (unable to stage) with 90% thick adherent slough to wound bed 10% on the edges of the wound noted dark brown necrotic tissue. Periwound intact irregular edges noted to wound bed. Right buttock UTS noted to be improving dark red tissue noted with irregular edges, periwound intact. Resident #19's primary Physician was Employee L, the Medical Director. Surveyors request copies of all notes Employee L made of his visits to see Resident #19. None of Employee L's notes refer to a skin condition or pressure wound. Employee L was not available for interview during the 8/5/19 - 8/7/19 portion of the survey. On 8/7/19 at 9:14am, an interview was conducted with Employee O, another facility Physician and the Acting Medical Director in Employee L's absence, in the conference room. When asked about skin assessments; he replied: I do not do a full skin exam, when they shower and look at their skin, they would determine that. I cover 6 different facilities and it's just not physically possible. I go by their assessment unless they say come look at this wound, then I look at it. The Administrator and Director of Nursing were informed of the findings at the end of day meeting on 08/07/2019. No further documentation was provided. 3. For Resident #155, facility staff failed to assess the resident and initiate treatment for [REDACTED]. In addition, the wound worsened. Resident #155 was admitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. Resident #155's most recent MDS Assessment was an Entry Assessment with an ARD of 07/29/2019. The Entry MDS did not have the BIMS or ADL Assessment completed. Resident #155 had a Skin/Wound Evaluation V5.0 assessment dated [DATE] at 6:42p.m. by LPN I. This assessment described a Stage 3 pressure ulcer with 30% slough. A Review of Resident #155's Physician order [REDACTED].>Santyl Ointment 250 UNIT/GM ([MEDICATION NAME]) Apply to sacrum topically every evening shift for decubitus related to RASH AND OTHER NONSPECIFIC SKIN ERUPTION (R21) clean sacral ulcer with NS, apply scant amount of Santyl ointment with light drsg (dressing) q (every) evening. No order was noted for an alternative/specialty air mattress. Resident #155's Comprehensive Care Plan revealed a Focus of: actual skin impairment pressure ulcer to coccyx (tailbone) This focus had a created on date of 08/02/2019 and a revision date of 08/04/2019. No orders related to wound care with an earlier start date were found. On the morning of 08/06/2019, an observation of Resident #155's wound was conducted by this surveyor and Employee B, the DON. Resident #155's wound was observed with a slough-filled base with red borders. The wound was covered with a clear plastic opsite style dressing over gauze. The dressing was clean but was not dated. Employee B documented her observation in a Skin/Wound note dated 08/06/2019 at 4:57p.m. The note states: assessment of residents (sic) coccyx wound assessed today noted stage 3 to coccyx with 50% slough to wound bed periwound intact. Will continue with current treatment plan. A review of the facility document entitled Pressure Ulcer Treatment Guidance revealed the following under the heading for Pressure Ulcers - Unstageable: Full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown, black) in the wound bed. Resident #155's primary Physician was Employee L, the Medical Director. Surveyors request copies of all notes Employee L made of his visits to see Resident #155. None of Employee L's notes refer to a skin condition or pressure wound. Employee L was not available for interview during the 8/5/19 - 8/7/19 portion of the survey. On 8/7/19 at 9:14am an interview was conducted with Employee O, another facility Physician and the Acting Medical Director in Employee L's absence, in the conference room. When asked about skin assessments; he replied: I do not do a full skin exam, when they shower and look at their skin, they would determine that. I cover 6 different facilities and it's just not physically possible. I go by their assessment unless they say come look at this wound, then I look at it. The Administrator and Director of Nursing were informed of the findings at the end of day meeting on 08/07/2019. No further documentation was provided. 4. For Resident #156, facility staff failed to carry over wound treatment orders from the hospital, resulting in a delay in treatment. In addition, the wound worsened. Resident #156 was admitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. Resident #156's most recent MDS Assessment was an Admission/5 Day Assessment with an ARD of 08/02/2019. The BIMS scored Resident #156 at a 14, indicating little to no impairment. Resident #156 was coded as requiring extensive assistance of 1 person for bed mobility, transfers, and dressing; and requiring extensive setup assistance for ambulation, eating, and personal hygiene. A review of Resident #156's medical record was conducted beginning on 08/05/2019. It was noted that Resident #156 was admitted to the facility from the hospital on [DATE]. Resident #156's hospital Discharge Documentation revealed, under Discharge Wound Care Instructions: Therahoney(8) Gel and Silicone foam dressing to sacral area/buttocks - change daily after cleansing with saline. An Admission Note dated 07/26/2019 at 4:03p.m. describes numerous small abrasions to Resident #156's arms and legs but does not describe a wound to the sacrum/buttocks. A Skin/Wound note dated 07/29/2019 at 10:21a.m. by Employee K, the Assistant Director of Nursing (ADON) states: New Admission Skin Assessment completed, resident with scattered old scabs to bilateral arms and feet, and small abrasion to Left knee, all of which are open to air. Resident has a vascular area to right great toe 1.5cm x .5cm no drainage noted. Resident also has a DTI (deep tissue injury) 6cm x 2.1 treatment in place. Resident is educated to the importance of off loading pressure to his sacrum, verbalizes understanding. A review of Resident #156's Physician order [REDACTED]. A Review of Resident #156's Comprehensive Care Plan reveals a Focus entitled The Resident has an actual pressure ulcer sacrum and right toe development r/t (related to) immobility. The focus has a Created On of 08/04/2019 and a Revision on of the same date. On the morning of 08/06/2019, this surveyor observed Resident #156's wound with the DON. The wound displayed eschar and slough to the base of the wound, with tunneling at the 12 o'clock

Based on observation, staff interview, clinical record review, and facility documentation review, the facility failed to ensure nursing staff have the appropriate skills and competencies to conduct assessment and treatment of [REDACTED].#5) in a survey sample of 46 Residents, resulting in harm for Resident #5. Immediate Jeopardy was identified on 8/6/19 at 6:17pm and the facility was notified. After verification, Immediate Jeopardy was abated on 8/7/19 at 6:55pm and the scope and severity was lowered to level three, isolated. The findings included; 1. For Resident #5, staff continually failed to accurately assess a pressure ulcer, resulting in harm. Resident #5 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. and chronic Foley catheter. Resident #5's most recent Minimum Data Set (MDS) assessment was a quarterly assessment with an Assessment Reference Date (ARD) of 4-26-19. The Resident was coded with mild cognitive impairment, and no aberrant behaviors. Resident #5 required extensive assistance to total dependence on one to two staff members, for activities of daily living care. The Resident was coded as not having any pressure ulcers at the assessment time, nor on admission. The Resident had a long standing Foley catheter (urine drainage) due to an obstruction, and was incontinent of bowel. The Resident was coded as at risk for pressure sores. At area M-0100 through M-1200 under the MDS skin conditions section of the assessment, the Resident was coded to be at risk for pressure ulcers, had no pressure ulcers, and had no other skin problems such as rashes, and or moisture associated skin damage. A wound observation occurred on 7-16-19 at 11:30 a.m., with Licensed practical nurse C (LPN C), and Certified nursing assistant N (CNA N). The nurse removed the bandage from the Resident's coccyx. The 4 inch by 4 inch single bandage had a solid center in it which was a tan [MEDICATION NAME] like non-adherent 2 inch by 2 inch square. The outer circumference of the square bandage was surrounded by a boarder of adherent malleable stretchy tape, reminiscent of Band-Aid fabric. There was no packing or medicated cream in the hollow wound. Immediately after removing the dressing a green purulent discharge was seen. The wound was circular, and deep with full muscle tissue loss and bone protrusion clearly visualized and palpated by the nurse. The wound had undermined and tunneled circumferentially around, only under the circular rolled wound edges. There was also noted yellow tan slough and black necrotic tissue inside the wound, and silvery white fascia could be seen covering the coccygeal bone protrusion. The LPN measured the wound with a long cotton swab and a wound measuring disposable paper tape. She measured the cotton swab after it was laid on the wound, and placed in the wound for an accurate measurement. The wound measured 2 centimeters (cm) long, 1.5 cm wide, and 1.5 cm deep. The exterior wound edges were rolled (epibole). The Resident was pre-medicated with pain medication and stated he felt no pain as the wound was measured. Nursing progress notes were reviewed from wound identification to the time of survey. No notes describe any pressure ulcer identification, treatments, assessments for pressure ulcers, or changes to the care plan for Resident #5 after the first identification of the wound on 4-29-19. The initial note described the pressure injury as a red bruise with open skin, and the skin evaluation document of 4-29-19 gave further measurements. Review of the weekly skin assessment sheets since admission PCC Skin & Wound - Total Body Skin Assessment documents revealed all (including the initial) were completed by LPN's. The findings were as follows; 1-29-19 - no new wounds 2-5-19 - no new wounds 2-12-19 - no new wounds 2-19-19 - no new wounds 2-26-19 - no new wounds 3-5-19 - no new wounds 3-13-19 - no new wounds 3-25-19 -no new wounds 4-1-19 - no new wounds 4-8-19 -no new wounds 4-15-19 -no new wounds 4-22-19 -no new wounds From 4-22-19 through 5-26-19, no weekly skin checks were completed. 5-27-19 -no new wounds 6-3-19 -no new wounds 6-10-19 -no new wounds 6-17-19 - no new wounds 6-24-19 - 2 new wounds (left and right buttocks) 7-1-19 -no new wounds 7-8-19 -no new wounds 7-15-19 -no new wounds. On 4-29-19, another type of assessment document was initiated and performed by all LPN staff, Skin and Wound Evaluation V 5.0. These documents were started for a new Pressure wound stage 2 on the Resident's sacrum and was described as being treated with [MEDICATION NAME] iodine after cleaning with normal saline, and no dressing. The wound measured 3 cm long x 1.3 cm wide, no depth, and healable. None of these documents were completed after this initial one until 1 month later, on 5-27-19. The Rest of these particular assessment documents follow below in chronological order: On 5-27-19 the next Skin and Wound Evaluation V 5.0 document occurred one month after the first one on 4-29-19. The document describes the sacrum wound as stage 2 unchanged, healable, and documents the measurements of the wound as 1.1 cm long x 0.5 cm wide, and no depth. The treatment remains the same. No eschar, no debridement, no dressing. On 6-3-19 Sacrum stage 2 pressure ulcer 1.7 cm long x 0.5 cm wide, no depth, same treatment. Healable. No eschar, No debridement, no dressing. On 6-10-19 sacrum stage 2 pressure ulcer 1.9 cm long x 0.5 cm wide, no depth, same treatment. Healable. No eschar, No debridement, no dressing. On 6-17-19 sacrum stage 2 pressure ulcer 1.2 cm long x 0.6 cm wide, no depth, same treatment. Healable. No eschar, No debridement, no dressing. On 6-24-19 staff pin pointed and documented the Coccyx portion of the sacrum, instead of just stating sacrum, stage 2 pressure ulcer 1.3 cm long x 0.9 cm wide, no depth, Normal saline, and now, cover with foam dressing. Healable. No eschar, No debridement. A Left buttock and a right buttock were found as New areas on 6-24-19, however, had nothing to do with the continuing Sacrum/Coccyx wound according to nursing staff. On 7-2-19 coccyx stage 2 pressure ulcer 1.4 cm long x 0.2 cm wide, no depth, same treatment. Healable. No debridement, No eschar. On 7-8-19 coccyx stage 2 pressure ulcer 1.5 cm long x 0.5 cm wide, no depth, same treatment. Healable, Deteriorating. No debridement, No eschar. On 7-9-19 (one day later) the last assessment documented coccyx stage 2 pressure ulcer 1.2 cm long x 0.6 cm wide, no depth, Eschar 20%, deteriorating, healable, treatment; normal saline and enzymatic debridement (ordered 6-3-19). No assessments by staff described a stage 4 pressure ulcer, and no assessments were completed from 7-14-19. through 7-16-19, until the surveyor found the stage 4 pressure ulcer on 7-16-19. All of the assessments, including the initial assessment, were completed by LPN's. The DON was requested to supply surveyors with all policies for skin assessments and pressure ulcers. The DON, and Corporate RN supplied 2 facility policies on skin assessments and pressure ulcers. They are as follows; 1. Pressure ulcers Manual - Skin Assessment Skin assessments will be completed for all patients. A licensed nurse will ensure that the skin risk assessment is done upon admission, and quarterly thereafter. A skin assessment will also be completed upon re-entry to the center (i.e., after ER visit, [MEDICAL TREATMENT], etc.) The weekly skin assessment will be completed thereafter. Care plan specific interventions will be developed based on skin risk assessment outcomes and individual patient needs. 2. Pressure ulcers Manual - Pressure Ulcer monitoring & A licensed nurse will assess patients for the presence of pressure ulcers: if a pressure ulcer is present, the nurse will evaluate for complications. Provide pain management prior to pressure ulcer treatment as indicated. The wound record will be completed weekly by a licensed nurse for any patient with pressure ulcers. There will be a wound record for each site. Guidance is provided for the staging of pressure ulcers by the National Pressure Ulcer Advisory Panel (NPUAP), and is as follows; NPUAP announces a change in terminology from pressure ulcer to pressure injury and updates the stages of pressure injury FOR IMMEDIATE RELEASE (MONTH) 13, (YEAR). Stage 2 Pressure Injury: Partial-thickness skin loss with exposed dermis Partial-thickness loss of skin with exposed dermis. The wound bed is viable, pink or red, moist, and may also present as an intact or ruptured serum-filled blister. Adipose (fat) is not visible and deeper tissues are not visible. Granulation tissue, slough and eschar are not present. These injuries commonly result from adverse microclimate and shear in the skin over the pelvis and shear in the heel. This stage should not be used to describe moisture associated skin damage (MASD) including incontinence associated [MEDICAL CONDITION] (IAD), intertriginous [MEDICAL CONDITION] (ITD), medical adhesive related skin injury (MARSI), or traumatic wounds (skin tears, burns, abrasions). Stage 3 Pressure Injury: Full-thickness loss of skin, in which adipose (fat) is visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. Slough and/or eschar may be visible. The depth of tissue damage varies by anatomical location; areas of significant (fat) adiposity can develop deep wounds. Undermining and tunneling may occur. Fascia, muscle, tendon, ligament, cartilage and/or bone are not exposed. If slough or eschar obscures the extent of tissue loss this is an Unstageable Pressure Injury. The wound may evolve rapidly to reveal the actual extent of tissue injury, or may resolve without tissue loss. Stage 4 Pressure Injury: If necrotic tissue, subcutaneous tissue, granulation tissue, fascia, muscle or other underlying structures are visible, this indicates a full thickness stage 4 pressure injury. Do not use (deep tissue pressure injury) DTPI to describe vascular, traumatic, neuropathic, or dermatologic conditions. The Administrator, DON, and the Registered Nurse (RN) Regional Consultant were made aware of the harm level deficiency at the end of day debrief on 7-16-19. No further information was supplied by the facility. The facility presented the following plan to remove the Immediate Jeopardy: F726 Center failed to ensure Nursing staff have appropriate skills and competencies to conduct assessment and treatment of [REDACTED]. Registered Nurse Consultant educated Director of Nursing (DON) on wound identification, Staging, and appropriate treatment on 8.6.2019. Competency validated through wound rounds and visualizing DON completing assessments. DON will assume responsibility of coordinating Weekly Wound Rounds. Registered Nursing staff educated in correct identification, wound staging, and appropriate treatments for initial assessment before there next scheduled shift.All licensed staff will be educated on re-evaluation of wounds, appropriate treatments, and notification to registered nurse and physician or extender if wound deterioration is suspected prior to next scheduled shift. This is validated through return demonstration utilizing the Skills Validation for Skin and Pressure ulcer prevention and management. Wound identification charts with appropriate treatments/products, based on staging, are available to staff in the narcotic books on each of the medication carts.

Based on observation, Resident interview, staff interview, clinical record review, and facility documentation review, the facility has failed to ensure the Medical Director has coordinated medical care in the facility and implemented resident care policies for one resident (Resident #5) in a survey sample of 46 Residents, resulting in harm for Resident #5. Immediate Jeopardy was identified on 8/6/19 at 6:17pm and the facility was notified. After verification, Immediate Jeopardy was abated on 8/7/19 at 6:55pm and the scope and severity was lowered to level three, isolated. The findings included; 1. For Resident #5, the facility staff failed to ensure the Medical Director has coordinated medical care, resulting in harm. Resident #5 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. and chronic Foley catheter. Resident #5's most recent Minimum Data Set (MDS) assessment was a quarterly assessment with an Assessment Reference Date (ARD) of 4-26-19. The Resident was coded with mild cognitive impairment, and no aberrant behaviors. Resident #5 required extensive assistance to total dependence on one to two staff members, for activities of daily living care. The Resident was coded as not having any pressure ulcers at the assessment time, nor on admission. The Resident had a long standing Foley catheter (urine drainage) due to an obstruction, and was incontinent of bowel. The Resident was coded as at risk for pressure sores. At area M-0100 through M-1200 under the MDS skin conditions section of the assessment, the Resident was coded to be at risk for pressure ulcers, had no pressure ulcers, and had no other skin problems such as rashes, and or moisture associated skin damage. A wound observation occurred on 7-16-19 at 11:30 a.m., with Licensed practical nurse C (LPN C), and Certified nursing assistant N (CNA N). The nurse removed the bandage from the Resident's coccyx. The 4 inch by 4 inch single bandage had a solid center in it which was a tan [MEDICATION NAME] like non-adherent 2 inch by 2 inch square. The outer circumference of the square bandage was surrounded by a boarder of adherent malleable stretchy tape, reminiscent of Band-Aid fabric. There was no packing or medicated cream in the hollow wound. Immediately after removing the dressing a green purulent discharge was seen. The wound was circular, and deep with full muscle tissue loss and bone protrusion clearly visualized and palpated by the nurse. The wound had undermined and tunneled circumferentially around, only under the circular rolled wound edges. There was also noted yellow tan slough and black necrotic tissue inside the wound, and silvery white fascia could be seen covering the coccygeal bone protrusion. The LPN measured the wound with a long cotton swab and a wound measuring disposable paper tape. She measured the cotton swab after it was laid on the wound, and placed in the wound for an accurate measurement. The wound measured 2 centimeters (cm) long, 1.5 cm wide, and 1.5 cm deep. The exterior wound edges were rolled (epibole). The Resident was pre-medicated with pain medication and stated he felt no pain as the wound was measured. Nursing progress notes were reviewed from wound identification to the time of survey. No notes describe any pressure ulcer identification, treatments, assessments for pressure ulcers, or changes to the care plan for Resident #5 after the first identification of the wound on 4-29-19. The initial note described the pressure injury as a red bruise with open skin, and the skin evaluation document of 4-29-19 gave further measurements. physician's orders [REDACTED]. reviewed and revealed no physicians order for prevention of pressure sores from bowel incontinent episodes such as an incontinence barrier cream. Only the following 4 orders appeared after the pressure sore developed for the sacral coccyx acquired pressure ulcer treatment; 1. Ordered 4-29-19 start 4-29-19 discontinued 7-8-19 Clean open area to sacrum with normal saline and apply [MEDICATION NAME] twice per day at morning and bedtime. No dressing. No change to this order occurred after 2.5 months without healing. 2. Ordered 6-3-19 start 6-4-19 discontinued 7-9-19 Clean wound with normal saline & apply [MEDICATION NAME] ointment to coccyx wound topically once per day & as needed with allevyn dressing. 3. Ordered 7-10-19 start 7-10-19 discontinued 7-16-19 Cleanse sacrum/coccyx with normal saline apply [MEDICATION NAME] gel (hydrogel water gel to keep wound bed moist) and cover with coversite once every day. 4. Ordered 7-16-19 start 7-17-19 Cleanse sacral wound with saline, apply [MEDICATION NAME] (iodine impregnated gauze for packing into a hole) and cover area with coversite one time per day, after the examination by surveyors and an LPN, and was not ordered to be administered until the following day (7-17-19) further delaying care. Review of the MAR/TAR's revealed that the pressure sore treatments that were ordered as above, were not administered on 5/18, 5/24, 6/4, 6/10, 6/20, 6/26, 7/8, and 7/9/19. No nursing notes reveal the reason for the omissions. It is of note to mention that the [MEDICATION NAME] ointment ordered on 6-3-19 was a debridement agent. Debridement is the removal of dead and damaged tissue from a wound. This can be completed by surgical/cutting out removal, or chemical enzyme/liquefying of dead tissue to remove it. Resident #5's skin wound evaluation documents on that date show no necrotic/dead tissue in need of debridement. An interview was conducted via telephone with the Resident's physician (who was also the facility medical director) and all surveyors present on 7-16-19 at 6:45 p.m. The doctor stated he had seen the Resident on 7-15-19 between the hours of 7:00 a.m., to 8:00 a.m. He stated that he was aware the Resident had a wound, and had reviewed the recent nursing notes which stated the Resident had a stage 2 pressure sore, and so in his progress note dated 7-15-19, he wrote a stage 2 sacral decubitus. The nursing notes were reviewed from the doctor's previous visit of 6-22-19, none stated the Resident had a stage 2 decubitus ulcer. The doctor was informed that an RN surveyor had assessed the wound this morning (7-16-19), and he was asked if he had been made aware of the findings. He stated No. The doctor was asked if he evaluated the wound, and he stated it looked like a stage 2 when I saw him, but I was interested in the shingles, my focus was not the wound. The surveyors asked if he could describe the wound, and he stated it was on his coccyx area. The doctor was asked if a debridement agent would be used for a stage 2 decubitus ulcer which had no eschar, and he stated No., The doctor went on to say, but he has been in failing health for several months with [MEDICAL CONDITION] which is an obvious factor for skin integrity, and we don't need to aggressively treat as the prognosis is poor. The doctor stated that the Resident was also losing weight and nutrition was an issue, with mineral loss. The doctor was asked why minerals and supplements had not been ordered as a replacement to mitigate this, and if that would be of value. The doctor stated yes it would be of value, but due to his age and failing health the Resident was supportive care at this stage and his overall prognosis was poor. The physician was asked why a Resident, regardless of age, who was ambulatory and recovering from a hospitalization and receiving aggressive occupational and physical therapy within the past few months would not be treated for [REDACTED]. The doctor was asked why none of his progress notes discuss evaluation of the wound until this last note yesterday, and he responded that the Resident's prognosis was poor, and I thought he had shingles, but probably just heat rash, I was not there to see the decubitus. The DON was requested to supply surveyors with all policies for skin assessments and pressure ulcers. The DON, and Corporate RN supplied 2 facility policies on skin assessments and pressure ulcers. They are as follows; 1. Pressure ulcers Manual - Skin Assessment Skin assessments will be completed for all patients. A licensed nurse will ensure that the skin risk assessment is done upon admission, and quarterly thereafter. A skin assessment will also be completed upon re-entry to the center (i.e., after ER visit, [MEDICAL TREATMENT], etc.) The weekly skin assessment will be completed thereafter. Care plan specific interventions will be developed based on skin risk assessment outcomes and individual patient needs. 2. Pressure ulcers Manual - Pressure Ulcer monitoring & A licensed nurse will assess patients for the presence of pressure ulcers: if a pressure ulcer is present, the nurse will evaluate for complications. Provide pain management prior to pressure ulcer treatment as indicated. The wound record will be completed weekly by a licensed nurse for any patient with pressure ulcers. There will be a wound record for each site. The Administrator, DON, and the Registered Nurse (RN) Regional Consultant were made aware of the harm level deficiency at the end of day debrief on 7-16-19. No further information was supplied by the facility. The facility presented the following plan to remove the Immediate Jeopardy: F841 Identification of those residents were the Medical Director failed to coordinate medical care in the center and ensure timely and appropriate treatment for [REDACTED].>Resident #5's Medical Director failed to coordinate medical care in the center and ensure timely and appropriate treatment for [REDACTED]. (redacted) , notified on 8/6/19 of negligence from lack of oversight. How corrective action will be accomplished for those residents having potential to be affected by the same deficient practice Acting Medical Director, Dr. (redacted) has been notified on 8/6/19 of Medical Director Responsibilities: those responsibilities are as follows 1. Directing and Coordinating care in the center 2. Coordinating Physical Exams, which also includes skin assessment, documenting all assessments in patient clinical record with current treatment plan. 3. Participates in Policy, Procedures and Guidelines to oversee comprehensive care of patients 4. Participates in Resident Care Management 5. Improves Performance of Medical Services within the center 6. Participates in QAPI process

Based on observation, Resident interview, staff interview, clinical record review, facility documentation review and in the course of a complaint investigation, the facility staff failed to perform services to prevent and promote the healing of pressure ulcers in two Residents (Residents' #2, and #20) in the survey sample of 23 Residents, resulting in harm for Resident #2. 1. For Resident #2, the facility staff failed to provide preventive care and assessment. Failed to monitor for the development of ulcers, and failed to implement a comprehensive care plan to prevent 2 avoidable pressure ulcers from forming on 3-24-16. The staff then failed to treat the first 2 ulcers, and, failed to assess, and implement a care plan for, and prevent three further ulcers from forming and being identified on 4-12-16, and 4-13-16, 19 days after the initial 2 ulcers were identified. The facility staff further failed to promote healing for all 5 pressure ulcers which included two stage 2 ulcers, one unstageable ulcer, one deep tissue injury, and a new stage 3 ulcer found by surveyors, resulting in harm. 2. For Resident #20, the facility staff failed to adequately assess, document and monitor skin breakdown. The findings included: 1. Resident #2 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Resident #2's Admission Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) of 3-18-16 coded the Resident with no cognitive impairment. Resident #2 required extensive physical assistance from one to two staff members, with activities of daily living, and was coded as not having any pressure ulcers on admission. The Resident had a long standing Foley catheter (urine drainage) due to an obstruction, and was incontinent of bowel. At area M-0100 through M-1200 under the MDS skin conditions section of the assessment, the Resident was coded to be at risk for pressure ulcers, had no pressure ulcers, and had no other skin problems such as rashes, and or moisture associated skin damage. The only preventive measures coded were a pressure reduction mattress for the bed, which all residents were given upon admission according to the Director of nursing (DON), and was the standard mattress used for all residents. A 14 day MDS assessment with an ARD date of 3-24-16 was completed, and at area M-0100 through M-1200 under the MDS skin conditions section of the assessment, the Resident was coded to be at risk for pressure ulcers. The Resident had two stage 2 pressure ulcers, that were not present on admission, and were identified on 3-24-16. The Resident had no other skin problems such as rashes, and or moisture associated skin damage. The only preventive measures coded were a pressure reduction mattress for the bed, which all residents were given upon admission according to the Director of nursing (DON), and was the standard mattress used for all residents. No new orders for treatment, nor new interventions were instituted after the 2 stage two pressure ulcers were identified, and through the time of survey. On 4-12-16 at 2:30 p.m. the first observation of Resident #2 was conducted during initial tour of the facility with Licensed Practical Nurse (LPN) E, he was found laying in bed partially on his right side with oxygen infusing at 5 liters per minute though a [MEDICAL CONDITION] mask, and a Foley catheter was noted to be draining dark yellow urine with white sediment in it. The Resident was able to speak and make his needs known, and stated he was thirsty and wanted water. A second observation of Resident #2 was conducted at 4:30 p.m., and the Resident was sleeping in bed on an Atmos 4000 static air mattress with the controls reading half way between minimum and maximum fill normal pressure. On 4-13-16 Resident #2's Admission full Nursing Assessment was reviewed and it was dated as complete on 3-17-16. The Skin section of the assessment revealed no pressure ulcers or skin integrity problems on the buttocks, sacrum or penis. Nothing was documented under skin treatment ordered or required. Review of the Weekly Skin Assessment, and Wound Record sheets were documented as follows: Documented on 3-21-16 no pressure ulcers, and groin red. Documented on 3-24-15 area (1) Coccyx pressure measuring 1.3 x 1 centimeters (cm) stage 2. Area (2) Coccyx pressure measuring 2.2 x 1.4 cm stage 2. Both wounds were documented on the weekly skin sheet as Worsening, beefy red, and [MEDICATION NAME] as the treatment, however, no physicians order appeared for this incontinence barrier cream, and it did not appear on the Treatment Administration Record (TAR) through the time of survey. As no order appeared in the clinical record or on the TAR, nursing staff were not documenting that it had ever been instituted or administered. Documented on 4-12-16; Area (1) Right Buttock (Coccyx) pressure measuring 3 x 2.3 cm stage 2. Area (2) Left Buttock (Coccyx) pressure no measurement and stage 2. Area (3) Left Trochanter (hip) pressure measuring 5 x 4 cm suspected deep tissue injury. Area (4) Sacrum pressure 9 x 8 cm stage 2. Area (5) Left Gluteal fold (Ishium) pressure 7 x 2 cm stage 2. No treatment was described in any of the weekly skin or wound records for 4-12-16. On 4-13-16 a third observation of Resident #2 was conducted at 10:00 a.m., and he was found lying in bed on his back with oxygen infusing at 5 liters per minute through a [MEDICAL CONDITION] mask, and a Foley catheter was noted to be draining dark yellow urine with white sediment in it. The Resident was able to speak and make his needs known, and stated he was uncomfortable and wanted to be repositioned. The Resident was still lying on an Atmos 4000 static air mattress with the controls reading half way between minimum and maximum fill normal pressure. On 4-13-16 a fourth observation was conducted of the Resident at 3:30 p.m., during wound measurement observations and incontinence care with LPN E. Resident #2 was found to have five pressure ulcers. The numbering of those 5 ulcers is in the following parentheses: (#1) left and right inner buttocks' with diffuse open stage 2 pressure areas measuring 10 x 6 cm combined, the (#2) left trochanter (hip) with a deep tissue injury measuring 4.5 x 2.5 cm, the (#3) left ischial area under the left buttock with red angry margins and a black eschar center obscuring the wound base, measuring 9 x 1.5 cm which was an unstageable wound, and sacrum area 9 X 8 cm stage 2 and a fifth (#5) wound was found by the surveyor not previously documented on the Resident's penis. During incontinence care the surveyor wished to view the Foley catheter care, and the penile meatus was cleaned and found to have foul purulent drainage which was tan in color, and thick with mucous strings. Upon LPN E's removal of the drainage from the penile meatus (#5) a stage 3 pressure ulcer was found measuring 1 x 1 cm with a small amount of yellow slough in the base of the wound. The pressure ulcer was created by pressure of the Foley catheter, which had not been repositioned or stabilized with a device to the Resident's extremity to prevent rubbing and pressure in one location. The Resident had a bowel movement during care, and it was noted to be firm and formed. LPN E was asked if the Resident had loose bowel movements, and she replied no that the Resident normally had formed bowel movements as we had just experienced. The Resident wore an incontinent brief which was dry prior to the bowel movement, as the Foley catheter contained all urine. The Resident was still laying on an Atmos 4000 static air mattress with the controls reading half way between minimum and maximum fill normal pressure. Guidance is provided for the staging of pressure ulcers as follows: National Pressure Ulcer Advisory Panel (NPUAP) announces a change in terminology from pressure ulcer to pressure injury and updates the stages of pressure injury FOR IMMEDIATE RELEASE April 13, 2016. Stage 2 Pressure Injury: Partial-thickness skin loss with exposed dermisPartial-thickness loss of skin with exposed dermis. The wound bed is viable, pink or red, moist, and may also present as an intact or ruptured serum-filled blister. Adipose (fat) is not visible and deeper tissues are not visible. Granulation tissue, slough and eschar are not present. These injuries commonly result from adverse microclimate and shear in the skin over the pelvis and shear in the heel. This stage should not be used to describe moisture associated skin damage (MASD) including incontinence associated [MEDICAL CONDITION] (IAD), intertriginous [MEDICAL CONDITION] (ITD), medical adhesive related skin injury (MARSI), or traumatic wounds (skin tears, burns, abrasions). Stage 3 Pressure Injury: Full-thickness skin lossFull-thickness loss of skin, in which adipose (fat) is visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. Slough and/or eschar may be visible. The depth of tissue damage varies by anatomical location; areas of significant adiposity can develop deep wounds. Undermining and tunneling may occur. Fascia, muscle, tendon, ligament, cartilage and/or bone are not exposed. If slough or eschar obscures the extent of tissue loss this is an Unstageable Pressure Injury. Nursing progress notes were reviewed from admission to the time of survey. No notes describe any pressure ulcer identification, treatments, assessments for pressure ulcers, or changes to the care plan for Resident #2. On 4-12-16, and 4-13-16, and during survey, nursing notes began to be documented that the Resident was non-compliant with turning and positioning, after 5 pressure ulcers had already formed, in the one month since admission. Nursing notes did describe Resident #2 and totally dependant on staff for positioning. No physician orders were obtained to prevent or treat pressure ulcers for Resident #2. On 4-12-16 during survey, the facility staff obtained an order for [REDACTED].#2's bed on 4-14-16, just prior to survey exit. The Resident was receiving iron and a multivitamin for [MEDICAL CONDITION], which had been ordered on admission, and prior to the identification of the multiple pressure ulcers. The physician orders also revealed an as needed (PRN) standing facility order, given to all Residents upon admission, and read; Wound Consult PRN. This had never been obtained for Resident #2. On 4-13-16 Resident #2's care plan was reviewed and revealed no measurable objectives, and that on 3-22-16 a new Focus was instituted which read; Impaired skin integrity pressure areas on coccyx, with potential for further skin impairment due to weakness, incontinence, [MEDICAL CONDITION], refusal to turn and diabetes. Expected skin breakdown due to non-compliance with positioning. Revised on 4-12-16. Goal Resident will have no evidence of skin impairment through next review, created on 3-22-16, and revised on 3-24-16. Interventions were keep skin clean & dry, Lotion to dry skin, peri-care with incontinence episodes, weekly skin assessments, treatments as ordered (none were ordered), and on 4-12-16, during survey, pressure reduction mattress was added. On 4-13-16 at the end of day meeting, facility staff were asked to show evidence of how Resident #2's wounds were unavoidable. On 4-14-16 at 9:30 a.m. the Director of Nursing (DON) was not able to provide any evidence or documentation as to the 5 wounds at different stages of development being unavoidable, she did however want surveyors to speak with the physician of Resident #2 who was also the facility medical director. The physician talked with surveyors and stated that the cause of pressure ulcers is not relieving pressure, and it it much easier to prevent wounds than try to heal them after they have formed. He went on to say offloading the wounds is #1 as far as interventions. The physician was asked what had been done to prevent these wounds to Resident #2, and what had been done to heal them, and prevent new wounds. The doctor stated he would have to assess the whole problem & then plan interventions. The Director of Nursing (DON) stated that [MEDICATION NAME] ointment had been used for Resident #2, from the time of admission, until 4-6-16, when [MEDICATION NAME] was begun. Manufacturer's guidance follows below for both ointments; [MEDICATION NAME] Protective Ointment Skin Protectant is described by the manufacturer as below: Contains, 98% [MEDICATION NAME], Clove oil helps mask odor, Vitamins A, D and E to soothe and condition sensitive skin. Indications for use, Skin protectant. Helps treat and prevent rash associated with diaper use or continued exposure to feces, urine or both. Protects skin from minor irritation associated with diaper [MEDICAL CONDITION] and exposure to feces and urine, and helps seal out wetness. Warnings; For external use only. Avoid contact with eyes. Not to be applied over deep or puncture wounds, infections or lacerations. If condition worsens or does not improve within 7 days, consult a doctor. [MEDICATION NAME] ointment is described by the manufacturer as below: Drug Facts Menthol 0.44% .External [MEDICATION NAME] / Anti-itch urine diarrhea perspiration fistula drainage feeding tube site leakage [MEDICAL CONDITION] scrapes itching Zinc Oxide 20.6% .Skin protectant / Anorectal astringent Active ingredients: Purpose A moisture barrier that prevents & helps heal skin irritations from: wound drainage (peri-wound skin) W a r n i n g s : For external use only Not for deep or puncture wounds. If condition worsens or does not improve within 7 days, consult a doctor. D i r e c t i o n s : C leanse skin gently with mild skin cleanser. Pat dry or allow to air dry. Apply a thin layer of [MEDICATION NAME] Ointment to reddened or irritated skin 2-4 times daily, or after each incontinent episode or diaper change to promote comfort and long [MEDICATION NAME] protection. Inactive ingredients: [MEDICATION NAME], [MEDICATION NAME]. Neither of the ointments are recommended for pressure ulcer use by the manufacturer's guidelines, and neither ointment was ordered by a physician. The DON stated these ointments were used for all residents with incontinence. Review of all of the Treatment and Medication Administration Records (MAR/TAR) for Resident #2 revealed no documentation that these ointments were ever administered, and gave no guidance to nursing as to when or how to apply these ointments as they did not appear anywhere in the clinical record, and were not applied after incontinence care, during surveyor wound observation. Review of the facility policy on Pressure Ulcer Prevention and Management Program revealed; Avoidable pressure ulcers happen if the Center did not do one or more of the following. 1). Evaluate the patient's clinical condition and pressure ulcer risk. 2). Define and implement interventions that are consistent with patient needs, patient goals, and recognized standards of practice, monitor and evaluate the impact of the interventions. 3). Revise interventions as appropriate. The facility staff documented that the Resident was at risk for pressure ulcer development on admission on 3-11-16, however, did not institute a care plan for 11 days after admission, and until 3-22-14, when the Resident was noted to have a red groin, and by 3-24-16, had (2) stage 2 pressure ulcers identified. No interventions were added or revised to promote healing from 3-22-16 until the time of survey on 4-12-16, and the Resident had then (5) pressure areas, to include; Two at stage two, one that was unstageable, one that was a deep tissue injury, and one that was found by the surveyor during wound and incontinence care that was a stage 3. At the time of survey on 4-12-16, the specialty mattress was ordered and was not applied until 4-14-16. There was an addition to the care plan on 3-25-16 that stated treatments as ordered, however, no treatments were ever ordered. Interventions were ineffective, not consistent with patient needs, not evaluated for impact nor revised, resulting in avoidable wounds. The Resident did not receive the necessary treatment and services to promote healing of the two initial pressure ulcers, and so did not prevent the three (multiple avoidable) added pressure ulcers from developing, resulting in harm for Resident #2. The Administrator, DON, and the Registered Nurse (RN) Regional Consultant were made aware of the harm level deficiency at the end of day debrief on 4-13-16, and 4-14-16. No further information was supplied by the facility. 2. For Resident #20, the facility staff failed to adequately assess, document and monitor skin breakdown. There was no weekly skin assessment documented between admission 2/15/16 and 2/25/16. And Left buttock-Pressure 3 x 3 x 0.1 (no stage or other descriptions were documented); Left buttock-Pressure 4 x 3 x 0.1 (no stage or other descriptions were documented); Resident #20 was admitted to the facility on [DATE] and discharged home on[DATE]. The [DIAGNOSES REDACTED]. Being Resident #20 was no longer in the facility, a closed record review was conducted. The most recent full Minimum Data Set (MDS) was an initial assessment with an Assessment Reference Date (ARD) of 2/22/16. The MDS coded Resident #20 with moderate cognitive impairment; required extensive assistance from 2 staff members for bed mobility, transfers and toilet use; required extensive assistance from one staff member for dressing, personal hygiene and bathing; and was frequently incontinent of bowel and bladder. Resident #20 was coded as being 65 inches in height and 190 pounds. The MDS coded Resident #20 with one Stage 2 pressure ulcer, present on admission; surgical wound (s); skin tear (s); skin and ulcer treatments: pressure reducing device for chair, pressure reducing device for bed, pressure ulcer care, surgical wound care and applications of ointments/medications other than to feet. On 4/13/16 Resident #20's electronic and paper clinical record was reviewed. The review revealed a computerized Admission Assessment/Screening-Nursing form dated 2/15/16 at 16:54 (4:54 p.m.) which included the following skin issue documentation: Units of measure in centimeters Site: Right Trochanter (hip) Surgical Incision 6 x 0.2; Right Trochanter (hip) Surgical Incision 9 x 0.2; Left buttock-Pressure 3 x 3 x 0.1 (no stage or other descriptions were documented); Left buttock-Pressure 4 x 3 x 0.1 (no stage or other descriptions were documented); Sacrum-Skin Tear 15 x 0.2 x 0.1 left lower arm-Skin Tear 4 x 3 x 0.1 The Wound Record (Revised) form dated 2/16/16 included the following documentation of skin issues present on admission: Wound #1 .left lower arm .skin tear . (measured in centimeters) .4 x 3 x 0.1 (length/width/depth) .Current treatment plan: [REDACTED] Wound #2 .sacrum .skin tear .15 x 0.1 x 0.2 .Current treatment plan: [REDACTED] Wound #3 .left buttock .pressure .Stage II .4 x 4 x 0.1 .Current treatment plan: [REDACTED] Wound #4 .right hip .surgical .9 x 0.1 x 0 .Current treatment plan: [REDACTED]. (name) in 10 days. Wound #5 .right hip .surgical .6 x 0.1 x 0 .Current treatment plan: [REDACTED]. (name) in 10 days. Weekly skin assessments performed by nurses were reviewed and included the following documented skin observations: There was no weekly skin assessment documented between admission 2/15/16 and 2/25/16. 2/25/16: Site-Type-Length-Width-Depth-Stage Right trochanter (hip) surgical incision (no measurements or incision description documented); Left buttock-Pressure 2 x 3 (no stage was documented); Left buttock-Pressure 2 x 3 (no stage was documented); Sacrum-Skin Tear (no measurements documented); Left lower arm-Skin Tear 5 x 5. 3/2/16: Abdomen-Bruising Groin-Rash Right Buttock-Rash Left Buttock-Pressure 2 x 3 N/A (not applicable)-no stage. 3/9/16: Left Buttock-Pressure 2.5 x 3 (no stage was documented); Notes: groin, sacrum, and in between thighs are red/rash. Resident #20's care plan included the following: Focus The resident has a pressure ulcer: Lt (left) buttock with potential for further pressure ulcer development r/t (related to) incontinence, oxygen use, decreased mobility .Interventions Administer treatments as ordered and monitor of effectiveness .Monitor nutritional status. Provide supplements as ordered, monitor intake and record .Position resident as needed. Focus The resident has a Skin Tears to Lt. lower arm and sacrum .Interventions Encourage good nutrition and hydration in order to promote healthier skin .The resident needs their nails kept short to reduce risk of scratching or injury from picking skin .Treatment as orders. Focus Potential for skin impairment .Interventions Keep skin clean and dry .Pressure reduction mattress .Weekly Skin Assessment. Physician's orders for wound care included, but not limited to, the following: 2/16/16-dry dressing daily to right hip every evening . 2/21/16-[MEDICATION NAME] Maximum Strength Paste 40% (Zinc Oxide) Apply to left Buttock topically every shift for [MEDICATION NAME]. Discontinued 2/28/16. 2/21/16-[MEDICATION NAME] Cream 0 UNIT/GM (units per gram) Apply to inner thighs topically every shift for redness. Continued until discharge. 2/28/16-Cleanse left buttock w/NS (with normal saline), cover w/[MEDICATION NAME] border QOD (every other day) .([MEDICATION NAME] is a self-adherent soft silicone foam dressing that absorbs exudate, maintains a moist wound environment and minimises (sic) the risk for maceration); Rewritten 3/1/16. 3/1/16-Cleanse left buttock w/NS, cover w/[MEDICATION NAME] border QOD . Continued until discharge. 3/9/16-9000 mattress for pressure relief. Treatments per physician orders were documented as administered. physician progress notes [REDACTED]. Nurse Progress Notes included the following documentation: 2/15/16 .Assessment .left arm has scattered bruising with a skin tear to lower arm, left buttocks has 2 stage 2 pressure ulcers that are left OTA (open to air), right hip has 2 surgical incisions .Recommendations: continue to monitor 2/28/16 15:13 (3:13 p.m.) .[MEDICATION NAME] maximum Strength Past 40% Apply to left Buttock topically every shift for [MEDICATION NAME] Change in treatment. 2/28/16 16:30 (4:30 p.m.) .Resident noted with open areas to left buttock which measure 6 x 2 x 0.2 w/spaces of epithelized tissue between. Treatment changed to [MEDICATION NAME] QOD . 3/1/16 23:14 (11:14 p.m.) .Cleanse left buttock w/NS, cover w/ [MEDICATION NAME] border QOD until every evening shift every 2 day (s) passed on to next shift. 3/2/16 23:56 (11:56 p.m.) .Surgical incisions to the right hip are dry and shows no signs of drainage or infection, treatment was D/Ced (discontinued) and incision left open to air. Progress notes contained documentation that Resident #20 was incontinent of bowel and bladder. On 4/14/16 at 8:40 a.m. an interview was conducted with the Corporate Registered Nurse (RN)-(Admin-D). Admin-D explained Resident #20 was admitted with a surgical wound to the right hip, a stage 2 pressure ulcer to left buttock and skin tears. The concern on if treatments were implemented upon admission was discussed. At 9:40 a.m. Admin-D stated Resident #20 Was admitted with no dressings on areas and hospital ordered (to) leave open to air. Admin-D presented a (Hospital Name) Clinical Handoff Checklist & Worksheet with a Collected On date of 2/15/16 with a Visit Start date of 2/9/16. The worksheet included Resident #20's skin assessments, summarized as follows: Left Buttock-Stage 1 no dressing-1 x 1 (not known if measurement was in centimeters or inches). Right Buttock-Stage 2, no dressing. Right Thigh incision-gauze and tape. Coccyx-crack in between right and left buttocks-skin tear. Left Arm-skin tear-Allevyn over top. On 4/16/16 at 11:45 a.m. an interview was conducted with the Assistant Director of Nursing (Admin-C). Admin-C explained Resident #20, and most residents, have a Protective standing ointment applied. Admin-C presented information about [MEDICATION NAME] Protective Ointment which is described as a semi-transparent protective ointment that protects and conditions the skin. Admin-C reviewed and discussed the treatments as ordered by the physician. Admin-C stated Resident #20 was discharged home on[DATE] with (Name of Company) home health to see the resident the following day. The discharge instructions included a list of the current medication and treatment records. When asked about the missing skin assessment for 2/22/16, Admin-C stated I don't have it. When asked if it was missed, Admin-C stated Yes. On 4/14/16 at approximately 12:20 p.m., the Administrator, Director of Nursing and Corporate RN were informed of concerns that accurate assessments of pressure ulcer areas on buttocks were not completed (not staged or described adequately) and the missing assessment for 2/22/16. The wound care policy was requested. On 4/14/16 at 1:10 p.m. Admin-C stated the facility Does not have a formal wound care protocol. It was discussed and questioned how a nurse would know how to properly assess and treat wounds without a facility protocol. A PRESSURE ULCER PREVENTION AND MANAGEMENT PROGRAM Nursing Orientation Teaching/Learning Module dated July 2014 was presented which included basic principles of managing skin and preventing ulcers. The program section Skin Assessments included: Perform weekly skin assessments; i.e., every 7 days. And, Care Plan specific interventions should be implemented based on skin assessment outcomes and individual patient needs. Section PRESSURE ULCER MANAGEMENT ONCE BREAKDOWN HAS OCCURRED: included Assess, document, and notify the patient, family and medical provider, Implement specific, individualized interventions such as the use of a pressure relieving mattress, wound treatments, and/or other types of pressure relieving devices. Implement a care plan that reflects appropriate goals, outcomes, interventions, and evaluations to determine effectiveness of interventions .Complete pressure ulcer documentation weekly. No further information was provided by the facility staff regarding the facility's failure to adequately document assessments and monitoring of Resident #20's wounds. Complaint Deficiency